hospital_name,last_updated_on,version,location_name,hospital_address,type_2_npi,license_number|MI,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name,,,,,,,,,,,,,,,,,,
Corewell Health Butterworth Hospital,5/1/2026,3.0.0,Corewell Health Butterworth Hospital,"100 Michigan St Ne, Grand Rapids, MI 49503",1922090554,1060000021,TRUE,Amy Assenmacher,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,billing_class,setting,drug_unit_of_measurement,drug_type_of_measurement,modifiers,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|methodology,standard_charge|min,standard_charge|max,additional_generic_notes
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],328.78,328.78,328.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,15708.96,14141.72,19941.83,11,percent of total billed charges,,,
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],7522.05,7522.05,7522.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,17128.77,17128.77,17128.77,1 through 10,percent of total billed charges,,,
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4035.78,4035.78,4035.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],7610.92,7610.92,7610.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4057.03,3929.8,4092.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],7308.35,7118.6,7745.98,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4168.26,4168.26,4168.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],17341.33,14251.99,17549.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine liposome",763,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],11335.97,11335.97,47149.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,9182.77,2316.9,26601.2,82,percent of total billed charges,,,
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,14925.34,14925.34,14925.34,1 through 10,percent of total billed charges,,,
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3121.6,3121.6,3121.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3829.58,1891.9,5136.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,11552.67,11552.67,11552.67,1 through 10,percent of total billed charges,,,
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1743.87,1743.87,3127.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1738.61,1227,6431.58,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],2846.95,2846.95,2846.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3127.62,1738.67,6896.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],9003.19,4668.72,16943.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1891.98,1687.06,5786.08,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6173.17,1897.08,17649.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],12915.77,2244.44,24048.92,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],12148.55,4748.57,15864.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2581.11,1222.47,15791.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],5601.02,5601.02,5601.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],10906.4,8117.38,32506.89,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",0.32,0.32,0.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",733.1,733.1,733.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, tyenne, 1 mg",784,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2965.48,1602.57,3746.83,1 through 10,percent of total billed charges,,,
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],135.8,135.8,135.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3872.39,3872.39,3872.39,1 through 10,percent of total billed charges,,,
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",100.04,100.04,100.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],234.33,234.33,234.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2267.52,2267.52,2267.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],4329.53,4329.53,4329.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred acetate 1 mg",790,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3470.32,1679.43,48965.33,1 through 10,percent of total billed charges,,,
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],10482.98,10482.98,10482.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],17480.31,17480.31,17480.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],295.93,295.93,295.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,1534.06,1534.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14.48,14.48,14.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, methylpred sod succ 5mg",801,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,461.34,461.34,461.34,1 through 10,percent of total billed charges,,,
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, magtrace per study dose",814,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],88.16,88.16,142.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Euflexxa inj per dose,875,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],4828.54,4828.54,4828.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7895.88,4561.27,15640.42,39,percent of total billed charges,,,
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2290.74,1415.91,2292.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1411.64,978.78,1601.51,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1760.07,437.03,2051.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1837.47,1782.76,2186.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1416.71,1061.24,1945.67,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1772.29,1766.2,2334.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1769.06,532,2087.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2885.6,1906.23,3050.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1065.63,1065.63,1065.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Injection,onabotulinumtoxinA",902,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1399.24,1399.24,1399.24,1 through 10,percent of total billed charges,,,
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],817.84,817.84,817.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 5%, 250 ml",963,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,217.99,217.99,217.99,1 through 10,percent of total billed charges,,,
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Albumin (human), 25%, 50ml",965,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3536.38,3536.38,3536.38,1 through 10,percent of total billed charges,,,
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1826.9,1826.9,1826.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
AbobotulinumtoxinA,1289,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",606.64,363.68,766.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Darbepoetin alfa, esrd use",1482,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],26374.77,26374.77,26374.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj vedolizumab iv 1 mg,1489,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2537.75,1753.08,3236.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],7065.68,3311.53,11018.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,6636.71,4133.95,12181.87,34,percent of total billed charges,,,
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1869.52,1755.87,3523.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,4397.37,4397.37,4397.37,1 through 10,percent of total billed charges,,,
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],1668.3,1668.3,1668.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,4099.86,4099.86,9762.3,1 through 10,percent of total billed charges,,,
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",910.57,910.57,910.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",570.81,570.81,570.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],3489.27,3489.27,3489.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2511.51,2511.51,2511.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1428.72,701.61,1543.97,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2336.98,1637.33,3393.92,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],8172.75,3406.62,15323.35,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],5335.77,5335.77,5335.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],965.83,965.83,965.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],12004.39,8065.91,20139.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",857.6,857.6,857.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 8 ($601 - $700),1508,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7303.48,4727.36,11799.24,12,percent of total billed charges,,,
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,8944.63,8944.63,8944.63,1 through 10,percent of total billed charges,,,
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",454.8,454.8,454.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,191.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,191.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",458.19,458.19,458.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],3007.95,3007.95,3007.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],12370.21,12370.21,12370.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,191.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 11 ($901 - $1000),1511,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1922.98,1868.48,1972.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],11203.14,11203.14,11203.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,11109.86,10139.43,11572.04,81,percent of total billed charges,,,
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1873.84,1796.47,1892.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,11088.09,11088.09,11088.09,1 through 10,percent of total billed charges,,,
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1047.58,1047.58,1047.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,11585.94,11585.94,11585.94,1 through 10,percent of total billed charges,,,
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10028.27,10028.27,10028.27,1 through 10,percent of total billed charges,,,
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1802.82,1802.82,1876.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,11306.18,11306.18,11306.18,1 through 10,percent of total billed charges,,,
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1069.07,1069.07,1069.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1047.58,1047.58,1047.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3446.98,3446.98,3446.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1058.11,1047.58,1075.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],5777.25,4991.68,5801.8,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],5794.91,5794.91,5794.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1877.34,1616.81,1886.48,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],7253.49,7253.49,10260.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1879.84,1879.84,1879.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],14113.75,14113.75,14113.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1069.07,1069.07,1069.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 21 ($1901-$2000),1521,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2268.94,2225.7,2270.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,12052.71,12052.71,12052.71,1 through 10,percent of total billed charges,,,
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,15489.9,12018.74,17130.9,31,percent of total billed charges,,,
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2160.89,2071.04,2162.89,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,17110.78,17110.78,17110.78,1 through 10,percent of total billed charges,,,
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,16751.34,16751.34,16751.34,1 through 10,percent of total billed charges,,,
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1231.02,1231.02,1231.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1206.27,1206.27,1206.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],3968.98,3968.98,3968.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1206.27,1206.27,1206.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3968.98,3968.98,3968.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1206.27,1206.27,1231.02,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2163.89,1931.29,2170.89,96,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],6377.39,6214.9,6394.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],6377.77,4462.68,6403.57,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],6387.49,6387.49,6387.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],11991.11,11991.11,16839.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 22 ($2001-$2500),1522,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7661.23,7661.23,7661.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 32 ($7001-$7500),1532,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],21320.65,21320.65,21320.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],8905.43,8905.43,8905.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,29928.7,29928.7,29928.7,1 through 10,percent of total billed charges,,,
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],8891.99,8891.99,11838.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],65.8,65.8,65.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,41013.78,41013.78,41013.78,1 through 10,percent of total billed charges,,,
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str, HDR Ir-192",2646,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],100.02,12.95,332.1,1754,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],52.58,41.58,130.52,3474,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,118.1,35.64,434.64,26589,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,27.63,78.36,4156,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,105.3,37.12,469.91,456,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],49.5,49.5,123.73,7553,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],126.26,50.51,143.97,132,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,68.89,92.1,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,117.45,62.25,296.61,1733,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],118.27,49.5,126.26,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,114.8,91.84,305.92,2068,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],123.73,115.9,127.58,592,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,27.63,76.25,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,103,38.86,417.11,157,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,69.07,69.07,508.66,1 through 10,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],126.29,126.29,216.24,70,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,27.63,88.22,5278,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,69.07,57.25,172.74,40,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],123.73,115.9,127.58,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,27.63,76.25,7821,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],145,69.07,234.34,503,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,79.8,50.75,197.75,85,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,27.63,83.27,5932,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],103.94,97.35,129.92,646,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],104.76,22.68,306.92,661,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],49.5,46.36,123.73,62454,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,27.63,87.37,35342,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],81.99,28.65,331.14,15099,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],79.28,23.34,338.7,2476,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],79.28,23.54,244.44,802,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],90.83,28.4,305.56,1040,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],124.33,84.53,124.53,267,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],117.45,112.34,359.17,7657,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,27.63,85.2,3114,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,69.07,87.31,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinic Visits and Related Services,5012,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],132.57,132.57,132.57,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],47.19,47.19,47.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],187.92,121.89,277.02,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],86.27,86.27,86.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,187.92,56.03,453.69,150,percent of total billed charges,,,
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,197.95,197.95,197.95,1 through 10,percent of total billed charges,,,
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,46.27,47.19,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,187.92,187.92,187.92,1 through 10,percent of total billed charges,,,
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,183.67,183.67,183.67,1 through 10,percent of total billed charges,,,
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,47.19,47.19,47.19,1 through 10,percent of total billed charges,,,
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,46.27,47.19,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,46.27,47.19,110,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],77.64,77.64,77.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,46.27,47.19,105,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],117.29,47.19,155.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],86.27,47.19,120,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,46.27,47.19,436,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],73.19,68.26,276.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],153.28,153.28,153.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],184.42,47.19,805.58,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],230.42,119.75,11296.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],187.92,47.19,1040.98,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,46.27,47.19,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],675.43,250,12287.63,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],84.88,84.88,162.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],154.6,153.61,201.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,725.29,409.36,3454.96,1 through 10,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,590.31,101.01,791.46,336,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84.88,84.88,85.24,127,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,559.71,192.91,689.31,14,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,673.74,437.66,1168.21,12,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,84.88,84.88,84.88,1 through 10,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84.88,84.88,85.24,74,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,85.24,85.24,85.24,1 through 10,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84.88,84.88,85.24,169,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],279.29,279.29,279.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],120.46,120.46,127.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84.88,84.88,85.24,162,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3766.89,3766.89,3766.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84.88,84.88,85.24,717,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],154.46,34.46,160.94,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],576.46,200,730.74,205,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],443.46,85.24,7998.42,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],453.55,187.4,7684.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],612.18,385.07,799.87,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],96.29,96.29,96.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],689.31,118.14,5416.99,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.24,85.24,85.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84.88,84.88,85.24,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],171.35,156.65,430.81,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],889.52,272.1,1171.85,622,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],268.36,234.76,459.97,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,885.84,352.92,1207.75,5926,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148.41,148.41,224.86,1791,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,875.5,148.41,1337.36,76,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",75.8,25,75.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],271.29,271.29,271.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148.7,148.41,224.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,908.82,306.62,1257.29,251,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,891.66,310.63,1218.05,204,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",310.8,310.8,310.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],158.74,158.06,559.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,693.17,501.32,1018.27,29,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,356,356,356,1 through 10,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148.41,148.41,224.86,920,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,148.7,148.41,901.06,1 through 10,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],168.64,168.64,168.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],366.24,209.47,579.24,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148.41,148.41,224.86,2246,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,545.38,414.05,670.84,1 through 10,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],223.73,223.32,419.48,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148.41,148.41,224.86,2196,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],459.5,148.41,648.26,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148.41,148.41,224.86,9936,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],268.26,152.17,481.5,521,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],622.87,223.71,1036.51,261,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],891.88,261.42,1193.71,3544,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],900.96,504.38,1235.21,336,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],741.31,148.41,963.66,161,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],158.74,158.06,360.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],908.82,200,1224.61,721,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148.41,148.41,224.86,1056,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148.41,148.41,148.7,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1770.85,798.82,2631.01,584,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],572.26,279.15,963.7,197,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1912.32,996.46,3067.75,6447,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],612.17,403.98,933.21,222,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",267.91,267.91,267.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",275.43,228.24,415.36,965,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1861.97,230.83,3225.01,102,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],637.22,417.21,767.12,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",230.83,230.83,232.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1903.5,484.51,2858.67,250,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],626.98,388.48,931.88,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1902.99,1056.14,3014.82,205,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",244.37,244.37,244.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1855.75,1062.45,3372.58,40,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",244,228.24,419.66,696,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,275.43,228.24,1591.3,11,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],626.48,626.48,626.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",244,228.24,395.44,1403,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],770,558.61,1677.82,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,1083,842.38,1934.36,12,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",241.15,228.24,415.36,1262,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],750.98,228.24,1603.87,116,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],510.79,343.45,914.69,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",259.73,228.24,418.02,6516,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1355.23,412.56,2628.88,370,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],578.67,393.38,957.46,2240,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1901.48,982,3228.02,3927,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1531.21,708.99,2435.45,184,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2002.31,1020.92,2995.2,358,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],411.07,301.75,763.85,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1899.16,688.41,3243.11,770,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",230.83,228.24,376.65,652,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",228.24,228.24,323.66,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1033.67,584.39,2595.03,209,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2919.78,1343.49,6129.26,295,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1136.98,682.94,2822.61,310,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3266.72,1629.74,6756.76,2929,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",520.04,330.73,1419.5,331,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2414.95,891.15,5712.41,49,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],983.82,601.4,2620.62,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",328.62,328.62,462.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3264.52,1474.88,6290.23,97,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,3314.63,1476.33,6275.17,89,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1039.23,714.88,2728.48,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,3165.73,2478.89,9102.41,21,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],204.58,204.58,204.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",515.74,328.62,1419.5,263,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,2538.48,2538.48,2900.29,1 through 10,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2709.05,1255.2,3386.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",513.87,328.62,1700,518,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1608,555.64,3306.16,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,1767,1381.68,3500.89,1 through 10,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1176.11,617.9,2674.58,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",513.79,328.62,1900,448,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1623.87,712.04,3535,101,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",542.23,328.62,1420.8,2317,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1079.59,683.46,2740.53,2860,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2585.02,1000,6644.66,243,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],3419.06,1769.44,7890.28,1756,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3179.17,1757.19,8043.75,158,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2931.6,1027.13,7945.02,99,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1577.26,767.73,3228.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3361.79,1450,6589.41,357,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",328.62,328.62,330.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",518.59,328.62,1421.06,278,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2906.47,2780.92,3411.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],13585.38,13585.38,13585.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,12234.4,2991.8,20328.92,41,percent of total billed charges,,,
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2608.69,1246.23,4251.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1429.67,1429.67,1429.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],2594.19,2594.19,2594.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3959.49,3959.49,3959.49,1 through 10,percent of total billed charges,,,
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,13950.78,13950.78,13950.78,1 through 10,percent of total billed charges,,,
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10367.35,10367.35,10367.35,1 through 10,percent of total billed charges,,,
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,1608,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1486.78,734.16,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1521.82,1521.82,1608,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],3413.37,3413.37,3413.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2720.5,2385.58,4669.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1546.07,1427,4341.26,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3232.02,1813.16,3473.99,98,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],7976.49,6440.24,12010.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],11941.51,6998.35,19428,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],23048.45,23048.45,23048.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],10203.36,10140.09,16418.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],14905.28,10264.93,27305.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1460.84,1460.84,1460.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],19782.22,19782.22,19782.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,25112.44,25112.44,25112.44,1 through 10,percent of total billed charges,,,
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2604.8,2604.8,2604.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,8664.82,8664.82,8664.82,1 through 10,percent of total billed charges,,,
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",991.81,991.81,1704.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],11348.45,11348.45,11348.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Trauma Response with Critical Care,5045,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],330.24,129.92,330.74,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],144.99,49.6,3921.02,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,141.73,70.3,406.62,220,percent of total billed charges,,,
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],314.52,190.79,314.52,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",173.23,106.5,191.38,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,161.96,161.96,161.96,1 through 10,percent of total billed charges,,,
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],320.94,320.94,320.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,288.87,201.41,612.03,1 through 10,percent of total billed charges,,,
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,422.69,422.69,422.69,1 through 10,percent of total billed charges,,,
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,300.91,292.14,8540.08,1 through 10,percent of total billed charges,,,
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],230.39,190.79,291.44,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",175.57,106.5,175.57,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],212.42,212.42,212.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",175.57,109.39,175.57,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],350.42,330.42,470.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],264.2,201.14,264.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",175.57,106.5,175.57,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",175.57,106.5,175.57,180,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],314.52,190.79,314.52,729,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],126.44,90.09,630.45,75,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],152.26,84.87,745.21,200,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],157.44,90.09,653.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],105.05,90.09,210.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],262.44,117.45,381.71,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",175.57,173.23,175.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],767.89,319.14,1385.55,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],503.32,406.8,533.22,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,557.49,291.5,2100.81,153,percent of total billed charges,,,
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],456.56,349.62,508.13,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",283.22,283.22,356.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,367.91,367.91,734.2,1 through 10,percent of total billed charges,,,
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,572.79,165.11,2046.74,11,percent of total billed charges,,,
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],337.88,337.88,337.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,4423.37,4423.37,4423.37,1 through 10,percent of total billed charges,,,
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,994.89,579.95,1857.03,12,percent of total billed charges,,,
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",283.22,218.37,356.52,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],731.88,731.88,731.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",283.22,214.15,447.44,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],704.61,598.92,704.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],3.23,3.23,3.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",283.22,214.15,362.56,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",283.22,207.82,356.52,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],382.26,208.83,956.65,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],430.56,164.35,514.35,270,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],414.1,311.97,1282.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],512.73,258.43,1376.05,138,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],292.31,231.53,13044.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],477.95,477.95,477.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],873.09,472.25,10551.42,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",276.71,214.15,362.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],717.67,717.67,717.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2813.13,2813.13,2813.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2411.82,782.99,12570.2,55,percent of total billed charges,,,
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],593.25,441.98,866.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",328.5,327.32,558.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2644.17,2644.17,2943.71,1 through 10,percent of total billed charges,,,
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],591.75,591.75,591.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",397.17,397.17,669.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],869.66,869.66,869.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",397.17,397.17,620.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",556.34,556.34,694,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],809.66,809.66,2000.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",476.51,328.1,710.13,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],620.09,261.93,1069.95,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1912.51,1912.51,3465.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1625.89,499.99,12993.37,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3157.52,2433.67,4691.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2788.89,2788.89,16908.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2476.2,1671.97,8946.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",605.57,556.34,992.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],9212.47,9212.47,12546.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,6178.26,2078.28,20019.1,57,percent of total billed charges,,,
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2404.19,1620.68,2685.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,4083.32,4083.32,4083.32,1 through 10,percent of total billed charges,,,
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1251.6,1251.6,1251.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,12324.5,12324.5,12324.5,1 through 10,percent of total billed charges,,,
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,6400.95,166.83,18295.5,11,percent of total billed charges,,,
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",980.47,980.47,1087.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],4839.82,4839.82,4839.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1383.12,981.01,1472.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],3.23,3.23,3.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3209.33,3209.33,3209.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1704.02,1704.02,6635.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1049.54,980.47,1471.51,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2581.91,398.45,6009.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2848.55,779.93,8885.16,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2128.01,1768.9,2698.03,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2569.01,2563.91,9032.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],9814.79,6975.18,12338.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",981.01,981.01,981.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,8133.89,2772.83,19495.35,15,percent of total billed charges,,,
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2333.75,2333.75,2333.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2471.4,2471.4,2471.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1962.28,1962.28,1962.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3556.08,3556.08,3556.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1962.68,1869.79,4324.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],8399.28,3320.9,20629.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],19261.23,19261.23,19261.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],25336.84,25336.84,25336.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],13428.74,13428.74,13428.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6673.35,6673.35,6673.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],13374.72,13374.72,13374.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6620.38,996.67,10162.97,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,13280.05,2786.4,32272.65,12,percent of total billed charges,,,
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",295.66,295.66,295.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2587.02,1182.64,5328.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",595.54,595.54,1597.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1945.58,1945.58,1945.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4226.58,2148.96,11461.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3547.92,2069.62,5881.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],973.34,529.63,9533.34,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],8667.12,2865.28,13610.08,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],31207.68,6240.47,40990.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hyperbaric Oxygen,5061,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],709.35,284.33,839.27,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],987.66,654.84,7424.47,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1412.41,738.11,5864.73,521,percent of total billed charges,,,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",410.2,366.69,1098.96,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],681.07,516.07,801.69,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1586.98,909.83,3552.72,1 through 10,percent of total billed charges,,,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,858.44,684.72,2795.31,13,percent of total billed charges,,,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],761.49,761.49,761.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1610.75,736.62,3079.47,16,percent of total billed charges,,,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],681.57,681.37,681.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,670.92,670.92,670.92,1 through 10,percent of total billed charges,,,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",377.12,150.85,530.35,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1240.85,1065.56,1380.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",377.12,150.85,525.53,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],567.48,567.48,709.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",377.12,150.85,541.17,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1240.85,913.48,1240.85,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],682.57,275.75,805.8,518,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",377.12,150.85,566.48,154,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1165.58,604.76,2715.49,389,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],996.2,364.27,2537.74,77,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1247.42,236,2697.94,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1021.47,185,2238.5,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1745.06,604.36,9285.91,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",366.69,150.85,484.2,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],3461.8,2142.17,7526.86,98,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1633.51,1286,1740.66,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3824.01,2306.17,7814.62,1232,percent of total billed charges,,,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1555.73,627.8,1637.35,72,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,3838.73,2370.38,6034.09,31,percent of total billed charges,,,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",868.45,868.45,910.08,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],1587.48,1587.48,1587.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,4002.25,1670.49,5988.21,41,percent of total billed charges,,,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1641.65,1641.65,1641.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1561.73,1506.02,1638.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,4637.72,2838.8,10541.12,34,percent of total billed charges,,,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,4446.04,1814.61,7900.52,11,percent of total billed charges,,,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",868.45,844.98,910.08,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",868.99,868.45,928.88,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],2857.46,1498.63,2997.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1306.81,1306.81,1534.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",868.45,844.98,921.46,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2611.04,1274.17,2997.27,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",868.64,844.98,910.43,269,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2755.13,908.83,3819.44,200,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1562.23,943.23,1652.62,839,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2775.28,1279.72,5217.38,834,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2872.41,1162.64,6069.52,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2775.28,1279.72,3952.23,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1652.42,1652.42,1652.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3896.6,2378.23,6270.47,124,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",868.45,844.98,910.08,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4940.76,4940.76,4940.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],6622.25,4311.69,11794.31,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2885.5,2308.4,3180.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7815.17,2511.3,13213.21,293,percent of total billed charges,,,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2748.1,2478.6,2757.45,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,5857.4,3220.75,18801.53,1 through 10,percent of total billed charges,,,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,1534.06,1534.6,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,5016.47,3286.56,11894.57,12,percent of total billed charges,,,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2542.31,2542.31,2542.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,8004.04,5732.71,10091.63,13,percent of total billed charges,,,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,6233.06,6233.06,6233.06,1 through 10,percent of total billed charges,,,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,1480.92,1534.6,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,1480.92,1534.86,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],3674.98,3674.98,3674.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,3423.15,3423.15,3423.15,1 through 10,percent of total billed charges,,,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,1485.22,1534.6,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],2308.97,2308.97,2308.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5047.52,5047.52,7034.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.22,1480.92,1536.17,109,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],5117.05,2217.83,8600.78,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2753.7,2429.6,2775.49,189,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],5849.79,1988.65,8701.29,175,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],8611.58,1630.75,11188.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],4967.47,1774.26,7848.23,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2748.1,2748.1,2748.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],7250.32,5059.55,12490.4,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.33,477.44,1534.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3870.39,3860.65,3996.05,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],11023.86,7884.49,25300.51,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,5882.99,2969.83,17288.72,277,percent of total billed charges,,,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3692.69,3428.12,6274.27,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2056.7,2052.49,3495.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,9057.22,7632.89,19436.17,1 through 10,percent of total billed charges,,,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,10123.94,8785.06,20117.71,1 through 10,percent of total billed charges,,,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3676.81,3676.81,3676.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10163.96,8301.27,27222.88,1 through 10,percent of total billed charges,,,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,23079.65,23079.65,23079.65,1 through 10,percent of total billed charges,,,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2052.89,2052.49,3398.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2052.49,2052.49,2052.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],6762.53,6762.53,6762.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2053.29,2053.29,3495.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6753.33,5934.15,10502.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2052.49,2052.49,3495.5,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3698.27,3358.31,6261.81,171,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],3208.14,2165.95,13637.55,159,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3280.88,2212.55,9824.47,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2955.19,2349.83,14526.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3993.91,2261.62,7089.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],12635.64,8165.02,20917.65,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3503.93,3503.93,3503.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6725.15,6725.15,6725.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],23633.64,20159.11,31387.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,11858.66,7280.58,26623.93,222,percent of total billed charges,,,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6289.47,6273.36,9902.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3495.5,3495.5,3503.93,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,17987.26,8846.15,19190.82,1 through 10,percent of total billed charges,,,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,22768.12,22475.42,28937.76,1 through 10,percent of total billed charges,,,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,19363.83,18723.32,23431.49,1 through 10,percent of total billed charges,,,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,22697.1,22697.1,22697.1,1 through 10,percent of total billed charges,,,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,13832.98,13832.98,13832.98,1 through 10,percent of total billed charges,,,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3495.5,3495.5,3506.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3495.69,3398.64,5769.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3495.87,3495.5,8449.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],539.25,539.25,634.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3495.5,3398.64,3496.3,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],6718.05,3542.22,20110.5,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6272.79,5724.25,6353.67,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],6962.53,5581.24,30372.63,91,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],7801.78,6718.05,33403.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],10678.67,10678.67,21811.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],20497.75,15849,30175.72,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3495.5,3398.64,4830.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],18122.32,18122.32,18122.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,16821.65,7299.99,28829.98,20,percent of total billed charges,,,
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],8265.42,8265.42,8265.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,29002.79,29002.79,29002.79,1 through 10,percent of total billed charges,,,
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],16876.01,16876.01,16876.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5129.01,5129.01,5129.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],9198.98,8845.05,9210.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3662.66,3662.66,20990.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],13811.32,12546.33,36116.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],13406.33,13406.33,13406.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],33258.01,23829.12,39039.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],44427.44,44427.44,55172,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,31980.92,12773.02,79858.57,43,percent of total billed charges,,,
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],16715.11,16715.11,16715.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9184.14,9184.14,9184.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,10208.65,10208.65,10208.65,1 through 10,percent of total billed charges,,,
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,200,200,200,1 through 10,percent of total billed charges,,,
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9325.52,9325.52,9325.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9325.52,9325.52,9325.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],16494.17,16387.13,17055.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],31249.25,21252.58,74604.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],31151.35,15373.32,73062.11,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],48699.46,48699.46,48699.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],39160.74,29972.84,77795.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],160,160,160,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],267.58,267.58,267.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,269.04,122.08,474.77,54,percent of total billed charges,,,
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",153.65,153.65,195.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],254.06,138.16,275.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,158.09,158.09,158.09,1 through 10,percent of total billed charges,,,
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,416.07,416.07,416.07,1 through 10,percent of total billed charges,,,
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",153.65,82.12,153.65,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",192.07,69.07,195.94,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",153.65,69.07,195.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",164.24,151.01,195.94,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],20.45,20.45,457.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],254.06,138.16,350.99,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],310.62,139.63,310.62,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],230.45,129.09,254.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],178.61,124.25,357.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],592.22,193,592.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",153.65,153.65,195.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],269.73,245,459.78,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],397.68,397.68,398.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,280.32,174.56,520.68,205,percent of total billed charges,,,
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],378.74,238.9,378.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",211.42,142.75,282.6,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,387.18,270.42,541.08,1 through 10,percent of total billed charges,,,
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,257.08,257.08,257.08,1 through 10,percent of total billed charges,,,
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,558.9,378.44,651.57,1 through 10,percent of total billed charges,,,
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],378.74,378.74,378.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",211.42,142.67,278.84,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",211.42,142.35,211.42,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,233.8,233.8,233.8,1 through 10,percent of total billed charges,,,
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],468.38,468.38,468.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",142.35,139.97,211.42,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",211.42,142.35,211.42,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],382.24,175.41,476.99,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],272.54,201.2,302.64,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],341.01,137.05,507.14,120,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],264.7,176.01,345.54,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],608.81,304.41,4025.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],387.18,249.48,786.51,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",211.42,211.42,282.6,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",282.6,282.6,282.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],371.76,371.76,372.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],217.98,132.57,483.89,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,227.93,170.48,564.15,415,percent of total billed charges,,,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],354.06,326,354.06,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",197.65,192.87,197.65,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,207.99,128.58,465.18,1 through 10,percent of total billed charges,,,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,335.43,212.6,799.47,19,percent of total billed charges,,,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,327.85,128.58,690,1 through 10,percent of total billed charges,,,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,286.56,225.73,964.23,1 through 10,percent of total billed charges,,,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],447.58,447.58,447.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,128.58,128.58,128.58,1 through 10,percent of total billed charges,,,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",197.65,191.8,197.65,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",197.65,128.58,197.65,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],650.32,650.32,650.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,152.98,144.94,219.49,1 through 10,percent of total billed charges,,,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],297.41,297.41,297.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",197.65,128.58,213.46,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],319.11,317.29,423.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",197.65,191.8,208.15,214,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],354.53,123.73,358.76,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],213.92,168.6,504.14,265,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],213.92,139.7,452.84,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],246.01,147.61,495.38,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],192.99,142.24,454.56,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],350,195.72,813.19,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",122.91,122.91,122.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",197.65,191.8,197.65,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],3857.64,2787.21,6263.92,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1294.05,1290.82,1613.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3217.02,1493.66,6601.57,347,percent of total billed charges,,,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1539.19,1536.69,1551.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",857.82,857.82,859.93,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,7123.03,7123.03,12527.78,1 through 10,percent of total billed charges,,,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",858.36,858.36,858.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3495.06,1995.27,5037.16,1 through 10,percent of total billed charges,,,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1542.69,1542.69,1542.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,3509,3509,3509,1 through 10,percent of total billed charges,,,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,9372.4,6326.45,14881.79,1 through 10,percent of total billed charges,,,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",857.82,857.82,857.82,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",857.82,837.64,868.36,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],25,25,25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,1499.04,1433.07,1553.87,1 through 10,percent of total billed charges,,,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2257.53,1511.8,2824.29,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1506.24,1506.24,1506.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",857.82,837.64,858.62,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",857.82,837.64,858.2,140,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1543.19,1419.09,1558.14,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2117.38,1084,3959.56,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2786.61,1357.18,4313.63,201,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3069.93,1838.75,5730.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2148.88,1155.8,3013.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3849.79,2539.76,7369.83,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",857.82,857.82,858.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],7700.52,5337.2,12774.22,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3034.29,2616.95,3467.78,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3853.17,2148.43,14394.49,618,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3120.14,2855.16,3186.83,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1739.11,1686.96,1739.91,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,8448.15,8448.15,8792.89,1 through 10,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,7874.03,4308.75,12545.27,25,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,8700.02,6790.74,12979.01,1 through 10,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,9077.53,6844.9,16168.96,16,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],3300.41,3300.41,3300.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1739.38,1686.96,1745.43,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3123.27,3123.27,3123.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,13777.98,13777.98,13777.98,1 through 10,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1739.11,1686.96,1790.07,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],5522.2,5212.85,5722.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,17574.05,17574.05,17574.05,1 through 10,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],5761.8,5761.8,5761.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1739.11,1686.96,1745.43,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5722.2,4291.65,10203,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1739.11,1686.96,1747.54,172,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3123.01,2772.42,6245.22,253,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],3075.72,2086.89,8095.26,354,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2974.58,1287.4,7562.82,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3594.29,2568.44,8170.03,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3075.72,2119.63,8770.08,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3122.76,3122.76,3122.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],9125.55,5740.16,19650.23,79,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1739.48,1686.96,1789.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3053.07,3053.07,3053.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6938.29,6586.43,7261.39,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],18523.73,9556.25,30841.76,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7785.49,4992.49,26734.31,955,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6865.13,6142.07,6934.67,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3829.52,3829.04,3933.21,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,18834.84,6344.83,38938.91,18,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,20622.6,8491.65,29207.05,33,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,15412.37,13256.21,17478.89,1 through 10,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,19120.5,11895.53,28337.39,23,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],6872.52,6872.52,6962.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,23888.94,23888.94,23888.94,1 through 10,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3829.23,3728.53,3863.85,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,15491.76,15491.76,32912.95,1 through 10,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],10498.92,6486.1,12635.95,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3829.41,3781.15,5744.85,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,10651.65,10651.65,10651.65,1 through 10,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],10377.79,5765.03,10445.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],11369.95,9240.89,12619.92,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3829.36,3728.53,4031.64,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3829.41,3728.53,3950.25,226,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10025.28,4754.69,19641.76,543,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],8473.04,4150.96,14289.14,87,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6871.63,6250.32,7143.06,289,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],9908.17,4084.95,18010.7,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],8687,3000,20118.67,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6867.03,6867.03,6867.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],19355.22,11473.5,31544.79,99,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3829.36,3728.53,3829.84,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],13009.84,10559.51,13434.17,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],29028.04,17363.7,34580.63,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,30126.49,14370.46,38808.96,535,percent of total billed charges,,,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],12571.91,11863.08,12830.47,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6896.62,6896.62,7356.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,29976.63,19955.61,39153.52,16,percent of total billed charges,,,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,29718.07,24326.45,36324.27,22,percent of total billed charges,,,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,30037.99,25816.85,38807.88,17,percent of total billed charges,,,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],12586.16,12425.14,13023,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,32460.47,32071.76,41299.64,1 through 10,percent of total billed charges,,,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6897.02,6859.28,6998.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6900.84,6896.62,7000.88,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],22691.97,17622.14,22962.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6911.85,6896.62,6999.84,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],10536.44,10447.31,10557.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],22691.97,16297.1,23040.24,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6902.94,6896.62,7000.34,130,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],18787.24,15229.28,22277,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],12502.07,11774.25,12832.06,950,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],18787.24,11792.86,29833.22,344,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],18169.48,4309.64,25032.06,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],18787.24,16771.16,21605.33,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],12321.52,12321.52,12321.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],29642.48,23087.72,36862.88,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6897.7,6896.78,7005.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],18276.13,3531.6,22834.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],52440.96,22227.2,76956.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,45063.13,22479.2,76540.23,94,percent of total billed charges,,,
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],17689.31,17388.34,18536.52,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9857.07,9857.07,10059.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],16770.96,16770.96,16770.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,86148.52,70692.29,103310.72,1 through 10,percent of total billed charges,,,
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,29234.56,29165.52,39839.61,1 through 10,percent of total billed charges,,,
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9857.07,9712.69,11004.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],32091.56,32091.56,32091.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9908.75,9857.07,9917.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],14997.67,14997.67,14997.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],31244.88,27153.71,32444.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9959.17,9765.8,11681.73,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],17698.56,16361.78,18692.02,257,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],48580.6,24641.46,65334.88,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],51039.93,21078.05,81224.16,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],32910.55,32910.55,38072.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],30597.92,30467.18,51320.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],17624.84,17624.84,17624.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],46079.9,33890.06,72097.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],325.65,325.65,326.97,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],443.88,386.37,443.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,427.6,377.69,1092.74,163,percent of total billed charges,,,
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],310.14,289.59,310.14,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,427.6,427.6,587.68,11,percent of total billed charges,,,
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",173.13,173.13,173.13,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,576.72,576.72,1020.6,1 through 10,percent of total billed charges,,,
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,563.69,563.69,1184.37,1 through 10,percent of total billed charges,,,
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],310.14,310.14,310.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,431.28,431.28,969.24,1 through 10,percent of total billed charges,,,
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",173.13,173.13,173.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],310.14,310.14,310.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",173.13,172.13,173.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",173.13,172.13,225.16,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],342.38,273.9,342.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],260.52,260.52,260.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],435.61,285.56,851.09,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",173.13,172.13,173.13,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],435.61,377.69,1153.45,116,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],313.94,166.29,313.94,261,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],449.92,197.61,841.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],362.06,362.06,373.95,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],576.72,576.72,1276.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",173.13,173.13,173.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],557.7,557.7,557.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],643.14,643.14,1358.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,664.32,495.66,1143.93,72,percent of total billed charges,,,
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],473.06,430.71,522.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",270.83,270.83,270.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,824.58,824.58,824.58,1 through 10,percent of total billed charges,,,
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,805.95,805.95,805.95,1 through 10,percent of total billed charges,,,
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",294.59,294.59,300.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",294.59,263.44,396.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",300.83,268.91,355.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],684.83,684.83,702.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",294.59,268.91,410.7,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],238.15,238.15,809.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],495.62,379.85,662.78,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],238.15,214.33,728.45,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],664.01,664.01,664.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],824.58,682.72,995.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Airway Endoscopy,5152,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],24933.74,24933.74,24933.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1390.87,1390.87,1390.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,8362.46,105.51,16777.53,54,percent of total billed charges,,,
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",924.32,924.32,924.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,6473.07,6473.07,8232.87,1 through 10,percent of total billed charges,,,
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",924.32,924.32,1414.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,9317.04,9317.04,9317.04,1 through 10,percent of total billed charges,,,
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",924.32,884.58,1976.21,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3041.28,3041.28,3041.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",924.32,924.32,924.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",924.32,924.32,1976.21,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4767.13,2696.16,7581.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1501.3,1043.31,1666.5,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],13446.03,13446.03,15015.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1659.3,125.39,12519.88,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3090.17,3090.17,3090.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],10134.87,6892.02,17053.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",924.32,924.32,1414.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,13677.81,8398.58,17787.57,33,percent of total billed charges,,,
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1951.72,1951.72,1951.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,15352.45,15352.45,15352.45,1 through 10,percent of total billed charges,,,
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",30432.89,30432.89,30432.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1976.21,1976.21,1976.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6502.32,6502.32,6502.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1976.21,1976.21,2466.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1976.21,1951.72,2466.67,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3543.65,3543.65,3543.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],9227.05,9227.05,9227.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],7738.55,6439.6,15331.95,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],4116.33,4116.33,4116.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],6935.53,6935.53,6935.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],12452.71,8207.75,16349.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1976.21,1976.21,1976.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],14040.8,9249.47,22555.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,11707.33,4880.7,26253.45,33,percent of total billed charges,,,
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3710.44,3710.44,3710.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,13118.1,13118.1,13118.1,1 through 10,percent of total billed charges,,,
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,25050.84,25050.84,25050.84,1 through 10,percent of total billed charges,,,
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3710.44,3710.44,3710.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3710.44,3710.44,3748.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3710.44,3567.09,3710.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3710.44,3710.44,3712.06,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6666.22,6648.85,6726.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],17989.32,17989.32,19231.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10481.72,2696.16,29154.93,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],15497.85,15497.85,15497.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],19699.51,18706.63,32190.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1484.47,1484.47,1484.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],8686.44,7239.6,12786.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,11541,8282.61,16283.28,88,percent of total billed charges,,,
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],216.94,216.94,216.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2300.54,2300,2300.54,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,9046.26,7511.17,13669.63,1 through 10,percent of total billed charges,,,
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,11045.81,11045.81,11045.81,1 through 10,percent of total billed charges,,,
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,10357,10357,10357,1 through 10,percent of total billed charges,,,
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2300.38,2300,2311.05,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2300.32,2300,2304.03,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2300.4,2300,2323.33,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],409.91,409.91,409.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2300.38,2300,2320.03,109,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10223.44,7045.88,15199.08,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],469.58,469.58,469.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],12752.95,12752.95,12752.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],12713.48,12713.48,12713.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],12284.27,6202.64,17618.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2300.4,2300,2304.57,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1727.83,867.46,10924.79,1 through 10,percent of total billed charges,,,
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",786.43,786.43,786.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",571.11,571.11,571.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",501.2,501.2,614.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",616.24,548.39,1637.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],712.41,712.41,1115.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10095.12,4652.41,14919.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],14340.63,14340.63,14340.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],8939.65,8939.65,8939.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",638.86,638.86,638.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2167.59,2167.59,2167.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],5726.87,3531.4,7635.78,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,5998.12,1739.03,7905.66,371,percent of total billed charges,,,
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1422.3,1422.3,1422.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,7213.22,7213.22,10366.79,1 through 10,percent of total billed charges,,,
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",793.97,793.97,794.82,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,4432.56,1886.73,6866.27,1 through 10,percent of total billed charges,,,
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,6295.6,6295.6,6295.6,1 through 10,percent of total billed charges,,,
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,4505.84,3569.06,7443.74,11,percent of total billed charges,,,
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",793.97,793.97,794.82,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,2285.47,2285.47,2285.47,1 through 10,percent of total billed charges,,,
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",793.97,793.97,794.82,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1194.74,1194.74,1194.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",793.97,793.97,794.82,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1959.29,900.31,2612.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",793.97,793.97,794.82,189,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2696.16,1125.26,5392.32,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1429.3,1342.88,1493.47,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2696.16,1259.41,3272.75,239,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2696.16,793.97,3115.39,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2426.54,793.97,3661.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],6694.55,4232.26,8028.54,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",793.97,793.97,794.82,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2821.18,2821.18,2821.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],8199.04,5876.85,15021.17,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7499.95,2067.28,11728.5,338,percent of total billed charges,,,
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3119.45,3119.45,3119.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,9538.8,9538.8,9538.8,1 through 10,percent of total billed charges,,,
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1738.29,1738.29,1738.29,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1738.29,1738.29,1738.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,8272.79,7742.33,15404.54,1 through 10,percent of total billed charges,,,
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,9472.15,7682.53,15443.68,1 through 10,percent of total billed charges,,,
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,6789.53,6789.53,9521.53,1 through 10,percent of total billed charges,,,
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1738.29,1677.99,1738.67,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1738.29,1677.99,2307.98,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],5720.74,5720.74,5720.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1738.29,1677.99,1738.29,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5719.5,5719.5,5719.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1738.29,1677.99,1738.29,142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3535.8,2576.26,9003.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],6783.13,2072.2,9840.24,187,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3120.45,1834.95,3138.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],4142.63,1738.29,7767.82,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],5913,4654.48,7440.08,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],8656.11,4653.93,11823.78,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1738.29,1738.29,1742.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],9792.42,6248.25,20140.44,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6030.05,6030.05,6030.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,10111.55,2738.09,20545.94,538,percent of total billed charges,,,
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5685.63,5602.11,6196.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,9628.38,9543.34,12074.05,1 through 10,percent of total billed charges,,,
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3170.79,3052.1,3170.79,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,11798.55,5949.64,24422.71,26,percent of total billed charges,,,
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,9537.59,6763.88,18623.43,13,percent of total billed charges,,,
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,6348.15,6348.15,6707.13,1 through 10,percent of total billed charges,,,
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],5386.13,5386.13,5386.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3170.79,3052.1,3170.98,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5484.13,5484.13,5484.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,9567.91,9567.91,9567.91,1 through 10,percent of total billed charges,,,
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3170.79,3170.79,3170.79,79,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],9431.23,9431.23,9431.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],10432.89,8264.82,10432.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3170.79,3170.79,3170.79,82,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3170.79,3052.1,3170.79,342,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5691.11,5219.03,5749.34,102,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],5257.11,3044.77,13715.19,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],5257.11,3691.06,14373.56,348,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],5257.11,4579.91,8452.44,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],6045.68,3805.69,14868.99,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5685.13,5685.13,5685.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],10202.26,7028,18211.11,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3052.1,3052.1,3052.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3170.79,3052.1,3170.79,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 ENT Procedures,5165,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],32076.42,32076.42,32085.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],142611.11,142611.11,142611.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,112817.51,93974.05,200028.38,1 through 10,percent of total billed charges,,,
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17049.26,17049.26,17049.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17049.37,17049.37,17049.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17048.99,17048.99,17048.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17048.99,17048.99,17048.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],71493.62,71493.62,71493.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],30553.38,442.39,30623.89,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],148221.84,125854.21,195677.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],194829.79,194829.79,194829.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],76884.87,76884.87,76884.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17477.42,17477.42,17477.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],623.33,498.66,730.54,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1191.46,1191.46,1191.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],683.68,678.18,717.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1221.13,622.63,8749.14,38,percent of total billed charges,,,
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2269.36,2269.36,2269.36,1 through 10,percent of total billed charges,,,
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",331.39,331.39,331.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,6275.38,6275.38,6275.38,1 through 10,percent of total billed charges,,,
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",381.66,381.66,381.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",469.53,469.53,469.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],436.14,436.14,436.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1090.37,1011.71,1635.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",327.41,132.55,331.39,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1342.37,1247.24,1759.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],600.64,271.59,897.47,117,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2793.47,2793.47,3905.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1361.96,1361.96,1756.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1408.66,593.35,5028.22,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1234.63,1234.63,1234.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",378.58,378.58,378.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1783.19,1699.31,9515.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1301.57,1301.57,1301.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1934.71,1282.41,10088.12,82,percent of total billed charges,,,
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1449.72,561.7,2752.68,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2111.79,2111.79,2111.79,1 through 10,percent of total billed charges,,,
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",832.64,832.64,832.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],1522.03,1522.03,1522.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1944.4,1748.21,3229.25,1 through 10,percent of total billed charges,,,
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1722.16,1722.16,1722.16,1 through 10,percent of total billed charges,,,
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1685.94,1685.94,1685.94,1 through 10,percent of total billed charges,,,
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",333.06,333.06,333.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6871.37,6871.37,6871.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",333.06,333.06,832.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1252.93,1252.93,1252.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2054.74,1478.84,2739.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",333.87,333.06,832.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],603.64,561.7,1526.59,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1025.43,304.81,2531.27,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",832.64,333.06,834.68,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1179.24,1179.24,2670.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1025.43,991.71,4753.91,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1907.82,1025.43,3133.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1963.44,1885.32,2043.87,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",832.64,832.64,832.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3173.29,1269.32,3184.27,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],6411.77,3538.03,8491.96,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2802.96,1208.87,3027.68,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,6441.07,3506.91,8514.07,234,percent of total billed charges,,,
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,7568.26,7076.96,7819.7,1 through 10,percent of total billed charges,,,
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1687.06,674.82,1687.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,6824.48,2851.87,9169.03,1 through 10,percent of total billed charges,,,
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,7419.85,7419.85,7553.96,1 through 10,percent of total billed charges,,,
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,8802.52,8802.52,8944.58,1 through 10,percent of total billed charges,,,
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],2800.63,2800.63,2800.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1687.06,1687.06,6544,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,7476.58,7476.58,7476.58,1 through 10,percent of total billed charges,,,
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1687.06,674.82,1689.17,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],5558.91,5558.91,5558.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1687.06,1661.24,9407.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],2538.63,2538.63,2934.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5322.55,2509.15,5550.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1687.06,674.82,1687.06,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4770.69,2629.27,7905.8,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2801.33,1211.34,3029.18,241,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],6300.43,2411.45,8279.13,142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],4367.74,2640.21,6426.11,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],7973.14,2550.2,9027.55,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],7793.65,4751.87,17102,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1687.06,1684.04,1710.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,15827.71,12537.89,22416.41,1 through 10,percent of total billed charges,,,
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8512.82,8512.82,8512.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2899.94,2899.94,2899.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2897.46,2897.46,2897.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5199.65,5197.88,5225.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],11542.82,9851.73,11979.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],11809.56,11809.56,11809.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,18935.17,13728.32,30417.91,19,percent of total billed charges,,,
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1726.11,1726.11,1726.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3088.34,3088.34,3088.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,17013.44,17013.44,17013.44,1 through 10,percent of total billed charges,,,
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,25405.86,25405.86,25405.86,1 through 10,percent of total billed charges,,,
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1726.11,1726.11,1726.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4300.77,4300.77,4300.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1698.29,1698.29,1698.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1726.11,1709.04,1730.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],12502.13,12502.13,12502.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3100.84,2014.93,3242.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],17658.28,15205.31,18608.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],16047.05,16047.05,16047.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],16615.21,16615.21,16615.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1734.53,1734.53,1734.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,34102.31,34102.31,34102.31,1 through 10,percent of total billed charges,,,
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],8930.99,8930.99,8930.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7984.92,7984.92,7984.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4909.71,3065.3,7619.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],15771.21,15771.21,15771.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,17955.55,10423.2,61930.12,1 through 10,percent of total billed charges,,,
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,32606.82,32606.82,32606.82,1 through 10,percent of total billed charges,,,
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,49735.55,49735.55,49735.55,1 through 10,percent of total billed charges,,,
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5733.55,5733.55,5733.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6080.66,6080.66,6080.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6089.08,6089.08,6251,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],18642.44,18642.44,18642.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],11649.84,11649.84,11649.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],22387.29,19989.25,114175.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],78505.95,78505.95,78505.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,58202.87,23374.81,81634.04,11,percent of total billed charges,,,
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,44388.67,44388.67,44388.67,1 through 10,percent of total billed charges,,,
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9626.91,9626.91,9626.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9626.91,9626.91,9626.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9624.8,9624.8,10853.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],32094.57,32094.57,32094.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10572.95,10572.95,10572.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9626.91,9624.8,9635.33,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],28862.29,22031.22,53845.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],19283.42,19283.42,19283.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],60834.61,60834.61,60834.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],64507.86,64507.86,64507.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9627.23,9627.23,9627.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,45666.28,35921.16,60768.02,1 through 10,percent of total billed charges,,,
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5550.71,5550.71,5550.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5525,5525,5525,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4067.22,4067.22,4067.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4071.43,4071.43,4071.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],32503.62,32503.62,32503.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],55000.21,55000.21,55000.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],52440.06,52440.06,52440.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,54555.19,47909.13,65852.37,21,percent of total billed charges,,,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13149.31,13149.31,13149.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13150.11,13150.11,13150.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,62701.91,62701.91,62701.91,1 through 10,percent of total billed charges,,,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13149.31,13149.31,13150.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13149.31,13149.31,13149.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],36954.55,36954.55,36954.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13149.31,13149.31,13149.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],23213.07,23213.07,23213.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13149.31,12378.17,13153.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],34402.78,34402.78,36471.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],45487.13,37819.6,51757.25,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2105.85,2105.85,2105.85,1 through 10,percent of total billed charges,,,
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,7448.84,7448.84,7448.84,1 through 10,percent of total billed charges,,,
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pacemaker and Similar Procedures,5221,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],793.11,793.11,793.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,38567.98,38567.98,38567.98,1 through 10,percent of total billed charges,,,
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5609.79,5609.79,5609.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],33065.71,33065.71,33065.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],49679.44,49679.44,49679.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],34492.04,34492.04,34492.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],30271.22,30271.22,30271.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],909.15,821.52,2507.01,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],875.35,703.98,9082.02,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1163.81,787.98,3521.16,345,percent of total billed charges,,,
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],670.45,598.13,1033.24,90,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",476.95,400.95,629.44,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1907.23,1019.84,4799.16,11,percent of total billed charges,,,
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,878.37,787.86,1115.51,1 through 10,percent of total billed charges,,,
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],598.13,598.13,1009.5,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",440.51,371.44,671.22,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",447.44,379.4,589.88,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],563.18,563.18,853.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1098.61,1098.61,1098.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",476.95,371.44,560.12,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],780.47,530.7,13491.49,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",400.95,371.44,719.54,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],679.02,561.83,1223.9,186,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1173.05,616.26,1788.3,146,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],634.76,422.88,1094.01,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1091.32,1091.32,1091.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],670.45,670.45,670.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1286.91,895.11,2897.18,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",371.44,364.35,379.4,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],764.63,137.88,2417.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,5177.08,1782.05,15202.91,55,percent of total billed charges,,,
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2077.94,2077.94,2078.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2305.2,2305.2,2305.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2267.89,1109.23,2336.78,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],6085.01,6085.01,6785.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1698.29,1698.29,2191.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2174.04,2174.04,2174.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1895.66,1536.7,2089.94,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],14084.43,14084.43,14084.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2492.23,2198.19,3100.88,107,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],14397.4,5062.1,16082.27,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],4231.24,3622.27,4956.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],8731.34,8731.34,8731.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,6509.4,5867.06,7642.87,93,percent of total billed charges,,,
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2787.11,2787.11,2787.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2856.18,2580.32,15901.13,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4498.63,4155.63,4700.93,143,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],7597.08,7579.29,7598.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],6351.83,5879,6972.34,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2022.14,1059.92,3876.53,127,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],945.24,680.64,1345.67,118,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1745.08,864.47,4540.36,1712,percent of total billed charges,,,
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",502.53,472.44,571.6,91,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],905.73,794.82,1355.84,132,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1471.65,839.16,4321.48,30,percent of total billed charges,,,
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],922.53,922.53,922.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1344.92,1080.31,3698.87,109,percent of total billed charges,,,
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],839.55,720.18,1356.35,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2372.04,1488.78,4309.72,63,percent of total billed charges,,,
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1262.29,502.53,3603.2,1 through 10,percent of total billed charges,,,
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",502.53,502.53,502.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],918.81,918.81,918.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",502.53,472.44,623.29,203,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,3663.42,3663.42,3663.42,1 through 10,percent of total billed charges,,,
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2177.7,2172.69,2205.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",502.53,472.44,708.66,218,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1941.94,1653.48,4607.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",502.53,502.53,753.8,139,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],756.19,659.61,945.24,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1593.34,625.53,2189.81,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",502.53,472.44,753.8,865,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],907.23,585.15,1353.84,1456,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1619.11,695.11,2529.13,183,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1619.11,1025.28,2522.8,1080,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1612.89,1199.4,4777.92,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1619.11,502.53,1902.17,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],905.23,715.23,1198.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2210.1,1053.74,4420.27,221,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",502.53,502.53,502.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",502.53,472.44,1438.3,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],964.53,964.53,964.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1912.53,1651.98,1929.26,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1900.58,1242.11,3397.7,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1826.96,1466.72,1852.77,121,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2405.91,1336.99,8468.02,666,percent of total billed charges,,,
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1016.79,1016.79,1016.79,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,3209.37,2375.96,5611.94,1 through 10,percent of total billed charges,,,
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],1858.63,1858.63,3727.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3085.02,1706.4,5320.38,18,percent of total billed charges,,,
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1016.79,1016.79,1016.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1678.07,1300.56,1837.52,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,5204.39,5204.39,14602.33,1 through 10,percent of total billed charges,,,
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,3028.52,2534,8033.4,11,percent of total billed charges,,,
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1016.79,991.71,1017.59,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1016.79,991.71,1021.81,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],3345.53,3345.53,3355.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1016.79,993.86,1018.9,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3121.44,2351.77,3359.68,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1530.02,1401.47,2957.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1016.79,991.71,1018.9,196,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2915.95,1302.86,4955.95,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2921.97,1302.86,4348.18,446,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1828.46,1478.46,1856.62,1002,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2921.97,1302.86,4640.48,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2921.97,1302.86,3991.01,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1636.78,1636.78,1656.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3058.61,2408.09,7585.43,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1016.79,991.71,1608,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1951.56,1951.56,1951.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],12661.44,12661.44,12834.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,13229.15,9305.2,27634.8,26,percent of total billed charges,,,
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3658.55,3365.69,3807.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2039.23,2039.23,2039.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,12033.48,12033.48,12033.48,1 through 10,percent of total billed charges,,,
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,13471.76,13471.76,13471.76,1 through 10,percent of total billed charges,,,
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2039.23,2039.23,2039.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3657.05,3657.05,3657.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2039.61,1995.98,2077.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2039.23,2039.23,2039.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2039.63,2039.23,2041.34,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3660.05,3310.05,3669.48,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],9263.66,9263.66,9927.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10673.39,8550.14,22162.32,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],10929.98,10929.98,10929.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],11445.29,11445.29,11445.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],919.18,919.18,1258.73,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2059.12,1474.92,2866.08,133,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,761.6,759.85,2384.27,1866,percent of total billed charges,,,
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2032.38,759.85,2856.84,29,percent of total billed charges,,,
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],875.41,801.38,1341.94,103,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",488.68,476.33,746.87,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1916.38,1250.59,2954.22,65,percent of total billed charges,,,
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],875.41,650.3,1347.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,2129.62,2075.23,4203.76,1 through 10,percent of total billed charges,,,
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1968.6,1569.07,2585.42,59,percent of total billed charges,,,
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",488.68,476.33,712.55,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],875.41,875.41,875.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",488.68,478.48,746.87,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1573.78,1396.88,3916.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,1307.67,1307.67,1307.67,1 through 10,percent of total billed charges,,,
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],919.18,919.18,922.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1607.9,1607.9,2201.85,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",488.68,476.33,1183.05,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",488.68,476.33,746.87,230,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],875.41,801.38,1202.64,1047,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],789.9,763.93,1532.66,268,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],789.9,763.93,2061.87,1314,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],908.39,763.93,2102.88,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],789.9,789.9,987.83,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],994.94,994.94,994.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2082.16,1596.86,3041.48,231,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",488.68,488.68,748.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1188.74,1086.44,1783.11,149,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2343.78,1770.88,3468.84,296,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1050.89,887.97,3632.88,4173,percent of total billed charges,,,
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1132.14,866.49,1703.71,268,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",883.26,631.99,947.98,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2534.88,890.01,4660.18,70,percent of total billed charges,,,
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],1155.24,1155.24,1155.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,2472.84,1912.3,4500.33,176,percent of total billed charges,,,
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2633.66,1990.15,3720.41,145,percent of total billed charges,,,
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1132.14,1132.14,1698.21,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,2385.87,2087.48,3198.28,16,percent of total billed charges,,,
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",883.26,883.26,883.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",883.26,631.99,1199.25,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,428.32,428.32,428.32,1 through 10,percent of total billed charges,,,
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1705.91,1132.64,2855.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",883.26,615.02,1158.75,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1900.48,1079.43,8050.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",631.99,615.02,947.98,72,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1329.09,950.99,1804.59,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2079.43,1877.55,3119.15,102,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1132.14,1034.7,1698.21,3243,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1023.04,989.4,2555.27,674,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",631.99,615.02,1089.61,544,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1023.04,989.4,2642.15,2815,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1023.04,1023.04,2268.14,168,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1176.5,989.4,2642.15,202,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1132.14,1099.14,1698.21,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2708.3,1992.62,4546.96,480,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",883.26,631.99,947.98,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1695.27,1695.27,1695.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2764.86,2343.81,3034.86,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],8212.92,5184.19,9531.41,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,4064.62,2235.26,9750.43,344,percent of total billed charges,,,
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2638.7,2549.7,3025.44,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,4356.86,2643.34,7737.72,1 through 10,percent of total billed charges,,,
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1469.92,1463.36,1676.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,6659.8,5351.37,15833.11,1 through 10,percent of total billed charges,,,
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,7178.22,4788.25,12916.46,1 through 10,percent of total billed charges,,,
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],2640.9,2640.9,3018.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,7595.43,7595.43,7595.43,1 through 10,percent of total billed charges,,,
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1470.46,1469.92,1713.93,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],4837.59,4837.59,4837.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1469.92,1463.36,1470.46,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],2211.89,2211.89,2211.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1469.92,1463.36,1676.66,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3873.18,3628.72,4843.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1469.92,1463.36,1577.51,63,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2360.22,966.42,5665.44,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2640.2,2349.7,3008.64,150,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2678.44,1652.15,7907.78,207,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3237.96,2360.22,6870.18,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3348.05,2116.08,6335.56,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2633.2,2479.47,2644.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],5834.4,3408.87,8590.03,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1469.92,1469.92,1469.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1469.92,1469.92,2257.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,17685.84,12931.44,34423.59,18,percent of total billed charges,,,
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5727.46,5721.29,7482.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3194.93,3194.93,3197.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,22104.18,20655.13,23418,1 through 10,percent of total billed charges,,,
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,18948.81,18948.81,18948.81,1 through 10,percent of total billed charges,,,
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],13085.6,13085.6,13085.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3190.71,3190.71,3190.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5722.29,5372.79,5990.95,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],15920.49,12884.59,16598.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],23036.74,15583.64,32416.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],18610.84,18610.84,18610.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],12359.19,9801.67,19735.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],20354.06,20354.06,33979.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2970.31,2970.31,2970.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3293.38,3293.38,3293.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],8409.84,5954.24,11111.65,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,9069.85,2533.27,14578.71,197,percent of total billed charges,,,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3401.49,1360.92,3423.55,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1891.58,1891.58,1892.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,9053.45,8501.18,12747.65,1 through 10,percent of total billed charges,,,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1892.12,1892.12,1892.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,12933.32,7814.54,23000.58,1 through 10,percent of total billed charges,,,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,8162.18,8162.18,8825.26,1 through 10,percent of total billed charges,,,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],3395.05,3395.05,3395.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1891.9,756.63,1892.12,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1891.98,1891.58,1893.69,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,7632.53,7632.53,7632.53,1 through 10,percent of total billed charges,,,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],3557.98,3557.98,3557.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1891.58,1803.1,1892.38,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],4311.51,4311.51,4853.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1891.58,1803.1,1892.38,69,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3394.55,1361.92,3438.97,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],7805.7,2399.56,14063.93,140,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],5417.94,2399.56,15020.79,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],6853.42,2537.64,21717.58,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],6061.05,2399.56,9369.29,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3395.89,3395.89,3395.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],9800.21,6826.35,15155.67,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1892.38,1892.38,1892.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1803.1,1803.1,1803.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6317.76,6317.76,6317.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],10732.54,10596.52,32528.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,10993.75,2537.64,31248.16,36,percent of total billed charges,,,
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6016.67,6016.67,6016.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3344.51,3344.51,3943,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,19575.69,19575.69,19575.69,1 through 10,percent of total billed charges,,,
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,15562.81,10039.51,18528.42,1 through 10,percent of total billed charges,,,
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3344.83,3344.83,3344.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3345.31,3344.91,3943,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3344.91,3344.51,3943,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],11007.14,11007.14,11007.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3344.88,3344.51,3943,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6013.04,5995.81,6991.79,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],5909.24,2696.16,11166.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],9423.42,1450.14,18151.55,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3748.36,2759.49,10299.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],11463.72,9873.53,12474.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5998.31,5998.31,5998.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],10054.03,10054.03,10766.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3344.83,3344.83,3344.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],17055.66,9119.68,28175.26,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5887.21,5312.17,5907.44,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,10332.91,4357.07,25300.77,938,percent of total billed charges,,,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,20934.9,9293.48,31644.03,15,percent of total billed charges,,,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5615.54,5336.41,5843.43,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3127.62,3007.18,3159.98,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,12366.32,5945.04,24744.59,33,percent of total billed charges,,,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,15954.92,9351.78,21635.33,25,percent of total billed charges,,,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],5319.61,5308.06,5608.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,22722.13,22722.13,33990.32,1 through 10,percent of total billed charges,,,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3127.22,3007.18,3131.44,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3127.54,3024.65,3133.81,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],8859.75,8186.77,10292.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,8097.91,8097.91,8097.91,1 through 10,percent of total billed charges,,,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],4249.73,4249.73,4708.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],9292.43,7646.45,10324.87,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3127.38,3007.18,3129.33,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3127.59,3007.18,3135.65,320,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],6716.84,3304.51,17321.25,91,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5616.05,5072.22,5787.2,354,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],6831.92,5012.51,17782.29,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],6716.08,3667.72,16527.74,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],6806.09,4129.74,23575.15,631,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5607.06,5607.06,5607.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],15338.96,9409.99,25337.39,97,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3127.22,3074.25,3127.62,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3131.43,3131.43,3456.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],10517.12,10513.54,10571.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],26334.78,16248.59,55259.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,27219.58,7584.39,45440.92,122,percent of total billed charges,,,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5580.41,5580.41,5580.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,17642.56,17642.56,54864.59,1 through 10,percent of total billed charges,,,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],9997.38,9727.2,10283.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,21479.45,21479.45,26254.33,1 through 10,percent of total billed charges,,,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],10002.5,10002.5,10002.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,25903.85,17418.33,27890.22,1 through 10,percent of total billed charges,,,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],10203,10203,10203,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5581.21,5580.41,5650.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5582.57,5582.57,9821.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],18570.26,18570.26,18570.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],16450.32,16450.32,18361.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5580.78,5580.41,5583.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5580.41,5580.41,5666.81,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],10037.54,9622.01,10201.76,99,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],21020.82,9738.17,47502.7,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],18439.09,9219.1,29978.54,71,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],27882.12,21248.24,30543.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],9802.3,9802.3,9802.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],25906.58,16249.95,47533.65,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5580.41,5580.41,5580.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],4282.25,2854.55,8807.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,4094.7,1178.57,9786.28,18,percent of total billed charges,,,
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],235.91,235.91,235.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",199.43,199.43,199.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,515.61,515.61,515.61,1 through 10,percent of total billed charges,,,
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,3635.2,3635.2,3635.2,1 through 10,percent of total billed charges,,,
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,3776.3,3776.3,3776.3,1 through 10,percent of total billed charges,,,
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",501.29,501.29,501.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",214.22,214.22,215.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",363.26,363.26,363.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],487.83,233.52,653.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",214.22,130.36,420.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1607.01,214.22,10274.25,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],837.43,837.43,837.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],850.4,850.4,850.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3112.43,3112.43,3112.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",130.36,130.36,130.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2920.15,739.65,15369.15,1 through 10,percent of total billed charges,,,
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1189.5,1189.5,1189.5,1 through 10,percent of total billed charges,,,
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",143.11,143.11,143.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],646.39,646.39,646.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],640.89,640.89,640.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",357.76,357.76,357.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",360.41,360.41,360.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",357.76,357.76,357.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],640.89,256.36,680.89,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1264.6,1264.6,1264.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1836,686.21,1897.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1850.29,1669.48,2065.29,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],9611.17,8840.4,13922.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7879.2,2447.99,12043.63,131,percent of total billed charges,,,
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1697.45,552.27,2365.01,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1098.4,439.2,1098.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,6921.6,5847.69,9807.96,1 through 10,percent of total billed charges,,,
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,9217.03,9217.03,9789.08,1 through 10,percent of total billed charges,,,
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1966.95,1966.95,1966.95,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10796.22,10243.24,12291.91,1 through 10,percent of total billed charges,,,
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,8323.23,8323.23,8323.23,1 through 10,percent of total billed charges,,,
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1098,1098,1098.54,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],3612.76,3612.76,3613.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1098,1061.54,1098.4,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1098,1061.54,1098.38,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1652.23,1652.23,1652.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1098,1061.54,1098.54,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],6631.2,2060.67,9352.62,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1790.41,714.36,1993.02,183,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4822.39,3565.87,7480.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],7739.1,6693.29,10626.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],7404.34,7404.34,7404.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1699.63,1699.63,1699.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],8839.04,5649.58,11978.51,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1098,1061.54,1098.38,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],7988.03,4715.3,16343.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3556.79,3195.36,11206.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,11003.63,3470.12,20192.57,187,percent of total billed charges,,,
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3328.76,3042.15,3969.65,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1848.97,1848.65,4665.12,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,9828.3,9828.3,10865.76,1 through 10,percent of total billed charges,,,
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],3448.4,3448.4,3448.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,11983.47,6203.96,14296.87,1 through 10,percent of total billed charges,,,
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,11881.39,8313.62,25483.72,1 through 10,percent of total billed charges,,,
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,8321.03,8321.03,8321.03,1 through 10,percent of total billed charges,,,
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1848.65,1848.65,1873.87,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1848.97,1848.65,1849.19,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],2782.19,2782.19,2782.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1848.97,1816.9,1864.2,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6083.51,6083.51,6083.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1848.65,1816.9,1884.05,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4894.32,2819.17,11188.74,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3322.63,2980.2,3590.46,147,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],9146.64,2550.84,16950.9,110,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],6764.26,2550.84,16714.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],10952.62,5446.84,19807.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],11471.89,8118.4,14956.31,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1848.97,1848.65,1849.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],17805.07,12629.92,25966.84,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5142.58,5125.27,5602.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,15040.51,3752.71,25628.83,117,percent of total billed charges,,,
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4898.29,4579.32,5592.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2724.82,2696.75,3749.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,9789.84,9789.84,21177.43,1 through 10,percent of total billed charges,,,
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],4980.83,4980.83,4980.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,14257.09,9675.98,21822.13,1 through 10,percent of total billed charges,,,
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],4640.55,4640.55,4640.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,15855.81,13906.9,16581.97,1 through 10,percent of total billed charges,,,
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2724.82,2724.82,2724.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2725.62,2725.62,2725.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],4126.09,4126.09,4126.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2724.82,2724.82,2724.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],8965.49,8965.49,9160.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2725.9,2724.82,3745.74,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],8803.36,5415.76,14889.41,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4899.82,4542.75,5224.71,182,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10577.24,3785.45,18977.18,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3785.45,3785.45,12048.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],11783.16,7374.81,18756.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4886.95,4886.95,4886.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],13643.53,9780.87,15968.32,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2725.22,2725.22,3750.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,27144.68,23744.44,30676.11,12,percent of total billed charges,,,
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4956.87,4956.87,4956.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],8891.1,8289.57,8920.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],20224.06,20224.06,20224.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],11967.68,11967.68,21652.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,36762.82,36762.82,36762.82,1 through 10,percent of total billed charges,,,
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],17185.11,17185.11,17185.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],12551.53,11962.62,12677.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Urology and Related Services,5377,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],20444.64,20444.64,20444.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,67788.74,61182.55,84357.24,12,percent of total billed charges,,,
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],19344.18,19344.18,19344.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11189.13,11189.13,11189.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10805.76,10805.76,10805.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],19342.84,17692.72,19513.85,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],61601.8,61601.8,69064.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],71759.36,71759.36,71759.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2532.28,2532.28,2532.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2561.57,2561.57,2561.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],2690.61,2690.61,2690.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1443.77,1443.77,1443.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],2669.42,2669.42,2669.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1504.46,1421.29,1608,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2646.3,1607.11,3783.23,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],11014.91,11014.91,11014.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],3784.95,3784.95,6070.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1521.82,1504.38,3479.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],171.72,171.72,3669.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],234.74,129.32,333.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,146.53,107.83,527.63,144,percent of total billed charges,,,
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,146.48,146.48,146.48,1 through 10,percent of total billed charges,,,
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],316.89,316.89,345.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",107.83,103.85,107.83,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,180.61,169.69,599.11,1 through 10,percent of total billed charges,,,
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,3444.26,3444.26,3444.26,1 through 10,percent of total billed charges,,,
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],324.81,324.81,324.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",107.83,107.83,107.83,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,103.85,103.85,103.85,1 through 10,percent of total billed charges,,,
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",107.83,103.85,107.83,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],291.02,291.02,291.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],352.07,301.56,373.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",107.83,107.83,176.9,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",107.83,103.85,176.9,141,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],242.61,82.33,738.46,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],317.28,145.39,320.83,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],194.05,125.59,399.86,70,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],155.24,153,4443.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],194.05,171.72,470.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],321.89,321.89,321.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],178.29,119.88,508.67,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",107.83,103.85,172.74,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],249.07,249.07,396.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],308.26,266.56,3960.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,748.65,265,4225.19,78,percent of total billed charges,,,
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",232.12,163.05,504.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],348.55,348.55,348.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3762.87,3762.87,3762.87,1 through 10,percent of total billed charges,,,
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,4712.47,718.86,5265.41,1 through 10,percent of total billed charges,,,
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1286.38,1286.38,1286.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",177.25,163.05,1420.69,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",163.05,163.04,315.9,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],4096.54,4096.54,4096.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],516.65,516.65,516.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",232.12,163.05,573.52,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",232.12,163.05,1467.8,80,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],223.59,222.44,288.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],519.07,182.03,4004.13,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],421.77,298.04,440.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],680.12,680.12,3186.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],840.44,210.6,9946.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",232.12,163.05,1536.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],843.57,843.57,1007.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],974.15,846.23,5061.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,522.8,309.85,1362.88,1 through 10,percent of total billed charges,,,
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],959.8,959.8,959.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],979.39,979.39,979.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",700.08,700.08,700.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",535.79,535.79,535.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",535.79,535.79,535.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],94.23,94.23,94.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",535.79,502.36,769.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1185.32,1185.32,1185.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],711.4,282.19,1156.98,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],965.55,963.3,994.73,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],714.8,714.8,714.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],484.78,484.78,484.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3220.31,3211.58,3267.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],8206.53,6822.71,11644.77,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3292.16,2541.76,9916.82,270,percent of total billed charges,,,
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3056.94,3047.02,3062.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1704.23,1704.23,1708.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,10264.77,10264.77,12887.64,1 through 10,percent of total billed charges,,,
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,7780.38,4108.78,11256.27,1 through 10,percent of total billed charges,,,
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],3060.12,3060.12,3060.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,6190.52,6190.52,6190.52,1 through 10,percent of total billed charges,,,
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,8944.9,4157.69,11842.64,1 through 10,percent of total billed charges,,,
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1705.03,1704.23,3009.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1704.23,1629.39,1706.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2948.07,1704.55,3009.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5607.43,5348.68,5610.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1704.42,1629.39,3009.35,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3065.02,2734.44,3088.33,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3653.22,2170.64,4443.84,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],3653.22,2244.44,4115.7,164,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3653.22,2922.58,4846.33,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3653.22,2940.84,5162.22,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3061.42,3061.42,3061.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],8743.63,6142.92,13615.09,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],9867.5,7806.13,16129.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,4616.38,3210.8,10846.46,93,percent of total billed charges,,,
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4778.29,4470.4,4781.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,5272.33,5272.33,5272.33,1 through 10,percent of total billed charges,,,
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2646.26,2646.26,2646.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,12278.86,12278.86,12278.86,1 through 10,percent of total billed charges,,,
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10271.11,8601.4,17543.6,1 through 10,percent of total billed charges,,,
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],3984.74,3984.74,3984.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],7816.83,7816.83,7816.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2646.31,2645.94,3950.69,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3949.28,2074.1,7793.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],4469.99,3889.33,8279.06,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4763.35,4746.9,4784.59,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],4087.28,3949.28,4655.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],4021.57,4021.57,4021.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],11373.8,10043.82,13988.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7613.49,7338.5,10250.6,1 through 10,percent of total billed charges,,,
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],7117.66,7117.66,7117.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,19965.63,19965.63,19965.63,1 through 10,percent of total billed charges,,,
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,19957.29,19957.29,19957.29,1 through 10,percent of total billed charges,,,
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3963.62,3963.62,3963.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],13042.76,13042.76,13042.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],7130.24,7130.24,7130.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],7506.77,5031.75,11977.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4961.71,4961.71,4961.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2525.4,2525.4,2525.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],20084.82,20084.82,20084.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1914.76,1674.76,6469.17,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],5063.33,3623.94,10017.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3849.76,1805.6,9864.85,158,percent of total billed charges,,,
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1880.51,1125.02,5879.59,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1046.84,1006.28,3432.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,9114.33,7081.76,13265.06,1 through 10,percent of total billed charges,,,
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10476.58,8160.42,21621.28,1 through 10,percent of total billed charges,,,
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,4596.28,4596.28,4596.28,1 through 10,percent of total billed charges,,,
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],5862.79,5862.79,5862.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1046.68,1046.68,1047.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1046.84,1008.43,3441.01,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],3109.48,3109.48,3109.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3109.48,2584.96,9501.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1575.83,1575.83,1575.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1046.68,1006.28,1069.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1046.68,1006.28,1084.95,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1882.01,1532.49,1896.28,109,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3354.53,1423.06,6110.21,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2680.71,1671.9,5169.23,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3126.85,2802.96,3980.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3662.76,1787.14,4115.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1880.01,1880.01,1880.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],8538.16,4655.94,10985.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1046.68,1006.28,1046.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],12800.15,12800.15,12800.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,26294.63,6398.49,57576.39,1 through 10,percent of total billed charges,,,
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3432.58,3432.58,3432.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,24049.47,24049.47,24049.47,1 through 10,percent of total billed charges,,,
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3432.58,3432.58,3469.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,10827.14,10827.14,10827.14,1 through 10,percent of total billed charges,,,
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9133.87,9133.87,9133.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3471.79,3471.79,9689.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3465.55,3465.55,3465.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],17717.8,7908.88,19902.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3432.58,3432.58,3432.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],13315.23,13315.23,13315.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Procedures,5432,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2433.73,286.3,2512.44,139,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1333.8,569.75,1641.88,92,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2403.86,693.01,2551.82,2007,percent of total billed charges,,,
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1475.66,174.08,1568.14,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",851.8,127.29,855.23,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2439.29,1934.43,3003.9,26,percent of total billed charges,,,
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],1584.82,1583.42,1589.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",227.29,227.29,227.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,2495.35,516.75,2512.44,72,percent of total billed charges,,,
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],175.56,175.56,175.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2455.67,1391.17,3151.31,91,percent of total billed charges,,,
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1015.75,509.2,1564.09,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",694.44,694.44,694.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,2424.49,1014.5,2441.1,1 through 10,percent of total billed charges,,,
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",851.8,154.36,855.23,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,118.22,118.22,223.25,1 through 10,percent of total billed charges,,,
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1155.95,1150.94,1562.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",852.66,127.72,869.29,100,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],2852.68,2294.44,2861.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1272.84,345.97,1682.13,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",852.66,158.22,855.23,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2430.59,477,2859.52,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",852.66,158.22,855.23,669,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1173.26,173.68,1710.76,954,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],133.27,106.62,1654.69,1449,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],133.27,128.89,1469.09,203,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],133.27,106.62,1054,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],153.26,122.61,1646.31,72,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1453.56,1054.19,1705.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2495.35,1396.9,2512.45,223,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",854.7,227.29,855.23,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1308.51,440.28,1524.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],703.6,284.42,1047.3,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],3028.33,752.29,6099.33,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3136.58,932.1,7015.61,344,percent of total billed charges,,,
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1188.65,408,2704.12,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1905.47,940.74,9315.38,1 through 10,percent of total billed charges,,,
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",952.34,720.16,1488.82,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],2621.92,2621.92,2621.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,2539.4,1483.54,3957.43,1 through 10,percent of total billed charges,,,
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],682.79,682.79,682.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,3862.11,3862.11,3862.11,1 through 10,percent of total billed charges,,,
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,3151.17,1972.87,3904.46,34,percent of total billed charges,,,
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],986.86,986.86,2033.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1018.01,1018.01,1018.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1110.56,440.26,1760.07,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1051.88,519.6,1626.67,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],148.48,148.48,148.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],558.56,558.56,2074.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1221.34,916.01,3688.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",952.34,371.19,1484.98,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",952.34,360.42,1827.43,155,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],671.95,321.95,2074.29,269,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],883.94,250,3354.3,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1001,86.84,3333.56,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],989.49,366.62,7053.52,227,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],4126.09,1113.9,4385.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2181.77,1130.22,5189.69,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1133.84,787.05,1481.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],3055.56,2605.09,3331.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],509.99,335.66,2540.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3155.43,1739.53,6785.17,71,percent of total billed charges,,,
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],514.76,256.46,1704.78,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,3176.89,3174.65,3297.81,1 through 10,percent of total billed charges,,,
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",479.31,479.31,479.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3344.16,3276.95,11858.89,1 through 10,percent of total billed charges,,,
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1025.81,1025.81,1025.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2663.44,2663.44,2663.44,1 through 10,percent of total billed charges,,,
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",582,582,582,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],854.84,854.84,854.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",286.32,190.88,715.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",286.32,286.32,286.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1077.11,1077.11,1077.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2355.19,2355.19,2355.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",286.32,190.88,1410.92,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2297.15,2297.15,2297.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1286.77,831.05,1304.18,148,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1675.02,1185.23,7211.13,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1387.05,817.02,2067.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],10821.28,10821.28,10821.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],873.65,873.65,873.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3278.37,3256.36,3294.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",475.04,475.04,475.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],7102.51,7102.51,7102.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,9266.31,9266.31,14451.48,1 through 10,percent of total billed charges,,,
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],3369.47,3369.47,3369.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,10831.47,10831.47,10831.47,1 through 10,percent of total billed charges,,,
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],4393.82,4393.82,4393.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],6089.88,6089.88,6089.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1847.53,1843.63,1847.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3337.58,3305.58,8102.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],9315.59,9315.59,9315.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5303.04,5303.04,11188.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,6618.96,6603.1,11983.07,1 through 10,percent of total billed charges,,,
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3517.71,3517.71,3517.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3566.56,3566.56,3566.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6684.09,6684.09,6684.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6308.6,5796.99,10746.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6471.09,6471.09,6471.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,34938.67,34938.67,34938.67,1 through 10,percent of total billed charges,,,
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6692.52,6692.52,6692.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],41775.34,41775.34,41775.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Neurostimulator and Related Procedures,5463,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],17296.08,17296.08,21570.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,60665.15,28252.18,114197.03,12,percent of total billed charges,,,
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,60806.21,60806.21,60806.21,1 through 10,percent of total billed charges,,,
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15302.99,15302.99,15302.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11580.59,11580.59,11580.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],18142.6,18142.6,37826.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11494.51,11494.51,11494.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11498.41,11498.41,15157.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],20598.15,13383.87,20656.23,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],43701.12,34701.52,62529.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],62936.42,62936.42,62936.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11401.03,11401.03,11401.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,71581.98,38645.95,179348.54,20,percent of total billed charges,,,
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],29265.76,28990.76,29277.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,91919.1,91919.1,91919.1,1 through 10,percent of total billed charges,,,
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,86264.78,58619.44,93780.77,1 through 10,percent of total billed charges,,,
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16333.84,16333.84,16333.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19637.89,16344.37,23990.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],54358.35,54358.35,54358.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16340.16,16340.16,16340.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16335.95,16333.84,20664.01,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],29274.62,27232.76,33383.25,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],52894.19,52894.19,52894.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],36514.76,35258.34,74328.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],65988.45,65988.45,65988.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],141683.24,141683.24,141683.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],29268.74,29268.74,29268.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],75047.79,75047.79,75047.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17496.35,17496.35,17496.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],21033.2,21033.2,21033.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,61425.13,61425.13,61425.13,1 through 10,percent of total billed charges,,,
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],47650.01,47650.01,47650.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Implantation of Drug Infusion Device,5471,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,9071.09,810.69,11664.48,1 through 10,percent of total billed charges,,,
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",441.07,441.07,441.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,7351.8,7351.8,7351.8,1 through 10,percent of total billed charges,,,
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",445.29,445.29,445.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],516.1,516.1,516.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3927.11,3927.11,3927.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],4716.91,4716.91,7656.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],7590.06,7590.06,7590.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",441.34,441.34,441.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laser Eye Procedures,5481,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2304.81,2151.96,2304.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],13989.65,13989.65,13989.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,4075.74,1974.77,23738.9,37,percent of total billed charges,,,
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2199.27,2052.65,2998.8,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1222.47,1214.53,1222.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3815.37,3815.37,3815.37,1 through 10,percent of total billed charges,,,
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],2049.1,2049.1,2049.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1229.65,1222.74,1759.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,12942.38,12942.38,12942.38,1 through 10,percent of total billed charges,,,
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3840.84,3840.84,3840.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1225.28,1225.28,1225.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2544.78,2242.2,8622.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2247.2,2247.2,2247.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2197.16,2049.1,2362.27,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2578.53,2578.53,13781.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1593.76,1593.76,1593.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2196.92,2196.92,2196.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],23924.88,23924.88,25289.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1223.01,1223.01,1223.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Intraocular Procedures,5491,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],13910.22,10872.6,28587.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],4061.23,3761.83,4147.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,4354.21,3082.95,11651.5,80,percent of total billed charges,,,
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3950.8,3868.19,4033.7,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2156.25,2156.25,2160.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,13210.52,13210.52,13210.52,1 through 10,percent of total billed charges,,,
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,11608.1,11608.1,11608.1,1 through 10,percent of total billed charges,,,
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],3951.3,3666.69,3951.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2156.25,2156.25,2156.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2156.25,2119.02,2692.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2158.36,2156.25,2162.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],6090.08,4916.26,7099.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2158.36,2156.25,2160.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3804.45,3789.37,5725.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],3789.37,2931.82,5684.06,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3951.8,3571.49,3995.36,125,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],5439.26,5439.26,13340.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3789.37,3789.37,5920.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3869.69,3869.69,3929.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],11872.54,9556.9,16384.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2156.25,2156.25,2162.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Intraocular Procedures,5492,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],10779.9,10779.9,10779.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],4168.05,4168.05,4168.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5004.69,5004.69,5004.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,5635.7,4582.15,27963.03,1 through 10,percent of total billed charges,,,
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,4495.71,4495.71,4495.71,1 through 10,percent of total billed charges,,,
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2798.09,2798.09,2798.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],5004.99,5004.99,5004.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2765.6,2765.6,2765.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2766,2766,2766,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],4164.82,4164.82,4164.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2774.03,2774.03,2774.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5005.69,4678.17,5043.88,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2767.71,2767.71,2767.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],4402.44,3789.37,25642.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4611.27,4611.27,4611.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2769.82,2769.82,2769.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Intraocular Procedures,5493,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7529.78,7529.78,7529.78,1 through 10,percent of total billed charges,,,
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,186.32,186.32,186.32,1 through 10,percent of total billed charges,,,
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",160.77,160.77,160.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],4869.56,4869.56,4869.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],346.7,346.7,346.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],5883.53,5883.53,5883.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",240.34,240.34,240.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],17224.51,17224.51,17224.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,9364.72,9364.72,11050.02,1 through 10,percent of total billed charges,,,
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",519.14,519.14,519.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",519.51,519.51,519.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 2 Extraocular, Repair, and Plastic Eye Procedures",5502,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],10352.03,5936.88,15330.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2087.48,2087.48,2087.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7563.28,2107.41,13438.92,116,percent of total billed charges,,,
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2080.43,2080.43,2080.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1250.87,1250.47,1251.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,18994.72,18994.72,18994.72,1 through 10,percent of total billed charges,,,
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,12177.27,12177.27,17399.31,1 through 10,percent of total billed charges,,,
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10361.43,10361.43,10361.43,1 through 10,percent of total billed charges,,,
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],2058.58,2058.58,2058.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1250.47,1217.88,1251.01,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1250.79,1250.47,1251.27,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,10639.52,10639.52,10639.52,1 through 10,percent of total billed charges,,,
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],6.46,6.46,6.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1250.47,1250.47,1251.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],4114.42,4114.42,4114.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2281.63,2252.57,2305.4,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1250.47,1217.88,1251.01,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4645.36,4645.36,9299.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],6011.7,1665.38,14463.42,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],9626.74,1294.7,16684.68,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1869.8,1869.8,1869.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],8432.3,5773.04,13544.99,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1250.47,1250.47,1250.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1250.47,1250.47,1250.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],14643.56,14643.56,14643.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,10329.67,3893.8,18583.45,22,percent of total billed charges,,,
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],3635.57,3635.57,3635.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",0.16,0.16,0.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2021.42,2021.26,2021.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2021.58,2021.58,2021.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2021.53,2021.26,6678.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3627.85,3627.85,3715.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10803.65,2798.58,18835.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1546.48,1546.48,1546.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],13682.78,12796.6,16742.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],88.77,71.01,204.77,239,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],229.23,108.54,961.47,786,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,277.34,108.54,949.32,8507,percent of total billed charges,,,
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],84.94,79.67,174.63,466,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,405,138.89,1096.33,113,percent of total billed charges,,,
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,47.19,96.24,244,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],86.27,86.27,86.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,196.83,100.93,842.4,320,percent of total billed charges,,,
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],209.05,209.05,209.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,201.09,106.09,939.75,282,percent of total billed charges,,,
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,263.65,105.46,1327.67,48,percent of total billed charges,,,
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],85.24,67.64,126.36,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,47.36,47.36,161.2,1 through 10,percent of total billed charges,,,
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,47.19,107.62,221,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,47.19,102.36,396,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],155.29,109.75,340.57,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,66.5,66.5,66.5,1 through 10,percent of total billed charges,,,
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],71.01,66.93,134.95,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,47.19,67.2,378,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],155.29,110,358.22,193,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,47.19,107.62,2730,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],163.98,81.99,491.05,983,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],85.24,79.67,177.79,4956,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],130.7,79.5,425.7,5781,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],150.31,82.84,489.56,411,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],130.7,79.29,425.7,350,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],85.34,58.46,175.03,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],301.61,108.54,961.47,1000,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47.19,47.19,96.24,179,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],80.58,80.58,80.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],107.21,50,115.09,543,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],436.87,173.34,699.03,895,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,437.4,173.34,804.33,10759,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],102.11,51.06,117.51,1081,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57,57,57.3,432,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,447.93,166.98,839.16,140,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],104.19,104.19,208.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57,57,57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,419.58,173.34,801.9,442,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],102.81,81.68,202.99,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,472.2,168.42,905.89,58,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,406.14,150,783.78,336,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57.3,57.3,57.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],230.53,208.42,334.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57,57,57.3,376,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,295.57,57,1276.92,1 through 10,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],102.11,102.11,115.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],187.54,57.3,281.31,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57,57,57.3,620,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,302.05,302.05,577.85,1 through 10,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57,57,57.3,505,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],85.77,80.97,107.21,93,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],187.54,131.28,345.08,306,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57,57,104.66,3777,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],102.11,66.37,104.19,11328,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],203.17,125.88,394.48,7201,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],235.57,106.74,394.48,1287,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],233.65,140.66,453.66,483,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],208.93,118.02,394.48,425,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],102.91,96.39,104.59,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],447.93,173.34,895.86,1149,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57,57,112.17,224,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",57,57,57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],109.4,109.4,109.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],230.2,77.99,258.97,221,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],817.23,490.86,2077.65,454,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,878.11,563.76,2257.82,5634,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],232.09,93.78,360.6,484,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",129.56,64.78,289.58,219,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,808.38,488.47,1672.19,102,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],236.83,219.24,838.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,898.29,447.15,2685.18,201,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,790.12,398.98,2166.73,177,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1169.24,633.04,2692.33,30,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],232.09,51.83,236.83,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],236.89,236.89,236.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,741.82,741.82,741.82,1 through 10,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",129.56,127.71,289.58,221,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],235.09,232.59,334.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],426.29,298.4,429.68,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",129.56,127.71,289.58,362,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,807.38,807.38,807.38,1 through 10,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],194.96,180.48,280.73,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",129.56,127.71,289.58,280,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],426.29,151.65,537.83,141,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],497.86,368.07,839.55,581,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",129.56,64.78,289.58,2030,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],497.86,347.86,991.48,4023,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],233.04,94.73,334.2,4684,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],547.31,385.2,945.93,251,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],497.86,250,846.36,212,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],236.3,185.09,236.83,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],808.38,467.95,2217.01,683,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",346.58,346.58,346.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",129.56,64.78,285.92,139,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],596.31,596.31,596.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],553.09,479.29,554.79,134,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1153.4,874.8,1593.67,271,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1163.16,773.25,1850.87,4271,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],526.47,483.72,526.87,425,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",362.96,293.89,362.96,215,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1252.45,552.25,2195.76,67,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],537.21,537.21,537.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",362.96,293.89,362.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1091.37,732.24,2092.34,146,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],530.07,487.72,530.47,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1266.28,823.24,1774.21,23,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1184.49,550,1935.71,115,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",293.89,293.89,293.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],342.65,342.65,342.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",362.96,69.07,362.96,237,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,619.07,619.07,960.54,1 through 10,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],530.47,530.47,530.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",362.96,293.89,362.96,442,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],966.98,725.23,1349.54,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,587.3,493.59,705.25,1 through 10,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],888.46,293.89,966.98,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],442.23,398.22,442.23,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",362.96,293.89,362.96,300,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],526.47,483.72,526.47,4092,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",362.96,293.89,362.96,1649,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],731.8,375.12,1212.06,387,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],731.8,512.26,1525.15,2615,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],841.57,583.11,1753.93,177,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],731.8,432.48,1255.37,155,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],527.07,527.07,527.27,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1163.16,529.87,1871.91,432,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",362.96,293.89,419.96,197,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",362.96,362.96,362.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],180.21,135.33,440.48,149,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],782.41,272.16,2321.68,202,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,849.91,313.68,2167.62,2581,percent of total billed charges,,,
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],172.68,93.29,419.79,396,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1037.13,401.53,2685.14,47,percent of total billed charges,,,
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",140.57,93.29,233.22,132,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],259.74,164.39,426.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",141.15,141.15,141.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,813.16,310.47,2612.05,90,percent of total billed charges,,,
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],170.93,170.93,170.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",233.22,233.22,233.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,814.16,300,2725.61,75,percent of total billed charges,,,
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],174.42,153.19,421.79,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1169.14,365.29,1792,11,percent of total billed charges,,,
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],176.33,176.33,176.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",95.76,45.73,233.22,119,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],173.93,173.93,173.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,698.33,200,2267.46,1 through 10,percent of total billed charges,,,
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",95.76,95.42,233.22,159,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],722.75,144.05,767.38,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,367.85,367.85,367.85,1 through 10,percent of total billed charges,,,
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",95.76,66.06,233.22,124,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],179.48,143.58,370.96,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],313.96,235.47,767.38,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],547.39,268.14,1242.63,337,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",95.76,45.73,233.22,852,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],174.42,111.1,422.29,3350,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],453.83,170.37,1208.73,1646,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],455.05,107.49,1368.65,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],456.07,136.89,1193.45,116,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],174.42,171.33,424.79,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],851.31,304.48,2992.66,271,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",140.57,93.29,233.22,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging with Contrast,5571,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],83.14,83.14,272.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],360.06,70.96,412.04,262,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1786.79,1129.26,3308.18,454,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1870.39,1257.48,3147.26,5821,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],344.41,244.91,468.64,568,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,458.19,187,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2047.85,1194.34,3208.12,104,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],349.91,349.91,349.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1768.3,853.77,3159.75,189,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1740.26,1115.54,3213.04,164,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],346.91,200,411.08,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1797.82,1140.83,3727.62,28,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,191.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],349.99,349.99,349.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],342.91,146.91,564.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,458.19,215,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,2351.4,2351.4,4279.99,1 through 10,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,458.19,278,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],629.84,314.92,943.8,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,458.19,220,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],288.05,283.24,464.51,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],629.84,211.23,815.12,157,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.42,191.42,458.19,1572,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],345.91,139.96,383.56,5435,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],834.76,584.73,1377.62,655,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],834.12,591.24,1672.8,3831,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],867.17,509.41,2250.02,222,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],834.12,587.09,1316.99,211,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],349.91,344.08,477.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1872.56,1090.31,3871.94,647,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",200.43,191.42,458.19,112,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",386.56,386.56,386.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],367.41,367.41,367.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2255.1,1477.93,3201.15,116,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],798.02,637.22,811.8,112,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2153.23,1537.57,2863.07,1452,percent of total billed charges,,,
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1914.08,1662.82,2724.09,27,percent of total billed charges,,,
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],758.6,702.04,763.6,270,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",423.47,417.3,492.54,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],716.37,716.37,716.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1914.08,834.66,2756.93,75,percent of total billed charges,,,
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1867.36,538,2728.59,1 through 10,percent of total billed charges,,,
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1966.19,1065.28,2762.72,58,percent of total billed charges,,,
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],758.6,562.6,1402.82,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],774.26,774.26,774.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2561.05,2561.05,2561.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",423.47,417.3,423.47,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",423.47,417.3,606.87,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1393.34,1289.47,1393.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],637.22,589.71,746.54,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",423.47,423.47,538.94,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],966.98,725.24,1393.34,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],758.6,702.04,758.6,2532,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",423.47,417.3,423.47,304,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],935.77,797.45,1755.72,202,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1022.22,705.61,2002.01,1003,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],862.36,684.06,1835.88,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1303.39,837.36,2287.38,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],759.4,719.4,882.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2072.38,1185.94,2897.86,154,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",423.47,417.3,423.47,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],812.78,812.78,812.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],324.1,246.02,797.69,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],738.96,438,2151.25,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,793.57,640.8,2124.84,292,percent of total billed charges,,,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],386.23,366.23,806.02,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",215.38,214.95,448.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2124.84,726.89,20920.72,1 through 10,percent of total billed charges,,,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],393.7,393.7,393.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,2115.97,1181.63,2205.71,1 through 10,percent of total billed charges,,,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,805.17,644.14,2155.88,1 through 10,percent of total billed charges,,,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,894.33,894.33,894.33,1 through 10,percent of total billed charges,,,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1692.21,1692.21,1692.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",215.38,215.38,215.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,361.89,361.89,361.89,1 through 10,percent of total billed charges,,,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",215.38,214.95,215.38,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],324.1,324.1,324.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",215.38,215.38,215.38,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],708.66,708.66,708.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",215.38,214.95,215.38,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],983.49,606.76,1048.78,185,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],386.53,351.53,806.82,200,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],776.67,435,1024.34,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],786.79,432.67,1131.01,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],835.68,670.69,851.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],356.43,356.43,356.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],876.43,679.02,2223.53,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",215.38,215.38,448.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],544.9,355.89,544.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],936.15,255,1363.61,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1215.49,827.87,1998.72,116,percent of total billed charges,,,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],517.24,497.24,541.84,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",671.91,288.51,679.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,288.51,288.51,288.51,1 through 10,percent of total billed charges,,,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1418.12,1418.12,1657.09,1 through 10,percent of total billed charges,,,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],520.84,520.84,520.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1162.5,1128.36,1882.98,1 through 10,percent of total billed charges,,,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",288.51,288.51,1251.68,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],320.84,320.84,320.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",288.51,288.51,503.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],949.3,949.3,949.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],505.16,505.16,505.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",288.51,281.7,671.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],949.3,949.3,949.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",288.51,281.7,288.51,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],969.83,714.51,2033.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],517.54,474.33,602.08,130,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1336.85,886.99,2110.95,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1605.18,1605.18,3096.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1162.98,870.02,1871.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",288.51,288.51,288.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1196.52,809.92,2359.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1320.97,1052.93,1722.69,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2988.25,1635.63,3985.38,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3264.63,1658.26,3601.86,306,percent of total billed charges,,,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1253.9,1233.9,1256.5,157,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,3375.27,3375.27,3493.41,1 through 10,percent of total billed charges,,,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",699.74,699.74,699.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3368.98,1662.81,3493.41,11,percent of total billed charges,,,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,3327.68,1892.4,3387.37,1 through 10,percent of total billed charges,,,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1910.97,1910.97,1910.97,1 through 10,percent of total billed charges,,,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1107.5,1049.05,1787.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1584.54,1584.54,1584.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",699.74,699.74,699.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",699.74,699.74,3069.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],2302.34,2302.34,2302.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",699.74,699.74,740.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1052.93,1052.93,1495.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2302.34,1726.76,2302.34,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",699.74,699.74,740.05,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2118.67,1614.26,2283.51,230,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1258,1088.25,1269.5,1305,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2118.67,1194.03,2280.44,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],2122.33,970.44,2622.51,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2106.67,869.89,2285.44,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1230.5,910.5,1260.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3109.97,1383.36,3543.78,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",699.74,699.74,740.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1470.55,1176.55,4896.16,90,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],5073.4,4469.49,12887.23,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,5186.62,4507.8,14696.45,809,percent of total billed charges,,,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1402.52,1302.52,4410.83,181,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",783.91,783.91,2127.12,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,5534.67,4268.97,15919.46,25,percent of total billed charges,,,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],3824.02,3824.02,6089.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,5258.03,3542.94,12455.09,32,percent of total billed charges,,,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,5118.32,4123.23,5557.9,25,percent of total billed charges,,,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1404.52,1204.52,4537.43,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,5158.68,4411.42,14264.47,11,percent of total billed charges,,,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",783.91,783.91,1100.77,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1208.37,1208.37,1208.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],2579.45,2197.86,2579.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",783.91,783.91,1242.1,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,7948.58,7948.58,7948.58,1 through 10,percent of total billed charges,,,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",783.91,781.8,815.36,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],1176.44,1152.26,1470.55,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2579.45,1929.29,6729.3,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",783.91,783.91,2563.68,176,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1404.67,1224.12,4663.63,1621,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],4747.81,4090.61,10151.48,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],6240.73,5487,11561.15,469,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],5164.32,2238.67,6093.76,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],6241.41,4361.84,11821.23,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1407.52,1403.52,1420.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],5306,4628.57,18330.57,72,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",815.36,783.91,2385.49,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1404.69,1404.69,1404.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],417.96,417.96,417.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,403.41,403.41,403.41,1 through 10,percent of total billed charges,,,
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],127.49,127.49,127.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",404.72,404.72,404.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],226.72,127.99,4785.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],417.96,417.96,417.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],14201.73,2064.27,23153.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3806.34,463.68,5718.77,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],475.73,475.23,4648.96,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,9802.62,1007.64,23958.41,83,percent of total billed charges,,,
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",461.49,461.49,522.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,14729.31,14729.31,14729.31,1 through 10,percent of total billed charges,,,
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],3524.19,1076.01,3784.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,15650.33,15650.33,15650.33,1 through 10,percent of total billed charges,,,
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,2056.43,2056.43,2056.43,1 through 10,percent of total billed charges,,,
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1638.77,1638.77,1638.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1654.67,1094.91,2799.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],5451.36,5451.36,5451.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2264.39,2264.39,2264.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],3420.05,3420.05,3420.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],645.61,645.61,645.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",267.37,261.46,2844.13,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],836.7,361.63,5653.21,140,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],3471.84,707.49,14640.46,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],7766.93,2048.6,24747,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],5844.05,1498.26,25206.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],6361.7,6361.7,7291.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],476.03,476.03,476.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1224.31,1224.31,1224.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],14352.39,7406.64,22066.02,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],13644.88,10057.62,13791.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3098.47,2631.85,6939.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,9824.65,7922.41,16108.61,63,percent of total billed charges,,,
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2336.72,2146.97,4490.23,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1941.76,1941.76,2082.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,10736.15,10736.15,10736.15,1 through 10,percent of total billed charges,,,
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,8440.31,8440.31,11958.03,1 through 10,percent of total billed charges,,,
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],3569.79,3569.79,3569.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,8576.49,8391.24,8967.98,1 through 10,percent of total billed charges,,,
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,13593.08,13593.08,13593.08,1 through 10,percent of total billed charges,,,
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1339.3,1339.3,1339.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2429.35,2429.35,2429.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],8478.35,8478.35,8478.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1773.47,1720.52,2363.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5463.81,5463.81,5811.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],2437.35,2437.35,2437.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1764.19,1764.19,1916.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1649.36,1317.61,2645.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10241.91,8333.46,14356.96,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2542.12,1934.18,4107.23,120,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],6729.94,5283.77,8333.46,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],8594.87,8594.87,8594.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],6247.45,5512.92,9092.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2719.15,2719.15,2719.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],8417.52,8338.95,17475.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2030.58,2030.58,2030.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],19359.81,8700.21,30866.52,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2913.73,398.99,5973.07,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1388.75,333.51,7181.22,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,5760.72,755.33,27174.3,188,percent of total billed charges,,,
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3561.78,563.11,5015.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,17992.12,16966.6,30989.79,1 through 10,percent of total billed charges,,,
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],1000.26,897.95,12490.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,25220.57,5026.86,35504.04,1 through 10,percent of total billed charges,,,
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],4508.2,4508.2,4508.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10063.33,10063.33,10063.33,1 through 10,percent of total billed charges,,,
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2461.09,2461.09,2461.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",281.19,140.96,3003.48,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],11038.35,11038.35,11038.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3219.58,1270,5486.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1198.1,212.12,3631.58,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1641.26,253.01,6030.42,236,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],9261.18,1629.37,20141.84,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],11191.03,924.74,28464.95,90,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],28813.74,28813.74,28813.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],5214.96,4395.63,23494.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4166.33,1681.65,5471.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],14772.78,7426.08,29888.19,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],717.07,583.21,8570.17,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],29260.02,16626.87,32505.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,21312.3,3773.55,40658.97,190,percent of total billed charges,,,
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1110.29,555.73,9524.81,112,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4072.34,1380.47,6804.18,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,21465.93,6544.8,38346.21,1 through 10,percent of total billed charges,,,
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,18305.92,3699.27,40532.4,1 through 10,percent of total billed charges,,,
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,29928.63,8490.2,41193.27,1 through 10,percent of total billed charges,,,
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],8611.6,8611.6,8611.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3746.26,3098.9,4358.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],9336.36,9336.36,9336.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4476.12,2140.82,6693.05,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6422.96,5695.27,7216.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1625.92,1020.19,11287.77,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],817.52,466.57,6996,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4645.14,1520.7,6623.72,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],17140.18,2081.12,37085.45,109,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1239.35,555.93,10120.21,728,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],11252.48,3569.05,26517.98,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],38577.31,12977.94,41088.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],8618.66,1376.23,28833.28,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],25660.8,16170.03,44525.7,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7086.45,6410.35,7141.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2760.74,2760.74,2760.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],5990.38,5990.38,5990.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,22825.97,13347.41,50830.4,1 through 10,percent of total billed charges,,,
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,48865.09,48865.09,48865.09,1 through 10,percent of total billed charges,,,
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3905.07,3905.07,3905.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1186.53,1186.53,3762.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],4528.26,1494.17,6204.51,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],25871.06,25871.06,25871.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],30286.17,30286.17,30286.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],16455.35,16455.35,16455.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],7081.2,3670.52,11884.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],28710.45,28001.29,30799.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,25742.1,12912.99,35802.4,30,percent of total billed charges,,,
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],9069.8,3680.99,10725.2,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5952.4,5952.4,5952.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],10817.83,10817.83,10817.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,26854.74,26854.74,26854.74,1 through 10,percent of total billed charges,,,
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,15800.76,15800.76,15800.76,1 through 10,percent of total billed charges,,,
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],1813.49,1813.49,1813.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4966.78,4966.78,4966.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4774.92,4445.37,4843.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],9290.22,3096.74,14814.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5716.09,5716.09,5989.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],16724.45,11626.28,29677.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6153.15,1788.99,10956.48,98,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],28066.4,17239.56,37862.61,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],9586.14,9586.14,9586.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5893.94,5893.94,8259.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],35896.77,35896.77,35896.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,26147.1,17436.58,31440.79,11,percent of total billed charges,,,
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],7340.12,7340.12,7340.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4129.26,4129.26,4129.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],5974.09,5974.09,5974.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4097.45,4097.45,4097.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],26829.96,19408.71,29341.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],27607.94,27607.94,27607.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],7467.61,7340.12,7468.41,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],17699.98,17699.98,17699.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 7 Radiation Therapy,5627,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",306.1,306.1,306.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],53.87,43.1,1815.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],37.96,30.55,272.16,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,195.86,92.48,601.83,323,percent of total billed charges,,,
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],46.18,42.76,51.3,159,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,92.48,92.48,273.86,12,percent of total billed charges,,,
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",254.9,28.64,1976.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,34.95,30.55,1617.34,1 through 10,percent of total billed charges,,,
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],51.3,51.3,51.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,583.32,148.21,5671.43,1 through 10,percent of total billed charges,,,
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",79.26,28.64,502.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1658.81,1658.81,1658.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28.64,28.24,377.12,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],4917.89,4917.89,6574.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],43.1,43.1,1390.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28.64,28.64,924.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],94.23,87.26,2330.96,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],189.68,129.68,303.19,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28.64,28.24,883.26,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],51.5,46.4,1312.81,336,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],232.58,155.32,793.37,191,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],197.8,140.62,248.95,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],161.9,156.58,323.8,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],51.3,47.51,51.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],340.2,189.54,890.19,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28.64,28.64,28.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],172.77,172.77,971.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],564.91,564.91,564.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],164.54,164.54,288.27,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,607.1,216.27,3687.81,44,percent of total billed charges,,,
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,283.35,283.35,283.35,1 through 10,percent of total billed charges,,,
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],167.9,167.9,167.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,450.36,450.36,450.36,1 through 10,percent of total billed charges,,,
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],164.54,164.54,164.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,426.73,426.73,426.73,1 through 10,percent of total billed charges,,,
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,321.89,321.89,321.89,1 through 10,percent of total billed charges,,,
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",175.12,175.12,1976.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",91.85,91.85,91.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",91.85,91.85,91.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],302.22,272.22,963.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",91.85,89.02,210.42,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],340.71,102.74,1904.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],253.88,108.13,1486.96,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],164.54,164.54,291.63,69,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],272.8,272.8,272.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],296.86,296.86,975.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],299.7,299.7,1777.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",160.92,160.92,160.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],362.67,362.67,2973.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],170.06,65.21,1071.83,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1489.1,360.41,25897.72,300,percent of total billed charges,,,
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],345.4,310.87,3270.65,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",279.24,192.81,617.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,27191.36,652.7,34128.29,1 through 10,percent of total billed charges,,,
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,791.86,446.31,1538.6,16,percent of total billed charges,,,
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,971.42,445.73,1546.18,1 through 10,percent of total billed charges,,,
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],192.81,192.81,192.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,665.46,665.46,1599.18,1 through 10,percent of total billed charges,,,
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],414.42,414.42,414.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",609.25,256.23,1976.21,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",192.81,192.81,268.88,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],2824.87,2824.87,2824.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,367.46,367.46,367.46,1 through 10,percent of total billed charges,,,
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],570.03,570.03,570.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",261.88,192.81,766.72,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],658.24,475.81,2330.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",224.75,192.81,750.48,77,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],345.6,315.37,2862.81,146,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],804.96,195.62,2103.14,146,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],520.98,232.69,2034.06,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1305.3,486.56,13200.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1394.76,869.16,47285.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],377.44,377.44,377.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],993.77,446.31,6690.4,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",617.46,617.46,617.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],9663.95,9663.95,9663.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,9891.54,3648.93,15271.75,32,percent of total billed charges,,,
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,1534.06,1536.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],960.27,960.27,1932.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,42806.83,18554.71,56324.11,1 through 10,percent of total billed charges,,,
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,9712.34,9712.34,9739.01,1 through 10,percent of total billed charges,,,
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,592.42,12253.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,1519.4,1538.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",868.45,868.45,868.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1440.68,1440.68,1440.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,896.4,1562.01,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],4487.75,2417.3,7504.37,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1036.55,784.57,1067.16,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],6341.02,6341.02,6341.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2925.01,2925.01,2925.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3749.74,3749.74,3749.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1534.06,1534.06,1534.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],14.88,9.89,2433.13,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],53.44,42.75,54.79,311,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,45.91,7.82,8893.79,563,percent of total billed charges,,,
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1181.74,17.91,3171.58,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24.73,24.73,1444.45,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,52.78,52.78,52.88,31,percent of total billed charges,,,
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,54.79,43.83,54.79,40,percent of total billed charges,,,
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,53.55,38.62,53.55,48,percent of total billed charges,,,
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],2635.61,2635.61,2815.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,53.23,11.81,53.23,1 through 10,percent of total billed charges,,,
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24.73,24.73,1608,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,5251.92,5251.92,5251.92,1 through 10,percent of total billed charges,,,
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24.73,24.73,1700,126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],81.38,81.38,442.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],2445.6,2445.6,2573.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24.73,24.73,1900,139,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],76.5,58.5,1012,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9.9,9.89,1419.18,677,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],18.09,14.18,2758.79,572,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],50.91,44.29,50.91,176,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],50.91,42.94,50.91,2420,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],50.91,50.72,50.91,82,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],50.72,44.12,58.33,141,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2638.76,2638.76,2638.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],54.79,38.13,54.79,394,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24.73,24.73,8504.37,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],490.07,70.75,2974.93,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],295.11,72.9,13120.61,143,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,213.4,70.23,3946.57,1454,percent of total billed charges,,,
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],204.03,68.34,3464.33,135,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",115.13,38.15,518.51,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,330.72,95.35,30479.11,32,percent of total billed charges,,,
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,278.03,72.91,4512.19,59,percent of total billed charges,,,
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,5848.9,156.97,6336.1,58,percent of total billed charges,,,
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],420.21,54.07,3577.99,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,151.8,104.92,412.29,1 through 10,percent of total billed charges,,,
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.2,38.15,370.6,127,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",38.15,36.71,338.76,196,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],2862.63,227.5,3929.34,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],109.06,57.86,2196.41,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",38.15,36.71,328.86,215,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],125.51,38.15,1986.36,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.2,36.71,1294.57,1548,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],251.26,67.16,9447.15,1108,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],165.71,67.48,4562.47,235,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],246.44,68.72,2719.27,968,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],162.21,72.7,2241.58,63,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],275.36,80.32,2633.29,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1464.03,1464.03,1795.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],402.35,98.4,3946.57,134,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",107.22,107.22,107.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",38.15,36.71,776.02,80,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Drug Administration,5692,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],425.81,203.67,1637.1,142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],244.36,173.21,5924.83,140,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,569.76,257.78,5735.33,2224,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",180.6,112.93,1295.27,140,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,828.09,340.49,74967.31,69,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],202.3,187.93,3116.27,143,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],377.9,377.9,1340.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",243.47,243.47,243.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,648.61,270.56,7425.44,65,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1178.41,174.07,28734.1,17,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],255.44,206.28,2033.84,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,2908.93,466.04,4899.24,1 through 10,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,357.48,357.48,357.48,1 through 10,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",182,112.93,3784.64,150,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,361.23,361.23,361.23,1 through 10,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",112.93,112.93,2742.53,376,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],522,371.57,32644.13,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,319.87,275.07,329.67,1 through 10,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],191.25,191.25,191.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",197.94,112.93,4891.58,170,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],477.38,315.83,13758.55,106,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",200.91,112.93,3539.74,1473,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],637.45,197.92,7660.37,1517,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],575.23,163.83,5485.4,335,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],247.62,188.7,5898.42,2042,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],263.52,167.96,6548.43,168,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],306.4,107.75,6705.22,112,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1001.27,1001.27,1001.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],475.15,203.59,9667.93,256,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",225.86,112.93,15026.86,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3568.09,570.95,24438.53,97,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],10494,482.01,43101.84,200,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2372.24,318.48,18948.28,274,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3020.2,712.11,36604.53,1825,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",812.94,278.82,8564.24,156,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1648.76,659.56,44609.94,101,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],12163.64,1707.86,12194.78,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,10816.49,657.72,105089.59,90,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2635.59,592.34,69668.44,18,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],486.52,358.72,35445.98,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,986.42,585.96,6685.36,24,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,2592.19,932.37,2724.19,1 through 10,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",463.57,240.67,8570.38,138,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],11950.88,442.21,12754.39,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",832.64,165.29,7031.89,217,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],20772.32,554.64,55097.36,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,285.6,285.6,285.6,1 through 10,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],12292.65,334.41,22364.32,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",731.59,202.52,12902.22,261,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],3948.85,875.04,22289.72,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",887.36,254.09,7070.11,1323,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],2254.71,857,27938.34,281,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],3145.52,372.56,15636.13,1946,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2395.71,767.14,36663.89,1517,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1074.76,382.94,18997.44,97,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],2223.08,649.05,17574.23,127,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],971.65,968.94,971.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2608.99,600.06,37172.11,196,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6455.68,271.59,19389.37,110,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],143.81,58.7,159.25,70,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],525.35,124.07,538.65,140,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,458.46,126.36,538.65,1915,percent of total billed charges,,,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],150.23,60.08,273.96,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,337.77,160.18,538.65,17,percent of total billed charges,,,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",83.86,81.41,244.23,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,457.41,150.85,538.65,73,percent of total billed charges,,,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,523.36,328.18,3227.36,1 through 10,percent of total billed charges,,,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,421.18,186.05,526.48,53,percent of total billed charges,,,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],153.3,55.9,300.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],153.33,153.33,153.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",83.86,81.41,152.93,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,222.41,222.41,222.41,1 through 10,percent of total billed charges,,,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],117.36,117.36,117.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",83.86,83.86,140.14,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],110.36,55.18,275.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",83.86,81.41,152.93,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],126.2,126.2,126.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],275.94,206.96,347.61,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",83.86,33.54,140.86,253,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],136.96,60.08,273.96,1274,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],205.67,117.42,391.39,102,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],235,110.22,392.91,591,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],434.13,108.97,573.41,95,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],226.62,77.56,313.88,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],150.83,150.83,451.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],468.99,145.28,538.65,252,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",83.86,83.86,251.58,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],160.97,160.97,160.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],329.52,251.16,412.69,145,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],405.21,201.85,748.44,241,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],324.56,299,392.68,272,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,452.63,243.06,748.44,3017,percent of total billed charges,,,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,404.92,166.91,748.44,45,percent of total billed charges,,,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",210.51,166.91,235.98,203,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],355.61,305.1,400.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",166.91,166.91,235.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,550.8,250.03,987.03,129,percent of total billed charges,,,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],355.61,328.14,400.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,415.22,261.03,765.73,86,percent of total billed charges,,,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],377.58,293.89,429.37,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,486.71,245.14,1352.38,17,percent of total billed charges,,,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.98,166.91,235.98,244,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,235.98,235.98,1243.49,1 through 10,percent of total billed charges,,,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],392.28,392.28,392.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.98,166.91,235.98,362,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],549.18,411.88,731.96,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.98,166.91,235.98,260,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],251.16,251.16,355.1,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],467.86,311.49,549.18,83,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",191.15,166.91,235.98,1491,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],304.52,275.21,392.28,2475,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],352.16,223.07,1001.49,286,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],352.16,204.65,640.11,1871,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],340.14,211.77,788.53,136,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],352.16,173.36,568.29,91,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],299.8,269.6,570.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.98,166.91,235.98,126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],513.86,271.62,871.65,355,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",235.98,166.91,235.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2475.07,671.43,4276.27,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],534.94,394.45,851.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2409.69,638.75,4286.03,730,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],509.47,372.68,736.35,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",368.26,360.75,451.31,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,769.15,639.79,3452.62,1 through 10,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],430.64,430.64,430.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,2537.73,681.21,4851.09,31,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2480.4,765.51,3845.29,22,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],663.71,509.47,663.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,2095.82,775.76,2475.93,1 through 10,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,659.35,640.09,766.16,1 through 10,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",368.26,284.4,498.05,94,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],587.32,587.32,587.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",368.26,284.4,652.66,105,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1211.71,985.72,1211.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,2816.8,2816.8,2816.8,1 through 10,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],554.16,492.11,2321.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",368.26,284.4,652.66,89,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],908.79,283.1,4892.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],509.47,364.97,672.68,300,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",368.26,218.98,652.66,359,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],985.72,623.94,4032.96,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1513.93,515.11,4027.67,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1184.81,427.46,3618.6,347,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1053.17,451.36,10525.43,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],510.27,510.27,510.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2537.73,747.57,4391.18,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",368.26,360.75,1037.05,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],399.25,312.3,411.8,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],3400.95,1593.56,5920.26,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,3365.65,2440.94,5858.81,972,percent of total billed charges,,,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],390.76,366.7,395.76,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,3487.05,2964.5,6070.14,12,percent of total billed charges,,,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",544.91,218.13,545.32,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],398.73,398.73,398.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.13,218.13,218.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3400.95,1295.87,6070.14,25,percent of total billed charges,,,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,3408.27,1926.62,5933,39,percent of total billed charges,,,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],829.88,829.88,980.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",544.91,218.13,545.32,126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,544.91,544.91,544.91,1 through 10,percent of total billed charges,,,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.13,217.96,545.32,169,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1345.71,717.71,1794.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.13,217.96,545.32,108,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],820.58,820.58,6685.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1683.81,475.25,1794.28,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.13,217.96,545.32,694,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],390.76,361.36,391.36,388,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1647.16,951.78,3460.06,619,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1593,1071.64,2530.36,74,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1434.93,545.32,1647.16,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1647.16,946.02,3979.07,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],977.48,977.48,977.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],3487.05,2196.87,6070.14,90,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",544.91,217.96,545.32,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],8626.65,8626.65,8626.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],262.07,262.07,432.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],348.73,103.68,755.34,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,419.8,123.29,877.23,358,percent of total billed charges,,,
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],70.53,37.95,333.99,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,387.81,210.68,792.7,13,percent of total billed charges,,,
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",87.67,24.8,130.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],239.94,239.94,239.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,422.54,170.1,1082.76,14,percent of total billed charges,,,
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,263.26,156.32,734.17,1 through 10,percent of total billed charges,,,
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,272.73,272.73,272.73,1 through 10,percent of total billed charges,,,
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],344.45,344.45,344.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",139,40.09,232.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",63.06,20.94,155.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",88.64,58.84,90,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],184.76,114.6,373.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],298.02,87.98,458.93,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",75.83,13.13,179.59,92,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],213.14,67.76,557.74,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],265,87.82,555.66,331,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],174.5,40,443.41,160,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],113,30.6,471.52,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],395.4,291.76,628.46,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15.52,15.52,15.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],430.11,179.82,694.98,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],40,37.07,40.38,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],158,100,177.39,91,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,151.23,121.15,177.39,1011,percent of total billed charges,,,
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],37.69,35.16,38.46,145,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21.04,20.9,90.11,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,170.89,124.74,325.62,18,percent of total billed charges,,,
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],249.8,249.8,249.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21.04,21.04,21.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,141.75,117.57,177.39,52,percent of total billed charges,,,
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,157.4,110.18,317.96,1 through 10,percent of total billed charges,,,
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,148.33,118.82,173.38,34,percent of total billed charges,,,
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],37.69,37.69,37.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],38.47,38.47,38.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],38.09,38.09,38.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21.04,20.9,120.32,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21.04,21.04,113.14,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],69.23,51.92,69.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],31.65,31.65,286.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21.04,21.04,113.14,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],69.23,48.44,69.23,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21.04,20.9,113.14,448,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],131.72,114.72,164.84,136,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],37.69,35.16,37.69,1631,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],143.21,114.57,228.26,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],131.72,95.95,164.84,697,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],143.21,60.3,188.84,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],38.46,38.29,38.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],162,113.4,177.39,120,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21.04,21.04,21.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21.04,21.04,21.04,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Minor Procedures,5732,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],112.59,65.61,140.13,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],60.13,31.84,61.11,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,112.59,90.47,358.86,514,percent of total billed charges,,,
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31.84,31.84,58.92,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],57.44,54.04,76.36,79,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,112.59,108.46,140.13,1 through 10,percent of total billed charges,,,
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,112.59,98.01,203.11,15,percent of total billed charges,,,
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],57.04,53.64,57.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,110.05,102.7,280.35,18,percent of total billed charges,,,
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,87.51,51.78,109.39,1 through 10,percent of total billed charges,,,
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31.84,31.84,139,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,31.84,31.84,31.84,1 through 10,percent of total billed charges,,,
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],47.24,47.24,47.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31.84,31.84,31.88,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],104.76,104.76,104.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],47.91,45.06,135.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31.84,31.84,100.91,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],98.51,78.57,104.76,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31.84,31.84,113.82,153,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],57.04,53.64,285.2,830,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],90.73,28.88,173.87,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],103.11,42.6,578.04,306,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],104.63,36.05,145.17,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],102.71,50.66,461.21,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],57.64,57.64,57.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],112.59,92.55,421.76,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31.84,31.84,51.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],129.95,117.6,129.95,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],111.91,26.31,205.82,331,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,554.26,156.85,831.87,3334,percent of total billed charges,,,
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],123.76,104.16,124.16,131,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,372.28,86.94,736.46,57,percent of total billed charges,,,
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",113.94,69.09,113.94,95,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,159.14,48.19,817.29,141,percent of total billed charges,,,
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,660.28,174.18,820.2,108,percent of total billed charges,,,
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],123.76,123.76,155.5,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,597.34,173.14,808.25,22,percent of total billed charges,,,
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],184.53,184.53,184.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",112.34,66.58,116.49,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",113.94,69.09,116.49,120,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],227.32,227.32,266.76,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,52.32,52.32,52.32,1 through 10,percent of total billed charges,,,
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",113.94,69.09,128.14,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],251.15,205.72,251.15,75,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],103.96,103.96,130.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",113.94,69.09,116.49,686,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],123.76,112,123.96,957,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],418.03,106.25,671.73,2375,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],326.87,76.4,671.73,285,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],418.03,106.25,737.93,235,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],369.9,99.04,699.06,140,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],123.76,123.76,123.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],698.2,178.2,891,505,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",112.34,66.58,118.59,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],3200.33,3200.33,3200.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",313.89,313.89,313.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],383.15,383.15,383.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,202.5,102.86,4104.1,130,percent of total billed charges,,,
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",823.89,823.89,823.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,202.5,202.5,4629.59,1 through 10,percent of total billed charges,,,
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,158.34,158.34,162.64,1 through 10,percent of total billed charges,,,
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,196.75,196.75,196.75,1 through 10,percent of total billed charges,,,
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",207.66,85.56,291.04,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",213.89,85.56,1501.4,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],703.75,703.75,703.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.56,85.56,213.89,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],155.76,153.57,383.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",207.66,85.56,1501.4,77,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],188.18,188.18,248.85,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],188.18,131.73,333.17,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],202.5,202.5,7876.79,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1501.4,1501.4,1501.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Minor Procedures,5735,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],36.86,29.49,79.77,153,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],36.54,28.65,38.37,800,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],36.17,17.9,36.17,2110,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,36.86,35.5,133,3466,percent of total billed charges,,,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,50.44,35.5,133,137,percent of total billed charges,,,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19.99,19.65,19.99,151,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],36.54,33.74,36.54,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19.99,19.99,19.99,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,36.86,33.17,52.26,74,percent of total billed charges,,,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],35.81,33.74,36.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,36.02,28.82,67.87,105,percent of total billed charges,,,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,66.47,35.81,101.62,74,percent of total billed charges,,,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],35.81,33.48,35.81,394,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19.99,19.99,28.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,105.46,105.46,105.46,1 through 10,percent of total billed charges,,,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],36.54,36.54,36.54,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],35.81,35.81,35.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,79.25,79.25,79.25,1 through 10,percent of total billed charges,,,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19.99,19.65,19.99,144,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19.99,19.65,19.99,268,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],47.5,33.31,65.77,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,15.92,15.92,15.93,1 through 10,percent of total billed charges,,,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19.99,19.65,19.99,168,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],28.65,26.78,34.72,70,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],58.18,44.41,65.77,108,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],35.81,33.07,35.81,14479,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19.99,19.65,19.99,666,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],45.5,34.25,49.73,1488,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],43.61,34.12,48.56,316,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],45.5,38.68,66.52,114,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],45.5,34.25,48.56,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],35.81,35.81,35.81,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],36.86,34.31,62.31,268,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",19.99,19.65,19.99,144,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Electronic Analysis of Devices,5741,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],38.37,38.37,38.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],92.84,89.48,92.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,490.16,353.73,709.08,22,percent of total billed charges,,,
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1000.63,1000.63,1000.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",118.27,118.27,118.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,736.06,613.1,736.06,1 through 10,percent of total billed charges,,,
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",49.2,49.2,49.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,49.2,49.2,49.2,1 through 10,percent of total billed charges,,,
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",118.27,69.07,118.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",49.2,49.2,118.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],191.05,191.05,191.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],191.05,157.2,377.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],88.13,84.88,88.13,68,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],211.79,211.79,211.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],406.07,406.07,882.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electronic Analysis of Devices,5742,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,4011.53,2210.94,8758.64,1 through 10,percent of total billed charges,,,
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",298.89,229.82,673.67,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",294.6,294.6,1047.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",288.42,224.56,604.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2169.72,294.09,2175.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],3347.33,3347.33,3347.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],894.18,382.38,1532.88,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1297.6,418.7,5478.84,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1111.68,370.56,2071.8,322,percent of total billed charges,,,
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",337.45,202.47,539.92,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1033.9,370.56,2977.6,1 through 10,percent of total billed charges,,,
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],725.34,231.74,1450.68,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1441.8,510.3,4393.04,22,percent of total billed charges,,,
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,1400.85,208.56,6724.08,1 through 10,percent of total billed charges,,,
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1127.4,1127.4,1127.4,1 through 10,percent of total billed charges,,,
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],967.12,370.37,1208.9,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1781.76,549.57,2747.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",472.43,134.98,742.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",337.45,67.49,1362.44,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],814.02,101.55,1459.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],1110.25,666.15,1998.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1339.8,472.38,3483.48,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",269.96,67.49,809.88,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],734.05,121.29,2058.73,821,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1339.8,267.96,3483.48,181,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],993.5,397.4,1788.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1875.72,1071.84,5895.12,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1020.6,429.3,2575.8,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",162.61,162.61,404.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2848.51,2270.6,3271.81,14,percent of total billed charges,,,
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],2843.57,2843.57,2843.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",716.65,716.65,716.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1301.72,1039.6,1603,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2872.06,2411.87,4514.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],3706.22,3706.22,3706.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],467.82,433.8,27436.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,467.82,424.04,4424.43,59,percent of total billed charges,,,
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,433.8,433.8,433.8,1 through 10,percent of total billed charges,,,
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1419.18,1419.18,1608,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,180.05,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,178.09,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1419.18,109.02,1608,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],99.26,54.14,436.81,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],195.29,187.01,198.31,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],1578.78,207.11,1598.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],85.33,85.16,1358.23,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],183.52,183.52,183.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1239.75,1239.75,1239.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",109.02,109.02,109.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",812.54,812.54,812.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],2464.54,2464.54,2464.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13.56,13.56,13.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],25.81,25.81,25.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Manipulation Therapy,5811,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],894.9,851.7,1185.38,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,841.25,37.3,1222.35,53,percent of total billed charges,,,
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.04,85.04,177.16,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.04,85.04,85.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1087.33,1087.33,1087.33,1 through 10,percent of total billed charges,,,
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",169.06,69.07,192.09,57,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.04,83.84,177.16,82,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",108.07,85.04,177.16,72,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],10.46,10.46,10.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",108.07,83.84,192.09,418,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],702.04,702.04,702.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],223.19,46.06,1271.51,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1706.49,1706.49,1706.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],768.26,180.55,858.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],487.26,239.18,2120.14,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.04,85.04,177.16,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Health and Behavior Services,5821,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,49.88,49.88,49.88,1 through 10,percent of total billed charges,,,
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",49.58,49.58,49.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",49.58,49.58,49.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],63,63,63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Health and Behavior Services,5822,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],162.78,122.78,542.61,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],749.29,404.55,1304.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,94.51,47.26,238.47,83,percent of total billed charges,,,
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],154.27,154.27,516.01,87,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",86.12,86.12,218.98,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,94.51,94.51,94.51,1 through 10,percent of total billed charges,,,
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,90.21,80.27,160.54,64,percent of total billed charges,,,
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,156.91,105.76,198.2,49,percent of total billed charges,,,
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],516.01,516.01,516.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,542.71,542.71,542.71,1 through 10,percent of total billed charges,,,
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",86.12,83.09,218.98,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",86.12,83.09,218.98,68,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],423.56,423.56,423.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],129.59,129.59,233.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",86.12,83.09,218.98,74,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],283.36,108.68,549.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",86.12,83.09,218.98,471,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],473.72,87.49,601.9,101,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],154.27,139.8,516.01,617,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],314.48,87.83,542.97,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],424.11,47.52,571.71,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],517.64,87.83,817.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],124.87,124.87,362.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],224,154.9,830.14,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",218.98,202.38,218.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Health and Behavior Services,5823,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1885.49,1885.49,1885.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",900.55,900.55,1804.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1490.14,1490.14,1490.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3615.93,3182.47,14360.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Alteplase recombinant,7048,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,575.83,575.83,575.83,1 through 10,percent of total billed charges,,,
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,728.91,728.91,728.91,1 through 10,percent of total billed charges,,,
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],471.79,471.79,471.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mmrv vaccine sc,9011,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1302.67,1302.67,1302.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj glucagon hcl, fresenius",9025,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",115.79,115.79,115.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Glucagon hydrochloride,9042,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1566.46,1566.46,1566.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2056.62,2056.62,2056.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit esrd on dialysi,9096,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,21320.32,17450.12,26417.25,1 through 10,percent of total billed charges,,,
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",196.65,196.65,196.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2246.26,2246.26,2343.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj retacrit non-esrd use,9097,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,955.18,955.18,955.18,1 through 10,percent of total billed charges,,,
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Rabies vaccine, im",9139,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],12036.09,12036.09,12036.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Agalsidase beta injection,9208,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2629.99,2213.02,16700.87,1 through 10,percent of total billed charges,,,
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6278.29,6278.29,6278.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,2674.73,2674.73,2674.73,1 through 10,percent of total billed charges,,,
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",360.6,360.6,360.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],6285.6,6285.6,6285.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],3187.53,3187.53,8621.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],23833.42,23833.42,23833.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],187.37,137.19,295.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],381.51,299.7,834.2,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,397.71,299.7,707.31,230,percent of total billed charges,,,
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],122.86,114.84,230.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,391.75,391.75,391.75,1 through 10,percent of total billed charges,,,
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",203.01,113.14,312.67,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,639.9,455.15,1208.03,1 through 10,percent of total billed charges,,,
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,546.28,546.28,546.28,1 through 10,percent of total billed charges,,,
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",161.19,128.08,316.47,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],108.28,108.28,108.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",179.05,111.95,332.02,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",134.98,88.06,318.74,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],136.27,136.27,144.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],228.85,210.92,522.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",156.95,88.06,311.02,305,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],137.69,97.82,248.1,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],355.88,221.87,747.38,170,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],336.52,239.03,605.33,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],395.11,293.7,768.3,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],344.16,274.56,1052.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],600.21,495.72,825.53,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",129.35,92.1,313.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Covid-19 Vaccine Administration,9398,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],46329.36,46329.36,46329.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,27836.89,20398.67,41803.94,31,percent of total billed charges,,,
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],10580.02,10580.02,10580.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3829.04,3829.04,3829.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],7303.18,7068.96,7823.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],16103.83,16103.83,16103.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],10676.59,10676.59,33147.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],12463.36,12463.36,12463.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Instill, bupivac and meloxic",9440,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],7293.01,137.57,29050.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],7474.98,7474.68,18749.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inj talimogene laherparepvec,9472,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,421740.1,400387.96,422119.17,1 through 10,percent of total billed charges,,,
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",80577.59,80577.59,81038.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",80681.14,80681.14,80681.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",82716.93,82716.93,82716.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",80384.19,80380.65,81038.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],136.41,135.78,365.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1139.75,474.63,145129.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, nusinersen, 0.1mg",9489,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],778.6,778.6,778.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1588.27,1337.79,1588.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1147.81,1090.94,1553.83,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,1583.09,1583.09,1583.09,1 through 10,percent of total billed charges,,,
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2083.22,1552.6,6303.76,68,percent of total billed charges,,,
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",495.42,495.42,632.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,3483.57,3483.57,3483.57,1 through 10,percent of total billed charges,,,
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",632.53,553.49,742.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",701.6,701.6,702.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,760.24,760.24,760.24,1 through 10,percent of total billed charges,,,
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11723.88,11723.88,11723.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1137.63,677.42,1371.96,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1090.94,897.13,2070.24,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],971.73,930.01,1686.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2066.91,1412.04,3329.78,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1147.81,1147.81,1147.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2146.84,1853.3,2389.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",691.6,691.6,31737.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Platelet pheres leukoreduced,9501,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,7605.37,7605.37,7670.26,1 through 10,percent of total billed charges,,,
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1404.42,1402.64,1406.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1094.98,1094.98,1297.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1256.94,1133.21,2000.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2000.68,2000.68,2000.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1825.83,1825.83,1825.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1419.18,1419.18,1419.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,4840.17,4840.17,4840.17,1 through 10,percent of total billed charges,,,
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2979.53,2391.04,3871.62,15,percent of total billed charges,,,
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Washed red blood cells unit,9518,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],967.2,967.2,1180.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1798.45,1361.86,7192.96,52,percent of total billed charges,,,
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],921.14,921.14,1398.5,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,2139.15,2139.15,2708.33,1 through 10,percent of total billed charges,,,
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1757.82,1331.09,2734.59,14,percent of total billed charges,,,
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",935.19,935.19,935.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",577.62,577.62,1700,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",508.55,508.55,508.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",868.34,508.55,1129.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],921.14,875.49,1190.66,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],823.34,823.34,823.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1783.99,1318.14,2955.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],232284.36,232284.36,232284.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",508.55,502.45,690.55,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",912.15,234.33,1049.26,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1536.74,1536.74,1536.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Platelets, hla-m, l/r, unit",9525,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],703.98,703.98,703.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],2031.63,1702.59,85768.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2276.97,1702.59,3712.85,127,percent of total billed charges,,,
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1245.98,920.88,1587.31,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6250.11,495.42,31298.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1354.5,1354.5,1798.21,1 through 10,percent of total billed charges,,,
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",443.59,385.31,544.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",577.62,577.62,577.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",527.5,234.33,9037.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",371.44,234.33,631.68,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],1285.58,920.88,2278.58,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],1523.54,1282.71,2628.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],2361.44,1815.64,3923.04,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1844.9,1844.9,1844.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],2120.8,1863.76,148051.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",295.13,295.13,32630.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Platelets pheresis path redu,9536,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],35.12,13.76,98.93,4743,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],36.44,10.18,104.04,9448,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,100.77,30.44,307.53,117523,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],33.36,13.11,90.17,11674,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",25.07,8.69,85.07,2211,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,85.06,19.98,280.67,1837,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],39.75,14.93,100.45,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23.91,16.05,64.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,70.17,25.47,221.94,4282,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],127.84,127.84,127.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,114.79,36.5,320.56,3492,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,118.84,118.84,118.84,1 through 10,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24.49,4.33,69.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,106.25,30.7,365.17,629,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],38.26,16.52,94.65,889,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],32.65,26.93,55.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,60.3,12.94,137.12,26,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],27.42,9.79,85.36,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28.3,9.03,94.64,1830,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24.15,8.37,83.51,2126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],85.39,23.1,271.89,389,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,6.3,6.3,31.15,1 through 10,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23.24,7.17,79.57,2602,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],23.45,10.8,85.9,674,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],74.58,26.5,201.53,3079,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",25.41,9.03,82.48,24146,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],32.74,13.11,87.5,123069,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],76.71,24.45,215.69,15594,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],77.15,23.9,245.38,81542,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],83.46,26.85,275.93,5714,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],71.3,22.76,224.25,4977,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],36.34,13.11,94.3,498,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],119.07,40,357.21,13363,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18.82,4.41,85.22,955,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.28,69.28,69.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],61.15,42.85,82.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],169.57,68.24,410.78,636,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],323.54,106.94,765.04,1231,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,361.28,121.5,905.61,15995,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],177.23,68.28,404.6,1104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",98.38,37.6,225.85,796,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,346.46,123.84,905.82,232,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],101.56,101.56,101.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",66.48,66.48,66.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,385.95,114.95,1000.35,568,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,337.39,110.1,869.29,425,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],147.93,59.17,401.07,127,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,354.16,91.83,723.52,85,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",76.62,36.43,203.04,717,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,363.38,182.34,1198.64,1 through 10,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],168.01,100.47,542.97,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],213.45,81.15,815.19,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.73,35.9,213.19,1043,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,105.35,42,368.95,1 through 10,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],251.4,111.11,608.09,438,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.58,31.46,222.48,956,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],137.06,57.75,291.52,112,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",88.9,37.02,203.39,7371,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],186.39,69.25,417.3,12475,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],208,88.76,491.31,1855,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],214.03,87.83,497.17,12966,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],204.14,80.76,512.54,712,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],197.24,71,493.1,623,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],139.28,49.65,331.53,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],357.66,107.5,881.28,1848,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",76.62,30.98,198.21,360,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",39.26,26.2,161.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Therapy Services,N801,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],26.82,26.82,174.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],105.91,105.91,108.98,294,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],415.53,405.27,478.71,725,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,415.53,400.3,478.71,9142,percent of total billed charges,,,
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,415.53,400.3,520.22,123,percent of total billed charges,,,
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],100.88,100.88,103.8,622,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55.17,55.17,55.17,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],102.93,102.93,102.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,415.53,405.27,478.71,330,percent of total billed charges,,,
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,406.15,406.15,467.9,279,percent of total billed charges,,,
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,403.73,403.73,465.12,43,percent of total billed charges,,,
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],100.88,100.88,103.8,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],100.88,100.88,117.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55.17,55.17,57.94,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55.17,55.17,57.94,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],185.28,132.36,185.28,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55.17,55.17,57.94,92,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],185.28,185.28,190.65,248,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],105.91,105.91,108.98,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],100.88,100.88,103.8,7590,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55.17,55.17,57.94,1030,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],338.7,327.56,338.7,1577,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],338.7,327.56,338.7,6661,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],339.25,327.56,389.5,381,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],338.7,327.56,338.7,385,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],100.88,100.88,103.8,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55.17,55.17,60.43,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],415.53,415.53,532.17,1075,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mammography Services,N804,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],108.08,108.08,108.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],573.54,321.56,574.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],408.86,303.18,719.71,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,355.17,239.4,581.69,257,percent of total billed charges,,,
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],382.81,292.21,807.45,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",76.82,66.48,199.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,399.68,399.68,399.68,1 through 10,percent of total billed charges,,,
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,465.35,327.09,718.13,1 through 10,percent of total billed charges,,,
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,303.83,191.5,625.76,1 through 10,percent of total billed charges,,,
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,296.27,296.27,302.03,1 through 10,percent of total billed charges,,,
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",107.47,82.86,142.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],1000.22,718.13,1000.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],314.01,314.01,314.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],421.13,315.85,1000.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",90.67,26.2,538.64,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],383.77,288.86,652.71,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],379.94,226.7,722.99,152,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],384.37,232.82,648.51,146,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],435.25,287.75,718.13,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],464.24,288.86,798.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],306.25,306.25,435.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],408.86,244.9,581.69,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9402.46,9402.46,9402.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Durable Medical Equipment,N805,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],22.28,11.45,97.29,71,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],245.43,22.29,816.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,454.91,199.54,927.77,65,percent of total billed charges,,,
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],22.94,12.34,31.74,216,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12.55,6.75,17.36,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,97.34,97.34,97.34,1 through 10,percent of total billed charges,,,
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],507.09,507.09,507.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,52.65,26.28,234.9,18,percent of total billed charges,,,
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,41.1,24.85,638.91,19,percent of total billed charges,,,
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],31.74,23.02,31.77,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12.55,6.75,17.73,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],31.74,31.74,31.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12.55,6.75,17.36,63,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],31.6,31.6,31.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],26.17,19.27,26.67,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12.55,6.75,17.36,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],42.28,22.77,551.38,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12.55,6.75,17.36,440,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],272.22,235.66,580.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],23.41,12.59,69.63,1803,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],324.21,158.84,585.45,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],412.15,412.15,412.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],367.89,367.89,367.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],21.65,21.65,21.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],52.56,26.28,88.29,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12.85,6.92,17.36,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],187.4,187.4,370.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],805.95,805.95,805.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,2390.53,1533.25,7002.24,12,percent of total billed charges,,,
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",328.62,328.62,328.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,81.81,81.81,81.81,1 through 10,percent of total billed charges,,,
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1419.18,1419.18,1419.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,202.32,202.32,202.32,1 through 10,percent of total billed charges,,,
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1419.18,1419.18,1419.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1419.18,334.76,1608,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1966.05,1966.05,2127.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],1299.25,1299.25,1299.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",334.76,334.76,1419.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Observation, Other",N811,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],275,56.28,1394.2,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,535.52,69.07,2016.04,85,percent of total billed charges,,,
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],618.46,618.46,650.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,68.89,69.07,139,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,194.4,169.4,194.4,14,percent of total billed charges,,,
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,190.01,186.38,208.34,32,percent of total billed charges,,,
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,68.89,69.07,183,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,68.89,69.07,199,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],113.18,113.18,113.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],623.78,623.78,623.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,68.89,69.07,232,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],179.29,86.69,535.45,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,68.89,69.07,1847,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],181.91,66,3681.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],264,59.4,823,94,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],191.63,46.3,699.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],362.74,145.53,713.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],194.4,194.4,251.91,92,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,56.28,69.07,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69.07,69.07,69.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-covered Services,N900,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],9.22,3.82,143.8,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],10,10,25.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,25.02,10.37,147.42,540,percent of total billed charges,,,
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],509.47,9.52,509.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11.17,2.69,168.93,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,29.96,12.96,84,1 through 10,percent of total billed charges,,,
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,48.42,42.69,929.66,27,percent of total billed charges,,,
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,62.96,62.96,62.96,1 through 10,percent of total billed charges,,,
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],20.26,20.26,20.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,63.34,5.38,209.7,11,percent of total billed charges,,,
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",98.54,5.38,168.95,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",75.56,2.69,191.98,68,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],138.73,138.73,241.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",76.83,2.75,186.91,99,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],13.99,3.08,432.69,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",76.83,2.69,168.95,737,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],53.37,31.11,188,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],9.71,5.2,509.47,79,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],55.17,33.31,148.79,417,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],63.89,47.89,216.11,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],39.75,33.87,458.39,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],64,51.84,251.1,71,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",76.25,2.75,168.95,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],117.75,117.75,117.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],235.59,96.39,873.28,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,154,37.31,873.28,326,percent of total billed charges,,,
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],111.72,111.72,118.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",138.16,61.33,161.19,68,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,120.17,120.17,120.17,1 through 10,percent of total billed charges,,,
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,241.56,106.11,983.55,17,percent of total billed charges,,,
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,274.43,204.27,358.83,13,percent of total billed charges,,,
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,326.95,326.95,326.95,1 through 10,percent of total billed charges,,,
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",115.13,91.92,161.19,144,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",115.13,69.07,184.04,117,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",115.13,91.92,177.14,213,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],205.97,205.2,241.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",115.13,68.89,161.19,1330,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],344.08,112.34,348.31,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],184.24,46.06,805.06,183,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],127.54,46.06,1846.27,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],227.4,69.09,1035.69,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],77.11,77.11,741.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],222.75,106.11,711.74,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",138.16,92.1,161.19,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",92.1,92.1,92.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Recognized by OPPS,N905,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [OP High Cost Drugs (%BC): 81] [Other Outpatient Implant (%BC): 81] [All Other OP (%BC): 81],1491.98,1491.98,1491.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,BCBS,All Commercial Plans,,79.34,,1257.91,632.41,1897.09,1 through 10,percent of total billed charges,,,
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,BCBS,Exchange,,79.34,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 65],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Cofinity,All Commercial Plans,,76,,1881.21,1881.21,1881.21,1 through 10,percent of total billed charges,,,
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1685.22,1685.22,1803.71,1 through 10,percent of total billed charges,,,
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 60],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,All Commercial Plans,,66.89,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.02,85.02,85.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Exchange,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 55],406.62,406.62,406.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",177.32,177.32,177.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE] [All Other OP (%BC): 50],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.02,85.02,85.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 79.49] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 75.27],1390.01,661.35,1483.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 66.07] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 62.56],614.18,614.18,614.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 91.41] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 86.56],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Group 0 ($): FEE SCHEDULE] [Endoscopy ($): FEE SCHEDULE] [Emergency Department (%BC): 52.11] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 66.46] [All Other OP (%BC): 49.35],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85.02,85.02,85.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[OP Surgery  (%BC): 81] [Observation (%BC): 81] [Emergency Department (%BC): 81] [Occupational Therapy (%BC): 81] [Physical Therapy (%BC): 81] [Respiratory Services/Therapy  (%BC): 81] [Speech Therapy (%BC): 81] [All Other OP (%BC): 81],1328.76,1328.76,1328.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Not Billable to FI,N907,APC,,,,,facility,outpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
PR EXC B9 LESION MRGN XCP SK TG T/A/L 3.1-4.0 CM,11404,CDM,975,RC,,,facility,both,,,,879.55,879.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADULT INPT ONLY ROOM,1210000001,CDM,121,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT TRANSPLANT ROOM,1210000002,CDM,121,RC,,,facility,both,,,,5178.84,5178.84,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MED/SURG ROOM,1210000004,CDM,121,RC,,,facility,both,,,,2495,2495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADULT M/S BURN ROOM,1210000007,CDM,121,RC,,,facility,both,,,,4135,4135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OBSTETRIC ROOM,1220000001,CDM,122,RC,,,facility,both,,,,2078,2078,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PEDS INTERMEDIATE ROOM,1230000002,CDM,123,RC,,,facility,both,,,,4924,4924,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PEDS ROOM,1230000003,CDM,123,RC,,,facility,both,,,,4924,4924,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REHABILITATION ROOM,1280000001,CDM,128,RC,,,facility,both,,,,2193,2193,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOSPITAL AT HOME ROOM,1610000007,CDM,161,RC,,,facility,both,,,,2495,2495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEWBORN LEVEL I,1700000001,CDM,170,RC,,,facility,both,,,,1851,1851,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEWBORN LEVEL II,1720000001,CDM,172,RC,,,facility,both,,,,4161,4161,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ICU ROOM,2010000001,CDM,201,RC,,,facility,both,,,,5841,5841,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PEDS ICU ROOM,2030000001,CDM,203,RC,,,facility,both,,,,10829,10829,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GR INTERMEDIATE ROOM,2060000001,CDM,206,RC,,,facility,both,,,,2672,2672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADULT ICU BURN ROOM,2070000001,CDM,207,RC,,,facility,both,,,,8948,8948,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRAUMA ICU ROOM,2080000002,CDM,208,RC,,,facility,both,,,,8307,8307,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & DRAIN SKIN ABSCESS SIMPLE,2301006001,CDM,230,RC,10060,HCPCS,facility,both,,,,281,281,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & DRAIN SKIN ABSCESS; COMPLICATED OR MULT,2301006101,CDM,230,RC,10061,HCPCS,facility,both,,,,399,399,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & DRAIN PILONIDAL CYST SIMPLE,2301008001,CDM,230,RC,10080,HCPCS,facility,both,,,,917,917,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & DRAIN PILONIDAL CYST COMPLIC,2301008101,CDM,230,RC,10081,HCPCS,facility,both,,,,1229,1229,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & REMOVE FOREIGN BODY SIMPLE,2301012001,CDM,230,RC,10120,HCPCS,facility,both,,,,438,438,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & REMOVE FOREIGN BODY COMPLIC,2301012101,CDM,230,RC,10121,HCPCS,facility,both,,,,2379,2379,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & DRAINAGE OF HEMATOMA/FLUID,2301014001,CDM,230,RC,10140,HCPCS,facility,both,,,,1738,1738,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS  PUNCTURE DRAINAGE OF LESION,2301016001,CDM,230,RC,10160,HCPCS,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & DRAINAGE COMPLEX PO WOUND INFECTION,2301018001,CDM,230,RC,,,facility,both,,,,5397,5397,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE SUBQ 20 SQ CM OR LESS,2301104201,CDM,230,RC,11042,HCPCS,facility,both,,,,467,467,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE MUSC/FASCIA 20 SQ CM OR LESS,2301104301,CDM,230,RC,11043,HCPCS,facility,both,,,,648,648,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE BONE 20 SQ CM OR LESS,2301104401,CDM,230,RC,11044,HCPCS,facility,both,,,,2781,2781,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE SUBQ TISSUE ADDTL 20 SQ CM,2301104501,CDM,230,RC,11045,HCPCS,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDEMENT MUSCLE &/FASCIA EA ADDL 20 SQ CM,2301104601,CDM,230,RC,11046,HCPCS,facility,both,,,,519,519,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE BONE ADDTL 20 SQ CM,2301104701,CDM,230,RC,,,facility,both,,,,1309,1309,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TANGENTIAL BIOPSY SKIN SINGLE LESION,2301110201,CDM,230,RC,,,facility,both,,,,489,489,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,2301110301,CDM,230,RC,,,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCH BIOPSY SKIN SINGLE LESION,2301110401,CDM,230,RC,11104,HCPCS,facility,both,,,,510,510,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION,2301110501,CDM,230,RC,11105,HCPCS,facility,both,,,,247,247,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISIONAL BIOPSY SKIN SINGLE LESION,2301110601,CDM,230,RC,11106,HCPCS,facility,both,,,,777,777,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,2301110701,CDM,230,RC,11107,HCPCS,facility,both,,,,577,577,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15,2301120001,CDM,230,RC,,,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAIN BLOOD FROM UNDER NAIL,2301174001,CDM,230,RC,,,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR OF NAIL BED,2301176001,CDM,230,RC,,,facility,both,,,,613,613,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND BODY <2.5CM,2301200101,CDM,230,RC,12001,HCPCS,facility,both,,,,217,217,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUP NPTERF WND BODY 2.6-7.5,2301200201,CDM,230,RC,12002,HCPCS,facility,both,,,,249,249,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND BODY 7.6-12.5,2301200401,CDM,230,RC,12004,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND BODY 12.6-20,2301200501,CDM,230,RC,12005,HCPCS,facility,both,,,,407,407,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND BODY 20.1-30,2301200601,CDM,230,RC,,,facility,both,,,,422,422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND BODY >30CM,2301200701,CDM,230,RC,,,facility,both,,,,435,435,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND FACE <2.5CM,2301201101,CDM,230,RC,12011,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND FACE 2.6-5,2301201301,CDM,230,RC,12013,HCPCS,facility,both,,,,280,280,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND FACE 5.1-7.5,2301201401,CDM,230,RC,12014,HCPCS,facility,both,,,,321,321,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND FACE 7.6-12.5,2301201501,CDM,230,RC,12015,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND FACE 12.6-20,2301201601,CDM,230,RC,,,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND FACE 20.1-30,2301201701,CDM,230,RC,,,facility,both,,,,393,393,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESUPERF WND FACE >30CM,2301201801,CDM,230,RC,,,facility,both,,,,445,445,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSURE OF SIMPLE WOUND SUPERFICIAL,2301202001,CDM,230,RC,,,facility,both,,,,623,623,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,2301203101,CDM,230,RC,12031,HCPCS,facility,both,,,,427,427,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,2301203201,CDM,230,RC,12032,HCPCS,facility,both,,,,478,478,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM,2301203401,CDM,230,RC,12034,HCPCS,facility,both,,,,550,550,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM,2301203501,CDM,230,RC,12035,HCPCS,facility,both,,,,629,629,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM,2301203601,CDM,230,RC,,,facility,both,,,,1036,1036,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE S/A/T/E > 30.0 CM,2301203701,CDM,230,RC,,,facility,both,,,,2108,2108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,2301204101,CDM,230,RC,12041,HCPCS,facility,both,,,,510,510,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,2301204201,CDM,230,RC,12042,HCPCS,facility,both,,,,589,589,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM,2301204401,CDM,230,RC,12044,HCPCS,facility,both,,,,644,644,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM,2301204501,CDM,230,RC,,,facility,both,,,,741,741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RINTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM,2301204601,CDM,230,RC,,,facility,both,,,,767,767,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM,2301204701,CDM,230,RC,,,facility,both,,,,1922,1922,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 2.5 CM/<,2301205101,CDM,230,RC,12051,HCPCS,facility,both,,,,427,427,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 2.6-5.0 CM,2301205201,CDM,230,RC,12052,HCPCS,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 5.1-7.5 CM,2301205301,CDM,230,RC,12053,HCPCS,facility,both,,,,564,564,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 7.6-12.5 CM,2301205401,CDM,230,RC,12054,HCPCS,facility,both,,,,650,650,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 12.6-20.0CM,2301205501,CDM,230,RC,,,facility,both,,,,747,747,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC 20.1-30.0CM,2301205601,CDM,230,RC,,,facility,both,,,,851,851,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE F/E/E/N/L/M&/MUC > 30.0 CM,2301205701,CDM,230,RC,,,facility,both,,,,976,976,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECMPL WND TRUNK 1.1-2.5CM,2301310001,CDM,230,RC,,,facility,both,,,,960,960,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECMPL WND TRUNK 2.6-7.5CM,2301310101,CDM,230,RC,,,facility,both,,,,629,629,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REP,SKIN,TRUNK,CMPLX,+5CM/<",2301310201,CDM,230,RC,,,facility,both,,,,186,186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC RECMPL WND SCALP,EXTR 1.1-2.5",2301312001,CDM,230,RC,,,facility,both,,,,586,586,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC RECMPL WND SCALP,EXTR 2.6-7.5",2301312101,CDM,230,RC,13121,HCPCS,facility,both,,,,1191,1191,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REP,SKIN,SCALP/EXTREM+5CM/<",2301312201,CDM,230,RC,13122,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC RECMPL WND HEAD,FAC,HAND 1.1-2.5",2301313101,CDM,230,RC,,,facility,both,,,,624,624,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC RECMPL WND HEAD,FAC,HAND 2.6-7.5",2301313201,CDM,230,RC,13132,HCPCS,facility,both,,,,1036,1036,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REP,FACE,GENITAL,HAND,FT+5CM/<",2301313301,CDM,230,RC,,,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC RECMPL WND LID,NOS,EAR 1.1-2.5",2301315101,CDM,230,RC,,,facility,both,,,,901,901,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC RECMPL WND LID,NOS,EAR 2.5-7.5",2301315201,CDM,230,RC,13152,HCPCS,facility,both,,,,1042,1042,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REP,EYELID,NOSE,EAR,LIP+5CM",2301315301,CDM,230,RC,,,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL RX BURN(S) 1ST DEGREE,2301600001,CDM,230,RC,16000,HCPCS,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRESS/DEBRID SMALL BURN NO ANES,2301602001,CDM,230,RC,16020,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRESS/DEBRID MED BURN NO ANESTH,2301602501,CDM,230,RC,16025,HCPCS,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE,2301603001,CDM,230,RC,16030,HCPCS,facility,both,,,,510,510,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESCHAROTOMY,2301603501,CDM,230,RC,,,facility,both,,,,441,441,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INCISION OF BURN SCAB, EACH ADDNTL",2301603601,CDM,230,RC,,,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL OF FOREIGN BODY,2302052001,CDM,230,RC,,,facility,both,,,,1648,1648,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL OF FOREIGN BODY DEEP/COMPLIC,2302052501,CDM,230,RC,,,facility,both,,,,4608,4608,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US,2302060001,CDM,230,RC,20600,HCPCS,facility,both,,,,387,387,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT,2302060401,CDM,230,RC,,,facility,both,,,,585,585,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US,2302060501,CDM,230,RC,20605,HCPCS,facility,both,,,,445,445,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US,2302060601,CDM,230,RC,,,facility,both,,,,940,940,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US,2302061001,CDM,230,RC,20610,HCPCS,facility,both,,,,511,511,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US,2302061101,CDM,230,RC,,,facility,both,,,,1080,1080,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLY/REMOVE CRANIAL FIX DEV,2302066001,CDM,230,RC,,,facility,both,,,,4780,4780,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX NOSE FRACTURE, W/O MANIPULATION",2302131001,CDM,230,RC,,,facility,both,,,,64.79,64.79,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS CLOSED TX OF NASAL BONE FX W/ MANIPULATION W/O STABILIZATION,2302131501,CDM,230,RC,,,facility,both,,,,1585,1585,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS CLOSED TX OF NASAL BONE FX W/ MANIPULATION W/ STABILIZATION,2302132001,CDM,230,RC,,,facility,both,,,,4902,4902,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX NASAL SEPTAL FRACTURE,2302133701,CDM,230,RC,,,facility,both,,,,3205,3205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX NOSE/JAW FRAC+WIRES,2302134501,CDM,230,RC,,,facility,both,,,,1601,1601,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX LEFORTE I+WIRES,2302142101,CDM,230,RC,,,facility,both,,,,4835,4835,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX LEFORTE III+WIRES,2302143101,CDM,230,RC,,,facility,both,,,,5653,5653,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX DENTAL RIDGE FX,2302144001,CDM,230,RC,,,facility,both,,,,3205,3205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX MANDIBLE FX,2302145001,CDM,230,RC,,,facility,both,,,,1201,1201,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX MANDIBLE FX+MANIPULATN,2302145101,CDM,230,RC,,,facility,both,,,,1647,1647,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX MANDIBLE FX+DENTAL FIX,2302145301,CDM,230,RC,,,facility,both,,,,5947,5947,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX STERNUM FRACTURE,2302182001,CDM,230,RC,,,facility,both,,,,348,348,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TREAT VERT BODY FRACT,2302231001,CDM,230,RC,,,facility,both,,,,700,700,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE SUBCUT SHOULDER FOREIGN BODY,2302333001,CDM,230,RC,,,facility,both,,,,1822,1822,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SHOULDER FOREIGN BODY DEEP SUBFASCIAL/IM,2302333301,CDM,230,RC,,,facility,both,,,,2877,2877,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX CLAVICLE FRACTURE,2302350001,CDM,230,RC,23500,HCPCS,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX SCAPULA FX,2302357001,CDM,230,RC,,,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX SCAPULA FX,MANIPULATN",2302357501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX PROX HUMERUS FRACTURE,2302360001,CDM,230,RC,23600,HCPCS,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX PROX HUMERUS FX,MANIP",2302360501,CDM,230,RC,23605,HCPCS,facility,both,,,,1632,1632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX GR TUBEROSITY HUM FX,2302362001,CDM,230,RC,,,facility,both,,,,439,439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX GR TUBER HUM FX,MANIP",2302362501,CDM,230,RC,,,facility,both,,,,1632,1632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,2302365001,CDM,230,RC,23650,HCPCS,facility,both,,,,291,291,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMOVAL ARM/ELBOW F.B.,SUPERFICIAL",2302420001,CDM,230,RC,,,facility,both,,,,1648,1648,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMOVAL ARM/ELBOW F.B.,DEEP",2302420101,CDM,230,RC,,,facility,both,,,,6521,6521,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX MID HUMERUS FRACTURE,2302450001,CDM,230,RC,,,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX MID HUMERUS FX,MANIPULATN",2302450501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX HUMERAL SUPRACONDYLAR FX,2302453001,CDM,230,RC,24530,HCPCS,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX HUM SUPRACONDYLR FX,MANIPU",2302453501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX HUMER EPICONDYLR FX,2302456001,CDM,230,RC,,,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX HUMER EPICONDYLR FX,MANIP",2302456501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX HUMER CONDYLR FX,2302457601,CDM,230,RC,,,facility,both,,,,537,537,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX HUMER CONDYLR FX,MANIP",2302457701,CDM,230,RC,,,facility,both,,,,1632,1632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX MONTEGGIA FX/DISLOC ELBOW,2302462001,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX RADIAL HEAD/NECK FX,2302465001,CDM,230,RC,,,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX RADIAL HEAD/NECK FX,MANIP",2302465501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX ULNAR FRACTURE PROX END W/O MANIPULATE,2302467001,CDM,230,RC,,,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX ULNAR FRACTURE PROX END W MANIPULATION,2302467501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE FOREARM/WRIST FOREIGN BODY,2302524801,CDM,230,RC,,,facility,both,,,,1632,1632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX RADIAL SHAFT FX,2302550001,CDM,230,RC,,,facility,both,,,,390,390,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX RADIAL SHAFT FX,MANIPULATN",2302550501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX RADIAL SHAFT FX W/DISLOCATION,2302552001,CDM,230,RC,,,facility,both,,,,6223,6223,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX ULNA SHAFT FX,2302553001,CDM,230,RC,,,facility,both,,,,437,437,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX ULNA SHAFT FX,MANIPULATN",2302553501,CDM,230,RC,,,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN,2302556001,CDM,230,RC,,,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX RAD/ULNA SHAFT FX,MANIP",2302556501,CDM,230,RC,25565,HCPCS,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX DIST RAD/ULNA FX,2302560001,CDM,230,RC,,,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX DIST RAD/ULNA FX,MANIPUL",2302560501,CDM,230,RC,25605,HCPCS,facility,both,,,,1632,1632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX NAVICULAR FX,2302562201,CDM,230,RC,,,facility,both,,,,510,510,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX NAVICULAR FX,MANIPULATN",2302562401,CDM,230,RC,,,facility,both,,,,1438,1438,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX CARPL B1 FX W/O MNPJ EA B1,2302563001,CDM,230,RC,,,facility,both,,,,439,439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX CARPL B1 FX W/MNPJ EA B1,2302563501,CDM,230,RC,,,facility,both,,,,1632,1632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX ULNA STYLOID FX,2302565001,CDM,230,RC,,,facility,both,,,,281,281,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX NAVIC/LUNATE FX/DISLOC,2302568001,CDM,230,RC,,,facility,both,,,,443,443,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN FINGER ABSCESS,SIMPLE",2302601001,CDM,230,RC,26010,HCPCS,facility,both,,,,303,303,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN FINGER ABSCESS,COMPLICATED",2302601101,CDM,230,RC,26011,HCPCS,facility,both,,,,1656,1656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS DRAINAGE TENDON SHEATH,2302602001,CDM,230,RC,26020,HCPCS,facility,both,,,,3143,3143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISE FINGER TENDON SHEATH,2302605501,CDM,230,RC,,,facility,both,,,,1678,1678,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS ARTHROTOMY WITH EXPLORE MCP,2302607501,CDM,230,RC,,,facility,both,,,,9915,9915,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA,2302608002,CDM,230,RC,26080,HCPCS,facility,both,,,,3151,3151,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR EXT TENDON FINGER,2302641801,CDM,230,RC,,,facility,both,,,,2528,2528,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HB RECONST POLYDACT DIGIT SOFT TIS & BONE,2302658701,CDM,230,RC,,,facility,both,,,,3318,3318,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX METACARPAL FX,2302660001,CDM,230,RC,,,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX METACARPAL FX,MANIP",2302660501,CDM,230,RC,,,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TREAT THUMB FX/DISLOC,MANIP",2302664501,CDM,230,RC,,,facility,both,,,,1598,1598,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSE RX PROX/MID FING SHFT FX,2302672001,CDM,230,RC,,,facility,both,,,,253,253,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSE RX PROX/MID FING SHFT FX,MANIP",2302672501,CDM,230,RC,,,facility,both,,,,737,737,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSE RX FINGR ARTICULAR FX,2302674001,CDM,230,RC,,,facility,both,,,,383,383,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSE RX FINGR ARTICULAR FX,MANIP",2302674201,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSE RX DIST FINGR FX,2302675001,CDM,230,RC,,,facility,both,,,,444,444,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSE RX DIST FINGR FX,MANIPULATN",2302675501,CDM,230,RC,,,facility,both,,,,663,663,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR,2302695101,CDM,230,RC,,,facility,both,,,,3318,3318,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMOVE PELV/HIP F.B.,SUBCUTANEOUS",2302708601,CDM,230,RC,,,facility,both,,,,2877,2877,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMOVE PELV/HIP F.B.,DEEP",2302708701,CDM,230,RC,,,facility,both,,,,3316,3316,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX ACETABULAR FX,2302722001,CDM,230,RC,,,facility,both,,,,1295,1295,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX ACETABULAR FX,MANIPULATN",2302722201,CDM,230,RC,,,facility,both,,,,2422,2422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX PROX/NECK FEMUR FX,2302723001,CDM,230,RC,,,facility,both,,,,439,439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX PROX/NECK FEMUR FX,MANIP",2302723201,CDM,230,RC,,,facility,both,,,,1865,1865,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX INTER/SUBTROCH FEMUR FX,2302723801,CDM,230,RC,,,facility,both,,,,1598,1598,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX INTER/SUBTROCH FX,MANIP",2302724001,CDM,230,RC,,,facility,both,,,,2141,2141,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX GR TROCHANTERIC FX,2302724601,CDM,230,RC,,,facility,both,,,,439,439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX FEMUR SHAFT FX,2302750001,CDM,230,RC,,,facility,both,,,,439,439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX CONDYLAR FX,2302750101,CDM,230,RC,,,facility,both,,,,439,439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX FEMUR SHAFT FX+MANIP,2302750201,CDM,230,RC,,,facility,both,,,,1700,1700,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX CONDYLAR FX+MANIP,2302750301,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX FEMUR,DISTAL",2302750801,CDM,230,RC,,,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX FEMUR,DISTAL+MANIP",2302751001,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX DIST FEM EPIPHYSIS,2302751601,CDM,230,RC,,,facility,both,,,,1164,1164,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX DIST FEM EPIPHYSIS+MANIP,2302751701,CDM,230,RC,,,facility,both,,,,1585,1585,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX PATELLA FX,2302752001,CDM,230,RC,,,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX TIBIAL PLATEAU FX,2302753001,CDM,230,RC,27530,HCPCS,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX TIB PLAT FX+MANIP,2302753201,CDM,230,RC,,,facility,both,,,,2986,2986,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX TIB TUBER FX,2302753801,CDM,230,RC,,,facility,both,,,,1089,1089,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX TIBIA SHAFT FX,2302775001,CDM,230,RC,,,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX TIBIA SHAFT FX,MANIPULATN",2302775201,CDM,230,RC,,,facility,both,,,,1937,1937,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX MED MALLEOLUS FX,2302776001,CDM,230,RC,,,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX MED MALLEOLUS FX,MANIP",2302776201,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MANIP,2302776701,CDM,230,RC,,,facility,both,,,,437,437,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TREATMENT PST MALLEOLUS FRACTURE W MANIP,2302776801,CDM,230,RC,,,facility,both,,,,1632,1632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX PROX/SHAFT FIBULA FX,2302778001,CDM,230,RC,,,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX PROX/SHAFT FIB FX,MANIP",2302778101,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX DIST FIBULA FX,2302778601,CDM,230,RC,,,facility,both,,,,694,694,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX DIST FIBULA FX,MANIP",2302778801,CDM,230,RC,27788,HCPCS,facility,both,,,,476,476,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANIP,2302780801,CDM,230,RC,27808,HCPCS,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX BIMALLEOLAR ANKLE FRACTURE W MANIP,2302781001,CDM,230,RC,27810,HCPCS,facility,both,,,,1640,1640,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX TRIMALLEOLAR FX,2302781601,CDM,230,RC,27816,HCPCS,facility,both,,,,701,701,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX TRIMALLEOLAR FX,MANIP",2302781801,CDM,230,RC,27818,HCPCS,facility,both,,,,1640,1640,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX WEIGHT BEAR DIST TIBIA,2302782401,CDM,230,RC,,,facility,both,,,,437,437,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX WEIGHT BEAR DIST TIB,MANIP",2302782501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMV FOOT FOREIGN BODY,SUBCUTANEOUS",2302819001,CDM,230,RC,,,facility,both,,,,674,674,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMV FOOT FOREIGN BODY,DEEP",2302819201,CDM,230,RC,,,facility,both,,,,1989,1989,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMV FOOT FOREIGN BODY,COMPLEX",2302819301,CDM,230,RC,,,facility,both,,,,1648,1648,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX HEEL FX,2302840001,CDM,230,RC,,,facility,both,,,,551,551,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX HEEL FX,MANIPULATN",2302840501,CDM,230,RC,,,facility,both,,,,558,558,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX TALUS FX,2302843001,CDM,230,RC,,,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX TALUS FX,MANIPULATN",2302843501,CDM,230,RC,,,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX TARSAL FX,EACH",2302845001,CDM,230,RC,,,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX TARSAL FX,MANIP,EACH",2302845501,CDM,230,RC,,,facility,both,,,,1598,1598,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED RX METATARSAL FX,2302847001,CDM,230,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CLOSED RX METATARSAL FX,MANIP",2302847501,CDM,230,RC,,,facility,both,,,,557,557,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLY LONG ARM SPLINT,2302910501,CDM,230,RC,29105,HCPCS,facility,both,,,,207,207,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC APPLY FOREARM SPLINT,STATIC",2302912501,CDM,230,RC,29125,HCPCS,facility,both,,,,207,207,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC APPLY FOREARM SPLINT,DYNAMIC",2302912601,CDM,230,RC,,,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC APPLY FINGER SPLINT,STATIC",2302913001,CDM,230,RC,,,facility,both,,,,206,206,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC APPLY FINGER SPLINT,DYNAMIC",2302913101,CDM,230,RC,,,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLY LONG LEG SPLINT,2302950501,CDM,230,RC,,,facility,both,,,,166,166,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLY LOWER LEG SPLINT,2302951501,CDM,230,RC,29515,HCPCS,facility,both,,,,164,164,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN ABSCESS/HEMATOMA,NASAL",2303000001,CDM,230,RC,,,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN ABSCESS/HEMATOMA,NASAL SEPTUM",2303002001,CDM,230,RC,30020,HCPCS,facility,both,,,,474,474,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE NASAL FOREIGN BODY,2303030001,CDM,230,RC,,,facility,both,,,,117,117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CTRL NOSEBLEED,ANTER,SIMPLE",2303090101,CDM,230,RC,30901,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CTRL NOSEBLEED,ANTER,COMPLEX",2303090301,CDM,230,RC,30903,HCPCS,facility,both,,,,203,203,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CTRL NOSEBLEED,POST,W/PACKS &/OR CAUT",2303090501,CDM,230,RC,30905,HCPCS,facility,both,,,,240,240,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPEAT CONTROL OF NOSEBLEED,2303090601,CDM,230,RC,30906,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT EMERGENCY ENDOTRACH AIRWAY,2303150001,CDM,230,RC,31500,HCPCS,facility,both,,,,321,321,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACH TUBE CHANGE,2303150201,CDM,230,RC,31502,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY FLEX DIAGNOSTIC,2303157501,CDM,230,RC,31575,HCPCS,facility,both,,,,564,564,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHEOSTOMY PLANNED,2303160001,CDM,230,RC,31600,HCPCS,facility,both,,,,4853,4853,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
BRNCHSC INCL FLUOR GDNCE DX W/CELL WASHG SPX,2303162201,CDM,230,RC,31622,HCPCS,facility,both,,,,5383,5383,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BRONCHOSCOPY,DIAGNOSTIC W LAVAGE",2303162401,CDM,230,RC,31624,HCPCS,facility,both,,,,2254,2254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRNCHSC W/THER ASPIR 1ST,2303164501,CDM,230,RC,31645,HCPCS,facility,both,,,,1863,1863,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION OF CHEST TUBE,2303255101,CDM,230,RC,32551,HCPCS,facility,both,,,,1647,1647,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING,2303255401,CDM,230,RC,32554,HCPCS,facility,both,,,,1043,1043,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,2303255501,CDM,230,RC,32555,HCPCS,facility,both,,,,1200,1200,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,2303301601,CDM,230,RC,,,facility,both,,,,3765,3765,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY,2303301701,CDM,230,RC,,,facility,both,,,,745,745,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS TEMPORARY PACEMAKER INSERTION,2303321001,CDM,230,RC,33210,HCPCS,facility,both,,,,7685,7685,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION INTRA-AORTIC BALLOON ASSIST DEV PERQ,2303396701,CDM,230,RC,,,facility,both,,,,1829,1829,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMV AORTIC BALLOON DEVICE,2303396801,CDM,230,RC,,,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
INSJ INTRA-AORT BALO ASSIST DEV VIA FEM ART OPEN,2303397001,CDM,230,RC,,,facility,both,,,,2502,2502,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL PERQ R HEART VAD ARTERIAL CANNULA SEPT INSJ,2303399201,CDM,230,RC,,,facility,both,,,,443,443,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOSITION VAD W/IMAGING DIFFERENT SESSION,2303399301,CDM,230,RC,,,facility,both,,,,386,386,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CATH, VEIN UMBILICAL NEWBORN",2303651001,CDM,230,RC,36510,HCPCS,facility,both,,,,127,127,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NON-TUNNEL CV CATH < 5 Y/O,2303655501,CDM,230,RC,36555,HCPCS,facility,both,,,,3354,3354,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NON-TUNNEL CV CATH,2303655601,CDM,230,RC,36556,HCPCS,facility,both,,,,3354,3354,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PICC W/O IMG GDN LESS THAN 5 YR,2303656801,CDM,230,RC,36568,HCPCS,facility,both,,,,2977,2977,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PICC W/O IMG GDN GREATER THAN 5 YR,2303656901,CDM,230,RC,36569,HCPCS,facility,both,,,,2227,2227,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERT CATH,ART,PERCUT,SHORTTERM",2303662001,CDM,230,RC,36620,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERT CATH,ART,CUTDOWN,SHORTTERM",2303662501,CDM,230,RC,36625,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CATH, UMBILICAL ARTERY",2303666001,CDM,230,RC,36660,HCPCS,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERT NEEDLE,INTRAOSSEOUS INFUSN",2303668001,CDM,230,RC,36680,HCPCS,facility,both,,,,413,413,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERT CANNULA,VEIN-VEIN",2303680001,CDM,230,RC,,,facility,both,,,,9382,9382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC BONE MARROW ASPIRATION,2303822001,CDM,230,RC,38220,HCPCS,facility,both,,,,1648,1648,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC BONE MARROW BIOPSY,2303822101,CDM,230,RC,38221,HCPCS,facility,both,,,,1648,1648,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE MARROW ASP POST BX,2303822201,CDM,230,RC,38222,HCPCS,facility,both,,,,2778,2778,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLOGENEIC LYMPHOCYTE INFUSIONS,2303824201,CDM,230,RC,,,facility,both,,,,2919,2919,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR LIP,FULL THICK,VERMILION",2304065001,CDM,230,RC,,,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR LIP,<1/2 VERT HEIGHT",2304065201,CDM,230,RC,,,facility,both,,,,637,637,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR LIP,>1/2 VERT HEIGHT",2304065401,CDM,230,RC,40654,HCPCS,facility,both,,,,1427,1427,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN MOUTH ABSC/CYST/HEMATOMA,SIMPL",2304080001,CDM,230,RC,40800,HCPCS,facility,both,,,,792,792,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN MOUTH ABSC/CYST/HEMAT,COMPLX",2304080101,CDM,230,RC,40801,HCPCS,facility,both,,,,556,556,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMOVAL FOREIGN BODY,MOUTH,SIMPLE",2304080401,CDM,230,RC,40804,HCPCS,facility,both,,,,942,942,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMOVAL FOREIGN BODY,MOUTH,COMPLEX",2304080501,CDM,230,RC,,,facility,both,,,,582,582,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR MOUTH LACERATION,<2.5CM",2304083001,CDM,230,RC,,,facility,both,,,,334,334,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR MOUTH LACERATION,>2.5CM",2304083101,CDM,230,RC,,,facility,both,,,,561,561,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC I&D MOUTH/TONG INTRA,LINGUAL",2304100001,CDM,230,RC,,,facility,both,,,,709,709,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC I&D MOUTH/TONG INTRA,SUBLING,SUPERF",2304100501,CDM,230,RC,,,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC I&D MOUTH/TONG INTRA,SUBLING,DEEP",2304100601,CDM,230,RC,,,facility,both,,,,1518,1518,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC I&D MOUTH/TONG INTRA,SUBMENTAL",2304100701,CDM,230,RC,,,facility,both,,,,1903,1903,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAORAL I&D SUBMANDIBULAR,2304100801,CDM,230,RC,41008,HCPCS,facility,both,,,,2859,2859,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC I&D MOUTH/TONG INTRA,MASTICATOR",2304100901,CDM,230,RC,,,facility,both,,,,662,662,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS BIOPSY OF FLOOR OF MOUTH,2304110801,CDM,230,RC,,,facility,both,,,,4971,4971,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR TONGUE LACER,<2.6CM",2304125001,CDM,230,RC,41250,HCPCS,facility,both,,,,343,343,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR TONGUE LACER,POST 1/3",2304125101,CDM,230,RC,,,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR TONGUE LACER,2.6CM+/COMPLX",2304125201,CDM,230,RC,41252,HCPCS,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF GUM LESION,2304180001,CDM,230,RC,41800,HCPCS,facility,both,,,,305,305,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMOVAL FOREIGN BODY, GUM",2304180501,CDM,230,RC,,,facility,both,,,,5670,5670,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALVEOLOPLASTY EACH QUADRANT SPECIFY,2304187401,CDM,230,RC,,,facility,both,,,,10122,10122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED TOOTH 1-3 EXTRACTIONS,2304189901,CDM,230,RC,41899,HCPCS,facility,both,,,,474,474,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED TOOTH 10-12 EXTRACTIONS,2304189902,CDM,230,RC,41899,HCPCS,facility,both,,,,1779,1779,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED TOOTH 4-6 EXTRACTIONS,2304189903,CDM,230,RC,41899,HCPCS,facility,both,,,,790,790,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED TOOTH 7-9 EXTRACTIONS,2304189904,CDM,230,RC,41899,HCPCS,facility,both,,,,1186,1186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE ABSCESS PALATE/UVULA,2304200001,CDM,230,RC,42000,HCPCS,facility,both,,,,247,247,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR PALATE LACER <2CM,2304218001,CDM,230,RC,,,facility,both,,,,536,536,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR PALATE LACER 2+CM OR COMPLX,2304218201,CDM,230,RC,,,facility,both,,,,6850,6850,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN ABSCESS PAROTID,SIMPLE",2304230001,CDM,230,RC,,,facility,both,,,,2806,2806,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INC/DRAIN PERITONSIL ABSCESS,2304270001,CDM,230,RC,42700,HCPCS,facility,both,,,,687,687,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EGD PLACE GASTROSTOMY TUBE,2304324601,CDM,230,RC,43246,HCPCS,facility,both,,,,1903,1903,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ESOPHAGOGASTRIC TAMPONADE,BALLOON",2304346001,CDM,230,RC,,,facility,both,,,,544,544,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI NASO OR ORO-GAST TUBE PL,2304375201,CDM,230,RC,43752,HCPCS,facility,both,,,,385,385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC GASTRIC INTUBATION/ASPIRATION, THERAPEUTIC",2304375301,CDM,230,RC,,,facility,both,,,,876,876,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOSITION GASTRIC FEEDING TUBE THRU DUODENUM,2304376101,CDM,230,RC,,,facility,both,,,,867,867,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,2304376201,CDM,230,RC,43762,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI PLACEMENT OF N-J TUBE,2304450001,CDM,230,RC,44500,HCPCS,facility,both,,,,948,948,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF RECTUM,2304510001,CDM,230,RC,45100,HCPCS,facility,both,,,,7533,7533,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROCTOSIGMOIDOSCOPY,REMV F.B.",2304530701,CDM,230,RC,,,facility,both,,,,4669,4669,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,2304908201,CDM,230,RC,49082,HCPCS,facility,both,,,,948,948,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABDOM PARACENTESIS DX/THER W IMAGING GUIDANCE,2304908301,CDM,230,RC,49083,HCPCS,facility,both,,,,1071,1071,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAIN BLADDER BY TROCAR/CATH BEDSIDE,2305110101,CDM,230,RC,,,facility,both,,,,1070,1070,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAIN BL W/CATH INSERTION,2305110201,CDM,230,RC,,,facility,both,,,,2108,2108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IRRIGATION OF BLADDER,2305170001,CDM,230,RC,51700,HCPCS,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERT,NON-INDWELLING BLADDER CATHETER",2305170101,CDM,230,RC,51701,HCPCS,facility,both,,,,220,220,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERT,TEMP INDWELLING BLAD CATH,SIMPLE",2305170201,CDM,230,RC,51702,HCPCS,facility,both,,,,165,165,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERT,TEMP INDWELLING BLAD CATH,COMP",2305170301,CDM,230,RC,51703,HCPCS,facility,both,,,,194,194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTOURETHROSCOPY,2305200001,CDM,230,RC,52000,HCPCS,facility,both,,,,1172,1172,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,2305228101,CDM,230,RC,,,facility,both,,,,2097,2097,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTO W/SIMPLE REMOVAL STONE & STENT,2305231001,CDM,230,RC,52310,HCPCS,facility,both,,,,2097,2097,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTO W/INSERT URETERAL STENT,2305233201,CDM,230,RC,,,facility,both,,,,10765,10765,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE SCROTAL WALL ABSCESS,2305510001,CDM,230,RC,,,facility,both,,,,2157,2157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL OF SCROTAL FOR.BODY,2305512001,CDM,230,RC,,,facility,both,,,,2097,2097,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D OF VULVA/PERINEUM ABSCESS,2305640501,CDM,230,RC,56405,HCPCS,facility,both,,,,335,335,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D BARTHOLIN GLAND ABSCESS,2305642001,CDM,230,RC,56420,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MARSUP BARTHOLIN GLAND CYST,2305644001,CDM,230,RC,,,facility,both,,,,2908,2908,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF VULVA LESION SINGLE,2305660501,CDM,230,RC,56605,HCPCS,facility,both,,,,904,904,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX VULVA EACH ADDTL LESION,2305660601,CDM,230,RC,56606,HCPCS,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,VULVA",2305682001,CDM,230,RC,,,facility,both,,,,195,195,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,VULVA,W/BIOPSY(S)",2305682101,CDM,230,RC,,,facility,both,,,,330,330,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL,2305741501,CDM,230,RC,,,facility,both,,,,3216,3216,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,ENTIRE VAGINA",2305742001,CDM,230,RC,,,facility,both,,,,553,553,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,ENTIRE VAGINA,W/BIOPSY(S)",2305742101,CDM,230,RC,,,facility,both,,,,770,770,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,CERVIX W/ADJ VAGINA",2305745201,CDM,230,RC,,,facility,both,,,,206,206,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSC,CERVIX W/ADJ VAG,W/BX & CURRETAG",2305745401,CDM,230,RC,,,facility,both,,,,316,316,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,CERVIX W/ADJ VAGINA,W/BX",2305745501,CDM,230,RC,,,facility,both,,,,364,364,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,CERVIX W/ADJ VAGINA, CURETTAG",2305745601,CDM,230,RC,,,facility,both,,,,464,464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,CERVIX W/ADJ VAG,W/LOOP BX",2305746001,CDM,230,RC,,,facility,both,,,,3075,3075,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC COLPOSCOPY,CERVIX W/ADJ VAG,W/LOOP CONIZ",2305746101,CDM,230,RC,,,facility,both,,,,3075,3075,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BIOPSY CERVIX, 1 OR MORE, OR EXCISION OF LESION",2305750001,CDM,230,RC,,,facility,both,,,,1005,1005,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOCERVICAL CURETTAGE BEDSIDE,2305750501,CDM,230,RC,,,facility,both,,,,1005,1005,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYOCAUTERY OF CERVIX,2305751101,CDM,230,RC,,,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CONIZATION CERVIX,KNIFE/LASER",2305752001,CDM,230,RC,,,facility,both,,,,3149,3149,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,2305810001,CDM,230,RC,58100,HCPCS,facility,both,,,,300,300,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HYSTEROSCOPY BX ENDOMETRIUM&/POLYPC W/WO D&C,2305855801,CDM,230,RC,,,facility,both,,,,8686,8686,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CERCLAGE REMOVAL WITHOUT ANES,2305899901,CDM,230,RC,,,facility,both,,,,2233,2233,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOCENTESIS DIAGNOSTIC,2305900001,CDM,230,RC,59000,HCPCS,facility,both,,,,743,743,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FETAL NON STRESS TEST,2305902501,CDM,230,RC,,,facility,both,,,,372,372,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSABDOM AMNIOINFUS W/ US,2305907001,CDM,230,RC,,,facility,both,,,,672,672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HB  VENTRICULAR PUNCTURE PREVIOUS BURR HOLE W/O NJX,2306102001,CDM,230,RC,61020,HCPCS,facility,both,,,,1081,1081,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCTURE SHUNT TUBE/RESERVOIR ASPIRATION/INJ PX,2306107001,CDM,230,RC,61070,HCPCS,facility,both,,,,843,843,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  TWIST DRILL HOLE IMPLT VENTRICULAR CATH/DEVICE,2306110701,CDM,230,RC,61107,HCPCS,facility,both,,,,634,634,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
BURR HOLE W/ASPIR HEMATOMA/CYST INTRACEREBRAL,2306115601,CDM,230,RC,,,facility,both,,,,12862,12862,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BURR HOLE IMPLANT VENTRICULAR CATH/OTHER DEVICE,2306121001,CDM,230,RC,,,facility,both,,,,827,827,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SPINAL PUNCTURE,LUMBAR,DIAGNOSTIC",2306227001,CDM,230,RC,62270,HCPCS,facility,both,,,,997,997,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJ(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EA BRANCH (IE OPHT, MAX, MAND)",2306440001,CDM,230,RC,,,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE",2306440501,CDM,230,RC,64405,HCPCS,facility,both,,,,831,831,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS",2306441501,CDM,230,RC,,,facility,both,,,,1812,1812,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE",2306441701,CDM,230,RC,,,facility,both,,,,2067,2067,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",2306441801,CDM,230,RC,,,facility,both,,,,839,839,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL",2306442001,CDM,230,RC,,,facility,both,,,,843,843,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",2306442501,CDM,230,RC,,,facility,both,,,,1985,1985,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",2306443001,CDM,230,RC,,,facility,both,,,,1088,1088,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",2306443501,CDM,230,RC,,,facility,both,,,,839,839,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE",2306444501,CDM,230,RC,,,facility,both,,,,839,839,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE",2306444701,CDM,230,RC,,,facility,both,,,,839,839,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",2306445001,CDM,230,RC,64450,HCPCS,facility,both,,,,906,906,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX ANES&/STEROID PLANTAR COMMON DIGITAL NERVE,2306445501,CDM,230,RC,,,facility,both,,,,303,303,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECT ANES/STEROID FORAMEN CERV/THORACIC W IMG GUIDE ,1 LEVEL",2306447901,CDM,230,RC,,,facility,both,,,,1088,1088,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL",2306448301,CDM,230,RC,,,facility,both,,,,1088,1088,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJ DX/THER AGNT PARAVERT FACET JOINT, CERV/THORAC, 1ST LEVEL",2306449001,CDM,230,RC,,,facility,both,,,,2078,2078,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS PERQ ELEC NRV FIELD STIMJ CRANIAL NRV W/O IMPLTJ,2306456701,CDM,230,RC,,,facility,both,,,,2711,2711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECT NERV BLCK,CERV PLEXUS",2306499901,CDM,230,RC,,,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECT NERV BLCK,FACIAL NERV",2306499902,CDM,230,RC,,,facility,both,,,,303,303,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NERVOUS SYSTEM SURGERY UNLISTED,2306499903,CDM,230,RC,,,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMV F.B.,EYE,SUPERF CONJUNC",2306520501,CDM,230,RC,,,facility,both,,,,199,199,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMV F.B.,EYE,EMBED CONJUNC",2306521001,CDM,230,RC,,,facility,both,,,,420,420,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMV F.B.,EYE,CORNEA,NO SLIT",2306522001,CDM,230,RC,65220,HCPCS,facility,both,,,,454,454,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMV F.B.,EYE,CORNEA,SLIT LAMP",2306522201,CDM,230,RC,,,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF EYELID ABSCESS,2306770001,CDM,230,RC,67700,HCPCS,facility,both,,,,307,307,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REMOVE EYELID FOREIGN BODY,EMBEDDED",2306793801,CDM,230,RC,,,facility,both,,,,620,620,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISE/DRAIN CONJUNCTIVA,2306802001,CDM,230,RC,,,facility,both,,,,971,971,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN EXT EAR ABSC/BLOOD,SIMPLE",2306900001,CDM,230,RC,,,facility,both,,,,889,889,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN EXT EAR ABSC/BLOOD,COMPLIC",2306900501,CDM,230,RC,69005,HCPCS,facility,both,,,,2444,2444,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMV EXT CANAL FOREIGN BODY,2306920001,CDM,230,RC,,,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC GERD TST W/ MUCOS IMPEDE ELECTROD,>1HR",2309103801,CDM,230,RC,,,facility,both,,,,1183,1183,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARDIOPLUMONARY RESUSCITATION,2309295001,CDM,230,RC,92950,HCPCS,facility,both,,,,352,352,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CARDIOVERSION, ELECTIVE;EXTERN",2309296001,CDM,230,RC,92960,HCPCS,facility,both,,,,1006,1006,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  CARDIOVERSION ELECTIVE ARRHYTHMIA INTERNAL SPX,2309296101,CDM,230,RC,,,facility,both,,,,655,655,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION FLOW DIRECTED CATHETER FOR MONITORING,2309350301,CDM,230,RC,93503,HCPCS,facility,both,,,,1869,1869,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDEMENT OPEN WOUND 20 SQ CM<,2309759701,CDM,230,RC,97597,HCPCS,facility,both,,,,211,211,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDEMENT OPEN WOUND EA ADDL 20 SQ CM,2309759801,CDM,230,RC,97598,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH NEG PRESS WOUND TX LESS THAN OR EQUAL TO 50 SQ CM WITH DME,2309760501,CDM,230,RC,97605,HCPCS,facility,both,,,,410,410,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX NEG PRESS WOUND TX GREATER THAN 50 SQ CM WITH DME,2309760601,CDM,230,RC,97606,HCPCS,facility,both,,,,462,462,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEG PRESSURE WOUND THERAPY NON DME </= 50 SQ CM,2309760701,CDM,230,RC,97607,HCPCS,facility,both,,,,402,402,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEG PRESSURE WOUND THERAPY NON DME >50 SQ CM,2309760801,CDM,230,RC,97608,HCPCS,facility,both,,,,477,477,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DELIVERY/BIRTHING ROOM RESUSCITATION,2309946501,CDM,230,RC,99465,HCPCS,facility,both,,,,1052,1052,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE NS 20FR 8MM,247L850934,CDM,274,RC,L8509,HCPCS,facility,both,,,,2106,2106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE NS 20FR 10MM,247L850935,CDM,274,RC,L8509,HCPCS,facility,both,,,,2106,2106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE NS 20FR 12MM,247L850936,CDM,274,RC,,,facility,both,,,,2106,2106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE NS 20FR 14MM,247L850937,CDM,274,RC,,,facility,both,,,,2106,2106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE LF 20FR 6MM,247L850938,CDM,274,RC,,,facility,both,,,,2243,2243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE LF 20FR 8MM,247L850939,CDM,274,RC,,,facility,both,,,,2243,2243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE LF 20FR 10MM,247L850940,CDM,274,RC,L8509,HCPCS,facility,both,,,,2243,2243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE LF 20FR 12MM,247L850941,CDM,274,RC,,,facility,both,,,,2243,2243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE LF 20FR 14MM,247L850942,CDM,274,RC,,,facility,both,,,,2243,2243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RX-SILVADENE CREAM 1000 GM,2500000005,CDM,250,RC,,,facility,both,,,,223.6,223.6,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RX-SILVADENE CREAM 400 GM,2500000006,CDM,250,RC,,,facility,both,,,,66.04,66.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RX-SILVADENE CREAM 50 GM,2500000007,CDM,250,RC,,,facility,both,,,,26.57,26.57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RX-SILVADENE CREAM 85 GM,2500000008,CDM,250,RC,,,facility,both,,,,48.44,48.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU NITRIC OXIDE HOURLY,2500000009,CDM,250,RC,,,facility,both,,,,292.15,292.15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV HYDRATION INFUSION INITIAL HOUR,2609636001,CDM,260,RC,96360,HCPCS,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV HYDRATE ADDTL HOURS,2609636101,CDM,260,RC,96361,HCPCS,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV INFUSION THERAPY UP TO 1 HR,2609636501,CDM,260,RC,96365,HCPCS,facility,both,,,,384,384,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV INFUSION THERAPY EACH ADDTL HR,2609636601,CDM,260,RC,96366,HCPCS,facility,both,,,,178,178,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV INFUSION ADDTL SEQUENTUAL UP TO 1 HR,2609636701,CDM,260,RC,96367,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV CONCURRENT INFUSION,2609636801,CDM,260,RC,96368,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN OF INJECTION SUBQ OR IM,2609637201,CDM,260,RC,96372,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN OF INJECTION SUBQ OR IM,2609637201,CDM,260,RC,96372,HCPCS,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV PUSH SINGLE OR INITIAL SUBSTANCE,2609637401,CDM,260,RC,96374,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV PUSH SINGLE OR INITIAL SUBSTANCE,2609637401,CDM,260,RC,96374,HCPCS,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV PUSH EACH ADDTL NEW SUBSTANCE,2609637501,CDM,260,RC,96375,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IV PUSH SAME DRUG 30 MIN AFTER,2609637601,CDM,260,RC,96376,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS,2609637901,CDM,260,RC,96379,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROLONGED IV INF, REQ PUMP- NON CHEMO",260C895701,CDM,260,RC,,,facility,both,,,,902,902,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC IV INFUSION, BAMLANIVIMAB AND ETESEVIMAB, INCLUDES INFUSION AND POG",260M024501,CDM,260,RC,,,facility,both,,,,901,901,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC IV INFUSION, SOTROVIMAB, INCLUDES INFUSION AND POST ADMINSTRATION G",260M024701,CDM,260,RC,,,facility,both,,,,901,901,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-MATTRESS AIR INFLATABLE 31X,2700000007,CDM,270,RC,,,facility,both,,,,135.52,135.52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRAY 16 FR FOLEY CATH,2700000009,CDM,270,RC,,,facility,both,,,,68.85,68.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU LARGE AMPUTEE SLING,2700000013,CDM,270,RC,,,facility,both,,,,748.4,748.4,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU HELIOX HOURLY,2710000001,CDM,271,RC,,,facility,both,,,,92.17,92.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU MATTRESS WARMING SMALL,2710000002,CDM,271,RC,,,facility,both,,,,145.3,145.3,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU NITRIC OXIDE DELIVERY SYSTEM,2710000003,CDM,271,RC,,,facility,both,,,,87.64,87.64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BED CLINTRON II HILLROM,2710000006,CDM,271,RC,,,facility,both,,,,216.64,216.64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BED DOLPHIN MATTRESS,2710000007,CDM,271,RC,,,facility,both,,,,178.1,178.1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BED P500,2710000008,CDM,271,RC,,,facility,both,,,,158.78,158.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BED TRIFLEX FOAM,2710000009,CDM,271,RC,,,facility,both,,,,256.92,256.92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BED TRIFLEX SYNERGY AIR,2710000010,CDM,271,RC,,,facility,both,,,,374.92,374.92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU BED COMPELLA AIR,2710000012,CDM,271,RC,,,facility,both,,,,310.56,310.56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU BED COMPELLA FOAM,2710000013,CDM,271,RC,,,facility,both,,,,235.14,235.14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU BED ENVELLA,2710000014,CDM,271,RC,,,facility,both,,,,332.74,332.74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BED CLINITRON RITE HITE,2710000015,CDM,271,RC,,,facility,both,,,,380.42,380.42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU BED COMPELLA AIR W/TRPZ,2710000020,CDM,271,RC,,,facility,both,,,,341.61,341.61,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU BED COMPELLA FOAM W/TRPZ,2710000021,CDM,271,RC,,,facility,both,,,,258.65,258.65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU BED ENVELLA W/TRPZ,2710000022,CDM,271,RC,,,facility,both,,,,366.02,366.02,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"SU BED CENTRELLA MAX 36""",2710000023,CDM,271,RC,,,facility,both,,,,145.23,145.23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"SU BED CENTRELLA MAX 40""",2710000024,CDM,271,RC,,,facility,both,,,,213.21,213.21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU BED TOTAL LIFT V5 W/POWER DRIVE,2710000025,CDM,271,RC,,,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU BED POSEY,2710000026,CDM,271,RC,,,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EAR MOLD/INSERT,271V526401,CDM,271,RC,V5264,HCPCS,facility,both,,,,215.36,215.36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EAR MOLD IMPRESSION,271V527501,CDM,271,RC,V5275,HCPCS,facility,both,,,,69.32,69.32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EAR MOLD IMPRESSION,271V527501,CDM,271,RC,V5275,HCPCS,facility,both,,,,71,71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADHESIVE SKIN OCTYL,2720000001,CDM,272,RC,,,facility,both,,,,66.68,66.68,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CERVICAL SLEEVE,2720000002,CDM,272,RC,,,facility,both,,,,160.25,160.25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYBER TM 200W LASER FEE ONE,2720000003,CDM,272,RC,,,facility,both,,,,6891,6891,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYBER TM 200W LASER FEE TWO,2720000004,CDM,272,RC,,,facility,both,,,,6250,6250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC D644 EMG NEEDLE KIT W/PROBE,2720000005,CDM,272,RC,,,facility,both,,,,2723.23,2723.23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC RADIOOGY BW PK-LF,2720000006,CDM,272,RC,,,facility,both,,,,52.9,52.9,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRESSING MEPITEL AG 8X12,2720000007,CDM,272,RC,,,facility,both,,,,318.67,318.67,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EFFLUENT CARTRIDGE CRRT,2720000008,CDM,272,RC,,,facility,both,,,,336.31,336.31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIDURAL SPINAL ELECTRODE 2-CONTACT,2720000009,CDM,272,RC,,,facility,both,,,,751.09,751.09,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HYPERBARIC IV EXT KIT,2720000010,CDM,272,RC,,,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER RENTAL CONTINUOUS FLOW,2720000011,CDM,272,RC,,,facility,both,,,,909.92,909.92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEPILEX AG 8X8,2720000012,CDM,272,RC,,,facility,both,,,,152.47,152.47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEPILEX AG BORDER 6X6,2720000013,CDM,272,RC,,,facility,both,,,,122.34,122.34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEPITEL AG 4X7,2720000014,CDM,272,RC,,,facility,both,,,,128.73,128.73,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEPITEL AG 8X20,2720000015,CDM,272,RC,,,facility,both,,,,508.15,508.15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEPITEL ONE 6X10,2720000016,CDM,272,RC,,,facility,both,,,,102.64,102.64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUMP BL1D002SK2-CP WILLIAMS MED PAIN SIN,2720000024,CDM,272,RC,,,facility,both,,,,504.38,504.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUMP BL1D002SK2-CP WILLIAMS MED PAIN SIN,2720000025,CDM,272,RC,,,facility,both,,,,504.38,504.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLING CEILING DISP MED CAP,2720000027,CDM,272,RC,,,facility,both,,,,154.59,154.59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU - TRAY BONE MARROW BIOPSY (11G X4),2720000029,CDM,272,RC,,,facility,both,,,,216.67,216.67,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU 1- CHANNEL DRAGONFLY 2.0-5.0 D1182,2720000030,CDM,272,RC,,,facility,both,,,,473.47,473.47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU AIRWAY SIZING KIT,2720000035,CDM,272,RC,,,facility,both,,,,1078.19,1078.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU BIPOLAR PROBE D1263,2720000036,CDM,272,RC,,,facility,both,,,,561.35,561.35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU BIPOLAR STIMULATING PROBE SIDE BY SIDE,2720000037,CDM,272,RC,,,facility,both,,,,458.2,458.2,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU CATHETER AIRWAY EXCHANGE 4M,2720000043,CDM,272,RC,,,facility,both,,,,322.06,322.06,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU CATHETER AIRWAY EXCHANGE 5,2720000044,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU CONCENTRIC PROBE D238,2720000045,CDM,272,RC,,,facility,both,,,,426.23,426.23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU CONCENTRIC/BIPOLAR STIM PROBE D191,2720000046,CDM,272,RC,,,facility,both,,,,426.23,426.23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D1260 PEDICLE SCREW BALL 2.3 MM,2720000047,CDM,272,RC,,,facility,both,,,,438.71,438.71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D1264 BALL TIP PROBE 160MM,2720000048,CDM,272,RC,,,facility,both,,,,488.81,488.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SU D1265 BALL-TIP PROBE, 200MM",2720000049,CDM,272,RC,,,facility,both,,,,554.26,554.26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D145 - 4-CONTACT (1X4) PLATINUM STRIP,2720000050,CDM,272,RC,,,facility,both,,,,2683.67,2683.67,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D190 PEDICLE SCREW BALL 2.3 MM,2720000051,CDM,272,RC,,,facility,both,,,,438.71,438.71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D200 BIPOLAR CORTICAL STIMULATOR PROBE,2720000052,CDM,272,RC,,,facility,both,,,,2651.29,2651.29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D339 MONOPOLAR PROBE MAGSTIM,2720000053,CDM,272,RC,,,facility,both,,,,536.41,536.41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D340 PRASS PROBE STIMULATOR,2720000054,CDM,272,RC,,,facility,both,,,,1261.59,1261.59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D344 PEDICLE SCREW BALL 3 MM,2720000055,CDM,272,RC,,,facility,both,,,,494.27,494.27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D346 XL PEDICLE SCREW BALL 3 MM,2720000056,CDM,272,RC,,,facility,both,,,,928.07,928.07,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D612 NVM5 PROBE SINGLE USE,2720000057,CDM,272,RC,,,facility,both,,,,1222.42,1222.42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SU D623 NVM5 MULTIMODALITY KIT, NEEDLE",2720000058,CDM,272,RC,,,facility,both,,,,4095.07,4095.07,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU DISPOSE BRONCHOSCOPE ALL SI,2720000059,CDM,272,RC,,,facility,both,,,,1192.58,1192.58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU DISPOSE BRONCHOSCOPE ALL SI,2720000059,CDM,272,RC,,,facility,both,,,,1192.55,1192.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU ELECTRODE LARYNGEAL STICKER,2720000060,CDM,272,RC,,,facility,both,,,,1325.89,1325.89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU ENDO TRACH TUBE 6.5MM,2720000061,CDM,272,RC,,,facility,both,,,,182.91,182.91,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU ENDOTRACHIAL TUBE 6MM,2720000062,CDM,272,RC,,,facility,both,,,,1157.68,1157.68,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU ENDOTRACHIAL TUBE 7MM,2720000063,CDM,272,RC,,,facility,both,,,,1157.68,1157.68,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU EPIDURAL SPINAL ELECTRODE 3-CONTACT,2720000064,CDM,272,RC,,,facility,both,,,,751.1,751.1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU MATTRESS SPR+ OVERLAY,2720000068,CDM,272,RC,,,facility,both,,,,240.52,240.52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU MONOPOLAR PROBE RHYTHMLINK D129,2720000069,CDM,272,RC,,,facility,both,,,,536.41,536.41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU MONOPOLAR TEFLON ELECTRODE,2720000070,CDM,272,RC,,,facility,both,,,,19.93,19.93,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU RELOADABLE CATHETER,2720000079,CDM,272,RC,,,facility,both,,,,3369.32,3369.32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU SET PRISMAFLEX HF1000,2720000080,CDM,272,RC,,,facility,both,,,,1085.53,1085.53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU SET PRISMAFLEX M-100,2720000081,CDM,272,RC,,,facility,both,,,,1034.41,1034.41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU SET PRISMAFLEX M-60,2720000082,CDM,272,RC,,,facility,both,,,,884.74,884.74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU TRAY SPINAL 24GA 4IN W/EPH/,2720000084,CDM,272,RC,,,facility,both,,,,108.35,108.35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU TRUFREEZE PASSIVE VENTING SPRAY KIT,2720000085,CDM,272,RC,,,facility,both,,,,6815.09,6815.09,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU TRUFREEZE RAPID ACTIVE VENTING SPRAY KIT,2720000086,CDM,272,RC,,,facility,both,,,,6815.09,6815.09,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU URETHRAL ELECTRODE,2720000087,CDM,272,RC,,,facility,both,,,,1696.47,1696.47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BAG AMBU PEDS,2720000091,CDM,272,RC,,,facility,both,,,,104.33,104.33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SU-BINDER ABD 12"" - 46-62""",2720000093,CDM,272,RC,,,facility,both,,,,75.29,75.29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SU-BINDER ABD 12"" 30-45""",2720000094,CDM,272,RC,,,facility,both,,,,62.23,62.23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SU-BINDER ABD 12"" 60-75""",2720000095,CDM,272,RC,,,facility,both,,,,94.51,94.51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BRONCHO CATH 32 LEFT,2720000096,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BRONCHO CATH LEFT,2720000097,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER AIRWAY EXCHANGE 7M,2720000098,CDM,272,RC,,,facility,both,,,,288.51,288.51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER BRONCHO RIGHT 39,2720000099,CDM,272,RC,,,facility,both,,,,284.55,284.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER BRONCHO RIGHT 39,2720000099,CDM,272,RC,,,facility,both,,,,284.56,284.56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER BRONCHO RIGHT ES 3,27200000A1,CDM,272,RC,,,facility,both,,,,284.55,284.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER INTUBAT 19.0FR 56,27200000A2,CDM,272,RC,,,facility,both,,,,288.51,288.51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER KIT LUMBAR ACCESS,27200000A3,CDM,272,RC,,,facility,both,,,,1299.5,1299.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER KIT LUMBAR ACCESS,27200000A4,CDM,272,RC,,,facility,both,,,,1299.5,1299.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER KIT LUMBAR ACCESS,27200000A4,CDM,272,RC,,,facility,both,,,,1299.52,1299.52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-ENDO TRACH TUBE 6.0MM,27200000A5,CDM,272,RC,,,facility,both,,,,182.91,182.91,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-FLOTRAC SENSOR MHD8,27200000A7,CDM,272,RC,,,facility,both,,,,1303.94,1303.94,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-FLOTRAC SENSOR MHD8,27200000A8,CDM,272,RC,,,facility,both,,,,1303.94,1303.94,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-FLOTRAC SENSOR MHD8,27200000A8,CDM,272,RC,,,facility,both,,,,1303.96,1303.96,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-GLIDESCOPE COVERS,27200000A9,CDM,272,RC,,,facility,both,,,,61.08,61.08,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-GLIDESCOPE COVERS,27200000B1,CDM,272,RC,,,facility,both,,,,61.08,61.08,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-INTRODUCER FROVA INTUBATING,27200000B2,CDM,272,RC,,,facility,both,,,,460.49,460.49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-INTRODUCER FROVA INTUBATING,27200000B2,CDM,272,RC,,,facility,both,,,,460.5,460.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TB089T I-FLOW CONT CATHETER 3.5,27200000B3,CDM,272,RC,,,facility,both,,,,164.17,164.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TB089T I-FLOW CONT. CATHETER 3.5,27200000B4,CDM,272,RC,,,facility,both,,,,164.17,164.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TB127T I-FLOW CONT CATHETER 5.0,27200000B5,CDM,272,RC,,,facility,both,,,,164.17,164.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TB127T I-FLOW CONT. CATHETER 5.0,27200000B6,CDM,272,RC,,,facility,both,,,,164.17,164.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TRIFUR SAFE 3 TRAN,27200000B7,CDM,272,RC,,,facility,both,,,,192.47,192.47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LMA FASTRACH SZ 3-5,27200000B8,CDM,272,RC,,,facility,both,,,,241.05,241.05,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-MASK LMA AMBU-ALL SIZES,27200000C3,CDM,272,RC,,,facility,both,,,,70.59,70.59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-MASK LMA AMBU-ALL SIZES,27200000C3,CDM,272,RC,,,facility,both,,,,34.23,34.23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-NEEDLE CSE 17G X 6IN 25G X 190,27200000C6,CDM,272,RC,,,facility,both,,,,152.65,152.65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-PUMP VAC PER DAY,27200000C8,CDM,272,RC,,,facility,both,,,,332.47,332.47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-SEALGUARD TUBES,27200000D1,CDM,272,RC,,,facility,both,,,,94.51,94.51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-SET VENTRICULOSTOMY DRAINAGE,27200000D2,CDM,272,RC,,,facility,both,,,,1593.22,1593.22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-SET VENTRICULOSTOMY DRAINAGE,27200000D3,CDM,272,RC,,,facility,both,,,,1593.22,1593.22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-SETS ENDOBRACHIAL BLOCKER 9,27200000D4,CDM,272,RC,,,facility,both,,,,790.38,790.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-SETS ENDOBRACHIAL BLOCKER 9,27200000D4,CDM,272,RC,,,facility,both,,,,790.39,790.39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-SONOSITE NEEDLE GUIDE KIT,27200000D6,CDM,272,RC,,,facility,both,,,,104.74,104.74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-SONOSITE NEEDLE GUIDE KIT,27200000D7,CDM,272,RC,,,facility,both,,,,104.74,104.74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRANSDUCER BIFURCATED KIT,27200000D8,CDM,272,RC,,,facility,both,,,,154.26,154.26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSDUCER SAFESET W/2PORT,27200000D9,CDM,272,RC,,,facility,both,,,,154.26,154.26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRANSDUCER W/SAFESET,2.72E+08,CDM,272,RC,,,facility,both,,,,97.65,97.65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSDUCER SAFESET W/1PORT,2.72E+09,CDM,272,RC,,,facility,both,,,,97.65,97.65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRANSGASTRIC JEJUN FEED TUB,2.72E+10,CDM,272,RC,,,facility,both,,,,1005.19,1005.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRAY CONTINUOUS EPIDURAL ANESTHESIA,2.72E+11,CDM,272,RC,,,facility,both,,,,131.08,131.08,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRAY CONTINUOUS EPIDURAL ANESTHESIA,2.72E+12,CDM,272,RC,,,facility,both,,,,131.08,131.08,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRAY EPIDURAL ARROW,2.72E+13,CDM,272,RC,,,facility,both,,,,159.39,159.39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRAY EPIDURAL ARROW,2.72E+14,CDM,272,RC,,,facility,both,,,,159.39,159.39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRAY SONOPLEX 21G X 4,2.72E+15,CDM,272,RC,,,facility,both,,,,164.17,164.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRAY SONOPLEX 21G X 4,2.72E+16,CDM,272,RC,,,facility,both,,,,164.17,164.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRAY SONOPLEX 22G X 2,27200000F1,CDM,272,RC,,,facility,both,,,,164.17,164.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRAY SONOPLEX 22G X 2,27200000F2,CDM,272,RC,,,facility,both,,,,164.17,164.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TRAY THORACENTESIS,27200000F3,CDM,272,RC,,,facility,both,,,,154.39,154.39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TUBE BRONCH CATH 41 FR. RT,27200000F4,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TUBE BRONCHIO CATH LEFT 37F,27200000F5,CDM,272,RC,,,facility,both,,,,283.05,283.05,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TUBE BRONCHIO CATH LEFT 37F,27200000F5,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TUBE BRONCHIO CATH LEFT 39F,27200000F6,CDM,272,RC,,,facility,both,,,,283.05,283.05,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TUBE BRONCHIO CATH LEFT 39F,27200000F6,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TUBE ENDOBRONCHIAL LEFT 35,27200000F7,CDM,272,RC,,,facility,both,,,,283.05,283.05,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TUBE ENDOBRONCHIAL LEFT 35,27200000F7,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-TUBE ET BRONC CATH RT 35FR,27200000F8,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SYSTEM SUCTION DRAINAGE 500ML (ACCORDION DRAINAGE BAG),27200000G1,CDM,272,RC,,,facility,both,,,,157.8,157.8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIDEOSCOPE 403-001-00 AMBU FLEXIBLE DISP,27200000G2,CDM,272,RC,,,facility,both,,,,1157.09,1157.09,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU EPIDURAL ID ADAPTER & KIT COMPUFLO,27200000G6,CDM,272,RC,,,facility,both,,,,318.01,318.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU EPIDURAL CATHCHEK COMPUFLO,27200000G7,CDM,272,RC,,,facility,both,,,,275.01,275.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC VYAIRE SUPERNO 2VA ET, MEDIUM/LARGE",27200000G8,CDM,272,RC,,,facility,both,,,,401.19,401.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER DUAL LUMEN 40CM,27200000G9,CDM,272,RC,,,facility,both,,,,561.49,561.49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER DUAL LUMEN 70CM,27200000H1,CDM,272,RC,,,facility,both,,,,651.33,651.33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D325-6 CONTACT (1X6) PLATINUM STRIP,27200000H2,CDM,272,RC,,,facility,both,,,,2898.36,2898.36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSTEOCOOL ABLATION GENERATOR FEE,27200000H3,CDM,272,RC,,,facility,both,,,,2433.38,2433.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BINDER ABDOMINAL 12 INCH 72-84,2720000100,CDM,272,RC,,,facility,both,,,,54.88,54.88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DUALCORE BIOPSY SYSTEM W/ COAX 14G 10CM,2720000101,CDM,272,RC,,,facility,both,,,,231.01,231.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DUALCORE BIOPSY SYSTEM W/ COAX 14G 16CM,2720000102,CDM,272,RC,,,facility,both,,,,231.01,231.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC D217 BALL TIP PROBE 100MM,2720000104,CDM,272,RC,,,facility,both,,,,474.57,474.57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FIBER DUST THULIUM FIBER LASER 1 CASE,2720000105,CDM,272,RC,,,facility,both,,,,4898.18,4898.18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CUSTOM TRACH TUBE,2720000106,CDM,272,RC,,,facility,both,,,,2811.59,2811.59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESERVOIR VENTRICULAR BUR HOLE(1067532) MEDTRONIC,2720000400,CDM,272,RC,,,facility,both,,,,1418.74,1418.74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KIT LUMBAR CATHETER ACCESSORY (1114008) INTEGRA,2720000401,CDM,272,RC,,,facility,both,,,,1338.55,1338.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU D353 EPIDURAL SPINAL ELECTRODE 3-CONTACT,2720000G48,CDM,272,RC,,,facility,both,,,,2753.19,2753.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IOPLEX IODOPHOR FOAM,272A621001,CDM,272,RC,A6210,HCPCS,facility,both,,,,100.01,100.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLOWTRIEVER SYSTEM,272C175702,CDM,272,RC,C1757,HCPCS,facility,both,,,,42949.97,42949.97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-WIRE GUIDE FIXED CORE .015I,272C176901,CDM,272,RC,C1769,HCPCS,facility,both,,,,121.21,121.21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SU-MICROWIRE, TORQ-FLEX",272C176904,CDM,272,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CATHETER VERT 7FR,272C188701,CDM,272,RC,C1887,HCPCS,facility,both,,,,234.24,234.24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-PUMP ON-Q C-BLOCK PUMP SINGLE 550ML,272C980401,CDM,272,RC,,,facility,both,,,,597.01,597.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU AMBIT PAIN PUMP,272C980601,CDM,272,RC,,,facility,both,,,,959.29,959.29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU AMBIT PAIN PUMP,272C980601,CDM,272,RC,C9806,HCPCS,facility,both,,,,959.29,959.29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DONOR BREAST MILK PER ML,272T210101,CDM,272,RC,T2101,HCPCS,facility,both,,,,0.75,0.75,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACAPELLA DUET,2740000001,CDM,274,RC,,,facility,both,,,,264.7,264.7,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPIROMETER GOSPIRAL PERSONAL,2740000003,CDM,274,RC,,,facility,both,,,,1933.5,1933.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW IMPLANT KIT,2740000006,CDM,274,RC,,,facility,both,,,,249812.17,249812.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-VAC CANNISTER W/O GEL,2740000008,CDM,274,RC,,,facility,both,,,,116.26,116.26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WEARABLE ACCESSORY KIT,2740000011,CDM,274,RC,,,facility,both,,,,638.24,638.24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE",274A446701,CDM,274,RC,A4467,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATE",274A550001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH",274A653001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES",274A800001,CDM,274,RC,A8000,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES",274A800101,CDM,274,RC,A8001,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH",274A928301,CDM,274,RC,A9283,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HEEL OR ELBOW PROTECTOR, EACH",274E019101,CDM,274,RC,E0191,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM",274L012001,CDM,274,RC,L0120,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR)",274L014001,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CHIN CUP (PLASTIC COLLAR WITH MANDIBULAR/OCCIPITAL PIECE)",274L015001,CDM,274,RC,L0150,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CERVICAL, COLLAR, SEMI-RIGID THERMOPLASTIC FOAM, TWO-PIECE, PREFABRICATED, OFF-THE-SHE",274L017201,CDM,274,RC,L0172,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH TF",274L017401,CDM,274,RC,L0174,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CERVICAL, MULTIPOST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUST",274L018001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJN",274L020001,CDM,274,RC,L0200,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC THORACIC, RIB BELT, CUSTOM FABRICATED",274L022001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TLSO, FLEXIBLE, TRUNK SUPPORT, UPPER THORACIC REGION, INCLUDES SHOF",274L045001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TLSO, FLEXIBLE, TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PAT",274L045601,CDM,274,RC,L0456,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TLSO, FLEXIBLE, TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PAF",274L045701,CDM,274,RC,L0457,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGI",274L046001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, FOUR RIGT",274L046401,CDM,274,RC,L0464,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR AND LATERAT",274L047201,CDM,274,RC,L0472,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFD",274L048601,CDM,274,RC,L0486,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDF",274L062101,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIT",274L062701,CDM,274,RC,L0627,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, MF",274L062801,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTER",274L063701,CDM,274,RC,L0637,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PD",274L064001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIF",274L064201,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERF",274L065001,CDM,274,RC,L0650,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO JACKET VEST",274L081001,CDM,274,RC,L0810,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYL",274L085901,CDM,274,RC,L0859,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIAL",274L086101,CDM,274,RC,L0861,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED",274L099901,CDM,274,RC,L0999,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, INFANT SIZET",274L100101,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED",274L149901,CDM,274,RC,L1499,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (PAVLIK HE",274L162001,CDM,274,RC,L1620,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, CUSTOM FABRICATED",274L168501,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABT",274L168601,CDM,274,RC,L1686,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHT",274L182001,CDM,274,RC,L1820,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC KNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, OFF-THE-SHELF",274L183001,CDM,274,RC,L1830,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC),T",274L183201,CDM,274,RC,L1832,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC),F",274L183301,CDM,274,RC,L1833,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MAF",274L183601,CDM,274,RC,L1836,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC KNEE ORTHOSIS (KO), SWEDISH TYPE, PREFABRICATED",274L185001,CDM,274,RC,,,facility,both,,,,1109.11,1109.11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PREF, OFF-THE-SHELF, KNEE ORTHOSIS (KO), SINGLE UPRIGHT, THIGH ANDT",274L185101,CDM,274,RC,,,facility,both,,,,1109.11,1109.11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE ORTHOSIS, ANKLE GAUNTLET OR SIMILAR, WITH OR WITHOUT JOINTS, PREFABRICATED, OFF-THE-SHELF",274L190201,CDM,274,RC,L1902,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT",274L193001,CDM,274,RC,L1930,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE FOOT ORTHOTIC(AFO)RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBOT",274L193201,CDM,274,RC,L1932,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM FABRICATED",274L194001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM FABRICATED",274L194501,CDM,274,RC,L1945,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CUSTOM, ANKLE FOOT ORTHOSIS, SPIRAL, PLASTIC",274L195001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM FABRICATED",274L196001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM FABRICATED",274L197001,CDM,274,RC,L1970,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KAFO FEMORAL FX CAST RIGID,274L213601,CDM,274,RC,L2136,HCPCS,facility,both,,,,1109.13,1109.13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT",274L220001,CDM,274,RC,L2200,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DORSI & PLANTAR FLEX ASS/RES,274L222001,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION ('T') STRAP, PADDED/LINED OR MALLEOLUS PAD",274L227001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINED",274L227501,CDM,274,RC,L2275,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID STIRRUP",274L237501,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINT",274L238001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDED",274L253001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT MODEL",274L254001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS OR THRUST BEARING, LOCK, EACH",274L261001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLEH",274L262401,CDM,274,RC,L2624,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION",274L282001,CDM,274,RC,L2820,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTION",274L283001,CDM,274,RC,L2830,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED",274L299901,CDM,274,RC,L2999,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH",274L321901,CDM,274,RC,,,facility,both,,,,1109.11,1109.11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACH",274L322101,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED, EACH",274L325301,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SURGICAL BOOT/SHOE, EACH",274L326002,CDM,274,RC,L3260,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PLASTAZOTE SANDAL, EACH",274L326501,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH",274L331001,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH",274L333201,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HEEL, PAD, REMOVABLE FOR SPUR",274L348501,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEW",274L363001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF",274L365001,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE), PREFABRICATED, OFF-THE-SHELF",274L367001,CDM,274,RC,L3670,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EO W/O JOINTS CF,274L370201,CDM,274,RC,L3702,HCPCS,facility,both,,,,421.48,421.48,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CUSTOM FAB ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXION ASSIST",274L373001,CDM,274,RC,,,facility,both,,,,1109.11,1109.11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CUFFS ADJ LOCK W/ ACTIVE CON,274L374001,CDM,274,RC,L3740,HCPCS,facility,both,,,,1705.57,1705.57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ELBOW ORTHOSIS, WITH ADJUSTABLE POSITION LOCKING JOINTS, PREFABRICE",274L376001,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EO WITH JNT PREFABRICATED,274L376002,CDM,274,RC,L3760,HCPCS,facility,both,,,,974.45,974.45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EWHO RIGID WO JNTS CF,274L376301,CDM,274,RC,L3763,HCPCS,facility,both,,,,1092.25,1092.25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EWHO W JOINTS CF,274L376401,CDM,274,RC,L3764,HCPCS,facility,both,,,,1143.06,1143.06,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EWHFO RIGID WO JNTS CF,274L376501,CDM,274,RC,,,facility,both,,,,1908.97,1908.97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHFO W JOINTS CUSTOM FAB,274L380602,CDM,274,RC,L3806,HCPCS,facility,both,,,,662.98,662.98,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTST",274L380603,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHFO WO JOINTS PRE CST,274L380702,CDM,274,RC,L3807,HCPCS,facility,both,,,,871.42,871.42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WRIST HAND FINGER ORTHOSIS, WITHOUT JOINTS, PREFABRICATED ITEM THAE",274L380703,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHFO RIGID WO JOINTS CF,274L380802,CDM,274,RC,L3808,HCPCS,facility,both,,,,519.91,519.91,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHFO WO JOINTS PRE OTS,274L380902,CDM,274,RC,L3809,HCPCS,facility,both,,,,364.94,364.94,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, OFF-THE-SHELF, ANY TYPE",274L380903,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HINGE EXT FLEX WRIST FIN CF,274L390001,CDM,274,RC,L3900,HCPCS,facility,both,,,,2425.8,2425.8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HINGE EXT FLEX WRST FNGR CF,274L390101,CDM,274,RC,,,facility,both,,,,3401.7,3401.7,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHO W NONTORSION JNTS CF,274L390501,CDM,274,RC,L3905,HCPCS,facility,both,,,,1447.42,1447.42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHO WO JOINTS CF,274L390602,CDM,274,RC,L3906,HCPCS,facility,both,,,,739.67,739.67,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHO COCKUP NONMOLDE OTS,274L390802,CDM,274,RC,L3908,HCPCS,facility,both,,,,107.02,107.02,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED, PREFABRICATED, OFF-THE-SHELF",274L390803,CDM,274,RC,,,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC HAND FINGER ORTHOSIS HFO, FLEXION GLOVE WITH ELASTIC FINGER CONTROF",274L391201,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HFO WO JOINTS CF,274L391301,CDM,274,RC,L3913,HCPCS,facility,both,,,,395.28,395.28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HO WO JOINTS CF,274L391901,CDM,274,RC,L3919,HCPCS,facility,both,,,,395.28,395.28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HFO W JOINTS CF,274L392101,CDM,274,RC,L3921,HCPCS,facility,both,,,,468.85,468.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HFO WITHOUT JOINTS PRE CST,274L392301,CDM,274,RC,,,facility,both,,,,154.78,154.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HFO WITHOUT JOINTS OTS,274L392401,CDM,274,RC,L3924,HCPCS,facility,both,,,,336.63,336.63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FO PIP DIP JNT SPRNG PRE OTS,274L392501,CDM,274,RC,,,facility,both,,,,95.88,95.88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTST",274L393101,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FO WO JOINTS CF,274L393301,CDM,274,RC,L3933,HCPCS,facility,both,,,,311.42,311.42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANT",274L396001,CDM,274,RC,L3960,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANT",274L396701,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT",274L398001,CDM,274,RC,L3980,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNAR, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT",274L398201,CDM,274,RC,L3982,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT",274L398401,CDM,274,RC,L3984,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIED",274L399901,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE",274L400201,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES",274L420501,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS",274L421001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INF",274L435001,CDM,274,RC,L4350,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WIT",274L436002,CDM,274,RC,L4360,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITF",274L436101,CDM,274,RC,L4361,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHO",274L438601,CDM,274,RC,L4386,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOF",274L438701,CDM,274,RC,L4387,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MA",274L439601,CDM,274,RC,L4396,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MAF",274L439701,CDM,274,RC,L4397,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, OFF-THE-SHELF",274L439801,CDM,274,RC,L4398,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, RD",274L463101,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BELOW KNEE POST SURGICAL APPLICAT NON-WEIGHT BEARING RIGID DRESSING,274L545001,CDM,274,RC,L5450,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABOVE KNEE POST SURGICAL APPLICAT NON-WEIGHT BEARING RIGID DRESSING,274L546001,CDM,274,RC,L5460,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PL",274L553001,CDM,274,RC,L5530,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACT",274L563701,CDM,274,RC,L5637,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET",274L564401,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL CUSHION",274L566801,CDM,274,RC,L5668,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICAM",274L567901,CDM,274,RC,L5679,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/SEAH",274L568501,CDM,274,RC,L5685,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBING",274L568801,CDM,274,RC,L5688,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, LIGHT",274L569201,CDM,274,RC,L5692,HCPCS,facility,both,,,,1109.13,1109.13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SYSTEM",274L591001,CDM,274,RC,L5910,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED",274L599901,CDM,274,RC,L5999,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF RIGID DRESSING ONLY",274L638801,CDM,274,RC,L6388,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SHEATH, BELOW KNEE, EACH",274L840001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SOCK, MULTIPLE PLY, BELOW KNEE, EACH",274L842001,CDM,274,RC,L8420,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNEE, EACH",274L843001,CDM,274,RC,L8430,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB, EACH",274L843501,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SHRINKER, BELOW KNEE, EACH",274L844001,CDM,274,RC,L8440,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SHRINKER, ABOVE KNEE, EACH",274L846001,CDM,274,RC,L8460,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SHRINKER, UPPER LIMB, EACH",274L846501,CDM,274,RC,L8465,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACH",274L847001,CDM,274,RC,L8470,HCPCS,facility,both,,,,1186.78,1186.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACH",274L848001,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PROSTHETIC SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH",274L848501,CDM,274,RC,,,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 16FR 10MM,274L850901,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 16FR 12MM,274L850902,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 16FR 14MM,274L850903,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 16FR 4MM,274L850904,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 16FR 6MM,274L850905,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 16FR 8MM,274L850906,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 20FR 10MM,274L850907,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 20FR 12MM,274L850908,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 20FR 14MM,274L850909,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 20FR 4MM,274L850910,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 20FR 6MM,274L850911,CDM,274,RC,L8509,HCPCS,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH ADVANTAGE SOFT 20FR 8MM,274L850912,CDM,274,RC,,,facility,both,,,,1751.85,1751.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 16FR 10MM,274L850913,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 16FR 12MM,274L850914,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 16FR 14MM,274L850915,CDM,274,RC,,,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 16FR 16MM,274L850916,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 16FR 4MM,274L850917,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 16FR 6MM,274L850918,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.46,1145.46,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 16FR 8MM,274L850919,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.46,1145.46,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 20FR 10MM,274L850920,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 20FR 12MM,274L850921,CDM,274,RC,,,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 20FR 14MM,274L850922,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 20FR 16MM,274L850923,CDM,274,RC,,,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 20FR 4MM,274L850924,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 20FR 6MM,274L850925,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH CLASSIC INDW 20FR 8MM,274L850926,CDM,274,RC,L8509,HCPCS,facility,both,,,,1145.44,1145.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACH-ESOPH VOICE PROS MD IN,274L850928,CDM,274,RC,,,facility,both,,,,6605.55,6605.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHEALTH DUALVALVE NS 20FR 6MM,274L850933,CDM,274,RC,L8509,HCPCS,facility,both,,,,2106,2106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW CONTROLLER AC ADAPTER 1430US,274Q047801,CDM,274,RC,Q0478,HCPCS,facility,both,,,,5005.8,5005.8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM POWER MODULE DC INPUT,274Q047802,CDM,274,RC,,,facility,both,,,,903.42,903.42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM POWER MODULE,274Q047901,CDM,274,RC,,,facility,both,,,,20827.58,20827.58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HM MOBILE POWER UNIT 107754,274Q047902,CDM,274,RC,Q0479,HCPCS,facility,both,,,,31229.6,31229.6,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM3 SYSTEM CONTROLLER,274Q048101,CDM,274,RC,Q0481,HCPCS,facility,both,,,,21470.35,21470.35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM POCKET CONTROLLER,274Q048102,CDM,274,RC,,,facility,both,,,,16742.18,16742.18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HMII SYSTEM CONTROLLER 106762,274Q048103,CDM,274,RC,Q0481,HCPCS,facility,both,,,,21362.72,21362.72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW CONTROLLER KIT,274Q048104,CDM,274,RC,Q0481,HCPCS,facility,both,,,,21213.59,21213.59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU HW CONTROLLER 1420,274Q048106,CDM,274,RC,Q0481,HCPCS,facility,both,,,,22934.24,22934.24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM DISPLAY MODULE,274Q048301,CDM,274,RC,,,facility,both,,,,9470.31,9470.31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM2 POWER MOD PAT CABLE,274Q048501,CDM,274,RC,,,facility,both,,,,4227.89,4227.89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM3 MODULAR CABLE 106525US,274Q048502,CDM,274,RC,Q0485,HCPCS,facility,both,,,,21362.72,21362.72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW BATTERY CHARGER 1600US,274Q048901,CDM,274,RC,Q0489,HCPCS,facility,both,,,,23812.57,23812.57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM BATTERY CHARGER 1440,274Q049501,CDM,274,RC,Q0495,HCPCS,facility,both,,,,25295.98,25295.98,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM 14 VOLT BATTERY CLIP 2865,274Q049701,CDM,274,RC,Q0497,HCPCS,facility,both,,,,4955.74,4955.74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM GOGEAR VEST 104231,274Q049801,CDM,274,RC,Q0498,HCPCS,facility,both,,,,1903.07,1903.07,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW PATIENT PACK 1475,274Q049802,CDM,274,RC,Q0498,HCPCS,facility,both,,,,2271.92,2271.92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW SHOULDER PACK 2060US,274Q049803,CDM,274,RC,Q0498,HCPCS,facility,both,,,,2405.57,2405.57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU- HM HOLSTER VEST 104226,274Q049805,CDM,274,RC,Q0498,HCPCS,facility,both,,,,1903.07,1903.07,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM BATTERY HOLSTER,274Q049806,CDM,274,RC,,,facility,both,,,,2112.02,2112.02,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HM CONSOLIDATION BAG BLACK,274Q049901,CDM,274,RC,,,facility,both,,,,1301.72,1301.72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU HM CONSOLIDATION BAG LEFT 106449,274Q049902,CDM,274,RC,Q0499,HCPCS,facility,both,,,,1480.76,1480.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU HM CONSOLIDATION BAG RIGHT 104233,274Q049903,CDM,274,RC,Q0499,HCPCS,facility,both,,,,1480.76,1480.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW WAIST PACK 2050US,274Q049904,CDM,274,RC,Q0499,HCPCS,facility,both,,,,2271.92,2271.92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM SHOWER BAG,274Q050101,CDM,274,RC,Q0501,HCPCS,facility,both,,,,1802.4,1802.4,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU HC HW SHOWER BAG 2000US,274Q050102,CDM,274,RC,Q0501,HCPCS,facility,both,,,,1603.71,1603.71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HM BATTERY 11V BACKUP PCTRL 106128,274Q050601,CDM,274,RC,Q0506,HCPCS,facility,both,,,,2405.57,2405.57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM 14 VOLT LI-ION BATTERY 2465,274Q050602,CDM,274,RC,Q0506,HCPCS,facility,both,,,,2815.76,2815.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW BATTERY 1650DE,274Q050603,CDM,274,RC,Q0506,HCPCS,facility,both,,,,3754.35,3754.35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU HM GOGEAR ACCESSORY KIT 106129,274Q050801,CDM,274,RC,Q0508,HCPCS,facility,both,,,,817.89,817.89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-DAILY VAD DRIVELINE MGT SYSTEM,274Q050802,CDM,274,RC,Q0508,HCPCS,facility,both,,,,138.7,138.7,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM SC BATTERY MODULES,274Q050803,CDM,274,RC,,,facility,both,,,,1179.34,1179.34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM STABILIZATION BELT,274Q050804,CDM,274,RC,,,facility,both,,,,504.38,504.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HM TRAVEL CASE 1260,274Q050805,CDM,274,RC,Q0508,HCPCS,facility,both,,,,769.78,769.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW CONTROLLER DC ADAPTER 1440,274Q050806,CDM,274,RC,Q0508,HCPCS,facility,both,,,,8631.4,8631.4,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-HW TRAVEL BAG,274Q050807,CDM,274,RC,Q0508,HCPCS,facility,both,,,,285.04,285.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-WEEKLEY VAD DRIVELINE MGT SYSTEM,274Q050808,CDM,274,RC,Q0508,HCPCS,facility,both,,,,158.3,158.3,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU HW ALARM ADAPTER 1450,274Q050810,CDM,274,RC,Q0508,HCPCS,facility,both,,,,1470.07,1470.07,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MIS SUP/AC IMP VAD NOPAY MED PART A,274Q050901,CDM,274,RC,,,facility,both,,,,158.3,158.3,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, RIGID, WITH SOFT INTERFACE",274S104001,CDM,274,RC,S1040,HCPCS,facility,both,,,,1186.76,1186.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLUG B004-0155 STRYKER OSTEONICS SIZE 4,2780000002,CDM,278,RC,,,facility,both,,,,283.04,283.04,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHUNT BG-103-250 BAERVELDT GLAUCOMA 250X,2780000008,CDM,278,RC,,,facility,both,,,,2976.4,2976.4,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHUNT BG-103-250 BAERVELDT GLAUCOMA 250X,2780000009,CDM,278,RC,,,facility,both,,,,2976.4,2976.4,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BLOCKER BRONCH 9FR ADULT,2780000010,CDM,272,RC,,,facility,both,,,,814.12,814.12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-BLOCKER BRONCH 9FR ADULT,2780000010,CDM,272,RC,,,facility,both,,,,814.11,814.11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TBT01089T I-FLOW CONT. STIMUCATH,2780000011,CDM,272,RC,,,facility,both,,,,322.81,322.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TBT01089T I-FLOW CONT STIMUCATH,2780000012,CDM,272,RC,,,facility,both,,,,322.81,322.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TBT01127T I-FLOW CONT STIMUCATH,2780000013,CDM,272,RC,,,facility,both,,,,322.81,322.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-KIT TBT01127T I-FLOW CONT. STIMUCATH,2780000014,CDM,272,RC,,,facility,both,,,,322.81,322.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIDERMAL AUTOGRAF TR/ARM/LG 1ST 100SQCM,2781511001,CDM,278,RC,,,facility,both,,,,3396.43,3396.43,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIDERMAL AUTGRFT  ADDTL 100SQCM,2781511101,CDM,278,RC,,,facility,both,,,,1.09,1.09,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-GOLD FIDUCIAL MARKERS,278A464801,CDM,278,RC,A4648,HCPCS,facility,both,,,,72.2,72.2,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-IRIDIUM 192 SEED,278C171701,CDM,278,RC,C1717,HCPCS,facility,both,,,,527.1,527.1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER 4.0FR PIC VENOUS,278C175109,CDM,278,RC,C1751,HCPCS,facility,both,,,,504.38,504.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER PIC 5.0FR,278C175110,CDM,278,RC,C1751,HCPCS,facility,both,,,,327.59,327.59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER TRIPLE LUMEN 7FR INFUSION,278C175111,CDM,278,RC,,,facility,both,,,,177.97,177.97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-CATHETER TRIPLE LUMEN 7FR INFUSION,278C175112,CDM,278,RC,,,facility,both,,,,177.97,177.97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPACEOAR HYDROGEL,278C188901,CDM,278,RC,C1889,HCPCS,facility,both,,,,10128.83,10128.83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-IODINE 125 SEED,278C263801,CDM,278,RC,,,facility,both,,,,176.14,176.14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU- EYEPLAQ HIGH NONSTRAND,278C263901,CDM,278,RC,C2639,HCPCS,facility,both,,,,402.88,402.88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-IODINE 125 NONSTRANDED SEED,278C263902,CDM,278,RC,,,facility,both,,,,166.51,166.51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-PALLADIUM 103 SEED,278C264001,CDM,278,RC,,,facility,both,,,,231.49,231.49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-PALLADIUM 103 NONSTRANDED,278C264101,CDM,278,RC,,,facility,both,,,,231.49,231.49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APLIGRAFT PER SQ CM,278Q410102,CDM,278,RC,,,facility,both,,,,112.39,112.39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB MI NEWBORN BLOOD SCREENING,3000000002,CDM,300,RC,,,facility,both,,,,236,236,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES EXTRACTION PRO,3000000004,CDM,300,RC,,,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES EXTRACTION RETRO,3000000005,CDM,300,RC,,,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES HEM NGS PANEL,3000000006,CDM,300,RC,,,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES KNOWN MUTATION,3000000007,CDM,300,RC,,,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESEARCH CA HOT SPOT V2,3000000008,CDM,300,RC,,,facility,both,,,,841,841,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESEARCH COMP CA PANEL,3000000009,CDM,300,RC,,,facility,both,,,,1942,1942,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESEARCH INHER DIS PANEL,3000000010,CDM,300,RC,,,facility,both,,,,363,363,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENIPUNCTURE,3003641501,CDM,300,RC,36415,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLLECT CAP BLD SPEC,3003641601,CDM,300,RC,36416,HCPCS,facility,both,,,,48,48,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTERIAL PUNCTURE,3003660001,CDM,300,RC,36600,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC  BASIC METABOLIC PANEL,3008004803,CDM,300,RC,80048,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC  BASIC METABOLIC PANEL,3008004803,CDM,300,RC,80048,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GABAPENTIN LEVEL,3008017101,CDM,300,RC,80171,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHOSPHATIDYLETHANOL (PETH) DRUG SCREEN QUANT,3008032104,CDM,300,RC,G0480,HCPCS,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREENING KETAMINE AND NORKETAMINE,3008035701,CDM,300,RC,,,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAPENTADOL CONF,3008037201,CDM,300,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NTRK GENE FUSION ANALYSIS,3008119401,CDM,300,RC,81194,HCPCS,facility,both,,,,1535,1535,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRAF LUNG PANEL,3008121001,CDM,300,RC,81210,HCPCS,facility,both,,,,333,333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB CEBPA MUTATION ANALYSIS,3008121802,CDM,300,RC,,,facility,both,,,,538,538,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EGFR LUNG PANEL,3008123501,CDM,300,RC,,,facility,both,,,,479,479,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLT3 GENE ANALYSIS INTERNAL TANDEM DUP VARIANTS,3008124502,CDM,300,RC,81245,HCPCS,facility,both,,,,490,490,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLT3 GENE ANALYSIS TYROSINE KINASE DOMAIN VARIANTS,3008124602,CDM,300,RC,81246,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB KIT MUTATION ANALYSIS,3008127201,CDM,300,RC,81272,HCPCS,facility,both,,,,945,945,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KRAS LUNG PANEL,3008127501,CDM,300,RC,81275,HCPCS,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOGENOMIC NEOPLASIA MICROARRAY ANALYSIS  ACGH,3008127702,CDM,300,RC,81277,HCPCS,facility,both,,,,2688,2688,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOGENOMIC NEOPLASIA MICROARRAY ANALYSI TECH ONLY,3008127703,CDM,300,RC,,,facility,both,,,,1210,1210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CMA HEMATOLOGIC DISORDERS,3008127704,CDM,300,RC,,,facility,both,,,,2581,2581,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CMA HEMATOLOGIC DISORDERS-TECH ONLY,3008127705,CDM,300,RC,,,facility,both,,,,632,632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
JAK2 TARGETED SEQUENCE ANALYSIS EXONS 12/13,3008127901,CDM,310,RC,81279,HCPCS,facility,both,,,,673,673,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MGMT GENE ANALYSIS,3008128701,CDM,300,RC,81287,HCPCS,facility,both,,,,548,548,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYD88 GENE ANALYSIS P.LEU265 (L265P) VARIANT,3008130501,CDM,300,RC,81305,HCPCS,facility,both,,,,775,775,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB NPM1 MUTATION ANALYSIS,3008131001,CDM,300,RC,81310,HCPCS,facility,both,,,,563,563,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NRAS,3008131101,CDM,300,RC,81311,HCPCS,facility,both,,,,622,622,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PDGFRA GENE ANALYS TARGETED SEQUENCE ANALYS,3008131401,CDM,300,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MPL GENE COMMON VARIANTS,3008133801,CDM,300,RC,81338,HCPCS,facility,both,,,,621,621,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HLA II LOW RESOLUTION HLA-DRB1/3/4/5 AND -DQB1,3008137500,CDM,300,RC,,,facility,both,,,,552,552,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HLA II HIGH RESOLUTION 1 ALLELE/ALLELE GROUP,3008138302,CDM,300,RC,81383,HCPCS,facility,both,,,,273,273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDH1 OR IDH2 GENE ANALYSIS,3008140302,CDM,300,RC,,,facility,both,,,,422,422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOLECULAR PATH LEVEL 4 DNA SEQ ANALYSIS,3008140303,CDM,310,RC,,,facility,both,,,,579,579,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KIR GENOTYPING,3008140304,CDM,300,RC,,,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MPL GENE ANALYSIS,3008140306,CDM,300,RC,,,facility,both,,,,535,535,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 6 TP53,3008140501,CDM,300,RC,81405,HCPCS,facility,both,,,,642,642,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FETAL CHRMOML ANEUPLOIDY,3008142001,CDM,300,RC,,,facility,both,,,,571,571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FETAL CHRMOML MICRODELTJ,3008142201,CDM,300,RC,,,facility,both,,,,1205,1205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GENE SOLID TUMOR ANALYSIS,3008145501,CDM,300,RC,,,facility,both,,,,3523,3523,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SARCOMA GENOMIC SEQ PANEL,3008145601,CDM,300,RC,81456,HCPCS,facility,both,,,,4198,4198,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOLECULAR POLE GENE MUTATION ANALYSIS,3008147910,CDM,300,RC,81479,HCPCS,facility,both,,,,698,698,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOLECULAR CXCR4 MUTATION ANALYSIS,3008147911,CDM,300,RC,81479,HCPCS,facility,both,,,,519,519,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMINO ACIDS QUANTITATIVE 6 OR MORE,3008213901,CDM,300,RC,,,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB CREATININE SERUM,3008256501,CDM,300,RC,,,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOASSAY ANALYTE QUANTITATIVE NGAL,3008352020,CDM,300,RC,,,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC HEMOGLOBIN,3008501803,CDM,300,RC,,,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC COAGUCHEK INR,3008561003,CDM,300,RC,,,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TB TESTING,3008658002,CDM,300,RC,86580,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM STS MI BLOOD,3008659201,CDM,300,RC,86592,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ANTI CMV MI BLOOD,3008664401,CDM,300,RC,86644,HCPCS,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ANTI HTLV I MI BLOOD,3008668701,CDM,300,RC,86687,HCPCS,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ANTI HTLV II MI BLOOD,3008668801,CDM,300,RC,86688,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ANTI HIV MI BLOOD,3008670301,CDM,300,RC,86703,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ANTI HBC MI BLOOD,3008670401,CDM,300,RC,86704,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM HBSAG MI BLOOD,3008670601,CDM,300,RC,86706,HCPCS,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM CHAGAS MI BLOOD,3008675304,CDM,300,RC,86753,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ANTI HCV MI BLOOD,3008680301,CDM,300,RC,86803,HCPCS,facility,both,,,,48,48,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ANTIBODY SCREEN MI BLOOD,3008685002,CDM,300,RC,86850,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIBODY ELUTION VERSITI,3008686001,CDM,300,RC,86860,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIBODY IDENTIFICATION VERSITI,3008687001,CDM,300,RC,86870,HCPCS,facility,both,,,,107,107,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3009 ANTIGLOBULIN VERSITI,3008688001,CDM,300,RC,86880,HCPCS,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM RH MI BLOOD,3008690101,CDM,300,RC,86901,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RH TYPING VERSITI,3008690102,CDM,300,RC,86901,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AGCHGV1 BLOOD TYPE ANTIGEN DONOR EA VERSITI,3008690201,CDM,300,RC,86902,HCPCS,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AGCHGV2 BLOOD TYPE ANTIGEN DONOR EA VERSITI,3008690202,CDM,300,RC,86902,HCPCS,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AGCHGV3 BLOOD TYPE ANTIGEN DONOR EA VERSITI,3008690203,CDM,300,RC,86902,HCPCS,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AGCHGV4 BLOOD TYPE ANTIGEN DONOR EA VERSITI,3008690204,CDM,300,RC,86902,HCPCS,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIGEN TYPE PT VERSITI,3008690501,CDM,300,RC,86905,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RH PHENOTYPE VERSITI,3008690601,CDM,300,RC,86906,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC FRESH FROZEN PLASMA, THAWED-NOT TRANSFUSED",3008692701,CDM,300,RC,,,facility,both,,,,244.38,244.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FROZEN BLOOD THAWED - NOT TRANSFUSED,3008693101,CDM,300,RC,,,facility,both,,,,244.38,244.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLO DIFF RBC ABSORPTION VERSITI,3008697801,CDM,300,RC,86978,HCPCS,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WARM VERSITI,3008697802,CDM,300,RC,,,facility,both,,,,43,43,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SEVERE AQT RESPIR SYND CORONAVIRUS,3008742601,CDM,300,RC,,,facility,both,,,,86.25,86.25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LAB COVID, INFLUENZA A/B",3008742801,CDM,300,RC,87428,HCPCS,facility,both,,,,99,99,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC IAAD IA SARSCOV & INFLUENZA VIRUS TYPES A&B,3008742802,CDM,300,RC,87428,HCPCS,facility,both,,,,99,99,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM HBV RNA MI BLOOD,3008751601,CDM,300,RC,87516,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HPV HIGH RISK 16 18,3008762502,CDM,300,RC,,,facility,both,,,,334,334,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NOVEL COVID-19 DETECT AGENT DNA QUANT,3008763504,CDM,300,RC,87635,HCPCS,facility,both,,,,217.5,217.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRICHOMONAS PCR - ALINITY,3008766104,CDM,300,RC,87661,HCPCS,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ZIKA VIRUS,3008766202,CDM,300,RC,,,facility,both,,,,51,51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB INFLUENZA EIA A OR B,3008780401,CDM,300,RC,87804,HCPCS,facility,both,,,,48,48,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MALARIA AG,3008789901,CDM,300,RC,87899,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BILIMETER TRANSCUTANEOUS,3008872001,CDM,300,RC,88720,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSCUTANEOUS CARBOXYHEMOGLOBIN,3008874001,CDM,300,RC,88740,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CELL CT MISC BODY FLUID,3008905001,CDM,300,RC,89050,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CELL CT W DIFF FLUID,3008905101,CDM,300,RC,89051,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHRL FECAL LEUKOCYTE,3008905501,CDM,300,RC,,,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYSTALS,3008906001,CDM,300,RC,89060,HCPCS,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SWEAT CHLORIDE COLLECTION,3008923001,CDM,300,RC,89230,HCPCS,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STAT COURIER LAB HANDLING FEE,3009900102,CDM,300,RC,99001,HCPCS,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEGAL BLOOD DRAW,3010000002,CDM,301,RC,,,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEGAL ETHANOL LEVEL,3010000003,CDM,301,RC,,,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BASIC METABOLIC PANEL,3018004802,CDM,301,RC,80048,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELECTROLYTE PANEL,3018005101,CDM,301,RC,80051,HCPCS,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPREHENSIVE METABOLIC PANEL,3018005301,CDM,301,RC,80053,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LIPID PANEL,3018006101,CDM,301,RC,80061,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RENAL FUNCTION PANEL,3018006901,CDM,301,RC,80069,HCPCS,facility,both,,,,39,39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACUTE HEPATITIS PANEL,3018007401,CDM,301,RC,80074,HCPCS,facility,both,,,,117,117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPATIC FUNCTION PANEL,3018007601,CDM,301,RC,80076,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG ASSAY ACETAMINOPHEN,3018014301,CDM,301,RC,80143,HCPCS,facility,both,,,,112,112,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG ASSAY ADALIMUMAB,3018014502,CDM,301,RC,,,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMIKACIN LEVEL,3018015001,CDM,301,RC,80150,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARBAMAZEPINE TOTAL,3018015601,CDM,301,RC,80156,HCPCS,facility,both,,,,98,98,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARBAMAZEPINE FREE TDA,3018015702,CDM,301,RC,,,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYCLOSPORINE,3018015801,CDM,301,RC,80158,HCPCS,facility,both,,,,111,111,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOZAPINE,3018015901,CDM,301,RC,80159,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIGOXIN TOTAL,3018016201,CDM,301,RC,80162,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VALPROIC ACID TOTAL,3018016401,CDM,301,RC,80164,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VALPROIC ACID FREE,3018016501,CDM,301,RC,80165,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ETHOSUXIMIDE LEVEL,3018016801,CDM,301,RC,,,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVEROLIMUS LEVEL,3018016901,CDM,301,RC,80169,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GENTAMICIN LEVEL,3018017001,CDM,301,RC,80170,HCPCS,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HALOPERIDOL LEVEL,3018017301,CDM,301,RC,,,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAMOTRIGINE LEVEL,3018017501,CDM,301,RC,80175,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LIDOCAINE,3018017601,CDM,301,RC,80176,HCPCS,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEVETIRACETAM LEVEL,3018017701,CDM,301,RC,80177,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LITHIUM LEVEL,3018017801,CDM,301,RC,80178,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG ASSAY SALICYLATE,3018017901,CDM,301,RC,80179,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYCOPHENOLIC ACID TDA,3018018002,CDM,301,RC,80180,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG ASSAY FLECAINIDE,3018018101,CDM,301,RC,80181,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXCARBAZEPINE (TRILEPTAL) TDA,3018018302,CDM,301,RC,80183,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHENOBARBITAL LEVEL,3018018401,CDM,301,RC,80184,HCPCS,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHENYTOIN TOTAL,3018018501,CDM,301,RC,80185,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHENYTOIN FREE,3018018601,CDM,301,RC,80186,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG ASSAY POSACONAZOLE,3018018701,CDM,301,RC,80187,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIMIDONE TDA,3018018802,CDM,301,RC,80188,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SIROLIMUS,3018019501,CDM,301,RC,80195,HCPCS,facility,both,,,,103,103,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TACROLIMUS LEVEL,3018019701,CDM,301,RC,80197,HCPCS,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THEOPHYLLINE LEVEL,3018019801,CDM,301,RC,80198,HCPCS,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOBRAMYCIN LEVEL,3018020001,CDM,301,RC,80200,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOPIRAMATE TDA,3018020102,CDM,301,RC,80201,HCPCS,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VANCOMYCIN LEVEL,3018020201,CDM,301,RC,80202,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ZONISAMIDE,3018020302,CDM,301,RC,80203,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG ASSAY METHOTREXATE,3018020401,CDM,301,RC,80204,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG ASSAY INFLIXIMAB,3018023001,CDM,301,RC,,,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LACOSAMIDE LEVEL,3018023502,CDM,301,RC,80235,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG ASSAY VORICONAZOLE,3018028501,CDM,301,RC,80285,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLECAINIDE,3018029903,CDM,301,RC,,,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MILRINONE LEVEL,3018029905,CDM,301,RC,,,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PAROXETINE LEVEL MAYO,3018029906,CDM,301,RC,,,facility,both,,,,50.53,50.53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POSACONAZOLE LEVEL,3018029907,CDM,301,RC,,,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROPRANOLOL,3018029908,CDM,301,RC,,,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VORICONAZOLE LEVEL,3018029910,CDM,301,RC,,,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APIXABAN LEVEL,3018029911,CDM,301,RC,80299,HCPCS,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC QUANT THERAPUTIC DRUG NOT ELSEWHERE SPECIFIED,3018029933,CDM,301,RC,80299,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB DRUG SCREEN CLASS A,3018030501,CDM,301,RC,80305,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANNABIN SCR UR,3018030701,CDM,301,RC,80307,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COCAINE SCR UR,3018030702,CDM,301,RC,80307,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCR ACID GC,3018030704,CDM,301,RC,80307,HCPCS,facility,both,,,,278,278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCR ALKALINE GC,3018030705,CDM,301,RC,80307,HCPCS,facility,both,,,,278,278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN LCMS W ADULTERATION,3018030707,CDM,301,RC,80307,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ETHANOL SCR UR,3018030709,CDM,301,RC,80307,HCPCS,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MECONIUM DRUG SCREEN,3018030712,CDM,301,RC,,,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN CLASS A,3018030716,CDM,301,RC,80307,HCPCS,facility,both,,,,186,186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD ETHANOL LEVEL,3018032001,CDM,301,RC,80320,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD ETHANOL LEVEL,3018032001,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  ALCOHOLS  W CONF,3018032002,CDM,301,RC,80320,HCPCS,facility,both,,,,12.5,12.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  ALCOHOLS  W CONF,3018032002,CDM,301,RC,G0480,HCPCS,facility,both,,,,12.5,12.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ETHANOL CONFIRMATION,3018032003,CDM,301,RC,80320,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ETHANOL CONFIRMATION,3018032003,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ETHANOL VITREOUS HUMOR,3018032004,CDM,301,RC,80320,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ETHANOL VITREOUS HUMOR,3018032004,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISOPROPANOL LEVEL,3018032005,CDM,301,RC,80320,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISOPROPANOL LEVEL,3018032005,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHANOL LEVEL,3018032006,CDM,301,RC,80320,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHANOL LEVEL,3018032006,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOXIC ALCOHOLS,3018032007,CDM,301,RC,80320,HCPCS,facility,both,,,,142,142,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOXIC ALCOHOLS,3018032007,CDM,301,RC,G0480,HCPCS,facility,both,,,,142,142,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VOLATILE SCREEN,3018032008,CDM,301,RC,80320,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VOLATILE SCREEN,3018032008,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NICOTINE ASSAY,3018032301,CDM,301,RC,80323,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NICOTINE ASSAY,3018032301,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMPHETAMINES CONFIRMATION,3018032401,CDM,301,RC,80324,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMPHETAMINES CONFIRMATION,3018032401,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMPHETAMINES MECONIUM CONF,3018032402,CDM,301,RC,80324,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMPHETAMINES MECONIUM CONF,3018032402,CDM,301,RC,G0480,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  AMPHETAMINES  W CONF,3018032403,CDM,301,RC,80324,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  AMPHETAMINES  W CONF,3018032403,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACETAMINOPHEN LEVEL,3018032901,CDM,301,RC,,,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IBUPROFEN LEVEL,3018032902,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SALICYLATES LEVEL,3018032903,CDM,301,RC,,,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CITALOPRAM LEVEL,3018033201,CDM,301,RC,80332,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CITALOPRAM LEVEL,3018033201,CDM,301,RC,80332,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CITALOPRAM LEVEL,3018033201,CDM,301,RC,G0480,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CITALOPRAM LEVEL,3018033201,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUOXETINE LEVEL,3018033202,CDM,301,RC,80332,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUOXETINE LEVEL,3018033202,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SERTRALINE LEVEL,3018033204,CDM,301,RC,80332,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SERTRALINE LEVEL,3018033204,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMITRIPTYLINE LEVEL,3018033501,CDM,301,RC,80335,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMITRIPTYLINE LEVEL,3018033501,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOMIPRAMINE LEVEL,3018033502,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DESIPRAMINE LEVEL,3018033503,CDM,301,RC,,,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DOXEPIN LEVEL,3018033504,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMIPRAMINE LEVEL,3018033505,CDM,301,RC,,,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NORTRIPTYLINE LEVEL,3018033506,CDM,301,RC,80335,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NORTRIPTYLINE LEVEL,3018033506,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIDEPRESSANTS TRICYCLIC OTHER CYCLICALS 1 OR 2,3018033508,CDM,301,RC,,,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIDEPRESSANTS NOS,3018033801,CDM,301,RC,80338,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIDEPRESSANTS NOS,3018033801,CDM,301,RC,G0480,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRAZODONE,3018033803,CDM,301,RC,80338,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRAZODONE,3018033803,CDM,301,RC,G0480,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENLAFAXINE LEVEL,3018033804,CDM,301,RC,,,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OLANZAPINE,3018034201,CDM,301,RC,80342,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OLANZAPINE,3018034201,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC QUETIAPINE BLD LEVEL,3018034202,CDM,301,RC,80342,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC QUETIAPINE BLD LEVEL,3018034202,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BARBITURATES CONFIRMATION,3018034501,CDM,301,RC,80345,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BARBITURATES CONFIRMATION,3018034501,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PENTOBARBITAL LEVEL,3018034502,CDM,301,RC,80345,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PENTOBARBITAL LEVEL,3018034502,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALPRAZOLAM LEVEL,3018034601,CDM,301,RC,80346,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALPRAZOLAM LEVEL,3018034601,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BENZO EXPANDED CONFIRMATION,3018034602,CDM,301,RC,80346,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BENZO EXPANDED CONFIRMATION,3018034602,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLORDIAZEPOX LEVEL,3018034603,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLONAZEPAM LEVEL,3018034604,CDM,301,RC,80346,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLONAZEPAM LEVEL,3018034604,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAZEPAM LEVEL,3018034605,CDM,301,RC,80346,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAZEPAM LEVEL,3018034605,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  BENZODIAZEPINES  W CONF,3018034606,CDM,301,RC,80346,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  BENZODIAZEPINES  W CONF,3018034606,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LORAZEPAM LEVEL,3018034607,CDM,301,RC,80346,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LORAZEPAM LEVEL,3018034607,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NORDIAZEPAM LEVEL,3018034608,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BUPRENORPHINE LEVEL,3018034801,CDM,301,RC,80348,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BUPRENORPHINE LEVEL,3018034801,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  BUPRENORPHINE  W CONF,3018034802,CDM,301,RC,80348,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  BUPRENORPHINE  W CONF,3018034802,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANNABINOIDS CONFIRMATION,3018034901,CDM,301,RC,80349,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANNABINOIDS CONFIRMATION,3018034901,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANNABIS MECONIUM CONF,3018034902,CDM,301,RC,80349,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANNABIS MECONIUM CONF,3018034902,CDM,301,RC,G0480,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  CANNABINOIDS  W CONF,3018034903,CDM,301,RC,80349,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  CANNABINOIDS  W CONF,3018034903,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COCAINE MECONIUM CONF,3018035301,CDM,301,RC,80353,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COCAINE MECONIUM CONF,3018035301,CDM,301,RC,G0480,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COCAINE METABOLITES CONF,3018035302,CDM,301,RC,80353,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COCAINE METABOLITES CONF,3018035302,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COCAINE METABOLITES LEVEL,3018035303,CDM,301,RC,80353,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COCAINE METABOLITES LEVEL,3018035303,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  COCAINE  W CONF,3018035304,CDM,301,RC,80353,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  COCAINE  W CONF,3018035304,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  FENTANYL  W CONF,3018035401,CDM,301,RC,80354,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  FENTANYL  W CONF,3018035401,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FENTANYL CONFIRMATION,3018035402,CDM,301,RC,80354,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FENTANYL CONFIRMATION,3018035402,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MECONIUM DRUG SCREENING FENTANYL,3018035403,CDM,301,RC,80354,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MECONIUM DRUG SCREENING FENTANYL,3018035403,CDM,301,RC,G0480,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  GABAPENTIN  W CONF,3018035501,CDM,301,RC,80355,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  GABAPENTIN  W CONF,3018035501,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 6MAM EXPANDED CONF,3018035601,CDM,301,RC,80356,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 6MAM EXPANDED CONF,3018035601,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  HEROIN MET  W CONF,3018035602,CDM,301,RC,80356,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  HEROIN MET  W CONF,3018035602,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  METHADONE  W CONF,3018035801,CDM,301,RC,80358,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  METHADONE  W CONF,3018035801,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHADONE CONF,3018035802,CDM,301,RC,80358,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHADONE CONF,3018035802,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHADONE CONF DAU,3018035803,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHADONE LEVEL,3018035804,CDM,301,RC,80358,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHADONE LEVEL,3018035804,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHADONE MECONIUM CONF,3018035805,CDM,301,RC,80358,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHADONE MECONIUM CONF,3018035805,CDM,301,RC,G0480,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  MDMA  W CONF,3018035901,CDM,301,RC,80359,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  MDMA  W CONF,3018035901,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MDA MDMA CONF,3018035902,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  METHYLPHENIDATE  W CONF,3018036001,CDM,301,RC,80360,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  METHYLPHENIDATE  W CONF,3018036001,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHYLPHENIDATE CONF,3018036002,CDM,301,RC,80360,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHYLPHENIDATE CONF,3018036002,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CODEINE MORPHINE LEVEL,3018036101,CDM,301,RC,80361,HCPCS,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CODEINE MORPHINE LEVEL,3018036101,CDM,301,RC,G0480,HCPCS,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  OPIATES  W CONF,3018036102,CDM,301,RC,80361,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  OPIATES  W CONF,3018036102,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HYDROCODONE LEVEL,3018036103,CDM,301,RC,,,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPIATES EXPANDED CONF,3018036104,CDM,301,RC,80361,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPIATES EXPANDED CONF,3018036104,CDM,301,RC,G0480,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPIATES MECONIUM CONF,3018036105,CDM,301,RC,80361,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPIATES MECONIUM CONF,3018036105,CDM,301,RC,G0480,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2,3018036201,CDM,301,RC,80362,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREENING OPIOIDS AND OPIATE ANALOGS 1 OR 2,3018036201,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  OXYCODONE  W CONF,3018036501,CDM,301,RC,80365,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  OXYCODONE  W CONF,3018036501,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXYCODONE EXPANDED CONF,3018036502,CDM,301,RC,80365,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXYCODONE EXPANDED CONF,3018036502,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXYCODONE LEVEL,3018036503,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXYCODONE MECONIUM CONF,3018036504,CDM,301,RC,80365,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXYCODONE MECONIUM CONF,3018036504,CDM,301,RC,G0480,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  PREGABALIN  W CONF,3018036601,CDM,301,RC,80366,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  PREGABALIN  W CONF,3018036601,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREENING SKELETAL MUSCLE RELAXANTS 1 OR 2,3018036901,CDM,301,RC,80369,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREENING SKELETAL MUSCLE RELAXANTS 1 OR 2,3018036901,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  TRAMADOL  W CONF,3018037301,CDM,301,RC,80373,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG SCREEN  TRAMADOL  W CONF,3018037301,CDM,301,RC,G0480,HCPCS,facility,both,,,,7.5,7.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRAMADOL CONF,3018037302,CDM,301,RC,80373,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRAMADOL CONF,3018037302,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRAMADOL CONF DAU,3018037303,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG/SUBSTANCE DEFINITIVE QUAL/QUANT NOS 1-3,3018037501,CDM,301,RC,80375,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRUG/SUBSTANCE DEFINITIVE QUAL/QUANT NOS 1-3,3018037501,CDM,301,RC,G0480,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GHB GAMMAHYDROXY AC,3018037503,CDM,301,RC,,,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBSTANCE ANALYSIS QUANT,3018037504,CDM,301,RC,80375,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBSTANCE ANALYSIS QUANT,3018037504,CDM,301,RC,G0480,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBSTANCE ANALYSIS QUAL,3018037701,CDM,301,RC,80377,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBSTANCE ANALYSIS QUAL,3018037701,CDM,301,RC,G0480,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACTH STIMULATION,3018040001,CDM,301,RC,80400,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GROWTH HORMONE STIMULATION PANEL,3018042801,CDM,301,RC,80428,HCPCS,facility,both,,,,389,389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GROWTH HORMONE SUPRJ PANEL GLUCOSE ADMN,3018043001,CDM,301,RC,,,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADULTERATION URINE,3018100301,CDM,301,RC,81003,HCPCS,facility,both,,,,10,10,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BETA HYDROXYBUTYRATE,3018201001,CDM,301,RC,82010,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACETYLCHOLINESTERASE AMNIOTIC FLUID MAYO,3018201301,CDM,301,RC,82013,HCPCS,facility,both,,,,81.48,81.48,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADRENOCORTICOTROPIC HORMONE,3018202401,CDM,301,RC,82024,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALBUMIN LEVEL,3018204001,CDM,301,RC,82040,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALBUMIN BODY FLUID,3018204201,CDM,301,RC,82042,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MICROALBUMIN URINE,3018204301,CDM,301,RC,82043,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC BREATH ALCOHOL,3018207502,CDM,301,RC,82075,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASSAY OF ALCOHOL (ETHANOL) SPEC XCP UR&BREATH IA,3018207701,CDM,301,RC,82077,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASSAY OF ALDOSTERONE,3018208803,CDM,301,RC,82088,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALPHA ANTITRYPSIN,3018210303,CDM,301,RC,82103,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AFP TUMOR MARKER,3018210502,CDM,301,RC,82105,HCPCS,facility,both,,,,51,51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AFP AMNIOTIC FLUID,3018210601,CDM,301,RC,,,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AFP AMNIOTIC FLUID MAYO,3018210602,CDM,301,RC,82106,HCPCS,facility,both,,,,48.1,48.1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMMONIA LEVEL,3018214001,CDM,301,RC,82140,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BILI AMNIOTIC FLUID,3018214301,CDM,301,RC,,,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMYLASE BODY FLUID,3018215001,CDM,301,RC,82150,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMYLASE SERUM,3018215003,CDM,301,RC,82150,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMYLASE URINE,3018215004,CDM,301,RC,82150,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMYLASE URINE 24 HR,3018215005,CDM,301,RC,82150,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIOTENSIN CONVERTING ENZYME,3018216401,CDM,301,RC,82164,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BETA-2-MICROGLOBULIN SERUM,3018223202,CDM,301,RC,82232,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BILIRUBIN TOTAL,3018224703,CDM,301,RC,82247,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BILIRUBIN TOTAL FLUID,3018224704,CDM,301,RC,82247,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BILIRUBIN DIRECT,3018224801,CDM,301,RC,82248,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OCCULT BLOOD SCREEN,3018227001,CDM,301,RC,82270,HCPCS,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OCCULT BLOOD GASTRIC,3018227101,CDM,301,RC,82271,HCPCS,facility,both,,,,11,11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEMOCCULT 1 3 DETERMINATIONS SYMPTOMATIC,3018227201,CDM,301,RC,82272,HCPCS,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OCCULT BLOOD IMMUNOASSAY DX,3018227401,CDM,301,RC,82274,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OCCULT BLOOD SCREEN IMMUNOASSAY,3018227402,CDM,301,RC,82274,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIT D 25 HYDROXY LEVEL,3018230601,CDM,301,RC,82306,HCPCS,facility,both,,,,91,91,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALCIUM LEVEL,3018231001,CDM,301,RC,82310,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALCIUM UR RANDOM LEVEL,3018231002,CDM,301,RC,82310,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IONIZED CALCIUM,3018233001,CDM,301,RC,82330,HCPCS,facility,both,,,,53.33,53.33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC IONIZED CALCIUM,3018233002,CDM,301,RC,82330,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALCIUM URINE 24 HR,3018234001,CDM,301,RC,82340,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CO2 LEVEL,3018237401,CDM,301,RC,82374,HCPCS,facility,both,,,,11,11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARBOXY HEMOGLOBIN,3018237501,CDM,301,RC,82375,HCPCS,facility,both,,,,97.46,97.46,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CEA ANTIGEN ASSAY,3018237801,CDM,301,RC,82378,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CERULOPLASMIN,3018239001,CDM,301,RC,82390,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMILUMINESCENT ASSAY,3018239708,CDM,301,RC,82397,HCPCS,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLORIDE,3018243501,CDM,301,RC,82435,HCPCS,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLORIDE URINE,3018243601,CDM,301,RC,82436,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLORIDE SWEAT ANALYSIS,3018243802,CDM,301,RC,82438,HCPCS,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHOLESTEROL,3018246501,CDM,301,RC,82465,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CITRATE URINE LEVEL,3018250702,CDM,301,RC,,,facility,both,,,,79,79,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASSAY OF CITRATE,3018250705,CDM,301,RC,82507,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BETA CROSSLINK CTX,3018252301,CDM,301,RC,82523,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLLAGEN CROSS LINKS ANY METHOD,3018252302,CDM,301,RC,,,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASSAY OF COPPER,3018252502,CDM,301,RC,82525,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CORTISOL LEVEL,3018253302,CDM,301,RC,82533,HCPCS,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CREATINE KINASE CPK TOTAL,3018255001,CDM,301,RC,82550,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CREATINE MB FRACTION,3018255301,CDM,301,RC,,,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CREATININE SERUM,3018256501,CDM,301,RC,82565,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC CREATININE,3018256502,CDM,301,RC,82565,HCPCS,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CREATININE OTHER SOURCE,3018257009,CDM,301,RC,82570,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CREATININE CLEARANCE,3018257501,CDM,301,RC,82575,HCPCS,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYOGLOBULINS,3018259502,CDM,301,RC,82595,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYANIDE LEVEL,3018260001,CDM,301,RC,,,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VITAMIN B12 LEVEL,3018260701,CDM,301,RC,82607,HCPCS,facility,both,,,,46,46,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTATIN C,3018261001,CDM,301,RC,82610,HCPCS,facility,both,,,,43,43,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DHEA SULFATE,3018262701,CDM,301,RC,82627,HCPCS,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC VITAMIN D 1,25 DIHYDROXY",3018265203,CDM,301,RC,82652,HCPCS,facility,both,,,,79,79,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELASTASE PANCREATIC FECAL QUANTITATIVE,3018265302,CDM,301,RC,82653,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ERYTHROPOIETIN,3018266802,CDM,301,RC,82668,HCPCS,facility,both,,,,39,39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESTRADIOL LEVEL,3018267001,CDM,301,RC,82670,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESTRIOL,3018267702,CDM,301,RC,82677,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ETHYLENE GLYCOL,3018269301,CDM,301,RC,82693,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FERRITIN,3018272801,CDM,301,RC,82728,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FETAL FIBRONECTIN,3018273101,CDM,301,RC,82731,HCPCS,facility,both,,,,204,204,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FOLATE LEVEL,3018274601,CDM,301,RC,82746,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FOLIC ACID RBC,3018274701,CDM,301,RC,,,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGG IGM OR IGA EA,3018278403,CDM,301,RC,82784,HCPCS,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGE EA,3018278501,CDM,301,RC,82785,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGG SUBCLASSES EACH,3018278701,CDM,301,RC,82787,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PH BLOOD,3018280001,CDM,301,RC,82800,HCPCS,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PH PCO2 PO2,3018280301,CDM,301,RC,82803,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC PH PCO2 PO2,3018280302,CDM,301,RC,82803,HCPCS,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PH PCO2 PO2 MEA O2,3018280502,CDM,301,RC,82805,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD GAS O2 SAT ONLY,3018281001,CDM,301,RC,82810,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GASTRIC ACID ANALYIS W/PH EACH SPECIMEN,3018293001,CDM,301,RC,82930,HCPCS,facility,both,,,,11,11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE BODY FLUID,3018294501,CDM,301,RC,82945,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE URINE,3018294505,CDM,301,RC,82945,HCPCS,facility,both,,,,10,10,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE QUANT BLOOD,3018294701,CDM,301,RC,82947,HCPCS,facility,both,,,,24,24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC GLUCOSE,3018294702,CDM,301,RC,82947,HCPCS,facility,both,,,,24,24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE 1 HOUR TOTAL,3018295001,CDM,301,RC,82950,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE 2 HR POST DOSE,3018295002,CDM,301,RC,,,facility,both,,,,11,11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE TOLERANCE,3018295101,CDM,301,RC,82951,HCPCS,facility,both,,,,39,39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE TOLERANCE ADDTL SAMPLE,3018295201,CDM,301,RC,82952,HCPCS,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE-6-P-DEHYDROGENASE QUANT,3018295505,CDM,301,RC,82955,HCPCS,facility,both,,,,24,24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLUCOSE MONITORING,3018296201,CDM,301,RC,82962,HCPCS,facility,both,,,,7,7,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GGT,3018297701,CDM,301,RC,82977,HCPCS,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FSH SERUM,3018300101,CDM,301,RC,83001,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LUTENIZING HORMONE,3018300202,CDM,301,RC,83002,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GROWTH HORMONE SERUM,3018300301,CDM,301,RC,83003,HCPCS,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HAPTOGLOBIN,3018301001,CDM,301,RC,83010,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC H PYLORI BREATH,3018301301,CDM,301,RC,83013,HCPCS,facility,both,,,,168,168,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC H PYLORI BREATH,3018301301,CDM,301,RC,83013,HCPCS,facility,both,,,,151,151,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC H PYLORI COLLECTION,3018301401,CDM,301,RC,83014,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HGB ELECTROPHERESIS CAPILLARY,3018302007,CDM,301,RC,83020,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HGB FRACTIONATION,3018302106,CDM,301,RC,83021,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLYCATED HEMOGLOBIN,3018303601,CDM,301,RC,83036,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHEMOGLOBIN,3018305001,CDM,301,RC,83050,HCPCS,facility,both,,,,27,27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEMOGLOBIN PLASMA FREE,3018305101,CDM,301,RC,83051,HCPCS,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOMOCYSTEINE TOTAL,3018309001,CDM,301,RC,83090,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOMOVANILLIC ACID,3018315002,CDM,301,RC,83150,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 5 HIAA,3018349701,CDM,301,RC,83497,HCPCS,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP AMH,3018351615,CDM,301,RC,83516,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOASSAY NONANTIBODY,3018351619,CDM,301,RC,83516,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MPO AB,3018351623,CDM,301,RC,83516,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROTEINASE 3 AB,3018351624,CDM,301,RC,83516,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC P1NP IMMUNOASSAY ANALYTE QUANTITATIVE NOS,3018352001,CDM,301,RC,83520,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3002601 IMMUNOASSAY ANALYTE QUANTITATIVE CHG 2 ARUP,3018352002,CDM,301,RC,,,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOASSAY QUANT TRYPTASE,3018352022,CDM,301,RC,83520,HCPCS,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOASSAY ANALYTE QUANTITATIVE NOS,3018352041,CDM,301,RC,83520,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOASSAY QUANT NOS ADA/FIX,3018352054,CDM,301,RC,,,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOGLOBULIN LIGHT CHAINS FREE,3018352101,CDM,301,RC,83521,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSULIN LEVEL,3018352501,CDM,301,RC,83525,HCPCS,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IRON,3018354001,CDM,301,RC,83540,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IRON BINDING CAPACITY,3018355001,CDM,301,RC,83550,HCPCS,facility,both,,,,27,27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB LACTIC ACID CSF,3018360501,CDM,301,RC,83605,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LACTIC ACID,3018360502,CDM,301,RC,83605,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC LACTATE,3018360503,CDM,301,RC,83605,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LDH,3018361502,CDM,301,RC,83615,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LACTOFERRIN FECAL QUALITATIVE,3018363001,CDM,301,RC,83630,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEAD BLOOD,3018365506,CDM,301,RC,83655,HCPCS,facility,both,,,,31,31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 0007655 ASSAY OF LEAD QUEST,3018365514,CDM,301,RC,,,facility,both,,,,2.98,2.98,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LECITHIN SPHINGOMYELIN,3018366101,CDM,301,RC,,,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAMELLAR BODY DENSITY,3018366401,CDM,301,RC,,,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LIPASE,3018369001,CDM,301,RC,83690,HCPCS,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LIPA1 ASSAY OF LIPOPROTEIN(A) MAYO,3018369501,CDM,301,RC,83695,HCPCS,facility,both,,,,79.07,79.07,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LIPOPROTEIN (A),3018369502,CDM,301,RC,83695,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HDL CHOLESTEROL,3018371801,CDM,301,RC,83718,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LDL CHOLESTEROL DIRECT,3018372101,CDM,301,RC,83721,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASSAY OF MAGNESIUM,3018373501,CDM,301,RC,83735,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOGLOBIN,3018387404,CDM,301,RC,83874,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NATRIURETIC PEPTIDE BNP,3018388001,CDM,301,RC,83880,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KAPPA OR LAMBDA LIGHT CHAIN,3018388303,CDM,301,RC,,,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OLIGOCLONAL IMMUNE,3018391601,CDM,301,RC,83916,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SERUM METHYLMELONIC ACID,3018392103,CDM,301,RC,83921,HCPCS,facility,both,,,,78,78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSMOLALITY BLOOD,3018393001,CDM,301,RC,83930,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSMOLALITY OTHER,3018393501,CDM,301,RC,83935,HCPCS,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSTEOCALCIN LEVEL,3018393701,CDM,301,RC,,,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXALATE URINE,3018394502,CDM,301,RC,,,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXALATE,3018394505,CDM,301,RC,83945,HCPCS,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PTH,3018397001,CDM,301,RC,83970,HCPCS,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PH OTHER THAN BLOOD,3018398601,CDM,301,RC,83986,HCPCS,facility,both,,,,10,10,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHENCYCLIDINE CONF,3018399201,CDM,301,RC,83992,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASSAY OF CALPROTECTIN FECAL,3018399301,CDM,301,RC,83993,HCPCS,facility,both,,,,46,46,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALK PHOSPHATASE,3018407501,CDM,301,RC,84075,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE ALKALINE PHOS,3018408003,CDM,301,RC,,,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALKALINE PHOSPHATASE ISOENZYMES,3018408004,CDM,301,RC,84080,HCPCS,facility,both,,,,31,31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHOSPHATIDYLGLYCEROL AMNIO,3018408101,CDM,301,RC,,,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHOSPHOROUS LEVEL,3018410002,CDM,301,RC,84100,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHOSPHOROUS URINE,3018410501,CDM,301,RC,84105,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC AMNISURE,3018411201,CDM,301,RC,84112,HCPCS,facility,both,,,,202,202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POTASSIUM LEVEL,3018413201,CDM,301,RC,84132,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC POTASSIUM,3018413202,CDM,301,RC,84132,HCPCS,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POTASSIUM URINE,3018413301,CDM,301,RC,84133,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRE ALBUMIN,3018413401,CDM,301,RC,84134,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROGESTERONE LEVEL,3018414402,CDM,301,RC,84144,HCPCS,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROCALCITONIN,3018414501,CDM,301,RC,84145,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROLACTIN LEVEL,3018414601,CDM,301,RC,84146,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSA SCREENING,3018415302,CDM,301,RC,84153,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSA TOTAL,3018415303,CDM,301,RC,84153,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSA FREE,3018415402,CDM,301,RC,84154,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROTEIN TOTAL SERUM,3018415501,CDM,301,RC,84155,HCPCS,facility,both,,,,11,11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROTEIN URINE,3018415601,CDM,301,RC,84156,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASSAY OF PROTEIN OTHER,3018415701,CDM,301,RC,84157,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROTEIN FRACTION SERUM,3018416501,CDM,301,RC,84165,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROTEIN FRACTION UR,3018416601,CDM,301,RC,84166,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PYRUVIC ACID,3018421002,CDM,301,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASSAY OF RENIN,3018424401,CDM,301,RC,84244,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SELENIUM LEVEL,3018425501,CDM,301,RC,84255,HCPCS,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SEX BINDING HORMONE,3018427001,CDM,301,RC,84270,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC SODIUM,3018429501,CDM,301,RC,84295,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SODIUM,3018429503,CDM,301,RC,84295,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SODIUM URINE,3018430002,CDM,301,RC,84300,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGF1,3018430501,CDM,301,RC,84305,HCPCS,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHOLESTEROL FLUID,3018431109,CDM,301,RC,84311,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FREE TESTOSTERONE,3018440201,CDM,301,RC,84402,HCPCS,facility,both,,,,55,55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 36170 ASSAY OF TESTOSTERONE FREE QUEST,3018440205,CDM,301,RC,84402,HCPCS,facility,both,,,,10.57,10.57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TESTOSTERONE,3018440302,CDM,301,RC,84403,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 36170 ASSAY OF TESTOSTERONE TOTAL QUEST,3018440311,CDM,301,RC,84403,HCPCS,facility,both,,,,8,8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 15983 ASSAY OF TESTOSTERONE TOTAL QUEST,3018440312,CDM,301,RC,84403,HCPCS,facility,both,,,,8,8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB THIAMIN VITAMIN B LEVEL,3018442501,CDM,301,RC,84425,HCPCS,facility,both,,,,48,48,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THIOCYANATE,3018443001,CDM,301,RC,84430,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THYROGLOBULIN,3018443202,CDM,301,RC,84432,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THYROXINE TOTAL,3018443602,CDM,301,RC,84436,HCPCS,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FREE T4,3018443901,CDM,301,RC,84439,HCPCS,facility,both,,,,27,27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TSH,3018444301,CDM,301,RC,84443,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THYROID STIMULATING IMMUNE GLOBULINS TSI,3018444502,CDM,301,RC,84445,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VITAMIN E LEVEL,3018444601,CDM,301,RC,84446,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AST,3018445001,CDM,301,RC,84450,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALT,3018446001,CDM,301,RC,84460,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSFERRIN,3018446601,CDM,301,RC,84466,HCPCS,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRIGLYCERIDE,3018447803,CDM,301,RC,84478,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOTAL T3,3018448001,CDM,301,RC,84480,HCPCS,facility,both,,,,43,43,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FREE T3,3018448101,CDM,301,RC,84481,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TROPONIN,3018448401,CDM,301,RC,84484,HCPCS,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BUN,3018452001,CDM,301,RC,84520,HCPCS,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UREA NITRO 24 HR UR,3018454002,CDM,301,RC,84540,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UREA NITRO RANDOM UR,3018454003,CDM,301,RC,84540,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UREA CLEARANCE,3018454501,CDM,301,RC,84545,HCPCS,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URIC ACID,3018455001,CDM,301,RC,84550,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URIC ACID OTHER,3018456002,CDM,301,RC,84560,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC URIC ACID OTHER, 24 HR",3018456003,CDM,301,RC,84560,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VMA URINE,3018458501,CDM,301,RC,84585,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VITAMIN A LEVEL,3018459001,CDM,301,RC,84590,HCPCS,facility,both,,,,31,31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ZINC LEVEL,3018463001,CDM,301,RC,84630,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C PEPTIDE,3018468101,CDM,301,RC,84681,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HCG BETA SUBUNIT,3018470202,CDM,301,RC,84702,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC HCG QUAL URINE,3018470301,CDM,301,RC,84703,HCPCS,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB PREG TEST SERUM QUAL,3018470302,CDM,301,RC,,,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEPHROCHECK-AKIR UNLISTED CHEM PROC,3018499902,CDM,301,RC,,,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 0090253 CALCULUS INFRARED SPECTROSCOPY QUEST,3028236524,CDM,302,RC,82365,HCPCS,facility,both,,,,13.6,13.6,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLERGEN SPECIFIC,3028600301,CDM,302,RC,86003,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MULTI ALLERGEN SCREN,3028600501,CDM,302,RC,,,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLG SPEC IGE RECOMB EA,3028600801,CDM,302,RC,86008,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACTIN ANTIBODY EACH,3028601501,CDM,302,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP DEP PLATELET AB,3028602201,CDM,302,RC,86022,HCPCS,facility,both,,,,226,226,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANCA SCREEN ANTIBODY,3028603601,CDM,302,RC,86036,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANCA TITER EACH ANTIBODY,3028603701,CDM,302,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANA HEP2 SUBSTRATE,3028603801,CDM,302,RC,86038,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANA SCREEN,3028603802,CDM,302,RC,86038,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANA TITER PATTERN,3028603901,CDM,302,RC,86039,HCPCS,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASO LEVEL,3028606001,CDM,302,RC,86060,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C REACTIVE PROTEIN,3028614001,CDM,302,RC,86140,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C REACTIVE PROTEIN ULTRASENSITIVE,3028614101,CDM,302,RC,86141,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BETA 2 GLYCOPROTEIN I ANTIBODY EACH,3028614601,CDM,302,RC,86146,HCPCS,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTICARDIOLIPIN ANTIBODY,3028614701,CDM,302,RC,86147,HCPCS,facility,both,,,,188,188,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARDIOLIPIN IGM AB,3028614703,CDM,302,RC,,,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLD AGGLUTININ TITER,3028615706,CDM,302,RC,86157,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C3 COMPLEMENT AG,3028616003,CDM,302,RC,86160,HCPCS,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C4 COMPLEMENT AG,3028616004,CDM,302,RC,86160,HCPCS,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPLEMENT TOTAL HEMOLYTIC CH50,3028616203,CDM,302,RC,86162,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYCLIC CITRULLINATED PEPTIDE AB,3028620001,CDM,302,RC,86200,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTI DNA ANTIBODY,3028622501,CDM,302,RC,86225,HCPCS,facility,both,,,,112,112,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOMYSIAL ANTIBODY EACH IG CLASS,3028623101,CDM,302,RC,86231,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NUCLEAR ANTIGEN ANTIBODY EACH,3028623505,CDM,302,RC,86235,HCPCS,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANCA SCREEN,3028625504,CDM,302,RC,,,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SMOOTH MUSCLE ANTIBODY,3028625537,CDM,302,RC,86255,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANCA TITER,3028625601,CDM,302,RC,,,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOMYSIAL AB IGA,3028625603,CDM,302,RC,,,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MITOCHONDRIAL ANTIBODY TITER,3028625604,CDM,302,RC,86256,HCPCS,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORESCENT ANTIBODY TITER CRITHIDIA LUCILLAE IFA,3028625615,CDM,302,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GLIADIN DGP ANTIBODY EACH IG CLASS,3028625801,CDM,302,RC,86258,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANCER ANTIGEN 15 3,3028630001,CDM,302,RC,86300,HCPCS,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANCER ANTIGEN 19 9,3028630101,CDM,302,RC,86301,HCPCS,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANCER ANTIGEN 125,3028630401,CDM,302,RC,86304,HCPCS,facility,both,,,,196,196,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MONONUCLEOSIS SCREEN,3028630801,CDM,302,RC,86308,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE,3028631604,CDM,302,RC,86316,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 0070070 IMMUNOASSAY INFECTIOUS AGENT ANTIBODY QUAN NOS QUEST,3028631710,CDM,302,RC,86317,HCPCS,facility,both,,,,15.42,15.42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOELECTROPHORESIS SERUM,3028633401,CDM,302,RC,86334,HCPCS,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOELECTROPHORESIS UR,3028633502,CDM,302,RC,86335,HCPCS,facility,both,,,,204,204,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INHIBIN A MATERNAL,3028633603,CDM,302,RC,86336,HCPCS,facility,both,,,,39,39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 0037933 ISLET CELL ANTIBODY QUEST,3028634124,CDM,302,RC,86341,HCPCS,facility,both,,,,37.16,37.16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CELLULAR FUNCTION ASSAY,3028635202,CDM,302,RC,86352,HCPCS,facility,both,,,,991,991,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC B CELL TOTAL CT,3028635501,CDM,302,RC,86355,HCPCS,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MONONUCLEAR CELL ANT QUANT,3028635603,CDM,302,RC,86356,HCPCS,facility,both,,,,195,195,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NATURAL KILLER TOTAL,3028635702,CDM,302,RC,86357,HCPCS,facility,both,,,,141,141,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC T CELL TOTAL COUNT,3028635902,CDM,302,RC,86359,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CD4 AND CD8 ABS CT W RATIO,3028636001,CDM,302,RC,86360,HCPCS,facility,both,,,,262,262,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABSOLUTE CD4 COUNT,3028636101,CDM,302,RC,86361,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TISSUE TRANSGLUTAMINASE EACH IG CLASS,3028636401,CDM,302,RC,86364,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTO STEM CELLS TOTAL CD34,3028636701,CDM,302,RC,86367,HCPCS,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STEM CELL TOTAL CT,3028636702,CDM,302,RC,86367,HCPCS,facility,both,,,,326,326,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTI THYROID,3028637601,CDM,302,RC,86376,HCPCS,facility,both,,,,119,119,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MITOCHONDRIAL ANTIBODY EACH,3028638101,CDM,302,RC,86381,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXIDATIVE BURST,3028638401,CDM,302,RC,,,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RHEUMATOID FACTOR,3028643001,CDM,302,RC,,,facility,both,,,,27,27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RHEUMATOID FACTOR QUANT,3028643101,CDM,302,RC,86431,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB TB TEST QUANTIFERON GOLD,3028648001,CDM,302,RC,86480,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB TB TESTING,3028658001,CDM,302,RC,,,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RPR,3028659201,CDM,302,RC,86592,HCPCS,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VDRL/RPR QUALITATIVE CSF,3028659203,CDM,302,RC,86592,HCPCS,facility,both,,,,13,13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RPR TITER,3028659302,CDM,302,RC,86593,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 0070070 ANTIBODY BLASTOMYCES QUEST,3028661209,CDM,302,RC,86612,HCPCS,facility,both,,,,6.73,6.73,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LYME DISEASE ANTIBODY,3028661804,CDM,302,RC,86618,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CMV SCREEN,3028664401,CDM,302,RC,86644,HCPCS,facility,both,,,,117,117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CMV IGM QUALITATIVE,3028664501,CDM,302,RC,86645,HCPCS,facility,both,,,,136,136,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EB VIRUS EARLY AG,3028666301,CDM,302,RC,86663,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EB VIRUS EBNA,3028666401,CDM,302,RC,86664,HCPCS,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EBV AB IGG OR IGM EA,3028666501,CDM,302,RC,86665,HCPCS,facility,both,,,,147,147,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC H PYLORI AB,3028667701,CDM,302,RC,,,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HTLV OR HIV ANTIBODY CONFIRMATORY TEST,3028668901,CDM,302,RC,86689,HCPCS,facility,both,,,,182,182,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HERPES SIMPLEX NES ANTIBODY,3028669401,CDM,302,RC,,,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HERPES IGG TP1,3028669501,CDM,302,RC,86695,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HERPES IGG TP2,3028669601,CDM,302,RC,86696,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV DIAGNOSTIC,3028670301,CDM,302,RC,,,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV EXPOSURE,3028670302,CDM,302,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV QUICK TEST,3028670303,CDM,302,RC,86703,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV SCREENING,3028670304,CDM,302,RC,,,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP B CORE ANTIBODY,3028670401,CDM,302,RC,86704,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP B CORE AB IGM,3028670501,CDM,302,RC,86705,HCPCS,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP B SURFACE AB,3028670601,CDM,302,RC,86706,HCPCS,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP A ANTIBODY,3028670801,CDM,302,RC,86708,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTI HAV IGM,3028670901,CDM,302,RC,86709,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUMPS IGG AB,3028673502,CDM,302,RC,86735,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYCOPLASMA ANTIBODY,3028673803,CDM,302,RC,86738,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYCOPLASMA SCREEN,3028673804,CDM,302,RC,,,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RUBELLA ANTIBODY IGG,3028676201,CDM,302,RC,86762,HCPCS,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RUBEOLA IGG,3028676501,CDM,302,RC,86765,HCPCS,facility,both,,,,117,117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SARS-COV-2 COVID-19 ANTIBODY,3028676902,CDM,302,RC,86769,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOXOPLASMOSIS AB,3028677701,CDM,302,RC,86777,HCPCS,facility,both,,,,117,117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOXOPLASMA ANTIBODY,3028677801,CDM,302,RC,86778,HCPCS,facility,both,,,,117,117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SYPHILIS IGG AB,3028678001,CDM,302,RC,86780,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VARICELLA ZOS IGG,3028678703,CDM,302,RC,86787,HCPCS,facility,both,,,,109,109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THYROGLOBULIN ANTIBODY,3028680002,CDM,302,RC,86800,HCPCS,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPATITIS C AB DX,3028680301,CDM,302,RC,86803,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPATITIS C AB SCR,3028680302,CDM,302,RC,86803,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HLA B27,3028681201,CDM,302,RC,86812,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIBODY HLA CLASS I & CLASS II ANTIGENS QUAL,3028682801,CDM,302,RC,86828,HCPCS,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIBODY HLA CLASS I HIGH DEFINITION PANEL QUAL,3028683201,CDM,302,RC,86832,HCPCS,facility,both,,,,809,809,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIBODY HLA CLASS II HIGH DEFINITION PANEL QUAL,3028683301,CDM,302,RC,86833,HCPCS,facility,both,,,,815,815,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIBODY SCREEN,3028685001,CDM,302,RC,86850,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELUTION,3028686001,CDM,302,RC,86860,HCPCS,facility,both,,,,62.23,62.23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIBODY IDENTIFICATION,3028687001,CDM,302,RC,86870,HCPCS,facility,both,,,,331,331,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIGLOBULIN DIRECT,3028688001,CDM,302,RC,86880,HCPCS,facility,both,,,,71,71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIBODY TITER,3028688601,CDM,302,RC,86886,HCPCS,facility,both,,,,69.88,69.88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABO,3028690001,CDM,302,RC,86900,HCPCS,facility,both,,,,127,127,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABO VERSITI,3028690003,CDM,302,RC,86900,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM ABO MI BLOOD,3028690004,CDM,302,RC,86900,HCPCS,facility,both,,,,127,127,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RH TYPING 3,3028690102,CDM,302,RC,,,facility,both,,,,37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTIGEN TESTING ANTIGLOBULIN,3028690501,CDM,302,RC,86905,HCPCS,facility,both,,,,331,331,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CROSSMATCH IMMEDIATE SPIN,3028692001,CDM,302,RC,86920,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CROSSMATCH INCUBATION,3028692101,CDM,302,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CROSSMATCH ANTIGLOBULIN,3028692201,CDM,302,RC,86922,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELECTRONIC CROSSMATCH,3028692301,CDM,302,RC,86923,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISOHEMAGGLUTININS,3028694101,CDM,302,RC,86941,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IRRADIATION,3028694501,CDM,302,RC,86945,HCPCS,facility,both,,,,38.54,38.54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VOLUME REDUCTION BLOOD OR PRODUCT,3028696001,CDM,302,RC,86960,HCPCS,facility,both,,,,35.76,35.76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PRODUCT POOLING,3028696501,CDM,302,RC,,,facility,both,,,,33.99,33.99,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIFFERENTIAL RBC ABSORPTION,3028697802,CDM,302,RC,,,facility,both,,,,79.29,79.29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VOLUME BLOOD PROD ALIQUOTING,3028698501,CDM,302,RC,86985,HCPCS,facility,both,,,,67.51,67.51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYPTOCOCCUS ANTIGEN,3028789901,CDM,302,RC,87899,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV1 P24 AG,3028789902,CDM,302,RC,87899,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD SMEAR MANUAL DIFFERENTIAL,3058500701,CDM,305,RC,85007,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLD COUNT SMEAR MCRSCP W/O MNL DIFRNTL WBC COUNT,3058500801,CDM,305,RC,85008,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEMATOCRIT,3058501401,CDM,305,RC,85014,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEMOGLOBIN,3058501801,CDM,305,RC,85018,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPLIT HEMOGLOBIN,3058501802,CDM,305,RC,85018,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CBC AUTO COMPLETE DIFFERENTIAL,3058502501,CDM,305,RC,85025,HCPCS,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CBC PLATELET NO DIFFERENTIAL,3058502701,CDM,305,RC,85027,HCPCS,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RETIC CT AUTOMATED,3058504501,CDM,305,RC,,,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RETIC CT W RETIC HGB,3058504601,CDM,305,RC,85046,HCPCS,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WBC AUTOMATED,3058504801,CDM,305,RC,85048,HCPCS,facility,both,,,,8,8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLATELET CT AUTOMATED,3058504901,CDM,305,RC,85049,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB RETICULATED PLATELET,3058505501,CDM,305,RC,85055,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE MARROW SMEAR INTERP,3058509701,CDM,305,RC,85097,HCPCS,facility,both,,,,583,583,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROMOGENIC SUBSTRATE ASSAY,3058513001,CDM,305,RC,,,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FACTOR II ACTIVITY,3058521001,CDM,305,RC,85210,HCPCS,facility,both,,,,31,31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FACTOR V ACTIVITY,3058522001,CDM,305,RC,85220,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FACTOR VII ACTIVITY,3058523001,CDM,305,RC,85230,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FACTOR VIII ACTIVITY,3058524002,CDM,305,RC,85240,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RISTOCETIN CO FACTOR,3058524501,CDM,305,RC,,,facility,both,,,,61,61,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VW FACTOR ANTIGEN,3058524601,CDM,305,RC,85246,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FACTOR IX ACTIVITY,3058525001,CDM,305,RC,85250,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FACTOR X ACTIVITY,3058526001,CDM,305,RC,85260,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FACTOR XI ACTIVITY,3058527001,CDM,305,RC,85270,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FACTOR XII ACTIVITY,3058528001,CDM,305,RC,85280,HCPCS,facility,both,,,,46,46,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTITHROMBIN III ACTIVITY,3058530001,CDM,305,RC,85300,HCPCS,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROTEIN C ACTIVITY,3058530301,CDM,305,RC,85303,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROTEIN S ACTIVITY,3058530601,CDM,305,RC,85306,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACTIVATED PROTEIN C APC RESISTANCE ASSAY,3058530702,CDM,305,RC,85307,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC ACT,3058534701,CDM,305,RC,85347,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC TEG COAGULATION TIME ACTIVATED,3058534702,CDM,305,RC,85347,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TEG ACT CLOT TIME,3058534703,CDM,305,RC,,,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FDP FSP,3058536201,CDM,305,RC,85362,HCPCS,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC D DIMER LATEX,3058537801,CDM,305,RC,,,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC D DIMER QUANT,3058537901,CDM,305,RC,85379,HCPCS,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FIBRINOGEN LEVEL,3058538401,CDM,305,RC,85384,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC TEG FIBRINOGEN ACTIVITY,3058538402,CDM,305,RC,85384,HCPCS,facility,both,,,,47,47,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TEG FIBRINOGEN LEVEL,3058538403,CDM,305,RC,,,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC TEG LY30 FIBRINOLYSINS SCREEN I&R,3058539001,CDM,305,RC,85390,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOTTING FUNCT ACTIVITY EACH ANALYTE,3058539701,CDM,305,RC,85397,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FETAL CELL KLEIBETKE,3058546001,CDM,305,RC,85460,HCPCS,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LMW HEPARIN ASSAY,3058552001,CDM,305,RC,85520,HCPCS,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XA HEPARIN ASSAY,3058552002,CDM,305,RC,85520,HCPCS,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IIA HEPARIN ASSAY,3058552004,CDM,305,RC,85520,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DOAC SCREEN HEPARIN ASSAY,3058552005,CDM,305,RC,85520,HCPCS,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPARIN NEUTRALIZATION,3058552501,CDM,305,RC,85525,HCPCS,facility,both,,,,27,27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC P2Y12 ANTI-PLATELET EFFECT,3058557601,CDM,305,RC,85576,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLATELET AGGREGATION,3058557602,CDM,305,RC,85576,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLATELET AGGREGATION ASPIRIN EFFECT,3058557603,CDM,305,RC,85576,HCPCS,facility,both,,,,71,71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLATELET FUNCTION ASSAY,3058557604,CDM,305,RC,85576,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC TEG PLATELET AGGREGATION IN VITRO EACH AGENT,3058557605,CDM,305,RC,85576,HCPCS,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TEG PLT AGGREGATION,3058557606,CDM,305,RC,,,facility,both,,,,109,109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROTIME,3058561001,CDM,305,RC,85610,HCPCS,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPLIT PROTIME,3058561002,CDM,305,RC,85610,HCPCS,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT MIXING STUDIES EA,3058561101,CDM,305,RC,85611,HCPCS,facility,both,,,,10,10,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LUPUS ANTICOAG LA1 OR LA2,3058561301,CDM,305,RC,85613,HCPCS,facility,both,,,,27,27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTO SED RATE,3058565201,CDM,305,RC,85652,HCPCS,facility,both,,,,16,16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SICKLE CELL,3058566002,CDM,305,RC,85660,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBIN TIME PLASMA,3058567001,CDM,305,RC,85670,HCPCS,facility,both,,,,9,9,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PTT,3058573001,CDM,305,RC,85730,HCPCS,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PTT MIX STUDIES EACH,3058573201,CDM,305,RC,85732,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VISCOSITY,3058581001,CDM,305,RC,85810,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EOSINOPHIL SMR UR,3058905001,CDM,305,RC,89050,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESPIR NFCT DS BCT/VIR 22 TRGT SARSCOV2,3060202U01,CDM,306,RC,0202U,HCPCS,facility,both,,,,709.69,709.69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NFCT AGT STI MULT AMP PRB TQ VAG ENDOCRV/MALE UR,3060402U01,CDM,306,RC,0402U,HCPCS,facility,both,,,,357,357,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NFCT AGT STI CHLMYD GONORR TRICH MULT AMP PRB UR,3060455U01,CDM,306,RC,0455U,HCPCS,facility,both,,,,357,357,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AFB CONCENTRATION,3068701501,CDM,306,RC,87015,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE BLOOD,3068704001,CDM,306,RC,87040,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE AEROBIC,3068707001,CDM,306,RC,87070,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE CSF,3068707002,CDM,306,RC,87070,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE TISSUE,3068707003,CDM,306,RC,87070,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STERILITY CHECK,3068707004,CDM,306,RC,87070,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE QUANTITATIVE,3068707101,CDM,306,RC,87071,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE ANAEROBIC,3068707501,CDM,306,RC,87075,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ID CULT ANAER EA ISOLATE,3068707601,CDM,306,RC,87076,HCPCS,facility,both,,,,79,79,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ID CULT AEROB EA ISOLATE,3068707701,CDM,306,RC,87077,HCPCS,facility,both,,,,67,67,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MS CULTURE URINE,3068707702,CDM,306,RC,,,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BACTERIA CULTURE SCREEN,3068708101,CDM,306,RC,87081,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CIPRO RES ENTERIC SC,3068708102,CDM,306,RC,,,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE LEGIONELLA,3068708103,CDM,306,RC,87081,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE THROAT,3068708104,CDM,306,RC,,,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STAPH AUREUS SCREEN,3068708105,CDM,306,RC,87081,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VRE SCREEN,3068708106,CDM,306,RC,,,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE URINE,3068708601,CDM,306,RC,87086,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ID CULTURE URINE,3068708802,CDM,306,RC,,,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULT FUNGUS HAIR SKIN OR NAILS,3068710101,CDM,306,RC,87101,HCPCS,facility,both,,,,46,46,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE FUNGUS,3068710201,CDM,306,RC,87102,HCPCS,facility,both,,,,51,51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULT BLOOD FUNGUS,3068710301,CDM,306,RC,87103,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ID CULT YEAST,3068710601,CDM,306,RC,87106,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ID CULT MOLD,3068710701,CDM,306,RC,87107,HCPCS,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULT MYCOPLASMA,3068710901,CDM,306,RC,87109,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLAMYDIA CULTURE,3068711001,CDM,306,RC,,,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACID FAST CULTURE,3068711601,CDM,306,RC,87116,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULT BLOOD AFB,3068711602,CDM,306,RC,87116,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE TYPING IMMUNOFLUORESCENT EACH ANTISERUM,3068714001,CDM,306,RC,,,facility,both,,,,23,23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULT TYPING IMUN METHOD EA,3068714701,CDM,306,RC,87147,HCPCS,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CULTURE TYPING NUCLEIC ACID PROBE DIR EA ORGANSM,3068714901,CDM,306,RC,,,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CUL TYP ID BLD PTHGN 6+ TRGT,3068715401,CDM,306,RC,87154,HCPCS,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MACRO EXAM ARTHROPOD,3068716801,CDM,306,RC,87168,HCPCS,facility,both,,,,11,11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MACRO EXAM PARASITE,3068716901,CDM,306,RC,87169,HCPCS,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PINWORM PREP,3068717201,CDM,306,RC,87172,HCPCS,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TISSUE HOMOGENIZATION FOR CULTURE,3068717601,CDM,306,RC,87176,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OVA AND PARASITES,3068717701,CDM,306,RC,87177,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MIC E TEST EACH,3068718101,CDM,306,RC,87181,HCPCS,facility,both,,,,15,15,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUSCEPTIBILITY DISK METHOD,3068718401,CDM,306,RC,87184,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUSCEPTIBILITY STUDY ENZYME,3068718501,CDM,306,RC,87185,HCPCS,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MIC TEST,3068718601,CDM,306,RC,87186,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC YEAST ANTIFUNGAL MIC,3068718602,CDM,306,RC,87186,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GRAM STAIN,3068720501,CDM,306,RC,87205,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACID FAST SMEAR,3068720601,CDM,306,RC,87206,HCPCS,facility,both,,,,31,31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALCOFLO WHITE STAIN,3068720602,CDM,306,RC,87206,HCPCS,facility,both,,,,31,31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PARASITEMIA LEVEL,3068720704,CDM,306,RC,87207,HCPCS,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRICHROME STAIN,3068720901,CDM,306,RC,87209,HCPCS,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WET MOUNT INFECTIOUS AGENTS,3068721001,CDM,306,RC,87210,HCPCS,facility,both,,,,68,68,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KOH TISSUE SLIDE,3068722001,CDM,306,RC,87220,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRAL CULTURE,3068725201,CDM,306,RC,87252,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ID VIRUS TISSUE CULTURE EA,3068725301,CDM,306,RC,,,facility,both,,,,55,55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRAL SHELL W STAIN,3068725401,CDM,306,RC,87254,HCPCS,facility,both,,,,111,111,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC O&P SCRN GIARDIA,3068726901,CDM,306,RC,,,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC O AND P SCREEN CRYPTOSPORIDIUM,3068727201,CDM,306,RC,,,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HERPES TYPE 2 DFA,3068727301,CDM,306,RC,,,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HERPES TYPE 1 DFA,3068727401,CDM,306,RC,,,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEGIONELLA PNEUMOPHILA DFA,3068727801,CDM,306,RC,87278,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RSV ANTIGEN,3068728001,CDM,306,RC,,,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PNEUMOCYSTIS DIR FA EX,3068728101,CDM,306,RC,,,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VARICELLA ZOSTER DFA,3068729001,CDM,306,RC,,,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADENOVIRUS ANTIGEN,3068730101,CDM,306,RC,,,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C DIFF TOXIN SCREEN,3068732401,CDM,306,RC,87324,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC O AND P SCR CRYPTOSPORIDIUM EIA,3068732801,CDM,306,RC,87328,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC O AND P SCR GIARDIA EIA,3068732901,CDM,306,RC,87329,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IAAD EIA HPYLORI STOOL,3068733801,CDM,306,RC,87338,HCPCS,facility,both,,,,75,75,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP B SURF ANTIGEN,3068734001,CDM,306,RC,87340,HCPCS,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP B SURFACE AG NEUTRALIZATION,3068734101,CDM,306,RC,87341,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV-1 AG W/HIV-1 & HIV-2 AB DIAGNOSTIC,3068738901,CDM,306,RC,87389,HCPCS,facility,both,,,,204,204,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV-1 AG W/HIV-1 & HIV-2 AB SCREEN,3068738906,CDM,306,RC,87389,HCPCS,facility,both,,,,166,166,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RSV ANTIGEN EIA,3068742001,CDM,306,RC,,,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ROTAVIRUS,3068742501,CDM,306,RC,,,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC IAAD IA SEVERE AQT RESPIR SYND CORONAVIRUS,3068742601,CDM,306,RC,87426,HCPCS,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C. DIFFICILE ANTIGEN EIA,3068744902,CDM,306,RC,87449,HCPCS,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CNS DNA AMP PROBE TYPE 12-25,3068748301,CDM,306,RC,87483,HCPCS,facility,both,,,,1232,1232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLAMYDOPHILA PCR,3068748601,CDM,306,RC,,,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLAMYDIA PCR RNA,3068749101,CDM,306,RC,87491,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLAMYDIA PCR UR,3068749102,CDM,306,RC,,,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLMD TRACH DNA AMP PROBE,3068749103,CDM,306,RC,,,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHLAMYDIA PCR RNA-ALINITY,3068749107,CDM,306,RC,87491,HCPCS,facility,both,,,,127,127,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C DIFF AMPLIFIED PROBE TECH,3068749301,CDM,306,RC,87493,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IADNA CHLMYD TRCHMTS&NEISRA GONORR MULT AMP PRB,3068749401,CDM,306,RC,87494,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CMV QUANT,3068749701,CDM,306,RC,87497,HCPCS,facility,both,,,,351,351,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENTEROVIRUS PCR,3068749801,CDM,306,RC,87498,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLU RT PCR 2 TYPES,3068750201,CDM,306,RC,87502,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLU RT PCR EA ADDTL,3068750301,CDM,306,RC,,,facility,both,,,,61,61,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB ENTERIC PATH PCR VERIGENE,3068750601,CDM,306,RC,87506,HCPCS,facility,both,,,,335,335,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HBV QUANT PCR,3068751701,CDM,306,RC,87517,HCPCS,facility,both,,,,364,364,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP C AMPLIFICATION,3068752101,CDM,306,RC,,,facility,both,,,,170,170,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM HCV RNA MI BLOOD,3068752102,CDM,306,RC,87521,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HCV QUANT PCR,3068752201,CDM,306,RC,87522,HCPCS,facility,both,,,,309,309,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HSV 1 OR 2 DNA PROBE,3068752902,CDM,306,RC,87529,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM HIV1 RNA MI BLOOD,3068753503,CDM,306,RC,87535,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV 1 QUANT RNA PCR,3068753601,CDM,306,RC,87536,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYCOPLASMA GENITALIUM AMPLIFIED PROBE TECH,3068756301,CDM,306,RC,87563,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYCOPLASMA GENITALIUM AMP PROBE -ALINITY,3068756302,CDM,306,RC,87563,HCPCS,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IADNA MTB RIFAMPIN RESISTANCE AMP PRB TQ,3068756401,CDM,306,RC,87564,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYCOPLASMA DNA PCR,3068758102,CDM,306,RC,,,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GONOCOCCUS PCR-ALINITY,3068759102,CDM,306,RC,87591,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GC PCR UR,3068759103,CDM,306,RC,,,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GONOCOCCUS PCR RNA,3068759104,CDM,306,RC,87591,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HPV HIGH RISK SCREEN,3068762402,CDM,306,RC,87624,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IADNA HPV SEP RPRT HI-RSK TYP&HI-RSK POOLD RSLTS,3068762601,CDM,306,RC,87626,HCPCS,facility,both,,,,176,176,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESP VIRUS 12 TO 25 TARGETS,3068763301,CDM,306,RC,87633,HCPCS,facility,both,,,,1093,1093,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NON HTP NOVEL  SARS-COV-2 COVID-19 AMP PRB,3068763503,CDM,306,RC,87635,HCPCS,facility,both,,,,217.5,217.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SARS COV 2 + FLU AB PCR POC ASSAY,3068763601,CDM,306,RC,,,facility,both,,,,297,297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE TQ,3068763701,CDM,306,RC,,,facility,both,,,,294.29,294.29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE TQ,3068763701,CDM,306,RC,87637,HCPCS,facility,both,,,,294.29,294.29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRSA AMPLIFIED PROBE,3068764101,CDM,306,RC,87641,HCPCS,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB GRP A STREP DNA PCR,3068765101,CDM,306,RC,87651,HCPCS,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GRP B STREP DNA PCR,3068765301,CDM,306,RC,87653,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRICHOMONAS PCR,3068766101,CDM,306,RC,87661,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC B PERTUSSIS DNA PCR,3068779805,CDM,306,RC,,,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DETECT AGENT NOS DNA AMP,3068779807,CDM,306,RC,87798,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDM WNV RNA MI BLOOD,3068779809,CDM,306,RC,87798,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NOS AMPLIFIED PROBE TQ EACH ORGANISM MGEN,3068779814,CDM,306,RC,,,facility,both,,,,113,113,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM,3068779822,CDM,306,RC,,,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC M TB/RIFAMPIN DNA AMPIFIED PROBE,3068779823,CDM,306,RC,,,facility,both,,,,11,11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DETECT AGENT BORDETELLA PCR DNA AMP,3068779843,CDM,306,RC,,,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADENOVIRUS PCR QUANT,3068779912,CDM,306,RC,87799,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT HHV7 VIRACOR,3068779915,CDM,306,RC,87799,HCPCS,facility,both,,,,247.5,247.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT HHV8 VIRACOR,3068779916,CDM,306,RC,87799,HCPCS,facility,both,,,,247.5,247.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EBV PCR,3068779918,CDM,306,RC,87799,HCPCS,facility,both,,,,283,283,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IADNA STREPTOCOCCUS GROUP CG DIRECT PROBE,3068780001,CDM,306,RC,,,facility,both,,,,109,109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DNA AMP PROBE MULTI ORGANISM,3068780101,CDM,306,RC,87801,HCPCS,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIV1 ANTIGEN W/HIV1 & HIV2 ANTIBODIES -ALERE,3068780601,CDM,306,RC,,,facility,both,,,,146,146,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESPIRATORY SYNCTIAL VIRUS IAADIADOO,3068780702,CDM,306,RC,,,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB TRICHOMONAS OSOM,3068780801,CDM,306,RC,87808,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAPID STREP SCREEN,3068788001,CDM,306,RC,87880,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEGIONELLA AG UR,3068789901,CDM,306,RC,87899,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PNEUMO AG URINE,3068789902,CDM,306,RC,87899,HCPCS,facility,both,,,,55,55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP C GENOTYPE,3068790201,CDM,306,RC,,,facility,both,,,,876,876,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB FERN TEST,306Q011401,CDM,306,RC,Q0114,HCPCS,facility,both,,,,24,24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINALYSIS DIP WITH MICROSCOPY,3078100001,CDM,307,RC,81000,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINALYSIS AUTOMATED W MICROSCOPY,3078100101,CDM,307,RC,81001,HCPCS,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POC URINALYSIS NON AUTO WO MICROSCOPY,3078100202,CDM,307,RC,81002,HCPCS,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINALYSIS SPECIFIC GRAVITY,3078100204,CDM,307,RC,,,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINALYSIS AUTOMATED WO MICROSCOPY,3078100301,CDM,307,RC,81003,HCPCS,facility,both,,,,11,11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPECIFIC GRAVITY URINE RANDOM,3078100303,CDM,307,RC,81003,HCPCS,facility,both,,,,10,10,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINE PREGNANCY TEST,3078102501,CDM,307,RC,81025,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINALYSIS VOLUME MEASURE TIMED COLLECTION,3078105001,CDM,307,RC,,,facility,both,,,,12,12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB RESEARCH MMRF PATH INTERPRETATION,3090000002,CDM,309,RC,,,facility,both,,,,267,267,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTOPSY COMPLETE,3100000001,CDM,310,RC,,,facility,both,,,,1467,1467,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTOPSY INF CNS,3100000002,CDM,310,RC,,,facility,both,,,,2158,2158,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTOPSY PARTIAL,3100000003,CDM,310,RC,,,facility,both,,,,1467,1467,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTOPSY PRIVATE COMPLETE,3100000004,CDM,310,RC,,,facility,both,,,,3022,3022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTOPSY PRIVATE PARTIAL,3100000005,CDM,310,RC,,,facility,both,,,,1813,1813,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB RESEARCH CYTOSLIDE PREP,3100000006,CDM,310,RC,,,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB RESEARCH FICOLL,3100000007,CDM,310,RC,,,facility,both,,,,48,48,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB RESEARCH FREEZE AND STORE,3100000008,CDM,310,RC,,,facility,both,,,,3.46,3.46,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MMRF PLASMA CELL SCREEN,3100000009,CDM,310,RC,,,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROC EMBED CUT STAIN H&E,3100000010,CDM,310,RC,,,facility,both,,,,17,17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES BLOCK ONLY,3100000011,CDM,310,RC,,,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES CUT STEP SECTION UNSTAINED,3100000012,CDM,310,RC,,,facility,both,,,,4.31,4.31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES CUT THICK SECTION,3100000013,CDM,310,RC,,,facility,both,,,,4.31,4.31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES DIGITALIZED SLIDES,3100000014,CDM,310,RC,,,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES EXPLANT TISSUE OR DEVICE,3100000015,CDM,310,RC,,,facility,both,,,,172,172,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES IHC ANTIBODY,3100000016,CDM,310,RC,,,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES IHC/HER2/ER/PR/CD20/CD117,3100000017,CDM,310,RC,,,facility,both,,,,43,43,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES IN SITU HYBRIDIZATION,3100000018,CDM,310,RC,,,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES PARAFFIN UNSTAIN SLIDE 1ST,3100000019,CDM,310,RC,,,facility,both,,,,4.81,4.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES PARAFFIN UNSTAIN SLIDE ADD,3100000020,CDM,310,RC,,,facility,both,,,,2.88,2.88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES PATH ANNOTATION OF SLIDE,3100000021,CDM,310,RC,,,facility,both,,,,24,24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES PROCESS EMBED CUT AND STAIN,3100000022,CDM,310,RC,,,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES PUNCH BLOCK,3100000023,CDM,310,RC,,,facility,both,,,,4.31,4.31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES RECUT BLOCK AND STAIN,3100000024,CDM,310,RC,,,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES RETRIEVE OFFSITE SL/BLK #1,3100000025,CDM,310,RC,,,facility,both,,,,19,19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES RETRIEVE OFFSITE SL/BLK AD,3100000026,CDM,310,RC,,,facility,both,,,,4.81,4.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES RETRIEVE ONSITE SLIDE/BLK,3100000027,CDM,310,RC,,,facility,both,,,,4.81,4.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES SPECIAL STAINS,3100000028,CDM,310,RC,,,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RES URINE,3100000029,CDM,310,RC,,,facility,both,,,,9,9,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDH1 COMMON VARIANTS,3108112001,CDM,310,RC,81120,HCPCS,facility,both,,,,590,590,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDH2 COMMON VARIANTS,3108112101,CDM,310,RC,81121,HCPCS,facility,both,,,,590,590,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCND1/IGH TRANSLOCATION ALYS,3108116801,CDM,310,RC,81168,HCPCS,facility,both,,,,360,360,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANS BCR ABL1 MAJOR,3108120601,CDM,310,RC,81206,HCPCS,facility,both,,,,280,280,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANS BCR ABL1 MINOR,3108120701,CDM,310,RC,81207,HCPCS,facility,both,,,,280,280,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANALYSIS GENE BRAF,3108121001,CDM,310,RC,81210,HCPCS,facility,both,,,,800,800,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALR VAR IN EXON 9,3108121901,CDM,310,RC,81219,HCPCS,facility,both,,,,516,516,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CFTR GENE ANALYSIS COMMON VARIANTS,3108122001,CDM,310,RC,,,facility,both,,,,774,774,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOGEN M ARRAY COPY NO&SNP,3108122901,CDM,310,RC,81229,HCPCS,facility,both,,,,832,832,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOGENOMIC MICROARRAY ANALYSIS,3108122902,CDM,310,RC,81229,HCPCS,facility,both,,,,1881,1881,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EGFR GENE ANALYSIS,3108123501,CDM,310,RC,81235,HCPCS,facility,both,,,,1184,1184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC F2 GENE ANALYSIS,3108124001,CDM,310,RC,81240,HCPCS,facility,both,,,,692,692,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC F5 GENE ANALYSIS LEIDEN VARIANT,3108124101,CDM,310,RC,81241,HCPCS,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANALYS GENE FMR1 DET,3108124301,CDM,310,RC,,,facility,both,,,,158,158,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANALYS GENE FMR1 CHA,3108124401,CDM,310,RC,,,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HFE GENE ANALYSIS COMMON VARIANTS,3108125601,CDM,310,RC,81256,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGH GENE REARRANGEMENT ANALYSIS,3108126101,CDM,310,RC,81261,HCPCS,facility,both,,,,581,581,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGH VARIABLE REGION SOMATIC MUTATION ANALYSIS,3108126301,CDM,310,RC,81263,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGK GENE REARRANGE ANALYSIS,3108126401,CDM,310,RC,,,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC,3108126501,CDM,310,RC,81265,HCPCS,facility,both,,,,387,387,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STR GENE ANALYSIS,3108126503,CDM,310,RC,81265,HCPCS,facility,both,,,,1980,1980,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STR GENE ANALYSIS ADDTL SPECIMEN,3108126601,CDM,310,RC,,,facility,both,,,,1550,1550,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHIMERISM ANALYSIS WO CELL SORT,3108126701,CDM,310,RC,81267,HCPCS,facility,both,,,,1005,1005,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHIMERISM ANALYSIS WITH CELL SORT,3108126801,CDM,310,RC,81268,HCPCS,facility,both,,,,1005,1005,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC JAK2 GENE ANALYSIS,3108127001,CDM,310,RC,,,facility,both,,,,255,255,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC JAK2 V617F MUTATION AN,3108127002,CDM,310,RC,81270,HCPCS,facility,both,,,,388,388,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KRAS GENE ANALYSIS VARIANTS 12/13,3108127501,CDM,310,RC,81275,HCPCS,facility,both,,,,440,440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KRAS ADDTL VARIANTS,3108127601,CDM,310,RC,81276,HCPCS,facility,both,,,,440,440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGH@/BCL2 TRANSLOCATION ALYS,3108127801,CDM,310,RC,81278,HCPCS,facility,both,,,,324,324,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MLH1 PROMOTER METHYLATION ANALYSIS,3108128801,CDM,310,RC,81288,HCPCS,facility,both,,,,548,548,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MTHFR GENE ANALYSIS COMMON VARIANTS,3108129101,CDM,310,RC,,,facility,both,,,,273,273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MICROSATELLITE INSTABILITY ANALYSIS,3108130101,CDM,310,RC,81301,HCPCS,facility,both,,,,619,619,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  PIK3CA GENE ANALYSIS TARGETED SEQUENCE ANALYSIS,3108130901,CDM,310,RC,,,facility,both,,,,461,461,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIPROCOLON SEPTIN 9,3108132701,CDM,310,RC,,,facility,both,,,,269,269,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SNRPN UBE3A METHYLATION ANALYSIS,3108133101,CDM,310,RC,81331,HCPCS,facility,both,,,,200,200,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRB GENE REARRANGE AMPLIFY,3108134001,CDM,310,RC,,,facility,both,,,,522,522,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRG GENE REARRANGEMENT ANALYSIS,3108134201,CDM,310,RC,81342,HCPCS,facility,both,,,,591,591,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HLA CLASS I&II LOW HLA-A -B -C -DRB1/3/4/5&DQB,3108137001,CDM,310,RC,,,facility,both,,,,1005,1005,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC 81373 HLA I LOW ONE LOCUS, EA",3108137301,CDM,310,RC,81373,HCPCS,facility,both,,,,319,319,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HTT HUNTINGTON GENE ANALYSIS,3108140101,CDM,310,RC,,,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MT-ATP6 GENE NARP,3108140102,CDM,310,RC,,,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MT-ND4 GENE LHON,3108140103,CDM,310,RC,,,facility,both,,,,496,496,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MT-ND5 GENE MELAS,3108140104,CDM,310,RC,,,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MT-TK GENE MERRF,3108140105,CDM,310,RC,,,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 CTNNB1,3108140305,CDM,310,RC,,,facility,both,,,,527,527,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE,3108144501,CDM,310,RC,,,facility,both,,,,1268,1268,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GENE SEQUENCE ANALYSIS 5 50,3108144502,CDM,310,RC,81445,HCPCS,facility,both,,,,2981,2981,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TARGETED GENOMIC SEQ ANALYSIS LUNG PANEL,3108144503,CDM,310,RC,81445,HCPCS,facility,both,,,,3578,3578,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TARGETED GENOMIC SEQ ANALYS,3108144504,CDM,310,RC,,,facility,both,,,,1495,1495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GENE ANALYSIS HEME,3108145001,CDM,310,RC,81450,HCPCS,facility,both,,,,3312,3312,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TARGETED GENOMIC SEQ ANALYSIS PANEL,3108145503,CDM,310,RC,,,facility,both,,,,4323,4323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PAN GENE FUSION PANEL RNA ANAYSIS,3108145601,CDM,310,RC,,,facility,both,,,,5448,5448,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MITOCHON DELETE KSS,3108147902,CDM,310,RC,,,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ERBB2 LUNG PANEL,3108147903,CDM,310,RC,,,facility,both,,,,161,161,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GNAS GENE ANALYSIS,3108147904,CDM,310,RC,81479,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB DNA EXTRACTION,3108147905,CDM,310,RC,81479,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED MOLECULAR PATHOLOGY PROCEDURE,3108147906,CDM,310,RC,,,facility,both,,,,717,717,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RNA EXTRACTION AND HOLD,3108147907,CDM,310,RC,81479,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOLECULAR BRAF GENE FUSION,3108147910,CDM,300,RC,81479,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IGL GENE REARRANGE ANALYSIS,3108147914,CDM,310,RC,,,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALK GENE FUSION,3108147915,CDM,310,RC,81479,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPC GENO 1A NS5A DRUG RES,3108790201,CDM,300,RC,,,facility,both,,,,579,579,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOLOGY BRUSHINGS,3108810401,CDM,310,RC,,,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOPATHOLOGY NONGYN,3108810801,CDM,310,RC,88108,HCPCS,facility,both,,,,118,118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PAP SMEAR INTERP,3108814101,CDM,310,RC,,,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THIN PREP DIAGNOSTIC WO INTERP,3108814201,CDM,310,RC,88142,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOL MATURAT INDEX,3108815501,CDM,310,RC,,,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTO NONGYN SMEAR,3108816001,CDM,310,RC,88160,HCPCS,facility,both,,,,147,147,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOLOGY SMEAR PREP SCREEN & INTERP,3108816101,CDM,310,RC,,,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTOLOGY EXTENDED STUDY,3108816201,CDM,310,RC,,,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FNA IMMEDIATE READ,3108817201,CDM,310,RC,88172,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTO FNA INTERP AND REPORT,3108817301,CDM,310,RC,88173,HCPCS,facility,both,,,,186,186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTO FNA IMMEDIATE ADDTL EVAL,3108817701,CDM,310,RC,88177,HCPCS,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLOW CYTOMETRY CELL CYCLE/DNA ANALYSIS,3108818202,CDM,310,RC,,,facility,both,,,,107,107,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CD20 1ST MARKER,3108818401,CDM,310,RC,,,facility,both,,,,259,259,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FETAL CELL FLOW CYTOMETRY,3108818403,CDM,310,RC,88184,HCPCS,facility,both,,,,289,289,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLOW CYTO 1ST MARKER,3108818404,CDM,310,RC,88184,HCPCS,facility,both,,,,289,289,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CD20 ADD MARKER,3108818501,CDM,310,RC,,,facility,both,,,,66,66,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLOW CYTO EA ADD MKR,3108818504,CDM,310,RC,88185,HCPCS,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TISSUE CULT LYMPHOCYTE,3108823001,CDM,310,RC,88230,HCPCS,facility,both,,,,517,517,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TISSUE CULT SOLID TISSUE,3108823301,CDM,310,RC,88233,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TISSUE CULT AMNIO FLUID,3108823501,CDM,310,RC,88235,HCPCS,facility,both,,,,647,647,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TISSUE CULT BONE MARROW,3108823701,CDM,310,RC,88237,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TISSUE CULT SOLID TUMOR,3108823901,CDM,310,RC,88239,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYOPRESERVATION EA,3108824001,CDM,310,RC,88240,HCPCS,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THAW EXPAND CRYO CELL EA ALQ,3108824101,CDM,310,RC,,,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROM ANALYSIS BREAK SYNDROMES,3108824801,CDM,310,RC,,,facility,both,,,,618,618,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAK SYNDROME CLASTOGEN STRESS,3108824901,CDM,310,RC,,,facility,both,,,,653,653,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROM ANALYSIS 5 CELL 1 KARYOTYPE,3108826101,CDM,310,RC,88261,HCPCS,facility,both,,,,707,707,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROM ANALYSIS 15 TO 20 CELL 2 KARYOTYPES,3108826201,CDM,310,RC,88262,HCPCS,facility,both,,,,805,805,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROM ANALYSIS 20 TO 25 CELLS,3108826401,CDM,310,RC,88264,HCPCS,facility,both,,,,799,799,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROM ANALYSIS AMNIO FLUID 15 CELL 1 KARYOTYPE,3108826701,CDM,310,RC,88267,HCPCS,facility,both,,,,585,585,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROM ANALYSIS AMNIO FLUID 6 TO 12 CELL 1 KARYOTYPE,3108826901,CDM,310,RC,88269,HCPCS,facility,both,,,,466,466,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DNA PRB EA LUNG PNL,3108827101,CDM,310,RC,,,facility,both,,,,103,103,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOL CYTO DNA PROB EA,3108827102,CDM,310,RC,88271,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FISH ANALYSIS 3 TO 5 CELLS,3108827201,CDM,310,RC,,,facility,both,,,,258,258,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FISH ANALYSIS 10 TO 30 CELL,3108827301,CDM,310,RC,88273,HCPCS,facility,both,,,,377,377,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTER FISH 25 TO 99 CELL,3108827401,CDM,310,RC,88274,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISH LUNG PANEL,3108827402,CDM,310,RC,,,facility,both,,,,288,288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTER FISH 100 TO 300 CELL,3108827501,CDM,310,RC,88275,HCPCS,facility,both,,,,310,310,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADDTL KARYOTYPE EA STUDY,3108828001,CDM,310,RC,88280,HCPCS,facility,both,,,,147,147,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROM ANAL ADDL BAND,3108828301,CDM,310,RC,,,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUSPECTED MOSAIC,3108828501,CDM,310,RC,88285,HCPCS,facility,both,,,,147,147,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHROM ANALYSIS HIGH RES,3108828901,CDM,310,RC,,,facility,both,,,,299,299,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURG PATH LEVEL I,3108830001,CDM,310,RC,88300,HCPCS,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURG PATH LEVEL II,3108830201,CDM,310,RC,88302,HCPCS,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURG PATH LEVEL III,3108830401,CDM,310,RC,88304,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURG PATH LEVEL IV,3108830501,CDM,310,RC,88305,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURG PATH LEVEL V,3108830701,CDM,310,RC,88307,HCPCS,facility,both,,,,390,390,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURG PATH LEVEL VI,3108830901,CDM,310,RC,88309,HCPCS,facility,both,,,,652,652,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DECALCIFICATION PROCEDURE,3108831101,CDM,310,RC,88311,HCPCS,facility,both,,,,31,31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPECIAL STAIN GROUP I,3108831201,CDM,310,RC,88312,HCPCS,facility,both,,,,218,218,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPECIAL STAIN GROUP II,3108831303,CDM,310,RC,88313,HCPCS,facility,both,,,,195,195,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HISTOCHEMICAL STAIN,3108831401,CDM,310,RC,,,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPECIAL STAIN I&R GROUP III ENZYME CONSITUENTS,3108831901,CDM,310,RC,88319,HCPCS,facility,both,,,,652,652,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PATH CONSULT OUTSIDE SLIDES,3108832102,CDM,310,RC,,,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PATH CONSULT REFERRED MATERIAL,3108832302,CDM,310,RC,88323,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PATH CONSULT COMPREHENSIVE REVIEW,3108832502,CDM,310,RC,,,facility,both,,,,337,337,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PATH CONSULT INTROPERATIVE,3108832901,CDM,310,RC,88329,HCPCS,facility,both,,,,71,71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FROZEN SECTION,3108833101,CDM,310,RC,88331,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADDTL FROZEN SECTION,3108833201,CDM,310,RC,88332,HCPCS,facility,both,,,,71,71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PATH CONSULT INTROPERATIVE CYTO EXAM,3108833301,CDM,310,RC,88333,HCPCS,facility,both,,,,652,652,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PATH CONSULT INTROPERATIVE CYTO EXAM ADDTL,3108833401,CDM,310,RC,88334,HCPCS,facility,both,,,,71,71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOCHEMICAL AB STAIN ADDTL,3108834101,CDM,310,RC,88341,HCPCS,facility,both,,,,186,186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNOCHEMICAL AB STAIN INITIAL,3108834202,CDM,310,RC,88342,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IHC EA MULTIPLEX AB STN,3108834401,CDM,310,RC,88344,HCPCS,facility,both,,,,289,289,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MORPH IHC EA AB STAIN,3108836001,CDM,310,RC,88360,HCPCS,facility,both,,,,188,188,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IN SITU HYB ADDTL PROBE,3108836401,CDM,310,RC,88364,HCPCS,facility,both,,,,232,232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISH INITIAL SINGLE PROBE,3108836501,CDM,310,RC,88365,HCPCS,facility,both,,,,290,290,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISH EA MULTIPLEX AB STN,3108836601,CDM,310,RC,,,facility,both,,,,275,275,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MORPH ISH INITIAL PROBE,3108836801,CDM,310,RC,88368,HCPCS,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MORPH ISH ADDTL PROBE,3108836901,CDM,310,RC,88369,HCPCS,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MORPH ISH EA MULTI PRB,3108837701,CDM,310,RC,,,facility,both,,,,350,350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC M/PHMTRC ALYS ISH QUANT/SEMIQ MNL EACH MULTIPRB,3108837702,CDM,310,RC,88377,HCPCS,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTO NONGYN SELECTIVE W INTERP,3118811201,CDM,311,RC,88112,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYTP INSITU HYBRID URINE SPEC 3-5 PROBES CPRT EA,3118812101,CDM,311,RC,88121,HCPCS,facility,both,,,,1074,1074,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THIN PREP SCREEN WO INTERP,3118814201,CDM,311,RC,88142,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PAP SCREEN AUTO,3118817501,CDM,311,RC,88175,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PAP DIAGNOSTIC AUTO,3118817502,CDM,311,RC,88175,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORESCENT STAIN EACH AB DIRECT,3128834601,CDM,312,RC,88346,HCPCS,facility,both,,,,336,336,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELECTRON MICROSCOPY DIAG,3128834801,CDM,312,RC,88348,HCPCS,facility,both,,,,914,914,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IF PER SPECIMEN EA ADD ANTIBODY STN,3128835001,CDM,312,RC,88350,HCPCS,facility,both,,,,103,103,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTOPSY ME RAD,3200000001,CDM,320,RC,,,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUOROSCOPY LESS THAN OR EQUAL TO 1 HOUR,3200000002,CDM,320,RC,,,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUOROSCOPY LESS THAN OR EQUAL TO 1 HOUR,3200000002,CDM,320,RC,,,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY COREVALVE ROTATIONAL,3200000003,CDM,320,RC,,,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION-CYSTO/VOIDING CYSTO,3205160001,CDM,320,RC,51600,HCPCS,facility,both,,,,1020,1020,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION URETHROGRAM,3205161001,CDM,320,RC,51610,HCPCS,facility,both,,,,681,681,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY EYE FOREIGN BODY,3207003001,CDM,320,RC,70030,HCPCS,facility,both,,,,197,197,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY EYE FOREIGN BODY,3207003001,CDM,320,RC,70030,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY MANDIBLE LESS THAN 4 VIEWS,3207010001,CDM,320,RC,70100,HCPCS,facility,both,,,,107,107,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY MANDIBLE LESS THAN 4 VIEWS,3207010001,CDM,320,RC,70100,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY MANDIBLE COMPLETE MIN 4 VIEWS,3207011001,CDM,320,RC,70110,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY MANDIBLE COMPLETE MIN 4 VIEWS,3207011001,CDM,320,RC,70110,HCPCS,facility,both,,,,377,377,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY MASTOIDS COMPLETE MIN 3 VIEWS PER SIDE,3207013001,CDM,320,RC,70130,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY MASTOIDS COMPLETE MIN 3 VIEWS PER SIDE,3207013001,CDM,320,RC,70130,HCPCS,facility,both,,,,158,158,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FACIAL BONES LESS THAN 3 VIEWS,3207014001,CDM,320,RC,70140,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FACIAL BONES LESS THAN 3 VIEWS,3207014001,CDM,320,RC,70140,HCPCS,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FACIAL BONES COMPLETE MIN 3 VIEWS,3207015001,CDM,320,RC,70150,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FACIAL BONES COMPLETE MIN 3 VIEWS,3207015001,CDM,320,RC,70150,HCPCS,facility,both,,,,383,383,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY NASAL BONES MIN 3 VIEWS,3207016001,CDM,320,RC,70160,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY NASAL BONES MIN 3 VIEWS,3207016001,CDM,320,RC,70160,HCPCS,facility,both,,,,237,237,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ORBITS OPTIC FORAMINA,3207019001,CDM,320,RC,70190,HCPCS,facility,both,,,,84,84,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ORBITS COMPLETE MIN 4 VIEWS,3207020001,CDM,320,RC,70200,HCPCS,facility,both,,,,380,380,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ORBITS COMPLETE MIN 4 VIEWS,3207020001,CDM,320,RC,70200,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SINUSES PARANASAL LESS THAN 3 VIEWS,3207021001,CDM,320,RC,70210,HCPCS,facility,both,,,,220,220,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SINUSES PARANASAL LESS THAN 3 VIEWS,3207021001,CDM,320,RC,70210,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SINUSES PARANASAL COMPLETE MIN 3 VIEWS,3207022001,CDM,320,RC,70220,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SINUSES PARANASAL COMPLETE MIN 3 VIEWS,3207022001,CDM,320,RC,70220,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SKULL LESS THAN 4 VIEWS,3207025001,CDM,320,RC,70250,HCPCS,facility,both,,,,344,344,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SKULL LESS THAN 4 VIEWS,3207025001,CDM,320,RC,70250,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SKULL COMPLETE MIN 4 VIEWS,3207026001,CDM,320,RC,70260,HCPCS,facility,both,,,,380,380,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SKULL COMPLETE MIN 4 VIEWS,3207026001,CDM,320,RC,70260,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH UNILAT,3207032801,CDM,320,RC,70328,HCPCS,facility,both,,,,275,275,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY TEMPOROMANDIBULAR JOINTS BILATERAL,3207033001,CDM,320,RC,70330,HCPCS,facility,both,,,,474,474,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY TEMPOROMANDIBULAR JOINTS BILATERAL,3207033001,CDM,320,RC,70330,HCPCS,facility,both,,,,307,307,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ORTHOPANTOGRAM (PANORAMIC),3207035501,CDM,320,RC,70355,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY NECK SOFT TISSUE,3207036001,CDM,320,RC,70360,HCPCS,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY NECK SOFT TISSUE,3207036001,CDM,320,RC,70360,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY PHARYNX/LARYNX INC FLUORO,3207037001,CDM,320,RC,70370,HCPCS,facility,both,,,,320,320,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SIALOGRAPHY S&I,3207039001,CDM,320,RC,70390,HCPCS,facility,both,,,,356,356,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RIBS UNILATERAL 2 VIEWS,3207110001,CDM,320,RC,71100,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RIBS UNILATERAL 2 VIEWS,3207110001,CDM,320,RC,71100,HCPCS,facility,both,,,,236,236,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RIBS UNILAT WITH PA CHEST MIN 3 VIEWS,3207110101,CDM,320,RC,71101,HCPCS,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RIBS UNILAT WITH PA CHEST MIN 3 VIEWS,3207110101,CDM,320,RC,71101,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RIBS BILATERAL 3 VIEWS,3207111001,CDM,320,RC,71110,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RIBS BILATERAL 3 VIEWS,3207111001,CDM,320,RC,71110,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RIBS BILATERAL WITH PA CHEST MIN 4 VIEWS,3207111101,CDM,320,RC,71111,HCPCS,facility,both,,,,389,389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RIBS BILATERAL WITH PA CHEST MIN 4 VIEWS,3207111101,CDM,320,RC,71111,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY STERNUM MIN 2 VIEWS,3207112001,CDM,320,RC,71120,HCPCS,facility,both,,,,236,236,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY STERNUM MIN 2 VIEWS,3207112001,CDM,320,RC,71120,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY STERNOCLAVICULAR JOINT MIN 3 VIEWS,3207113001,CDM,320,RC,71130,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY STERNOCLAVICULAR JOINT MIN 3 VIEWS,3207113001,CDM,320,RC,71130,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SPINE SINGLE VIEW,3207202001,CDM,320,RC,72020,HCPCS,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CERVICAL PA & LAT 2 TO 3 VIEWS,3207204001,CDM,320,RC,72040,HCPCS,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CERVICAL PA & LAT 2 TO 3 VIEWS,3207204001,CDM,320,RC,72040,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY-SPINE CERVICAL COMPLETE,3207205001,CDM,320,RC,72050,HCPCS,facility,both,,,,398,398,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY-SPINE CERVICAL COMPLETE,3207205001,CDM,320,RC,72050,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SPINE CERVIAL COMP FLX AN,3207205201,CDM,320,RC,72052,HCPCS,facility,both,,,,457,457,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SPINE CERVIAL COMP FLX AN,3207205201,CDM,320,RC,72052,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY THORACIC 2 VIEWS,3207207001,CDM,320,RC,72070,HCPCS,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY THORACIC 2 VIEWS,3207207001,CDM,320,RC,72070,HCPCS,facility,both,,,,168,168,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY THORACIC 3 VIEWS,3207207201,CDM,320,RC,72072,HCPCS,facility,both,,,,193,193,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY THORACIC 3 VIEWS,3207207201,CDM,320,RC,72072,HCPCS,facility,both,,,,276,276,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC X-RAY SPINE THORACOLUMBAR 2 OR 3 VIEWS,3207208001,CDM,320,RC,72080,HCPCS,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC X-RAY SPINE THORACOLUMBAR 2 OR 3 VIEWS,3207208001,CDM,320,RC,72080,HCPCS,facility,both,,,,206,206,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ENTIRE SPINE 1 VIEW,3207208101,CDM,320,RC,72081,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ENTIRE SPINE 1 VIEW,3207208101,CDM,320,RC,72081,HCPCS,facility,both,,,,155,155,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ENTIRE SPINE 2 TO 3 VIEWS,3207208201,CDM,320,RC,72082,HCPCS,facility,both,,,,230,230,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ENTIRE SPINE 2 TO 3 VIEWS,3207208201,CDM,320,RC,72082,HCPCS,facility,both,,,,255,255,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ENTIRE SPINE 4 TO 5 VIEWS,3207208301,CDM,320,RC,72083,HCPCS,facility,both,,,,264,264,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ENTIRE SPINE 4 TO 5 VIEWS,3207208301,CDM,320,RC,72083,HCPCS,facility,both,,,,293,293,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ENTIRE SPINE MIN 6 VIEWS,3207208401,CDM,320,RC,,,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ENTIRE SPINE MIN 6 VIEWS,3207208401,CDM,320,RC,,,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SPINE LUMBAR 2 OR 3 VIEWS,3207210001,CDM,320,RC,72100,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SPINE LUMBAR 2 OR 3 VIEWS,3207210001,CDM,320,RC,72100,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY L UMBAR SPINE MIN 4 VIEWS,3207211001,CDM,320,RC,72110,HCPCS,facility,both,,,,365,365,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY L UMBAR SPINE MIN 4 VIEWS,3207211001,CDM,320,RC,72110,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SPINE LUMBAR COMP WITH AD,3207211401,CDM,320,RC,72114,HCPCS,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SPINE LUMBAR COMP WITH AD,3207211401,CDM,320,RC,72114,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY LUMBAR SPINE BEND 2 OR 3 VIEWS,3207212001,CDM,320,RC,,,facility,both,,,,316,316,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY LUMBAR SPINE BEND 2 OR 3 VIEWS,3207212001,CDM,320,RC,,,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY PELVIS 1 OR 2 VIEWS,3207217001,CDM,320,RC,72170,HCPCS,facility,both,,,,221,221,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY PELVIS 1 OR 2 VIEWS,3207217001,CDM,320,RC,72170,HCPCS,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY PELVIS MIN 3 VIEWS,3207219001,CDM,320,RC,72190,HCPCS,facility,both,,,,355,355,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY PELVIS MIN 3 VIEWS,3207219001,CDM,320,RC,72190,HCPCS,facility,both,,,,306,306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SACROILIAC JOINT 2 VIEWS OR LESS,3207220001,CDM,320,RC,72200,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SACROILIAC JOINT 2 VIEWS OR LESS,3207220001,CDM,320,RC,72200,HCPCS,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SACROILIAC JOINTS MIN 3 VIEWS,3207220201,CDM,320,RC,72202,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SACROILIAC JOINTS MIN 3 VIEWS,3207220201,CDM,320,RC,72202,HCPCS,facility,both,,,,334,334,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SACRUM/COCCYX MIN 2 VIEWS,3207222001,CDM,320,RC,72220,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SACRUM/COCCYX MIN 2 VIEWS,3207222001,CDM,320,RC,72220,HCPCS,facility,both,,,,236,236,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DISCOGRAPHY CERVICAL/THORACIC S&I,3207228501,CDM,320,RC,,,facility,both,,,,1758,1758,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DISCOGRAPHY LUMBAR S&I,3207229501,CDM,320,RC,72295,HCPCS,facility,both,,,,1807,1807,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CLAVICLE COMPLETE,3207300001,CDM,320,RC,73000,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CLAVICLE COMPLETE,3207300001,CDM,320,RC,73000,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SCAPULA COMPLETE,3207301001,CDM,320,RC,73010,HCPCS,facility,both,,,,242,242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SCAPULA COMPLETE,3207301001,CDM,320,RC,73010,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SHOULDER 1 VIEW,3207302001,CDM,320,RC,73020,HCPCS,facility,both,,,,231,231,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SHOULDER 1 VIEW,3207302001,CDM,320,RC,73020,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SHOULDER COMPLETE MIN 2 VIEWS,3207303001,CDM,320,RC,73030,HCPCS,facility,both,,,,315,315,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SHOULDER COMPLETE MIN 2 VIEWS,3207303001,CDM,320,RC,73030,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ACROMIOCLAVICULAR JOINT BILATERAL,3207305001,CDM,320,RC,73050,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ACROMIOCLAVICULAR JOINT BILATERAL,3207305001,CDM,320,RC,73050,HCPCS,facility,both,,,,355,355,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HUMERUS MIN 2 VIEWS,3207306001,CDM,320,RC,73060,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HUMERUS MIN 2 VIEWS,3207306001,CDM,320,RC,73060,HCPCS,facility,both,,,,240,240,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ELBOW 2 VIEWS,3207307001,CDM,320,RC,73070,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ELBOW 2 VIEWS,3207307001,CDM,320,RC,73070,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ELBOW COMPLETE MIN 3 VIEWS,3207308001,CDM,320,RC,73080,HCPCS,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ELBOW COMPLETE MIN 3 VIEWS,3207308001,CDM,320,RC,73080,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FOREARM 2 VIEWS,3207309001,CDM,320,RC,73090,HCPCS,facility,both,,,,240,240,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FOREARM 2 VIEWS,3207309001,CDM,320,RC,73090,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY UPPER EXT INFANT MIN 2 VIEWS,3207309201,CDM,320,RC,73092,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY UPPER EXT INFANT MIN 2 VIEWS,3207309201,CDM,320,RC,73092,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY WRIST 2 VIEWS,3207310001,CDM,320,RC,73100,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY WRIST 2 VIEWS,3207310001,CDM,320,RC,73100,HCPCS,facility,both,,,,117,117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY WRIST COMPLETE MIN 3 VIEWS,3207311001,CDM,320,RC,73110,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY WRIST COMPLETE MIN 3 VIEWS,3207311001,CDM,320,RC,73110,HCPCS,facility,both,,,,238,238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HAND 2 VIEWS,3207312001,CDM,320,RC,73120,HCPCS,facility,both,,,,239,239,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HAND 2 VIEWS,3207312001,CDM,320,RC,73120,HCPCS,facility,both,,,,168,168,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HAND MIN 3 VIEWS,3207313001,CDM,320,RC,73130,HCPCS,facility,both,,,,193,193,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HAND MIN 3 VIEWS,3207313001,CDM,320,RC,73130,HCPCS,facility,both,,,,276,276,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FINGER MIN 2 VIEWS,3207314001,CDM,320,RC,73140,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FINGER MIN 2 VIEWS,3207314001,CDM,320,RC,73140,HCPCS,facility,both,,,,197,197,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP UNILATERAL 1 VIEW WITH PELVIS,3207350101,CDM,320,RC,73501,HCPCS,facility,both,,,,194,194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP UNILATERAL 1 VIEW WITH PELVIS,3207350101,CDM,320,RC,73501,HCPCS,facility,both,,,,236,236,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP UNILATERAL 2 TO 3 VIEWS WITH PELVIS,3207350201,CDM,320,RC,73502,HCPCS,facility,both,,,,273,273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP UNILATERAL 2 TO 3 VIEWS WITH PELVIS,3207350201,CDM,320,RC,73502,HCPCS,facility,both,,,,207,207,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP UNILATERAL MIN 4 VIEWS WITH PELVIS,3207350301,CDM,320,RC,73503,HCPCS,facility,both,,,,342,342,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP BILATERAL 2 TO 3 VIEWS WITH PELVIS,3207352101,CDM,320,RC,73521,HCPCS,facility,both,,,,389,389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP BILATERAL 2 TO 3 VIEWS WITH PELVIS,3207352101,CDM,320,RC,73521,HCPCS,facility,both,,,,344,344,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP BILATERAL 3 TO 4 VIEWS WITH PELVIS,3207352201,CDM,320,RC,73522,HCPCS,facility,both,,,,344,344,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP BILATERAL 3 TO 4 VIEWS WITH PELVIS,3207352201,CDM,320,RC,73522,HCPCS,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP BILATERAL 5 VIEWS WITH PELVIS,3207352301,CDM,320,RC,73523,HCPCS,facility,both,,,,475,475,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HIP BILATERAL 5 VIEWS WITH PELVIS,3207352301,CDM,320,RC,73523,HCPCS,facility,both,,,,462,462,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FEMUR 1 VIEW,3207355101,CDM,320,RC,73551,HCPCS,facility,both,,,,198,198,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FEMUR 1 VIEW,3207355101,CDM,320,RC,73551,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FEMUR MIN 2 VIEWS,3207355201,CDM,320,RC,73552,HCPCS,facility,both,,,,263,263,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FEMUR MIN 2 VIEWS,3207355201,CDM,320,RC,73552,HCPCS,facility,both,,,,194,194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY KNEE 1 OR 2 VIEWS,3207356001,CDM,320,RC,73560,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY KNEE 1 OR 2 VIEWS,3207356001,CDM,320,RC,73560,HCPCS,facility,both,,,,225,225,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY KNEE 3 VIEWS,3207356201,CDM,320,RC,73562,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY KNEE 3 VIEWS,3207356201,CDM,320,RC,73562,HCPCS,facility,both,,,,259,259,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY KNEE COMPLETE,3207356401,CDM,320,RC,73564,HCPCS,facility,both,,,,298,298,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY KNEE COMPLETE,3207356401,CDM,320,RC,73564,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY STANDING KNEES AP 2 VIEWS,3207356501,CDM,320,RC,73565,HCPCS,facility,both,,,,228,228,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY STANDING KNEES AP 2 VIEWS,3207356501,CDM,320,RC,73565,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY TIBIA & FIBULA 2 VIEWS,3207359001,CDM,320,RC,73590,HCPCS,facility,both,,,,240,240,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY TIBIA & FIBULA 2 VIEWS,3207359001,CDM,320,RC,73590,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY LOW EXT INFANT 2 VIEWS,3207359201,CDM,320,RC,73592,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY LOW EXT INFANT 2 VIEWS,3207359201,CDM,320,RC,73592,HCPCS,facility,both,,,,148,148,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ANKLE 2 VIEWS,3207360001,CDM,320,RC,73600,HCPCS,facility,both,,,,277,277,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ANKLE 2 VIEWS,3207360001,CDM,320,RC,73600,HCPCS,facility,both,,,,221,221,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ANKLE COMPLETE MIN 3 VIEWS,3207361001,CDM,320,RC,73610,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ANKLE COMPLETE MIN 3 VIEWS,3207361001,CDM,320,RC,73610,HCPCS,facility,both,,,,319,319,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FOOT 2 VIEWS,3207362001,CDM,320,RC,73620,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FOOT 2 VIEWS,3207362001,CDM,320,RC,73620,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FOOT COMPLETE MIN 3 VIEWS,3207363001,CDM,320,RC,73630,HCPCS,facility,both,,,,238,238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY FOOT COMPLETE MIN 3 VIEWS,3207363001,CDM,320,RC,73630,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CALCANEOUS MIN 2 VIEWS,3207365001,CDM,320,RC,73650,HCPCS,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CALCANEOUS MIN 2 VIEWS,3207365001,CDM,320,RC,73650,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY TOES MIN 2 VIEWS,3207366001,CDM,320,RC,73660,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY TOES MIN 2 VIEWS,3207366001,CDM,320,RC,73660,HCPCS,facility,both,,,,238,238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABDOMEN AP,3207401801,CDM,320,RC,74018,HCPCS,facility,both,,,,217,217,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABDOMEN AP,3207401801,CDM,320,RC,74018,HCPCS,facility,both,,,,152,152,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABD FLAT AND ERECT OR DEC,3207401901,CDM,320,RC,,,facility,both,,,,320,320,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABD FLAT AND ERECT OR DEC,3207401901,CDM,320,RC,,,facility,both,,,,223,223,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABD FLAT AND ERECT OR DEC COMP,3207401902,CDM,320,RC,74019,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABD FLAT AND ERECT OR DEC COMP,3207401902,CDM,320,RC,74019,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABD FLAT AND ERECT OR DEC-3 VIEWS,3207402101,CDM,320,RC,74021,HCPCS,facility,both,,,,201,201,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABD FLAT AND ERECT OR DEC-3 VIEWS,3207402101,CDM,320,RC,74021,HCPCS,facility,both,,,,353,353,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABD COMP W/PA CHEST,3207402201,CDM,320,RC,74022,HCPCS,facility,both,,,,329,329,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ABD COMP W/PA CHEST,3207402201,CDM,320,RC,74022,HCPCS,facility,both,,,,231,231,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADIOLOGIC EXAM PHRNX&/CRV ESOPH CONTRAST STUDY,3207421001,CDM,320,RC,74210,HCPCS,facility,both,,,,651,651,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ESOPHAGUS,3207422001,CDM,320,RC,74220,HCPCS,facility,both,,,,242,242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADIOLOGIC EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,3207422101,CDM,320,RC,74221,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SWALLOW FUNCTION WITH VIDEO,3207423001,CDM,320,RC,74230,HCPCS,facility,both,,,,339,339,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY UPPER GI WO KUB,3207424001,CDM,320,RC,74240,HCPCS,facility,both,,,,362,362,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY UPPER GI AIR WO KUB,3207424601,CDM,320,RC,74246,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY,3207424801,CDM,320,RC,74248,HCPCS,facility,both,,,,380,380,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY SMALL BOWEL FOLLOW THRU,3207425001,CDM,320,RC,74250,HCPCS,facility,both,,,,290,290,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY COLON/BARIUM ENEMA,3207427001,CDM,320,RC,74270,HCPCS,facility,both,,,,354,354,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY COLON/BARIUM ENEMA WITH AIR,3207428001,CDM,320,RC,,,facility,both,,,,526,526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY THEAURAPEUTIC ENEMA,3207428301,CDM,320,RC,74283,HCPCS,facility,both,,,,419,419,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHOLANGIOGRAPHY OPERATIVE S&I,3207430001,CDM,320,RC,,,facility,both,,,,111,111,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ERCP OF PANCREATIC DUCT,3207432901,CDM,320,RC,,,facility,both,,,,459,459,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ERCP BOTH PANCREAT & BILARY,3207433001,CDM,320,RC,,,facility,both,,,,277,277,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY INTRO LONG GASTRO TUBE S&I,3207434001,CDM,320,RC,74340,HCPCS,facility,both,,,,393,393,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY INTRO LONG GASTRO TUBE S&I,3207434001,CDM,320,RC,74340,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY PERC PLACE ENTEROCLYSIS TUBE,3207435501,CDM,320,RC,,,facility,both,,,,623,623,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY GUIDE GI DILATION S&I,3207436001,CDM,320,RC,,,facility,both,,,,380,380,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHOLANGIOPL WITH OR WO STENT S&I,3207436301,CDM,320,RC,,,facility,both,,,,727,727,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY INTRAVENOUS PYELOGRAM,3207440001,CDM,320,RC,,,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY NEPHROTOMOGRAM,3207441501,CDM,320,RC,,,facility,both,,,,337,337,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RETROGRADE UROGRAPHY WITH OR WO KUB,3207442001,CDM,320,RC,,,facility,both,,,,401,401,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY NEPHROSTO/LOOPOGRAMS S&I,3207442501,CDM,320,RC,74425,HCPCS,facility,both,,,,546,546,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CYSTOGRAM S&I,3207443001,CDM,320,RC,74430,HCPCS,facility,both,,,,546,546,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY URETHROGRAM RETRO S&I,3207445001,CDM,320,RC,74450,HCPCS,facility,both,,,,375,375,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY VOIDING CYSTOGRAM S&I,3207445501,CDM,320,RC,74455,HCPCS,facility,both,,,,670,670,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY RENAL CYST STUDY,3207447001,CDM,320,RC,74470,HCPCS,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY DILATION OF URETERS,3207448501,CDM,320,RC,,,facility,both,,,,2317,2317,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY HYSTEROSALPINGOGRAM S&I,3207474001,CDM,320,RC,74740,HCPCS,facility,both,,,,406,406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY PERINEOGRAM,3207477501,CDM,320,RC,74775,HCPCS,facility,both,,,,436,436,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIO SPINAL SELECTIVE S&I,3207570501,CDM,320,RC,75705,HCPCS,facility,both,,,,7607,7607,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIOGRAPHY ADRENAL UNILATERAL S&I,3207573101,CDM,320,RC,,,facility,both,,,,3877,3877,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PULM ARTERY ANGIO BILATERAL,3207574301,CDM,320,RC,75743,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ANGIOGRAPHY PULMONARY,3207574601,CDM,320,RC,75746,HCPCS,facility,both,,,,3723,3723,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERNAL MAMMARY SELECTIVE,3207575601,CDM,320,RC,,,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LYMPHANGIOGRAPHY UNILATERAL S&I,3207580101,CDM,320,RC,,,facility,both,,,,984,984,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LYMPHANGIOGRAPHY BILATERAL S&I,3207580301,CDM,320,RC,,,facility,both,,,,1858,1858,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LYMPHA PELVIC/ABD UNILATERAL S&I,3207580501,CDM,320,RC,75805,HCPCS,facility,both,,,,4517,4517,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LYMPHA PELVIC/ABD BILATERAL S&I,3207580701,CDM,320,RC,75807,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHUNTOGRAM INVEST SHUNT S&I,3207580901,CDM,320,RC,75809,HCPCS,facility,both,,,,549,549,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPLENOPORTOGRAM,3207581001,CDM,320,RC,,,facility,both,,,,4517,4517,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGRAM EXTREMITY UNILATERAL S&I,3207582001,CDM,320,RC,75820,HCPCS,facility,both,,,,1799,1799,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGRAM EXTREMITY UNILATERAL S&I,3207582001,CDM,320,RC,75820,HCPCS,facility,both,,,,2242,2242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGRAM EXTREMITY BILATERAL S&I,3207582201,CDM,320,RC,75822,HCPCS,facility,both,,,,2032,2032,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGRAM EXTREMITY BILATERAL S&I,3207582201,CDM,320,RC,75822,HCPCS,facility,both,,,,2717,2717,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGRAPHY INFERIOR VENA CAVA,3207582501,CDM,320,RC,75825,HCPCS,facility,both,,,,3664,3664,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGRAPHY INFERIOR VENA CAVA,3207582501,CDM,320,RC,75825,HCPCS,facility,both,,,,4651,4651,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGR CAVAL SUP S&I,3207582701,CDM,320,RC,75827,HCPCS,facility,both,,,,1799,1799,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGR CAVAL SUP S&I,3207582701,CDM,320,RC,75827,HCPCS,facility,both,,,,2199,2199,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENO RENAL UNILATERAL,3207583101,CDM,320,RC,75831,HCPCS,facility,both,,,,5673,5673,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENO RENAL BILATERAL,3207583301,CDM,320,RC,75833,HCPCS,facility,both,,,,8510,8510,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOGRAPHY SINUS OR JUGULAR,3207586001,CDM,320,RC,75860,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENO SUP SAG SINUS RAD S&I,3207587001,CDM,320,RC,75870,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENO SUPSAGGITAL SINUS,3207587201,CDM,320,RC,,,facility,both,,,,1099,1099,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PORTOGRAPHY PERC WITH HEMODYNAMIC,3207588501,CDM,320,RC,75885,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PORTOGRAPHY PERC TRANSHEPATIC,3207588701,CDM,320,RC,75887,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPATIC VENO WITH HEMO EVAL,3207588901,CDM,320,RC,75889,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPATIC VENOGRAPHY,3207589101,CDM,320,RC,75891,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS SAMPLING W/CATH,3207589301,CDM,320,RC,75893,HCPCS,facility,both,,,,7795,7795,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSCATHETER THERAPY S&I,3207589401,CDM,320,RC,75894,HCPCS,facility,both,,,,4057,4057,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIOGRAPHY THRU EXISTING CATH,3207589801,CDM,320,RC,75898,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CVC STRIP VIA NEW PUNC S&I,3207590101,CDM,320,RC,75901,HCPCS,facility,both,,,,413,413,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CVC STRIP VIA NEW PUNC S&I,3207590101,CDM,320,RC,75901,HCPCS,facility,both,,,,348,348,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CVC DECLOT THRU DEVICE LUMEN S&I,3207590201,CDM,320,RC,,,facility,both,,,,480,480,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOVASC RPR THORA DIST S&I,3207595901,CDM,320,RC,,,facility,both,,,,737,737,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY TRANSCATHETER S&I,3207597001,CDM,320,RC,75970,HCPCS,facility,both,,,,1456,1456,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE DRAIN CATHETER,3207598401,CDM,320,RC,75984,HCPCS,facility,both,,,,149,149,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE DRAIN CATHETER,3207598401,CDM,320,RC,75984,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR-RAD GUID PERC DRAINCATH S&I,3207598901,CDM,320,RC,75989,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR-RAD GUID PERC DRAINCATH S&I,3207598901,CDM,320,RC,75989,HCPCS,facility,both,,,,410,410,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SNIFF TEST FLUORO,3207600001,CDM,320,RC,76000,HCPCS,facility,both,,,,367,367,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHILD FB SINGLE VIEW,3207601001,CDM,320,RC,76010,HCPCS,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHILD FB SINGLE VIEW,3207601001,CDM,320,RC,76010,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FISTULA AND CONTRAST,3207608001,CDM,320,RC,76080,HCPCS,facility,both,,,,643,643,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FISTULA AND CONTRAST,3207608001,CDM,320,RC,76080,HCPCS,facility,both,,,,860,860,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST SURG SPECIMEN EACH,3207609801,CDM,320,RC,76098,HCPCS,facility,both,,,,720,720,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST SURG SPECIMEN EACH,3207609801,CDM,320,RC,76098,HCPCS,facility,both,,,,635,635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D RENDER W/O POST PROCESSING,3207637602,CDM,320,RC,76376,HCPCS,facility,both,,,,791,791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D RENDER W/O POST PROCESSING,3207637602,CDM,320,RC,76376,HCPCS,facility,both,,,,529,529,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D RENDERING INDEPENDENT,3207637701,CDM,320,RC,76377,HCPCS,facility,both,,,,834,834,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D RENDERING INDEPENDENT,3207637701,CDM,320,RC,76377,HCPCS,facility,both,,,,700,700,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORO GUIDANCE UNSPECIFIED,3207649601,CDM,320,RC,76496,HCPCS,facility,both,,,,411,411,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORO GUIDANCE UNSPECIFIED,3207649601,CDM,320,RC,76496,HCPCS,facility,both,,,,113,113,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MULTITOM RAX CT- 3 D IMAGING,3207649701,CDM,320,RC,76497,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DR BODY COMPOSITION,3207649901,CDM,320,RC,76499,HCPCS,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORO GUIDANCE CVC,3207700101,CDM,320,RC,77001,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORO GUIDANCE CVC,3207700101,CDM,320,RC,77001,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT,3207700201,CDM,320,RC,77002,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORO GUIDANCE FOR NEEDLE PLACEMENT,3207700201,CDM,320,RC,77002,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORO GUIDANCE OF NEEDLE/CATH TIP,3207700301,CDM,320,RC,77003,HCPCS,facility,both,,,,185,185,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUORO GUIDANCE OF NEEDLE/CATH TIP,3207700301,CDM,320,RC,77003,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDE FOR TISSUE ABLATION,3207701301,CDM,320,RC,77013,HCPCS,facility,both,,,,3426,3426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GALACTOGRAM SINGLE DUCT  S&I,3207705301,CDM,320,RC,77053,HCPCS,facility,both,,,,485,485,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GALACTOGRAM MULTIPLE DUCTS S&I,3207705401,CDM,320,RC,,,facility,both,,,,342,342,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY JOINT STRESS VIEW,3207707101,CDM,320,RC,77071,HCPCS,facility,both,,,,155,155,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE AGE STUDIES,3207707201,CDM,320,RC,77072,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE AGE STUDIES,3207707201,CDM,320,RC,77072,HCPCS,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE LENGTH STUDY,3207707301,CDM,320,RC,77073,HCPCS,facility,both,,,,194,194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED,3207707401,CDM,320,RC,77074,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE SURVEY COMPLETE SKELETON,3207707501,CDM,320,RC,77075,HCPCS,facility,both,,,,361,361,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE SURVEY COMPLETE SKELETON,3207707501,CDM,320,RC,77075,HCPCS,facility,both,,,,242,242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE SURVEY INFANT,3207707601,CDM,320,RC,77076,HCPCS,facility,both,,,,281,281,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS,3207707701,CDM,320,RC,77077,HCPCS,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE DENSITY AXIAL,3207708001,CDM,320,RC,77080,HCPCS,facility,both,,,,352,352,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE DENSITY AXIAL,3207708001,CDM,320,RC,77080,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE DENSITY APPENDICULAR,3207708101,CDM,320,RC,77081,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE DENSITY AXIAL WITH VFA,3207708501,CDM,320,RC,77085,HCPCS,facility,both,,,,621,621,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY BONE DENSITY AXIAL WITH VFA,3207708501,CDM,320,RC,77085,HCPCS,facility,both,,,,538,538,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY VERTEBRAL FRACTURE ASSESS,3207708601,CDM,320,RC,77086,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY VERTEBRAL FRACTURE ASSESS,3207708601,CDM,320,RC,77086,HCPCS,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NON-OPHTHALMIC FLUORESCENT VASCULAR ANGIOGRAPHY,320C973301,CDM,320,RC,C9733,HCPCS,facility,both,,,,1178,1178,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY ARTHROGRAM WRIST S & I,3227311501,CDM,322,RC,,,facility,both,,,,393,393,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACIC AORTOGRAM,3237560501,CDM,323,RC,75605,HCPCS,facility,both,,,,7607,7607,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABDOMINAL AORTOGRAM,3237562501,CDM,323,RC,75625,HCPCS,facility,both,,,,5313,5313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABDOMINAL AORTOGRAM WITH BILATERAL RUNOFF,3237563001,CDM,323,RC,75630,HCPCS,facility,both,,,,6111,6111,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIO UNILATERAL EXTREMITY S&I,3237571001,CDM,323,RC,75710,HCPCS,facility,both,,,,5305,5305,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIO BILATERAL EXTREMITIES,3237571601,CDM,323,RC,75716,HCPCS,facility,both,,,,6102,6102,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIO VISCERAL SELECTIVE OR SUPRASELECTIVE S&I,3237572601,CDM,323,RC,75726,HCPCS,facility,both,,,,7607,7607,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIO VISCERAL SELECTIVE OR SUPRASELECTIVE S&I,3237572601,CDM,323,RC,75726,HCPCS,facility,both,,,,6104,6104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PELVIC ANGIOGRAPHY S&I,3237573601,CDM,323,RC,75736,HCPCS,facility,both,,,,7607,7607,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PULM ARTERY ANGIO UNILATERAL,3237574101,CDM,323,RC,75741,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EACH ADDTL VESSEL AFTER BASIC EXAM,3237577401,CDM,323,RC,75774,HCPCS,facility,both,,,,2200,2200,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST SINGLE VIEW,3247104501,CDM,324,RC,71045,HCPCS,facility,both,,,,178,178,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST SINGLE VIEW,3247104501,CDM,324,RC,71045,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST 2 VIEWS,3247104601,CDM,324,RC,71046,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST 2 VIEWS,3247104601,CDM,324,RC,71046,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST SPECIAL VIEWS,3247104602,CDM,324,RC,71046,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST SPECIAL VIEWS,3247104602,CDM,324,RC,71046,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST PA LAT & LORDOTIC,3247104701,CDM,324,RC,71047,HCPCS,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST PA LAT & LORDOTIC,3247104701,CDM,324,RC,71047,HCPCS,facility,both,,,,337,337,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST COMPLETE MIN FOUR VIEWS,3247104801,CDM,324,RC,71048,HCPCS,facility,both,,,,388,388,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST COMPLETE MIN FOUR VIEWS,3247104801,CDM,324,RC,71048,HCPCS,facility,both,,,,270,270,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST PA LATERAL & OBLIQUE,3247104802,CDM,324,RC,71048,HCPCS,facility,both,,,,388,388,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC XRAY CHEST PA LATERAL & OBLIQUE,3247104802,CDM,324,RC,71048,HCPCS,facility,both,,,,270,270,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMO SUBQ/IM NONHORMONE ANTINEOP,3319640101,CDM,331,RC,96401,HCPCS,facility,both,,,,289,289,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMO SUBQ/IM HORMONAL ANTINEO,3319640201,CDM,331,RC,96402,HCPCS,facility,both,,,,278,278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMO IV PUSH SINGLE / INITIAL,3319640901,CDM,331,RC,96409,HCPCS,facility,both,,,,319,319,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMOTHERAPY ADMIN INTRA-ARTERIAL PUSH TQ,3319642001,CDM,331,RC,96420,HCPCS,facility,both,,,,728,728,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERITONEAL CHEMOTHERAPY,3319644601,CDM,331,RC,,,facility,both,,,,468,468,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRATHECAL ADMIN CHEMOTHER,3319645001,CDM,331,RC,96450,HCPCS,facility,both,,,,700,700,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRATHECAL ADMIN CHEMOTHER,3319645001,CDM,331,RC,96450,HCPCS,facility,both,,,,856,856,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT RAD ONC LOCALIZATION,3337701401,CDM,333,RC,,,facility,both,,,,1109,1109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY SIMULATION SIMPLE,3337728001,CDM,333,RC,77280,HCPCS,facility,both,,,,464,464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD TH-SIMULATION INTERMEDIATE,3337728501,CDM,333,RC,77285,HCPCS,facility,both,,,,1351.54,1351.54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY SIMULATION COMPLEX,3337729001,CDM,333,RC,77290,HCPCS,facility,both,,,,1232,1232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY RESP MOTION MGMT SIM,3337729301,CDM,333,RC,77293,HCPCS,facility,both,,,,923,923,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY 3D TREATMENT PLAN,3337729501,CDM,333,RC,77295,HCPCS,facility,both,,,,5508,5508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY BASIC DOSIMETRY,3337730001,CDM,333,RC,77300,HCPCS,facility,both,,,,464,464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMRT PLAN WITH HISTOGRAMS,3337730101,CDM,333,RC,77301,HCPCS,facility,both,,,,5837,5837,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY ISODOSE TELETHPY COMPLEX,3337730701,CDM,333,RC,77307,HCPCS,facility,both,,,,1232,1232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY BRACHY ISODOSE SIMPLE,3337731601,CDM,333,RC,,,facility,both,,,,475,475,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY BRACHY ISODOSE INTERMED,3337731701,CDM,333,RC,77317,HCPCS,facility,both,,,,1120,1120,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY BRACHY ISODOSE COMPLEX,3337731801,CDM,333,RC,,,facility,both,,,,1120,1120,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY TELETHERAPY PORT PLAN,3337732101,CDM,333,RC,77321,HCPCS,facility,both,,,,1120,1120,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY SPECIAL DOSIMETRY,3337733101,CDM,333,RC,77331,HCPCS,facility,both,,,,539,539,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY TREATMENT DEVICES SIMPLE,3337733201,CDM,333,RC,77332,HCPCS,facility,both,,,,464,464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY TREATMENT DEVICE INTERM,3337733301,CDM,333,RC,77333,HCPCS,facility,both,,,,576,576,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY TREATMENT DEVICES COMPLEX,3337733401,CDM,333,RC,77334,HCPCS,facility,both,,,,1120,1120,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY WEEKLY PHYSICS CONSULT,3337733601,CDM,333,RC,77336,HCPCS,facility,both,,,,464,464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY DESIGN MLC DEVICE IMRT,3337733801,CDM,333,RC,77338,HCPCS,facility,both,,,,1232,1232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY MED PHYSICS SPECIAL CON,3337737001,CDM,333,RC,77370,HCPCS,facility,both,,,,464,464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY STER SRS CRANIAL 1 FRAC,3337737201,CDM,333,RC,77372,HCPCS,facility,both,,,,20111,20111,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY STEREO BODY,3337737301,CDM,333,RC,77373,HCPCS,facility,both,,,,5938,5938,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMRT DELIVERY SIMPLE,3337738501,CDM,333,RC,77385,HCPCS,facility,both,,,,1778,1778,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMRT DELIVERY COMPLEX,3337738601,CDM,333,RC,77386,HCPCS,facility,both,,,,2145,2145,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY IMAGE GUIDANCE,3337738701,CDM,333,RC,77387,HCPCS,facility,both,,,,609,609,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMAGE FUSION,3337739901,CDM,333,RC,77399,HCPCS,facility,both,,,,422,422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY SIMPLE,3337740201,CDM,333,RC,77402,HCPCS,facility,both,,,,2064,2064,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY INTERMEDIATE,3337740701,CDM,333,RC,77407,HCPCS,facility,both,,,,2148,2148,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY COMPLEX,3337741201,CDM,333,RC,77412,HCPCS,facility,both,,,,2558,2558,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY PORT FILMS,3337741701,CDM,333,RC,77417,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY SPECIAL TX PROCEDURE,3337747001,CDM,333,RC,77470,HCPCS,facility,both,,,,2001,2001,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY BRACHY INTRACAVI SIMPLE,3337776101,CDM,333,RC,,,facility,both,,,,1635,1635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY BRACHY INTRACAV INTERME,3337776201,CDM,333,RC,,,facility,both,,,,1635,1635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY HDR BRACH INTER 1 CH,3337777001,CDM,333,RC,77770,HCPCS,facility,both,,,,3872,3872,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY HDR BRACH INTER 2-12 CH,3337777101,CDM,333,RC,77771,HCPCS,facility,both,,,,4453,4453,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY LDR BRACH INTER OVER 9,3337777801,CDM,333,RC,77778,HCPCS,facility,both,,,,1758,1758,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY SURFACE APP W/ RAD SOUR,3337778901,CDM,333,RC,77789,HCPCS,facility,both,,,,299,299,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD THERAPY HANDLING & LOADING,3337779001,CDM,333,RC,77790,HCPCS,facility,both,,,,841,841,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD TH-LDR BRACHY INTERSTITIAL 1-9 CH,3337779901,CDM,333,RC,77799,HCPCS,facility,both,,,,4053.08,4053.08,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMO IV PUSH EA ADDTL DRUG,3359641101,CDM,335,RC,96411,HCPCS,facility,both,,,,254,254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMO IV INFUSION INITIAL DRUG 1 HOUR,3359641301,CDM,335,RC,96413,HCPCS,facility,both,,,,526,526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMO IV INFUSION INITIAL DRUG ADDTL HOUR,3359641501,CDM,335,RC,96415,HCPCS,facility,both,,,,216,216,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMO IV INFUSION EACH SEQUENTUAL DRUG,3359641701,CDM,335,RC,96417,HCPCS,facility,both,,,,353,353,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMOTHERAPY UNSPECIFIED,3359654901,CDM,335,RC,96549,HCPCS,facility,both,,,,248,248,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMO EXTEND IV INFUS W/PUMP,335G049801,CDM,335,RC,G0498,HCPCS,facility,both,,,,861,861,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM THYROID UPTAKE MEASUREMENT,3417801201,CDM,341,RC,,,facility,both,,,,559,559,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM THYROID IMAGING WITH BLOOD FLOW,3417801301,CDM,341,RC,78013,HCPCS,facility,both,,,,466,466,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM THYROID UPTAKE IMAGE WITH FLOW,3417801401,CDM,341,RC,78014,HCPCS,facility,both,,,,953,953,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM THYROID TOTAL BODY,3417801801,CDM,341,RC,78018,HCPCS,facility,both,,,,1034,1034,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM THYROID CA METS UPTAKE,3417802001,CDM,341,RC,78020,HCPCS,facility,both,,,,201,201,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM PARATHYROID PLANAR IMAGING,3417807001,CDM,341,RC,,,facility,both,,,,485,485,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM PARATHYROID SPECT CT,3417807201,CDM,341,RC,78072,HCPCS,facility,both,,,,1182,1182,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM BONE MARROW IMAGING LIMITED,3417810201,CDM,341,RC,78102,HCPCS,facility,both,,,,489,489,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM BONE MARROW IMAGING MULT,3417810301,CDM,341,RC,,,facility,both,,,,534,534,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM SPLEEN IMAGING,3417818501,CDM,341,RC,,,facility,both,,,,485,485,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM KINETICS  PLATELET SURVIVAL,3417819101,CDM,341,RC,,,facility,both,,,,485,485,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM LYMPHATICS/LYMPH GLANDS,3417819501,CDM,341,RC,78195,HCPCS,facility,both,,,,761,761,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM HEPATOBILIARY SCAN,3417822601,CDM,341,RC,78226,HCPCS,facility,both,,,,691,691,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM HEPATOBILIARY WITH PHARM,3417822701,CDM,341,RC,78227,HCPCS,facility,both,,,,1491,1491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM SALIVARY GLAND IMAGING,3417823101,CDM,341,RC,,,facility,both,,,,485,485,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM GASTRIC EMPTYING STUDY,3417826401,CDM,341,RC,78264,HCPCS,facility,both,,,,842,842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM GI BLEED SCAN WITH LABELED RBC,3417827801,CDM,341,RC,78278,HCPCS,facility,both,,,,555,555,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM MECKELS STUDY,3417829001,CDM,341,RC,78290,HCPCS,facility,both,,,,644,644,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM BONE SCAN LIMITED,3417830001,CDM,341,RC,78300,HCPCS,facility,both,,,,661,661,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM BONE MULTIPLE AREAS,3417830501,CDM,341,RC,,,facility,both,,,,791,791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM BONE SCAN TOTAL BODY,3417830601,CDM,341,RC,78306,HCPCS,facility,both,,,,874,874,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM BONE/JOINT 3 PHASE STUDY,3417831501,CDM,341,RC,78315,HCPCS,facility,both,,,,1004,1004,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCRD IMG PET PRFUJ W/METAB DUAL RADIOTRACER,3417843201,CDM,341,RC,,,facility,both,,,,12601,12601,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCRD IMG PET PRFUJ W/METAB 2RTRACER CNCRNT CT,3417843301,CDM,341,RC,78433,HCPCS,facility,both,,,,12091,12091,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AQMBF PET REST AND PHARMACOLOGIC STRESS,3417843401,CDM,341,RC,78434,HCPCS,facility,both,,,,6343,6343,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM CARDIAC PERFUSION SPECT SINGLE,3417845101,CDM,341,RC,78451,HCPCS,facility,both,,,,1859,1859,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCARDIAL PERFUSION STRESS & REST,3417845201,CDM,341,RC,78452,HCPCS,facility,both,,,,3480,3480,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCARDIAL PERFUSION STRESS & REST,3417845201,CDM,341,RC,78452,HCPCS,facility,both,,,,4049,4049,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM CARDIAC BLOOD POOL IMAGE SINGLE,3417847201,CDM,341,RC,78472,HCPCS,facility,both,,,,1076,1076,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM CARDIAC BLOOD POOL IMAGE SINGLE,3417847201,CDM,341,RC,78472,HCPCS,facility,both,,,,952,952,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM LUNG VENTILATION,3417857901,CDM,341,RC,,,facility,both,,,,742,742,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM LUNG PERFUSION,3417858001,CDM,341,RC,78580,HCPCS,facility,both,,,,536,536,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM LUNG VENTILATION/PERFUSION,3417858201,CDM,341,RC,78582,HCPCS,facility,both,,,,1066,1066,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM LUNG QUANT PERFUSION,3417859701,CDM,341,RC,78597,HCPCS,facility,both,,,,1238,1238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM LUNG QUANT VENT/PERF,3417859801,CDM,341,RC,78598,HCPCS,facility,both,,,,1038,1038,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM DYNAMIC FLOW/BRAIN SCAN,3417860601,CDM,341,RC,78606,HCPCS,facility,both,,,,696,696,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM CISTERNOGRAPHY,3417863001,CDM,341,RC,78630,HCPCS,facility,both,,,,618,618,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM SHUNT PATENCY,3417864501,CDM,341,RC,78645,HCPCS,facility,both,,,,975,975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM CSF LEAK STUDY,3417865001,CDM,341,RC,,,facility,both,,,,2325,2325,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM RENAL STATICS ONLY,3417870001,CDM,341,RC,,,facility,both,,,,461,461,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM RENAL FLOW ONLY,3417870101,CDM,341,RC,,,facility,both,,,,485,485,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM RENAL VASC FLOW/FUNCTION WO RX,3417870701,CDM,341,RC,78707,HCPCS,facility,both,,,,832,832,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM RENAL VASC FLOW/FUNCTION WITH RX,3417870801,CDM,341,RC,78708,HCPCS,facility,both,,,,1645,1645,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM VOIDING CYSTOURETHROGRAM,3417874001,CDM,341,RC,,,facility,both,,,,485,485,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RP LOCLZJ TUM PLNR 1 AREA SGL DAY IMAGING,3417880001,CDM,341,RC,78800,HCPCS,facility,both,,,,999,999,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM TUMOR WHOLE BODY SINGLE DAY,3417880201,CDM,341,RC,78802,HCPCS,facility,both,,,,1646,1646,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM TUMOR SPECT,3417880301,CDM,341,RC,78803,HCPCS,facility,both,,,,2177,2177,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM TUMOR IMAGING WHOLEBODY 2 OR MORE DAYS,3417880401,CDM,341,RC,,,facility,both,,,,1972,1972,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM INJECTION PX NON IMAGING PROBE STUDY,3417880801,CDM,341,RC,,,facility,both,,,,492,492,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING,3417883001,CDM,341,RC,78830,HCPCS,facility,both,,,,2505,2505,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG/1 AREA IMG>2+D,3417883101,CDM,341,RC,78831,HCPCS,facility,both,,,,5592,5592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RP LOCLZJ TUM SPECT CT 2AREA 1D IMG/1 AR IMG>2+D,3417883201,CDM,341,RC,78832,HCPCS,facility,both,,,,6343,6343,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM FUSION DATA SET,3417899901,CDM,341,RC,78999,HCPCS,facility,both,,,,476,476,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADIOPHARMACEUTICAL THEARPY ORAL,3427900501,CDM,342,RC,79005,HCPCS,facility,both,,,,915,915,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM RADIOPHAR TX IV NONTHYROID,3427910101,CDM,342,RC,,,facility,both,,,,543,543,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM RADIOTX MONOCLONAL ANTIBODY,3427940301,CDM,342,RC,,,facility,both,,,,388,388,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM RADIOPAHARM THEARPY INTRA-ARTERIAL,3427944501,CDM,342,RC,79445,HCPCS,facility,both,,,,781,781,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM AIM SPECIALTY HEALTH,349G100701,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM CRANBERRY PEAK,349G100801,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM STANSON,349G101001,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AGILEMD'S CLINICAL DECISION SUPPORT MECH,349G101201,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVIDENCECARE IMAGING ADVISOR,349G101301,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INVENIQA'S SEMANTIC ANSWERS IN MEDICINE,349G101401,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RELIANT MEDICAL GROUP CDSM,349G101501,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPEED OF CARE CDSM,349G101601,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEALTHHELPS CLINICAL DECISION SUPPORT MECH,349G101701,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INFINX CDSM,349G101801,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LOGICNETS AUC SOLUTION,349G101901,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CURBSIDE CLINICAL AUGMENTED WORKFLOW,349G102001,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EHEAHTLINE CLINICAL DECISION SUPPORT MECH,349G102101,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERMOUNTAIN CLINICAL DECISION SUPPOORT MECH,349G102201,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERSIVIA CLINICAL DECIISION SUPPORT,349G102301,CDM,349,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC QUAN CT TISS CHARAC I&R W/CNCRNT CT EXAM,3500722T01,CDM,350,RC,0722T,HCPCS,facility,both,,,,4402,4402,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CERE PRFUJ ALYS C+ W/O CT/CTA SAME ANATOMY,3507047301,CDM,350,RC,,,facility,both,,,,599,599,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY UPPER EXT WO & WITH CONTRAST,3507320601,CDM,350,RC,73206,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY UPPER EXT WO & WITH CONTRAST,3507320601,CDM,350,RC,73206,HCPCS,facility,both,,,,970,970,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY LOWER EXT WITH & WO CONTRAST,3507370601,CDM,350,RC,73706,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY LOWER EXT WITH & WO CONTRAST,3507370601,CDM,350,RC,73706,HCPCS,facility,both,,,,970,970,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT COLONOGRAPHY WO CONTRAST DIAGNOSTIC,3507426101,CDM,350,RC,74261,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT COLONOGRAPHY WO CONTRAST DIAGNOSTIC,3507426101,CDM,350,RC,74261,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT COLONOGRAPHY WITH CONTRAST DIAGNOSTIC,3507426201,CDM,350,RC,74262,HCPCS,facility,both,,,,1276,1276,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT COLONOGRAPHY WITH CONTRAST DIAGNOSTIC,3507426201,CDM,350,RC,74262,HCPCS,facility,both,,,,890,890,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT COLONOGRAPHY SCREENING,3507426301,CDM,350,RC,74263,HCPCS,facility,both,,,,1134,1134,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT COLONOGRAPHY SCREENING,3507426301,CDM,350,RC,74263,HCPCS,facility,both,,,,1455,1455,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CALCIUM SCORING,3507557101,CDM,350,RC,75571,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CCTA  WITH DISEASE STRXR,3507557301,CDM,350,RC,75573,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUID DRAIN ABS/SEP PERC S&I,3507598901,CDM,350,RC,,,facility,both,,,,575,575,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D RENDER W/O POST PROCESSING,3507637601,CDM,350,RC,76376,HCPCS,facility,both,,,,791,791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D RENDER W/O POST PROCESSING,3507637601,CDM,350,RC,76376,HCPCS,facility,both,,,,529,529,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LIMITED OR LOCAL FU STUDY,3507638001,CDM,350,RC,76380,HCPCS,facility,both,,,,440,440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LIMITED OR LOCAL FU STUDY,3507638001,CDM,350,RC,76380,HCPCS,facility,both,,,,628,628,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT VALVULAR CALCIUM SCORING,3507649702,CDM,350,RC,,,facility,both,,,,727,727,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT VALVULAR CALCIUM SCORING,3507649702,CDM,350,RC,,,facility,both,,,,509,509,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAG LOW DOSE WHOLE BODY CT MULT MYELOMA,3507649703,CDM,350,RC,,,facility,both,,,,3208,3208,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAG LOW DOSE WHOLE BODY CT MULT MYELOMA,3507649703,CDM,350,RC,,,facility,both,,,,2246,2246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDED NEEDLE PLACEMENT S&I,3507701201,CDM,350,RC,77012,HCPCS,facility,both,,,,199,199,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDED NEEDLE PLACEMENT S&I,3507701201,CDM,350,RC,77012,HCPCS,facility,both,,,,842,842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD CT GUIDE FOR TISSUE ABLATION,3507701301,CDM,350,RC,77013,HCPCS,facility,both,,,,3426,3426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D ANAT SEG IMAGING PREOP,350C800101,CDM,350,RC,,,facility,both,,,,440,440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT PERFUSION BRAIN,3510042T01,CDM,351,RC,0042T,HCPCS,facility,both,,,,577,577,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT PERFUSION BRAIN,3510042T01,CDM,351,RC,0042T,HCPCS,facility,both,,,,641,641,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT HEAD OR BRAIN WO CONSTRAST,3517045001,CDM,351,RC,70450,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT HEAD OR BRAIN WO CONSTRAST,3517045001,CDM,351,RC,70450,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT HEAD OR BRAIN WITH CONTRAST,3517046001,CDM,351,RC,70460,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT HEAD OR BRAIN WITH CONTRAST,3517046001,CDM,351,RC,70460,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT HEAD OR BRAIN WO & WITH CONTRAST,3517047001,CDM,351,RC,70470,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT HEAD OR BRAIN WO & WITH CONTRAST,3517047001,CDM,351,RC,70470,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTA HEAD&NECK C+ W/NONCONTRAST IMG&POST-PXESSING,3517047101,CDM,351,RC,70471,HCPCS,facility,both,,,,1294,1294,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTA HEAD&NECK C+ W/NONCONTRAST IMG&POST-PXESSING,3517047101,CDM,351,RC,70471,HCPCS,facility,both,,,,1165,1165,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CERE PRFUJ ALYS C+ W/CT/CTA SAME ANATOMY,3517047201,CDM,351,RC,70472,HCPCS,facility,both,,,,899,899,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CT ORBIT,SEL,PIT,TEMP WO CONTRAST",3517048001,CDM,351,RC,70480,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CT ORBIT,SEL,PIT,TEMP WO CONTRAST",3517048001,CDM,351,RC,70480,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CT ORBIT,SEL,PIT,TEMP WITH CONTRAST",3517048101,CDM,351,RC,70481,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CT ORBIT,SEL,PIT,TEMP WITH CONTRAST",3517048101,CDM,351,RC,70481,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CT ORB,SEL,PIT,TEMP WO & WITH CONTRAST",3517048201,CDM,351,RC,70482,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CT ORB,SEL,PIT,TEMP WO & WITH CONTRAST",3517048201,CDM,351,RC,70482,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT MAXILLOFACIAL WO CONTRAST,3517048601,CDM,351,RC,70486,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT MAXILLOFACIAL WO CONTRAST,3517048601,CDM,351,RC,70486,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT MAXILLOFACIAL WITH CONTRAST,3517048701,CDM,351,RC,70487,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT MAXILLOFACIAL WITH CONTRAST,3517048701,CDM,351,RC,70487,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT MAXILLOFACIAL WO & WITH CONTRAST,3517048801,CDM,351,RC,70488,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT MAXILLOFACIAL WO & WITH CONTRAST,3517048801,CDM,351,RC,70488,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT SOFT TISSUE NECK WO CONTRAST,3517049001,CDM,351,RC,70490,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT SOFT TISSUE NECK WO CONTRAST,3517049001,CDM,351,RC,70490,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT SOFT TISSUE NECK WITH CONTRAST,3517049101,CDM,351,RC,70491,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT SOFT TISSUE NECK WITH CONTRAST,3517049101,CDM,351,RC,70491,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT SOFT TISSUE NECK WO & WITH CONTRAST,3517049201,CDM,351,RC,70492,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT SOFT TISSUE NECK WO & WITH CONTRAST,3517049201,CDM,351,RC,70492,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY HEAD WO & WITH CONTRAST,3517049601,CDM,351,RC,70496,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY HEAD WO & WITH CONTRAST,3517049601,CDM,351,RC,70496,HCPCS,facility,both,,,,970,970,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY NECK WO &WITH CONTRAST,3517049801,CDM,351,RC,70498,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY NECK WO &WITH CONTRAST,3517049801,CDM,351,RC,70498,HCPCS,facility,both,,,,970,970,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORAX WO CONTRAST,3527125001,CDM,352,RC,71250,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORAX WO CONTRAST,3527125001,CDM,352,RC,71250,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORAX WITH CONTRAST,3527126001,CDM,352,RC,71260,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORAX WITH CONTRAST,3527126001,CDM,352,RC,71260,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORAX WO & WITH CONTRAST,3527127001,CDM,352,RC,71270,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORAX WO & WITH CONTRAST,3527127001,CDM,352,RC,71270,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C,3527127101,CDM,352,RC,71271,HCPCS,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C,3527127101,CDM,352,RC,71271,HCPCS,facility,both,,,,546,546,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY CHEST WO & WITH CONTRAST,3527127501,CDM,352,RC,71275,HCPCS,facility,both,,,,970,970,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY CHEST WO & WITH CONTRAST,3527127501,CDM,352,RC,71275,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CERVICAL SPINE WO CONTRAST,3527212501,CDM,352,RC,72125,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CERVICAL SPINE WO CONTRAST,3527212501,CDM,352,RC,72125,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CERVICAL SPINE WITH CONTRAST,3527212601,CDM,352,RC,72126,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CERVICAL SPINE WITH CONTRAST,3527212601,CDM,352,RC,72126,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CERVICAL SPINE WO & WITH CONTRAST,3527212701,CDM,352,RC,72127,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CERVICAL SPINE WO & WITH CONTRAST,3527212701,CDM,352,RC,72127,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORACIC SPINE WO CONTRAST,3527212801,CDM,352,RC,72128,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORACIC SPINE WO CONTRAST,3527212801,CDM,352,RC,72128,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORACIC SPINE WITH CONTRAST,3527212901,CDM,352,RC,72129,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORACIC SPINE WITH CONTRAST,3527212901,CDM,352,RC,72129,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORACIC SPINE WO & WITH CONTRAST,3527213001,CDM,352,RC,72130,HCPCS,facility,both,,,,1096,1096,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT THORACIC SPINE WO & WITH CONTRAST,3527213001,CDM,352,RC,72130,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LUMBAR SPINE WO CONTRAST,3527213101,CDM,352,RC,72131,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LUMBAR SPINE WO CONTRAST,3527213101,CDM,352,RC,72131,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LUMBAR SPINE WITH CONTRAST,3527213201,CDM,352,RC,72132,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LUMBAR SPINE WITH CONTRAST,3527213201,CDM,352,RC,72132,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LUMBAR SPINE WO & WITH CONTRAST,3527213301,CDM,352,RC,72133,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LUMBAR SPINE WO & WITH CONTRAST,3527213301,CDM,352,RC,72133,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY PELVIS WO & WITH CONTRAST,3527219101,CDM,352,RC,72191,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY PELVIS WO & WITH CONTRAST,3527219101,CDM,352,RC,72191,HCPCS,facility,both,,,,970,970,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT PELVIS WO CONTRAST,3527219201,CDM,352,RC,72192,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT PELVIS WO CONTRAST,3527219201,CDM,352,RC,72192,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT PELVIS WITH CONTRAST,3527219301,CDM,352,RC,72193,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT PELVIS WITH CONTRAST,3527219301,CDM,352,RC,72193,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT PELVIS WO & WITH CONTRAST,3527219401,CDM,352,RC,72194,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT PELVIS WO & WITH CONTRAST,3527219401,CDM,352,RC,72194,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT UPPER EXTREMITY WO CONTRAST,3527320001,CDM,352,RC,73200,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT UPPER EXTREMITY WO CONTRAST,3527320001,CDM,352,RC,73200,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT UPPER EXTREMITY WITH CONTRAST,3527320101,CDM,352,RC,73201,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT UPPER EXTREMITY WITH CONTRAST,3527320101,CDM,352,RC,73201,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT UPPER EXTREMITY WO & WITH CONTRAST,3527320201,CDM,352,RC,73202,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT UPPER EXTREMITY WO & WITH CONTRAST,3527320201,CDM,352,RC,73202,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LOWER EXTREMITY WO CONTRAST,3527370001,CDM,352,RC,73700,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LOWER EXTREMITY WO CONTRAST,3527370001,CDM,352,RC,73700,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LOWER EXTREMITY WITH CONTRAST,3527370101,CDM,352,RC,73701,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LOWER EXTREMITY WITH CONTRAST,3527370101,CDM,352,RC,73701,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LOWER EXTREMITY WO & WITH CONTRAST,3527370201,CDM,352,RC,73702,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT LOWER EXTREMITY WO & WITH CONTRAST,3527370201,CDM,352,RC,73702,HCPCS,facility,both,,,,1360,1360,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABDOMEN WO CONTRAST,3527415001,CDM,352,RC,74150,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABDOMEN WO CONTRAST,3527415001,CDM,352,RC,74150,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABDOMEN WITH CONTRAST,3527416001,CDM,352,RC,74160,HCPCS,facility,both,,,,1313,1313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABDOMEN WITH CONTRAST,3527416001,CDM,352,RC,74160,HCPCS,facility,both,,,,916,916,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABDOMEN WO & WITH CONTRAST,3527417001,CDM,352,RC,74170,HCPCS,facility,both,,,,1565,1565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABDOMEN WO & WITH CONTRAST,3527417001,CDM,352,RC,74170,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIO ABD/PELVIS WO & WITH CONTRAST,3527417401,CDM,352,RC,74174,HCPCS,facility,both,,,,2858,2858,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIO ABD/PELVIS WO & WITH CONTRAST,3527417401,CDM,352,RC,74174,HCPCS,facility,both,,,,2000,2000,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY ABDOMEN WO & WITH CONTRAST,3527417501,CDM,352,RC,74175,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ANGIOGRAPHY ABDOMEN WO & WITH CONTRAST,3527417501,CDM,352,RC,74175,HCPCS,facility,both,,,,970,970,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABD/PELVIS WO CONTRAST,3527417601,CDM,352,RC,74176,HCPCS,facility,both,,,,1250,1250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABD/PELVIS WO CONTRAST,3527417601,CDM,352,RC,74176,HCPCS,facility,both,,,,1786,1786,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABD/PELVIS WITH CONTRAST,3527417701,CDM,352,RC,74177,HCPCS,facility,both,,,,1938,1938,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABD/PELVIS WITH CONTRAST,3527417701,CDM,352,RC,74177,HCPCS,facility,both,,,,2769,2769,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABD/PELVIS WO & WITH CONTRAST,3527417801,CDM,352,RC,74178,HCPCS,facility,both,,,,3304,3304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABD/PELVIS WO & WITH CONTRAST,3527417801,CDM,352,RC,74178,HCPCS,facility,both,,,,2313,2313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTA ABDOMINAL AORTOGRAM WITH BILATERAL ILIOFEMORAL,3527563501,CDM,352,RC,75635,HCPCS,facility,both,,,,970,970,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTA ABDOMINAL AORTOGRAM WITH BILATERAL ILIOFEMORAL,3527563501,CDM,352,RC,75635,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT RECONSTRUCTION AORTA FOR SURGERY,352G028801,CDM,352,RC,G0288,HCPCS,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT RECONSTRUCTION AORTA FOR SURGERY,352G028801,CDM,352,RC,G0288,HCPCS,facility,both,,,,257,257,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM AIM SPECIALTY HEALTH,359G100701,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM CRANBERRY PEAK,359G100801,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM STANSON,359G101001,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AGILEMD'S CLINICAL DECISION SUPPORT MECH,359G101201,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVIDENCECARE IMAGING ADVISOR,359G101301,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INVENIQA'S SEMANTIC ANSWERS IN MEDICINE,359G101401,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RELIANT MEDICAL GROUP CDSM,359G101501,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPEED OF CARE CDSM,359G101601,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEALTHHELPS CLINICAL DECISION SUPPORT MECH,359G101701,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INFINX CDSM,359G101801,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LOGICNETS AUC SOLUTION,359G101901,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CURBSIDE CLINICAL AUGMENTED WORKFLOW,359G102001,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EHEAHTLINE CLINICAL DECISION SUPPORT MECH,359G102101,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERMOUNTAIN CLINICAL DECISION SUPPOORT MECH,359G102201,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERSIVIA CLINICAL DECIISION SUPPORT,359G102301,CDM,359,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CELL-SAVER,3600000001,CDM,360,RC,,,facility,both,,,,1851,1851,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CELL-SAVER/PER 1/2 HOUR,3600000002,CDM,360,RC,,,facility,both,,,,220,220,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESWL SERVICE UNILATERAL,3600000003,CDM,360,RC,,,facility,both,,,,10056,10056,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESWL SERVICE UNILATERAL,3600000003,CDM,360,RC,,,facility,both,,,,9051,9051,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTRA CORPOREAL CIRC,3600000004,CDM,360,RC,,,facility,both,,,,13682,13682,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTRACORP CIRC STANDBY 1/2HR,3600000005,CDM,360,RC,,,facility,both,,,,165,165,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HYPERTHERMIC CHEMO PER 15 MIN,3600000006,CDM,360,RC,,,facility,both,,,,518,518,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRACEPT GENERATOR RENTAL,3600000007,CDM,360,RC,,,facility,both,,,,539,539,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER FORTEC CO2 RENTAL,3600000008,CDM,360,RC,,,facility,both,,,,1522,1522,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER FORTEC XPS GREEN LIGHT RENTAL,3600000009,CDM,360,RC,,,facility,both,,,,8070,8070,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC N BLOCK CONT INFUSION,3600000013,CDM,360,RC,,,facility,both,,,,1848,1848,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC N BLOCK CONT INFUSION,3600000013,CDM,360,RC,,,facility,both,,,,1872,1872,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSTEOCOOL ABLATION GENERATOR FEE,3600000015,CDM,360,RC,,,facility,both,,,,2929,2929,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSTEOCOOL ABLATION GENERATOR FEE,3600000015,CDM,360,RC,,,facility,both,,,,2842,2842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIPHERAL NERVE BLOCK,3600000016,CDM,360,RC,,,facility,both,,,,965,965,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIPHERAL NERVE BLOCK,3600000016,CDM,360,RC,,,facility,both,,,,1072,1072,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRE-SURGICAL GRAFT PREPARATION,3600000017,CDM,360,RC,,,facility,both,,,,2945,2945,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY ADDL 15 MIN LEVEL I,3600000018,CDM,360,RC,,,facility,both,,,,1010,1010,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY ADDL 15 MIN LEVEL I,3600000018,CDM,360,RC,,,facility,both,,,,838,838,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY ADDL 15 MIN LEVEL II,3600000019,CDM,360,RC,,,facility,both,,,,943,943,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY ADDL 15 MIN LEVEL II,3600000019,CDM,360,RC,,,facility,both,,,,1130,1130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY ADDL 15 MIN LEVEL III,3600000020,CDM,360,RC,,,facility,both,,,,1463,1463,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY ADDL 15 MIN LEVEL III,3600000020,CDM,360,RC,,,facility,both,,,,1236,1236,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY ADDL 15 MIN LEVEL IV,3600000021,CDM,360,RC,,,facility,both,,,,1484,1484,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY ADDL 15 MIN LEVEL IV,3600000021,CDM,360,RC,,,facility,both,,,,1853,1853,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY FIRST 1/2 HR LEVEL I,3600000022,CDM,360,RC,,,facility,both,,,,3791,3791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY FIRST 1/2 HR LEVEL I,3600000022,CDM,360,RC,,,facility,both,,,,4735,4735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY FIRST 1/2 HR LEVEL II,3600000023,CDM,360,RC,,,facility,both,,,,4103,4103,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY FIRST 1/2 HR LEVEL II,3600000023,CDM,360,RC,,,facility,both,,,,5117,5117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY FIRST 1/2 HR LEVEL III,3600000024,CDM,360,RC,,,facility,both,,,,4802,4802,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY FIRST 1/2 HR LEVEL III,3600000024,CDM,360,RC,,,facility,both,,,,5901,5901,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY FIRST 1/2 HR LEVEL IV,3600000025,CDM,360,RC,,,facility,both,,,,7031,7031,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGERY FIRST 1/2 HR LEVEL IV,3600000025,CDM,360,RC,,,facility,both,,,,5761,5761,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK-CONT INF BILATERAL,3600000026,CDM,360,RC,,,facility,both,,,,5571,5571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK-CONT INF BILATERAL,3600000026,CDM,360,RC,,,facility,both,,,,6017,6017,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK-CONT INF UNILAT,3600000027,CDM,360,RC,,,facility,both,,,,3714,3714,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK-CONT INF UNILAT,3600000027,CDM,360,RC,,,facility,both,,,,4893,4893,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK-SINGLE INJ BILATERAL,3600000028,CDM,360,RC,,,facility,both,,,,3114,3114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK-SINGLE INJ BILATERAL,3600000028,CDM,360,RC,,,facility,both,,,,2550,2550,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK-SINGLE INJ UNILAT,3600000029,CDM,360,RC,,,facility,both,,,,1275,1275,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK-SINGLE INJ UNILAT,3600000029,CDM,360,RC,,,facility,both,,,,1518,1518,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FORTEC BLUE LIGHT CYSTOSCOPY LASER FEE,3600000030,CDM,360,RC,,,facility,both,,,,2166,2166,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URONAV MRI FUSION SYSTEM RENTAL,3600000045,CDM,360,RC,,,facility,both,,,,2503,2503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ULTRASOUND URONAV MRI FUSION SYSTEM RENTAL,3600000046,CDM,360,RC,,,facility,both,,,,1085,1085,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLEXIBLE FORTEC CO2  RENTAL,3600000062,CDM,360,RC,,,facility,both,,,,3053,3053,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SERVICE AKSM CRYOSURGERY PROSTATE RENTAL,3600000063,CDM,360,RC,,,facility,both,,,,6240,6240,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER LUMENIS ACUPULSE DUO CO2 RENTAL,3600000069,CDM,360,RC,,,facility,both,,,,1200,1200,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  LASER WISDOM MEDICAL LEONARDO DUAL DIODE RENTAL,3600000070,CDM,360,RC,,,facility,both,,,,1200,1200,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER LUMENIS VERSAPULSE 100W HOLMIUM RENTAL,3600000071,CDM,360,RC,,,facility,both,,,,1013,1013,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER LUMENIS PULSE 100H HOLMIUM RENTAL,3600000072,CDM,360,RC,,,facility,both,,,,1013,1013,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER QUANTA LITHO 100W HOLMIUM RENTAL,3600000073,CDM,360,RC,,,facility,both,,,,1013,1013,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER CONMED 7500 ABC RENTAL,3600000074,CDM,360,RC,,,facility,both,,,,1050,1050,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  LASER INPHASE WOLF TRUE BLUE RENTAL,3600000075,CDM,360,RC,,,facility,both,,,,1125,1125,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER CANDELA CO2RE CO2 RENTAL,3600000076,CDM,360,RC,,,facility,both,,,,750,750,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER SHARPLAN 40C CO2 RENTAL,3600000077,CDM,360,RC,,,facility,both,,,,900,900,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER LUMENIS ULTRAPULSE DUO CO2 RENTAL,3600000078,CDM,360,RC,,,facility,both,,,,1800,1800,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER QUANTA CYBER TM THULIUM RENTAL,3600000079,CDM,360,RC,,,facility,both,,,,1200,1200,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER BOSTON SCIENTIFIC GREENLIGHT XPS RENTAL,3600000080,CDM,360,RC,,,facility,both,,,,1200,1200,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER LUMENIS PULSE 30H HOLMIUM RENTAL,3600000081,CDM,360,RC,,,facility,both,,,,675,675,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER LUMENIS VERSAPULSE 80/100W HOLMIUM / YAG RENTAL,3600000082,CDM,360,RC,,,facility,both,,,,1425,1425,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER IRIDEX OCULIGHT TX KTP  RENTAL,3600000083,CDM,360,RC,,,facility,both,,,,900,900,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER AMS KTP AURA XP RENTAL,3600000084,CDM,360,RC,,,facility,both,,,,900,900,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER LUMENIS SELECTA II OPHTHALMIC YAG RENTAL,3600000085,CDM,360,RC,,,facility,both,,,,975,975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER QUANTA FIBER DUST TFL RENTAL,3600000086,CDM,360,RC,,,facility,both,,,,1350,1350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER BOSTON SCIENTIFIC MOSES HOLMIUM RENTAL,3600000087,CDM,360,RC,,,facility,both,,,,1350,1350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER OLYMPUS SOLTIVE TFL RENTAL,3600000088,CDM,360,RC,,,facility,both,,,,1350,1350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER COLOPLAST TFL RENTAL,3600000089,CDM,360,RC,,,facility,both,,,,1350,1350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER BOSTON SCIENTIFIC THUVERA TFL RENTAL,3600000090,CDM,360,RC,,,facility,both,,,,1350,1350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER LISA LASER REVOLIX THULIUM RENTAL,3600000091,CDM,360,RC,,,facility,both,,,,1050,1050,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER OMNIGUIDE INTELLIGUIDE CO2 RENTAL,3600000092,CDM,360,RC,,,facility,both,,,,1050,1050,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER AMS KTP AURA XP RENTAL,3600000093,CDM,360,RC,,,facility,both,,,,900,900,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LASER OMNIGUIDE BEACON CO2 AGILITI RENTAL,3600000094,CDM,360,RC,,,facility,both,,,,1050,1050,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ULTRASOUND FORTEC  RENTAL,3600000095,CDM,360,RC,,,facility,both,,,,2250,2250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL/RPLC NSTIM SYSTEM SLEEP APNEA,3600431T01,CDM,360,RC,,,facility,both,,,,77823,77823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TCAT RMVL/DEBULK ICAR MASS SUCTION DEVICE PERQ,3600644T01,CDM,360,RC,,,facility,both,,,,13437,13437,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYOABLATION OF SOFT TISSUE TUMOR EXTREMITY W/ US GID,3602789901,CDM,360,RC,,,facility,both,,,,10533,10533,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY W/BIOPSY MICROSCOPE/TELESCOPE,3603153601,CDM,360,RC,31536,HCPCS,facility,both,,,,11508,11508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAUTERINE FETAL TRANSFUSION,3603646001,CDM,360,RC,,,facility,both,,,,1173,1173,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC STAB PHELB VARICOSE VEINS 1 EXT < 10""",3603779901,CDM,360,RC,,,facility,both,,,,4274,4274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ESOPHAGOSTOMY, FSTL ESOPH, XTRNL; CRV APPR",3604335201,CDM,360,RC,,,facility,both,,,,1851,1851,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STRTCTC CPTR ASSTD PX EXTRADURAL CRANIAL,3606178201,CDM,360,RC,61782,HCPCS,facility,both,,,,2245,2245,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STEREOTACTIC COMPUTER ASSISTED PX SPINAL,3606178301,CDM,360,RC,61783,HCPCS,facility,both,,,,1539,1539,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR,3606366301,CDM,360,RC,,,facility,both,,,,23374,23374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVJ/RMVL IMPLANTED SPINAL NEUROSTIM GENERATOR,3606368801,CDM,360,RC,,,facility,both,,,,12423,12423,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ ANES > OCCIPITAL NERVE,3606440501,CDM,360,RC,,,facility,both,,,,1282,1282,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PVB THORACIC SINGLE INJECTION SITE W/IMG GID,3606446101,CDM,360,RC,,,facility,both,,,,2179,2179,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PVB THORACIC SECOND & ADDL INJ SITE W/IMG GID,3606446201,CDM,360,RC,,,facility,both,,,,1633,1633,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAP BLOCK UNILATERAL BY INJECTION(S),3606448602,CDM,360,RC,64486,HCPCS,facility,both,,,,437,437,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TCATH STENT PLACEMT ANTEGRADE CAROTID/INNOMINATE,3610000001,CDM,361,RC,,,facility,both,,,,10939,10939,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLC EXTRACRA STENT INITIAL VESSEL,3610075T01,CDM,361,RC,,,facility,both,,,,1735,1735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLC EXTRACRAN STENT ADDTL VESSEL,3610076T01,CDM,361,RC,,,facility,both,,,,2150,2150,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SACROPLASTY UNILATERAL INJECTION,3610200T01,CDM,361,RC,0200T,HCPCS,facility,both,,,,6445,6445,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SACROPLASTY BILATERAL INJECTION,3610201T01,CDM,361,RC,0201T,HCPCS,facility,both,,,,6445,6445,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ILIAC ATHRECTOMY,3610238T01,CDM,361,RC,,,facility,both,,,,22486,22486,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABLTJ PERC CRYOABLTJ IMG GDN UXTR/PERPH NERVE,3610440T01,CDM,361,RC,,,facility,both,,,,26947,26947,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABLTJ PERC CRYOABLTJ IMG GDN LXTR/PERPH NERVE,3610441T01,CDM,361,RC,0441T,HCPCS,facility,both,,,,23893,23893,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABLTJ PERC CRYOABLTJ IMG GDN NRV PLEX/TRNCL NRV,3610442T01,CDM,361,RC,0442T,HCPCS,facility,both,,,,17895,17895,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TCAT RMVL/DEBULK ICAR MASS SUCTION DEVICE PERQ,3610644T01,CDM,361,RC,0644T,HCPCS,facility,both,,,,15378,15378,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HISTOTRIPSY MAL HEPATOCELLULAR TISS W/IMG GDN,3610686T01,CDM,361,RC,0686T,HCPCS,facility,both,,,,31501,31501,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL,3611000401,CDM,361,RC,,,facility,both,,,,402,402,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESSION,3611000501,CDM,361,RC,10005,HCPCS,facility,both,,,,805,805,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESSION,3611000501,CDM,361,RC,10005,HCPCS,facility,both,,,,647,647,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,3611000601,CDM,361,RC,10006,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,3611000601,CDM,361,RC,10006,HCPCS,facility,both,,,,470,470,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION,3611000701,CDM,361,RC,10007,HCPCS,facility,both,,,,758,758,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION,3611000701,CDM,361,RC,10007,HCPCS,facility,both,,,,859,859,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL,3611000801,CDM,361,RC,,,facility,both,,,,843,843,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL,3611000801,CDM,361,RC,,,facility,both,,,,935,935,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION,3611000901,CDM,361,RC,10009,HCPCS,facility,both,,,,647,647,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION,3611000901,CDM,361,RC,10009,HCPCS,facility,both,,,,1074,1074,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL,3611001001,CDM,361,RC,,,facility,both,,,,491,491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL,3611001001,CDM,361,RC,,,facility,both,,,,1265,1265,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/MR GDN 1ST LESION,3611001101,CDM,361,RC,,,facility,both,,,,4239,4239,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/MR GDN EA ADDL,3611001201,CDM,361,RC,,,facility,both,,,,3633,3633,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/O GDN 1ST LESION,3611002101,CDM,361,RC,,,facility,both,,,,603,603,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMG CATH FLUID COL SOFT TISSUE,3611003001,CDM,361,RC,10030,HCPCS,facility,both,,,,647,647,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMG CATH FLUID COL SOFT TISSUE,3611003001,CDM,361,RC,10030,HCPCS,facility,both,,,,1296,1296,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ DEV SOFT TISSUE 1ST LESION,3611003501,CDM,361,RC,10035,HCPCS,facility,both,,,,2099,2099,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERC DEV SOFT TISS ADDTL LESION,3611003601,CDM,361,RC,10036,HCPCS,facility,both,,,,2436,2436,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCTURE DRAINAGE OF LESION,3611016001,CDM,361,RC,10160,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCTURE DRAINAGE OF LESION,3611016001,CDM,361,RC,10160,HCPCS,facility,both,,,,319,319,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRID SUBQ TISSUE TO 20SQCM,3611104201,CDM,361,RC,11042,HCPCS,facility,both,,,,408,408,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM SUTURES W ANESTH OTHR SURGEON,3611585101,CDM,361,RC,,,facility,both,,,,4682,4682,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POCKET REVISION,3611799901,CDM,361,RC,17999,HCPCS,facility,both,,,,3309,3309,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED PROCEDURE SKIN,3611799902,CDM,361,RC,17999,HCPCS,facility,both,,,,224,224,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED PROCEDURE SKIN,3611799902,CDM,361,RC,17999,HCPCS,facility,both,,,,190,190,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS BIOPSY OF FAT TISSUE,3611799903,CDM,361,RC,17999,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS BIOPSY OF FAT TISSUE,3611799903,CDM,361,RC,17999,HCPCS,facility,both,,,,319,319,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHANGE OF A SEROMA DRAIN,3611799904,CDM,361,RC,,,facility,both,,,,4626,4626,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHANGE OF A SEROMA DRAIN,3611799904,CDM,361,RC,,,facility,both,,,,1867,1867,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYST BREAST ASPIRATION,3611900001,CDM,361,RC,19000,HCPCS,facility,both,,,,635,635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCT ASPIRATION CYST EACH ADDT,3611900101,CDM,361,RC,19001,HCPCS,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MASTOTOMY WITH DRAINAGE,3611902001,CDM,361,RC,,,facility,both,,,,2114,2114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GALACTOGRAM INJECTION,3611903001,CDM,361,RC,19030,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CORE BX 1ST LESION WITH STEREOTACTIC GUIDE,3611908101,CDM,361,RC,19081,HCPCS,facility,both,,,,2762,2762,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CORE BX ADDTL LESION WITH STEREOTACTIC GUIDE,3611908201,CDM,361,RC,19082,HCPCS,facility,both,,,,2762,2762,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX BREAST 1ST LESION WITH US GUIDANCE,3611908301,CDM,361,RC,19083,HCPCS,facility,both,,,,2287,2287,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX BREAST ADDTL LESION WITH US GUIDANCE,3611908401,CDM,361,RC,19084,HCPCS,facility,both,,,,2563,2563,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX BRST 1ST LES MRI IMG GUID,3611908501,CDM,361,RC,19085,HCPCS,facility,both,,,,4136,4136,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX BRST ADD LES MRI IMG GUID,3611908601,CDM,361,RC,19086,HCPCS,facility,both,,,,1275,1275,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST LOCAL DEVICE 1ST LESION WITH MAM GUIDE,3611928102,CDM,361,RC,19281,HCPCS,facility,both,,,,1791,1791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST LOCAL DEVICE ADDTL LESION WITH MAM GUIDE,3611928202,CDM,361,RC,19282,HCPCS,facility,both,,,,498,498,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST LOCAL DEVICE 1ST LESION WITH STEREO GUIDE,3611928301,CDM,361,RC,19283,HCPCS,facility,both,,,,710,710,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST LOCAL DEVICE ADDTL LESION WITH STEREO GUIDE,3611928401,CDM,361,RC,19284,HCPCS,facility,both,,,,498,498,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST LOCAL DEVICE 1ST LESION WITH US GUIDE,3611928501,CDM,361,RC,19285,HCPCS,facility,both,,,,710,710,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST LOCAL DEVICE ADDTL LESION WITH US GUIDE,3611928601,CDM,361,RC,19286,HCPCS,facility,both,,,,498,498,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX MUSCLE,3612020601,CDM,361,RC,20206,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX MUSCLE,3612020601,CDM,361,RC,20206,HCPCS,facility,both,,,,1297,1297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX BONE SUPERFICIAL PERC,3612022001,CDM,361,RC,20220,HCPCS,facility,both,,,,1297,1297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX BONE SUPERFICIAL PERC,3612022001,CDM,361,RC,20220,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX BONE DEEP PERC,3612022501,CDM,361,RC,20225,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX BONE DEEP PERC,3612022501,CDM,361,RC,20225,HCPCS,facility,both,,,,1297,1297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION OF SINUS TRACT,3612050001,CDM,361,RC,20500,HCPCS,facility,both,,,,1391,1391,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION OF SINUS TRACT,3612050001,CDM,361,RC,20500,HCPCS,facility,both,,,,1246,1246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SINOGRAM,3612050101,CDM,361,RC,20501,HCPCS,facility,both,,,,359,359,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SINOGRAM,3612050101,CDM,361,RC,20501,HCPCS,facility,both,,,,414,414,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ SGL TENDON SHEATH/LIGMNT,3612055001,CDM,361,RC,20550,HCPCS,facility,both,,,,425,425,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES,3612055201,CDM,361,RC,20552,HCPCS,facility,both,,,,348,348,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ARTHROCENTESIS SMALL JT,3612060001,CDM,361,RC,20600,HCPCS,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS SM JT US,3612060401,CDM,361,RC,20604,HCPCS,facility,both,,,,514,514,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH INJECTION ARTHROCENTESIS INTERMEDIATE JT WITHOUT US,3612060501,CDM,361,RC,20605,HCPCS,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH INJECTION ARTHROCENTESIS INTERMEDIATE JT WITHOUT US,3612060501,CDM,361,RC,20605,HCPCS,facility,both,,,,389,389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ARTHROCENTESIS INTERMEDIATE JT WITH US,3612060601,CDM,361,RC,20606,HCPCS,facility,both,,,,822,822,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ARTHROCENTESIS MAJOR JT WITHOUT US,3612061001,CDM,361,RC,20610,HCPCS,facility,both,,,,272,272,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ARTHROCENTESIS MAJOR JT WITHOUT US,3612061001,CDM,361,RC,20610,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS MAJOR JT WITH US,3612061101,CDM,361,RC,20611,HCPCS,facility,both,,,,944,944,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS MAJOR JT WITH US,3612061101,CDM,361,RC,20611,HCPCS,facility,both,,,,661,661,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION INJECTION GANGLION CYST,3612061201,CDM,361,RC,,,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIR/INJEC BONE CYST,3612061501,CDM,361,RC,20615,HCPCS,facility,both,,,,639,639,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIR/INJEC BONE CYST,3612061501,CDM,361,RC,20615,HCPCS,facility,both,,,,2067,2067,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SRS HEADFRAME PLACE RAD ONC,3612066001,CDM,361,RC,,,facility,both,,,,5659,5659,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT RF BONE TUMOR ABLATION,3612098201,CDM,361,RC,20982,HCPCS,facility,both,,,,12660,12660,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABLAT THERAPY OF 1 OR MORE BONE TUMORS,3612098301,CDM,361,RC,20983,HCPCS,facility,both,,,,17849,17849,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CRYOBALATION OF GLUTEAL MASS,3612099901,CDM,361,RC,20999,HCPCS,facility,both,,,,28073,28073,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYOBLATION SOFT TISSUE W/ULTRASOUND GUIDANCE,3612099902,CDM,361,RC,20999,HCPCS,facility,both,,,,10533,10533,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR-BIOPSY OF NECK OR CHEST,3612155001,CDM,361,RC,21550,HCPCS,facility,both,,,,1544,1544,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR-BIOPSY OF NECK OR CHEST,3612155001,CDM,361,RC,21550,HCPCS,facility,both,,,,3626,3626,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VERTEBROPLASTY THORACIC,3612251001,CDM,361,RC,22510,HCPCS,facility,both,,,,3254,3254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VERTEBROPLASTY LUMBAR,3612251101,CDM,361,RC,22511,HCPCS,facility,both,,,,3254,3254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EACH ADD VERTEBRAL LEVEL,3612251201,CDM,361,RC,22512,HCPCS,facility,both,,,,1759,1759,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KYPHOPLASTY THORACIC,3612251301,CDM,361,RC,22513,HCPCS,facility,both,,,,15966,15966,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KYPHOPLASTY LUMBAR,3612251401,CDM,361,RC,22514,HCPCS,facility,both,,,,14726,14726,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EACH ADDITIONAL LEVEL,3612251501,CDM,361,RC,22515,HCPCS,facility,both,,,,14726,14726,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABLATION SOFT TISSUE SPINE,3612289901,CDM,361,RC,22899,HCPCS,facility,both,,,,4534,4534,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR BX ABDOMINAL WALL MASS,3612299901,CDM,361,RC,22999,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR BX ABDOMINAL WALL MASS,3612299901,CDM,361,RC,22999,HCPCS,facility,both,,,,5556,5556,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL,3612306501,CDM,361,RC,,,facility,both,,,,4443,4443,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SHOULDER ARTHROGRAPHY,3612335001,CDM,361,RC,23350,HCPCS,facility,both,,,,1103,1103,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ARTHROCENTESIS ELBOW,3612422001,CDM,361,RC,24220,HCPCS,facility,both,,,,1211,1211,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ARTHROGRAM WRIST,3612524601,CDM,361,RC,25246,HCPCS,facility,both,,,,1203,1203,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADIAL TUNNEL INJECTION,3612599901,CDM,361,RC,,,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX DRAIN ABCESS FINGER SIMPLE,3612601001,CDM,361,RC,,,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS BX  SOFT TISSUE OF HAND,3612698901,CDM,361,RC,26989,HCPCS,facility,both,,,,1804,1804,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS BX  SOFT TISSUE OF HAND,3612698901,CDM,361,RC,26989,HCPCS,facility,both,,,,1787,1787,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION HIP ARTHROGRAM,3612709301,CDM,361,RC,27093,HCPCS,facility,both,,,,1202,1202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDED SI JOINT INJECTION,3612709601,CDM,361,RC,27096,HCPCS,facility,both,,,,5316,5316,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDED SI JOINT INJECTION,3612709601,CDM,361,RC,27096,HCPCS,facility,both,,,,974,974,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FOR SACROILIAC JT ANEST,3612709602,CDM,361,RC,27096,HCPCS,facility,both,,,,2231,2231,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FOR SACROILIAC JT ANEST,3612709602,CDM,361,RC,27096,HCPCS,facility,both,,,,1398,1398,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CEMETOPLASTY PELVIS,3612729901,CDM,361,RC,27299,HCPCS,facility,both,,,,15966,15966,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX PX CNTRST KNE ARTG CNTRST ENHNCD CT/MRI KNE,3612736901,CDM,361,RC,27369,HCPCS,facility,both,,,,578,578,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ARTHROCENTESIS ANKLE,3612764801,CDM,361,RC,27648,HCPCS,facility,both,,,,966,966,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS TRACHEAL BIOPSY,3613189901,CDM,361,RC,31899,HCPCS,facility,both,,,,1657,1657,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX PLEURA PERC NEEDLE,3613240001,CDM,361,RC,32400,HCPCS,facility,both,,,,1617,1617,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG,3613240801,CDM,361,RC,32408,HCPCS,facility,both,,,,2370,2370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION TUNNLED PLEURAL CATH,3613255001,CDM,361,RC,32550,HCPCS,facility,both,,,,3273,3273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH INSERTION OF CHEST TUBE,3613255101,CDM,361,RC,,,facility,both,,,,1671,1671,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM TUNN PLEURAL CATH WITH CUF,3613255201,CDM,361,RC,32552,HCPCS,facility,both,,,,4331,4331,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACENTESIS WITH IMAGE GUIDANCE,3613255502,CDM,361,RC,32555,HCPCS,facility,both,,,,1048,1048,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACENTESIS WITH IMAGE GUIDANCE,3613255502,CDM,361,RC,32555,HCPCS,facility,both,,,,563,563,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT CATH PLEURA WITH IMAGE GUIDANCE,3613255701,CDM,361,RC,32557,HCPCS,facility,both,,,,2207,2207,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT CATH PLEURA WITH IMAGE GUIDANCE,3613255701,CDM,361,RC,32557,HCPCS,facility,both,,,,1675,1675,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMICAL PLEURODESIS,3613256001,CDM,361,RC,,,facility,both,,,,926,926,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FIBRINOLYSIS CHEST TUBE INITIAL,3613256101,CDM,361,RC,,,facility,both,,,,2243,2243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FIBRINOLYSIS CHEST TUBE SUBSEQUENT,3613256201,CDM,361,RC,,,facility,both,,,,2618,2618,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABLATION THER 1+ PULM TUMORS PERQ CRYOABLATION,3613299401,CDM,361,RC,32994,HCPCS,facility,both,,,,21925,21925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT RF LUNG TISSUE ABLATION,3613299801,CDM,361,RC,32998,HCPCS,facility,both,,,,16648,16648,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  PLEURAL TUNNELED CATHETER EXCHANGE,3613299901,CDM,361,RC,,,facility,both,,,,5162,5162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLEURAL DRAIN EXCHANGE,3613299902,CDM,361,RC,32999,HCPCS,facility,both,,,,1285,1285,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION OF PLEURAL DRAIN,3613299903,CDM,361,RC,32999,HCPCS,facility,both,,,,693,693,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CREATION OF PERICARDIAL WINDOW,3613302501,CDM,361,RC,,,facility,both,,,,11941,11941,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TEMPORARY PACEMAKER INSERTION,3613321001,CDM,361,RC,33210,HCPCS,facility,both,,,,6715,6715,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RELOCATE PPM POCKET,3613322201,CDM,361,RC,33222,HCPCS,facility,both,,,,2619,2619,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RELOCATE ICD POCKET,3613322301,CDM,361,RC,33223,HCPCS,facility,both,,,,2487,2487,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION SUBQ CARDIAC RHYTHM MONITOR W/PRGRMG,3613328501,CDM,361,RC,33285,HCPCS,facility,both,,,,10902,10902,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR,3613328601,CDM,361,RC,33286,HCPCS,facility,both,,,,1642,1642,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RPR THOR AORTA WO SUBCLAV,3613388101,CDM,361,RC,,,facility,both,,,,6769,6769,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACE DISTAL EXTEN THOR INITIAL,3613388301,CDM,361,RC,,,facility,both,,,,3863,3863,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC AAA GRAFT A-AO,3613470101,CDM,361,RC,,,facility,both,,,,14116,14116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC AAA GRAFT A-AO W RUPTURE,3613470201,CDM,361,RC,,,facility,both,,,,14116,14116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC AAA GRAFT AORTO-UNI-ILIAC,3613470301,CDM,361,RC,,,facility,both,,,,13431,13431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC AAA GRAFT AORTO-UNI-ILIAC W/RUPTURE,3613470401,CDM,361,RC,,,facility,both,,,,10808,10808,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASDC AAA GRAFT AORTO-BI-ILIAC,3613470501,CDM,361,RC,,,facility,both,,,,9443,9443,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC AAA GRAFT AORTO-BI-ILIAC W/RUPTURE,3613470601,CDM,361,RC,,,facility,both,,,,11383,11383,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC ILIO-ILIAC GRAFT,3613470701,CDM,361,RC,,,facility,both,,,,11383,11383,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC ILIO-ILIAC GRAFT W/RUPTURE,3613470801,CDM,361,RC,,,facility,both,,,,8976,8976,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC GRAFT EXTENSION,3613470901,CDM,361,RC,,,facility,both,,,,10876,10876,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC GRAFT EXTENSION DELAYED 1ST VESS,3613471001,CDM,361,RC,,,facility,both,,,,4783,4783,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC GRAFT EXTENSION DELAYED EA ADDL,3613471101,CDM,361,RC,,,facility,both,,,,4942,4942,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOGRAFT FIXATION DEVICE,3613471201,CDM,361,RC,,,facility,both,,,,4942,4942,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ ACCESS & CLSR FEMORAL ART,3613471301,CDM,361,RC,,,facility,both,,,,1409,1409,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPEN FEM ART EXPOS W/CONDUIT,3613471401,CDM,361,RC,,,facility,both,,,,1409,1409,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPN AX/SUBCLA ART EXPOS,3613471501,CDM,361,RC,,,facility,both,,,,1409,1409,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPEN AX/SUBCLA ART EXPOS W/CONDUIT,3613471601,CDM,361,RC,,,facility,both,,,,1409,1409,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDO ILIAC OCCLUDING DEVICE,3613480801,CDM,361,RC,,,facility,both,,,,998,998,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROM AV GRAFT,3613587501,CDM,361,RC,,,facility,both,,,,5635,5635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRO NEEDLE/INTRACATH,3613600001,CDM,361,RC,36000,HCPCS,facility,both,,,,507,507,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBIN INJECTION WITH NEEDLE,3613600201,CDM,361,RC,36002,HCPCS,facility,both,,,,436,436,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION EXT VENOGRAPHY,3613600501,CDM,361,RC,36005,HCPCS,facility,both,,,,256,256,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION EXT VENOGRAPHY,3613600501,CDM,361,RC,36005,HCPCS,facility,both,,,,588,588,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRO OF CATH SVC OR IVC,3613601001,CDM,361,RC,36010,HCPCS,facility,both,,,,1977,1977,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRO OF CATH SVC OR IVC,3613601001,CDM,361,RC,36010,HCPCS,facility,both,,,,2370,2370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS 1ST ORDER,3613601101,CDM,361,RC,36011,HCPCS,facility,both,,,,1693,1693,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS 2ND ORDER,3613601201,CDM,361,RC,36012,HCPCS,facility,both,,,,856,856,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS 2ND ORDER,3613601201,CDM,361,RC,36012,HCPCS,facility,both,,,,1134,1134,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTERIAL CATH,3613601301,CDM,361,RC,36013,HCPCS,facility,both,,,,1264,1264,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CATH PLACE PULMONARY ARTERY,3613601401,CDM,361,RC,36014,HCPCS,facility,both,,,,1051,1051,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CATH PLC SEG SUBSEG PULM,3613601501,CDM,361,RC,36015,HCPCS,facility,both,,,,934,934,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTREMITY INJECTION NON SELECTIVE,3613614001,CDM,361,RC,36140,HCPCS,facility,both,,,,1543,1543,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AORTA (TRANSLUMBAR),3613616001,CDM,361,RC,,,facility,both,,,,1072,1072,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRO OF CATH AORTA,3613620001,CDM,361,RC,36200,HCPCS,facility,both,,,,1971,1971,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ART ARTERIO 1ST ABOV DIA,3613621501,CDM,361,RC,36215,HCPCS,facility,both,,,,2294,2294,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ART ARTERIO 2ND ABOV DIA,3613621601,CDM,361,RC,36216,HCPCS,facility,both,,,,3801,3801,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ART ARTERIO 3RD ABOV DIA,3613621701,CDM,361,RC,36217,HCPCS,facility,both,,,,4546,4546,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SEL CATHPL EA ADDTL IN VASC FAM,3613621801,CDM,361,RC,36218,HCPCS,facility,both,,,,1254,1254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARCH ANGIOGRAM S&I,3613622101,CDM,361,RC,36221,HCPCS,facility,both,,,,4307,4307,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAROTD XTRCRN ART CTH PL,3613622201,CDM,361,RC,36222,HCPCS,facility,both,,,,4584,4584,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAROTD COM ART CTH PLC,3613622301,CDM,361,RC,36223,HCPCS,facility,both,,,,9481,9481,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAROTD IN ART CTH PLC,3613622401,CDM,361,RC,36224,HCPCS,facility,both,,,,13555,13555,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBCLAVIAN ART CATH PLC,3613622501,CDM,361,RC,36225,HCPCS,facility,both,,,,13485,13485,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VERTEBRAL ART CATH PLC,3613622601,CDM,361,RC,36226,HCPCS,facility,both,,,,15509,15509,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLCTV CATH XTRNL CAROTID ANGIO XTRNL CAROTD CIRC,3613622701,CDM,361,RC,36227,HCPCS,facility,both,,,,7903,7903,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAROTD XTRNL ART CTH PL,3613622702,CDM,361,RC,36227,HCPCS,facility,both,,,,7903,7903,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLC CATH INTRACRAN ART,3613622801,CDM,361,RC,36228,HCPCS,facility,both,,,,5799,5799,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACE CATHETER IN ARTERY,3613624501,CDM,361,RC,36245,HCPCS,facility,both,,,,1802,1802,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PL CATH ART 2ND BELOW DIA,3613624601,CDM,361,RC,36246,HCPCS,facility,both,,,,1372,1372,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUP MESENT ARTERY 3RD ORDER,3613624701,CDM,361,RC,36247,HCPCS,facility,both,,,,2284,2284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PL CATH ART EA ADDTL BELOW DI,3613624801,CDM,361,RC,36248,HCPCS,facility,both,,,,1036,1036,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RENAL ANGIO UNILATERAL 1ST ORDE,3613625101,CDM,361,RC,36251,HCPCS,facility,both,,,,5322,5322,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RENAL ANGIO BILATERAL 1ST ORDER,3613625201,CDM,361,RC,36252,HCPCS,facility,both,,,,5440,5440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RENAL ANGIO UNILATERAL 2ND AND UP,3613625301,CDM,361,RC,36253,HCPCS,facility,both,,,,7175,7175,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VASCULAR INJECTION,3613629901,CDM,361,RC,36299,HCPCS,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ NONCMPND SCLRSNT 1 VEIN,3613646501,CDM,361,RC,,,facility,both,,,,6164,6164,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ NONCMPND SCLRSNT MULTI VEIN,3613646601,CDM,361,RC,,,facility,both,,,,6047,6047,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SCLERO SOLN VEIN SINGLE,3613647001,CDM,361,RC,,,facility,both,,,,421,421,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SCLEROSANT MULTIPLE INCMPTNT VEINS,3613647101,CDM,361,RC,36471,HCPCS,facility,both,,,,1216,1216,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS ABLATION 1ST VEIN,3613647801,CDM,361,RC,,,facility,both,,,,7074,7074,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS ABLATION ADDTL VEINS,3613647901,CDM,361,RC,,,facility,both,,,,769,769,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PORTAL VEIN CATH,3613648101,CDM,361,RC,36481,HCPCS,facility,both,,,,1387,1387,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOVEN ABLATION CHEM ADHESIVE INITIAL,3613648201,CDM,361,RC,,,facility,both,,,,19182,19182,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOVEN ABLATION CHEM ADHESIVE SBSQ,3613648301,CDM,361,RC,,,facility,both,,,,9590,9590,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SEL ORGAN BLOOD SAMPLE,3613650001,CDM,361,RC,36500,HCPCS,facility,both,,,,1668,1668,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT CENTRAL LINE AGE 5 AND UNDER,3613655501,CDM,361,RC,,,facility,both,,,,3781,3781,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT CENTRAL LINE AGE 5 AND OVER,3613655601,CDM,361,RC,36556,HCPCS,facility,both,,,,2638,2638,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT CENTRAL LINE AGE 5 AND OVER,3613655601,CDM,361,RC,36556,HCPCS,facility,both,,,,2930,2930,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT TUN CVC AGE 5 AND UNDER,3613655701,CDM,361,RC,36557,HCPCS,facility,both,,,,8761,8761,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMPLANT VENOUS TUNNELED,3613655801,CDM,361,RC,36558,HCPCS,facility,both,,,,2638,2638,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMPLANT VENOUS TUNNELED,3613655801,CDM,361,RC,36558,HCPCS,facility,both,,,,2945,2945,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PORT A CATH PLACEMENT AGE 5 AND UNDER,3613656001,CDM,361,RC,36560,HCPCS,facility,both,,,,8311,8311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PORT A CATH PLACEMENT,3613656101,CDM,361,RC,36561,HCPCS,facility,both,,,,5893,5893,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PORT A CATH PLACEMENT,3613656101,CDM,361,RC,36561,HCPCS,facility,both,,,,2638,2638,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS TUN CTR INS CATH WITH PUMP,3613656301,CDM,361,RC,,,facility,both,,,,8392,8392,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS 2 TUN CATH 2 SITE WO PORT,3613656501,CDM,361,RC,36565,HCPCS,facility,both,,,,8311,8311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS 2 TUN CATH 2 SITE WITH PORT,3613656601,CDM,361,RC,,,facility,both,,,,27948,27948,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PICC W/O IMG GDN < 5 YR,3613656801,CDM,361,RC,36568,HCPCS,facility,both,,,,1553.24,1553.24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PICC W/O IMG GDN GREATER THAN 5 YR,3613656901,CDM,361,RC,36569,HCPCS,facility,both,,,,1225,1225,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PICC W/O IMG GDN GREATER THAN 5 YR,3613656901,CDM,361,RC,36569,HCPCS,facility,both,,,,1946,1946,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS PICC WITH PORT AGE 5 AND UNDER,3613657001,CDM,361,RC,,,facility,both,,,,4669,4669,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS PICC WITH PORT,3613657101,CDM,361,RC,,,facility,both,,,,3760,3760,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PICC W/RS&I <5 YEARS,3613657201,CDM,361,RC,36572,HCPCS,facility,both,,,,2631,2631,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERTION PICC W/RS&I, 5 YRS OR OLDER",3613657301,CDM,361,RC,36573,HCPCS,facility,both,,,,2130,2130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERTION PICC W/RS&I, 5 YRS OR OLDER",3613657301,CDM,361,RC,36573,HCPCS,facility,both,,,,1409,1409,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR CVA CATHETER,3613657501,CDM,361,RC,36575,HCPCS,facility,both,,,,999,999,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR CENT VAD WITH SUB PORT,3613657601,CDM,361,RC,,,facility,both,,,,9583,9583,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLACE CATH ONLY WITH PT/PUMP,3613657801,CDM,361,RC,,,facility,both,,,,6907,6907,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLC NON-TUNNL SAME ACCESS,3613658001,CDM,361,RC,36580,HCPCS,facility,both,,,,1588,1588,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLC NON-TUNNL SAME ACCESS,3613658001,CDM,361,RC,36580,HCPCS,facility,both,,,,2533,2533,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLC CMPLT TNLD SAME ACCES,3613658101,CDM,361,RC,36581,HCPCS,facility,both,,,,2945,2945,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLC CMPLT TNLD SAME ACCES,3613658101,CDM,361,RC,36581,HCPCS,facility,both,,,,2638,2638,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLC COMPLT TUNL WITH PT SAME,3613658201,CDM,361,RC,36582,HCPCS,facility,both,,,,5335,5335,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLC COMPLT TUNL WITH PT SAME,3613658201,CDM,361,RC,36582,HCPCS,facility,both,,,,2638,2638,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLC COMPLT TUNL WITH PMP SAM,3613658301,CDM,361,RC,,,facility,both,,,,9603,9603,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPLETE REPLACEMENT PICC RS&I,3613658401,CDM,361,RC,36584,HCPCS,facility,both,,,,1702,1702,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPLETE REPLACEMENT PICC RS&I,3613658401,CDM,361,RC,36584,HCPCS,facility,both,,,,1463,1463,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLC PICC WITH PT SAME ACCESS,3613658501,CDM,361,RC,,,facility,both,,,,3971,3971,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE IMPLANT VEN TUNNELED,3613658901,CDM,361,RC,36589,HCPCS,facility,both,,,,563,563,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE IMPLANT VEN TUNNELED,3613658901,CDM,361,RC,36589,HCPCS,facility,both,,,,1329,1329,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE TUNLD CATH W PT/PUMP,3613659002,CDM,361,RC,36590,HCPCS,facility,both,,,,1629,1629,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE TUNLD CATH W PT/PUMP,3613659002,CDM,361,RC,36590,HCPCS,facility,both,,,,1296,1296,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH DECLOTTING CATH/ACCESS DEVICE,3613659301,CDM,361,RC,36593,HCPCS,facility,both,,,,605,605,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMV CVC OBSTR SEP ACCESS,3613659501,CDM,361,RC,36595,HCPCS,facility,both,,,,2638,2638,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMV CVC OBSTR SEP ACCESS,3613659501,CDM,361,RC,36595,HCPCS,facility,both,,,,2945,2945,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MECH REMOVE TUNNELED CV CATH,3613659601,CDM,361,RC,,,facility,both,,,,1671,1671,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RPSTN CENTRAL CATH WITH FLUORO,3613659701,CDM,361,RC,36597,HCPCS,facility,both,,,,1446,1446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RPSTN CENTRAL CATH WITH FLUORO,3613659701,CDM,361,RC,36597,HCPCS,facility,both,,,,1296,1296,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION WITH FLUORO EXISTING CV DEVICE,3613659801,CDM,361,RC,36598,HCPCS,facility,both,,,,853,853,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION WITH FLUORO EXISTING CV DEVICE,3613659801,CDM,361,RC,36598,HCPCS,facility,both,,,,294,294,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTERIAL CANNULATION,3613662001,CDM,361,RC,36620,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBEC CANULDECLOT WO BAL,3613686001,CDM,361,RC,,,facility,both,,,,1535,1535,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTERNAL CANNULA WITH BAL,3613686101,CDM,361,RC,,,facility,both,,,,5304,5304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR AV DIALYSIS SHUNT,3613690101,CDM,361,RC,36901,HCPCS,facility,both,,,,1203,1203,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR TRANSLUMIN ANGIO PERIPH SEG,3613690201,CDM,361,RC,36902,HCPCS,facility,both,,,,10040,10040,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR DIALYS CIRC STNT PERIPH SEG,3613690301,CDM,361,RC,,,facility,both,,,,32828,32828,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR MECHANICAL THROMBECT DIALYSIS CIRCUIT,3613690401,CDM,361,RC,36904,HCPCS,facility,both,,,,13098,13098,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR DIALYSIS SHUNT MECH THR ANG,3613690501,CDM,361,RC,36905,HCPCS,facility,both,,,,20872,20872,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT,3613690601,CDM,361,RC,36906,HCPCS,facility,both,,,,54099,54099,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR ANGIO CENTRAL DIALYSIS SEG,3613690701,CDM,361,RC,36907,HCPCS,facility,both,,,,2452,2452,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR ANGIO CTR DIALYSIS SEG STNT,3613690801,CDM,361,RC,,,facility,both,,,,4415,4415,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIALYSIS CIRCUIT VASC EMBOLI OCCLS EVASC IMG S&I,3613690901,CDM,361,RC,,,facility,both,,,,14324,14324,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TIPS INSERTION,3613718201,CDM,361,RC,37182,HCPCS,facility,both,,,,12090,12090,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TIPS REVISION,3613718301,CDM,361,RC,37183,HCPCS,facility,both,,,,8829,8829,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIM ART MECH THROMBECTOMY,3613718401,CDM,361,RC,37184,HCPCS,facility,both,,,,11543,11543,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIM ART MECH THROMBECTOMY ADD ON,3613718501,CDM,361,RC,37185,HCPCS,facility,both,,,,3659,3659,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SEC ART MECH THROMBECTOMY ADD ON,3613718601,CDM,361,RC,,,facility,both,,,,4108,4108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS MECH THROMBECTOMY,3613718701,CDM,361,RC,37187,HCPCS,facility,both,,,,11470,11470,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS MECH THROMBECTOMY ADD ON,3613718801,CDM,361,RC,,,facility,both,,,,10094,10094,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVC FILTER PLACEMENT,3613719101,CDM,361,RC,37191,HCPCS,facility,both,,,,5618,5618,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVC FILTER PLACEMENT,3613719101,CDM,361,RC,37191,HCPCS,facility,both,,,,6935,6935,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVC FILTER RETRIEVAL,3613719301,CDM,361,RC,37193,HCPCS,facility,both,,,,2891,2891,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVC FILTER RETRIEVAL,3613719301,CDM,361,RC,37193,HCPCS,facility,both,,,,2781,2781,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX REMOVE INTRAVASCULAR FOREIGN BODY,3613719701,CDM,361,RC,37197,HCPCS,facility,both,,,,3922,3922,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX REMOVE INTRAVASCULAR FOREIGN BODY,3613719701,CDM,361,RC,37197,HCPCS,facility,both,,,,2947,2947,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSCATHETER BIOPSY,3613720001,CDM,361,RC,37200,HCPCS,facility,both,,,,5481,5481,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBOLYTIC VEN THER INITIAL,3613721201,CDM,361,RC,37212,HCPCS,facility,both,,,,3508,3508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBOLYTIC THER REMOVAL,3613721401,CDM,361,RC,37214,HCPCS,facility,both,,,,4603,4603,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSCATH STENT CCA WITH EPS,3613721501,CDM,361,RC,37215,HCPCS,facility,both,,,,2464,2464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSCATH STENT CCA WO EPS,3613721601,CDM,361,RC,37216,HCPCS,facility,both,,,,2464,2464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TCATH STENT PLACEMT ANTEGRADE CAROTID/INNOMINATE,3613721801,CDM,361,RC,,,facility,both,,,,2328,2328,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIOPLASTY ILIAC INIT VESSEL,3613722001,CDM,361,RC,37220,HCPCS,facility,both,,,,7292,7292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ILIAC STENT,3613722101,CDM,361,RC,37221,HCPCS,facility,both,,,,9256,9256,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ILIAC TLA EACH ADDTL,3613722201,CDM,361,RC,37222,HCPCS,facility,both,,,,5735,5735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIOPLASTY FEMORL POP UNI,3613722401,CDM,361,RC,37224,HCPCS,facility,both,,,,6595,6595,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FEM/POP ATHRECTOMY,3613722501,CDM,361,RC,37225,HCPCS,facility,both,,,,16022,16022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FEM/POP STENT,3613722601,CDM,361,RC,37226,HCPCS,facility,both,,,,13865,13865,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTERIAL STENT INITIAL,3613723601,CDM,361,RC,37236,HCPCS,facility,both,,,,8087,8087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTERIAL STENT ADDITIONAL,3613723701,CDM,361,RC,,,facility,both,,,,6886,6886,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS STENT INITIAL,3613723801,CDM,361,RC,37238,HCPCS,facility,both,,,,7922,7922,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS STENT ADDITIONAL,3613723901,CDM,361,RC,37239,HCPCS,facility,both,,,,1311,1311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VASC EMBOLIZE/OCCLUDE VENOUS,3613724101,CDM,361,RC,37241,HCPCS,facility,both,,,,17524,17524,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VASC EMBOLIZE/OCCLUDE ARTERY,3613724201,CDM,361,RC,37242,HCPCS,facility,both,,,,15833,15833,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VASC EMBOLIZE/OCCLUDE ORGAN,3613724301,CDM,361,RC,37243,HCPCS,facility,both,,,,17114,17114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VASC EMBOLIZE/OCCLUDE BLEED,3613724401,CDM,361,RC,37244,HCPCS,facility,both,,,,11543,11543,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VASC EMBOLIZE/OCCLUDE BLEED,3613724401,CDM,361,RC,37244,HCPCS,facility,both,,,,17114,17114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR ANGIOPL BALLN TRNSL 1ST ART,3613724601,CDM,361,RC,37246,HCPCS,facility,both,,,,5327,5327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR PTA RENAL ARTERIES BILATERA,3613724602,CDM,361,RC,37246,HCPCS,facility,both,,,,8207,8207,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR PTA BRACHIOENCEPH EA AD ART,3613724701,CDM,361,RC,37247,HCPCS,facility,both,,,,6159,6159,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR PTA VENOUS EACH,3613724801,CDM,361,RC,37248,HCPCS,facility,both,,,,5278,5278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR PTA VENOUS EACH,3613724801,CDM,361,RC,37248,HCPCS,facility,both,,,,4940,4940,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR PTA VENOUS EACH ADDL,3613724901,CDM,361,RC,37249,HCPCS,facility,both,,,,2503,2503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVUS NON CORONARY INITIAL VESSEL,3613725201,CDM,361,RC,37252,HCPCS,facility,both,,,,17028,17028,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVUS NON CORONARY EACH ADDTL,3613725301,CDM,361,RC,37253,HCPCS,facility,both,,,,17028,17028,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FIBRIN SHEATHOPLASTY,3613779901,CDM,361,RC,37799,HCPCS,facility,both,,,,1040,1040,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STENT NEUROFORM PLACEMENT,3613779902,CDM,361,RC,,,facility,both,,,,4390,4390,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBIN INJECTION W/NEEDLE,3613779903,CDM,361,RC,37799,HCPCS,facility,both,,,,679,679,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENOUS ABLATION,3613779904,CDM,361,RC,37799,HCPCS,facility,both,,,,3847,3847,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION OF ARTERIAL COIL MARKER,3613779905,CDM,361,RC,,,facility,both,,,,12818,12818,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ SPLENOPORTOGRAM,3613820001,CDM,361,RC,,,facility,both,,,,624,624,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE MARROW BIOPSY,3613822101,CDM,361,RC,38221,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE MARROW BIOPSY,3613822101,CDM,361,RC,38221,HCPCS,facility,both,,,,1440,1440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE MARROW BIOPSY,3613822201,CDM,361,RC,38222,HCPCS,facility,both,,,,2711,2711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE MARROW BIOPSY,3613822201,CDM,361,RC,38222,HCPCS,facility,both,,,,2428,2428,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE MARROW ASP POST BX,3613822202,CDM,361,RC,38222,HCPCS,facility,both,,,,2439,2439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BONE MARROW ASP POST BX,3613822202,CDM,361,RC,38222,HCPCS,facility,both,,,,2185,2185,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY NDLE SUPER LYMPH NOD,3613850501,CDM,361,RC,38505,HCPCS,facility,both,,,,1297,1297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY NDLE SUPER LYMPH NOD,3613850501,CDM,361,RC,38505,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM INJECTION LYMPHANGIOGRAM,3613879001,CDM,361,RC,38790,HCPCS,facility,both,,,,3095,3095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM SENTINAL NODE INJECTION,3613879201,CDM,361,RC,38792,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CANNULATION, THORACIC DUCT",3613879401,CDM,361,RC,38794,HCPCS,facility,both,,,,2601,2601,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDED LYMPH NODE CRYOABLATION,3613899902,CDM,361,RC,,,facility,both,,,,16876,16876,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION OF CYST OF SPLEEN,3613899991,CDM,361,RC,,,facility,both,,,,858,858,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION OF CYST OF SPLEEN,3613899991,CDM,361,RC,,,facility,both,,,,990,990,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF SALIVARY GLAND ND,3614240001,CDM,361,RC,42400,HCPCS,facility,both,,,,573,573,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF SALIVARY GLAND ND,3614240001,CDM,361,RC,42400,HCPCS,facility,both,,,,812,812,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SIALOGRAM,3614255001,CDM,361,RC,42550,HCPCS,facility,both,,,,522,522,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EGD ENDOSCOPIC STENT PLACEMENT W/WIRE& DILATION,3614326601,CDM,361,RC,43266,HCPCS,facility,both,,,,12565,12565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESOPHAGUS DIL OVER GUIDEWIR,3614345301,CDM,361,RC,,,facility,both,,,,2253,2253,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESOPHAGEAL STENT PLACEMENT,3614349901,CDM,361,RC,,,facility,both,,,,3177,3177,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ESOPHAOSTOMY EXCHANGE, E-TUBE EXCHANGE",3614349902,CDM,361,RC,,,facility,both,,,,869,869,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI NASO OR ORO-GAST TUBE PL,3614375201,CDM,361,RC,43752,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI NASO OR ORO-GAST TUBE PL,3614375201,CDM,361,RC,43752,HCPCS,facility,both,,,,281,281,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REPOSITION N-G TO N-J,3614376101,CDM,361,RC,43761,HCPCS,facility,both,,,,761,761,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REPOSITION N-G TO N-J,3614376101,CDM,361,RC,43761,HCPCS,facility,both,,,,527,527,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,3614376201,CDM,361,RC,43762,HCPCS,facility,both,,,,581,581,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC,3614376301,CDM,361,RC,,,facility,both,,,,963,963,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PYLOROPLASTY,3614380001,CDM,361,RC,,,facility,both,,,,2417,2417,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR ALCOHOL SCLEROSIS KIDNEY,3614399901,CDM,361,RC,,,facility,both,,,,2929,2929,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STOMACH SURGERY PROCEDURE,3614399902,CDM,361,RC,,,facility,both,,,,2193,2193,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS RETRIEVAL OF FOREIGN BODY NON-VASCULAR,3614399903,CDM,361,RC,,,facility,both,,,,1055,1055,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADJUSTMENT OF GASTRIC BAND DIAMETER VIA SUBCUTANEOUS PORT BY INJECTION OR ASPIRATION,3614399904,CDM,361,RC,43999,HCPCS,facility,both,,,,389,389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GASTROJEJUNOSTOMY,3614430001,CDM,361,RC,,,facility,both,,,,4048,4048,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI PLACEMENT OF N-J TUBE,3614450001,CDM,361,RC,44500,HCPCS,facility,both,,,,828,828,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI PLACEMENT OF N-J TUBE,3614450001,CDM,361,RC,44500,HCPCS,facility,both,,,,746,746,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI COLONIC STENT PLACEMENT,3614479901,CDM,361,RC,,,facility,both,,,,2810,2810,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJ REPLACEMENT,3614479902,CDM,361,RC,,,facility,both,,,,1122,1122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SP GI STENT PLACEMENT SM BOWEL,3614479903,CDM,361,RC,,,facility,both,,,,3294,3294,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION INTO NJ TUBE WITH FLUOROSCOPY,3614479904,CDM,361,RC,44799,HCPCS,facility,both,,,,985,985,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR ANAL FISTULA W/FIBRIN GLUE,3614539901,CDM,361,RC,,,facility,both,,,,8395,8395,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX LIVER PERC NEEDLE,3614700001,CDM,361,RC,47000,HCPCS,facility,both,,,,1392,1392,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX LIVER PERC NEEDLE,3614700001,CDM,361,RC,47000,HCPCS,facility,both,,,,1297,1297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIPSY LIVER W/OTHER MAJOR,3614700101,CDM,361,RC,,,facility,both,,,,2459,2459,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RF ABLATION,3614738201,CDM,361,RC,47382,HCPCS,facility,both,,,,10455,10455,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABLAT TUMR LIVER PERC CRYO,3614738301,CDM,361,RC,,,facility,both,,,,39673,39673,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALCOHOL ABLATION OF LIVER LESION,3614739901,CDM,361,RC,,,facility,both,,,,3410,3410,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS REMOVAL OF INTRAHEPATIC FOREIGN BODY,3614739902,CDM,361,RC,,,facility,both,,,,5208,5208,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS ASPIRATION OF LIVER CYST,3614739903,CDM,361,RC,,,facility,both,,,,957,957,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHOLECYSTOSTOMY,3614749001,CDM,361,RC,47490,HCPCS,facility,both,,,,4874,4874,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHOLECYSTOSTOMY,3614749001,CDM,361,RC,47490,HCPCS,facility,both,,,,3586,3586,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION FOR CHOLANGIOGRAM EXISTING,3614753101,CDM,361,RC,47531,HCPCS,facility,both,,,,5075,5075,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION FOR CHOLANGIOGRAM EXISTING,3614753101,CDM,361,RC,47531,HCPCS,facility,both,,,,4072,4072,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION FOR CHOLANGIOGRAM NEW,3614753201,CDM,361,RC,47532,HCPCS,facility,both,,,,7039,7039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLMT BILIARY DRAIN CATH EXT,3614753301,CDM,361,RC,47533,HCPCS,facility,both,,,,3273,3273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLMT BILIARY DRAIN CTH INEX,3614753401,CDM,361,RC,47534,HCPCS,facility,both,,,,3273,3273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BILI DRG CTH CONV EX INT EX,3614753501,CDM,361,RC,47535,HCPCS,facility,both,,,,3656,3656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHANGE BILIARY DRG CATH,3614753601,CDM,361,RC,47536,HCPCS,facility,both,,,,5045,5045,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHANGE BILIARY DRG CATH,3614753601,CDM,361,RC,47536,HCPCS,facility,both,,,,3275,3275,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL BILIARY DRAING CATH,3614753701,CDM,361,RC,47537,HCPCS,facility,both,,,,1757,1757,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL BILIARY DRAING CATH,3614753701,CDM,361,RC,47537,HCPCS,facility,both,,,,1098,1098,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERC PLMT BILE DUCT STENT E,3614753801,CDM,361,RC,,,facility,both,,,,11016,11016,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PER PLMT BILE DUCT STNT WO,3614753901,CDM,361,RC,,,facility,both,,,,20872,20872,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PER PLMT BILE DUC STNT W/CA,3614754001,CDM,361,RC,,,facility,both,,,,17890,17890,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLMT ACCESS THRU BILIARY TREE INTO SMALL BWL,3614754101,CDM,361,RC,,,facility,both,,,,14115,14115,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DILATE BILIARY DUCT AMPULLA,3614754201,CDM,361,RC,47542,HCPCS,facility,both,,,,12853,12853,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DILATE BILIARY DUCT AMPULLA,3614754201,CDM,361,RC,47542,HCPCS,facility,both,,,,1822,1822,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOLUMINAL BX BILIARY TREE,3614754301,CDM,361,RC,47543,HCPCS,facility,both,,,,2548,2548,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOLUMINAL BX BILIARY TREE,3614754301,CDM,361,RC,47543,HCPCS,facility,both,,,,2293,2293,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL DUCT GLBLDR CALCULI,3614754401,CDM,361,RC,47544,HCPCS,facility,both,,,,2620,2620,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BILIARY NDSC INTRAOPERATIVE,3614755001,CDM,361,RC,,,facility,both,,,,5028,5028,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY BILIARY BRUSH,3614755201,CDM,361,RC,47552,HCPCS,facility,both,,,,4003,4003,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BILIARY ENDO VIA T-TUB W/BX,3614755301,CDM,361,RC,,,facility,both,,,,4670,4670,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BILIARY ENDOSCOPY, PERCUTANEOUS W CALC REMOVAL",3614755401,CDM,361,RC,47554,HCPCS,facility,both,,,,15605,15605,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERC DILATAT BILIARY STRICT,3614755501,CDM,361,RC,,,facility,both,,,,4670,4670,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERC DILAT BILARY STRICTURE,3614755601,CDM,361,RC,,,facility,both,,,,11169,11169,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHOLEDOCAL STENT INSERTION,3614780101,CDM,361,RC,,,facility,both,,,,1163,1163,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR-UNLISTED PROC BILIARY TRACT,3614799901,CDM,361,RC,,,facility,both,,,,2355,2355,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS REMOVAL OF BILIARY STENT,3614799902,CDM,361,RC,,,facility,both,,,,2278,2278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COIL EMBOLIZATION OF CYSTIC DUCT FISTULA VIA EXISTING DRAIN TRACT,3614799904,CDM,361,RC,,,facility,both,,,,8994,8994,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY PANCREAS PERC NEEDLE,3614810201,CDM,361,RC,,,facility,both,,,,1951,1951,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY PANCREAS PERC NEEDLE,3614810201,CDM,361,RC,,,facility,both,,,,1731,1731,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX ABD PARACENTESIS WITHOUT IMAGE,3614908201,CDM,361,RC,,,facility,both,,,,1100,1100,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABD PARACENTESIS WITH IMAGING,3614908301,CDM,361,RC,49083,HCPCS,facility,both,,,,1077,1077,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABD PARACENTESIS WITH IMAGING,3614908301,CDM,361,RC,49083,HCPCS,facility,both,,,,1202,1202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY ABD RETROPERITON PERC NEEDL,3614918001,CDM,361,RC,49180,HCPCS,facility,both,,,,1297,1297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY ABD RETROPERITON PERC NEEDL,3614918001,CDM,361,RC,49180,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SCLEROTHER FLUID COLLECTION,3614918501,CDM,361,RC,49185,HCPCS,facility,both,,,,647,647,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SCLEROTHER FLUID COLLECTION,3614918501,CDM,361,RC,49185,HCPCS,facility,both,,,,2617,2617,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION AIR/CONTRAST PERITONEAL CAVITY SPX,3614940001,CDM,361,RC,,,facility,both,,,,1022,1022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMAGE CATH FLUID DRAIN VISCERAL,3614940501,CDM,361,RC,49405,HCPCS,facility,both,,,,1636,1636,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMAGE CATH FLUID DRAIN VISCERAL,3614940501,CDM,361,RC,49405,HCPCS,facility,both,,,,3885,3885,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMAGE CATH FLUID PERI OR RETRO PERC,3614940601,CDM,361,RC,49406,HCPCS,facility,both,,,,2390,2390,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMAGE CATH FLUID PERI OR RETRO PERC,3614940601,CDM,361,RC,49406,HCPCS,facility,both,,,,1636,1636,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMAGE CATH FLUID TRANSVAGINAL,3614940701,CDM,361,RC,,,facility,both,,,,6268,6268,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS TUN IPER CATHETER,3614941801,CDM,361,RC,49418,HCPCS,facility,both,,,,4034,4034,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS TUN IPER CATHETER,3614941801,CDM,361,RC,49418,HCPCS,facility,both,,,,3355,3355,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT TUN PERIT CATH PERM,3614942101,CDM,361,RC,,,facility,both,,,,9415,9415,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE TUN PERIT CATH,3614942201,CDM,361,RC,,,facility,both,,,,3407,3407,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE TUN PERIT CATH,3614942201,CDM,361,RC,,,facility,both,,,,5004,5004,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHG CATH ABSC CYST DRAIN,3614942301,CDM,361,RC,49423,HCPCS,facility,both,,,,1889,1889,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHG CATH ABSC CYST DRAIN,3614942301,CDM,361,RC,49423,HCPCS,facility,both,,,,4024,4024,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ CONTR ABSCESS OR CYST,3614942401,CDM,361,RC,49424,HCPCS,facility,both,,,,340,340,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ CONTR ABSCESS OR CYST,3614942401,CDM,361,RC,49424,HCPCS,facility,both,,,,590,590,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVIS PERITONEAL VENOUS SHU,3614942601,CDM,361,RC,,,facility,both,,,,6991,6991,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ EVAL PREV PER-VEN SHUNT,3614942701,CDM,361,RC,,,facility,both,,,,668,668,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL PERITON VENOUS SHUN,3614942901,CDM,361,RC,,,facility,both,,,,6607,6607,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI INSERT G TUBE,3614944001,CDM,361,RC,49440,HCPCS,facility,both,,,,1671,1671,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI INSERT DUODENAL JEJUNAL,3614944101,CDM,361,RC,49441,HCPCS,facility,both,,,,1673,1673,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI INSERT CECOTOMY/COLONIC,3614944201,CDM,361,RC,49442,HCPCS,facility,both,,,,2562,2562,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI CONVERT G TUBE TO GJ TUBE,3614944601,CDM,361,RC,49446,HCPCS,facility,both,,,,1497,1497,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI CONVERT G TUBE TO GJ TUBE,3614944601,CDM,361,RC,49446,HCPCS,facility,both,,,,1677,1677,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REPLACE G OR CECOST COLO,3614945001,CDM,361,RC,49450,HCPCS,facility,both,,,,745,745,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REPLACE G OR CECOST COLO,3614945001,CDM,361,RC,49450,HCPCS,facility,both,,,,869,869,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REPLACE DUODENAL JEJUNAL,3614945101,CDM,361,RC,49451,HCPCS,facility,both,,,,745,745,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REPLACE DUODENAL JEJUNAL,3614945101,CDM,361,RC,49451,HCPCS,facility,both,,,,940,940,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REPLACE GJ TUBE,3614945201,CDM,361,RC,49452,HCPCS,facility,both,,,,840,840,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REPLACE GJ TUBE,3614945201,CDM,361,RC,49452,HCPCS,facility,both,,,,745,745,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REMOVAL OF GI TUBE OBSTR,3614946001,CDM,361,RC,,,facility,both,,,,853,853,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI REMOVAL OF GI TUBE OBSTR,3614946001,CDM,361,RC,,,facility,both,,,,1087,1087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI INJECTION GI TUBE,3614946501,CDM,361,RC,49465,HCPCS,facility,both,,,,270,270,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GI INJECTION GI TUBE,3614946501,CDM,361,RC,49465,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDED PELVIC CUL-DE-SAC ASP W/TRANSGLUT APPROACH,3614999901,CDM,361,RC,,,facility,both,,,,2369,2369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAIN EXCHANGE WITH A PERCUTANEOUS DEBRIDEMENT,3614999902,CDM,361,RC,49999,HCPCS,facility,both,,,,2815,2815,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAIN EXCHANGE WITH A PERCUTANEOUS DEBRIDEMENT,3614999902,CDM,361,RC,49999,HCPCS,facility,both,,,,1764,1764,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGICAL PROCEDURE ABDOMEN,3614999903,CDM,361,RC,49999,HCPCS,facility,both,,,,4742,4742,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SURGICAL PROCEDURE ABDOMEN,3614999903,CDM,361,RC,49999,HCPCS,facility,both,,,,5269,5269,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS REMOVAL OF DROP STONE VIA DRAIN CATH,3614999904,CDM,361,RC,,,facility,both,,,,1952,1952,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYOABLATION OF PELVIC LYMPH NODE,3614999905,CDM,361,RC,,,facility,both,,,,27926,27926,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ABLATION OF SOFT TISSUE MASS ABDOMEN, PERIOTONEUM & OMENTUM",3614999906,CDM,361,RC,49999,HCPCS,facility,both,,,,19938,19938,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDED PERCUTANEOUS GASTROSTOMY TUBE PLACEMENT,3614999907,CDM,361,RC,,,facility,both,,,,1931,1931,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABDOMINAL  ASPIRATION FLUID COLLECTION,3614999908,CDM,361,RC,49999,HCPCS,facility,both,,,,2152,2152,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHANCE OF PERITONEAL DRAIN,3614999910,CDM,361,RC,49999,HCPCS,facility,both,,,,4163,4163,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FIBRIN GLUE INJECTION,3614999912,CDM,361,RC,49999,HCPCS,facility,both,,,,1391,1391,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX KIDNEY PERC NEEDLE,3615020001,CDM,361,RC,50200,HCPCS,facility,both,,,,1399,1399,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE URETER STENT  PERCUT,3615038201,CDM,361,RC,50382,HCPCS,facility,both,,,,4238,4238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE URETER STENT  PERCUT,3615038201,CDM,361,RC,50382,HCPCS,facility,both,,,,5419,5419,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE URETER STENT  PERCUT,3615038401,CDM,361,RC,50384,HCPCS,facility,both,,,,4238,4238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE EXT/INT URETER STENT,3615038701,CDM,361,RC,50387,HCPCS,facility,both,,,,1842,1842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE EXT/INT URETER STENT,3615038701,CDM,361,RC,50387,HCPCS,facility,both,,,,1650,1650,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE RENAL TUBE WITH FLUORO,3615038901,CDM,361,RC,50389,HCPCS,facility,both,,,,650,650,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE RENAL TUBE WITH FLUORO,3615038901,CDM,361,RC,50389,HCPCS,facility,both,,,,592,592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION/INJECT OF RENAL CYST,3615039001,CDM,361,RC,50390,HCPCS,facility,both,,,,857,857,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION/INJECT OF RENAL CYST,3615039001,CDM,361,RC,50390,HCPCS,facility,both,,,,666,666,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHITAKER TEST,3615039601,CDM,361,RC,,,facility,both,,,,824,824,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FOR NEPHRR AND/OR URTRGRM,3615043001,CDM,361,RC,50430,HCPCS,facility,both,,,,2658,2658,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEPROSTGRM URTRGRM DRN INJ,3615043101,CDM,361,RC,50431,HCPCS,facility,both,,,,927,927,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEPROSTGRM URTRGRM DRN INJ,3615043101,CDM,361,RC,50431,HCPCS,facility,both,,,,1695,1695,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACEMENT NEPHROSTOMY CATHETER,3615043201,CDM,361,RC,50432,HCPCS,facility,both,,,,4116,4116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACEMENT NEPHROSTOMY CATHETER,3615043201,CDM,361,RC,50432,HCPCS,facility,both,,,,1843,1843,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACEMENT NEPHROSTOMY CATHETER,3615043202,CDM,361,RC,50432,HCPCS,facility,both,,,,2400,2400,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACEMENT NEPHROURET CATH NEW AC,3615043301,CDM,361,RC,50433,HCPCS,facility,both,,,,4620,4620,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONVERT NEPHROSTOMY CATHETER,3615043401,CDM,361,RC,50434,HCPCS,facility,both,,,,2084,2084,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONVERT NEPHROSTOMY CATHETER,3615043401,CDM,361,RC,50434,HCPCS,facility,both,,,,5189,5189,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHANGE NEPHROSTOMY CATHETER,3615043501,CDM,361,RC,50435,HCPCS,facility,both,,,,1650,1650,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCHANGE NEPHROSTOMY CATHETER,3615043501,CDM,361,RC,50435,HCPCS,facility,both,,,,1842,1842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT RF RENAL TISSUE ABLATION,3615059201,CDM,361,RC,50592,HCPCS,facility,both,,,,14904,14904,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT ABLATION TUMOR RENAL PERC CRYO,3615059301,CDM,361,RC,50593,HCPCS,facility,both,,,,25224,25224,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOLUM BX URETER RENAL PEL,3615060601,CDM,361,RC,,,facility,both,,,,2138,2138,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ PROC VIA URETERAL CATH,3615068401,CDM,361,RC,,,facility,both,,,,743,743,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE OF URETEROSTOMY,3615068801,CDM,361,RC,50688,HCPCS,facility,both,,,,1866,1866,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE OF URETEROSTOMY,3615068801,CDM,361,RC,50688,HCPCS,facility,both,,,,4507,4507,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECT ILEAL CONDUIT (LOOPOGR),3615069001,CDM,361,RC,,,facility,both,,,,555,555,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECT ILEAL CONDUIT (LOOPOGR),3615069001,CDM,361,RC,,,facility,both,,,,402,402,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLMT URETERAL STENT PERC,3615069301,CDM,361,RC,50693,HCPCS,facility,both,,,,3201,3201,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLMT URETERAL STENT PERC,3615069301,CDM,361,RC,50693,HCPCS,facility,both,,,,4619,4619,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLMT URET STENT PERC WO CATH,3615069401,CDM,361,RC,50694,HCPCS,facility,both,,,,4738,4738,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLMT URET STENT PERC WITH CATH,3615069501,CDM,361,RC,50695,HCPCS,facility,both,,,,4738,4738,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URETERAL EMBOLIZATION/OCCLUSION W/IMG GID RS&I,3615070501,CDM,361,RC,,,facility,both,,,,1468,1468,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BALLOON DILATE URTRL STRICT,3615070601,CDM,361,RC,50706,HCPCS,facility,both,,,,1468,1468,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER,3615110201,CDM,361,RC,51102,HCPCS,facility,both,,,,1842,1842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER,3615110201,CDM,361,RC,51102,HCPCS,facility,both,,,,1702,1702,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH INSERT TEMP BLAD CATH COMPLETE,3615170301,CDM,361,RC,,,facility,both,,,,218,218,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE CYSTOSTOMY TUBE,3615170501,CDM,361,RC,51705,HCPCS,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE CYSTOSTOMY TUBE,3615170501,CDM,361,RC,51705,HCPCS,facility,both,,,,277,277,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE CYSTO TUBE COMPLICATED,3615171001,CDM,361,RC,,,facility,both,,,,2644,2644,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH EMG - PAD,3615178402,CDM,361,RC,,,facility,both,,,,352,352,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DILATION OF URETERS,3615235101,CDM,361,RC,,,facility,both,,,,4227,4227,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITL PLACEMENT NEHROURETERAL STENT VIA EXISTING ILEAL CONDUIT,3615389901,CDM,361,RC,53899,HCPCS,facility,both,,,,5110,5110,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URETER OR URETHRA DILATION,3615389902,CDM,361,RC,,,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI PROSTATE BIOPSY NEEDLE,3615570001,CDM,361,RC,,,facility,both,,,,2622,2622,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI PROSTATE BIOPSY NEEDLE,3615570001,CDM,361,RC,,,facility,both,,,,2094,2094,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SALPINOGRAPHY,3615834001,CDM,361,RC,58340,HCPCS,facility,both,,,,744,744,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SALPINOGRAPHY,3615834001,CDM,361,RC,58340,HCPCS,facility,both,,,,670,670,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYST ASPIRATION VIA ABD,3615880501,CDM,361,RC,,,facility,both,,,,4842,4842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIR DRAIN OVARIAN CYST,3615899901,CDM,361,RC,,,facility,both,,,,1196,1196,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS BIOPSY OF VAGINAL CUFF,3615899903,CDM,361,RC,,,facility,both,,,,1449,1449,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS BIOPSY OF VAGINAL CUFF,3615899903,CDM,361,RC,,,facility,both,,,,3252,3252,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT GUIDED CRYOABLATION OF VAGINAL CUFF,3615899905,CDM,361,RC,,,facility,both,,,,6833,6833,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEEDLE BX THYROID,3616010001,CDM,361,RC,60100,HCPCS,facility,both,,,,1230,1230,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEEDLE BX THYROID,3616010001,CDM,361,RC,60100,HCPCS,facility,both,,,,647,647,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION THYROID CYST,3616030001,CDM,361,RC,60300,HCPCS,facility,both,,,,1808,1808,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION THYROID CYST,3616030001,CDM,361,RC,60300,HCPCS,facility,both,,,,1134,1134,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ETHANOL ABLATION OF THYROID,3616069901,CDM,361,RC,,,facility,both,,,,7018,7018,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CISTERNAL OR LATERAL CERVICAL PUNCTURE, WITHOUT INJECTION",3616105001,CDM,361,RC,,,facility,both,,,,1037,1037,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CERVICAL APPROACH,3616105501,CDM,361,RC,,,facility,both,,,,1904,1904,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRAIN CANAL SHUNT ASPIRATION NUC MED,3616107001,CDM,361,RC,61070,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TEMP BALL OCCLUS HEAD NECK,3616162301,CDM,361,RC,,,facility,both,,,,19100,19100,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMBOLIZATION INTRACRANIAL SPINAL,3616162401,CDM,361,RC,61624,HCPCS,facility,both,,,,17512,17512,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMBOLIZATION EXTRACRANIAL,3616162601,CDM,361,RC,61626,HCPCS,facility,both,,,,11543,11543,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRACRANIAL ANGIOPLASTY,3616163001,CDM,361,RC,61630,HCPCS,facility,both,,,,2616,2616,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRACRAN ANGIOPLSTY W STENT,3616163501,CDM,361,RC,61635,HCPCS,facility,both,,,,2464,2464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DILATE IC VASOSPASM INITITIAL,3616164001,CDM,361,RC,,,facility,both,,,,2565,2565,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SAME VASC FAM EACH ADD PTA,3616164101,CDM,361,RC,,,facility,both,,,,2936,2936,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIFF VASC FAM EA ADD PTA,3616164201,CDM,361,RC,,,facility,both,,,,3157,3157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ ART MECHTHROMBECT,3616164501,CDM,361,RC,61645,HCPCS,facility,both,,,,9758,9758,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC PRLNG ADM RX AGNT 1ST,3616165001,CDM,361,RC,61650,HCPCS,facility,both,,,,2214,2214,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVASC PRLNG ADM RX AGNT AD,3616165101,CDM,361,RC,61651,HCPCS,facility,both,,,,2238,2238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANEURYSM COIL,3616170801,CDM,361,RC,,,facility,both,,,,6098,6098,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMBOLIZATION ANEURYSM,3616171001,CDM,361,RC,,,facility,both,,,,4561,4561,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INVERT DISC ASPIRATION PERC,3616226701,CDM,361,RC,62267,HCPCS,facility,both,,,,1370,1370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INVERT DISC ASPIRATION PERC,3616226701,CDM,361,RC,62267,HCPCS,facility,both,,,,1529,1529,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LUMBAR PUNCTURE DIAGNOSTIC,3616227001,CDM,361,RC,62270,HCPCS,facility,both,,,,660,660,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LUMBAR PUNCTURE DIAGNOSTIC,3616227001,CDM,361,RC,62270,HCPCS,facility,both,,,,871,871,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LUMBAR PUNCTURE THERAPEUTIC,3616227201,CDM,361,RC,62272,HCPCS,facility,both,,,,792,792,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LUMBAR PUNCTURE THERAPEUTIC,3616227201,CDM,361,RC,62272,HCPCS,facility,both,,,,880,880,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ EPIDURAL BLOOD PATCH,3616227301,CDM,361,RC,62273,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD INJ EPIDURAL BLOOD PATCH,3616227302,CDM,361,RC,62273,HCPCS,facility,both,,,,585,585,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD INJ EPIDURAL BLOOD PATCH,3616227302,CDM,361,RC,62273,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LUMBAR APPROACH,3616228401,CDM,361,RC,62284,HCPCS,facility,both,,,,2861,2861,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERC DISK DECOMPRESSION,3616228701,CDM,361,RC,,,facility,both,,,,11023,11023,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION DISKOGRAPHY LUMBAR,3616229001,CDM,361,RC,62290,HCPCS,facility,both,,,,1749,1749,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION DISKOGRAPHY CERVICAL THORACIC,3616229101,CDM,361,RC,,,facility,both,,,,1837,1837,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYELOGRAM CERVICAL,3616230201,CDM,361,RC,62302,HCPCS,facility,both,,,,1858,1858,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYELOGRAM  THORACIC,3616230301,CDM,361,RC,62303,HCPCS,facility,both,,,,1858,1858,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYELOGRAM LUMBOSACRAL,3616230401,CDM,361,RC,62304,HCPCS,facility,both,,,,1858,1858,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYELOGRAM  COMPLETE,3616230501,CDM,361,RC,62305,HCPCS,facility,both,,,,2137,2137,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR INJ EPI SUBAR EA CERV THORA,3616232101,CDM,361,RC,62321,HCPCS,facility,both,,,,695,695,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR INJ EPI SUB EA LUMBARSACRAL,3616232301,CDM,361,RC,62323,HCPCS,facility,both,,,,1030,1030,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR INJ EPI SUB EA LUMBARSACRAL,3616232301,CDM,361,RC,62323,HCPCS,facility,both,,,,585,585,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,3616232801,CDM,361,RC,62328,HCPCS,facility,both,,,,1422,1422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,3616232801,CDM,361,RC,62328,HCPCS,facility,both,,,,940,940,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,3616232901,CDM,361,RC,62329,HCPCS,facility,both,,,,661,661,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,3616232901,CDM,361,RC,62329,HCPCS,facility,both,,,,1456,1456,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELEC ANLYS IMPLT ITHCL/EDRL PMP W/REPR PHYS/QHP,3616237001,CDM,361,RC,,,facility,both,,,,902,902,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL,3616365001,CDM,361,RC,63650,HCPCS,facility,both,,,,18007,18007,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR,3616366101,CDM,361,RC,63661,HCPCS,facility,both,,,,3664,3664,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT/REPLACE OF SPINAL NEUROSTIM PULSE GEN,3616368501,CDM,361,RC,63685,HCPCS,facility,both,,,,97637,97637,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH,3616440001,CDM,361,RC,64400,HCPCS,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE",3616441701,CDM,361,RC,,,facility,both,,,,2331,2331,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION AA&STRD INTERCOSTAL NRV SINGLE LVL,3616442001,CDM,361,RC,64420,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL",3616442101,CDM,361,RC,64421,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL",3616442101,CDM,361,RC,64421,HCPCS,facility,both,,,,955,955,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ANES ILIOINGUINAL ILIOHYPOGASTRIC NRVS,3616442501,CDM,361,RC,64425,HCPCS,facility,both,,,,2013,2013,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ANES ILIOINGUINAL ILIOHYPOGASTRIC NRVS,3616442501,CDM,361,RC,64425,HCPCS,facility,both,,,,797,797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",3616443001,CDM,361,RC,64430,HCPCS,facility,both,,,,979,979,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",3616443001,CDM,361,RC,64430,HCPCS,facility,both,,,,955,955,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION AA&/STRD SCIATIC NERVE W/IMG GDN,3616444502,CDM,361,RC,,,facility,both,,,,993,993,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HB 64450 INJ NRV BLK PERIPHER/BRANCH,3616445001,CDM,361,RC,64450,HCPCS,facility,both,,,,792,792,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IM,3616445101,CDM,361,RC,64451,HCPCS,facility,both,,,,1022,1022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG,3616445401,CDM,361,RC,64454,HCPCS,facility,both,,,,885,885,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACIC FASCIAL PLANE BLOCK UNI INJECTION,3616446601,CDM,361,RC,64466,HCPCS,facility,both,,,,1128,1128,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ TRANSFOR CERV THOR SINGLE,3616447901,CDM,361,RC,64479,HCPCS,facility,both,,,,955,955,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ TRANSFOR CERV THOR EA ADDTL,3616448001,CDM,361,RC,64480,HCPCS,facility,both,,,,1232,1232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ TRANSFOR LUMB SACR SINGLE,3616448301,CDM,361,RC,64483,HCPCS,facility,both,,,,955,955,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ TRANSFOR LUMB SACR SINGLE,3616448301,CDM,361,RC,64483,HCPCS,facility,both,,,,856,856,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ TRANSFOR LUMB SACR EA ADDTL,3616448401,CDM,361,RC,64484,HCPCS,facility,both,,,,1048,1048,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ TRANSFOR LUMB SACR EA ADDTL,3616448401,CDM,361,RC,64484,HCPCS,facility,both,,,,309,309,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FACET JT CERV THOR SINGLE,3616449001,CDM,361,RC,64490,HCPCS,facility,both,,,,856,856,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FACET JT CERV THOR SINGLE,3616449001,CDM,361,RC,64490,HCPCS,facility,both,,,,1457,1457,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FACET JT CERV THOR EA ADDTL,3616449101,CDM,361,RC,64491,HCPCS,facility,both,,,,1584,1584,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FACET JT CERV THOR EA ADDTL,3616449101,CDM,361,RC,64491,HCPCS,facility,both,,,,320,320,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ CERV THOR FAC JT 3+,3616449201,CDM,361,RC,64492,HCPCS,facility,both,,,,359,359,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ CERV THOR FAC JT 3+,3616449201,CDM,361,RC,64492,HCPCS,facility,both,,,,2183,2183,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FACET JT LUMB SACR SINGLE,3616449301,CDM,361,RC,64493,HCPCS,facility,both,,,,856,856,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FACET JT LUMB SACR SINGLE,3616449301,CDM,361,RC,64493,HCPCS,facility,both,,,,1058,1058,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FACET JT LUMB SACR EA ADDTL,3616449401,CDM,361,RC,64494,HCPCS,facility,both,,,,1077,1077,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FACET JT LUMB SACR EA ADDTL,3616449401,CDM,361,RC,64494,HCPCS,facility,both,,,,303,303,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ LUMB SACR FACET JT 3+,3616449501,CDM,361,RC,64495,HCPCS,facility,both,,,,333,333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ LUMB SACR FACET JT 3+,3616449501,CDM,361,RC,64495,HCPCS,facility,both,,,,2258,2258,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ ANESTHETIC AGENT STELLATE GANGLION BLOCK,3616451001,CDM,361,RC,64510,HCPCS,facility,both,,,,1954,1954,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUPERIOR HYPOGASTRIC NERVE BLOCK,3616451701,CDM,361,RC,64517,HCPCS,facility,both,,,,1632,1632,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ ANESTHETIC AGENT SYMPATHETIC LUMBAR BLOCK,3616452001,CDM,361,RC,64520,HCPCS,facility,both,,,,856,856,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ ANESTHETIC AGENT SYMPATHETIC LUMBAR BLOCK,3616452001,CDM,361,RC,64520,HCPCS,facility,both,,,,1634,1634,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT INJ CELIAC PLEX W ANESTHETI,3616453001,CDM,361,RC,64530,HCPCS,facility,both,,,,979,979,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT INJ CELIAC PLEX W ANESTHETI,3616453001,CDM,361,RC,64530,HCPCS,facility,both,,,,1232,1232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERV PAROTID&SUBMANDIBLE SALIVARY GLNDS,3616461101,CDM,361,RC,64611,HCPCS,facility,both,,,,1139,1139,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE,3616462001,CDM,361,RC,64620,HCPCS,facility,both,,,,4566,4566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG,3616462401,CDM,361,RC,64624,HCPCS,facility,both,,,,4108,4108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN,3616462501,CDM,361,RC,,,facility,both,,,,7027,7027,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTRJ NEUROLYTIC AGENT PUDENDAL NERVE,3616463001,CDM,361,RC,64630,HCPCS,facility,both,,,,2723,2723,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA,3616463301,CDM,361,RC,64633,HCPCS,facility,both,,,,4589,4589,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA,3616463401,CDM,361,RC,64634,HCPCS,facility,both,,,,4589,4589,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTR NROLYTIC AGNT PARVERTEB FCT SINGL LMBR/SACRAL,3616463501,CDM,361,RC,64635,HCPCS,facility,both,,,,4589,4589,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTR NROLYTIC AGNT PARVERTEB FT ADDL LUMBR/SACRAL,3616463601,CDM,361,RC,64636,HCPCS,facility,both,,,,4589,4589,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE,3616464001,CDM,361,RC,64640,HCPCS,facility,both,,,,1965,1965,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION OF TRUNK MUSCLES 1-5,3616464601,CDM,361,RC,64646,HCPCS,facility,both,,,,1089,1089,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION OF TRUNK MUSCLES 1-5,3616464601,CDM,361,RC,64646,HCPCS,facility,both,,,,660,660,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION OF  TRUNK MUSCLE(S) 6 OR MORE,3616464701,CDM,361,RC,64647,HCPCS,facility,both,,,,1253,1253,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION OF  TRUNK MUSCLE(S) 6 OR MORE,3616464701,CDM,361,RC,64647,HCPCS,facility,both,,,,660,660,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT INJ CELIAC PLEX W NEUROLYTIC,3616468001,CDM,361,RC,64680,HCPCS,facility,both,,,,1239,1239,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  DSTRJ NULYT W/WORAD MNTR SUPRIOR HYPOGSTR PLEXUS,3616468101,CDM,361,RC,64681,HCPCS,facility,both,,,,1472,1472,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DISK ASPIRATION BIOPSY,3616499901,CDM,361,RC,,,facility,both,,,,1893,1893,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRADISCAL INJECTION,3616499902,CDM,361,RC,64999,HCPCS,facility,both,,,,2111,2111,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SYNO CYST INJ/ASP SPINE,3616499903,CDM,361,RC,,,facility,both,,,,961,961,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SYNO CYST INJ/ASP SPINE,3616499903,CDM,361,RC,,,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  ULTRASOUND-GUIDED HEPATIC HILAR NERVE BLOCK,3616499904,CDM,361,RC,64999,HCPCS,facility,both,,,,1703,1703,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION OF CRICOPHARYNGEAL MUSCLE,3616499905,CDM,361,RC,,,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RADIOFREQUENCY ABLATION OF LUMBAR SYMPATHETIC PLEXUS,3616499906,CDM,361,RC,64999,HCPCS,facility,both,,,,5434,5434,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION OF HAND (1-4 DIGITS),3616499907,CDM,361,RC,,,facility,both,,,,834,834,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GANGLION IMPAR BLOCK,3616499908,CDM,361,RC,64999,HCPCS,facility,both,,,,2088,2088,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRACRANIAL STENT IN VEIN,3616499909,CDM,361,RC,,,facility,both,,,,2464,2464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RENAL HILAR BLOCK,3616499911,CDM,361,RC,,,facility,both,,,,906,906,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERITONEOGRAM RS&I,3617419001,CDM,361,RC,,,facility,both,,,,1904,1904,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC VENOGRAPHY OTHER VEIN, SELECTIVE RS&I",3617649901,CDM,361,RC,,,facility,both,,,,5130,5130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL,3617704801,CDM,361,RC,,,facility,both,,,,1157,1157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH ADMIN OF INJECTION SUBQ OR IM,3619637201,CDM,361,RC,96372,HCPCS,facility,both,,,,107,107,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH ADMIN OF INJECTION SUBQ OR IM,3619637201,CDM,361,RC,96372,HCPCS,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMOTX ADMN CNS REQ SPINAL PUNCTURE,3619645001,CDM,361,RC,96450,HCPCS,facility,both,,,,980,980,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEG PRESS WOUND TX GREATER THAN 50 SQ CM WITH DME,3619760601,CDM,361,RC,97606,HCPCS,facility,both,,,,547,547,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACE VESSEL CLOSURE DEVICE,361G026901,CDM,361,RC,G0269,HCPCS,facility,both,,,,978,978,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACE VESSEL CLOSURE DEVICE,361G026901,CDM,361,RC,G0269,HCPCS,facility,both,,,,1087,1087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANESTHESIA 1ST HALF HOUR,3700000001,CDM,370,RC,,,facility,both,,,,791,791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANESTHESIA 1ST HALF HOUR,3700000001,CDM,370,RC,,,facility,both,,,,792,792,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANESTHESIA ADDITIONAL 15 MIN,3700000002,CDM,370,RC,,,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANESTHESIA ADDITIONAL 15 MIN,3700000002,CDM,370,RC,,,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ INTERLAMINAR L/S NO IMAGE,3706232201,CDM,361,RC,,,facility,both,,,,1022,1022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIDURAL CATH PLACEMENT C/T NO IMAGE,3706232401,CDM,370,RC,62324,HCPCS,facility,both,,,,1147,1147,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIDURAL CATH PLACEMENT C/T NO IMAGE,3706232401,CDM,370,RC,62324,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIDURAL CATH PLACEMENT L/S NO IMAGE,3706232601,CDM,370,RC,62326,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIDURAL CATH PLACEMENT L/S NO IMAGE,3706232601,CDM,370,RC,62326,HCPCS,facility,both,,,,1147,1147,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CON SED SAME PHYS/QHP 1ST 15<5,3709915101,CDM,370,RC,99151,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,3709915201,CDM,370,RC,99152,HCPCS,facility,both,,,,122,122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,3709915301,CDM,370,RC,99153,HCPCS,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COVID-19 CONVALESCENT PLASMA,390C950701,CDM,390,RC,,,facility,both,,,,1159,1159,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LTOWB LOW TITER GROUP O POS WHOLE BLOOD,390P901001,CDM,390,RC,P9010,HCPCS,facility,both,,,,1549,1549,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PLATELET PHERSIS LEUKORED LG VOL SPLIT UNIT,390P901101,CDM,390,RC,P9011,HCPCS,facility,both,,,,525.83,525.83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRYO BLOOD SPLIT UNIT,390P901102,CDM,390,RC,,,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FFP BLOOD SPLIT UNIT,390P901103,CDM,390,RC,P9011,HCPCS,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLATELETS PHERESIS PATH REDU SPLIT UNIT,390P901104,CDM,390,RC,P9011,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLT HLA APH BLOOD SPLIT UNIT,390P901105,CDM,390,RC,,,facility,both,,,,654,654,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLT PH BLOOD SPLIT UNIT,390P901106,CDM,390,RC,,,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLT PH IRRADIATED BLOOD SPLIT UNIT,390P901107,CDM,390,RC,,,facility,both,,,,406,406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RBC BLOOD SPLIT UNIT,390P901108,CDM,390,RC,P9011,HCPCS,facility,both,,,,672,672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RBC IRRADIATED BLOOD SPLIT UNIT,390P901109,CDM,390,RC,P9011,HCPCS,facility,both,,,,183,183,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RBC WASHED BLOOD SPLIT UNIT,390P901110,CDM,390,RC,,,facility,both,,,,217,217,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RBC WASHED IRR BLOOD SPLIT UNIT,390P901111,CDM,390,RC,,,facility,both,,,,242,242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD CRYOPRECIPITATE EACH,390P901201,CDM,390,RC,P9012,HCPCS,facility,both,,,,138.51,138.51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD RBC LEUKORED EACH,390P901601,CDM,390,RC,P9016,HCPCS,facility,both,,,,672,672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD FRESH FROZEN PLASMA,390P901701,CDM,390,RC,,,facility,both,,,,120.56,120.56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RED BLOOD CELLS UNIT,390P902101,CDM,390,RC,,,facility,both,,,,650.22,650.22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD RBC WASHED EACH,390P902201,CDM,390,RC,P9022,HCPCS,facility,both,,,,701.53,701.53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WASHED RBC LEUKORED IRR,390P902202,CDM,390,RC,P9022,HCPCS,facility,both,,,,726.53,726.53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLASMA POOLED MULT DONOR SOLVENT/DETERGENT TREAT FROZ EA UNIT,390P902301,CDM,390,RC,,,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PLATELET LEUKORED EACH,390P903101,CDM,390,RC,,,facility,both,,,,222.35,222.35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PLT LEUKORED IRR EACH,390P903301,CDM,390,RC,,,facility,both,,,,2184,2184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PL PH LEUKORED EACH,390P903501,CDM,390,RC,,,facility,both,,,,1218.38,1218.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PLATELET PHERSIS LEUKORED LG VOL EACH,390P903502,CDM,390,RC,P9035,HCPCS,facility,both,,,,1462,1462,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PLT PH LEUKORED IRR EACH,390P903701,CDM,390,RC,P9037,HCPCS,facility,both,,,,1313.28,1313.28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD RBC LEUKORED IRR EACH,390P904001,CDM,390,RC,P9040,HCPCS,facility,both,,,,672,672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PLASMA CRYO RED EACH,390P904401,CDM,390,RC,P9044,HCPCS,facility,both,,,,120.56,120.56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LIQUID PLASMA IRRADIATED,390P904402,CDM,390,RC,P9044,HCPCS,facility,both,,,,288,288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD PLT HLA LEUKORED APH EACH,390P905201,CDM,390,RC,P9052,HCPCS,facility,both,,,,2116.13,2116.13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BLOOD, L/R, FROZ/DEGLY/WASH",390P905401,CDM,390,RC,,,facility,both,,,,470.27,470.27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLOOD RBC DEGLYCEROLIZED EACH,390P905701,CDM,390,RC,P9057,HCPCS,facility,both,,,,649,649,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HB PLASMA FRESH FROZEN 8-24 HOURS,390P905902,CDM,390,RC,P9059,HCPCS,facility,both,,,,120.56,120.56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLATELETS PHERESIS PATH REDU,390P907301,CDM,390,RC,P9073,HCPCS,facility,both,,,,1603.13,1603.13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSFUSION BLOOD OR BLOOD PRODUCT,3913643001,CDM,391,RC,36430,HCPCS,facility,both,,,,983,983,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIGITAL DIAG MAMMOGRAM UNILATERAL,4017706501,CDM,401,RC,77065,HCPCS,facility,both,,,,453,453,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIGITAL DIAG MAMMOGRAM UNILATERAL,4017706501,CDM,401,RC,77065,HCPCS,facility,both,,,,378,378,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIGITAL DIAG MAMMOGRAM BILATERAL,4017706601,CDM,401,RC,77066,HCPCS,facility,both,,,,435,435,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIGITAL DIAG MAMMOGRAM BILATERAL,4017706601,CDM,401,RC,77066,HCPCS,facility,both,,,,522,522,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,401G027901,CDM,401,RC,G0279,HCPCS,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS BILATERAL,401G027901,CDM,401,RC,G0279,HCPCS,facility,both,,,,269,269,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,401G027902,CDM,401,RC,G0279,HCPCS,facility,both,,,,122,122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,401G027902,CDM,401,RC,G0279,HCPCS,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC QUANTITATIVE US TISS CHARAC I&R W/DX US SM ANAT,4020690T01,CDM,402,RC,,,facility,both,,,,1531,1531,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC QUANTITATIVE US TISS CHARAC I&R W/DX US SM ANAT,4020690T01,CDM,402,RC,,,facility,both,,,,2186,2186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINE CAPACITY MEASURE BY US,4025179801,CDM,402,RC,51798,HCPCS,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINE CAPACITY MEASURE BY US,4025179801,CDM,402,RC,51798,HCPCS,facility,both,,,,113,113,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US GUIDED DRAIN-ABS/SPEC PERC,4027598901,CDM,402,RC,75989,HCPCS,facility,both,,,,557,557,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US NEONATE HEAD,4027650601,CDM,402,RC,76506,HCPCS,facility,both,,,,710,710,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BED US OCULAR,4027651201,CDM,402,RC,76512,HCPCS,facility,both,,,,613,613,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US SOFT TISSUE HEAD/NECK,4027653601,CDM,402,RC,76536,HCPCS,facility,both,,,,866,866,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US SOFT TISSUE HEAD/NECK,4027653601,CDM,402,RC,76536,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US CHEST,4027660401,CDM,402,RC,76604,HCPCS,facility,both,,,,851,851,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US CHEST,4027660401,CDM,402,RC,76604,HCPCS,facility,both,,,,794,794,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US BREAST COMPLETE,4027664101,CDM,402,RC,76641,HCPCS,facility,both,,,50,766,766,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US BREAST LIMITED,4027664201,CDM,402,RC,76642,HCPCS,facility,both,,,50,575,575,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ABDOMEN COMPLETE,4027670001,CDM,402,RC,76700,HCPCS,facility,both,,,,1300,1300,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ABDOMEN COMPLETE,4027670001,CDM,402,RC,76700,HCPCS,facility,both,,,,856,856,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ABDOMEN LIMITED,4027670501,CDM,402,RC,76705,HCPCS,facility,both,,,,836,836,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ABDOMEN LIMITED,4027670501,CDM,402,RC,76705,HCPCS,facility,both,,,,542,542,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US AAA SCREENING,4027670601,CDM,402,RC,76706,HCPCS,facility,both,,,,552,552,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US AAA SCREENING,4027670601,CDM,402,RC,76706,HCPCS,facility,both,,,,591,591,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US RETROPERITONEAL COMPLETE,4027677001,CDM,402,RC,76770,HCPCS,facility,both,,,,879,879,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US RETROPERITONEAL COMPLETE,4027677001,CDM,402,RC,76770,HCPCS,facility,both,,,,842,842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US RETROPERITONEAL LIMITED,4027677501,CDM,402,RC,76775,HCPCS,facility,both,,,,861,861,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US RETROPERITONEAL LIMITED,4027677501,CDM,402,RC,76775,HCPCS,facility,both,,,,733,733,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US TRANSPLANT COMPLETE,4027677601,CDM,402,RC,76776,HCPCS,facility,both,,,,938,938,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREG UTER 1ST TRIM LESS THAN 14 WEEKS,4027680101,CDM,402,RC,76801,HCPCS,facility,both,,,,896,896,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREG UTER 1ST TRIM LESS THAN 14 WEEKS,4027680101,CDM,402,RC,76801,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US OB <14 WKS ADDL FETUS,4027680201,CDM,402,RC,76802,HCPCS,facility,both,,,,138,138,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US OB <14 WKS ADDL FETUS,4027680201,CDM,402,RC,76802,HCPCS,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREGNANCY COMPLETE,4027680501,CDM,402,RC,76805,HCPCS,facility,both,,,,903,903,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREGNANCY COMPLETE,4027680501,CDM,402,RC,76805,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US OB  GREATER THAN OR = 14 WKS ADDL FETUS,4027681001,CDM,402,RC,76810,HCPCS,facility,both,,,,206,206,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US OB  GREATER THAN OR = 14 WKS ADDL FETUS,4027681001,CDM,402,RC,76810,HCPCS,facility,both,,,,297,297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREGNANT DETAILED SINGLE,4027681101,CDM,402,RC,76811,HCPCS,facility,both,,,,1117,1117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREGNANT DETAILED SINGLE,4027681101,CDM,402,RC,76811,HCPCS,facility,both,,,,1697,1697,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREG DETAILED EA ADDL GEST,4027681201,CDM,402,RC,76812,HCPCS,facility,both,,,,628,628,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREGNANT UTERUS LIMITED,4027681501,CDM,402,RC,76815,HCPCS,facility,both,,,,867,867,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREGNANT UTERUS LIMITED,4027681501,CDM,402,RC,76815,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREG UTERUS FOLLOW UP,4027681601,CDM,402,RC,76816,HCPCS,facility,both,,,,386,386,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PREG UTERUS FOLLOW UP,4027681601,CDM,402,RC,76816,HCPCS,facility,both,,,,612,612,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US TRANSVAGINAL PREG UTERUS,4027681701,CDM,402,RC,76817,HCPCS,facility,both,,,,743,743,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US TRANSVAGINAL PREG UTERUS,4027681701,CDM,402,RC,76817,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US FETAL BIOPHYSICAL PROFILE W NST,4027681801,CDM,402,RC,76818,HCPCS,facility,both,,,,929,929,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US FETAL BIOPHYSICAL PROFILE WO NST,4027681901,CDM,402,RC,76819,HCPCS,facility,both,,,,466,466,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US FETAL BIOPHYSICAL PROFILE WO NST,4027681901,CDM,402,RC,76819,HCPCS,facility,both,,,,808,808,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DOPPLER FETAL UMBILICAL ART,4027682001,CDM,402,RC,76820,HCPCS,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DOPPLER FETAL UMBILICAL ART,4027682001,CDM,402,RC,76820,HCPCS,facility,both,,,,645,645,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DOPP VELCO FET MID CEREB,4027682101,CDM,402,RC,76821,HCPCS,facility,both,,,,649,649,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US FETAL ECHOCARDIOGRAHPY,4027682502,CDM,402,RC,,,facility,both,,,,1478,1478,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PELVIS TRANSVAGINAL,4027683001,CDM,402,RC,76830,HCPCS,facility,both,,,,884,884,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PELVIS TRANSVAGINAL,4027683001,CDM,402,RC,76830,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US HYSTEROSONOGRAPHY W &WO DOPPLER,4027683101,CDM,402,RC,76831,HCPCS,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US HYSTEROSONOGRAPHY W &WO DOPPLER,4027683101,CDM,402,RC,76831,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PELVIC COMPLETE,4027685601,CDM,402,RC,76856,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PELVIC COMPLETE,4027685601,CDM,402,RC,76856,HCPCS,facility,both,,,,886,886,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PELVIS LIMITED/FOLLOW UP,4027685701,CDM,402,RC,76857,HCPCS,facility,both,,,,386,386,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US PELVIS LIMITED/FOLLOW UP,4027685701,CDM,402,RC,76857,HCPCS,facility,both,,,,595,595,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US SCROTUM,4027687001,CDM,402,RC,76870,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US SCROTUM,4027687001,CDM,402,RC,76870,HCPCS,facility,both,,,,874,874,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US TRANSRECTAL,4027687201,CDM,402,RC,76872,HCPCS,facility,both,,,,591,591,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROSTATE VOLUME STUDY,4027687301,CDM,402,RC,,,facility,both,,,,946,946,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US EXTREMITY NONVASCULAR COMPLETE,4027688101,CDM,402,RC,76881,HCPCS,facility,both,,,,891,891,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US EXTREMITY NONVASCULAR LIMITED,4027688201,CDM,402,RC,76882,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US EXTREMITY NONVASCULAR LIMITED,4027688201,CDM,402,RC,76882,HCPCS,facility,both,,,,444,444,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US NRV&ACC STRUX 1XTR COMPRE,4027688301,CDM,402,RC,76883,HCPCS,facility,both,,,,578,578,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US CONGENITAL HIP LIMITED STATIC,4027688601,CDM,402,RC,76886,HCPCS,facility,both,,,,367,367,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL,4027693601,CDM,402,RC,76936,HCPCS,facility,both,,,,1072,1072,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US GUIDANCE FOR VASCULAR ACCESS,4027693701,CDM,402,RC,76937,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US GUIDANCE FOR VASCULAR ACCESS,4027693701,CDM,402,RC,76937,HCPCS,facility,both,,,,216,216,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ULTRASOUND GUIDANCE TISSUE ABL,4027694001,CDM,402,RC,76940,HCPCS,facility,both,,,,354,354,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US GUIDED FETAL TRANS/CORDO,4027694101,CDM,402,RC,76941,HCPCS,facility,both,,,,638,638,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GUIDE NEEDLE PLACE S&I,4027694201,CDM,402,RC,76942,HCPCS,facility,both,,,,1166,1166,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GUIDE NEEDLE PLACE S&I,4027694201,CDM,402,RC,76942,HCPCS,facility,both,,,,826,826,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GUIDE NEEDLE PLACE S&I,4027694202,CDM,402,RC,76942,HCPCS,facility,both,,,,1166,1166,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GUIDE NEEDLE PLACE S&I,4027694202,CDM,402,RC,76942,HCPCS,facility,both,,,,530,530,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US GUIDANCE FOR AMNIO PROCED,4027694601,CDM,402,RC,76946,HCPCS,facility,both,,,,692,692,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US GUIDANCE RADIOELEMENT,4027696501,CDM,402,RC,,,facility,both,,,,3478,3478,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ULTRASOUND ELASTOGRAPHY PARENCHYMA,4027698101,CDM,402,RC,76981,HCPCS,facility,both,,,,937,937,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ULTRASOUND ELASTOGRAPHY FIRST TARGET LESION,4027698201,CDM,402,RC,,,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ULTRASOUND ELASTOGRAPY EA ADDL TAGET LESION,4027698301,CDM,402,RC,,,facility,both,,,,366,366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US INTRAOPERATIVE,4027699801,CDM,402,RC,76998,HCPCS,facility,both,,,,1180,1180,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST TOMO SCREEN BILATERAL,4037706301,CDM,403,RC,77063,HCPCS,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST TOMO SCREEN BILATERAL,4037706301,CDM,403,RC,77063,HCPCS,facility,both,,,,268,268,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIGITAL SCREENING MAMMOGRAM,4037706701,CDM,403,RC,77067,HCPCS,facility,both,,,,329,329,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIGITAL SCREENING MAMMOGRAM,4037706701,CDM,403,RC,77067,HCPCS,facility,both,,,,412,412,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCRD IMG PET PRFUJ 1STD REST/STRESS CNCRNT CT,4047843001,CDM,404,RC,78430,HCPCS,facility,both,,,,6343,6343,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCRD IMG PET PRFUJ MLT STD RST&STRS CNCRNT CT,4047843101,CDM,404,RC,78431,HCPCS,facility,both,,,,9893,9893,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC MYOCARDIAL IMAGING, PET, METABOLIC EVAL",4047845901,CDM,404,RC,,,facility,both,,,,6657,6657,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC MYOCARDIAL IMAGING, PET, PERFUSION, SINGLE STUDY STRESS/REST",4047849101,CDM,404,RC,,,facility,both,,,,7023,7023,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC MYOCARDIAL IMAGING, PET, PERFUSION, MULTIPLE, AT REST AND/OR STRESS",4047849201,CDM,404,RC,,,facility,both,,,,7023,7023,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PET BRAIN IMAGING,4047860801,CDM,404,RC,78608,HCPCS,facility,both,,,,8705,8705,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PET/CT TUMOR IMAGE LIMITED,4047881401,CDM,404,RC,78814,HCPCS,facility,both,,,,6315,6315,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PET/CT TUMOR IMAGE SKULL TO MID THIGH,4047881501,CDM,404,RC,78815,HCPCS,facility,both,,,,6524,6524,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PET/CT TUMOR IMAGE FULL BODY,4047881601,CDM,404,RC,78816,HCPCS,facility,both,,,,7249,7249,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM AIM SPECIALTY HEALTH,404G100701,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM CRANBERRY PEAK,404G100801,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM STANSON,404G101001,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AGILEMD'S CLINICAL DECISION SUPPORT MECH,404G101201,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVIDENCECARE IMAGING ADVISOR,404G101301,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INVENIQA'S SEMANTIC ANSWERS IN MEDICINE,404G101401,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RELIANT MEDICAL GROUP CDSM,404G101501,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPEED OF CARE CDSM,404G101601,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEALTHHELPS CLINICAL DECISION SUPPORT MECH,404G101701,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INFINX CDSM,404G101801,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LOGICNETS AUC SOLUTION,404G101901,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CURBSIDE CLINICAL AUGMENTED WORKFLOW,404G102001,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EHEAHTLINE CLINICAL DECISION SUPPORT MECH,404G102101,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERMOUNTAIN CLINICAL DECISION SUPPOORT MECH,404G102201,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERSIVIA CLINICAL DECIISION SUPPORT,404G102301,CDM,404,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENTILATOR INITIAL DAY,4109400201,CDM,410,RC,94002,HCPCS,facility,both,,,,1039,1039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC JET VENTILATOR INITIAL DAY,4109400202,CDM,410,RC,94002,HCPCS,facility,both,,,,1194,1194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSCILLATOR VENTILATOR INITIAL DAY,4109400203,CDM,410,RC,94002,HCPCS,facility,both,,,,1194,1194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENTILATOR SUBSEQUENT DAY,4109400301,CDM,410,RC,94003,HCPCS,facility,both,,,,1039,1039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC JET VENTILATOR SUBSEQUENT DAY,4109400302,CDM,410,RC,94003,HCPCS,facility,both,,,,1194,1194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSCILLATOR VENTILATOR SUBSEQUENT DAY,4109400303,CDM,410,RC,94003,HCPCS,facility,both,,,,1194,1194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAR SEAT/BED TEST INFT THRU 12 MO 60 MIN,4109478001,CDM,410,RC,94780,HCPCS,facility,both,,,,161,161,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAR SEAT/BED TEST INFT THRU 12 MO EA ADDL 30 MIN,4109478101,CDM,410,RC,94781,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HDVCH RESPIRATORY NEONATAL TRANSPORT,4120000001,CDM,412,RC,,,facility,both,,,,242,242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AIRWAY INHALATION TREATMENT,4129464001,CDM,412,RC,94640,HCPCS,facility,both,,,,367,367,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PENTAMIDINE TREATMENT,4129464201,CDM,412,RC,94642,HCPCS,facility,both,,,,290,290,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CBT 1ST HOUR,4129464401,CDM,412,RC,94644,HCPCS,facility,both,,,,217,217,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CBT EACH ADDTL HOUR,4129464501,CDM,412,RC,94645,HCPCS,facility,both,,,,141,141,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIPAP/CPAP,4129466001,CDM,412,RC,94660,HCPCS,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CBT VELETRI DAILY CHARGE,4129479901,CDM,412,RC,94799,HCPCS,facility,both,,,,2146,2146,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HYPERBARIC O2 EACH 30 MINUTES,413G027701,CDM,413,RC,G0277,HCPCS,facility,both,,,,619,619,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THERAP PROS ACTIVE EXERCISE,419G023701,CDM,419,RC,G0237,HCPCS,facility,both,,,,163,163,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THER 6 MIN WALK WITH REPORT,419G023801,CDM,419,RC,G0238,HCPCS,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THERAPEUTIC PROC 2 OR MORE,419G023901,CDM,419,RC,G0239,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT CPM SET UP,4200000003,CDM,420,RC,,,facility,both,,,,372,372,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT CPM-DAILY,4200000004,CDM,420,RC,,,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT,4209091201,CDM,420,RC,,,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT BFB TRAING W/EMG&/MANOMETRY EA ADDL 15 MIN CNTCT,4209091301,CDM,420,RC,,,facility,both,,,,132,132,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT CANALITH REPOSITIONING PROC,4209599201,CDM,420,RC,95992,HCPCS,facility,both,,,,145,145,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT TRACTION MECHANICAL,4209701201,CDM,420,RC,97012,HCPCS,facility,both,,,,128,128,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT ELECTRIC STIM UNATTENDED,4209701401,CDM,420,RC,97014,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT VASOPNEUMATIC,4209701601,CDM,420,RC,97016,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT PARAFFIN BATH THERAPY,4209701801,CDM,420,RC,97018,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT WHIRLPOOL,4209702201,CDM,420,RC,97022,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT ELECTRICAL STIM MANUAL PER 15 MIN,4209703201,CDM,420,RC,97032,HCPCS,facility,both,,,,67,67,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT IONTOPHORESIS PER 15 MIN,4209703301,CDM,420,RC,97033,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT CONTRAST BATH PER 15 MIN,4209703401,CDM,420,RC,,,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT ULTRASOUND PER 15 MIN,4209703501,CDM,420,RC,97035,HCPCS,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT THERAPEUTIC PROC PER 15 MIN,4209711001,CDM,420,RC,97110,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT NEUROMUSCULAR RE-EDUCATION PER 15 MIN,4209711201,CDM,420,RC,97112,HCPCS,facility,both,,,,75,75,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT AQUATIC THERAPY (PER UNIT),4209711301,CDM,420,RC,97113,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT GAIT TRAINING PER 15 MIN,4209711601,CDM,420,RC,97116,HCPCS,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT MASSAGE PER 15 MIN,4209712401,CDM,420,RC,97124,HCPCS,facility,both,,,,50,50,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT MANUAL THERAPY PER 15 MIN,4209714001,CDM,420,RC,97140,HCPCS,facility,both,,,,75,75,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT THERAPEUTIC FUNCTIONAL ACTIVITY,4209753001,CDM,420,RC,97530,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT ADL/SELFCARE/HMETRN PER UNIT,4209753501,CDM,420,RC,97535,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT WHEELCHAIR MGT EA 15 MINUTES,4209754201,CDM,420,RC,97542,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT WORK HARD/COND INITIAL 2 HRS,4209754501,CDM,420,RC,,,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT WORK HARD/COND EACH ADDTL HOUR,4209754601,CDM,420,RC,,,facility,both,,,,313,313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAREGIVER TRAINING STRATEGIES&TQ 1ST 30 MINUTES,4209755001,CDM,420,RC,97550,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAREGIVER TRAINING STRATEGIES&TQ EA ADDL 15 MIN,4209755101,CDM,420,RC,97551,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GROUP CAREGIVER TRAINING STRATEGIES & TECHNIQUE,4209755201,CDM,420,RC,97552,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT DEBRIDEMENT 20 SQ CM OR LESS,4209759701,CDM,420,RC,97597,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT DEBRIDEMENT ADDTL 20 SQ CM,4209759801,CDM,420,RC,,,facility,both,,,,281,281,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT NON-SELECTIVE DEBRIDEMENT,4209760201,CDM,420,RC,,,facility,both,,,,211,211,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT NEG PRESS WOUND TX LESS THAN OR EQUAL TO 50 SQ CM WITH DME,4209760501,CDM,420,RC,,,facility,both,,,,452,452,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT PHYS PERFORM/FCE PER UNIT,4209775001,CDM,420,RC,97750,HCPCS,facility,both,,,,79,79,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT ORTHOTICS MGMT & TRAINJ INITIAL ENCTR EA 15 MINS,4209776001,CDM,420,RC,97760,HCPCS,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT PROSTHETICS TRAINING INITIAL ENCTR EA 15 MINS,4209776101,CDM,420,RC,97761,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN,4209776301,CDM,420,RC,97763,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT OL DIGITAL ASSMT&MGMT EST PT <7 D 5-10 MIN,4209897001,CDM,420,RC,,,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT OL DIGITAL ASSMT&MGMT EST PT <7 D 11-20 MIN,4209897101,CDM,420,RC,,,facility,both,,,,68,68,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT OL DIGITAL ASSMT&MGMT EST PT <7 D 21+ MIN,4209897201,CDM,420,RC,,,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT ELEC STIM (UNATT) WOUND CARE,420G028201,CDM,420,RC,G0282,HCPCS,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT THERAPEUTIC PROCEDURE GROUP,4239715001,CDM,423,RC,97150,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT LOW COMPLEX EVALUATION,4249716101,CDM,424,RC,97161,HCPCS,facility,both,,,,182,182,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT MOD COMPLEX EVALUATION,4249716201,CDM,424,RC,97162,HCPCS,facility,both,,,,191,191,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT HIGH COMPLEX EVALUATION,4249716301,CDM,424,RC,97163,HCPCS,facility,both,,,,195,195,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT RE EVALUATION,4249716401,CDM,424,RC,97164,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT FEEDING/SWALLOWING TREATMENT,4309252601,CDM,430,RC,92526,HCPCS,facility,both,,,,214,214,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT CANALITH REPOSITIONING PROC,4309599201,CDM,430,RC,95992,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT ELECTRIC STIM UNATTENDED,4309701401,CDM,430,RC,97014,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT VASOPNEUMATIC,4309701601,CDM,430,RC,97016,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT PARAFFIN BATH,4309701801,CDM,430,RC,97018,HCPCS,facility,both,,,,14,14,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT WHIRLPOOL,4309702201,CDM,430,RC,97022,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT ELECTRICAL STIM MANUAL PER 15 MIN,4309703201,CDM,430,RC,97032,HCPCS,facility,both,,,,67,67,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTA ELECTRICAL STIM MANUAL PER 15 MIN,4309703202,CDM,430,RC,,,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT IONTOPHORESIS PER 15 MIN,4309703301,CDM,430,RC,97033,HCPCS,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT CONTRAST BATH PER 15 MIN,4309703401,CDM,430,RC,,,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT ULTRASOUND PER 15 MIN,4309703501,CDM,430,RC,97035,HCPCS,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT THERAPEUTIC PROC PER 15 MIN,4309711001,CDM,430,RC,97110,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTA THERAPEUTIC PROC PER 15 MIN,4309711002,CDM,430,RC,,,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT NEUROMUSCULAR RE-EDUCATION PER 15 MIN,4309711201,CDM,430,RC,97112,HCPCS,facility,both,,,,75,75,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTA NEUROMUSULAR RE-EDUCATION PER 15 MIN,4309711202,CDM,430,RC,,,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,4309712901,CDM,430,RC,97129,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES,4309713001,CDM,430,RC,97130,HCPCS,facility,both,,,,51,51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT MANUAL THERAPY PER 15 MIN,4309714001,CDM,430,RC,97140,HCPCS,facility,both,,,,75,75,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT THERAPEUTIC FUNCTIONAL ACTIVITY,4309753001,CDM,430,RC,97530,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTA THERAPEUTIC FUNCTIONAL ACTIVITY,4309753002,CDM,430,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT SENSORY INTEGRAT PER UNIT,4309753301,CDM,430,RC,97533,HCPCS,facility,both,,,,134,134,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT ADL/SELFCARE/HMETRN PER UNIT,4309753501,CDM,430,RC,97535,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTA ADL/SELFCARE/HMETRN PER UNIT,4309753502,CDM,430,RC,,,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT COMMUN/WORK REINTEGR / UNIT,4309753701,CDM,430,RC,97537,HCPCS,facility,both,,,,69,69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT WHEELCHAIR MGT EA 15 MINUTES,4309754201,CDM,430,RC,97542,HCPCS,facility,both,,,,65,65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTA WHEELCHAIR MGT EA 15 MIN,4309754202,CDM,430,RC,,,facility,both,,,,71,71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT WORK HARD/COND INITIAL 2 HRS,4309754501,CDM,430,RC,,,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT WORK HARD/COND EACH ADDTL HOUR,4309754601,CDM,430,RC,,,facility,both,,,,313,313,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAREGIVER TRAINING STRATEGIES&TQ 1ST 30 MINUTES,4309755001,CDM,430,RC,97550,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAREGIVER TRAINING STRATEGIES&TQ EA ADDL 15 MIN,4309755101,CDM,430,RC,97551,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GROUP CAREGIVER TRAINING STRATEGIES & TECHNIQUE,4309755201,CDM,430,RC,,,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT DEBRIDEMENT 20 SQ CM OR LESS,4309759701,CDM,430,RC,97597,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT DEBRIDEMENT ADDTL 20 SQ CM,4309759801,CDM,430,RC,,,facility,both,,,,281,281,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT NON-SELECTIVE DEBRIDEMENT,4309760201,CDM,430,RC,97602,HCPCS,facility,both,,,,211,211,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT NEG PRESS WOUND TX LESS THAN OR EQUAL TO 50 SQ CM WITH DME,4309760501,CDM,430,RC,97605,HCPCS,facility,both,,,,452,452,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT NEG PRESS WOUND TX GREATER THAN 50 SQ CM WITH DME,4309760601,CDM,430,RC,97606,HCPCS,facility,both,,,,714,714,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT PHYS PERFORM/FCE PER UNIT,4309775001,CDM,430,RC,97750,HCPCS,facility,both,,,,79,79,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT ASSIST TECH ASSMNT EA 15 MIN,4309775501,CDM,430,RC,97755,HCPCS,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT ORTHOTICS MGMT & TRAINJ INITIAL ENCTR EA 15 MINS,4309776001,CDM,430,RC,97760,HCPCS,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT PROSTHETICS TRAINING INITIAL ENCTR EA 15 MINS,4309776101,CDM,430,RC,97761,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN,4309776301,CDM,430,RC,97763,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT OL DIGITAL ASSMT&MGMT EST PT <7 D 5-10 MIN,4309897001,CDM,430,RC,,,facility,both,,,,28,28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT OL DIGITAL ASSMT&MGMT EST PT <7 D 11-20 MIN,4309897101,CDM,430,RC,,,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT OL DIGITAL ASSMT&MGMT EST PT <7 D 21+ MIN,4309897201,CDM,430,RC,,,facility,both,,,,72,72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT THERAPEUTIC PROCEDURE GROUP,4339715001,CDM,433,RC,97150,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT ORAL/PHARY SWALLOWING EVALU,4349261001,CDM,434,RC,92610,HCPCS,facility,both,,,,333,333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT LOW COMPLEX EVALUATION,4349716501,CDM,434,RC,97165,HCPCS,facility,both,,,,226,226,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT MOD COMPLEX EVALUATION,4349716601,CDM,434,RC,97166,HCPCS,facility,both,,,,230,230,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT HIGH COMPLEX EVALUATION,4349716701,CDM,434,RC,97167,HCPCS,facility,both,,,,242,242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OT RE EVALUATION,4349716801,CDM,434,RC,97168,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GROUP THERAPY,4409250802,CDM,440,RC,92508,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST NASAL FUNCTION STUDIES,4409251201,CDM,440,RC,92512,HCPCS,facility,both,,,,325,325,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST THERAP SVCS SPCH GEN DEVICE,4409260901,CDM,440,RC,92609,HCPCS,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST COGNITIVE PERFORM PER HOUR,4409612501,CDM,440,RC,96125,HCPCS,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,4409712901,CDM,440,RC,97129,HCPCS,facility,both,,,,52,52,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES,4409713001,CDM,440,RC,97130,HCPCS,facility,both,,,,51,51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAREGIVER TRAINING STRATEGIES&TQ 1ST 30 MINUTES,4409755001,CDM,440,RC,97550,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAREGIVER TRAINING STRATEGIES&TQ EA ADDL 15 MIN,4409755101,CDM,440,RC,97551,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GROUP CAREGIVER TRAINING STRATEGIES & TECHNIQUE,4409755201,CDM,440,RC,97552,HCPCS,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLP OL DIGITAL ASSMT&MGMT EST PT <7 D 5-10 MIN,4409897001,CDM,440,RC,,,facility,both,,,,31,31,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLP OL DIGITAL ASSMT&MGMT EST PT <7 D 11-20 MIN,4409897101,CDM,440,RC,,,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLP OL DIGITAL ASSMT&MGMT EST PT <7 D 21+ MIN,4409897201,CDM,440,RC,,,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST SPEECH/LANGUAGE/VOICE THERAPY,4419250701,CDM,441,RC,92507,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST FEEDING/SWALLOWING TREATMENT,4419252601,CDM,441,RC,92526,HCPCS,facility,both,,,,214,214,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST VOICE PROSTHETIC EVALUATION,4419259701,CDM,441,RC,92597,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST SPEECH FLUENCY EVALUATION,4449252101,CDM,444,RC,92521,HCPCS,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST SPEECH SOUND PROD EVALUATION,4449252201,CDM,444,RC,92522,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST SPEECH COMP/EXPRESS EVAL,4449252301,CDM,444,RC,92523,HCPCS,facility,both,,,,299,299,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST BEHAVORIAL QUALITATIVE EVAL,4449252401,CDM,444,RC,92524,HCPCS,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV F2F 1ST HR,4449260501,CDM,444,RC,92605,HCPCS,facility,both,,,,684,684,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST EVAL SPCH GEN DEVICE 1ST HR,4449260701,CDM,444,RC,92607,HCPCS,facility,both,,,,618,618,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST EVAL SPCH GEN DEVICE ADDTL 30 MIN,4449260801,CDM,444,RC,92608,HCPCS,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST ORAL/PHARY SWALLOWING EVALU,4449261001,CDM,444,RC,92610,HCPCS,facility,both,,,,333,333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST MOTION FLUOR EVAL SWLNG FUNCJ C/V REC,4449261101,CDM,444,RC,92611,HCPCS,facility,both,,,,438,438,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST FIBEROPT ENDO EVAL OF SWALLOW,4449261201,CDM,444,RC,92612,HCPCS,facility,both,,,,528,528,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLEXIBLE ENDOSCOPIC EVAL LARYN SENSORY C/V REC,4449261401,CDM,444,RC,,,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST EVAL NONSPEECH GEN ADDTL 30 MIN,4449261801,CDM,444,RC,,,facility,both,,,,226,226,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ST ASSESSMENT OF APHASIA,4449610501,CDM,444,RC,96105,HCPCS,facility,both,,,,420,420,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 1 ACTIVATION LEVEL 1 NON NOTIFICATION,4500000001,CDM,450,RC,,,facility,both,,,,9613,9613,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 1 ACTIVATION LEVEL 2 NON NOTIFICATION,4500000002,CDM,450,RC,,,facility,both,,,,7805,7805,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 1 OR 2 EVALUATION NON NOTIFICATION,4500000003,CDM,450,RC,,,facility,both,,,,3579,3579,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 3 ACTIVATION LEVEL 1 NON NOTIFICATION,4500000004,CDM,450,RC,,,facility,both,,,,7706,7706,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 3 ACTIVATION LEVEL 2 NON NOTIFICATION,4500000005,CDM,450,RC,,,facility,both,,,,5154,5154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 3 EVALUATION NON NOTIFICATION,4500000006,CDM,450,RC,,,facility,both,,,,3022,3022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION,4501002101,CDM,450,RC,10021,HCPCS,facility,both,,,,447,447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE OF SKIN ABSCESS SIMPLE,4501006001,CDM,450,RC,10060,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE OF SKIN ABSCESS COMP,4501006101,CDM,450,RC,10061,HCPCS,facility,both,,,,348,348,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE PILONIDAL CYST SIMPLE,4501008001,CDM,450,RC,10080,HCPCS,facility,both,,,,805,805,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INCISION & DRAINAGE PILONIDAL CYST COMPLICATED,4501008101,CDM,450,RC,10081,HCPCS,facility,both,,,,1074,1074,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVE FOREIGN BODY SUBQ SIMPLE,4501012001,CDM,450,RC,10120,HCPCS,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVE FOREIGN BODY SUBQ COMPLEX,4501012101,CDM,450,RC,10121,HCPCS,facility,both,,,,2088,2088,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE OF HEMATOMA FLUID,4501014001,CDM,450,RC,10140,HCPCS,facility,both,,,,1518,1518,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST,4501016001,CDM,450,RC,10160,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INCISION & DRAINAGE COMPLEX PO WOUND INFECTION,4501018001,CDM,450,RC,10180,HCPCS,facility,both,,,,2439,2439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDEMENT INFECTED SKIN UP TO 10%,4501100001,CDM,450,RC,11000,HCPCS,facility,both,,,,568,568,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDEMENT EACH ADDTL 10%,4501100101,CDM,450,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS,4501101001,CDM,450,RC,,,facility,both,,,,1525,1525,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DBRDMT FX&/DISLC SUBQ T/M/F BONE,4501101201,CDM,450,RC,,,facility,both,,,,2439,2439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDE SUBQ 20 SQ CM OR LESS,4501104201,CDM,450,RC,11042,HCPCS,facility,both,,,,408,408,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM OR LESS,4501104301,CDM,450,RC,11043,HCPCS,facility,both,,,,566,566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDE BONE 20 SQ CM OR LESS,4501104401,CDM,450,RC,,,facility,both,,,,2430,2430,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDE SUBQ EA ADDTL 20 SQ CM,4501104501,CDM,450,RC,11045,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDEMENT MUSCLE &/FASCIA EA ADDL 20 SQ CM,4501104601,CDM,450,RC,,,facility,both,,,,532,532,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED  PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1,4501105501,CDM,450,RC,,,facility,both,,,,243,243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INCISIONAL BIOPSY SKIN SINGLE LESION,4501110601,CDM,450,RC,,,facility,both,,,,914,914,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXCISE SKIN TAGS 15 TAGS OR LESS,4501120001,CDM,450,RC,11200,HCPCS,facility,both,,,,183,183,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SHAVING SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM,4501130101,CDM,450,RC,,,facility,both,,,,547,547,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/<,4501130501,CDM,450,RC,,,facility,both,,,,256,256,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6-1.0 CM,4501130601,CDM,450,RC,,,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SHAVE SKIN LESION FACE 0.5 CM OR LESS,4501131001,CDM,450,RC,,,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC BENIGN LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM,4501140101,CDM,450,RC,,,facility,both,,,,1630,1630,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC BENIGN LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM,4501140201,CDM,450,RC,11402,HCPCS,facility,both,,,,1448,1448,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC BENIGN LESION MRGN XCP SK TG T/A/L 2.1-3.0 CM,4501140301,CDM,450,RC,11403,HCPCS,facility,both,,,,2546,2546,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC BENIGN LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/<,4501142001,CDM,450,RC,,,facility,both,,,,1672,1672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC BENIGN LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0 CM,4501142101,CDM,450,RC,11421,HCPCS,facility,both,,,,1263,1263,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC BENIGN LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM,4501142201,CDM,450,RC,11422,HCPCS,facility,both,,,,2042,2042,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXCISE BENIGN LESION FACE 0.5 CM OR LESS,4501144001,CDM,450,RC,,,facility,both,,,,992,992,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXCISE BENIGN LESION FACE 0.6 TO 1 CM,4501144101,CDM,450,RC,,,facility,both,,,,1240,1240,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC BENIGN LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM,4501144301,CDM,450,RC,,,facility,both,,,,1939,1939,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRIMMING NONDYSTROPHIC NAILS ANY NUMBER,4501171901,CDM,450,RC,11719,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDE NAIL  6 OR MORE,4501172101,CDM,450,RC,,,facility,both,,,,181,181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED AVULSION OF NAIL PLATE SINGLE,4501173001,CDM,450,RC,11730,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL,4501173201,CDM,450,RC,11732,HCPCS,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAIN BLOOD FROM UNDER NAIL,4501174001,CDM,450,RC,11740,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVAL OF NAIL BED,4501175001,CDM,450,RC,11750,HCPCS,facility,both,,,,447,447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR OF NAIL BED,4501176001,CDM,450,RC,11760,HCPCS,facility,both,,,,536,536,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED RECONSTRUCTION OF NAIL BED WITH GRAFT,4501176201,CDM,450,RC,,,facility,both,,,,2364,2364,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXCISION OF NAIL FOLD TOE,4501176501,CDM,450,RC,11765,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERT OF IMPLANT,4501197101,CDM,450,RC,,,facility,both,,,,5130,5130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVE CONTRACEPTIVE CAPSULE,4501197601,CDM,450,RC,,,facility,both,,,,1189,1189,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVE DRUG IMPLANT DEVICE,4501198201,CDM,450,RC,11982,HCPCS,facility,both,,,,346,346,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR SIMPLE WOUND TRUNK/SCALP 2.5 CM OR LESS,4501200101,CDM,450,RC,12001,HCPCS,facility,both,,,,190,190,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR SIMPLE WOUND TRUNK/SCALP 2.6 TO 7.5 CM,4501200201,CDM,450,RC,12002,HCPCS,facility,both,,,,218,218,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR SIMPLE WOUND TRUNK/SCALP 7.6 TO 12.5 CM,4501200401,CDM,450,RC,12004,HCPCS,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR SIMPLE WOUND TRUNK/SCALP 12.6 TO 20 CM,4501200501,CDM,450,RC,12005,HCPCS,facility,both,,,,356,356,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM,4501200601,CDM,450,RC,12006,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM,4501200701,CDM,450,RC,12007,HCPCS,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,4501201101,CDM,450,RC,12011,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,4501201301,CDM,450,RC,12013,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR SIMPLE WOUND FACE 5.1 TO 7.5 CM,4501201401,CDM,450,RC,12014,HCPCS,facility,both,,,,282,282,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SIMPLE REPAIR F/E/E/N/L/M 7.6-12.5CM,4501201501,CDM,450,RC,12015,HCPCS,facility,both,,,,325,325,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM,4501201601,CDM,450,RC,12016,HCPCS,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR SIMPLE WOUND FACE 20.1 TO 30 CM,4501201701,CDM,450,RC,,,facility,both,,,,532,532,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSURE OF SIMPLE WOUND SUPERFICIAL,4501202001,CDM,450,RC,12020,HCPCS,facility,both,,,,608,608,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSURE OF SIMPLE WOUND SUPERFICIAL WITH PACK,4501202101,CDM,450,RC,,,facility,both,,,,421,421,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE WOUND TRUNK/SCALP 2.5 CM OR LESS,4501203101,CDM,450,RC,12031,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE WOUND TRUNK/SCALP 2.6 TO 7.5 CM,4501203201,CDM,450,RC,12032,HCPCS,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM,4501203401,CDM,450,RC,12034,HCPCS,facility,both,,,,481,481,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND TRUNK/SCALP 12.6 TO 20 CM,4501203501,CDM,450,RC,12035,HCPCS,facility,both,,,,553,553,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM,4501203601,CDM,450,RC,12036,HCPCS,facility,both,,,,905,905,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND TRUNK/SCALP 30.1 CM OR GREATER,4501203701,CDM,450,RC,12037,HCPCS,facility,both,,,,2139,2139,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE WOUND NECK/EXTREMITY 2.5 CM OR LESS,4501204101,CDM,450,RC,12041,HCPCS,facility,both,,,,447,447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE WOUND NECK/EXTREMITY 2.6 TO 7.5 CM,4501204201,CDM,450,RC,12042,HCPCS,facility,both,,,,515,515,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND NECK/EXTREMITY 7.6 TO 12.5 CM,4501204401,CDM,450,RC,12044,HCPCS,facility,both,,,,566,566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND NECK/EXTREMITY 12.8,4501204501,CDM,450,RC,12045,HCPCS,facility,both,,,,752,752,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND NECK/EXTREMITY 20.1 TO 30 CM,4501204601,CDM,450,RC,12046,HCPCS,facility,both,,,,977,977,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE WOUND FACE 2.5 CM OR LESS,4501205101,CDM,450,RC,12051,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE WOUND FACE 2.6 TO 5 CM,4501205201,CDM,450,RC,12052,HCPCS,facility,both,,,,429,429,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR INTERMEDIATE WOUND FACE 5.1 TO 7.5 CM,4501205301,CDM,450,RC,12053,HCPCS,facility,both,,,,493,493,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND FACE 7.6 TO 12.5 CM,4501205401,CDM,450,RC,12054,HCPCS,facility,both,,,,568,568,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND FACE 12.6 TO 20 CM,4501205501,CDM,450,RC,12055,HCPCS,facility,both,,,,652,652,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND FACE 20.1 TO 30 CM,4501205601,CDM,450,RC,,,facility,both,,,,863,863,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX TRUNK 2.6-7.5 CM,4501310101,CDM,450,RC,,,facility,both,,,,839,839,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/<,4501310201,CDM,450,RC,,,facility,both,,,,350,350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM,4501312001,CDM,450,RC,13120,HCPCS,facility,both,,,,1220,1220,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM,4501312101,CDM,450,RC,13121,HCPCS,facility,both,,,,1040,1040,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/<,4501312201,CDM,450,RC,13122,HCPCS,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX WOUND F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,4501313101,CDM,450,RC,13131,HCPCS,facility,both,,,,597,597,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COMPLEX WOUND FACE 2.6 TO 7.5 CM,4501313201,CDM,450,RC,13132,HCPCS,facility,both,,,,905,905,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,4501313301,CDM,450,RC,13133,HCPCS,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM,4501315101,CDM,450,RC,13151,HCPCS,facility,both,,,,791,791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM,4501315201,CDM,450,RC,13152,HCPCS,facility,both,,,,911,911,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/<,4501315301,CDM,450,RC,13153,HCPCS,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED LATE CLOSURE OF WOUND,4501316001,CDM,450,RC,13160,HCPCS,facility,both,,,,4453,4453,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<,4501404001,CDM,450,RC,,,facility,both,,,,3273,3273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TISSUE TRAN 10.1 TO 30 SQ CM,4501404101,CDM,450,RC,,,facility,both,,,,4530,4530,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ADJNT TIS TRNSFR/REARGMT ANY AREA 30.1-60 SQ CM,4501430101,CDM,450,RC,,,facility,both,,,,12013,12013,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PINCH GRAFT UP TO 2 CM,4501505001,CDM,450,RC,,,facility,both,,,,1264,1264,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FULL THICK GRAFT 20 SQ CM OR LESS,4501524001,CDM,450,RC,,,facility,both,,,,2333,2333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SUB GRFT F/S/N/H/F/G/M/D <100SQ CM 1ST 25 SQ CM,4501527501,CDM,450,RC,,,facility,both,,,,3224,3224,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA,4501576001,CDM,450,RC,,,facility,both,,,,4210,4210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRESSING CHANGE WITH ANESTHESIA,4501585201,CDM,450,RC,15852,HCPCS,facility,both,,,,1472,1472,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BURN TX 1ST DEGREE BURN,4501600001,CDM,450,RC,16000,HCPCS,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,4501602001,CDM,450,RC,16020,HCPCS,facility,both,,,,232,232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BURN CLINIC-TREAT BURN MEDIUM,4501602501,CDM,450,RC,16025,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BURN CLINIC-TREAT BURN LARGE,4501603001,CDM,450,RC,16030,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION OF BURN SCAB INIT,4501603501,CDM,450,RC,,,facility,both,,,,545,545,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESCHAROTOMY ADDITIONAL INCISION,4501603601,CDM,450,RC,,,facility,both,,,,228,228,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DESTRUCT 1ST BENIGN LESION,4501700001,CDM,450,RC,,,facility,both,,,,248,248,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DESTRUCT BENIGN LESION 2-14,4501700301,CDM,450,RC,,,facility,both,,,,158,158,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DESTRUCT BENIGN LESION 1 TO 14,4501711001,CDM,450,RC,,,facility,both,,,,248,248,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CHEMICAL CAUTERIZATION OF GRANULATION TISSUE,4501725001,CDM,450,RC,17250,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED  UNLISTED PX SKIN MUC MEMBRANE & SUBQ TISSUE,4501799901,CDM,450,RC,,,facility,both,,,,680,680,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CYST BREAST ASPIRATION,4501900001,CDM,450,RC,19000,HCPCS,facility,both,,,,635,635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED MASTOTOMY WITH DRAINAGE,4501902001,CDM,450,RC,19020,HCPCS,facility,both,,,,2841,2841,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED INCISION AND DRAINAGE OF NIPPLE,4501949901,CDM,450,RC,,,facility,both,,,,4379,4379,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXPLORE WOUND NECK,4502010001,CDM,450,RC,,,facility,both,,,,861,861,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK,4502010201,CDM,450,RC,20102,HCPCS,facility,both,,,,1950,1950,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXPLORE WOUND EXTREMITY,4502010301,CDM,450,RC,20103,HCPCS,facility,both,,,,3543,3543,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE,4502052001,CDM,450,RC,20520,HCPCS,facility,both,,,,1744,1744,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP,4502052501,CDM,450,RC,,,facility,both,,,,4523,4523,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION STEROID CARPAL TUN,4502052601,CDM,450,RC,,,facility,both,,,,564,564,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION TENDON LIGAMENT,4502055001,CDM,450,RC,,,facility,both,,,,425,425,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION TENDON ORIGIN INSERT,4502055101,CDM,450,RC,,,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES,4502055201,CDM,450,RC,20552,HCPCS,facility,both,,,,348,348,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION TRIGGER POINT 3 OR MORE,4502055301,CDM,450,RC,20553,HCPCS,facility,both,,,,482,482,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLE,4502056001,CDM,450,RC,,,facility,both,,,,133,133,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED NEEDLE INSERTION W/O INJECTION 3 OR MORE MUSCLES,4502056101,CDM,450,RC,,,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION ARTHROCENTESIS SMALL JT,4502060001,CDM,450,RC,20600,HCPCS,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT,4502060401,CDM,450,RC,,,facility,both,,,,660,660,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION ARTHROCENTESIS INTERMEDIATE JT WITHOUT US,4502060501,CDM,450,RC,20605,HCPCS,facility,both,,,,389,389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ARTHROCENT INTMD JT LT W US,4502060601,CDM,450,RC,20606,HCPCS,facility,both,,,,822,822,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION ARTHROCENTESIS MAJOR JT WITHOUT US,4502061001,CDM,450,RC,20610,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ARTHROCENTESIS MAJOR JT WITH US,4502061101,CDM,450,RC,20611,HCPCS,facility,both,,,,944,944,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ASPIRATION INJECTION GANGLION CYST,4502061201,CDM,450,RC,20612,HCPCS,facility,both,,,,532,532,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT REMOVE WIRE PIN,4502065001,CDM,450,RC,20650,HCPCS,facility,both,,,,2913,2913,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX,4502066001,CDM,450,RC,,,facility,both,,,,5659,5659,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION HALO CRANIAL INCLUDING REMOVAL,4502066101,CDM,450,RC,,,facility,both,,,,300,300,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED HALO REMOVAL APP BY OTHER PHYS,4502066501,CDM,450,RC,,,facility,both,,,,1601,1601,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVAL IMPLANT SUPERFICIAL SEPARATE PROCEDURE,4502067001,CDM,450,RC,,,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM,4502069001,CDM,450,RC,,,facility,both,,,,7476,7476,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLANT DIGIT COMPLETE,4502081601,CDM,450,RC,,,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLANT FINGER COMPLETE,4502082201,CDM,450,RC,,,facility,both,,,,5639,5639,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED MONITOR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME,4502095001,CDM,450,RC,,,facility,both,,,,855,855,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MAN TMJ WITH ANESTHESIA,4502107301,CDM,450,RC,,,facility,both,,,,1811,1811,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC,4502111001,CDM,450,RC,21110,HCPCS,facility,both,,,,5309,5309,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX NASAL FX WITHOUT STABILIZATION,4502131501,CDM,450,RC,21315,HCPCS,facility,both,,,,1876,1876,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TREATMENT NASAL FRACTURE W/STABILIZATION,4502132001,CDM,450,RC,,,facility,both,,,,14480,14480,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OPEN TX NASAL FX UNCOMPLICATED,4502132501,CDM,450,RC,,,facility,both,,,,3751,3751,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX NASAL SEPTAL FRACT W/WO STABILIZATION,4502133701,CDM,450,RC,,,facility,both,,,,3794,3794,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX NASOMAXILLARY COMPLEX FRACTURE,4502134501,CDM,450,RC,,,facility,both,,,,1783,1783,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX PALATAL/MAXILLARY FX W/FIXATION/SPLINT,4502142101,CDM,450,RC,,,facility,both,,,,4906,4906,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT CRANIOFACIAL FRACTURE,4502143101,CDM,450,RC,,,facility,both,,,,2291,2291,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE,4502144001,CDM,450,RC,,,facility,both,,,,12410,12410,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ,4502148001,CDM,450,RC,21480,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESET DISLOCATED JAW,4502148501,CDM,450,RC,,,facility,both,,,,1553,1553,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERDENTAL WIRING,4502149701,CDM,450,RC,,,facility,both,,,,4023,4023,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX VRT BDY FX W/O MANJ REQ&W/CSTING/BRACING,4502231001,CDM,450,RC,,,facility,both,,,,893,893,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL FB SHOULDER SUBQ,4502333001,CDM,450,RC,,,facility,both,,,,1848,1848,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SHOULDER FOREIGN BODY DEEP,4502333301,CDM,450,RC,,,facility,both,,,,3406,3406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLSD TX CLAVICULAR FRACTURE W/MANIPULATION,4502350501,CDM,450,RC,,,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLSD TX STERNOCLAVICULAR DISLC W/O MANIPULATION,4502352001,CDM,450,RC,,,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION,4502352501,CDM,450,RC,,,facility,both,,,,424,424,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION,4502354001,CDM,450,RC,,,facility,both,,,,433,433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION,4502354501,CDM,450,RC,23545,HCPCS,facility,both,,,,279,279,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION,4502357001,CDM,450,RC,23570,HCPCS,facility,both,,,,502,502,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX SCAPULAR FX W/MANJ W/WO SKELETAL TRACTION,4502357501,CDM,450,RC,23575,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION,4502360001,CDM,450,RC,,,facility,both,,,,478,478,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX PROX HUMRL FX W/MANJ W/WO SKELETAL TRACJ,4502360501,CDM,450,RC,23605,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX GREATER HUMERAL TUBEROSITY FX W/O MANJ,4502362001,CDM,450,RC,23620,HCPCS,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,4502362501,CDM,450,RC,,,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES,4502365001,CDM,450,RC,23650,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,4502365501,CDM,450,RC,23655,HCPCS,facility,both,,,,2398,2398,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ,4502366501,CDM,450,RC,23665,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX SHOULDER DISLC W/SURG/ANTMCL NECK FX W/MANJ,4502367501,CDM,450,RC,23675,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ID ARM ELBOW DEEP ABSCESS,4502393001,CDM,450,RC,,,facility,both,,,,4431,4431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ID UPPER ARM ELBOW  BURSA,4502393101,CDM,450,RC,23931,HCPCS,facility,both,,,,2368,2368,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS,4502420001,CDM,450,RC,24200,HCPCS,facility,both,,,,1688,1688,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP,4502420101,CDM,450,RC,,,facility,both,,,,7720,7720,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR TEND MSCL UPPER ARM,4502434101,CDM,450,RC,,,facility,both,,,,9808,9808,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,4502450001,CDM,450,RC,,,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,4502450501,CDM,450,RC,24505,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/WO MANJ,4502453001,CDM,450,RC,24530,HCPCS,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ,4502453501,CDM,450,RC,24535,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MANJ,4502456001,CDM,450,RC,,,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ,4502456501,CDM,450,RC,24565,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MANJ,4502457601,CDM,450,RC,,,facility,both,,,,604,604,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MANJ,4502457701,CDM,450,RC,24577,HCPCS,facility,both,,,,1672,1672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,4502460001,CDM,450,RC,24600,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TREATMENT CLOSED ELBOW DISLOCATION REQ ANES,4502460501,CDM,450,RC,24605,HCPCS,facility,both,,,,2248,2248,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ,4502462001,CDM,450,RC,24620,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ,4502464001,CDM,450,RC,24640,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION,4502465001,CDM,450,RC,24650,HCPCS,facility,both,,,,502,502,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION,4502465501,CDM,450,RC,24655,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ,4502467001,CDM,450,RC,24670,HCPCS,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ,4502467501,CDM,450,RC,24675,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED REDUCTION OF ELBOW WITH FX,4502499901,CDM,450,RC,24999,HCPCS,facility,both,,,,411,411,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISE TENDON SHEATH WRIST,4502500001,CDM,450,RC,,,facility,both,,,,5399,5399,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL FOREARM FOREIGN BODY,4502524801,CDM,450,RC,,,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR TENDON MUSCLE FLEX,4502526001,CDM,450,RC,,,facility,both,,,,5963,5963,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR TENDON EXTENSOR,4502527001,CDM,450,RC,,,facility,both,,,,5582,5582,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR RADIUS OR ULNA,4502540001,CDM,450,RC,,,facility,both,,,,11500,11500,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION,4502550001,CDM,450,RC,,,facility,both,,,,440,440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX RADIAL SHAFT FX WITH MANIPULATION,4502550501,CDM,450,RC,25505,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT,4502552001,CDM,450,RC,,,facility,both,,,,6782,6782,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,4502553001,CDM,450,RC,,,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION,4502553501,CDM,450,RC,25535,HCPCS,facility,both,,,,490,490,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN,4502556001,CDM,450,RC,25560,HCPCS,facility,both,,,,367,367,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ,4502556501,CDM,450,RC,25565,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ,4502560001,CDM,450,RC,25600,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,4502560501,CDM,450,RC,25605,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX CARPAL SCAPHOID FRACTURE W/O MANJ,4502562201,CDM,450,RC,,,facility,both,,,,575,575,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX CARPAL SCAPHOID FRACTURE W/MANJ,4502562401,CDM,450,RC,25624,HCPCS,facility,both,,,,1403,1403,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX CARPAL BONE FX W/O MANJ EACH BONE,4502563001,CDM,450,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX CARPAL BONE FX W/MANJ EACH BONE,4502563501,CDM,450,RC,25635,HCPCS,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TREATMENT ULNAR STYLOID FRACTURE,4502565001,CDM,450,RC,,,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLSD TX DISLOCATED WRIST W MANIPULATION,4502566001,CDM,450,RC,25660,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED  CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ,4502567501,CDM,450,RC,25675,HCPCS,facility,both,,,,332,332,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX SCAPHOPERILUN FX DS,4502568001,CDM,450,RC,,,facility,both,,,,499,499,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX LUNATE DISLOCATION W/MANIPULATION,4502569001,CDM,450,RC,25690,HCPCS,facility,both,,,,1621,1621,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE FINGER ABSCESS SIMPLE,4502601001,CDM,450,RC,26010,HCPCS,facility,both,,,,265,265,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE FINGER ABSCESS COMPLICATED,4502601101,CDM,450,RC,26011,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE TENDON SHEATH,4502602001,CDM,450,RC,26020,HCPCS,facility,both,,,,3066,3066,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ARTHROTOMY WITH EXPLORE MCP,4502607501,CDM,450,RC,,,facility,both,,,,3928,3928,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA,4502608001,CDM,450,RC,,,facility,both,,,,3552,3552,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVISE FINGER JOINT EACH,4502614001,CDM,450,RC,,,facility,both,,,,7018,7018,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SYNOVECTOMY FLEXR TEND,4502614501,CDM,450,RC,26145,HCPCS,facility,both,,,,3729,3729,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PARTIAL REMOVAL FINGER BONE,4502623601,CDM,450,RC,26236,HCPCS,facility,both,,,,3728,3728,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR FLEX TEND HAND,4502635001,CDM,450,RC,,,facility,both,,,,6333,6333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR PROFUNDUS TEND,4502637001,CDM,450,RC,,,facility,both,,,,6349,6349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR EXT TENDON HAND,4502641001,CDM,450,RC,,,facility,both,,,,2863,2863,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR EXT TENDON FINGER,4502641801,CDM,450,RC,26418,HCPCS,facility,both,,,,2218,2218,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR GRAFT TENDON FINGER,4502642001,CDM,450,RC,,,facility,both,,,,7514,7514,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR BUTONNIERE DEFORMITY,4502642601,CDM,450,RC,,,facility,both,,,,7250,7250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DSTL XTNSR TDN INSJ W/WO PERCUTAN PINNING,4502643201,CDM,450,RC,,,facility,both,,,,1892,1892,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR EXT TENDON DIST,4502643301,CDM,450,RC,,,facility,both,,,,3897,3897,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REALIGN EXTN TEND HAND,4502643701,CDM,450,RC,,,facility,both,,,,4143,4143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CAPSULECTOMY/CAPSULOTOMY MTCARPHLNGL JOINT EACH,4502652001,CDM,450,RC,,,facility,both,,,,3925,3925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RELEASE FINGER CONTRACTURE,4502652501,CDM,450,RC,,,facility,both,,,,7018,7018,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COLLAT LIG MCP,4502654001,CDM,450,RC,,,facility,both,,,,3897,3897,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR  HAND MUSCLES,4502659101,CDM,450,RC,,,facility,both,,,,6646,6646,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX METACARPAL FX W/O MANIPULATION EACH BONE,4502660001,CDM,450,RC,,,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX METACARPAL FX W/MANIPULATION EACH BONE,4502660501,CDM,450,RC,26605,HCPCS,facility,both,,,,429,429,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTAN FIX METACARPAL FX,4502660801,CDM,450,RC,,,facility,both,,,,5286,5286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OPEN TX METACARPAL FRACTURE SINGLE EA BONE,4502661501,CDM,450,RC,,,facility,both,,,,5952,5952,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX CARPO/METACARPAL DISLOCATION THUMB W/MANJ,4502664101,CDM,450,RC,26641,HCPCS,facility,both,,,,291,291,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ,4502664501,CDM,450,RC,26645,HCPCS,facility,both,,,,1637,1637,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PRQ SKELETAL FIX CARPO/METACARPAL FX DISLC THUMB,4502665001,CDM,450,RC,,,facility,both,,,,17004,17004,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES,4502667001,CDM,450,RC,26670,HCPCS,facility,both,,,,344,344,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT HAND DISLOCATON,4502667501,CDM,450,RC,26675,HCPCS,facility,both,,,,1892,1892,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX METACARPOPHALANGEAL DISLC W/MANJ W/O ANES,4502670001,CDM,450,RC,26700,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX METACARPOPHALANGEAL DISLC W/MANJ W/ANES,4502670501,CDM,450,RC,26705,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPEN TX MCP DISLOCATION,4502671501,CDM,450,RC,,,facility,both,,,,9381,9381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX FINGER FX WITHOUT MAN,4502672001,CDM,450,RC,26720,HCPCS,facility,both,,,,247,247,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA,4502672501,CDM,450,RC,26725,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUT SKEL FIX FINGER,4502672701,CDM,450,RC,,,facility,both,,,,7450,7450,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA,4502673501,CDM,450,RC,,,facility,both,,,,5474,5474,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX ARTCLR FX INVG MTCRPHLNGL/IPHAL JT W/O MANJ,4502674001,CDM,450,RC,,,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ,4502674201,CDM,450,RC,26742,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPEN TX ARTICULAR FX,4502674601,CDM,450,RC,26746,HCPCS,facility,both,,,,6385,6385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA,4502675001,CDM,450,RC,,,facility,both,,,,288,288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA,4502675501,CDM,450,RC,26755,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUT SKELETAL FIX DP,4502675601,CDM,450,RC,,,facility,both,,,,8526,8526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OPEN TX DISTAL PHALANG,4502676501,CDM,450,RC,,,facility,both,,,,4855,4855,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX IPHAL JT DISLC W/MANJ W/O ANES,4502677001,CDM,450,RC,26770,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT FINGER DISLOCATION,4502677501,CDM,450,RC,26775,HCPCS,facility,both,,,,596,596,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERC SKELETAL FIX INTERPHAL,4502677601,CDM,450,RC,,,facility,both,,,,6359,6359,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPEN TX INTERPHALANGEAL,4502678501,CDM,450,RC,26785,HCPCS,facility,both,,,,8509,8509,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ARTHRODESIS INTERPHALANGEAL JT W/WO INT FIXJ,4502686001,CDM,450,RC,,,facility,both,,,,3925,3925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR,4502695101,CDM,450,RC,26951,HCPCS,facility,both,,,,2913,2913,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP,4502695201,CDM,450,RC,26952,HCPCS,facility,both,,,,2913,2913,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR SIMPLE WOUND UNSPECIFIED LENGTH,4502698901,CDM,450,RC,26989,HCPCS,facility,both,,,,1804,1804,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE HIP FOREIGN BODY,4502708601,CDM,450,RC,,,facility,both,,,,3406,3406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE HIP FOREIGN BODY DEEP,4502708701,CDM,450,RC,,,facility,both,,,,3925,3925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA,4502709601,CDM,450,RC,,,facility,both,,,,387,387,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TREATMENT COCCYGEAL FRACTURE,4502720001,CDM,450,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX ACETABULUM HIP/SOCKT FX W/O MANJ,4502722001,CDM,450,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX ACETABULM HIP/SOCKT FX MANJ W/WO SKEL TRACJ,4502722201,CDM,450,RC,27222,HCPCS,facility,both,,,,962,962,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FEM FX PROX END NCK W/O MANJ,4502723001,CDM,450,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT THIGH FRACTURE,4502723201,CDM,450,RC,27232,HCPCS,facility,both,,,,2377,2377,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MANJ,4502723801,CDM,450,RC,,,facility,both,,,,1892,1892,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVISION OF UNSTABLE KNEECAP,4502724001,CDM,450,RC,,,facility,both,,,,3033,3033,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX GREATER TROCHANTERIC FX W/O MANJ,4502724601,CDM,450,RC,,,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX HIP DISLOCATION TRAUMATIC W/O ANESTHESIA,4502725001,CDM,450,RC,27250,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA,4502725201,CDM,450,RC,27252,HCPCS,facility,both,,,,2678,2678,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX SPONT HIP DISL WITHOUT,4502725601,CDM,450,RC,,,facility,both,,,,363,363,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TX SPON HIP DISLC W/ MANJ ANES,4502725701,CDM,450,RC,,,facility,both,,,,6073,6073,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX POST HIP ARTHRP DISLC W/O ANES,4502726501,CDM,450,RC,27265,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX POST HIP ARTHRP DISLC REQ ANES,4502726601,CDM,450,RC,27266,HCPCS,facility,both,,,,4070,4070,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX FEMORAL FRACTURE PROX HEAD W/MANJ,4502726801,CDM,450,RC,,,facility,both,,,,3724,3724,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION AND DRAINAGE THIGH BURSA KNEE,4502730101,CDM,450,RC,,,facility,both,,,,3335,3335,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REMOVAL THIGH KNEE DEEP,4502737201,CDM,450,RC,,,facility,both,,,,4014,4014,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION,4502750001,CDM,450,RC,27500,HCPCS,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/O MANJ,4502750101,CDM,450,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ,4502750201,CDM,450,RC,27502,HCPCS,facility,both,,,,3379,3379,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/MANJ,4502750301,CDM,450,RC,27503,HCPCS,facility,both,,,,1601,1601,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/O MANJ,4502750801,CDM,450,RC,,,facility,both,,,,436,436,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MANJ,4502751001,CDM,450,RC,27510,HCPCS,facility,both,,,,1601,1601,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DISTAL FEMORAL EPIPHYSL SEPARATION W/O MANJ,4502751601,CDM,450,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DSTL FEM EPIPHYSL SEP W/MANJ W/WO SKIN/SKEL,4502751701,CDM,450,RC,,,facility,both,,,,1876,1876,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX PATELLAR FRACTURE W/O MANIPULATION,4502752001,CDM,450,RC,,,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX TIBIAL FX PROXIMAL W/O MANIPULATION,4502753001,CDM,450,RC,,,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX TIBIAL FX PROXIMAL W/WO MANJ W/SKEL TRACJ,4502753201,CDM,450,RC,27532,HCPCS,facility,both,,,,2913,2913,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX INTERCONDYLAR SPI&/TUBRST FX KNE W/WO MAN,4502753801,CDM,450,RC,,,facility,both,,,,671,671,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX KNEE DISLOCATION W/O ANESTHESIA,4502755001,CDM,450,RC,27550,HCPCS,facility,both,,,,277,277,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT KNEE DISLOCATION,4502755201,CDM,450,RC,27552,HCPCS,facility,both,,,,1656,1656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA,4502756001,CDM,450,RC,27560,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA,4502756201,CDM,450,RC,27562,HCPCS,facility,both,,,,995,995,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED MANIPULATION KNEE JOINT UNDER GEN ANESTHESIA,4502757001,CDM,450,RC,,,facility,both,,,,8596,8596,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED PROCEDURE FEMUR/KNEE,4502759901,CDM,450,RC,27599,HCPCS,facility,both,,,,339,339,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR ACHILLES TENDON,4502765001,CDM,450,RC,,,facility,both,,,,9039,9039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR EXT TENDON LEG,4502766401,CDM,450,RC,,,facility,both,,,,8721,8721,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR OF TIBIA,4502772001,CDM,450,RC,,,facility,both,,,,13604,13604,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX TIBIAL SHAFT FX W/O MANIPULATION,4502775001,CDM,450,RC,,,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,4502775201,CDM,450,RC,27752,HCPCS,facility,both,,,,1891,1891,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION,4502776001,CDM,450,RC,,,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ,4502776201,CDM,450,RC,27762,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MANJ,4502776701,CDM,450,RC,27767,HCPCS,facility,both,,,,492,492,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TREATMENT PST MALLEOLUS FRACTURE W/MANJ,4502776801,CDM,450,RC,,,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX PROX FIBULA/SHFT FX W/O MANJ,4502778001,CDM,450,RC,27780,HCPCS,facility,both,,,,502,502,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX PROX FIBULA/SHFT FX W/MANJ,4502778101,CDM,450,RC,27781,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ,4502778601,CDM,450,RC,27786,HCPCS,facility,both,,,,333,333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX DSTL FIBULAR FX LAT MALLS W/MANJ,4502778801,CDM,450,RC,27788,HCPCS,facility,both,,,,416,416,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANJ,4502780801,CDM,450,RC,27808,HCPCS,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,4502781001,CDM,450,RC,27810,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX TRIMALLEOLAR ANKLE FX W/O MANIPULATION,4502781601,CDM,450,RC,27816,HCPCS,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION,4502781801,CDM,450,RC,27818,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MANJ,4502782401,CDM,450,RC,27824,HCPCS,facility,both,,,,492,492,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ,4502782501,CDM,450,RC,27825,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX PROX TIBFIB JT DISLC W/O ANES,4502783001,CDM,450,RC,27830,HCPCS,facility,both,,,,380,380,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA,4502784001,CDM,450,RC,27840,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT ANKLE DISLOCATION,4502784201,CDM,450,RC,27842,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED ANKLE REDUCTION,4502789901,CDM,450,RC,27899,HCPCS,facility,both,,,,561,561,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PARTIAL REMOVAL OF TOE,4502812401,CDM,450,RC,,,facility,both,,,,8623,8623,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PARTIAL REMOVAL OF TOE JT,4502816001,CDM,450,RC,,,facility,both,,,,10059,10059,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REMOVAL OF FOOT SU,4502819001,CDM,450,RC,28190,HCPCS,facility,both,,,,657,657,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REMOVAL OF FOOT DEEP,4502819201,CDM,450,RC,28192,HCPCS,facility,both,,,,2242,2242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REMOVAL OF FOOT COM,4502819301,CDM,450,RC,,,facility,both,,,,1951,1951,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR TEND FLX FOOT,4502820001,CDM,450,RC,,,facility,both,,,,4960,4960,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REP TENDON EXT FOOT,4502820801,CDM,450,RC,,,facility,both,,,,5217,5217,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION,4502840001,CDM,450,RC,,,facility,both,,,,433,433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX CALCANEAL FRACTURE W/MANIPULATION,4502840501,CDM,450,RC,28405,HCPCS,facility,both,,,,490,490,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX TALUS FRACTURE W/O MANIPULATION,4502843001,CDM,450,RC,,,facility,both,,,,431,431,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX TALUS FRACTURE W/MANIPULATION,4502843501,CDM,450,RC,28435,HCPCS,facility,both,,,,1656,1656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX TARSAL WITHOUT EACH,4502845001,CDM,450,RC,,,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX TARSAL WITH MAN EACH,4502845501,CDM,450,RC,28455,HCPCS,facility,both,,,,1892,1892,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX METATARSAL FRACTURE W/O MANIPULATION,4502847001,CDM,450,RC,,,facility,both,,,,502,502,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX METAR FX W/MANJ,4502847501,CDM,450,RC,28475,HCPCS,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FX GRT TOE PHLX/PHLG W/O MANJ,4502849001,CDM,450,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FX GRT TOE PHLX/PHLG W/MANJ,4502849501,CDM,450,RC,28495,HCPCS,facility,both,,,,277,277,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ER FIX FX GR TOE WITH MAN PERC,4502849601,CDM,450,RC,,,facility,both,,,,5612,5612,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ,4502851001,CDM,450,RC,,,facility,both,,,,322,322,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ,4502851501,CDM,450,RC,28515,HCPCS,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TREATMENT SESAMOID FRACTURE,4502853001,CDM,450,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX TARSAL DISLC OTH/THN TALOTARSAL W/O ANES,4502854001,CDM,450,RC,,,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT TARSAL DISLOCATION,4502854501,CDM,450,RC,,,facility,both,,,,3925,3925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX TALOTARSAL JOINT DISLC W/O ANES,4502857001,CDM,450,RC,,,facility,both,,,,499,499,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT TALO TARSAL DISLOCATION,4502857501,CDM,450,RC,,,facility,both,,,,3925,3925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES,4502860001,CDM,450,RC,,,facility,both,,,,370,370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT TARSOMETATARSAL DISLOCATION,4502860501,CDM,450,RC,28605,HCPCS,facility,both,,,,678,678,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX METATARSOPHLNGL JT DISLC W/O ANES,4502863001,CDM,450,RC,28630,HCPCS,facility,both,,,,277,277,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX METATARSOPHLNGL JT DISLC REQ ANES,4502863501,CDM,450,RC,,,facility,both,,,,6548,6548,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,4502866001,CDM,450,RC,28660,HCPCS,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLTX INTERPHALANGEAL JOINT DISLOCATION REQ ANES,4502866501,CDM,450,RC,,,facility,both,,,,1255,1255,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUT SKELETAL FIX IP,4502866601,CDM,450,RC,,,facility,both,,,,8526,8526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPEN TREATMENT INTERPHALANGEAL JOINT DISLOCATION,4502867501,CDM,450,RC,,,facility,both,,,,9126,9126,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED AMPUTATION TOE METATARSOPHALANGEAL JOINT,4502882001,CDM,450,RC,,,facility,both,,,,4429,4429,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION CAST SHOULDER HAND LONG ARM,4502906501,CDM,450,RC,29065,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION CAST ELBOW FINGER SHORT ARM,4502907501,CDM,450,RC,29075,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION CAST HAND & LOWER FOREARM GAUNTLET,4502908501,CDM,450,RC,29085,HCPCS,facility,both,,,,694,694,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLY LONG ARM SPLINT,4502910501,CDM,450,RC,29105,HCPCS,facility,both,,,,181,181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC,4502912501,CDM,450,RC,29125,HCPCS,facility,both,,,,181,181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION SHORT ARM SPLINT DYNAMIC,4502912601,CDM,450,RC,,,facility,both,,,,181,181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION FINGER SPLINT STATIC,4502913001,CDM,450,RC,29130,HCPCS,facility,both,,,,181,181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STRAPPING SHOULDER,4502924001,CDM,450,RC,,,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STRAPPING ELBOW  WRIST,4502926001,CDM,450,RC,,,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STRAPPING HAND FINGER,4502928001,CDM,450,RC,,,facility,both,,,,296,296,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION HIP SPICA CAST 1 LEG,4502930501,CDM,450,RC,29305,HCPCS,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIP SPICA 1.5 OR DOUBL,4502932501,CDM,450,RC,,,facility,both,,,,532,532,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION LONG LEG CAST THIGH-TOE,4502934501,CDM,450,RC,29345,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION SHORT LEG CAST BELOW KNEE-TOE,4502940501,CDM,450,RC,29405,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION SHORT LEG CAST WALKING/AMBULATORY,4502942501,CDM,450,RC,,,facility,both,,,,287,287,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION RIGID TOTAL CONTACT LEG CAST,4502944501,CDM,450,RC,,,facility,both,,,,412,412,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLY LONG LEG SPLINT,4502950501,CDM,450,RC,29505,HCPCS,facility,both,,,,162,162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED APPLICATION SHORT LEG SPLINT CALF FOOT,4502951501,CDM,450,RC,29515,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED STRAPPING KNEE,4502953001,CDM,450,RC,,,facility,both,,,,285,285,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED STRAPPING ANKLE &/FOOT,4502954001,CDM,450,RC,,,facility,both,,,,296,296,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STRAPPING TOES,4502955001,CDM,450,RC,,,facility,both,,,,256,256,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED STRAPPING UNNA BOOT,4502958001,CDM,450,RC,,,facility,both,,,,222,222,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE FULL ARM LEG CAST,4502970501,CDM,450,RC,,,facility,both,,,,457,457,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WEDGING OF CAST,4502971001,CDM,450,RC,,,facility,both,,,,316,316,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REP SPICA BODY CAST JA,4502972001,CDM,450,RC,,,facility,both,,,,296,296,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED WINDOWING CAST,4502973001,CDM,450,RC,,,facility,both,,,,718,718,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED WEDGING OF CAST,4502974001,CDM,450,RC,,,facility,both,,,,316,316,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH,4503000001,CDM,450,RC,,,facility,both,,,,443,443,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED I&D NASAL SEPT ABSCESS,4503002001,CDM,450,RC,,,facility,both,,,,463,463,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BIOPSY INTRANASAL,4503010001,CDM,450,RC,,,facility,both,,,,4658,4658,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED FB REMOVAL INTRANASAL,4503030001,CDM,450,RC,30300,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CONTRL NASAL HEMORRHAGE SIMPLE,4503090101,CDM,450,RC,30901,HCPCS,facility,both,,,,112,112,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX,4503090301,CDM,450,RC,30903,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST,4503090501,CDM,450,RC,30905,HCPCS,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ,4503090601,CDM,450,RC,30906,HCPCS,facility,both,,,,347,347,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NASAL ENDOSCOPY DX,4503123101,CDM,450,RC,,,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED NASAL/SINUS ENDOSCOPY SURG WITH CONTROL OF NASAL HEM,4503123801,CDM,450,RC,,,facility,both,,,,3316,3316,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INTUBATION ENDOTRACHEAL,4503150001,CDM,450,RC,31500,HCPCS,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHEOTOMY TUBE CHANGE,4503150201,CDM,450,RC,31502,HCPCS,facility,both,,,,305,305,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY INDIRECT,4503150501,CDM,450,RC,,,facility,both,,,,230,230,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY WITH REM FB,4503151101,CDM,450,RC,,,facility,both,,,,505,505,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED LARYNGOSCOPY DIRECT DIAGNOSTIC EXCEPT NEWBORN,4503152501,CDM,450,RC,31525,HCPCS,facility,both,,,,2570,2570,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY WITH FB REMOVAL,4503153001,CDM,450,RC,,,facility,both,,,,5830,5830,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED LARYNGOSCOPY FLEX DIAGNOSTIC,4503157501,CDM,450,RC,31575,HCPCS,facility,both,,,,624,624,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY FF WITH BIO,4503157601,CDM,450,RC,,,facility,both,,,,5593,5593,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED LARYNGOSCOPY FLEXIBLE WITH REMOVAL OF FOREIGN BODY(S),4503157701,CDM,450,RC,,,facility,both,,,,1104,1104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY FF WITH REM,4503157801,CDM,450,RC,,,facility,both,,,,5593,5593,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHEOSTOMY ER TRANST,4503160301,CDM,450,RC,,,facility,both,,,,1785,1785,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHEOSTOMY CRICOTHYROID,4503160501,CDM,450,RC,,,facility,both,,,,1261,1261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHEOBRONCH THROUGH TRACH,4503161501,CDM,450,RC,,,facility,both,,,,1577,1577,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BRNCHSC INCL FLUOR GDNCE DX W/CELL WASHG SPX,4503162201,CDM,450,RC,,,facility,both,,,,7436,7436,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BRNCHSC W/BRNCL ALVEOLAR LAVAGE,4503162401,CDM,450,RC,31624,HCPCS,facility,both,,,,2748,2748,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BRONCH WITH FOREIGN BODY REMOVAL,4503163501,CDM,450,RC,31635,HCPCS,facility,both,,,,2986,2986,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BRNCHSC W/THER ASPIR 1ST,4503164501,CDM,450,RC,,,facility,both,,,,1863,1863,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED THORACOTOMY WITH EXPLORATION,4503210001,CDM,450,RC,32100,HCPCS,facility,both,,,,7441,7441,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED THORCOTOMY CTRL TRAUMTC HEMRRG&/RPR LNG TEAR,4503211001,CDM,450,RC,,,facility,both,,,,8328,8328,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED THORACOTOMY WITH CARDIAC MASSAGE,4503216001,CDM,450,RC,32160,HCPCS,facility,both,,,,8552,8552,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INSERTION OF CHEST TUBE,4503255101,CDM,450,RC,32551,HCPCS,facility,both,,,,1439,1439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED THORACENTESIS WO IMAGE GUIDANCE,4503255401,CDM,450,RC,32554,HCPCS,facility,both,,,,912,912,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,4503255501,CDM,450,RC,32555,HCPCS,facility,both,,,,1048,1048,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT CATH PLEURA WO IMAGE GUIDANCE,4503255601,CDM,450,RC,32556,HCPCS,facility,both,,,,1671,1671,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PNEUMOTHORAX THERAPEUTIC,4503296001,CDM,450,RC,,,facility,both,,,,737,737,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,4503301601,CDM,450,RC,33016,HCPCS,facility,both,,,,2875,2875,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TEMPORARY PACEMAKER INSERTION,4503321001,CDM,450,RC,33210,HCPCS,facility,both,,,,6715,6715,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR OF CARDIAC WOUND WITHOUT BYPASS,4503330001,CDM,450,RC,,,facility,both,,,,31553,31553,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR BLOOD VESSEL NECK,4503520101,CDM,450,RC,,,facility,both,,,,5731,5731,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,4503520601,CDM,450,RC,,,facility,both,,,,3911,3911,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR BLOOD VESSEL DIRECT HAND FINGER,4503520701,CDM,450,RC,,,facility,both,,,,5326,5326,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR BLOOD VESSEL DIRECT LOWER EXTREMITY,4503522601,CDM,450,RC,35226,HCPCS,facility,both,,,,2874,2874,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INTRACATH EXTREM ARTERY,4503614001,CDM,450,RC,,,facility,both,,,,1396,1396,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VENIPUNCTURE 3 YRS OLDER,4503641001,CDM,450,RC,36410,HCPCS,facility,both,,,,21,21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENIPUNCTURE CUTDOWN AGE 1 OR UNDER,4503642001,CDM,450,RC,,,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENIPUNCTURE CUTDOWN AGE 1 AND OVER,4503642501,CDM,450,RC,,,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION OF CATHETER VEIN,4503651001,CDM,450,RC,,,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INSERT CENTRAL LINE AGE 5 AND UNDER,4503655501,CDM,450,RC,36555,HCPCS,facility,both,,,,3781,3781,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INSERT CENTRAL LINE AGE 5 AND OVER,4503655601,CDM,450,RC,36556,HCPCS,facility,both,,,,2930,2930,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/>,4503655801,CDM,450,RC,36558,HCPCS,facility,both,,,,2945,2945,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INSERTION PICC W/O IMG GDN < 5 YR,4503656801,CDM,450,RC,,,facility,both,,,,3019,3019,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INSERTION PICC W/RS&I, 5 YRS OR OLDER",4503657301,CDM,450,RC,36573,HCPCS,facility,both,,,,1409,1409,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED RPR CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ SIT,4503657601,CDM,450,RC,,,facility,both,,,,9583,9583,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPLACE CATH ONLY WITH PT/PUMP,4503657801,CDM,450,RC,,,facility,both,,,,6907,6907,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED COMPLETE REPLACEMENT PICC RS&I,4503658401,CDM,450,RC,36584,HCPCS,facility,both,,,,1702,1702,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVE IMPLANT VEN TUNNELED,4503658901,CDM,450,RC,,,facility,both,,,,1238,1238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DECLOTTING CATH/ACCESS DEVICE,4503659301,CDM,450,RC,36593,HCPCS,facility,both,,,,605,605,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED MECH REMOVE TUNNELED CV CATH,4503659601,CDM,450,RC,,,facility,both,,,,2975,2975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WITHDRAWAL OF ARTERIAL BLOOD,4503660001,CDM,450,RC,36600,HCPCS,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ARTERIAL CANNULATION,4503662001,CDM,450,RC,36620,HCPCS,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION CATHETER ARTERY,4503662501,CDM,450,RC,36625,HCPCS,facility,both,,,,186,186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION CATHETER ARTERY NEWBORN,4503666001,CDM,450,RC,,,facility,both,,,,178,178,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLCMNT NDL INTRAOSSEOU,4503668001,CDM,450,RC,36680,HCPCS,facility,both,,,,403,403,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED THROMBOLYSIS CEREBRAL IV INFUSION,4503719501,CDM,450,RC,37195,HCPCS,facility,both,,,,573,573,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VASCULAR EMBOLIZATION OR OCCLUSION HEMORRHAGE,4503724401,CDM,450,RC,,,facility,both,,,,19786,19786,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LIGATION  ARTERY EXTER,4503761801,CDM,450,RC,,,facility,both,,,,223,223,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED LIGATION OF FEMORAL VEIN,4503765001,CDM,450,RC,,,facility,both,,,,11850,11850,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED VASCULAR SURGERY REPAIR OF VARICOSE VEINS,4503779901,CDM,450,RC,,,facility,both,,,,566,566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAIN ABSC LYMPH NODE SIMPLE,4503830001,CDM,450,RC,,,facility,both,,,,3406,3406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RPR LIP FULL THICKNESS VERMILION ONLY,4504065001,CDM,450,RC,40650,HCPCS,facility,both,,,,2145,2145,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR LIP,4504065201,CDM,450,RC,40652,HCPCS,facility,both,,,,621,621,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPAIR LIP FULL/COMPLEX,4504065401,CDM,450,RC,,,facility,both,,,,1391,1391,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED INCISION AND DRAINAGE OF LIP,4504079901,CDM,450,RC,40799,HCPCS,facility,both,,,,1062,1062,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE OF MOUTH LESION SIMPLE,4504080001,CDM,450,RC,40800,HCPCS,facility,both,,,,692,692,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRG ABSC CST HMTMA VESTIBULE MOUTH COMP,4504080101,CDM,450,RC,40801,HCPCS,facility,both,,,,604,604,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED RMVL EMBEDDED FB VESTIBULE MOUTH SMPL,4504080401,CDM,450,RC,40804,HCPCS,facility,both,,,,828,828,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL FOREIGN BODY MOUTH,4504080501,CDM,450,RC,,,facility,both,,,,635,635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSURE LACERATION VESTIBULE MOUTH 2.5 CM/<,4504083001,CDM,450,RC,40830,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL,4504083101,CDM,450,RC,40831,HCPCS,facility,both,,,,1094,1094,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAORAL I&D ABSCESS,4504100001,CDM,450,RC,41000,HCPCS,facility,both,,,,839,839,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAORAL INCISION,4504100501,CDM,450,RC,41005,HCPCS,facility,both,,,,468,468,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INTRAORAL I&D, SUBMENTAL",4504100701,CDM,450,RC,,,facility,both,,,,3247,3247,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAORAL I&D SUBMANDIBULAR,4504100801,CDM,450,RC,41008,HCPCS,facility,both,,,,4096,4096,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAORAL I&D TONGUE,4504100901,CDM,450,RC,41009,HCPCS,facility,both,,,,696,696,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTRAORAL I&D SUBMENTAL,4504101601,CDM,450,RC,,,facility,both,,,,9202,9202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REP LAC TONGUE,4504125001,CDM,450,RC,41250,HCPCS,facility,both,,,,403,403,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR ONE THIRD TONGUE,4504125101,CDM,450,RC,,,facility,both,,,,329,329,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REP LAC TOUNGUE OVER 2.6CM,4504125201,CDM,450,RC,41252,HCPCS,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDEMENT OF TONGUE GRAFT,4504159901,CDM,450,RC,,,facility,both,,,,15331,15331,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D ABSC DENTOALVEOLAR,4504180001,CDM,450,RC,41800,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL FB DENTOAVEOLAR,4504180501,CDM,450,RC,,,facility,both,,,,6711,6711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED ASPIRATION OF DENTAL ABSCESS,4504189901,CDM,450,RC,41899,HCPCS,facility,both,,,,859,859,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED DENTAL SEAL PROCEDURE,4504189902,CDM,450,RC,41899,HCPCS,facility,both,,,,541,541,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED GINGIVAL TISSUE REPAIR,4504189903,CDM,450,RC,,,facility,both,,,,822,822,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED TOOTH 1-3 EXTRACTIONS,4504189904,CDM,450,RC,41899,HCPCS,facility,both,,,,465,465,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED TOOTH REIMPLANTATION,4504189905,CDM,450,RC,41899,HCPCS,facility,both,,,,689,689,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE ABSCESS PALATE UVULA,4504200001,CDM,450,RC,42000,HCPCS,facility,both,,,,216,216,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR PALATE LAC UP TO 2CM,4504218001,CDM,450,RC,,,facility,both,,,,634,634,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR LACERATION PALATE,4504218201,CDM,450,RC,,,facility,both,,,,8109,8109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SAILOLITHOTOMY-UNCOMP,4504233001,CDM,450,RC,42330,HCPCS,facility,both,,,,3451,3451,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DILAT&CATHJ SALIVARY DUCT W/WO INJECTION,4504266001,CDM,450,RC,,,facility,both,,,,674,674,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D PERITONSILLAR ABSC,4504270001,CDM,450,RC,42700,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED I&D ABSC RTRPHRNGL/PARAPHARYNGEAL INTRAORAL,4504272001,CDM,450,RC,,,facility,both,,,,4389,4389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REMOV FROM PHARYNX,4504280901,CDM,450,RC,42809,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUTURE PHARYNX WOUND/INJURY,4504290001,CDM,450,RC,,,facility,both,,,,1923,1923,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OROPHARYNGEAL HEMORRHA,4504296001,CDM,450,RC,,,facility,both,,,,535,535,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ASPIRATION PERITONSILLAR ABSCESS,4504299901,CDM,450,RC,42999,HCPCS,facility,both,,,,895,895,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESOPHAGOSCOPY DIAGNOSTIC,4504320001,CDM,450,RC,,,facility,both,,,,1502,1502,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESOPHAGOGASTRODUODENO W/FB REM,4504324701,CDM,450,RC,43247,HCPCS,facility,both,,,,1337,1337,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRESSURE TREATMENT ESOPHAGUS,4504346001,CDM,450,RC,,,facility,both,,,,694,694,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED GI NASO OR ORO-GAST TUBE PL,4504375201,CDM,450,RC,43752,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE,4504375301,CDM,450,RC,,,facility,both,,,,897,897,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,4504376201,CDM,450,RC,43762,HCPCS,facility,both,,,,581,581,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRO LONG GASTROINTEST TUBE,4504450001,CDM,450,RC,44500,HCPCS,facility,both,,,,3836,3836,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED PROCEDURE SMALL INTESTINE,4504479901,CDM,450,RC,,,facility,both,,,,1122,1122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D RECTAL ABSCESS SUBMUCOS,4504500501,CDM,450,RC,,,facility,both,,,,2000,2000,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROCTOSIGMOID W/O DILA,4504530001,CDM,450,RC,45300,HCPCS,facility,both,,,,857,857,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROCTOSIGMOIDOSCOPY; REM FB,4504530701,CDM,450,RC,,,facility,both,,,,4325,4325,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SIGMOIDOSCOPY FLEXIBLE,4504533001,CDM,450,RC,,,facility,both,,,,972,972,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DILAT RCT STRIX SPX UNDER ANES OTH/THN LOCAL,4504591001,CDM,450,RC,,,facility,both,,,,1971,1971,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED RMVL FECAL IMPACTION/FB SPX UNDER ANES,4504591501,CDM,450,RC,,,facility,both,,,,1237,1237,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED FOREIGN BODY REMOVAL RECTUM,4504599901,CDM,450,RC,45999,HCPCS,facility,both,,,,2546,2546,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLACEMENT OF SETON,4504602001,CDM,450,RC,,,facility,both,,,,6602,6602,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D ISCHIO/PERIRECTAL,4504604001,CDM,450,RC,46040,HCPCS,facility,both,,,,2556,2556,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D OF PERIANAL ABSCESS,4504605001,CDM,450,RC,46050,HCPCS,facility,both,,,,922,922,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION THROMB HEMORROID,4504608301,CDM,450,RC,46083,HCPCS,facility,both,,,,370,370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS,4504622101,CDM,450,RC,,,facility,both,,,,4666,4666,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISION HEMORRHOID EXTERNAL,4504623001,CDM,450,RC,,,facility,both,,,,3466,3466,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED HEMORRHOIDECTOMY EXTERNAL 2 OR MORE,4504625001,CDM,450,RC,,,facility,both,,,,3952,3952,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC THROMBOSED HEMORRHOID XTRNL,4504632001,CDM,450,RC,46320,HCPCS,facility,both,,,,3653,3653,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD,4504660001,CDM,450,RC,,,facility,both,,,,203,203,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ANOSCOPY W/RMVL FOREIGN BODY,4504660801,CDM,450,RC,46608,HCPCS,facility,both,,,,1095,1095,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ANOSCOPY CONTROL BLEEDING,4504661401,CDM,450,RC,,,facility,both,,,,1463,1463,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DSTRJ LESION ANUS SMPL ELTRDSICCATION,4504691001,CDM,450,RC,,,facility,both,,,,4286,4286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED MANUAL REDUC PROLAPSED HEMORRHOID,4504699901,CDM,450,RC,46999,HCPCS,facility,both,,,,1961,1961,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED LIGATION OF BLEEDING VESSEL POST HEMORRHOIDECTOMY,4504699902,CDM,450,RC,,,facility,both,,,,1896,1896,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PREPERITONEAL PEL PACK F/HEMRRG ASSOC PEL TRMA,4504901301,CDM,450,RC,,,facility,both,,,,3186,3186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,4504908201,CDM,450,RC,49082,HCPCS,facility,both,,,,925,925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ABD PARACENTESIS WITH IMAGING,4504908301,CDM,450,RC,49083,HCPCS,facility,both,,,,1202,1202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMBEDDED IP CATH EXIT-SITE,4504943601,CDM,450,RC,,,facility,both,,,,4077,4077,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED GI REPLACE G OR CECOST COLO,4504945001,CDM,450,RC,49450,HCPCS,facility,both,,,,869,869,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPLACE DUODENAL JEJUNAL,4504945101,CDM,450,RC,49451,HCPCS,facility,both,,,,1087,1087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CHANGE OF URETEROSTOMY,4505068801,CDM,450,RC,50688,HCPCS,facility,both,,,,6077,6077,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CYSTOSTOMY CYSTOTOMY W/DRAINAGE,4505104001,CDM,450,RC,51040,HCPCS,facility,both,,,,4153,4153,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ASPIRATION BLADDER NEEDLE,4505110001,CDM,450,RC,,,facility,both,,,,2091,2091,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ASPIRATION BLADDER TROCAR/INTRACATHETER,4505110101,CDM,450,RC,,,facility,both,,,,1268,1268,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER,4505110201,CDM,450,RC,51102,HCPCS,facility,both,,,,1842,1842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IRRIGATION OF BLADDER SIMPLE,4505170001,CDM,450,RC,51700,HCPCS,facility,both,,,,264,264,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INSERT NON-INDWELLING BLADDER CATHETER,4505170101,CDM,450,RC,51701,HCPCS,facility,both,,,,193,193,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED FOLEY CATH INSERT,4505170201,CDM,450,RC,51702,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT TEMP BLAD CATH COMPLETE,4505170301,CDM,450,RC,51703,HCPCS,facility,both,,,,189,189,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CHANGE CYSTOSTOMY TUBE,4505170501,CDM,450,RC,51705,HCPCS,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CHANGE CYSTOSTOMY TUBE COMPLICATED,4505171001,CDM,450,RC,51710,HCPCS,facility,both,,,,859,859,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CYSTOURETHROSCOPY,4505200001,CDM,450,RC,52000,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CYSTO BLADDER W/URETERAL CATHETERIZATION,4505200501,CDM,450,RC,,,facility,both,,,,3144,3144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,4505228101,CDM,450,RC,52281,HCPCS,facility,both,,,,3360,3360,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CYSTO W/SIMPLE REMOVAL STONE & STENT,4505231001,CDM,450,RC,52310,HCPCS,facility,both,,,,2320,2320,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CYSTOSCOPY, REMOV CALCULUS, COMPLIC",4505231501,CDM,450,RC,,,facility,both,,,,10184,10184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRG OF SKENE'S GLAND ABSCESS OR CYST,4505306001,CDM,450,RC,53060,HCPCS,facility,both,,,,3294,3294,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DILATE URETHRAL STRIX DILATOR MALE 1ST,4505360001,CDM,450,RC,53600,HCPCS,facility,both,,,,580,580,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DILAT URETHRAL STRIX DILATOR MALE SBSQ,4505360101,CDM,450,RC,,,facility,both,,,,268,268,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST,4505362001,CDM,450,RC,,,facility,both,,,,4286,4286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DILATION URETHRA INITIAL,4505366001,CDM,450,RC,,,facility,both,,,,276,276,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLIT PREPUCE EXCEPT NB,4505400101,CDM,450,RC,,,facility,both,,,,4149,4149,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INC CIRCUMCISION,4505416301,CDM,450,RC,,,facility,both,,,,6347,6347,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IRRIGATION CORPORA CAVERNOSA PRIAPISM,4505422001,CDM,450,RC,54220,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECT CORPORA CAVERNOSA,4505423501,CDM,450,RC,54235,HCPCS,facility,both,,,,370,370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CORPORA CAVERNOSA-GLANS PENIS FSTLJ PRIAPISM,4505443501,CDM,450,RC,,,facility,both,,,,8465,8465,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FORESKIN MANIPULATION,4505445001,CDM,450,RC,54450,HCPCS,facility,both,,,,360,360,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D OF EPIDIDYMIS TEST,4505470001,CDM,450,RC,54700,HCPCS,facility,both,,,,1842,1842,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCT ASPIR HYDROCELE,4505500001,CDM,450,RC,,,facility,both,,,,855,855,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAIN SCROT WALL ABSCESS,4505510001,CDM,450,RC,55100,HCPCS,facility,both,,,,1894,1894,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL OF SCROTUM LESION,4505512001,CDM,450,RC,,,facility,both,,,,2482,2482,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED I&D VULVA/PERINEAL ABSCESS,4505640501,CDM,450,RC,56405,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED I&D BARTHOLIN GLAND ABCESS,4505642001,CDM,450,RC,56420,HCPCS,facility,both,,,,404,404,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MARSPLIZATN BARTH GLAN,4505644001,CDM,450,RC,,,facility,both,,,,3278,3278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF VULVA LESION SINGLE,4505660501,CDM,450,RC,56605,HCPCS,facility,both,,,,1019,1019,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX VULVA EACH ADDTL LESION,4505660601,CDM,450,RC,,,facility,both,,,,276,276,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PARTIAL REMOVAL OF HYMEN,4505670001,CDM,450,RC,,,facility,both,,,,5108,5108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXC BARTHOLINS GLAND/CYST,4505674001,CDM,450,RC,,,facility,both,,,,3824,3824,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED COLPOCENTESIS SEPARATE PROCEDURE,4505702001,CDM,450,RC,,,facility,both,,,,6111,6111,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D VAGINAL HEMATOMA OBS/PP,4505702201,CDM,450,RC,,,facility,both,,,,3406,3406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED I&D VAGINAL HEMATOMA NON-OBSTETRICAL,4505702301,CDM,450,RC,,,facility,both,,,,3830,3830,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BIOPSY VAGINA SIMPLE,4505710001,CDM,450,RC,,,facility,both,,,,1569,1569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IRRIGATION/APP MED VAGINA,4505715001,CDM,450,RC,,,facility,both,,,,361,361,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INSERT PESSARY OTHER DEVICE,4505716001,CDM,450,RC,,,facility,both,,,,263,263,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INTRO ANY HEMOSTATIC AGENT/PACK VAG HEMRRG SPX,4505718001,CDM,450,RC,,,facility,both,,,,607,607,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED COLPORRHAPHY SUTURE INJURY VAGINA,4505720001,CDM,450,RC,,,facility,both,,,,3097,3097,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED COLPOPERINEORRHAPHY SUTURE INJ VAGINA&/PERINEU,4505721001,CDM,450,RC,,,facility,both,,,,6237,6237,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL,4505741001,CDM,450,RC,57410,HCPCS,facility,both,,,,9676,9676,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL VAG FB UNDER ANESTH,4505741501,CDM,450,RC,57415,HCPCS,facility,both,,,,3625,3625,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED COLP CERVIX INCLUDE UP VAGINA,4505745201,CDM,450,RC,,,facility,both,,,,572,572,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BIOPSY CERVIX, 1 OR MORE, OR EXCISION OF LESION",4505750001,CDM,450,RC,,,facility,both,,,,1190,1190,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHELORRHAPHY,4505772001,CDM,450,RC,,,facility,both,,,,5106,5106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DILATION CERVICAL CANAL INSTRUMENTAL SPX,4505780001,CDM,450,RC,,,facility,both,,,,3554,3554,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ENDOMETRIAL BIOPSY,4505810001,CDM,450,RC,,,facility,both,,,,259,259,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DILATION & CURETTAGE DX&/THER NONOBSTETRIC,4505812001,CDM,450,RC,,,facility,both,,,,4522,4522,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOMECTOMY EXCS LEIOM,4505814501,CDM,450,RC,,,facility,both,,,,7069,7069,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVAL IUD,4505830101,CDM,450,RC,58301,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OVARIAN CYSTECTOMY,4505892501,CDM,450,RC,,,facility,both,,,,7069,7069,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED FEMALE GENITAL PROCEDURE NON OB,4505899901,CDM,450,RC,,,facility,both,,,,375,375,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EPISIOTOMY OR VAGINAL REPAIR,4505930001,CDM,450,RC,59300,HCPCS,facility,both,,,,3820,3820,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VAGINAL DELIVERY ONLY,4505940901,CDM,450,RC,59409,HCPCS,facility,both,,,,3603,3603,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DELIVERY OF PLACENTA,4505941401,CDM,450,RC,59414,HCPCS,facility,both,,,,3492,3492,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TX INCOMPLETE ABORTION ANY TRIMESTER SURGICAL,4505981201,CDM,450,RC,,,facility,both,,,,2700,2700,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX OF MISSED ABORTION,4505982001,CDM,450,RC,,,facility,both,,,,3195,3195,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VENTRICULAR PUNCTURE PREVIOUS BURR HOLE W/O NJX,4506102001,CDM,450,RC,,,facility,both,,,,973,973,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BRAIN CANAL SHUNT ASPIRATION,4506107001,CDM,450,RC,61070,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TWST DRL HOLE IMPLT VENT CA,4506110701,CDM,450,RC,61107,HCPCS,facility,both,,,,619,619,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPLACE REVISION BRAIN SHUNT,4506223001,CDM,450,RC,,,facility,both,,,,9234,9234,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REPROGRAMMING CSF SHUNT,4506225201,CDM,450,RC,62252,HCPCS,facility,both,,,,538,538,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED LUMBAR PUNCTURE DIAGNOSTIC,4506227001,CDM,450,RC,62270,HCPCS,facility,both,,,,871,871,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED LUMBAR PUNCTURE THERAPEUTIC,4506227201,CDM,450,RC,62272,HCPCS,facility,both,,,,761,761,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION EPIDURAL BLOOD/CLOT PATCH,4506227301,CDM,450,RC,62273,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJ(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EA BRANCH (IE OPHT, MAX, MAND)",4506440001,CDM,450,RC,64400,HCPCS,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE",4506440501,CDM,450,RC,64405,HCPCS,facility,both,,,,730,730,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC N BLOCK INJ VAGUS,4506440801,CDM,450,RC,,,facility,both,,,,359,359,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS",4506441501,CDM,450,RC,64415,HCPCS,facility,both,,,,2043,2043,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE",4506441701,CDM,450,RC,,,facility,both,,,,2017,2017,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",4506441801,CDM,450,RC,,,facility,both,,,,1101,1101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL,4506442001,CDM,450,RC,,,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL",4506442101,CDM,450,RC,,,facility,both,,,,1278,1278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",4506442501,CDM,450,RC,,,facility,both,,,,2349,2349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",4506443001,CDM,450,RC,64430,HCPCS,facility,both,,,,1288,1288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",4506443501,CDM,450,RC,,,facility,both,,,,993,993,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE",4506444501,CDM,450,RC,,,facility,both,,,,993,993,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE",4506444701,CDM,450,RC,64447,HCPCS,facility,both,,,,736,736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",4506445001,CDM,450,RC,64450,HCPCS,facility,both,,,,885,885,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG,4506445101,CDM,450,RC,,,facility,both,,,,1022,1022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG,4506445401,CDM,450,RC,,,facility,both,,,,3839,3839,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED THORACIC FASCIAL PLANE BLOCK UNI INJECTION,4506446601,CDM,450,RC,64466,HCPCS,facility,both,,,,1128,1128,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED LOWER XTR FASCIAL PLANE BLOCK UNI INJECTION,4506447301,CDM,450,RC,64473,HCPCS,facility,both,,,,111,111,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FORAMEN EPIDURAL C/T,4506447901,CDM,450,RC,,,facility,both,,,,1288,1288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ FORAMEN EPIDURAL L/S,4506448301,CDM,450,RC,,,facility,both,,,,1103,1103,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TAP BLOCK UNILATERAL BY INJECTIONS(S),4506448601,CDM,450,RC,,,facility,both,,,,885,885,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ PARAVERT F JNT/CT 1 LEV,4506449001,CDM,450,RC,,,facility,both,,,,3309,3309,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INJECTION ANES AGENT SPHENOPALATINE GANGLION,4506450501,CDM,450,RC,64505,HCPCS,facility,both,,,,892,892,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED  NEUROPLASTY &/TRANSPOS MEDIAN NRV CARPAL TUNNE,4506472101,CDM,450,RC,,,facility,both,,,,6924,6924,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION OF SPINAL NERVE,4506477201,CDM,450,RC,,,facility,both,,,,4230,4230,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUTURE DIGITAL NERVE,4506483101,CDM,450,RC,,,facility,both,,,,5695,5695,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUTURE MEDIAN MTR NERV,4506483501,CDM,450,RC,,,facility,both,,,,8146,8146,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUTURE PERIPHERAL NERV,4506485601,CDM,450,RC,,,facility,both,,,,7669,7669,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED INJECTION ANESTHESTIC AGENT CERVICAL PLEXUS,4506499901,CDM,450,RC,64999,HCPCS,facility,both,,,,760,760,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED INJECTION ANESTHETIC AGENT FACIAL NERVE,4506499902,CDM,450,RC,64999,HCPCS,facility,both,,,,352,352,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED INTRANASAL ADMIN OF ANESTH AGENT SPHENO GANGLIAN,4506499903,CDM,450,RC,,,facility,both,,,,429,429,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED INJECTION ANESTHESTIC AGENT SERRATUS NERVE,4506499904,CDM,450,RC,,,facility,both,,,,1299,1299,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED INJECTION ANESTHESTIC AGENT ERECTOR SPINAE,4506499905,CDM,450,RC,64999,HCPCS,facility,both,,,,3274,3274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REM EXT EYE CONJ SU,4506520501,CDM,450,RC,65205,HCPCS,facility,both,,,,278,278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REM EXT EYE CONJ EM,4506521001,CDM,450,RC,65210,HCPCS,facility,both,,,,544,544,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REM FROM CORNEAL WO,4506522001,CDM,450,RC,65220,HCPCS,facility,both,,,,635,635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REM FROM CORNEAL W SL,4506522201,CDM,450,RC,65222,HCPCS,facility,both,,,,635,635,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM FB INTRAOCULAR EYE LENS,4506523501,CDM,450,RC,65235,HCPCS,facility,both,,,,4792,4792,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REP CONJNCT LAC DIR CL,4506527001,CDM,450,RC,,,facility,both,,,,5162,5162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR EYE SOCKET WOUND,4506529001,CDM,450,RC,,,facility,both,,,,6205,6205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM CORNEAL EPITHELIUM,4506543501,CDM,450,RC,,,facility,both,,,,1747,1747,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVISION OF IRIS,4506676101,CDM,450,RC,66761,HCPCS,facility,both,,,,1383,1383,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED UNLISTED PROCEDURE IRRIGATION OF EYE,4506699901,CDM,450,RC,,,facility,both,,,,3594,3594,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED  INTRAVITREAL NJX PHARMACOLOGIC AGT SPX,4506702801,CDM,450,RC,,,facility,both,,,,2167,2167,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED BLEPHAROTOMY DRAINAGE ABSCESS EYELID,4506770001,CDM,450,RC,67700,HCPCS,facility,both,,,,555,555,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION OF EYELID FOLD,4506771501,CDM,450,RC,67715,HCPCS,facility,both,,,,4054,4054,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISION CHALAZION SINGLE,4506780001,CDM,450,RC,,,facility,both,,,,2279,2279,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED SUTR WND EYELID/MARGIN/TARSUS/CONJUNC PRTL THICK,4506793001,CDM,450,RC,67930,HCPCS,facility,both,,,,3059,3059,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RPR EYELID WOUND PT,4506793501,CDM,450,RC,67935,HCPCS,facility,both,,,,4083,4083,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE FB EYELID,4506793801,CDM,450,RC,67938,HCPCS,facility,both,,,,868,868,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CANTHOPLASTY,4506795001,CDM,450,RC,,,facility,both,,,,2721,2721,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INC CONJUNC DRAIN CYST,4506802001,CDM,450,RC,,,facility,both,,,,1122,1122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE EYELID LINING LESION,4506811001,CDM,450,RC,,,facility,both,,,,4135,4135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INC DRAIN LACRIMAL SAC,4506842001,CDM,450,RC,,,facility,both,,,,4068,4068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REP LACRIMIL DUCT CANALICULI,4506870001,CDM,450,RC,,,facility,both,,,,5796,5796,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROBE NASOLACRIML DUCT,4506881501,CDM,450,RC,,,facility,both,,,,4193,4193,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROBE LACRIMAL CANALICULI,4506884001,CDM,450,RC,,,facility,both,,,,475,475,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPLE,4506900001,CDM,450,RC,69000,HCPCS,facility,both,,,,867,867,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA CMPLX,4506900501,CDM,450,RC,69005,HCPCS,facility,both,,,,2755,2755,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS,4506902001,CDM,450,RC,69020,HCPCS,facility,both,,,,1168,1168,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR,4506911001,CDM,450,RC,,,facility,both,,,,11789,11789,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL FOREIGN BODY EAR,4506920001,CDM,450,RC,69200,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED REMOVE IMPACT CERUMEN IRRIGATE,4506920901,CDM,450,RC,69209,HCPCS,facility,both,,,,159,159,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE IMPACT CERUMEN W INSTR,4506921001,CDM,450,RC,69210,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYRINGOTOMY ASPIRATION FLAT,4506942001,CDM,450,RC,69420,HCPCS,facility,both,,,,440,440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TYMPANOSTOMY W/ LOCAL OR TOP ANESTH,4506943301,CDM,450,RC,,,facility,both,,,,2940,2940,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NASOPHARYNGOSCOPY W/ENDOSCOPE,4509251101,CDM,450,RC,92511,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CPR,4509295001,CDM,450,RC,92950,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TEMP TRANSCUTANEOUS PACING,4509295301,CDM,450,RC,92953,HCPCS,facility,both,,,,667,667,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CARDIOVERSION,4509296001,CDM,450,RC,92960,HCPCS,facility,both,,,,879,879,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED AIRWAY INHALATION TREATMENT,4509464001,CDM,450,RC,94640,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV HYDRATION INFUSION INITIAL HOUR,4509636001,CDM,450,RC,96360,HCPCS,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV HYDRATE ADDTL HOURS,4509636101,CDM,450,RC,96361,HCPCS,facility,both,,,,86,86,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV INFUSION THERAPY UP TO 1 HR,4509636501,CDM,450,RC,96365,HCPCS,facility,both,,,,404,404,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV INFUSION THERAPY EACH ADDTL HR,4509636601,CDM,450,RC,96366,HCPCS,facility,both,,,,164,164,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV INFUSION ADDTL SEQUENTUAL UP TO 1 HR,4509636701,CDM,450,RC,96367,HCPCS,facility,both,,,,236,236,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV CONCURRENT INFUSION,4509636801,CDM,450,RC,96368,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ADMIN OF INJECTION SUBQ OR IM,4509637201,CDM,450,RC,96372,HCPCS,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV PUSH SINGLE OR INITIAL SUBSTANCE,4509637401,CDM,450,RC,96374,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV PUSH EACH ADDTL NEW SUBSTANCE,4509637501,CDM,450,RC,96375,HCPCS,facility,both,,,,213,213,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IV PUSH SAME DRUG 30 MIN AFTER,4509637601,CDM,450,RC,96376,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CHEMO SUBQ/IM NONHORMONE ANTINEOP,4509640101,CDM,450,RC,96401,HCPCS,facility,both,,,,289,289,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDEMENT 20 SQ CM OR LESS,4509759701,CDM,450,RC,97597,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED DEBRIDEMENT ADDTL 20 SQ CM,4509759801,CDM,450,RC,,,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED  RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS,4509760201,CDM,450,RC,,,facility,both,,,,814,814,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED NEG PRSR WOUND 50CM OR LESS,4509760501,CDM,450,RC,97605,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED NEG PRESSURE WOUND THERAPY NON DME >50 SQ CM,4509760801,CDM,450,RC,,,facility,both,,,,1659,1659,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED THERAPUTIC PHLEBOTOMY,4509919501,CDM,450,RC,,,facility,both,,,,503,503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VISIT CATEGORY 1,4509928101,CDM,450,RC,99281,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VISIT CATEGORY 2,4509928201,CDM,450,RC,99282,HCPCS,facility,both,,,,514,514,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VISIT CATEGORY 3,4509928301,CDM,450,RC,99283,HCPCS,facility,both,,,,682,682,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VISIT CATEGORY 4,4509928401,CDM,450,RC,99284,HCPCS,facility,both,,,,1325,1325,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VISIT CATEGORY 5,4509928501,CDM,450,RC,99285,HCPCS,facility,both,,,,1815,1815,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VISIT CRITICAL CARE 30 TO 74 MIN,4509929101,CDM,450,RC,99291,HCPCS,facility,both,,,,4094,4094,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED CRITICAL CARE EACH ADDTL 30 MIN,4509929201,CDM,450,RC,,,facility,both,,,,299,299,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPIROMETRY,4609401001,CDM,460,RC,94010,HCPCS,facility,both,,,,170,170,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPIROMETRY PRE & POST,4609406001,CDM,460,RC,94060,HCPCS,facility,both,,,,343,343,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCHOPROVACTION,4609407001,CDM,460,RC,94070,HCPCS,facility,both,,,,393,393,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TV VC INSP EFFORT,4609415001,CDM,460,RC,94150,HCPCS,facility,both,,,,170,170,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAPULMONARY SURFACTANT ADMINISTJ PHYS/QHP,4609461001,CDM,460,RC,94610,HCPCS,facility,both,,,,634,634,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PULMONARY STRESS TESTING,4609461801,CDM,460,RC,94618,HCPCS,facility,both,,,,530,530,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PULMONARY STRESS TESTING,4609461801,CDM,460,RC,94618,HCPCS,facility,both,,,,478,478,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUSSION & POST DRAINAGE,4609466701,CDM,460,RC,94667,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUSSION & POST DRAINAGE SUBSEQUENT,4609466801,CDM,460,RC,94668,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MECHANICAL CHEST WALL OSCILLATION,4609466901,CDM,460,RC,94669,HCPCS,facility,both,,,,192,192,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METABOLIC CART PROFILE,4609468101,CDM,460,RC,94681,HCPCS,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PLETHYSMOGRAPHY,4609472601,CDM,460,RC,94726,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GAS DILUT/WASHOUT LUNG VOL W/WO DISTRIB VENT&VOL,4609472701,CDM,460,RC,94727,HCPCS,facility,both,,,,474,474,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C.O. DIFFUSION,4609472901,CDM,460,RC,94729,HCPCS,facility,both,,,,119,119,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OXIMETRY MULTIPLE,4609476101,CDM,460,RC,94761,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC NONINVASV OXYGEN SATUT, CONTINUOUS",4609476201,CDM,460,RC,94762,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR,4609476202,CDM,460,RC,94762,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PED HOME APNEA RECORD & DOWNLOAD,4609477601,CDM,460,RC,,,facility,both,,,,137,137,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAPNOGRAPHY DAILY UNLISTED,4609479901,CDM,460,RC,94799,HCPCS,facility,both,,,,225,225,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PULMONARY COMPLIANCE STUDY UNLISTED,4609479902,CDM,460,RC,94799,HCPCS,facility,both,,,,172,172,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SMOKE ANALYZER PULMONARY SERVICE,4699479901,CDM,469,RC,,,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL FB XTRNL AUDITORY CANAL W/O ANES,4706920001,CDM,470,RC,,,facility,both,,,,328,328,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT,4706920901,CDM,470,RC,,,facility,both,,,,164,164,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT,4706921001,CDM,470,RC,,,facility,both,,,,164,164,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREATMENT OF AUDITORY PROCESING DISORDER; INDIV,4709250701,CDM,470,RC,,,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEMP TEST I&R CERVICAL,4709251701,CDM,470,RC,92517,HCPCS,facility,both,,,,678,678,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEMP TEST I&R OCULAR,4709251801,CDM,470,RC,,,facility,both,,,,494,494,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEMP TST I&R CERVICAL&OCULAR,4709251901,CDM,470,RC,92519,HCPCS,facility,both,,,,860,860,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPONTANEOUS NYSTAGMUS W/GAZE,4709253101,CDM,470,RC,,,facility,both,,,,55,55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POSITIONAL NYSTAGMUS TEST,4709253201,CDM,470,RC,92532,HCPCS,facility,both,,,,39,39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALORIC BITHERMAL,4709253701,CDM,470,RC,92537,HCPCS,facility,both,,,,825,825,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALORIC BITHERMAL,4709253701,CDM,470,RC,92537,HCPCS,facility,both,,,,917,917,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALORIC MONOTHERMAL,4709253801,CDM,470,RC,92538,HCPCS,facility,both,,,,825,825,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CALORIC MONOTHERMAL,4709253801,CDM,470,RC,92538,HCPCS,facility,both,,,,917,917,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPONTANEOUS NYSTAGMUS,4709254101,CDM,470,RC,92541,HCPCS,facility,both,,,,224,224,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPONTANEOUS NYSTAGMUS,4709254101,CDM,470,RC,92541,HCPCS,facility,both,,,,202,202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSCILLATING TRACKING,4709254501,CDM,470,RC,92545,HCPCS,facility,both,,,,371,371,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SINUSIODAL ROTATION TEST,4709254601,CDM,470,RC,92546,HCPCS,facility,both,,,,598,598,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC USE OF VERTICAL LEADS,4709254701,CDM,470,RC,,,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POSTUROGRAPHY,4709254801,CDM,470,RC,,,facility,both,,,,394,394,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POSTUROGRAPHY,4709254801,CDM,470,RC,,,facility,both,,,,354,354,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POSTUROGRAPHY SOT/MCT/ADT,4709254901,CDM,470,RC,,,facility,both,,,,370,370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPEECH AUDIOLMETRY THRESHOLD,4709255501,CDM,470,RC,92555,HCPCS,facility,both,,,,159,159,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPEECH AUDIOLMETRY THRESHOLD,4709255501,CDM,470,RC,92555,HCPCS,facility,both,,,,129,129,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STENGER PURE TONE,4709256501,CDM,470,RC,,,facility,both,,,,155,155,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STENGER PURE TONE,4709256501,CDM,470,RC,,,facility,both,,,,153,153,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACOUSTIC REFLEX TESTING,4709256801,CDM,470,RC,,,facility,both,,,,260,260,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACOUSTIC REFLEX TESTING,4709256801,CDM,470,RC,,,facility,both,,,,264,264,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACOUSTIC IMMITTANCE TESTING,4709257001,CDM,470,RC,,,facility,both,,,,138,138,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FILTERED SPEECH HEARING,4709257101,CDM,470,RC,,,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FILTERED SPEECH HEARING,4709257101,CDM,470,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STAGGERED SPONDAIC WORD,4709257201,CDM,470,RC,,,facility,both,,,,362,362,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SYNTHETIC SENTENCE IDENTIFICATION TEST,4709257601,CDM,470,RC,,,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STENGER SPEECH TEST,4709257701,CDM,470,RC,,,facility,both,,,,526,526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VISUAL REINFORCE AUDIOMETRY,4709257901,CDM,470,RC,92579,HCPCS,facility,both,,,,466,466,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VISUAL REINFORCE AUDIOMETRY,4709257901,CDM,470,RC,92579,HCPCS,facility,both,,,,459,459,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONDITIONED PLAY AUDIOGRAM,4709258201,CDM,470,RC,92582,HCPCS,facility,both,,,,459,459,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONDITIONED PLAY AUDIOGRAM,4709258201,CDM,470,RC,92582,HCPCS,facility,both,,,,466,466,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SELECT PICTURE AUDIOMETRY,4709258301,CDM,470,RC,,,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELECTROCOCHLEOGRAPHY,4709258401,CDM,470,RC,92584,HCPCS,facility,both,,,,393,393,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELECTROACOUS EVAL HEARING AID MONAURAL,4709259401,CDM,470,RC,,,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELECTROACOUS EVAL HEARING AID BINAURAL,4709259501,CDM,470,RC,,,facility,both,,,,109,109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EAR PROTECTOR ATTENUATION MEASUREMENTS,4709259601,CDM,470,RC,,,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DX ANALYSIS COCHLEAR IMPLANT AGE 7 OR UNDER WITH PROG,4709260101,CDM,470,RC,92601,HCPCS,facility,both,,,,560,560,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DX ANALYSIS COCHLEAR IMPLANT AGE 7 OR UNDER WITH PROG,4709260101,CDM,470,RC,92601,HCPCS,facility,both,,,,569,569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPROGRAM COCHLEAR IMPLANT AGE 6 OR UNDER,4709260201,CDM,470,RC,92602,HCPCS,facility,both,,,,470,470,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPROGRAM COCHLEAR IMPLANT AGE 6 OR UNDER,4709260201,CDM,470,RC,92602,HCPCS,facility,both,,,,477,477,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DX ANALYSIS COCHLEAR IMPLANT AGE 7 OR OLDER WITH PROG,4709260301,CDM,470,RC,92603,HCPCS,facility,both,,,,535,535,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DX ANALYSIS COCHLEAR IMPLANT AGE 7 OR OLDER WITH PROG,4709260301,CDM,470,RC,92603,HCPCS,facility,both,,,,542,542,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPROGRAM COCHLEAR IMPLANT AGE 7 OR OLDER,4709260401,CDM,470,RC,92604,HCPCS,facility,both,,,,430,430,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPROGRAM COCHLEAR IMPLANT AGE 7 OR OLDER,4709260401,CDM,470,RC,92604,HCPCS,facility,both,,,,477,477,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN,4709262001,CDM,470,RC,,,facility,both,,,,325,325,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN,4709262101,CDM,470,RC,,,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TINNITUS ASSESSMENT,4709262501,CDM,470,RC,,,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX SWALLOWING DYSFUNCTION&/ORAL FUNCJ FEEDING,4709262601,CDM,470,RC,,,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV EA ADDL 15,4709262701,CDM,470,RC,,,facility,both,,,,49,49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVALUATION HEARING AID CANDIDACY 1ST 30 MINUTES,4709262801,CDM,470,RC,,,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVALUATION HEARING AID CANDIDACY EA ADDL 15 MIN,4709262901,CDM,470,RC,,,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUDITORY REHABILITATION PRELINGUAL HEARING LOSS,4709263001,CDM,470,RC,,,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING AID SELECTION SERVICES 1ST 30 MINUTES,4709263101,CDM,470,RC,,,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING AID SELECTION SERVICES EA ADDL 15 MIN,4709263201,CDM,470,RC,,,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUDITORY REHABILITATION POSTLINGUAL HEARING LOSS,4709263301,CDM,470,RC,,,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING AID FITTING SERVICES 1ST 60 MINUTES,4709263401,CDM,470,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING AID FITTING SERVICES EA ADDL 15 MINUTES,4709263501,CDM,470,RC,,,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING AID POST-FITTING F-UP SVC 1ST 30 MINUTES,4709263601,CDM,470,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING AID POST-FITTING F-UP SVC EA ADDL 15 MIN,4709263701,CDM,470,RC,,,facility,both,,,,20,20,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BEHAVIORAL VERIFICATION OF AMPLIFICATION,4709263801,CDM,470,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING AID MEAS VERIF W/PROBE MICROPHONE,4709263901,CDM,470,RC,,,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING DEVICE VERIFICATION ELECTROACOUSTIC ALYS,4709264101,CDM,470,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARING ASSISTIVE DEVICE SUPPL TECH FITTING SVC,4709264201,CDM,470,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AEP SCR AUDITORY POTENTIAL,4709265001,CDM,470,RC,92650,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AEP HEARING STATUS DETER I&R,4709265101,CDM,470,RC,92651,HCPCS,facility,both,,,,476,476,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AEP THRSHLD EST MLT FREQ I&R,4709265201,CDM,470,RC,92652,HCPCS,facility,both,,,,735,735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AEP NEURODIAGNOSTIC I&R,4709265301,CDM,470,RC,92653,HCPCS,facility,both,,,,648,648,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CANALITH REPOSITIONING PROCEDURE,4709599201,CDM,470,RC,,,facility,both,,,,99,99,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT,4709612701,CDM,470,RC,,,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL OF IMPACTED WAX MD,470G026801,CDM,470,RC,,,facility,both,,,,137,137,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BASIC VESTIBULAR EVALUATION,4719254001,CDM,471,RC,92540,HCPCS,facility,both,,,,815,815,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POSITIONAL NYSTAGMUS,4719254201,CDM,471,RC,,,facility,both,,,,258,258,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPTOKINETIC NYSTAGMUS,4719254401,CDM,471,RC,92544,HCPCS,facility,both,,,,258,258,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TYMPANOMETRY AND REFLEX THRESH,4719255001,CDM,471,RC,92550,HCPCS,facility,both,,,,170,170,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SCREENING PURETONE AIR,4719255101,CDM,471,RC,92551,HCPCS,facility,both,,,,110,110,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SCREENING PURETONE AIR,4719255101,CDM,471,RC,92551,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PURETONE AUDIOMETRY AIR ONLY,4719255201,CDM,471,RC,92552,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PURETONE AUDIOMETRY AIR ONLY,4719255201,CDM,471,RC,92552,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PURETONE AUDIOMETRY AIR AND BONE,4719255301,CDM,471,RC,92553,HCPCS,facility,both,,,,417,417,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PURETONE AUDIOMETRY AIR AND BONE,4719255301,CDM,471,RC,92553,HCPCS,facility,both,,,,339,339,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THRESHOLD WITH SPEECH RECOGNITION,4719255601,CDM,471,RC,92556,HCPCS,facility,both,,,,202,202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THRESHOLD WITH SPEECH RECOGNITION,4719255601,CDM,471,RC,92556,HCPCS,facility,both,,,,249,249,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPREHENSIVE AUDIOGRAM,4719255701,CDM,471,RC,92557,HCPCS,facility,both,,,,466,466,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPREHENSIVE AUDIOGRAM,4719255701,CDM,471,RC,92557,HCPCS,facility,both,,,,303,303,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVOKED OTOACOUSTIC EMISSIONS SCREEN AUTO ANALYS,4719255801,CDM,471,RC,,,facility,both,,,,362,362,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TYMPANOMETRY,4719256701,CDM,471,RC,92567,HCPCS,facility,both,,,,114,114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TYMPANOMETRY,4719256701,CDM,471,RC,92567,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTOACOUSTIC EMISSION LIMITED,4719258701,CDM,471,RC,92587,HCPCS,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTOACOUSTIC COMP OR DIAG,4719258801,CDM,471,RC,,,facility,both,,,,340,340,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTOACOUSTIC COMP OR DIAG,4719258801,CDM,471,RC,,,facility,both,,,,378,378,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV 1ST HR,4719262601,CDM,471,RC,92626,HCPCS,facility,both,,,,253,253,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROGRAMMING DEV EVAL ICDS W/SS ELTRD IN PERSON,4800575T01,CDM,480,RC,0575T,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROGATION DEV EVAL ICDS W/SS ELTRD IN PERSON,4800576T01,CDM,480,RC,0576T,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM INTERROG DEV EVAL SS LD ICDS < 90D TECH,4800579T01,CDM,480,RC,0579T,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROGRMG DEV EVAL SCRMS PHYS/QHP REMOTE,4800650T01,CDM,480,RC,,,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRGRMG DEV EVAL LDLS PM SYS 2CHMBR IN PERSON,4800804T01,CDM,480,RC,0804T,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRGRMG DEV EVAL LDLS PM SINGLE CAR CHAMBER IP,4800826T01,CDM,480,RC,0826T,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CCTA WO & WITH DISEASE STRXR,4807557201,CDM,480,RC,75572,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CT CCTA WO & WITH CONTRAST,4807557401,CDM,480,RC,75574,HCPCS,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC N-INVAS EST C FFR AUGMNT SW ALYS CTA I&R PHY/QHP,4807558001,CDM,480,RC,75580,HCPCS,facility,both,,,,4819,4819,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARDIOVERSION,4809296001,CDM,480,RC,92960,HCPCS,facility,both,,,,879,879,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PDE IMPLANT SUBCUTANEOUS LEAD,4809326001,CDM,480,RC,93260,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PDE IMPLANT SUBCUTANEOUS LEAD,4809326001,CDM,480,RC,93260,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROGATION LEAD DEFIBRILL,4809326101,CDM,480,RC,93261,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROGATION LEAD DEFIBRILL,4809326101,CDM,480,RC,93261,HCPCS,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOTE MNTR WIRELESS P-ART PRS SNR UP TO 30 D,4809326401,CDM,480,RC,93264,HCPCS,facility,both,,,,203,203,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOTE MNTR WIRELESS P-ART PRS SNR UP TO 30 D,4809326401,CDM,480,RC,93264,HCPCS,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRGRMG DEV EVAL 1 LEAD PM/LDLS PM 1 CAR CHMBR IP,4809327901,CDM,480,RC,93279,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PDE IMPLANT DUAL LEAD,4809328001,CDM,480,RC,93280,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PDE MULTIPLE LEAD PACEMAKER,4809328101,CDM,480,RC,93281,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PDE SINGLE LEAD TRANS DEFIB,4809328201,CDM,480,RC,93282,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PDE DUAL LEAD TRANS DEFIB,4809328301,CDM,480,RC,93283,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PDE MULTIPLE LEAD TRANS DEFIB,4809328401,CDM,480,RC,93284,HCPCS,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON,4809328501,CDM,480,RC,,,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON,4809328501,CDM,480,RC,,,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERI-PX DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON,4809328601,CDM,480,RC,93286,HCPCS,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB,4809328701,CDM,480,RC,93287,HCPCS,facility,both,,,,109,109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROG DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON,4809328801,CDM,480,RC,93288,HCPCS,facility,both,,,,84,84,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROG DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON,4809328801,CDM,480,RC,93288,HCPCS,facility,both,,,,92,92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INTERROG EVAL F2F 1/DUAL/MLT LEADS IMPLTBL DFB,4809328901,CDM,480,RC,,,facility,both,,,,150,150,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDE ANALYSIS HEART RHYTHM DATA ELEMENT,4809328902,CDM,480,RC,93289,HCPCS,facility,both,,,,95,95,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IDE ANALYSIS HEART RHYTHM DATA ELEMENT,4809328902,CDM,480,RC,93289,HCPCS,facility,both,,,,105,105,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROG DEV EVAL ICPMS PHYS/QHP IN PERSON,4809329001,CDM,480,RC,93290,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROG DEV EVAL SCRMS PHYS/QHP IN PERSON,4809329101,CDM,480,RC,93291,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM INTERROG PM/LDLS PM/IDS <90 D PHYS/QHP,4809329601,CDM,480,RC,93296,HCPCS,facility,both,,,,122,122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM INTERROG PM/LDLS PM/IDS <90 D PHYS/QHP,4809329601,CDM,480,RC,93296,HCPCS,facility,both,,,,170,170,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM INTERROG SCRMS <30 D PHYS/QHP,4809329701,CDM,480,RC,93297,HCPCS,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REM INTERROG ICPMS <30 D PHYS/QHP,4809329801,CDM,480,RC,93298,HCPCS,facility,both,,,,64,64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED EP EVALUATION,4809364201,CDM,480,RC,,,facility,both,,,,2374,2374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TILT TABLE,4809366001,CDM,480,RC,93660,HCPCS,facility,both,,,,688,688,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOIMPEDNACE DERIVED PHYSIOLOGIC CV ANALYSIS,4809370101,CDM,480,RC,,,facility,both,,,,283,283,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROGATION VAD IN PRSON W/PHYS/QHP ANALYSIS,4809375001,CDM,480,RC,93750,HCPCS,facility,both,,,,443,443,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMBULATORY BP MNTR W/SW 24 HR+ RECORDING ONLY,4809378601,CDM,480,RC,,,facility,both,,,,361,361,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMBULATORY BP MNTR W/SW 24 HR+ SCANNING A/R,4809378801,CDM,480,RC,,,facility,both,,,,361,361,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  MV02-RESTING MEASURED OXYGEN CONSUMPTION,4809479901,CDM,410,RC,,,facility,both,,,,312,312,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTERNAL COUNTERPULSATION,480G016601,CDM,480,RC,G0166,HCPCS,facility,both,,,,334,334,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSCATHETER RENAL DENERVATION PERCUTANEOUS UNILATERAL,4810338T02,CDM,481,RC,0338T,HCPCS,facility,both,,,,18811,18811,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSCATHETER RENAL DENERVATION PERCUTANEOUS BILATERAL,4810339T01,CDM,481,RC,0339T,HCPCS,facility,both,,,,29444,29444,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM INSERT/REPLACE SYSTEM PLS GEN AND LEAD(S),4810408T01,CDM,481,RC,0408T,HCPCS,facility,both,,,,72096,72096,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM GENERATOR INSERTION,4810409T01,CDM,481,RC,,,facility,both,,,,50827,50827,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM ATRIAL LEAD INSERTION,4810410T01,CDM,481,RC,,,facility,both,,,,18617,18617,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM VENTRICULAR LEAD INSERTION,4810411T01,CDM,481,RC,,,facility,both,,,,18617,18617,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM GENERATOR REMOVAL,4810412T01,CDM,481,RC,,,facility,both,,,,13039,13039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM LEAD REMOVAL,4810413T01,CDM,481,RC,,,facility,both,,,,13039,13039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM GENERATOR CHANGE,4810414T01,CDM,481,RC,,,facility,both,,,,50827,50827,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM LEAD REVISION,4810415T01,CDM,NULL,RC,,,facility,both,,,,2086,2086,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CCM POCKET REVISION,4810416T01,CDM,481,RC,,,facility,both,,,,6055,6055,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TMVI W/PROSTHETIC VALVE PERCUTANEOUS APPRCH,4810483T01,CDM,481,RC,,,facility,both,,,,17489,17489,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL & RPLMNT WIRELESS CAR STIM PG COMPNT,4810519T01,CDM,481,RC,,,facility,both,,,,32664,32664,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAPROCEDURAL CORONARY FFR W/3D FUNCJL MAPPING,4810523T01,CDM,481,RC,,,facility,both,,,,6434,6434,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISCHEMIA MONITOR SYSTEM INSERTION,4810525T01,CDM,481,RC,,,facility,both,,,,27385,27385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISCHEMIA MONITOR LEAD INSERTION,4810526T01,CDM,481,RC,,,facility,both,,,,21642,21642,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISCHEMIA MONITOR GENERATOR INSERTION,4810527T01,CDM,481,RC,,,facility,both,,,,21642,21642,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISCHEMIA MONITOR SYSTEM REMOVAL,4810530T01,CDM,481,RC,,,facility,both,,,,13326,13326,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISCHEMIA MONITOR LEAD REMOVAL,4810531T01,CDM,481,RC,,,facility,both,,,,8884,8884,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ISCHEMIA MONITOR GENERATOR REMOVAL,4810532T01,CDM,481,RC,,,facility,both,,,,8884,8884,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TTVR PERCUTANEOUS APPROACH INITIAL PROSTHESIS,4810569T01,CDM,481,RC,0569T,HCPCS,facility,both,,,,15787,15787,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TTVR PERCUTANEOUS APPROACH EACH ADDL PROSTHESIS,4810570T01,CDM,481,RC,0570T,HCPCS,facility,both,,,,3946,3946,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS/RPLCMT ICDS W/SUBSTERNAL ELETRODE,4810571T01,CDM,481,RC,0571T,HCPCS,facility,both,,,,56423,56423,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT SUBSTERNAL IMPLANT DEFIB ELECTRODE,4810572T01,CDM,481,RC,,,facility,both,,,,28208,28208,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMVL SUBSTERNAL IMPLANT DEFIB ELECTRODE,4810573T01,CDM,481,RC,,,facility,both,,,,13039,13039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOSITION PRVS IMPLANT SUBSTERNAL DEFIB ELECTRODE,4810574T01,CDM,481,RC,,,facility,both,,,,13039,13039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOS PREV IMPLNTD SS IMPLTBL DFB PACING ELCTRD,4810574T02,CDM,481,RC,,,facility,both,,,,10204,10204,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EP EVAL IMPLANT CARD DEFIB W/SUBSTERNAL ELECTRODE(S),4810577T01,CDM,481,RC,,,facility,both,,,,3951,3951,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMVL SUBSTERNAL IMPLANT DEFIB PLSE GEN ONLY,4810580T01,CDM,481,RC,,,facility,both,,,,13039,13039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMVL & REPLCMNT SUBSTERNAL IMPLANT DEFIB PLSE GEN,4810614T01,CDM,481,RC,,,facility,both,,,,51655,51655,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TCAT RMVL/DEBULK INTRACAR MASS SUCTION DEVICE PERQ,4810644T01,CDM,481,RC,0644T,HCPCS,facility,both,,,,17600,17600,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TTVI REPLACEMENT PERQ,4810646T01,CDM,481,RC,,,facility,both,,,,16358,16358,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS TRANSLUMINCAL CORONARY LITHOTRIPSY,4810715T01,CDM,481,RC,,,facility,both,,,,3678,3678,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT DUAL-CHMBR LEADLESS PCMKR R ATRL & R VNTRCLR,4810795T02,CDM,481,RC,0795T,HCPCS,facility,both,,,,50633,50633,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT DUAL-CHMBR LEADLESS PCMKR R ATRL CMPNT,4810796T01,CDM,NULL,RC,,,facility,both,,,,64698,64698,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT DUAL-CHMBR LEADLESS PCMKR R VNTRCLR CMPNT,4810797T01,CDM,481,RC,,,facility,both,,,,64698,64698,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRNSCTHTR RMVL & REPLACEMENT DUAL-CHMBR LEADLESS PCMKR,4810801T01,CDM,481,RC,,,facility,both,,,,59491,59491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRNSCTHTR RMVL & REPLACEMENT DUAL-CHMBR LEADLESS PCMKR R ATRIAL,4810802T01,CDM,481,RC,,,facility,both,,,,59491,59491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRNSCTHTR RMVL & REPLACEMENT DUAL-CHMBR LEADLESS PCMKR R VNTRCLR,4810803T01,CDM,NULL,RC,,,facility,both,,,,59491,59491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRNSCTHTR INSERT SINGLE CHMBR LEADLESS PCMKR R ATRL CMPNT,4810823T01,CDM,481,RC,0823T,HCPCS,facility,both,,,,50633,50633,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRNSCTHTR RMVL & REPLACEMENT SINGLE-CHMBR LEADLESS PCMKR R ATRIAL,4810825T01,CDM,481,RC,,,facility,both,,,,59491,59491,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ TRNSCATH THER RX DLVR INTRAC BAL 1 MAJ C ART,4810913T01,CDM,481,RC,0913T,HCPCS,facility,both,,,,15549,15549,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ TRNSCATH THER RX DLVR INTRAC BAL SEPARATE,4810914T01,CDM,481,RC,0914T,HCPCS,facility,both,,,,10885,10885,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSRTN PERM CCDM-D SYS PG&DUAL TRANSVNS ELTRDS/LDS,4810915T01,CDM,481,RC,,,facility,both,,,,73741,73741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH REMOVE FOREIGN BODY SUBQ SIMPLE,4811012001,CDM,481,RC,,,facility,both,,,,489,489,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH DRAINAGE OF HEMATOMA FLUID,4811014001,CDM,481,RC,10140,HCPCS,facility,both,,,,1518,1518,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  INCISION & DRAINAGE COMPLEX PO WOUND INFECTION,4811018001,CDM,481,RC,10180,HCPCS,facility,both,,,,6729,6729,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/<,4811104301,CDM,481,RC,11043,HCPCS,facility,both,,,,566,566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDEMENT MUSCLE &/FASCIA EA ADDL 20 SQ CM,4811104601,CDM,481,RC,11046,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSURE OF SPLIT WOUND,4811202001,CDM,481,RC,12020,HCPCS,facility,both,,,,777,777,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,4813301601,CDM,481,RC,33016,HCPCS,facility,both,,,,2875,2875,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY,4813301701,CDM,481,RC,33017,HCPCS,facility,both,,,,2875,2875,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY,4813302001,CDM,481,RC,,,facility,both,,,,41623,41623,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PACEMAKER INSERT ATRIAL,4813320601,CDM,481,RC,33206,HCPCS,facility,both,,,,11969,11969,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PACEMAKER INSERT VENTRICLE,4813320701,CDM,481,RC,33207,HCPCS,facility,both,,,,11969,11969,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PACEMAKER INSERT A/V LEADS,4813320801,CDM,481,RC,33208,HCPCS,facility,both,,,,14694,14694,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HC TEMPORARY PACEMAKER INSERTION,4813321001,CDM,481,RC,33210,HCPCS,facility,both,,,,6715,6715,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX,4813321101,CDM,481,RC,,,facility,both,,,,16898,16898,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW PPM TO EXIST SINGLE LEAD,4813321201,CDM,481,RC,33212,HCPCS,facility,both,,,,9822,9822,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW PPM TO EXIST DUAL LEADS,4813321301,CDM,481,RC,33213,HCPCS,facility,both,,,,14097,14097,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UPGRADE SINGLE TO DUAL SYSTEM,4813321401,CDM,481,RC,,,facility,both,,,,8008,8008,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOSITION RA OR RV LEAD,4813321501,CDM,481,RC,33215,HCPCS,facility,both,,,,4181,4181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT ONE LEAD TO EXIST DEVICE,4813321601,CDM,481,RC,33216,HCPCS,facility,both,,,,7672,7672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT TWO LEADS TO EXIST DEVICE,4813321701,CDM,481,RC,33217,HCPCS,facility,both,,,,8056,8056,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR SINGLE LEAD,4813321801,CDM,481,RC,33218,HCPCS,facility,both,,,,3384,3384,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR TWO LEADS,4813322001,CDM,481,RC,,,facility,both,,,,3386,3386,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW PPM TO EXIST MULTI LEAD,4813322101,CDM,481,RC,33221,HCPCS,facility,both,,,,14996,14996,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RELOCATE SKIN POCKET IMPLANTABLE DEFIBRILLATOR,4813322301,CDM,481,RC,33223,HCPCS,facility,both,,,,2391,2391,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LV LEAD ADDED TO EXIST DEVICE,4813322401,CDM,481,RC,33224,HCPCS,facility,both,,,,8372,8372,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LV LEAD ADDED TO NEW DEVICE,4813322501,CDM,481,RC,33225,HCPCS,facility,both,,,,3467,3467,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOSITION LV LEAD,4813322601,CDM,481,RC,33226,HCPCS,facility,both,,,,5099,5099,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PPM BATTERY CHANGE SINGLE LEAD,4813322701,CDM,481,RC,33227,HCPCS,facility,both,,,,10058,10058,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PPM BATTERY CHANGE DUAL LEADS,4813322801,CDM,481,RC,33228,HCPCS,facility,both,,,,11032,11032,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PPM BATTERY CHANGE MULTI LEAD,4813322901,CDM,481,RC,33229,HCPCS,facility,both,,,,14996,14996,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW ICD TO EXIST DUAL LEADS,4813323001,CDM,481,RC,,,facility,both,,,,46592,46592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW ICD TO EXIST MULTI LEAD,4813323101,CDM,481,RC,,,facility,both,,,,35610,35610,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PACEMAKER BATTERY REMOVAL,4813323301,CDM,481,RC,33233,HCPCS,facility,both,,,,6569,6569,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE ONE PPM LEAD,4813323401,CDM,481,RC,33234,HCPCS,facility,both,,,,2772,2772,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE TWO PPM LEADS,4813323501,CDM,481,RC,33235,HCPCS,facility,both,,,,2983,2983,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INST NEW ICD TO EXIST SINGLE LEAD,4813324001,CDM,481,RC,,,facility,both,,,,22317,22317,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ICD BATTERY REMOVAL,4813324101,CDM,481,RC,33241,HCPCS,facility,both,,,,2772,2772,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE ICD LEADS,4813324401,CDM,481,RC,33244,HCPCS,facility,both,,,,2752,2752,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW ICD SYSTEM,4813324901,CDM,481,RC,33249,HCPCS,facility,both,,,,26448,26448,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ICD BATTERY CHANGE SINGLE LEAD,4813326201,CDM,481,RC,33262,HCPCS,facility,both,,,,18567,18567,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ICD BATTERY CHANGE DUAL LEAD,4813326301,CDM,481,RC,33263,HCPCS,facility,both,,,,18567,18567,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ICD BATTERY CHANGE MULTI LEAD,4813326401,CDM,481,RC,33264,HCPCS,facility,both,,,,26448,26448,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCLUSION LEFT ATRIAL APPENDAGE OPEN ANY METHOD,4813326701,CDM,481,RC,,,facility,both,,,,18918,18918,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW SUBQ ICD SYSTEM,4813327001,CDM,481,RC,33270,HCPCS,facility,both,,,,26448,26448,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSRT SUBQ IMPLANTABLE DFB ELECTRODE,4813327101,CDM,481,RC,,,facility,both,,,,22076,22076,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE SUBQ ICD LEAD,4813327201,CDM,481,RC,33272,HCPCS,facility,both,,,,2752,2752,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOS PREV IMPLANTED SUBQ IMPLANT DFB,4813327301,CDM,481,RC,33273,HCPCS,facility,both,,,,10204,10204,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INS SNGLE CHAMBER LEADLESS PPM,4813327401,CDM,481,RC,33274,HCPCS,facility,both,,,,23369,23369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PHRENIC NERVE STIMULATOR SYSTEM,4813327601,CDM,481,RC,33276,HCPCS,facility,both,,,,69862,69862,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL PHRENIC NERVE STIMULATOR SYSTEM,4813327801,CDM,481,RC,,,facility,both,,,,10167,10167,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL PHRNC NRV STIMULATOR TRANSVNS STIMJ/SNSG LD,4813327901,CDM,481,RC,,,facility,both,,,,10167,10167,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL PHRENIC NRV STIMULATOR PULSE GENERATOR ONLY,4813328001,CDM,481,RC,33280,HCPCS,facility,both,,,,10167,10167,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOSITIONING PHRENIC NRV STIMULATOR TRANSVNS LD,4813328101,CDM,481,RC,,,facility,both,,,,10167,10167,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION SUBQ CARDIAC RHYTHM MONITOR W/PRGRMG,4813328501,CDM,481,RC,33285,HCPCS,facility,both,,,,10902,10902,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR,4813328601,CDM,481,RC,33286,HCPCS,facility,both,,,,1642,1642,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL&RPLCMT PHRENIC NRV STIMULATOR PLS GENERATOR,4813328701,CDM,481,RC,,,facility,both,,,,45932,45932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL&RPLCMT PHRNC NRV STIM TRNSVNS STIMJ/SNSG LD,4813328801,CDM,481,RC,,,facility,both,,,,20149,20149,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR,4813328901,CDM,481,RC,33289,HCPCS,facility,both,,,,23226,23226,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSJ GRAFT AORTA/GREAT VESSEL W/BYPASS,4813333501,CDM,481,RC,,,facility,both,,,,10087,10087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEFT ATRIAL APPENDAGE IMPLANT,4813334001,CDM,481,RC,33340,HCPCS,facility,both,,,,7847,7847,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAVR/TAVI WITHPROS VALVEPERC AP,4813336101,CDM,481,RC,33361,HCPCS,facility,both,,,,14721,14721,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAVR OPEN AXIL ART APPROACH,4813336301,CDM,481,RC,,,facility,both,,,,26127,26127,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VALVULOPLASTY AORTIC VALVE OPEN CARD BYP COMPLEX,4813339101,CDM,481,RC,,,facility,both,,,,15049,15049,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERC MITRAL VALVE REPAIR INITIAL,4813341801,CDM,481,RC,33418,HCPCS,facility,both,,,,15787,15787,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERC MITRAL VALVE REPAIR ADDTL,4813341901,CDM,481,RC,33419,HCPCS,facility,both,,,,3946,3946,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TAS CONGENITAL CARDIAC ANOMALIES ANY METHOD,4813374101,CDM,481,RC,33741,HCPCS,facility,both,,,,6242,6242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RPR THOR AORTA WITH SUBCLAV,4813388001,CDM,481,RC,,,facility,both,,,,7900,7900,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ TRLUML ANGP NT/RECR COA,4813389701,CDM,481,RC,33897,HCPCS,facility,both,,,,5327,5327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ P-ART REVSC ST 1ST NML NATIVE CONNJ UNI,4813390001,CDM,481,RC,33900,HCPCS,facility,both,,,,22026,22026,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ P-ART REVSC ST 1ST NML NATIVE CONNJ BI,4813390101,CDM,481,RC,,,facility,both,,,,56289,56289,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ P-ART REVSC ST 1ST ABNOR CONNJ UNILATERAL,4813390201,CDM,481,RC,33902,HCPCS,facility,both,,,,22026,22026,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ P-ART REVSC ST 1ST ABNORMAL CONNJ BILATERAL,4813390301,CDM,481,RC,33903,HCPCS,facility,both,,,,56289,56289,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ P-ART REVSC ST EA ADDL VSL/SEP LES NM/ABNL,4813390401,CDM,481,RC,33904,HCPCS,facility,both,,,,5484,5484,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECMO/ECLS INSJ OF PRPH CANNULA 6 YRS&OLDER PERQ,4813395201,CDM,481,RC,33952,HCPCS,facility,both,,,,2390,2390,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRA AORTIC BALLOON PLACEMENT,4813396701,CDM,481,RC,33967,HCPCS,facility,both,,,,1829,1829,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMV AORTIC BALLOON DEVICE,4813396801,CDM,481,RC,33968,HCPCS,facility,both,,,,1004,1004,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INSERT VAD, PERQ, W/RS&I LT HEART, ARTERIAL ACCESS ONLY",4813399001,CDM,481,RC,33990,HCPCS,facility,both,,,,19022,19022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL PERQ R HEART VAD ARTERIAL CANNULA SEPT INSJ,4813399201,CDM,481,RC,33992,HCPCS,facility,both,,,,2858,2858,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOSITION VAD W/IMAGING DIFFERENT SESSION,4813399301,CDM,481,RC,,,facility,both,,,,2243,2243,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSJ PERQ VAD W/RS&I R HEART VENOUS ACCESS ONLY,4813399501,CDM,481,RC,33995,HCPCS,facility,both,,,,21136,21136,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL PERQ R HEART VAD VENOUS CANNULA SEPT INSJ,4813399701,CDM,481,RC,,,facility,both,,,,4057,4057,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REMOVAL RIGHT ATRIUM,4813399902,CDM,481,RC,,,facility,both,,,,2981,2981,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HIS LEAD ADDED TO NEW DEVICE,4813399903,CDM,481,RC,,,facility,both,,,,4430,4430,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW BI-V ICD W/HIS,4813399904,CDM,481,RC,,,facility,both,,,,25354,25354,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT VAD PERC VENOUS ACCESS,4813399905,CDM,481,RC,,,facility,both,,,,24306,24306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OCCLUTECH ATRIAL FLOW REGULATOR,4813399906,CDM,481,RC,,,facility,both,,,,3693,3693,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PACEMAKER INSERT HIS LEADS,4813399907,CDM,481,RC,,,facility,both,,,,18776,18776,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERICARDIOPLASTY,4813399908,CDM,481,RC,,,facility,both,,,,3053,3053,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE INTRACORONARY GUIDEWIRE,4813399909,CDM,481,RC,,,facility,both,,,,3739,3739,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRICUSPID VALVE REPLACEMENT,4813399911,CDM,481,RC,,,facility,both,,,,20692,20692,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPOSITIONING OF IABP,4813399914,CDM,481,RC,,,facility,both,,,,1004,1004,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE AND REPLACE SAME LEADLESS PACEMAKER,4813399915,CDM,481,RC,,,facility,both,,,,2670,2670,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT NEW PPM WITH LV LEADS,4813399916,CDM,481,RC,33999,HCPCS,facility,both,,,,14012,14012,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SENTINEL DEVICE INSERTION,4813399918,CDM,481,RC,,,facility,both,,,,1385,1385,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAA DEVICE LEAK OCCLUSION,4813399920,CDM,481,RC,33999,HCPCS,facility,both,,,,7847,7847,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOVASC VISCER AORTA REPAIR FENEST 2 ENDOGRAFT,4813484201,CDM,481,RC,,,facility,both,,,,15641,15641,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOVASC REPAIR VISC AND INFRARENAL ABDOM AORTA 1 PROSTHS,4813484501,CDM,481,RC,,,facility,both,,,,14077,14077,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOVASC REPAIR VISCER & INFRAREMAL ABDOM AORTA 2 PROSTH,4813484601,CDM,481,RC,,,facility,both,,,,14859,14859,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLCTV CATH PLMT VEN SYS 2ND ORDER/> SLCTV BRANC,4813601201,CDM,481,RC,36012,HCPCS,facility,both,,,,1134,1134,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLCTV CATH PLMT VEN SYS 2ND ORDER/> SLCTV BRANC,4813601201,CDM,481,RC,36012,HCPCS,facility,both,,,,2268,2268,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CATH PLC SEG SUBSEG PULM,4813601501,CDM,481,RC,36015,HCPCS,facility,both,,,,1039,1039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRODUCTION CATHETER AORTA,4813620001,CDM,481,RC,36200,HCPCS,facility,both,,,,1715,1715,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HC ART ARTERIO 1ST ABOV DIA,4813621501,CDM,481,RC,36215,HCPCS,facility,both,,,,2055,2055,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH SEL CATHPL EA ADDTL IN VASC FAM,4813621801,CDM,481,RC,36218,HCPCS,facility,both,,,,1254,1254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLCTV CATHJ 2ND ORDER ABDL PEL/LXTR ART BRNCH,4813624601,CDM,481,RC,36246,HCPCS,facility,both,,,,1194,1194,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLCTV CATHJ 3RD+ ORD SLCTV ABDL PEL/LXTR BRNCH,4813624701,CDM,481,RC,36247,HCPCS,facility,both,,,,1986,1986,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLCTV CATH 1STORD W/WO ART PUNCT/FLUORO/S&I UN,4813625101,CDM,481,RC,36251,HCPCS,facility,both,,,,5332,5332,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CATHETER PLACEMENT INTO PULMONARY VEIN,4813629901,CDM,481,RC,,,facility,both,,,,3582,3582,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMPLANT VENOUS TUNNELED >5 YRS,4813655801,CDM,481,RC,,,facility,both,,,,3763,3763,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ AV FISTULA CREATION UPPER EXTMTY SEP ACCESS SITES,4813683701,CDM,481,RC,,,facility,both,,,,62576,62576,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRCT MECHANICAL THROMBECT DIALYSIS CIRCUIT,4813690401,CDM,481,RC,,,facility,both,,,,16736,16736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIM ART MECH THROMBECTOMY ADD ON,4813718501,CDM,481,RC,37185,HCPCS,facility,both,,,,3641,3641,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SEC PRQ TRLUML THRMBC N-CORONARY N-INTRACRANIAL,4813718601,CDM,481,RC,37186,HCPCS,facility,both,,,,10804,10804,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVC FILTER RTRVL,4813719301,CDM,481,RC,,,facility,both,,,,3641,3641,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE INTRAVASCULAR FOREIGN BODY,4813719701,CDM,481,RC,37197,HCPCS,facility,both,,,,4486,4486,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAR STENT W/DIST EMB PRO,4813721501,CDM,481,RC,,,facility,both,,,,2143,2143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ILIAC TLA,4813722001,CDM,481,RC,37220,HCPCS,facility,both,,,,7292,7292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ILIAC REVASC W/STENT,4813722101,CDM,481,RC,37221,HCPCS,facility,both,,,,30928,30928,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ILIAC TLA EACH ADDITIONAL,4813722201,CDM,481,RC,,,facility,both,,,,6341,6341,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSE OPN/PRG FEM/POP W/ANGIOPLASTY UNI,4813722401,CDM,481,RC,37224,HCPCS,facility,both,,,,6341,6341,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4813722601,CDM,481,RC,37226,HCPCS,facility,both,,,,15868,15868,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI,4813722801,CDM,481,RC,37228,HCPCS,facility,both,,,,9256,9256,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH ARTERIAL STENT INITIAL,4813723601,CDM,481,RC,37236,HCPCS,facility,both,,,,8087,8087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH ARTERIAL STENT ADDITIONAL,4813723701,CDM,481,RC,,,facility,both,,,,5649,5649,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH VENOUS STENT INITIAL,4813723801,CDM,481,RC,37238,HCPCS,facility,both,,,,7922,7922,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH VENOUS STENT ADDITIONAL,4813723901,CDM,481,RC,37239,HCPCS,facility,both,,,,5517,5517,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH VASC EMBOLIZE/OCCLUDE ARTERY,4813724201,CDM,481,RC,37242,HCPCS,facility,both,,,,15833,15833,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VASC EMBOLIZE/OCCLUDE BLEED,4813724401,CDM,481,RC,37244,HCPCS,facility,both,,,,17114,17114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRLML BALO ANGIOP OPEN/PERQ IMG S&I 1ST ART,4813724601,CDM,481,RC,37246,HCPCS,facility,both,,,,5919,5919,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I 1ST VEIN,4813724801,CDM,481,RC,37248,HCPCS,facility,both,,,,4940,4940,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH IVUS NON CORONARY INITIAL VESSEL,4813725201,CDM,481,RC,37252,HCPCS,facility,both,,,,17028,17028,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH IVUS NON CORONARY EACH ADDTL,4813725301,CDM,481,RC,37253,HCPCS,facility,both,,,,17028,17028,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IVT ANGIOP UNI SF LES 1ST VSL,4813725401,CDM,481,RC,,,facility,both,,,,6341,6341,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IVT ANGIOP UNI SF LES EA ADDL VSL,4813725501,CDM,481,RC,,,facility,both,,,,5514,5514,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IVT ANGIOP UNI CPLX LES 1ST VSL,4813725601,CDM,481,RC,,,facility,both,,,,6341,6341,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IVT ANGIOP UNI CPLX LES EA ADDL VSL,4813725701,CDM,481,RC,,,facility,both,,,,5514,5514,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IVT ST PLMT UNI SF LES 1ST VSL,4813725801,CDM,481,RC,37258,HCPCS,facility,both,,,,10284,10284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IVT ST PLMT UNI SF LES EA ADDL VSL,4813725901,CDM,481,RC,,,facility,both,,,,6341,6341,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IVT ST PLMT UNI CPLX LES 1ST VSL,4813726001,CDM,481,RC,,,facility,both,,,,10284,10284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IVT ST PLMT UNI CPLX LES EA ADDL VSL,4813726101,CDM,481,RC,,,facility,both,,,,6341,6341,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAVASCULAR LITHOTRIPSY IVT WITHIN SAME ARTERY,4813726201,CDM,481,RC,,,facility,both,,,,8507,8507,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ANGIOP UNI SF LES 1ST VSL,4813726301,CDM,481,RC,37263,HCPCS,facility,both,,,,7046,7046,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ANGIOP UNI SF LES EA ADDL VSL,4813726401,CDM,481,RC,,,facility,both,,,,4190,4190,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ANGIOP UNI CPLX LES 1ST VSL,4813726501,CDM,481,RC,37265,HCPCS,facility,both,,,,7046,7046,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ANGIOP UNI CPLX LES EA ADDL VSL,4813726601,CDM,481,RC,,,facility,both,,,,8507,8507,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ST PLMT UNI SF LES 1ST VSL,4813726701,CDM,481,RC,,,facility,both,,,,15406,15406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ST PLMT UNI SF LES EA ADDL VSL,4813726801,CDM,481,RC,,,facility,both,,,,4190,4190,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ST PLMT UNI CPLX LES 1ST VSL,4813726901,CDM,481,RC,,,facility,both,,,,15406,15406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ST PLMT UNI CPLX LES EA ADD VSL,4813727001,CDM,481,RC,,,facility,both,,,,16667,16667,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ATHRC UNI SF LES 1ST VSL,4813727101,CDM,481,RC,,,facility,both,,,,15406,15406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ATHRC UNI SF LES EA ADDL VSL,4813727201,CDM,481,RC,,,facility,both,,,,4190,4190,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ATHRC UNI CPLX LES 1ST VSL,4813727301,CDM,481,RC,,,facility,both,,,,15406,15406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ATHRC UNI CPLX LES EA ADDL VSL,4813727401,CDM,481,RC,,,facility,both,,,,8507,8507,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ST ATHRC UNI SF LES 1ST VSL,4813727501,CDM,481,RC,,,facility,both,,,,23314,23314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ST ATHRC UNI SF LES EA ADDL VSL,4813727601,CDM,481,RC,,,facility,both,,,,4190,4190,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC FPVT ST ATHRC UNI CPLX LES 1ST VSL,4813727701,CDM,481,RC,,,facility,both,,,,23314,23314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVSC FPVT ST ATHRC UNI CPLX LES EA ADD VSL,4813727801,CDM,481,RC,,,facility,both,,,,8507,8507,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAVASCULAR LITHOTRIPSY FPVT W/IN SAME ARTERY,4813727901,CDM,481,RC,,,facility,both,,,,8507,8507,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ANGIOP UNI SF LES 1ST VSL,4813728001,CDM,481,RC,37280,HCPCS,facility,both,,,,34508,34508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ANGIOP UNI SF LES EA ADDL VSL,4813728101,CDM,481,RC,,,facility,both,,,,8627,8627,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ANGIOP UNI CPLX LES 1ST VSL,4813728201,CDM,481,RC,,,facility,both,,,,34508,34508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ANGIOP UNI CPLX LES EA ADDL VSL,4813728301,CDM,481,RC,,,facility,both,,,,17254,17254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ST PLMT UNI SF LES 1ST VSL,4813728401,CDM,481,RC,,,facility,both,,,,54797,54797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ST PLMT UNI SF LES EA ADDL VSL,4813728501,CDM,481,RC,,,facility,both,,,,13699,13699,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ST PLMT UNI CPLX LES 1ST VSL,4813728601,CDM,481,RC,,,facility,both,,,,54797,54797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ST PLMT UNI CPLX LES EA ADD VSL,4813728701,CDM,481,RC,,,facility,both,,,,27399,27399,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ATHRC UNI SF LES 1ST VSL,4813728801,CDM,481,RC,,,facility,both,,,,54797,54797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ATHRC UNI SF LES EA ADDL VSL,4813728901,CDM,481,RC,,,facility,both,,,,13699,13699,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ATHRC UNI CPLX LES 1ST VSL,4813729001,CDM,481,RC,,,facility,both,,,,54797,54797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ATHRC UNI CPLX LES EA ADDL VSL,4813729101,CDM,481,RC,,,facility,both,,,,27399,27399,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ST ATHRC UNI SF LES 1ST VSL,4813729201,CDM,481,RC,,,facility,both,,,,54797,54797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ST ATHRC UNI SF LES EA ADDL VSL,4813729301,CDM,481,RC,,,facility,both,,,,13699,13699,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC TPVT ST ATHRC UNI CPLX LES 1ST VSL,4813729401,CDM,481,RC,,,facility,both,,,,54797,54797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVSC TPVT ST ATHRC UNI CPLX LES EA ADD VSL,4813729501,CDM,481,RC,,,facility,both,,,,27399,27399,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IMVT ANGIOP UNI SF LES 1ST VSL,4813729601,CDM,481,RC,37296,HCPCS,facility,both,,,,34508,34508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IMVT ANGIOP UNI SF LES EA ADDL VSL,4813729701,CDM,481,RC,,,facility,both,,,,8627,8627,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IMVT ANGIOP UNI CPLX LES 1ST VSL,4813729801,CDM,481,RC,,,facility,both,,,,34508,34508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVSC EVASC IMVT ANGIOP UNI CPLX LES EA ADDL VSL,4813729901,CDM,481,RC,,,facility,both,,,,17254,17254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVUS NON-CORONARY WITHOUT BASE PROCEDURE,4813779902,CDM,481,RC,,,facility,both,,,,9068,9068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LVOT PSEUDO ANEURYSM CLOSURE,4813779903,CDM,481,RC,,,facility,both,,,,24034,24034,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AORTOGRAPHY THORACIC W/O SRLGRPHY RADIOLOGICAL S&I,4817560001,CDM,481,RC,,,facility,both,,,,9824,9824,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH EACH ADDTL VESSEL AFTER BASIC EXAM,4817577401,CDM,481,RC,75774,HCPCS,facility,both,,,,2200,2200,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIOPLASTY INITIAL,4819292001,CDM,481,RC,92920,HCPCS,facility,both,,,,5795,5795,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ATHERECTOMY INITIAL,4819292401,CDM,481,RC,92924,HCPCS,facility,both,,,,8087,8087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BM PRQ TRLUML CORONARY STENT W/ANGIO ONE ART/BRNCH,4819292801,CDM,481,RC,92928,HCPCS,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DE PRQ TRLUML CORONARY STENT W/ANGIO ONE ART/BRNCH,4819292802,CDM,481,RC,92928,HCPCS,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRQ TCAT PLMT NTRAC ST 2+LES,4819293001,CDM,481,RC,92930,HCPCS,facility,both,,,,54797,54797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BM PRQ TRLUML CORONRY STENT/ATH/ANGIO ONE ART/BRNCH,4819293301,CDM,481,RC,,,facility,both,,,,12931,12931,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DE PRQ TRLUML CORONRY STENT/ATH/ANGIO ONE ART/BRNCH,4819293302,CDM,481,RC,92933,HCPCS,facility,both,,,,12931,12931,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BM PRQ TRLUML CORONARY BYP GRFT REVASC ONE VESSEL,4819293701,CDM,481,RC,92937,HCPCS,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DE PRQ TRLUML CORONARY BYP GRFT REVASC ONE VESSEL,4819293702,CDM,481,RC,92937,HCPCS,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BM PRQ TRLUML CORONRY TOT OCCLUS REVASC MI ONE VSL,4819294101,CDM,481,RC,92941,HCPCS,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DE  PRQ TRLUML CORONRY TOT OCCLUS REVASC MI ONE VSL,4819294102,CDM,481,RC,92941,HCPCS,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BM PRQ TRLUML CORONRY CHRONIC OCCLUS REVASC ONE VSL,4819294301,CDM,481,RC,92943,HCPCS,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DE PRQ TRLUML CORONRY CHRONIC OCCLUS REVASC ONE VSL,4819294302,CDM,481,RC,92943,HCPCS,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRQ TRL RVS CH OCC ANT&RTRGR,4819294501,CDM,481,RC,92945,HCPCS,facility,both,,,,34508,34508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CTH CPR,4819295001,CDM,481,RC,92950,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ TRLUML CORONRY LITHOTRP,4819297201,CDM,481,RC,92972,HCPCS,facility,both,,,,2503,2503,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MECHANICAL THROMBECTOMY CORONARY,4819297301,CDM,481,RC,92973,HCPCS,facility,both,,,,808,808,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAVAS IMAGE CORO IVUS/OCT INITIAL VESSEL,4819297801,CDM,481,RC,92978,HCPCS,facility,both,,,,3572,3572,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAVAS IMAGE CORO IVUS/OCT ADDTL VESSEL,4819297901,CDM,481,RC,92979,HCPCS,facility,both,,,,2013,2013,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VALVULOPLASTY AORTIC VALVE,4819298601,CDM,481,RC,92986,HCPCS,facility,both,,,,8060,8060,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VALVULOPLASTY MITRAL VALVE,4819298701,CDM,481,RC,92987,HCPCS,facility,both,,,,10381,10381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VALVULOPLASTY PULMONARY VALVE,4819299001,CDM,481,RC,92990,HCPCS,facility,both,,,,8087,8087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PULMONARY ARTERY ANGIO SINGLE VESSEL,4819299701,CDM,481,RC,92997,HCPCS,facility,both,,,,8087,8087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RIGHT HEART CATH,4819345101,CDM,481,RC,93451,HCPCS,facility,both,,,,7935,7935,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEFT HEART CATH,4819345201,CDM,481,RC,93452,HCPCS,facility,both,,,,7935,7935,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RIGHT & LEFT HEART CATH,4819345301,CDM,481,RC,93453,HCPCS,facility,both,,,,7851,7851,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CORONARY ANGIOGRAPHY,4819345401,CDM,481,RC,93454,HCPCS,facility,both,,,,4551,4551,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CORONARY ANGIOGRAPHY WITH BYPASS GRAFT,4819345501,CDM,481,RC,93455,HCPCS,facility,both,,,,5234,5234,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RIGHT HEART CATH WITH CORONARY ANGIO,4819345601,CDM,481,RC,93456,HCPCS,facility,both,,,,10699,10699,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RIGHT HEART CATH WITH CORO/GRAFT ANGIO,4819345701,CDM,481,RC,93457,HCPCS,facility,both,,,,9606,9606,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEFT HEART CATH WITH CORONARY ANGIO,4819345801,CDM,481,RC,93458,HCPCS,facility,both,,,,8684,8684,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEFT HEART CATH WITH CORO/GRAFT ANGIO,4819345901,CDM,481,RC,93459,HCPCS,facility,both,,,,9369,9369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RIGHT & LEFT HEART CATH WITH CORONARY ANGIO,4819346001,CDM,481,RC,93460,HCPCS,facility,both,,,,9601,9601,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RIGHT & LEFT HEART CATH WITH CORO/GRAFT ANGIO,4819346101,CDM,481,RC,93461,HCPCS,facility,both,,,,10285,10285,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LEFT HEART CATH BY TRANSEPTAL PUNCTURE,4819346201,CDM,481,RC,93462,HCPCS,facility,both,,,,5552,5552,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN PHARM AGENT,4819346301,CDM,481,RC,93463,HCPCS,facility,both,,,,281,281,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHYSIOLOGIC EXERCISE STUDY,4819346401,CDM,481,RC,93464,HCPCS,facility,both,,,,894,894,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION SWAN GANZ CATH,4819350301,CDM,481,RC,,,facility,both,,,,1285,1285,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOCARDIAC BIOPSY,4819350501,CDM,481,RC,93505,HCPCS,facility,both,,,,2290,2290,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONGENITAL SELECTIVE CORONARY ANGIOGRAPHY,4819356301,CDM,481,RC,93563,HCPCS,facility,both,,,,502,502,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONGENITAL LV OR LA GRAM,4819356501,CDM,481,RC,93565,HCPCS,facility,both,,,,395,395,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONGENITAL RV OR RA GRAM,4819356601,CDM,481,RC,93566,HCPCS,facility,both,,,,517,517,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUPRAVALVULAR AORTOGRAPHY,4819356701,CDM,481,RC,93567,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PULMONARY ANGIOGRAPHY,4819356801,CDM,481,RC,93568,HCPCS,facility,both,,,,688,688,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX DRG C-CATHJ SLCTV P-ART ANGIOGRAPHY UNI,4819356901,CDM,481,RC,93569,HCPCS,facility,both,,,,668,668,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FRACTIONAL FLOW RESERVE 1ST VESSEL,4819357101,CDM,481,RC,93571,HCPCS,facility,both,,,,5595,5595,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FRACTIONAL FLOW RESERVE ADDTL,4819357201,CDM,481,RC,93572,HCPCS,facility,both,,,,4793,4793,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX DRG C-CATHJ SLCTV P-ART ANGIOGRAPHY BI,4819357301,CDM,481,RC,93573,HCPCS,facility,both,,,,1336,1336,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX DRG C-CATHJ SLCTV PULM VEN ANGIOGRAPHY,4819357401,CDM,481,RC,93574,HCPCS,facility,both,,,,668,668,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX DRG C-CATHJ SLCTV PULM ANGRPH MAPCA CHD EA,4819357501,CDM,481,RC,93575,HCPCS,facility,both,,,,668,668,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ATRIAL SEPTAL CLOSURE,4819358001,CDM,481,RC,93580,HCPCS,facility,both,,,,13515,13515,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENTRICULAR SEPTAL CLOSURE,4819358101,CDM,481,RC,93581,HCPCS,facility,both,,,,25891,25891,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS TRANSCATHETER SEPTAL REDUCTION THER,4819358301,CDM,481,RC,,,facility,both,,,,10571,10571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VNGRPH CHD ANOM/PERSIST SVC,4819358401,CDM,481,RC,93584,HCPCS,facility,both,,,,463,463,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VNGRPH CHD AZYGS/HEMIAZYGS,4819358501,CDM,481,RC,93585,HCPCS,facility,both,,,,948,948,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VNGRPH CHD CORONARY SINUS,4819358601,CDM,481,RC,,,facility,both,,,,713,713,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VNGRPH CHD VNVN CLTRL AT/ABV,4819358701,CDM,481,RC,93587,HCPCS,facility,both,,,,948,948,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VNGRPH CHD VNVN CLTRL BELOW,4819358801,CDM,481,RC,,,facility,both,,,,948,948,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ TRANSCATH CLS MITRAL,4819359001,CDM,481,RC,93590,HCPCS,facility,both,,,,41990,41990,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ TRANSCATH CLS AORTIC,4819359101,CDM,481,RC,,,facility,both,,,,41990,41990,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC R HRT CATH CHD NML NT CNJ,4819359301,CDM,481,RC,93593,HCPCS,facility,both,,,,2777,2777,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC R HRT CATH CHD ABNL NT CNJ,4819359401,CDM,481,RC,93594,HCPCS,facility,both,,,,2754,2754,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC L HRT CATH CHD NM/ABN NT CNJ,4819359501,CDM,481,RC,93595,HCPCS,facility,both,,,,8860,8860,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC R&L HRT CATH CHD NML NT CNJ,4819359601,CDM,481,RC,93596,HCPCS,facility,both,,,,4166,4166,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC R&L HRT CATH CHD ABNL NT CNJ,4819359701,CDM,481,RC,93597,HCPCS,facility,both,,,,4166,4166,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAR OUTP MEAS DRG CATH CHD,4819359801,CDM,481,RC,93598,HCPCS,facility,both,,,,517,517,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BUNDLE OF HIS RECORDING,4819360001,CDM,481,RC,,,facility,both,,,,13366,13366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  INTRA-ATRIAL RECORDING,4819360201,CDM,481,RC,,,facility,both,,,,10461,10461,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RIGHT VENTRICULAR RECORDING,4819360301,CDM,481,RC,,,facility,both,,,,2242,2242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VENT OR ATRIAL MAP TACHY,4819360901,CDM,481,RC,93609,HCPCS,facility,both,,,,2273,2273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRA ATRIAL PACING,4819361001,CDM,481,RC,,,facility,both,,,,10461,10461,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAVENTRICULAR PACING,4819361201,CDM,481,RC,93612,HCPCS,facility,both,,,,10461,10461,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D MAPPING FOR EP,4819361301,CDM,481,RC,93613,HCPCS,facility,both,,,,4825,4825,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INDUC ARRHYTH BY HEART RHYTHM PACING,4819361801,CDM,481,RC,93618,HCPCS,facility,both,,,,2242,2242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPREHENSIVE EP WO INDUCTION,4819361901,CDM,481,RC,93619,HCPCS,facility,both,,,,10211,10211,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPREHENSIVE EP WITH INDUCTION,4819362001,CDM,481,RC,93620,HCPCS,facility,both,,,,14102,14102,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LA PACING & RECORDING FROM CORONARY SINUS,4819362101,CDM,481,RC,93621,HCPCS,facility,both,,,,12248,12248,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPRE ELECTROPHYSIOL XM W/LEFT VENTR PACNG/REC,4819362201,CDM,481,RC,93622,HCPCS,facility,both,,,,4264,4264,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STIMULATION POST DRUG INFUSION,4819362301,CDM,481,RC,93623,HCPCS,facility,both,,,,3967,3967,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ICD LEAD EVALUATION,4819364001,CDM,481,RC,,,facility,both,,,,2927,2927,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ICD LEAD & GENERATOR EVALUATION,4819364101,CDM,481,RC,93641,HCPCS,facility,both,,,,2853,2853,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ICD EVALUATION WITH PROGRAMMING,4819364201,CDM,481,RC,93642,HCPCS,facility,both,,,,2063,2063,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBQ ICD SYSTEM EVALUATION,4819364401,CDM,481,RC,,,facility,both,,,,2121,2121,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABLATION AV NODE,4819365001,CDM,481,RC,93650,HCPCS,facility,both,,,,4791,4791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPRE EP EVAL ABLTJ 3D MAPG TX SVT,4819365301,CDM,481,RC,93653,HCPCS,facility,both,,,,27433,27433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPRE EP EVAL ABLTJ 3D MAPG TX VT,4819365401,CDM,481,RC,93654,HCPCS,facility,both,,,,22290,22290,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABLATION 2ND SEPERATE SITE SVT/VT,4819365501,CDM,481,RC,93655,HCPCS,facility,both,,,,3735,3735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPRE EP EVAL ABLTJ ATR FIB PULM VEIN ISOLATION,4819365601,CDM,481,RC,93656,HCPCS,facility,both,,,,37856,37856,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABLATION 2ND SITE POST PVI AFIB,4819365701,CDM,481,RC,93657,HCPCS,facility,both,,,,3735,3735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANGIOGRAPHY CORONARY W/ IFR W/O ADM PHARM STRESS AGENT,4819379901,CDM,481,RC,93799,HCPCS,facility,both,,,,18333,18333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION THROMBECTOMY CORONARY,4819379902,CDM,481,RC,93799,HCPCS,facility,both,,,,1725,1725,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARDIAC IV DRUG INFUSION,4819379905,CDM,481,RC,93799,HCPCS,facility,both,,,,11037,11037,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARDIOMEMS RECALIBRATION,4819379906,CDM,481,RC,93799,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FFR AND IVUS,4819379907,CDM,481,RC,,,facility,both,,,,14490,14490,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FFR RESERVE,4819379908,CDM,481,RC,93799,HCPCS,facility,both,,,,7844,7844,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LVAD RAMP STUDY,4819379910,CDM,481,RC,,,facility,both,,,,384,384,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADENOSINE CHALLENGE,4819379913,CDM,481,RC,93799,HCPCS,facility,both,,,,1274,1274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RFR INITIAL & ADDTL CORONARY ARTERIES,4819379914,CDM,481,RC,93799,HCPCS,facility,both,,,,18333,18333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BALLOON ANGIOPLASTY PREV PLACED UNDER DEPLOYED STENT W/O STENOSIS, OCCLUSION OR HEMODYNAMIC SIGNIFICANCE",4819379915,CDM,481,RC,93799,HCPCS,facility,both,,,,9462,9462,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PROC FRAC FLOW RES (FFR) W/O ADENOSINE,4819379917,CDM,481,RC,93799,HCPCS,facility,both,,,,6140,6140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NONINVASIVE PROGRAM STIMULATION OF A PACEMAKER,4819379919,CDM,481,RC,,,facility,both,,,,1733.12,1733.12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DFR/FFR W/O BASE PROCEDURE,4819379921,CDM,481,RC,93799,HCPCS,facility,both,,,,3575,3575,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHOCKWAVE LITHOTRIPSY W/O BASE PROCEDURE,4819379922,CDM,481,RC,,,facility,both,,,,3198,3198,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEIN OF MARSHALL ABLATION,4819379924,CDM,481,RC,,,facility,both,,,,29796,29796,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DFR AORTIC VALVE,4819379926,CDM,481,RC,,,facility,both,,,,2160,2160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERCUTANEOUS TRANSLUMINAL MECH THROMBECTOMY,481C756401,CDM,481,RC,,,facility,both,,,,11409,11409,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVASC INTRAVASC LITHOTRIPSY,481C976401,CDM,481,RC,C9764,HCPCS,facility,both,,,,10150,10150,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVASC INTRA LITHOTRIP-STENT,481C976501,CDM,481,RC,C9765,HCPCS,facility,both,,,,26279,26279,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVASC INTRA LITHOTRIP-ATHER,481C976601,CDM,481,RC,,,facility,both,,,,26279,26279,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVASC LITHOTRIP-STENT-ATHER,481C976701,CDM,481,RC,,,facility,both,,,,42034,42034,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVASC LITHOTRIP TIBI/PERONE,481C977201,CDM,481,RC,,,facility,both,,,,26279,26279,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVASC LITHOTR-STENT TIB/PER,481C977301,CDM,481,RC,,,facility,both,,,,42034,42034,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REVASC LITHOTR-ATHER TIB/PER,481C977401,CDM,481,RC,,,facility,both,,,,42034,42034,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  REVASC LITH-STEN-ATH TIB/PER,481C977501,CDM,481,RC,,,facility,both,,,,40306,40306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ILIAC FEMORAL ANGIO WITH HEART CATH,481G027801,CDM,481,RC,G0278,HCPCS,facility,both,,,,1469,1469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STRESS TEST MAXIMUM,4829301701,CDM,482,RC,93017,HCPCS,facility,both,,,,935,935,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STRESS TEST MAXIMUM,4829301701,CDM,482,RC,93017,HCPCS,facility,both,,,,912,912,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METABOLIC STRESS TEST B,4829462101,CDM,482,RC,94621,HCPCS,facility,both,,,,680,680,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METABOLIC STRESS TEST B,4829462101,CDM,482,RC,94621,HCPCS,facility,both,,,,1216,1216,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO RESEARCH,4830000001,CDM,483,RC,,,facility,both,,,,1031.3,1031.3,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO RESEARCH,4830000001,CDM,483,RC,,,facility,both,,,,928.17,928.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO RESEARCH ADDITIONAL TIME,4830000002,CDM,483,RC,,,facility,both,,,,297,297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO RESEARCH ADDITIONAL TIME,4830000002,CDM,483,RC,,,facility,both,,,,330,330,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCARDIAL CONTRAST PERF ECHO,4830439T01,CDM,483,RC,,,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO COMPLETE CARDIAC ANOMALY,4839330302,CDM,483,RC,93303,HCPCS,facility,both,,,,1196,1196,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO COMPLETE CARDIAC ANOMALY,4839330302,CDM,483,RC,93303,HCPCS,facility,both,,,,1178,1178,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO LIMITED CARDIAC ANOMALY,4839330401,CDM,483,RC,93304,HCPCS,facility,both,,,,497,497,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO COMP WITH DOPPLER & COLOR FLOW,4839330601,CDM,483,RC,93306,HCPCS,facility,both,,,,1169,1169,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO COMPLETE WO DOPPLER & COLOR FLOW,4839330701,CDM,483,RC,,,facility,both,,,,826,826,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO COMPLETE WO DOPPLER & COLOR FLOW,4839330701,CDM,483,RC,,,facility,both,,,,743,743,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO-LIMITED OR FOLLOW-UP,4839330801,CDM,483,RC,93308,HCPCS,facility,both,,,,440,440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO-LIMITED OR FOLLOW-UP,4839330801,CDM,483,RC,93308,HCPCS,facility,both,,,,611,611,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO TRANSESOPHAGEAL,4839331201,CDM,483,RC,93312,HCPCS,facility,both,,,,1192,1192,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSESOPHAGEAL ECHO CARD ANOMALY,4839331501,CDM,483,RC,93315,HCPCS,facility,both,,,,1162,1162,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSESOPHAGEAL ECHO CARD ANOMALY,4839331501,CDM,483,RC,93315,HCPCS,facility,both,,,,1161,1161,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TEE INTRAOPERATIVE MONITORING,4839331801,CDM,483,RC,,,facility,both,,,,1370,1370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D ECHO OF THE HEART,4839331901,CDM,483,RC,93319,HCPCS,facility,both,,,,597,597,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 3D ECHO OF THE HEART,4839331901,CDM,483,RC,93319,HCPCS,facility,both,,,,402,402,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO DOPPLER COMPLETE,4839332001,CDM,483,RC,93320,HCPCS,facility,both,,,,167,167,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO DOPPLER COMPLETE,4839332001,CDM,483,RC,93320,HCPCS,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO DOPPLER LIMITED,4839332101,CDM,483,RC,93321,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO COLOR FLOW STUDY,4839332501,CDM,483,RC,93325,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO STRESS,4839335001,CDM,483,RC,93350,HCPCS,facility,both,,,,850,850,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO STRESS,4839335001,CDM,483,RC,93350,HCPCS,facility,both,,,,836,836,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO STRESS CONTRAST AGENT,4839335201,CDM,483,RC,93352,HCPCS,facility,both,,,,116,116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO STRESS CONTRAST AGENT,4839335201,CDM,483,RC,93352,HCPCS,facility,both,,,,113,113,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TEE GUIDE PERQ STRUCTURAL INTERVENTION,4839335501,CDM,483,RC,93355,HCPCS,facility,both,,,,682,682,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCRD STRAIN IMG SPECKLE TRCK ASSMT MYOCRD MECH,4839335601,CDM,483,RC,93356,HCPCS,facility,both,,,,493,493,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MYOCRD STRAIN IMG SPECKLE TRCK ASSMT MYOCRD MECH,4839335601,CDM,483,RC,93356,HCPCS,facility,both,,,,483,483,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRACARDIAC ECHO,4839366201,CDM,483,RC,93662,HCPCS,facility,both,,,,3919,3919,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO COMP CARD ANOMALY WITH CONTRAST,483C892101,CDM,483,RC,C8921,HCPCS,facility,both,,,,1355,1355,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO COMP CARD ANOMALY WITH CONTRAST,483C892101,CDM,483,RC,C8921,HCPCS,facility,both,,,,1376,1376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO LMT CARDIAC ANOMALY WITH CONTRAST,483C892202,CDM,483,RC,C8922,HCPCS,facility,both,,,,1178,1178,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO LMT CARDIAC ANOMALY WITH CONTRAST,483C892202,CDM,483,RC,C8922,HCPCS,facility,both,,,,1060,1060,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHOCARDIOGRAM LIMITED CONTRAST,483C892402,CDM,483,RC,C8924,HCPCS,facility,both,,,,1056,1056,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHOCARDIOGRAM LIMITED CONTRAST,483C892402,CDM,483,RC,C8924,HCPCS,facility,both,,,,1037,1037,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO TRANSESOPHAGEAL WITH CONTRAST,483C892502,CDM,483,RC,C8925,HCPCS,facility,both,,,,1227,1227,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSESOPHAGEAL ECHO CARD ANOMALY WITH CONTRAST,483C892601,CDM,483,RC,C8926,HCPCS,facility,both,,,,2091,2091,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO STRESS WITH CONTRAST,483C892802,CDM,483,RC,C8928,HCPCS,facility,both,,,,1222,1222,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHO STRESS WITH CONTRAST,483C892802,CDM,483,RC,C8928,HCPCS,facility,both,,,,1198,1198,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHOCARDIOGRAM COMPLETE CONTRAST,483C892902,CDM,483,RC,C8929,HCPCS,facility,both,,,,1830,1830,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECHOCARDIOGRAM COMPLETE CONTRAST,483C892902,CDM,483,RC,C8929,HCPCS,facility,both,,,,1817,1817,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"TTE W OR W/O CONTR, CONT ECG",483C893001,CDM,483,RC,,,facility,both,,,,2753,2753,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"TTE W OR W/O CONTR, CONT ECG",483C893001,CDM,483,RC,,,facility,both,,,,2478,2478,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DISCHRG MEDS RECONCILED W/CURRENT MED LIST,5101111F01,CDM,510,RC,1111F,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TIS TRNFR E/N/E/L 10 SQ CM/&LT,5101406001,CDM,510,RC,,,facility,both,,,,6571,6571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TIS TRNFR E/N/E/L10.1-30SQCM,5101406101,CDM,510,RC,,,facility,both,,,,6663,6663,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC STRAPPING UNNA BOOT,5102958001,CDM,510,RC,29580,HCPCS,facility,both,,,,192,192,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLY MULTILAY COMPRS LWR LEG,5102958101,CDM,510,RC,29581,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE IMPACT CERUMEN IRRIGATE,5106920901,CDM,510,RC,69209,HCPCS,facility,both,,,,159,159,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCHIATRIC DIAGNOSTIC EVALUATION,5109079101,CDM,510,RC,90791,HCPCS,facility,both,,,,224,224,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCHOTHERAPY PATIENT &/ FAMILY 30 MINUTES,5109083201,CDM,510,RC,90832,HCPCS,facility,both,,,,224,224,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCHOTHERAPY PT&/FAMILY W/E&M SRVCS 30 MIN,5109083301,CDM,510,RC,,,facility,both,,,,286,286,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYOTHERAPY PATIENT &/ FAMILY 45 MINUTES,5109083401,CDM,510,RC,90834,HCPCS,facility,both,,,,224,224,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSCYOTHERAPY PT&/FAMILY W/E&M SRVCS 45 MIN,5109083601,CDM,510,RC,,,facility,both,,,,244,244,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCHOTHERAPY PATIENT &/ FAMILY 60 MINUTES,5109083701,CDM,510,RC,90837,HCPCS,facility,both,,,,231,231,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCHOTHERAPY PATIENT &/ FAMILY 60 MINUTES,5109083701,CDM,510,RC,90837,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTICOAG MNGMNT - INITIAL 90,5109379201,CDM,510,RC,,,facility,both,,,,683,683,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANTICOAG MNGMNT - SUBSEQUENT,5109379301,CDM,510,RC,,,facility,both,,,,232,232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL GENETIC COUNSELING 30MIN,5109604002,CDM,510,RC,,,facility,both,,,"PN,CR",138.97,138.97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GENETIC COUNSELING 30 MIN,5109604101,CDM,510,RC,96041,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT,5109612701,CDM,510,RC,96127,HCPCS,facility,both,,,,76,76,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEALTH BEHAVIOR ASSESSMENT/RE-ASSESSMENT,5109615601,CDM,510,RC,96156,HCPCS,facility,both,,,,125,125,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEALTH BEHAVIOR IVNTJ INDIV F2F 1ST 30 MIN,5109615801,CDM,510,RC,96158,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEALTH BEHAVIOR IVNTJ INDIV F2F EA ADDL 15 MIN,5109615901,CDM,510,RC,96159,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM,5109616001,CDM,510,RC,96160,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAREGIVER HLTH RISK ASSMT SCORE DOC STND INSTRM,5109616101,CDM,510,RC,96161,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEALTH BEHAVIOR IVNTJ FAM W/PT F2F 1ST 30 MIN,5109616701,CDM,510,RC,,,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 MIN,5109896601,CDM,510,RC,98966,HCPCS,facility,both,,,,36,36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NONPHYSICIAN TELEPHONE ASSESSMENT 11-20 MIN,5109896701,CDM,510,RC,98967,HCPCS,facility,both,,,,73,73,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NONPHYSICIAN TELEPHONE ASSESSMENT 21-30 MIN,5109896801,CDM,510,RC,98968,HCPCS,facility,both,,,,109,109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EST PT OV BRIEF,5109921101,CDM,510,RC,,,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EST PT OV PROB FOCUSED,5109921201,CDM,510,RC,,,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EST PT OV LOW COMPLEX,5109921301,CDM,510,RC,,,facility,both,,,,137,137,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EST PT OV MOD COMPLEX,5109921401,CDM,510,RC,,,facility,both,,,,171,171,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EST PT OV MOD COMPLEX,5109921401,CDM,510,RC,,,facility,both,,,,188,188,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EST PT OV HIGH COMPLEX,5109921501,CDM,510,RC,99215,HCPCS,facility,both,,,,196,196,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL PREVENTIVE MEDICINE NEW PATIENT,5109938101,CDM,510,RC,99381,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL PREVENTIVE MEDICINE NEW PT AGE 1-4 YRS,5109938201,CDM,510,RC,99382,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS,5109938301,CDM,510,RC,99383,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL PREVENTIVE MEDICINE NEW PT AGE 12-17 YR,5109938401,CDM,510,RC,99384,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL PREVENTIVE MEDICINE NEW PT AGE 18-39YRS,5109938501,CDM,510,RC,99385,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS,5109938601,CDM,510,RC,99386,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS&>,5109938701,CDM,510,RC,99387,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1Y,5109939101,CDM,510,RC,99391,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIODIC PREVENTIVE MED EST PATIENT 1-4YRS,5109939201,CDM,510,RC,99392,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIODIC PREVENTIVE MED EST PATIENT 5-11YRS,5109939301,CDM,510,RC,99393,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIODIC PREVENTIVE MED EST PATIENT 12-17YRS,5109939401,CDM,510,RC,99394,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIODIC PREVENTIVE MED EST PATIENT 18-39 YRS,5109939501,CDM,510,RC,99395,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS,5109939601,CDM,510,RC,99396,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIODIC PREVENTIVE MED EST PATIENT 65YRS& OLDER,5109939701,CDM,510,RC,99397,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOTE PHYSIOLOGIC MONITORING 20 MIN+ PER MONTH,5109945701,CDM,510,RC,,,facility,both,,,,122,122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  REMOTE PHYSIOLOGIC MONITORING EA ADDL 20 MIN MO,5109945801,CDM,510,RC,,,facility,both,,,,139,139,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSITIONAL CARE MANAGE SRVC 14 DAY DC,5109949501,CDM,510,RC,99495,HCPCS,facility,both,,,,438,438,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSITIONAL CARE MANAGE SRVC 14 DAY DC,5109949501,CDM,510,RC,99495,HCPCS,facility,both,,,,361,361,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DC,5109949601,CDM,510,RC,99496,HCPCS,facility,both,,,,438,438,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DC,5109949601,CDM,510,RC,99496,HCPCS,facility,both,,,,361,361,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEDICATION THERAPY INITIAL 15 MIN NEW PATIENT,5109960501,CDM,510,RC,99605,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEDICATION THERAPY INITIAL 15 MIN ESTABLISHED PT,5109960601,CDM,510,RC,99606,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEDICATION THERAPY EACH ADDITIONAL 15 MIN,5109960701,CDM,510,RC,99607,HCPCS,facility,both,,,,33,33,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL PREVENTIVE EXAM,510G040201,CDM,510,RC,G0402,HCPCS,facility,both,,,,339,339,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PPPS, INITIAL VISIT",510G043801,CDM,510,RC,G0438,HCPCS,facility,both,,,,311,311,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC PPPS, SUBSEQ VISIT",510G043901,CDM,510,RC,G0439,HCPCS,facility,both,,,,271,271,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOSPITAL OUTPT CLINIC VISIT,510G046301,CDM,510,RC,G0463,HCPCS,facility,both,,,,149,149,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOSPITAL OUTPT CLINIC VISIT,510G046301,CDM,510,RC,G0463,HCPCS,facility,both,,,,164,164,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UC FB REM FROM CORNEAL WO SLIT,5166522001,CDM,516,RC,65220,HCPCS,facility,both,,,,445,445,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
QUAN MR ALYS TISS COMPOSITION W/MRI 1ORGN,6100649T01,CDM,610,RC,0649T,HCPCS,facility,both,,,,5133,5133,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC QUAN MRI ALYS BRAIN W/O DIAGNOSTIC MRI SAME SESS,6100865T01,CDM,610,RC,,,facility,both,,,,735,735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC QUAN MRI ALYS BRAIN WITH DIAGNOSTIC MRI,6100866T01,CDM,610,RC,0866T,HCPCS,facility,both,,,,735,735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ORBIT FACE &/NECK W/O CONTRAST,6107054001,CDM,610,RC,70540,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ORBIT FACE &/NECK W/O CONTRAST,6107054001,CDM,610,RC,70540,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI NECK WITH CONTRAST,6107054201,CDM,610,RC,70542,HCPCS,facility,both,,,,2060,2060,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI NECK WITH CONTRAST,6107054201,CDM,610,RC,70542,HCPCS,facility,both,,,,1853,1853,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL,6107054301,CDM,610,RC,70543,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL,6107054301,CDM,610,RC,70543,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CHEST WO CONTRAST,6107155001,CDM,610,RC,71550,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CHEST WO CONTRAST,6107155001,CDM,610,RC,71550,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CHEST WITH CONTRAST,6107155101,CDM,610,RC,,,facility,both,,,,1422,1422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CHEST WITH CONTRAST,6107155101,CDM,610,RC,,,facility,both,,,,2113,2113,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CHEST WO & WITH CONTRAST,6107155201,CDM,610,RC,71552,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CHEST WO & WITH CONTRAST,6107155201,CDM,610,RC,71552,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA CHEST WO & WITH CONTRAST,6107155503,CDM,610,RC,71555,HCPCS,facility,both,,,,3506,3506,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA CHEST WO & WITH CONTRAST,6107155503,CDM,610,RC,71555,HCPCS,facility,both,,,,2624,2624,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI PELVIS WO CONTRAST,6107219501,CDM,610,RC,72195,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI PELVIS WO CONTRAST,6107219501,CDM,610,RC,72195,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI PELVIS WITH CONTRAST,6107219601,CDM,610,RC,72196,HCPCS,facility,both,,,,2299,2299,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI PELVIS WITH CONTRAST,6107219601,CDM,610,RC,72196,HCPCS,facility,both,,,,1422,1422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI PELVIS WO & WITH CONTRAST,6107219701,CDM,610,RC,72197,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI PELVIS WO & WITH CONTRAST,6107219701,CDM,610,RC,72197,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT NON JOINT WO CONTRAST,6107321801,CDM,610,RC,73218,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT NON JOINT WO CONTRAST,6107321801,CDM,610,RC,73218,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT NON JOINT WITH CONTRAST,6107321901,CDM,610,RC,,,facility,both,,,,1422,1422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT NON JOINT WITH CONTRAST,6107321901,CDM,610,RC,,,facility,both,,,,2256,2256,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT NON JOINT WO & WITH CONTRAST,6107322001,CDM,610,RC,73220,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT NON JOINT WO & WITH CONTRAST,6107322001,CDM,610,RC,73220,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT JOINT WO CONRAST,6107322101,CDM,610,RC,73221,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT JOINT WO CONRAST,6107322101,CDM,610,RC,73221,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT JOINT WITH CONTRAST,6107322201,CDM,610,RC,73222,HCPCS,facility,both,,,,1422,1422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT JOINT WITH CONTRAST,6107322201,CDM,610,RC,73222,HCPCS,facility,both,,,,2366,2366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT JOINT WO & WITH CONTRAST,6107322301,CDM,610,RC,73223,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI UPPER EXT JOINT WO & WITH CONTRAST,6107322301,CDM,610,RC,73223,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA UPPER EXT WO OR WITH CONTRAST,6107322501,CDM,610,RC,73225,HCPCS,facility,both,,,,5161,5161,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA UPPER EXTREMITY WITH CONTRAST,6107322502,CDM,610,RC,,,facility,both,,,,4203,4203,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT NON JOINT WO CONTRAST,6107371801,CDM,610,RC,73718,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT NON JOINT WO CONTRAST,6107371801,CDM,610,RC,73718,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT NON JOINT WITH CONTRAST,6107371901,CDM,610,RC,73719,HCPCS,facility,both,,,,2366,2366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT NON JOINT WITH CONTRAST,6107371901,CDM,610,RC,73719,HCPCS,facility,both,,,,1655,1655,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT NON JOINT WO & WITH CONTRAST,6107372001,CDM,610,RC,73720,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT NON JOINT WO & WITH CONTRAST,6107372001,CDM,610,RC,73720,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT JOINT WO CONTRAST,6107372101,CDM,610,RC,73721,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT JOINT WO CONTRAST,6107372101,CDM,610,RC,73721,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT JOINT WITH CONTRAST,6107372201,CDM,610,RC,73722,HCPCS,facility,both,,,,2366,2366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT JOINT WITH CONTRAST,6107372201,CDM,610,RC,73722,HCPCS,facility,both,,,,1655,1655,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT JOINT WO & WITH CONTRAST,6107372301,CDM,610,RC,73723,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LOWER EXT JOINT WO & WITH CONTRAST,6107372301,CDM,610,RC,73723,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ABDOMEN WO CONTRAST,6107418101,CDM,610,RC,74181,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ABDOMEN WO CONTRAST,6107418101,CDM,610,RC,74181,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ABDOMEN WITH CONTRAST,6107418201,CDM,610,RC,74182,HCPCS,facility,both,,,,2256,2256,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ABDOMEN WITH CONTRAST,6107418201,CDM,610,RC,74182,HCPCS,facility,both,,,,1422,1422,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ABDOMEN WO & WITH CONTRAST,6107418301,CDM,610,RC,74183,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI ABDOMEN WO & WITH CONTRAST,6107418301,CDM,610,RC,74183,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI FETAL SINGLE OR 1ST FETUS,6107471201,CDM,610,RC,74712,HCPCS,facility,both,,,,1514,1514,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI FETAL EA ADDL FETUSES,6107471301,CDM,610,RC,,,facility,both,,,,794,794,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC FOR MORPHOLOGY,6107555701,CDM,610,RC,75557,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC FOR MORPHOLOGY,6107555701,CDM,610,RC,75557,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC WITH STRESS IMAGING,6107555901,CDM,610,RC,75559,HCPCS,facility,both,,,,1620,1620,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC WITH STRESS IMAGING,6107555901,CDM,610,RC,75559,HCPCS,facility,both,,,,3201,3201,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC FOR MORPHOLOGY WO & WITH CONTRAST,6107556101,CDM,610,RC,75561,HCPCS,facility,both,,,,1708,1708,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC FOR MORPHOLOGY WO & WITH CONTRAST,6107556101,CDM,610,RC,75561,HCPCS,facility,both,,,,2441,2441,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC WITH STRESS IMAGING & CONTRAST,6107556301,CDM,610,RC,75563,HCPCS,facility,both,,,,4741,4741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC WITH STRESS IMAGING & CONTRAST,6107556301,CDM,610,RC,75563,HCPCS,facility,both,,,,2335,2335,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC VELOCITY FLOW MAP,6107556501,CDM,610,RC,75565,HCPCS,facility,both,,,,279,279,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CARDIAC VELOCITY FLOW MAP,6107556501,CDM,610,RC,75565,HCPCS,facility,both,,,,225,225,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MR SAFETY IMPLANT&/FB ASSMT CLIN STAF 1ST 15 MIN,6107601401,CDM,610,RC,,,facility,both,,,,77,77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MR SAFETY IMPLANT&/FB ASSMT CLIN STAFF EA ADD 30,6107601501,CDM,610,RC,,,facility,both,,,,135,135,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MR SAFETY DETERMINATION PHYSICIAN/OTHER QHP,6107601601,CDM,610,RC,,,facility,both,,,,278,278,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MR SAFETY MED PHYSICS XM CUSTOMIZATION PLNG&MNTR,6107601701,CDM,610,RC,,,facility,both,,,,761,761,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MR SAFETY IMPLT ELECTRONICS PREPJ SUPVJ PHYS/QHP,6107601801,CDM,610,RC,,,facility,both,,,,289,289,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MR SAFETY IMPLANT POS&/IMMOBLJ SUPVJ PHYS/QHP,6107601901,CDM,610,RC,,,facility,both,,,,187,187,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI SPECTROSCOPY,6107639001,CDM,610,RC,76390,HCPCS,facility,both,,,,3219,3219,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MAGNETIC RESONANCE ELASTOGRAPHY,6107639101,CDM,610,RC,76391,HCPCS,facility,both,,,,1523,1523,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC WHOLE BODY MRI,6107649801,CDM,610,RC,76498,HCPCS,facility,both,,,,3333,3333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI GUIDANCE FOR NEEDLE PLACE,6107702101,CDM,610,RC,,,facility,both,,,,3117,3117,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL,6107704701,CDM,610,RC,77047,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN WO CONTRAST,6117055101,CDM,611,RC,70551,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN WO CONTRAST,6117055101,CDM,611,RC,70551,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN W CONTRAST,6117055201,CDM,611,RC,70552,HCPCS,facility,both,,,,1655,1655,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN W CONTRAST,6117055201,CDM,611,RC,70552,HCPCS,facility,both,,,,2366,2366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN WO & WITH CONTRAST,6117055301,CDM,611,RC,70553,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN WO & WITH CONTRAST,6117055301,CDM,611,RC,70553,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN BY TECH,6117055401,CDM,611,RC,70554,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN BY TECH,6117055401,CDM,611,RC,70554,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN BY PHYS/PSYCH,6117055501,CDM,611,RC,,,facility,both,,,,1762,1762,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BRAIN INTRAOP WO CONTRAST,6117055701,CDM,611,RC,70557,HCPCS,facility,both,,,,1620,1620,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CERVICAL SPINE WO CONTRAST,6127214101,CDM,612,RC,72141,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CERVICAL SPINE WO CONTRAST,6127214101,CDM,612,RC,72141,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CERVICAL SPINE WITH CONTRAST,6127214201,CDM,612,RC,72142,HCPCS,facility,both,,,,1655,1655,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CERVICAL SPINE WITH CONTRAST,6127214201,CDM,612,RC,72142,HCPCS,facility,both,,,,2366,2366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI THORACIC SPINE WO CONTRAST,6127214601,CDM,612,RC,72146,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI THORACIC SPINE WO CONTRAST,6127214601,CDM,612,RC,72146,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI THORACIC SPINE WITH CONTRAST,6127214701,CDM,612,RC,72147,HCPCS,facility,both,,,,2366,2366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI THORACIC SPINE WITH CONTRAST,6127214701,CDM,612,RC,72147,HCPCS,facility,both,,,,1655,1655,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LUMBAR SPINE WO CONTRAST,6127214801,CDM,612,RC,72148,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LUMBAR SPINE WO CONTRAST,6127214801,CDM,612,RC,72148,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LUMBAR SPINE WITH CONTRAST,6127214901,CDM,612,RC,72149,HCPCS,facility,both,,,,1655,1655,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LUMBAR SPINE WITH CONTRAST,6127214901,CDM,612,RC,72149,HCPCS,facility,both,,,,2366,2366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CERVICAL SPINE WO & WITH CONTRAST,6127215601,CDM,612,RC,72156,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI CERVICAL SPINE WO & WITH CONTRAST,6127215601,CDM,612,RC,72156,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI THORACIC SPINE WO & WITH CONTRAST,6127215701,CDM,612,RC,72157,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI THORACIC SPINE WO & WITH CONTRAST,6127215701,CDM,612,RC,72157,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LUMBAR SPINE WO & WITH CONTRAST,6127215801,CDM,612,RC,72158,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI LUMBAR SPINE WO & WITH CONTRAST,6127215801,CDM,612,RC,72158,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRGFUS STEREOTACTIC ABLATION TARGET INTRACRANIAL,6146171501,CDM,614,RC,61715,HCPCS,facility,both,,,,39301,39301,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI TEMPOROMANDIBULAR JOINT(S),6147033601,CDM,614,RC,70336,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI TEMPOROMANDIBULAR JOINT(S),6147033601,CDM,614,RC,70336,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABBREV MRI BREAST WITHOUT & WITH CONTRAST W/CAD BILATERAL,6147704901,CDM,614,RC,77049,HCPCS,facility,both,,,,400,400,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BREAST WITH CONTRAST W/CAD BILATERAL,614C890601,CDM,614,RC,,,facility,both,,,,1713,1713,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRI BREAST WITHOUT & WITH CONTRAST W/CAD BILATERAL,614C890801,CDM,614,RC,C8908,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAD BREAST MRI,614C893701,CDM,614,RC,C8937,HCPCS,facility,both,,,,440,440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA HEAD WO CONTRAST,6157054401,CDM,615,RC,70544,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA HEAD WO CONTRAST,6157054401,CDM,615,RC,70544,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA HEAD WITH CONTRAST,6157054501,CDM,615,RC,70545,HCPCS,facility,both,,,,2366,2366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA HEAD WITH CONTRAST,6157054501,CDM,615,RC,70545,HCPCS,facility,both,,,,1654,1654,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA HEAD WO & WITH CONTRAST,6157054601,CDM,615,RC,70546,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA HEAD WO & WITH CONTRAST,6157054601,CDM,615,RC,70546,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA NECK WO CONTRAST,6157054701,CDM,615,RC,70547,HCPCS,facility,both,,,,1068,1068,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA NECK WO CONTRAST,6157054701,CDM,615,RC,70547,HCPCS,facility,both,,,,1526,1526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA NECK WITH CONTRAST,6157054801,CDM,615,RC,,,facility,both,,,,2299,2299,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA NECK WO & WITH CONTRAST,6157054901,CDM,615,RC,70549,HCPCS,facility,both,,,,1975,1975,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA NECK WO & WITH CONTRAST,6157054901,CDM,615,RC,70549,HCPCS,facility,both,,,,2823,2823,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA PELVIS W OR WO CONTRAST,6167219801,CDM,616,RC,72198,HCPCS,facility,both,,,,2870,2870,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA PELVIS W OR WO CONTRAST,6167219801,CDM,616,RC,72198,HCPCS,facility,both,,,,3506,3506,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA PELVIS WITH CONTRAST,6167219802,CDM,616,RC,,,facility,both,,,,2956,2956,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA PELVIS WITHOUT CONTRAST,6167219803,CDM,616,RC,72198,HCPCS,facility,both,,,,2574,2574,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA PELVIS WITHOUT CONTRAST,6167219803,CDM,616,RC,72198,HCPCS,facility,both,,,,1494,1494,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA LOWER EXTREMITY W CONTRAST,6167372501,CDM,616,RC,,,facility,both,,,,2592,2592,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA LOWER EXTREMITY W CONTRAST,6167372501,CDM,616,RC,,,facility,both,,,,3738,3738,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA LOWER EXTREMITY WO CONTRAST,6167372503,CDM,616,RC,73725,HCPCS,facility,both,,,,2264,2264,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA LOWER EXTREMITY WO CONTRAST,6167372503,CDM,616,RC,73725,HCPCS,facility,both,,,,1672,1672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA-LOWER EXTREM W & W/O CONTR,6167372504,CDM,616,RC,73725,HCPCS,facility,both,,,,3955,3955,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA-LOWER EXTREM W & W/O CONTR,6167372504,CDM,616,RC,73725,HCPCS,facility,both,,,,4394,4394,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA CHEST WITH CONTRAST,6187155501,CDM,618,RC,71555,HCPCS,facility,both,,,,1982,1982,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA CHEST WITH CONTRAST,6187155501,CDM,618,RC,71555,HCPCS,facility,both,,,,2819,2819,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA CHEST WITHOUT CONTRAST,6187155502,CDM,618,RC,71555,HCPCS,facility,both,,,,2159,2159,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA CHEST WITHOUT CONTRAST,6187155502,CDM,618,RC,71555,HCPCS,facility,both,,,,1617,1617,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA SPINE WITH CONTRAST,6187215901,CDM,618,RC,,,facility,both,,,,2744,2744,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA SPINE WITH CONTRAST,6187215901,CDM,618,RC,,,facility,both,,,,1920,1920,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA SPINE WITH OR WO CONTRAST,6187215902,CDM,618,RC,72159,HCPCS,facility,both,,,,2156,2156,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA SPINE WITH OR WO CONTRAST,6187215902,CDM,618,RC,72159,HCPCS,facility,both,,,,3697,3697,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA SPINE WITHOUT CONTRAST,6187215903,CDM,618,RC,,,facility,both,,,,1437,1437,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA SPINE WITHOUT CONTRAST,6187215903,CDM,618,RC,,,facility,both,,,,2464,2464,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA ABDOMEN WITH  CONTRAST,6187418501,CDM,618,RC,74185,HCPCS,facility,both,,,,2307,2307,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA ABDOMEN WITH  CONTRAST,6187418501,CDM,618,RC,74185,HCPCS,facility,both,,,,2587,2587,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA ABDOMEN WITHOUT CONTRAST,6187418502,CDM,618,RC,74185,HCPCS,facility,both,,,,1914,1914,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA ABDOMEN WITHOUT CONTRAST,6187418502,CDM,618,RC,74185,HCPCS,facility,both,,,,2159,2159,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA ABDOMEN WO & WITH CONTRAST,6187418503,CDM,618,RC,74185,HCPCS,facility,both,,,,2624,2624,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MRA ABDOMEN WO & WITH CONTRAST,6187418503,CDM,618,RC,74185,HCPCS,facility,both,,,,3506,3506,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM AIM SPECIALTY HEALTH,619G100701,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM CRANBERRY PEAK,619G100801,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLINICAL DECISION SUPPORT MECHANISM STANSON,619G101001,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AGILEMD'S CLINICAL DECISION SUPPORT MECH,619G101201,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVIDENCECARE IMAGING ADVISOR,619G101301,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INVENIQA'S SEMANTIC ANSWERS IN MEDICINE,619G101401,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RELIANT MEDICAL GROUP CDSM,619G101501,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPEED OF CARE CDSM,619G101601,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEALTHHELPS CLINICAL DECISION SUPPORT MECH,619G101701,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INFINX CDSM,619G101801,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LOGICNETS AUC SOLUTION,619G101901,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CURBSIDE CLINICAL AUGMENTED WORKFLOW,619G102001,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EHEAHTLINE CLINICAL DECISION SUPPORT MECH,619G102101,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERMOUNTAIN CLINICAL DECISION SUPPOORT MECH,619G102201,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERSIVIA CLINICAL DECIISION SUPPORT,619G102301,CDM,619,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUPPLY G200093 IMPELLA CP WITH SMART ASSIST,6240000001,CDM,624,RC,,,facility,both,,,,97592.5,97592.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AORTIC COREVALVE SYSTEM G100012,6240000002,CDM,624,RC,,,facility,both,,,,30900,30900,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APOLLO INTREPID G160020,6240000003,CDM,624,RC,,,facility,both,,,,46350,46350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GORE AAA EXCLUDER G150057,6240000005,CDM,624,RC,,,facility,both,,,,10349.06,10349.06,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GORE AAA EXTENDER G150057,6240000006,CDM,624,RC,,,facility,both,,,,2723.43,2723.43,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEARTMATE III G140113 DEVICE,6240000007,CDM,624,RC,,,facility,both,,,,95318.91,95318.91,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESEARCH SUPPLY 624 COREVALVE EVOLUT,6240000008,CDM,624,RC,,,facility,both,,,,33990,33990,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESEARCH SUPPLY 624 COREVALVE SURVATI,6240000009,CDM,624,RC,,,facility,both,,,,30900,30900,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESEARCH SUPPLY 624 NELLIX POLYMER,6240000010,CDM,624,RC,,,facility,both,,,,309,309,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RESEARCH SUPPLY 624 NELLIX SYSTEM,6240000011,CDM,624,RC,,,facility,both,,,,17510,17510,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G160209 LOTUS EDGE  REPRISE IDE,6240000012,CDM,624,RC,,,facility,both,,,,29273.03,29273.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G190020-CORDELLA PROACTIVE HF,6240000014,CDM,624,RC,,,facility,both,,,,25613.53,25613.53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G190272-PVCA GOLD CATHETER IDE,6240000015,CDM,624,RC,,,facility,both,,,,10300,10300,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
LOW RISK BICUSPID G160022,6240000018,CDM,624,RC,,,facility,both,,,,35949.38,35949.38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G190087 CITADEL EMBOLIZATION DEVICE STUDY IDE,6240000020,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G230034 IDE GORE® ASCENDING STENT GRAFT,6240000021,CDM,624,RC,,,facility,both,,,,24720,24720,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G230034 IDE GORE® TBE AORTIC COMPONENT,6240000022,CDM,624,RC,,,facility,both,,,,28325,28325,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G230034 IDE GORE® TBE SIDE BRANCH COMPONENT,6240000023,CDM,624,RC,,,facility,both,,,,5665,5665,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G230034 IDE GORE® TRI-LOBE BALLOON CATHETER,6240000024,CDM,624,RC,,,facility,both,,,,618,618,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G230212 IMPEDE-FX RAPIDFILL AAA-SHAPE STUDY IDE,6240000025,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONFORM CLAAS IMPLANT WITH DELIVERY SYSTEM,6240000027,CDM,624,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G200126 IMPELLA ECP,6240000030,CDM,624,RC,,,facility,both,,,,25750,25750,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G220046 EMBLOK DEVICE STUDY IDE,6240000031,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-G220289 - THECAFLEX DRX SYSTEM - IDE RESEARCH,6240000032,CDM,624,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G240209 PREVAIL DCB RESEARCH,6240000033,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU ASG PROCEDURE SECONDARY - CAPITATED CASE,6240000040,CDM,624,RC,,,facility,both,,,,77250,77250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G150249 CORCINCH DEVICE STUDY IDE,6240000067,CDM,624,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G200119-TTVR SYSTEM IDE CAT. A - RESEARCH,6240000068,CDM,624,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU G230145  GORE TRBR IDE CAT. B -RESEARCH,6240000069,CDM,624,RC,,,facility,both,,,,0.01,0.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G240020 INNOVATE BRIOVAD RESEARCH,6240000070,CDM,624,RC,,,facility,both,,,,241116,241116,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G250008 ARISE III IDE GORE® ASCENDING STENT GRAFT,6240000071,CDM,624,RC,,,facility,both,,,,24720,24720,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G160196 COSIRA-II RESEARCH,6240000072,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G210258 REPRIEVE RESEARCH,6240000074,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SU â  G220046 - EMBLOK EMBOLIC PROTECTION SYSTEM,6240000075,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU-G240257 VORO SCAFFOLD,6240000076,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G250078 AGENT PACLITAXEL COATED BALLOON CATHETER,6240000077,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G190225 VIRTUE SIROLIMUS ANGIOINFUSION BALLON SAB,6240000078,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SU G240300 FARAPULSE⢠PULSED FIELD ABLATION SYSTEM,6240000079,CDM,624,RC,,,facility,both,,,,1,1,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RX DEFINITY 636,6360000023,CDM,636,RC,,,facility,both,,,,49.54,49.54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNE GLOBULIN (IG) HUMAN GAMASTAN IM USE  0-2ML,6369028101,CDM,636,RC,,,facility,both,,,,145.92,145.92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMMUNE GLOBULIN (IG) HUMAN GAMASTAN IM USE  2-4 ML,6369028102,CDM,636,RC,,,facility,both,,,,291.84,291.84,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HBIG IMMUNE GLOBULIN,6369037101,CDM,636,RC,,,facility,both,,,,493.4,493.4,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE RSV MONOCLONAL ANTB SEASONAL DOSE 0.5ML IM USE,6369038001,CDM,636,RC,90380,HCPCS,facility,both,,,,742.5,742.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE RSV MONOCLONAL ANTB SEASONAL DOSE 1 ML IM USE,6369038101,CDM,636,RC,90381,HCPCS,facility,both,,,,742.5,742.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RSV MONOCLONAL ANTB SEASONAL DOSE 0.7 ML IM USE,6369038201,CDM,636,RC,,,facility,both,,,,911,911,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC VACCINE ADMIN INTRANASAL/ORAL SINGLE,6369047301,CDM,636,RC,,,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHIKUNGUNYA VIRUS VACCINE RECOMBINANT FOR IM USE,6369059301,CDM,636,RC,,,facility,both,,,,465,465,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE MENB-4C VACC 2 DOSE IM,6369062001,CDM,636,RC,90620,HCPCS,facility,both,,,,166.8,166.8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MENB RECOMBINANT LIPOPROTEIN VACCINE IM,6369062101,CDM,636,RC,,,facility,both,,,,240.88,240.88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHOLERA VACCINE ADULT 1 DOSE LIVE FOR ORAL USE,6369062501,CDM,636,RC,,,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HEP A ADULT IM,6369063201,CDM,636,RC,90632,HCPCS,facility,both,,,,170.53,170.53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HEP A PEDS IM,6369063301,CDM,636,RC,90633,HCPCS,facility,both,,,,80.28,80.28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPATITIS A & B VACCINE HEPA-HEPB ADULT IM,6369063601,CDM,636,RC,90636,HCPCS,facility,both,,,,247.22,247.22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HIB PRP OMP,6369064701,CDM,636,RC,,,facility,both,,,,97.36,97.36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HIB PRP-T IM,6369064801,CDM,636,RC,90648,HCPCS,facility,both,,,,26.81,26.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HPV,6369064901,CDM,636,RC,90649,HCPCS,facility,both,,,,378.17,378.17,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HPV VIRUS 9 VAL IM,6369065101,CDM,636,RC,90651,HCPCS,facility,both,,,,334.43,334.43,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU ADJUVANT IM,6369065301,CDM,636,RC,90653,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU PRESERVATIVE FREE AGE 3 OR OLDER,6369065601,CDM,636,RC,90656,HCPCS,facility,both,,,,38,38,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU AGE 3 OR UNDER,6369065701,CDM,636,RC,,,facility,both,,,,27.64,27.64,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLUZONE AGE 3 OR OLDER,6369065801,CDM,636,RC,,,facility,both,,,,29.22,29.22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU NASAL,6369066001,CDM,636,RC,90660,HCPCS,facility,both,,,,65.51,65.51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAIV3 VACCINE LIVE FOR INTRANASAL USE,6369066003,CDM,636,RC,,,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU SPLIT VIRUS PRESERVATIVE FREE,6369066202,CDM,636,RC,90662,HCPCS,facility,both,,,,84.77,84.77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE PNEUMOCOCCAL 13 VAL IM,6369067001,CDM,636,RC,,,facility,both,,,,344.72,344.72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PCV15 VACCINE FOR INTRAMUSCULAR USE,6369067101,CDM,636,RC,90671,HCPCS,facility,both,,,,705.93,705.93,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU 4 VALENT NASAL,6369067201,CDM,636,RC,,,facility,both,,,,1.32,1.32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RIV3 VACCINE PRESERVATIVE FREE FOR IM USE,6369067301,CDM,636,RC,90673,HCPCS,facility,both,,,,110,110,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE RABIES,6369067501,CDM,636,RC,,,facility,both,,,,840.72,840.72,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE RSV VACCINE PREF SUBUNIT BIVALENT FOR IM USE,6369067801,CDM,636,RC,90678,HCPCS,facility,both,,,,378.6,378.6,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE RSV VACC PREF RECOMBINANT ADJUVANTED FOR IM USE,6369067901,CDM,636,RC,90679,HCPCS,facility,both,,,,355.49,355.49,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE ROTOVIRUS 3 DOSE,6369068001,CDM,636,RC,90680,HCPCS,facility,both,,,,251.34,251.34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLUBLOK PREFILLED SYRINGE,6369068201,CDM,636,RC,90682,HCPCS,facility,both,,,,84.77,84.77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE PCV21 FOR INTRAMUSCULAR USE,6369068401,CDM,636,RC,90684,HCPCS,facility,both,,,,430,430,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU QUAD SPLIT VIRUS,6369068501,CDM,636,RC,,,facility,both,,,,39.61,39.61,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU NO PRESERVATIVE 4 VAL 3 OR OLDER,6369068601,CDM,636,RC,90686,HCPCS,facility,both,,,,35.37,35.37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLU QUADRIVAL AGE 3 OR OLDER IM,6369068801,CDM,636,RC,,,facility,both,,,,31.91,31.91,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TYPHOID VACCINE LIVE ORAL,6369069001,CDM,636,RC,90690,HCPCS,facility,both,,,,151.8,151.8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TYPHOID VACCINE VI CAPSULAR POLYSACCHARIDE IM,6369069101,CDM,636,RC,90691,HCPCS,facility,both,,,,151.8,151.8,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FLUAD- AIIV4 VACC INACTIVATED PRSRV FR 0.5ML DOS IM USE,6369069401,CDM,636,RC,,,facility,both,,,,203.19,203.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE DTAP IPV KINRIX,6369069601,CDM,636,RC,90696,HCPCS,facility,both,,,,110.96,110.96,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE PENTACEL,6369069801,CDM,636,RC,,,facility,both,,,,157.89,157.89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE DTAP,6369070001,CDM,636,RC,90700,HCPCS,facility,both,,,,48.85,48.85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE DT AGE 7 OR UNDER,6369070201,CDM,636,RC,,,facility,both,,,,22.68,22.68,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE MMR,6369070701,CDM,636,RC,90707,HCPCS,facility,both,,,,129.12,129.12,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MEASLES MUMPS RUBELLA VARICELLA VACC LIVE SUBQ,6369071001,CDM,636,RC,90710,HCPCS,facility,both,,,,153.6,153.6,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE POLIO SUBQ,6369071301,CDM,636,RC,90713,HCPCS,facility,both,,,,66.25,66.25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE TETANUS DIPTHERIA TOXOID,6369071401,CDM,636,RC,90714,HCPCS,facility,both,,,,70.91,70.91,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE TDAP AGE 7 OR OLDER,6369071501,CDM,636,RC,90715,HCPCS,facility,both,,,,90.05,90.05,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE VARICELLA CHICKEN POX,6369071601,CDM,636,RC,90716,HCPCS,facility,both,,,,216.73,216.73,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC YELLOW FEVER VACCINE LIVE SUBQ,6369071701,CDM,636,RC,90717,HCPCS,facility,both,,,,244.6,244.6,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE DTAP HEP B IPV IM,6369072301,CDM,636,RC,90723,HCPCS,facility,both,,,,156.18,156.18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE PNEUMOVAX SUBQ OR IM,6369073202,CDM,636,RC,90732,HCPCS,facility,both,,,,158.27,158.27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE MENINGITIS ACYW SUBQ,6369073301,CDM,636,RC,,,facility,both,,,,257.61,257.61,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE MENINGOCOCCAL CONJ,6369073401,CDM,636,RC,90734,HCPCS,facility,both,,,,274.89,274.89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE ZOSTAVAX SUBQ,6369073601,CDM,636,RC,,,facility,both,,,,495.59,495.59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HEP B ADULT 2 DOSE SCHEDULE,6369073901,CDM,636,RC,90739,HCPCS,facility,both,,,,82.2,82.2,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEPB VACCINE DIALYSIS/IMMUNSUP PAT 3 DOSE IM,6369074001,CDM,636,RC,,,facility,both,,,,560.65,560.65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEP B VACCINE PED/ADOLESC 3 DOSE SCHEDULE IM,6369074401,CDM,636,RC,90744,HCPCS,facility,both,,,,32.41,32.41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE HEPATITIS B ADULT DOSE,6369074601,CDM,636,RC,,,facility,both,,,,168.75,168.75,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE COMVAX HIB,6369074801,CDM,636,RC,,,facility,both,,,,146.01,146.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HZV ZOSTER VACC RECOMBINANT ADJUVANTED IM NJX,6369075001,CDM,636,RC,90750,HCPCS,facility,both,,,,234.18,234.18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MODERNA SARSCOV2 VACC 3MCG/0.3ML TRIS-SUCROSE IM USE,6369131801,CDM,636,RC,,,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PFIZER SARSCOV2 VACC 10MCG/0.3ML TRIS-SUCROSE IM USE,6369131901,CDM,636,RC,,,facility,both,,,,176,176,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PFIZER SARSCOV2 VACC 30MCG/0.3ML TRIS-SUCROSE IM USE,6369132001,CDM,636,RC,,,facility,both,,,,262,262,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MODERNA SARSCOV2 VACCINE 25 MCG/0.25 ML FOR IM USE,6369132101,CDM,636,RC,91321,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MODERNA SARSCOV2 VACCINE 50 MCG/0.5 ML FOR IM USE,6369132201,CDM,636,RC,91322,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SARSCOV2 VACCINE 10 MCG/0.2 ML FOR IM USE,6369132301,CDM,636,RC,,,facility,both,,,,863,863,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NM RUBIDIUM/ PER DOSE,636A955501,CDM,636,RC,,,facility,both,,,,1101,1101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION RHO D IMMUNE GLOBULIN FULL DOSE,636J279001,CDM,636,RC,J2790,HCPCS,facility,both,,,,247.06,247.06,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IUD UNCLASSIFIED,636J349001,CDM,636,RC,,,facility,both,,,,1472.55,1472.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IUD MIRENA,636J729801,CDM,636,RC,J7298,HCPCS,facility,both,,,,1472.55,1472.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IUD COPPER DEVICE,636J730001,CDM,636,RC,,,facility,both,,,,1636.89,1636.89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IUD SKYLA,636J730101,CDM,636,RC,,,facility,both,,,,2992.27,2992.27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE FLULAVAL QIV PREFILLED SYRINGE,636Q203601,CDM,636,RC,,,facility,both,,,,28.22,28.22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SKIN CADAVER 1/4 SQ FT REG,636Q410001,CDM,636,RC,,,facility,both,,,,9.24,9.24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SKIN CADAVER 1/6SQ FT MESHED,636Q410002,CDM,636,RC,,,facility,both,,,,9.19,9.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SKIN CADAVER 1/6SQ FT NON-MESH,636Q410003,CDM,636,RC,,,facility,both,,,,9.19,9.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SKIN CADAVER 1/9 SQ FT,636Q410004,CDM,636,RC,,,facility,both,,,,9.27,9.27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OMNIGRAFT KIT STAPL  2.5X2.5 CM,636Q410502,CDM,636,RC,,,facility,both,,,,3376.58,3376.58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OMNIGRAFT KIT STAPL  4X4 CM,636Q410503,CDM,636,RC,,,facility,both,,,,4100.25,4100.25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OMNIGRAFT KIT STAPL  7X7 CM,636Q410504,CDM,636,RC,,,facility,both,,,,8200.5,8200.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIMATRIX 1 SQ CM 14MM DISC,636Q411002,CDM,636,RC,,,facility,both,,,,836.77,836.77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIMATRIX 1 SQ CM 18MM DISC,636Q411003,CDM,636,RC,,,facility,both,,,,678.62,678.62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIMATRIX 1 SQ CM 3X3 CM,636Q411004,CDM,636,RC,,,facility,both,,,,272.98,272.98,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIMATRIX 1 SQ CM 4X4CM MESHED,636Q411005,CDM,636,RC,,,facility,both,,,,200.55,200.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRIMATRIX 2X2 SQ CM,636Q411006,CDM,636,RC,,,facility,both,,,,540.69,540.69,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GRAFIX PL PRIME 1.5X2.0CM (3),636Q413301,CDM,636,RC,,,facility,both,,,,1200.21,1200.21,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GRAFIX PL PRIME 2.0X3.0CM (6),636Q413302,CDM,636,RC,,,facility,both,,,,750.13,750.13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GRAFIX PL PRIME 3.0X4.0CM (12),636Q413303,CDM,636,RC,,,facility,both,,,,361.78,361.78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GRAFIXPL PRIME 16.0MM DISC (2),636Q413304,CDM,636,RC,Q4133,HCPCS,facility,both,,,,1099.56,1099.56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL 1 SQ CM 1.5X1.5 CM,636Q413701,CDM,636,RC,,,facility,both,,,,927.16,927.16,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL 1 SQ CM 15MM DISC,636Q413702,CDM,636,RC,,,facility,both,,,,686.19,686.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL 1 SQ CM 18MM DISC,636Q413703,CDM,636,RC,,,facility,both,,,,842.87,842.87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL 1 SQ CM 2X3 CM,636Q413704,CDM,636,RC,,,facility,both,,,,634.83,634.83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL BIODEXCEL 1 SQ CM 3.5  X 3.5CM,636Q413706,CDM,636,RC,,,facility,both,,,,261.19,261.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL BIODEXCEL 1 SQ CM 4X4 CM,636Q413707,CDM,636,RC,,,facility,both,,,,222.03,222.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL BIODEXCEL 1 SQ CM 4X8 CM,636Q413708,CDM,636,RC,,,facility,both,,,,139.19,139.19,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL 1 SQ CM 12MM DISC,636Q413709,CDM,636,RC,,,facility,both,,,,1258.05,1258.05,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL 1 SQ CM 17MM DISC,636Q413710,CDM,636,RC,,,facility,both,,,,916.36,916.36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL 1 SQ CM 24MM DISC,636Q413711,CDM,636,RC,,,facility,both,,,,590.01,590.01,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOEXCEL BIODEXCEL 1 SQ CM 5X5 CM,636Q413712,CDM,636,RC,,,facility,both,,,,160.83,160.83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPIFIX 1 SQ CM,636Q418601,CDM,636,RC,Q4186,HCPCS,facility,both,,,,443.55,443.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPICORD 1 SQ CM,636Q418701,CDM,636,RC,Q4187,HCPCS,facility,both,,,,443.55,443.55,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LOCM ISOVUE 250 PER ML,636Q996601,CDM,636,RC,,,facility,both,,,,2.77,2.77,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LOCM OMNI 300-349 PER ML,636Q996701,CDM,636,RC,,,facility,both,,,,3.27,3.27,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 1 ACTIVATION LEVEL 1 PRE NOTIFICATION,681G039001,CDM,681,RC,G0390,HCPCS,facility,both,,,,9613,9613,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 1 ACTIVATION LEVEL 2 PRE NOTIFICATION,681G039002,CDM,681,RC,G0390,HCPCS,facility,both,,,,7805,7805,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 1 PRE NOTIFICATION EVALUATION,681G039003,CDM,681,RC,,,facility,both,,,,3579,3579,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 3 ACTIVATION LEVEL 1 PRE NOTIFICATION,683G039004,CDM,683,RC,G0390,HCPCS,facility,both,,,,7706,7706,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 3 ACTIVATION LEVEL 2 PRE NOTIFICATION,683G039005,CDM,683,RC,G0390,HCPCS,facility,both,,,,5154,5154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED TRAUMA CENTER 3 EVALUATION,683G039006,CDM,683,RC,,,facility,both,,,,3022,3022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY ADDITIONAL 15 MIN,7100000007,CDM,710,RC,,,facility,both,,,,156,156,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY ADDITIONAL 15 MIN,7100000007,CDM,710,RC,,,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY CVRU ADDTL 15 MIN,7100000008,CDM,710,RC,,,facility,both,,,,134,134,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY CVRU FIRST 1/2 HOUR,7100000009,CDM,710,RC,,,facility,both,,,,622,622,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY CVRU LEVEL IV,7100000010,CDM,710,RC,,,facility,both,,,,6032,6032,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY FIRST 1/2 HOUR,7100000011,CDM,710,RC,,,facility,both,,,,730,730,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY FIRST 1/2 HOUR,7100000011,CDM,710,RC,,,facility,both,,,,657,657,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY PHASE 2 EACH 15 MIN,7100000012,CDM,710,RC,,,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY PHASE 2 EACH 15 MIN,7100000012,CDM,710,RC,,,facility,both,,,,87,87,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY PHASE 2 EACH 15 MIN,7100000013,CDM,710,RC,,,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RECOVERY PHASE 2 EACH 15 MIN,7100000013,CDM,710,RC,,,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MONITOR FETAL INTERNAL,7200000001,CDM,720,RC,,,facility,both,,,,608,608,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOCENTESIS,7205900001,CDM,720,RC,59000,HCPCS,facility,both,,,,753,753,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMNIOTIC FLUID REDUCTION,7205900101,CDM,720,RC,59001,HCPCS,facility,both,,,,719,719,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OCT FETAL CONTRACTION STRESS T,7205902001,CDM,720,RC,59020,HCPCS,facility,both,,,,258,258,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OB BREECH VERSION (ECV),7205941201,CDM,720,RC,59412,HCPCS,facility,both,,,,4348,4348,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LABOR INDUCTION,7210000001,CDM,721,RC,,,facility,both,,,,1087,1087,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LABOR ROOM FEE EACH HOUR,7210000002,CDM,721,RC,,,facility,both,,,,182,182,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DELIVERY CHARGE,7220000001,CDM,722,RC,59409,HCPCS,facility,both,,,,4782,4782,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OB INSERTION CERVICAL DILATOR,7225920001,CDM,722,RC,59200,HCPCS,facility,both,,,,392,392,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DELIVERY OF PLACENTA,7225941401,CDM,722,RC,59414,HCPCS,facility,both,,,,3022,3022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CIRCUMCISION,CLAMP,NEWBORN",7235415001,CDM,723,RC,54150,HCPCS,facility,both,,,,1678,1678,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EKG COMPUTER,7309300501,CDM,730,RC,93005,HCPCS,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTERNAL ECG>48HR<7D RECORDING,7309324201,CDM,730,RC,93242,HCPCS,facility,both,,,,201,201,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTERNAL ECG>48HR<7D RECORDING,7309324201,CDM,730,RC,93242,HCPCS,facility,both,,,,230,230,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTERNAL ECG>7D<15D RECORDING,7309324601,CDM,730,RC,93246,HCPCS,facility,both,,,,288,288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTERNAL ECG>7D<15D RECORDING,7309324601,CDM,730,RC,93246,HCPCS,facility,both,,,,252,252,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EKG-SINGLE EVENT ECG RECORDING,7309327001,CDM,730,RC,93270,HCPCS,facility,both,,,,138,138,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EKG TRACING INITIAL PREV EXAM,730G040401,CDM,730,RC,G0404,HCPCS,facility,both,,,,60,60,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOLTER HOOK-UP,7319322501,CDM,731,RC,93225,HCPCS,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOLTER SCAN ONLY,7319322601,CDM,731,RC,93226,HCPCS,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS,7409570001,CDM,740,RC,95700,HCPCS,facility,both,,,,741,741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS,7409570001,CDM,740,RC,95700,HCPCS,facility,both,,,,988,988,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VIDEO BY TECH 2-12 HR UNMONITORED,7409570501,CDM,740,RC,,,facility,both,,,,741,741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VIDEO BY TECH 2-12 HR UNMONITORED,7409570501,CDM,740,RC,,,facility,both,,,,988,988,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VIDEO BY TECH 2-12 HR INTERMITTENT MNTR,7409570601,CDM,740,RC,95706,HCPCS,facility,both,,,,988,988,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VIDEO BY TECH 2-12 HR INTERMITTENT MNTR,7409570601,CDM,740,RC,95706,HCPCS,facility,both,,,,741,741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VIDEO BY TECH 2-12HR CONTINUOUS R-T MNTR,7409570701,CDM,740,RC,95707,HCPCS,facility,both,,,,741,741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VIDEO BY TECH 2-12HR CONTINUOUS R-T MNTR,7409570701,CDM,740,RC,95707,HCPCS,facility,both,,,,988,988,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VID BY TECH EA INCR 12-26HR UNMONITORED,7409570801,CDM,740,RC,,,facility,both,,,,1112,1112,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VID BY TECH EA INCR 12-26HR UNMONITORED,7409570801,CDM,740,RC,,,facility,both,,,,1482,1482,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VID BY TECH EA INCR 12-26 HR INTMT MNTR,7409570901,CDM,740,RC,95709,HCPCS,facility,both,,,,1894,1894,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VID BY TECH EA INCR 12-26 HR INTMT MNTR,7409570901,CDM,740,RC,95709,HCPCS,facility,both,,,,1420,1420,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VID TECH EA INCR 12-26 HR CONT R-T MNTR,7409571001,CDM,740,RC,,,facility,both,,,,1112,1112,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG W/O VID TECH EA INCR 12-26 HR CONT R-T MNTR,7409571001,CDM,740,RC,,,facility,both,,,,1482,1482,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH 2-12 HOURS UNMONITORED,7409571101,CDM,740,RC,,,facility,both,,,,772,772,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH 2-12 HOURS UNMONITORED,7409571101,CDM,740,RC,,,facility,both,,,,578,578,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH 2-12 HR INTERMITTENT MONITORING,7409571201,CDM,740,RC,95712,HCPCS,facility,both,,,,988,988,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH 2-12 HR INTERMITTENT MONITORING,7409571201,CDM,740,RC,95712,HCPCS,facility,both,,,,741,741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH 2-12 HR CONTINUOUS R-T MONITORING,7409571301,CDM,740,RC,95713,HCPCS,facility,both,,,,1894,1894,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH 2-12 HR CONTINUOUS R-T MONITORING,7409571301,CDM,740,RC,95713,HCPCS,facility,both,,,,1420,1420,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED,7409571401,CDM,740,RC,95714,HCPCS,facility,both,,,,1137,1137,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED,7409571401,CDM,740,RC,95714,HCPCS,facility,both,,,,1516,1516,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH EA INCR 12-26 HR INTERMITTENT MNTR,7409571501,CDM,740,RC,95715,HCPCS,facility,both,,,,1420,1420,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH EA INCR 12-26 HR INTERMITTENT MNTR,7409571501,CDM,740,RC,95715,HCPCS,facility,both,,,,1894,1894,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH EA INCR 12-26 HR CONT R-T MNTR,7409571601,CDM,740,RC,95716,HCPCS,facility,both,,,,2660,2660,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VEEG BY TECH EA INCR 12-26 HR CONT R-T MNTR,7409571601,CDM,740,RC,95716,HCPCS,facility,both,,,,3547,3547,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POLYSOM UNDER 6 YRS 4 ADDL PARAM ATTND,7409578201,CDM,740,RC,95782,HCPCS,facility,both,,,,7816,7816,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POLYSOM UNDER 6 YRS 4 ADDL PARAM ATTND,7409578201,CDM,740,RC,95782,HCPCS,facility,both,,,,5862,5862,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POLYSOM UNDER 6 YRS W/CPAP/BILVL VENT 4 ADDL PARAM ATTND,7409578301,CDM,740,RC,95783,HCPCS,facility,both,,,,6528,6528,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POLYSOM UNDER 6 YRS W/CPAP/BILVL VENT 4 ADDL PARAM ATTND,7409578301,CDM,740,RC,95783,HCPCS,facility,both,,,,8704,8704,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLEEP STUDY ATTENDED LIMITED,7409580701,CDM,740,RC,95807,HCPCS,facility,both,,,,1463,1463,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POLYSOM 6 YRS OR OLDER  4 ADDL PARAM ATTND,7409581001,CDM,740,RC,95810,HCPCS,facility,both,,,,4096,4096,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POLYSOM 6 YRS OR OLDER  4 ADDL PARAM ATTND,7409581001,CDM,740,RC,95810,HCPCS,facility,both,,,,3555,3555,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POLYSOM 6 YRS OR OLDER W/CPAP/BILVL VENT 4 ADDL PARAM ATTND,7409581101,CDM,740,RC,95811,HCPCS,facility,both,,,,3555,3555,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POLYSOM 6 YRS OR OLDER W/CPAP/BILVL VENT 4 ADDL PARAM ATTND,7409581101,CDM,740,RC,95811,HCPCS,facility,both,,,,4096,4096,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG 41 TO 60 MINUTES,7409581201,CDM,740,RC,95812,HCPCS,facility,both,,,,798,798,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG 61 TO 119 MINUTES,7409581301,CDM,740,RC,95813,HCPCS,facility,both,,,,958,958,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG AWAKE/DROWSY,7409581601,CDM,740,RC,95816,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG AWAKE AND ASLEEP,7409581901,CDM,740,RC,95819,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG COMA OR SLEEP ONLY,7409582201,CDM,740,RC,95822,HCPCS,facility,both,,,,1002,1002,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG CEREBRAL DEATH,7409582401,CDM,740,RC,,,facility,both,,,,782,782,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELECTROCORTICOGRAM INTRAOP,7409582901,CDM,740,RC,95829,HCPCS,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAOP NEURO MON PER 15 MIN,7409594001,CDM,740,RC,95940,HCPCS,facility,both,,,,238,238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG IOM,7409595501,CDM,740,RC,95955,HCPCS,facility,both,,,,1035,1035,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EEG HEMISPHERIC FUNCTION/WADA,7409595801,CDM,740,RC,95958,HCPCS,facility,both,,,,2093,2093,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CORTICAL MAPPING,7409596101,CDM,740,RC,,,facility,both,,,,2184,2184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRAIN MAPPING ADDITIONAL HOURS,7409596201,CDM,740,RC,,,facility,both,,,,1091,1091,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOSCOPY LEVEL I PER MINUTE,7500000005,CDM,750,RC,,,facility,both,,,,51,51,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOSCOPY LEVEL II PER MINUTE,7500000006,CDM,750,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOSCOPY LEVEL III PER MINUTE,7500000007,CDM,750,RC,,,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOSCOPY LEVEL III PER MINUTE,7500000007,CDM,750,RC,,,facility,both,,,,101,101,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOSCOPY LEVEL IV PER MINUTE,7500000008,CDM,750,RC,,,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRRT DAILY,7610000001,CDM,761,RC,,,facility,both,,,,2528.81,2528.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CRRT INITIAL SET UP,7610000002,CDM,761,RC,,,facility,both,,,,1934,1934,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PIRRT DAILY,7610000004,CDM,761,RC,,,facility,both,,,,1992,1992,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEAR INFRARED SPECTROSCPY STUDIES LOW EXT WOUNDS,7610493T01,CDM,761,RC,,,facility,both,,,,102,102,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NCNTC NR IFR SPECTRSC OTH/THN PAD EA ANTMC SITE,7610859T01,CDM,761,RC,,,facility,both,,,,202,202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NCNTC NR IFR SPECTRSC SCR PAD W/PROV MANEUVERS,7610860T01,CDM,761,RC,,,facility,both,,,,202,202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL,7611000401,CDM,761,RC,,,facility,both,,,,345,345,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION,7611000501,CDM,761,RC,10005,HCPCS,facility,both,,,,805,805,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,7611000601,CDM,761,RC,10006,HCPCS,facility,both,,,,470,470,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION,7611000701,CDM,761,RC,,,facility,both,,,,2560,2560,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION,7611002101,CDM,761,RC,10021,HCPCS,facility,both,,,,447,447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACNE SURGERY,7611004001,CDM,761,RC,,,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF SKIN ABSCESS SIMPLE,7611006001,CDM,761,RC,10060,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF SKIN ABSCESS COMP,7611006101,CDM,761,RC,10061,HCPCS,facility,both,,,,348,348,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE FOREIGN BODY SUBQ SIMPLE,7611012001,CDM,761,RC,10120,HCPCS,facility,both,,,,382,382,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE FOREIGN BODY SUBQ COMPLEX,7611012101,CDM,761,RC,10121,HCPCS,facility,both,,,,2088,2088,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF HEMATOMA FLUID,7611014001,CDM,761,RC,10140,HCPCS,facility,both,,,,1297,1297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF HEMATOMA FLUID,7611014001,CDM,761,RC,10140,HCPCS,facility,both,,,,1518,1518,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX PUNCTURE DRAINAGE OF LESION,7611016001,CDM,761,RC,10160,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION & DRAINAGE COMPLEX PO WOUND INFECTION,7611018001,CDM,761,RC,,,facility,both,,,,2432,2432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE SUBQ 20 SQ CM OR LESS,7611104201,CDM,761,RC,11042,HCPCS,facility,both,,,,408,408,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE MUSC/FASCIA 20 SQ CM OR LESS,7611104301,CDM,761,RC,11043,HCPCS,facility,both,,,,566,566,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE BONE 20 SQ CM OR LESS,7611104401,CDM,761,RC,11044,HCPCS,facility,both,,,,2430,2430,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE SUBQ TISSUE ADDTL 20 SQ CM,7611104501,CDM,761,RC,11045,HCPCS,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDEMENT MUSCLE &/FASCIA EA ADDL 20 SQ CM,7611104601,CDM,761,RC,11046,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE BONE ADDTL 20 SQ CM,7611104701,CDM,761,RC,11047,HCPCS,facility,both,,,,932,932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRIM SKIN LESION,7611105501,CDM,761,RC,11055,HCPCS,facility,both,,,,181,181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC TRIM BENIGN HYPERKERATOTIC SKIN LESION,2-4",7611105601,CDM,761,RC,11056,HCPCS,facility,both,,,,199,199,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRIM SKIN LESIONS 5 OR MORE,7611105701,CDM,761,RC,,,facility,both,,,,237,237,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TANGENTIAL BIOPSY SKIN SINGLE LESION,7611110201,CDM,761,RC,11102,HCPCS,facility,both,,,,290,290,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,7611110301,CDM,761,RC,11103,HCPCS,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF FLOOR OF MOUTH,7611110401,CDM,761,RC,,,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCH BIOPSY SKIN SINGLE LESION,7611110402,CDM,761,RC,11104,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION,7611110501,CDM,761,RC,11105,HCPCS,facility,both,,,,216,216,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISIONAL BIOPSY SKIN SINGLE LESION,7611110601,CDM,761,RC,11106,HCPCS,facility,both,,,,679,679,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,7611110701,CDM,761,RC,,,facility,both,,,,598,598,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE SKIN TAGS 15 TAGS OR LESS,7611120001,CDM,761,RC,11200,HCPCS,facility,both,,,,183,183,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA EA 10,7611120101,CDM,761,RC,11201,HCPCS,facility,both,,,,121,121,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHAVE SKIN LESION TRUNK 0.5 CM OR LESS,7611130001,CDM,761,RC,11300,HCPCS,facility,both,,,,354,354,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHAVE SKIN LESION TRUNK 0.6 TO 1 CM,7611130101,CDM,761,RC,11301,HCPCS,facility,both,,,,469,469,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHAVE SKIN LESION TRUNK 1.1 TO 2 CM,7611130201,CDM,761,RC,11302,HCPCS,facility,both,,,,540,540,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/<,7611130501,CDM,761,RC,11305,HCPCS,facility,both,,,,269,269,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6-1.0 CM,7611130601,CDM,761,RC,11306,HCPCS,facility,both,,,,331,331,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0.5 CM/<,7611131002,CDM,761,RC,11310,HCPCS,facility,both,,,,263,263,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION TRUNK 0.5 CM OR LESS,7611140001,CDM,761,RC,11400,HCPCS,facility,both,,,,724,724,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION TRUNK 0.6 TO 1 CM,7611140101,CDM,761,RC,11401,HCPCS,facility,both,,,,905,905,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION TRUNK 1.1 TO 2 CM,7611140201,CDM,761,RC,11402,HCPCS,facility,both,,,,1074,1074,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION TRUNK 2.1 TO 3 CM,7611140301,CDM,761,RC,11403,HCPCS,facility,both,,,,1651,1651,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXC BENIGN LESION MRGN XCP SK TG T/A/L 3.1-4.0 CM,7611140401,CDM,761,RC,11404,HCPCS,facility,both,,,,2361,2361,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION TRUNK,7611140402,CDM,761,RC,,,facility,both,,,,3182,3182,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION TRUNK 4.1 CM OR GREATER,7611140601,CDM,761,RC,11406,HCPCS,facility,both,,,,2578,2578,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION SCALP 0.5 CM OR LESS,7611142001,CDM,761,RC,11420,HCPCS,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION SCALP 0.6 TO 1 CM,7611142101,CDM,761,RC,11421,HCPCS,facility,both,,,,1467,1467,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION SCALP 1.1 TO 2 CM,7611142201,CDM,761,RC,11422,HCPCS,facility,both,,,,1514,1514,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION SCALP 2.1 TO 3 CM,7611142301,CDM,761,RC,,,facility,both,,,,1589,1589,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION SCALP 3.1 TO 4 CM,7611142401,CDM,761,RC,,,facility,both,,,,1928,1928,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION SCALP 4.1 CM OR GREATER,7611142601,CDM,761,RC,,,facility,both,,,,8441,8441,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION FACE 0.5 CM OR LESS,7611144001,CDM,761,RC,11440,HCPCS,facility,both,,,,665,665,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION FACE 0.6 TO 1 CM,7611144101,CDM,761,RC,11441,HCPCS,facility,both,,,,688,688,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION FACE 1.1 TO 2 CM,7611144201,CDM,761,RC,11442,HCPCS,facility,both,,,,860,860,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION FACE 2.1 TO 3 CM,7611144301,CDM,761,RC,11443,HCPCS,facility,both,,,,1672,1672,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION FACE 3.1 TO 4 CM,7611144401,CDM,761,RC,,,facility,both,,,,1694,1694,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE BENIGN LESION FACE 4.1 CM OR GREATER,7611144601,CDM,761,RC,11446,HCPCS,facility,both,,,,2526,2526,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION TRUNK 0.5 CM OR LESS,7611160001,CDM,761,RC,,,facility,both,,,,992,992,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION TRUNK 0.6 TO 1 CM,7611160101,CDM,761,RC,,,facility,both,,,,735,735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION TRUNK 1.1 TO 2 CM,7611160201,CDM,761,RC,11602,HCPCS,facility,both,,,,1039,1039,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION TRUNK 2.1 TO 3 CM,7611160301,CDM,761,RC,11603,HCPCS,facility,both,,,,1246,1246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION TRUNK 3.1 TO 4 CM,7611160401,CDM,761,RC,11604,HCPCS,facility,both,,,,1496,1496,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION TRUNK 4.1 CM OR GREATER,7611160601,CDM,761,RC,11606,HCPCS,facility,both,,,,1954,1954,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION SCALP 0.5 CM OR LESS,7611162001,CDM,761,RC,,,facility,both,,,,1934,1934,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION SCALP 0.6 TO 1 CM,7611162101,CDM,761,RC,,,facility,both,,,,735,735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION SCALP 1.1 TO 2 CM,7611162201,CDM,761,RC,11622,HCPCS,facility,both,,,,2226,2226,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION SCALP 2.1 TO 3 CM,7611162301,CDM,761,RC,11623,HCPCS,facility,both,,,,1954,1954,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION SCALP 3.1 TO 4 CM,7611162401,CDM,761,RC,11624,HCPCS,facility,both,,,,1954,1954,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION FACE 0.5 CM OR LESS,7611164001,CDM,761,RC,11640,HCPCS,facility,both,,,,735,735,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION FACE 0.6 TO 1 CM,7611164101,CDM,761,RC,11641,HCPCS,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION FACE 1.1 TO 2 CM,7611164201,CDM,761,RC,11642,HCPCS,facility,both,,,,974,974,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION FACE 2.1 TO 3 CM,7611164301,CDM,761,RC,11643,HCPCS,facility,both,,,,1691,1691,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE MALIGNANT LESION FACE 3.1 TO 4 CM,7611164401,CDM,761,RC,,,facility,both,,,,1934,1934,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRIM NAIL (S) ANY NUMBER,7611171901,CDM,761,RC,11719,HCPCS,facility,both,,,,119,119,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE NAIL 1 TO 5,7611172001,CDM,761,RC,11720,HCPCS,facility,both,,,,173,173,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDE NAIL 6 OR MORE,7611172101,CDM,761,RC,11721,HCPCS,facility,both,,,,198,198,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AVULSION OF NAIL PLATE SINGLE,7611173001,CDM,761,RC,11730,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AVULSION OF NAIL PLATE EACH ADDTL,7611173201,CDM,761,RC,,,facility,both,,,,131,131,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL OF NAIL BED,7611175001,CDM,761,RC,11750,HCPCS,facility,both,,,,447,447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISION OF NAIL FOLD TOE,7611176501,CDM,761,RC,,,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SKIN LESION UP TO 7,7611190001,CDM,761,RC,11900,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/<,7611195001,CDM,761,RC,11950,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC,7611195101,CDM,761,RC,11951,HCPCS,facility,both,,,,765,765,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC,7611195201,CDM,761,RC,11952,HCPCS,facility,both,,,,765,765,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUBCUTANEOUS INJECTION FILLING MATRL >10.0 CC,7611195401,CDM,761,RC,,,facility,both,,,,765,765,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE CONTRACEPTIVE CAPSULE,7611197601,CDM,761,RC,,,facility,both,,,,834,834,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT DRUG IMPLANT DEVICE,7611198101,CDM,761,RC,11981,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE DRUG IMPLANT DEVICE,7611198201,CDM,761,RC,11982,HCPCS,facility,both,,,,403,403,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVE AND REINSERT IMPLANT DEVICE,7611198301,CDM,761,RC,11983,HCPCS,facility,both,,,,403,403,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REPAIR SIMPLE WOUND TRUNK/SCALP 2.5 CM OR LESS,7611200101,CDM,761,RC,,,facility,both,,,,190,190,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR SIMPLE WOUND TRUNK/SCALP 2.5 CM OR LESS,7611200102,CDM,761,RC,,,facility,both,,,,219,219,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR SIMPLE WOUND TRUNK/SCALP 2.6 TO 7.5 CM,7611200201,CDM,761,RC,12002,HCPCS,facility,both,,,,218,218,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR SIMPLE WOUND FACE 2.5 CM OR LESS,7611201101,CDM,761,RC,12011,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SIMPLE LAC 2.6-5CM FACE,7611201301,CDM,761,RC,,,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SIMPLE REPAIR F/E/E/N/L/M 2.6 CM - 5.0 CM,7611201302,CDM,761,RC,12013,HCPCS,facility,both,,,,245,245,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SIMPLE LAC 5.1-7.5CM FACE,7611201401,CDM,761,RC,,,facility,both,,,,326,326,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SIMPLE  LAC 7.6-12.5CM FACE,7611201501,CDM,761,RC,,,facility,both,,,,778,778,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SIMPLE LAC 12.6-20CM FACE,7611201601,CDM,761,RC,,,facility,both,,,,658,658,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSURE OF SIMPLE WOUND SUPERFICIAL,7611202001,CDM,761,RC,,,facility,both,,,,703,703,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND TRUNK/SCALP 2.5 CM OR LESS,7611203101,CDM,761,RC,12031,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND TRUNK/SCALP 2.6 TO 7.5 CM,7611203201,CDM,761,RC,12032,HCPCS,facility,both,,,,418,418,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND NECK/EXTREMITY 2.5 CM OR LESS,7611204101,CDM,761,RC,12041,HCPCS,facility,both,,,,517,517,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND NECK/EXTREMITY 2.6 TO 7.5 CM,7611204201,CDM,761,RC,12042,HCPCS,facility,both,,,,515,515,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND FACE 2.5 CM OR LESS,7611205101,CDM,761,RC,12051,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR INTERMEDIATE WOUND FACE 2.6 TO 5 CM,7611205201,CDM,761,RC,12052,HCPCS,facility,both,,,,429,429,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  INTMD LAC 5.1-7.5 CM,7611205301,CDM,761,RC,12053,HCPCS,facility,both,,,,493,493,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTMD LAC 7.6-12.5CM FACE,7611205401,CDM,761,RC,,,facility,both,,,,658,658,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  INTMD LAC 12.6-20CM FACE,7611205501,CDM,761,RC,,,facility,both,,,,658,658,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COMPLEX WOUND TRUNK 1.1 TO 2.5 CM,7611310001,CDM,761,RC,,,facility,both,,,,1220,1220,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COMPLEX WOUND TRUNK 2.6 TO 7. 5CM,7611310101,CDM,761,RC,13101,HCPCS,facility,both,,,,839,839,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/<,7611310201,CDM,761,RC,13102,HCPCS,facility,both,,,,188,188,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COMPLEX WOUND SCALP 2.6 TO 7.5 CM,7611312101,CDM,761,RC,13121,HCPCS,facility,both,,,,1040,1040,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPLEX LAC 1.1 TO 2.5 CM,7611313101,CDM,761,RC,13131,HCPCS,facility,both,,,,570,570,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COMPLEX LAC 2.6 TO 7.5CM,7611313201,CDM,761,RC,13132,HCPCS,facility,both,,,,905,905,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,7611313301,CDM,761,RC,13133,HCPCS,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COMPLEX WOUND EYE/NOSE/EARS 1.1 TO 2.5CM,7611315101,CDM,761,RC,13151,HCPCS,facility,both,,,,791,791,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR COMPLEX WOUND EYE/NOSE/EARS 2.6 TO 7.5CM,7611315201,CDM,761,RC,13152,HCPCS,facility,both,,,,911,911,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADJNT TIS TRNSFR/REARGMT ANY AREA 30.1-60 SQ CM,7611430101,CDM,761,RC,14301,HCPCS,facility,both,,,,4692,4692,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PREP SITE F/S/N/H/F/G/M/D GT ADDL 100 SQ CM/1PCT,7611500201,CDM,761,RC,,,facility,both,,,,2364,2364,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PREP SITE TRUNK/ARM/LEG 1ST 100 SQ CM/1PCT,7611500202,CDM,761,RC,15002,HCPCS,facility,both,,,,2285,2285,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT,7611500401,CDM,761,RC,15004,HCPCS,facility,both,,,,741,741,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPLIT AGRFT T/A/L 1ST 100 CM/&/1% BDY INFT/CHLD,7611510001,CDM,761,RC,15100,HCPCS,facility,both,,,,1688,1688,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPLIT AGRFT T/A/L EA 100 CM/EA 1% BDY INFT/CHLD,7611510101,CDM,761,RC,15101,HCPCS,facility,both,,,,280,280,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1 %,7611512001,CDM,761,RC,15120,HCPCS,facility,both,,,,3676,3676,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPLIT AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 1 %,7611512101,CDM,761,RC,,,facility,both,,,,329,329,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F 20 CM/<,7611524001,CDM,761,RC,15240,HCPCS,facility,both,,,,2285,2285,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SKIN SUB GFT TRNK ARM LEG,7611527101,CDM,761,RC,15271,HCPCS,facility,both,,,,1958,1958,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SKIN SUB GFT TRNK ARM LEG ADD,7611527201,CDM,761,RC,15272,HCPCS,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APP SKN SUB GRFT T/A/L AREA/>100SCM 1ST 100SCM,7611527301,CDM,761,RC,,,facility,both,,,,4692,4692,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APP SKN SUB GRFT T/A/L AREA>/=100SCM ADL 100SQCM,7611527401,CDM,761,RC,,,facility,both,,,,100,100,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SKIN SUB GRAFT FACE/NK/HF/G,7611527501,CDM,761,RC,15275,HCPCS,facility,both,,,,2671,2671,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SKIN SUB GRAFT F/N/HF/G ADDL,7611527601,CDM,761,RC,15276,HCPCS,facility,both,,,,97,97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUB GRFT F/S/N/H/F/G/M/D >/= 100SCM 1ST 100SQ CM,7611527701,CDM,761,RC,,,facility,both,,,,2125,2125,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SUB GRFT F/S/N/H/F/G/M/D >/= 100SCM ADL 100SQ CM,7611527801,CDM,761,RC,,,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRESSING CHANGE WITH ANESTHESIA,7611585201,CDM,761,RC,,,facility,both,,,,1262,1262,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SUTURES OR STAPLES NOT REQUIRING ANESTHESIA,7611585301,CDM,761,RC,15853,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SUTURES OR STAPLES NOT REQUIRING ANESTHESIA,7611585301,CDM,761,RC,15853,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SUTURES AND STAPLES NOT REQUIRING ANESTHESIA,7611585401,CDM,761,RC,15854,HCPCS,facility,both,,,,126,126,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL SUTURES AND STAPLES NOT REQUIRING ANESTHESIA,7611585401,CDM,761,RC,15854,HCPCS,facility,both,,,,140,140,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX BURN CLINIC-TREAT BURN SMALL,7611602001,CDM,761,RC,16020,HCPCS,facility,both,,,,232,232,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX BURN CLINIC-TREAT BURN MEDIUM,7611602501,CDM,761,RC,16025,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX BURN CLINIC-TREAT BURN LARGE,7611603001,CDM,761,RC,,,facility,both,,,,517,517,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS INCISION OF BURN SCAB INIT,7611603501,CDM,761,RC,,,facility,both,,,,615,615,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESCHAROTOMY FIRST INCISION,7611603502,CDM,761,RC,,,facility,both,,,,451,451,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS ESCHAROTOMY ADDITIONAL INCISION,7611603601,CDM,761,RC,,,facility,both,,,,258,258,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ESCHAROTOMY EACH ADDITIONAL INCISION,7611603602,CDM,761,RC,,,facility,both,,,,236,236,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DESTRUCT 1ST BENIGN LESION,7611700001,CDM,761,RC,17000,HCPCS,facility,both,,,,211,211,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DESTRUCT BENIGN LESION 2-14,7611700301,CDM,761,RC,17003,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DESTRUCT BENIGN LESION 1 TO 14,7611711001,CDM,761,RC,17110,HCPCS,facility,both,,,,183,183,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMICAL CAUTERIZATION,7611725001,CDM,761,RC,17250,HCPCS,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 02 SAT NIR SKIN MUCOUS MEM OR SUBQ TISSUE,7611799901,CDM,761,RC,,,facility,both,,,,250,250,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OPEN BIOPSY OF BREAST,7611910101,CDM,761,RC,,,facility,both,,,,8343,8343,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISION OF CYST BREAST,7611912001,CDM,761,RC,19120,HCPCS,facility,both,,,,8622,8622,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST LOCAL DEVICE 1ST LESION WITH MRI GUIDE,7611928701,CDM,761,RC,19287,HCPCS,facility,both,,,,2471,2471,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BREAST LOCAL DEVICE ADDTL LESION WITH MRI GUIDE,7611928801,CDM,761,RC,,,facility,both,,,,335,335,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NIPPLE/AREOLA RECONSTRUCTION,7611935001,CDM,761,RC,,,facility,both,,,,13543,13543,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 02 SAT NIR BREAST,7611949901,CDM,761,RC,,,facility,both,,,,4532,4532,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION STEROID CARPAL TUN,7612052601,CDM,761,RC,20526,HCPCS,facility,both,,,,367,367,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION TENDON LIGAMENT,7612055001,CDM,761,RC,20550,HCPCS,facility,both,,,,474,474,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SINGLE TENDON ORIGIN/INSERTION,7612055101,CDM,761,RC,20551,HCPCS,facility,both,,,,711,711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES,7612055201,CDM,761,RC,20552,HCPCS,facility,both,,,,348,348,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRIGGER POINT INJ 3 + MUSCLE,7612055301,CDM,761,RC,20553,HCPCS,facility,both,,,,482,482,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX INJECTION ARTHROCENTESIS SMALL JT,7612060001,CDM,761,RC,20600,HCPCS,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECTION ARTHROCENTESIS INTERMEDIATE JT WITHOUT US,7612060501,CDM,761,RC,20605,HCPCS,facility,both,,,,389,389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US,7612060601,CDM,761,RC,20606,HCPCS,facility,both,,,,959,959,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX INJECTION ARTHROCENTESIS MAJOR JT WITHOUT US,7612061001,CDM,761,RC,20610,HCPCS,facility,both,,,,446,446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION INJECTION GANGLION CYST,7612061201,CDM,761,RC,,,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS APPLY REM FIXATION DEVICE,7612066001,CDM,761,RC,,,facility,both,,,,5659,5659,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RAD ONC HALO REMOVAL,7612066501,CDM,761,RC,,,facility,both,,,,1601,1601,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL IMPLANT  SUPERFICIAL,7612067001,CDM,761,RC,20670,HCPCS,facility,both,,,,1297,1297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 02 SAT NIR MUSCULOSKELETAL SYSTEM GENERAL,7612099901,CDM,761,RC,,,facility,both,,,,272,272,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PT SHOCKWAVE,7612099902,CDM,761,RC,20999,HCPCS,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2 CM/>,7612101201,CDM,761,RC,21012,HCPCS,facility,both,,,,4233,4233,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL <2CM,7612101301,CDM,761,RC,21013,HCPCS,facility,both,,,,4192,4192,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISION BENIGN TUMOR/CYST MANDIBLE ENCL & CURT,7612104001,CDM,761,RC,,,facility,both,,,,3751,3751,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TREATMENT NASAL FRACTURE W/STABILIZATION,7612132001,CDM,761,RC,21320,HCPCS,facility,both,,,,4304,4304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS CLOSED TX NOSE/JAW FX,7612134501,CDM,761,RC,,,facility,both,,,,2010,2010,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT CRANIOFACIAL FRACTURE,7612143101,CDM,761,RC,,,facility,both,,,,2258,2258,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREAT DENTAL RIDGE FRACTURE,7612144501,CDM,761,RC,21445,HCPCS,facility,both,,,,7887,7887,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS RESET DISLOCATED JAW,7612148501,CDM,761,RC,,,facility,both,,,,1785,1785,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY SOFT TISSUE NECK/THORAX,7612155001,CDM,761,RC,21550,HCPCS,facility,both,,,,1766,1766,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISION TUMOR SUBQ NECK THORAX,7612155501,CDM,761,RC,21555,HCPCS,facility,both,,,,1694,1694,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS CLOSED TX VERT FX W/O MANIP,7612231001,CDM,761,RC,,,facility,both,,,,880,880,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC 02 SAT NIR ABDOMEN, MUSCULOSKELETAL SYSTEM",7612299901,CDM,761,RC,,,facility,both,,,,272,272,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REMOVAL SHOULDER FOREIGN BODY DEEP,7612333301,CDM,761,RC,,,facility,both,,,,3406,3406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION,7612350001,CDM,761,RC,23500,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION,7612357001,CDM,761,RC,23570,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION,7612360001,CDM,761,RC,23600,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX GREATER HUMERAL TUBEROSITY FX W/O MANJ,7612362001,CDM,761,RC,23620,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ,7612366501,CDM,761,RC,23665,HCPCS,facility,both,,,,1656,1656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REMOVAL OF ARM FOREIGN BODY,7612420101,CDM,761,RC,,,facility,both,,,,7720,7720,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX HUMERAL SHAFT FX WITHOUT MAN,7612450001,CDM,761,RC,24500,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/WO MANJ,7612453001,CDM,761,RC,24530,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ,7612453501,CDM,761,RC,,,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MANJ,7612456001,CDM,761,RC,24560,HCPCS,facility,both,,,,435,435,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MANJ,7612457601,CDM,761,RC,24576,HCPCS,facility,both,,,,507,507,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,7612460001,CDM,761,RC,,,facility,both,,,,329,329,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION,7612465001,CDM,761,RC,24650,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION,7612465501,CDM,761,RC,,,facility,both,,,,1656,1656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ,7612467001,CDM,761,RC,24670,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ,7612467501,CDM,761,RC,24675,HCPCS,facility,both,,,,1656,1656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REMOVAL FOREARM FOREIGN BODY,7612524801,CDM,761,RC,,,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX RAD SHAFT WITHOUT,7612550001,CDM,761,RC,25500,HCPCS,facility,both,,,,381,381,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,7612553001,CDM,761,RC,25530,HCPCS,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION,7612553501,CDM,761,RC,,,facility,both,,,,490,490,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN,7612556001,CDM,761,RC,25560,HCPCS,facility,both,,,,367,367,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ,7612556501,CDM,761,RC,25565,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ,7612560001,CDM,761,RC,25600,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,7612560501,CDM,761,RC,25605,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX NAVICULAR WITHOUT MAN,7612562201,CDM,761,RC,25622,HCPCS,facility,both,,,,498,498,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX CARP SCAP WITHOUT,7612563001,CDM,761,RC,25630,HCPCS,facility,both,,,,428,428,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TREATMENT ULNAR STYLOID FRACTURE,7612565001,CDM,761,RC,25650,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX INCISION AND DRAINAGE FINGER ABSCESS SIMPLE,7612601101,CDM,761,RC,,,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISE FINGER TENDON SHEATH,7612605501,CDM,761,RC,26055,HCPCS,facility,both,,,,1892,1892,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHROTOMY WITH EXPLORE MCP,7612607501,CDM,761,RC,,,facility,both,,,,8663,8663,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA,7612608001,CDM,761,RC,,,facility,both,,,,3552,3552,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HB RECONST POLYDACT DIGIT SOFT TIS & BONE,7612658701,CDM,761,RC,26587,HCPCS,facility,both,,,,3928,3928,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX RDCRPL/INTERCARPL DISLC 1/> BONES W/MANJ,7612660001,CDM,761,RC,26600,HCPCS,facility,both,,,,580,580,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT HAND DISLOCATON,7612667501,CDM,761,RC,,,facility,both,,,,1892,1892,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSE RX PROX/MID FING SHFT FX,7612672001,CDM,761,RC,26720,HCPCS,facility,both,,,,247,247,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX ARTCLR FX INVG MTCRPHLNGL/IPHAL JT W/O MANJ,7612674001,CDM,761,RC,26740,HCPCS,facility,both,,,,374,374,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT FINGER DISLOCATION,7612677501,CDM,761,RC,,,facility,both,,,,688,688,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR,7612695101,CDM,761,RC,,,facility,both,,,,3366,3366,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REMOVE HIP FOREIGN BODY,7612708601,CDM,761,RC,,,facility,both,,,,3406,3406,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REMOVE HIP FOREIGN BODY DEEP,7612708701,CDM,761,RC,,,facility,both,,,,3925,3925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA,7612709601,CDM,761,RC,,,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLSD TX PELVIC RING FX W/O MANIPULATION,7612719701,CDM,761,RC,27197,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TREATMENT COCCYGEAL FRACTURE,7612720001,CDM,761,RC,27200,HCPCS,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX ACETABULUM HIP/SOCKT FX W/O MANJ,7612722001,CDM,761,RC,27220,HCPCS,facility,both,,,,416,416,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT THIGH FRACTURE,7612723201,CDM,761,RC,,,facility,both,,,,2342,2342,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REVISION OF UNSTABLE KNEECAP,7612724001,CDM,761,RC,,,facility,both,,,,2987,2987,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX GREATER TROCHANTERIC FX W/O MANJ,7612724601,CDM,761,RC,27246,HCPCS,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/O MANJ,7612750101,CDM,761,RC,,,facility,both,,,,495,495,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/O MANJ,7612750801,CDM,761,RC,27508,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MANJ,7612751001,CDM,761,RC,,,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX PATELLAR FRACTURE W/O MANIPULATION,7612752001,CDM,761,RC,27520,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX TIBIAL FX PROXIMAL W/O MANIPULATION,7612753001,CDM,761,RC,27530,HCPCS,facility,both,,,,371,371,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX INTERCONDYLAR SPI&/TUBRST FX KNE W/WO MAN,7612753801,CDM,761,RC,27538,HCPCS,facility,both,,,,580,580,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT KNEE DISLOCATION,7612755201,CDM,761,RC,27552,HCPCS,facility,both,,,,1941,1941,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA,7612756001,CDM,761,RC,,,facility,both,,,,329,329,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX TIBIAL FX WITHOUT MAN,7612775001,CDM,761,RC,27750,HCPCS,facility,both,,,,323,323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION,7612776001,CDM,761,RC,27760,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MANJ,7612776701,CDM,761,RC,27767,HCPCS,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS CLTX POST ANKLE FX,7612776702,CDM,761,RC,,,facility,both,,,,492,492,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS CLTX POST ANKLE FX W/MANIP,7612776801,CDM,761,RC,,,facility,both,,,,1656,1656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX PROX FIBULA/SHFT FX W/O MANJ,7612778001,CDM,761,RC,27780,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX PROX FIB WITHOUT MAN,7612778002,CDM,761,RC,,,facility,both,,,,502,502,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ,7612778601,CDM,761,RC,27786,HCPCS,facility,both,,,,333,333,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX DSTL FIBULAR FX LAT MALLS W/MANJ,7612778801,CDM,761,RC,27788,HCPCS,facility,both,,,,416,416,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANJ,7612780801,CDM,761,RC,27808,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,7612781001,CDM,761,RC,27810,HCPCS,facility,both,,,,1433,1433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX TRIMALLEOLAR ANKLE FX W/O MANIPULATION,7612781601,CDM,761,RC,,,facility,both,,,,356,356,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION,7612781801,CDM,761,RC,,,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MANJ,7612782401,CDM,761,RC,27824,HCPCS,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ,7612782501,CDM,761,RC,27825,HCPCS,facility,both,,,,1932,1932,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT ANKLE DISLOCATION,7612784201,CDM,761,RC,,,facility,both,,,,1656,1656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 02 SAT NIR LEG OR ANKLE,7612789901,CDM,761,RC,,,facility,both,,,,285,285,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX FB REMOVAL OF FOOT DEEP,7612819201,CDM,761,RC,,,facility,both,,,,2242,2242,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX CALCANEAL WITHOUT MAN,7612840001,CDM,761,RC,28400,HCPCS,facility,both,,,,426,426,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX TALUS WITHOUT MAN,7612843001,CDM,761,RC,28430,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX TARSAL WITHOUT EACH,7612845001,CDM,761,RC,28450,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX METATARSAL WITHOUT MAN,7612847001,CDM,761,RC,28470,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CLOSED TX GREAT TOE WITHOUT MAN,7612849001,CDM,761,RC,28490,HCPCS,facility,both,,,,240,240,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ,7612851001,CDM,761,RC,28510,HCPCS,facility,both,,,,326,326,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT TARSAL DISLOCATION,7612854501,CDM,761,RC,,,facility,both,,,,3925,3925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT TALO TARSAL DISLOCATION,7612857501,CDM,761,RC,,,facility,both,,,,3925,3925,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES,7612860001,CDM,761,RC,,,facility,both,,,,320,320,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS TREAT TARSOMETATARSAL DISLOCATION,7612860501,CDM,761,RC,,,facility,both,,,,783,783,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AMPUTATION TOE INTERPHALANGEAL JOINT,7612882501,CDM,761,RC,,,facility,both,,,,5008,5008,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC 02 SAT NIR FOOT OR TOES,7612889901,CDM,761,RC,,,facility,both,,,,285,285,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY LONG ARM CAST,7612906501,CDM,761,RC,29065,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY SHORT ARM CAST,7612907501,CDM,761,RC,29075,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY LONG ARM SPLINT,7612910501,CDM,761,RC,29105,HCPCS,facility,both,,,,181,181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY SHORT ARM SPLINT,7612912501,CDM,761,RC,29125,HCPCS,facility,both,,,,181,181,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS APPLY FOREARM SPLINT,7612912601,CDM,761,RC,,,facility,both,,,,149,149,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLY FINGER SPLINT,7612913001,CDM,761,RC,,,facility,both,,,,209,209,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY LONG LEG CAST,7612934501,CDM,761,RC,29345,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLY LONG LEG WALKING CAST,7612935501,CDM,761,RC,29355,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAST CYLINDER SYNTHETIC,7612936501,CDM,761,RC,,,facility,both,,,,729,729,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY SHORT LEG CAST,7612940501,CDM,761,RC,29405,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY SHORT LEG WALKING CAST,7612942501,CDM,761,RC,29425,HCPCS,facility,both,,,,248,248,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY RIGID CONTACT CAST LEG,7612944501,CDM,761,RC,29445,HCPCS,facility,both,,,,248,248,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY LONG LEG SPLINT,7612950501,CDM,761,RC,29505,HCPCS,facility,both,,,,187,187,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX APPLY SHORT LEG SPLINT,7612951501,CDM,761,RC,29515,HCPCS,facility,both,,,,143,143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM,7613002001,CDM,761,RC,30020,HCPCS,facility,both,,,,535,535,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY INTRANASAL,7613010001,CDM,761,RC,30100,HCPCS,facility,both,,,,3455,3455,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FB REMOVAL INTRANASAL,7613030001,CDM,761,RC,,,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONTRL NASAL HEMORRHAGE SIMPLE,7613090101,CDM,761,RC,30901,HCPCS,facility,both,,,,112,112,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CTRL NOSEBLEED,ANTER,SIMPLE",7613090102,CDM,761,RC,,,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC CTRL NOSEBLEED,ANTER,SIMPLE",7613090103,CDM,761,RC,,,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX,7613090301,CDM,761,RC,30903,HCPCS,facility,both,,,,177,177,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST,7613090501,CDM,761,RC,,,facility,both,,,,291,291,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NASAL ENDOSCOPY DX,7613123101,CDM,761,RC,31231,HCPCS,facility,both,,,,215,215,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NASAL/SINUS NDSC SURG W/BX POLYPECT/DBRDMT SPX,7613123701,CDM,761,RC,,,facility,both,,,,4939,4939,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS NASAL SINUS ENDOSCOPY,7613123801,CDM,761,RC,,,facility,both,,,,3026,3026,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT,7613150201,CDM,761,RC,31502,HCPCS,facility,both,,,,305,305,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY FLEX DIAGNOSTIC,7613157501,CDM,761,RC,31575,HCPCS,facility,both,,,,624,624,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY FLEXIBLE W/BIOPSY(IES),7613157601,CDM,761,RC,31576,HCPCS,facility,both,,,,4958,4958,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LARYNGOSCOPY WITH STROBOSCOPY,7613157901,CDM,761,RC,31579,HCPCS,facility,both,,,,745,745,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHEOSTOMY PLANNED,7613160001,CDM,761,RC,,,facility,both,,,,10459,10459,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACHEOBRONCH THROUGH TRACH,7613161501,CDM,761,RC,31615,HCPCS,facility,both,,,,1472,1472,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
BRNCHSC INCL FLUOR GDNCE DX W/CELL WASHG SPX,7613162201,CDM,761,RC,31622,HCPCS,facility,both,,,,5955,5955,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BRONCHOSCOPY,DIAGNOSTIC W LAVAGE",7613162401,CDM,761,RC,31624,HCPCS,facility,both,,,,2505,2505,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCHIAL ALVEOLAR LAVAGE,7613172001,CDM,761,RC,31720,HCPCS,facility,both,,,,315,315,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT PLASTIC REPAIR,7613182001,CDM,761,RC,31820,HCPCS,facility,both,,,,9911,9911,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRACH TAKEDOWN OR DOWNSIZE,7613189901,CDM,761,RC,31899,HCPCS,facility,both,,,,277,277,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL NDWELLG TUNNELED PLEURAL CATHETER W/CUFF,7613255201,CDM,761,RC,32552,HCPCS,facility,both,,,,4331,4331,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACENTESIS WO IMAGE GUIDANCE,7613255401,CDM,761,RC,,,facility,both,,,,1600,1600,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORSC DX LUNGS/PERICAR/MED/PLEURAL SPACE W/O BX,7613260101,CDM,761,RC,,,facility,both,,,,18736,18736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACOSCOPY WITH BIOPSYIES OF PLEURA,7613260901,CDM,761,RC,,,facility,both,,,,18736,18736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACOSCOPY W/PLEURODESIS,7613265001,CDM,761,RC,,,facility,both,,,,18736,18736,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACOSCOPY W/PARTIAL PULMONARY DECORTICATION,7613265101,CDM,761,RC,,,facility,both,,,,22483,22483,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,7613325501,CDM,761,RC,,,facility,both,,,,3183,3183,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECMO INITIAL DAY VV,7613394601,CDM,761,RC,33946,HCPCS,facility,both,,,,4675,4675,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECMO INITIAL DAY VA,7613394701,CDM,761,RC,33947,HCPCS,facility,both,,,,4675,4675,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECMO SUBSEQUENT DAY VV,7613394801,CDM,761,RC,33948,HCPCS,facility,both,,,,3099,3099,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECMO SUBSEQUENT DAY VA,7613394901,CDM,761,RC,33949,HCPCS,facility,both,,,,3099,3099,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ECMO/ECLS RMVL OF PRPH CANNULA PRQ 6 YRS & OLDER,7613396601,CDM,761,RC,33966,HCPCS,facility,both,,,,2390,2390,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX PL CATH ART 2ND BELOW DIA,7613624601,CDM,761,RC,,,facility,both,,,,1372,1372,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX SUP MESENT ARTERY 3RD ORDER,7613624701,CDM,761,RC,36247,HCPCS,facility,both,,,,2065,2065,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RENAL ANGIO BILATERAL 2 AND UP,7613625401,CDM,761,RC,,,facility,both,,,,5882,5882,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VNPNXR <3 YEARS PHYS/QHP SKILL SCALP VEIN,7613640501,CDM,761,RC,36405,HCPCS,facility,both,,,,29,29,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VNPNXR <3 YEARS PHYS/QHP SKILL OTHER VEIN,7613640601,CDM,761,RC,36406,HCPCS,facility,both,,,,26,26,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NON ROUTINE BLOOD DRAW,7613641001,CDM,761,RC,36410,HCPCS,facility,both,,,,23,23,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX COLLECT CAP BLD SPEC,7613641601,CDM,761,RC,36416,HCPCS,facility,both,,,,48,48,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS INSERTION OF CATHETER VEIN,7613651001,CDM,761,RC,,,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PHOTOPHERESIS,7613652201,CDM,761,RC,36522,HCPCS,facility,both,,,,8010,8010,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PICC W/O IMG GDN LESS THAN 5 YR,7613656801,CDM,761,RC,,,facility,both,,,,3019,3019,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERTION PICC W/O IMG GDN GREATER THAN 5 YR,7613656901,CDM,761,RC,36569,HCPCS,facility,both,,,,2248,2248,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DECLOTTING CATH/ACCESS DEVICE,7613659301,CDM,761,RC,36593,HCPCS,facility,both,,,,605,605,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS WITHDRAWAL OF ARTERIAL BLOOD,7613660001,CDM,761,RC,,,facility,both,,,,210,210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS INSERTION CATHETER ARTERY,7613662501,CDM,761,RC,,,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS INSERTION CATHETER ARTERY NEWBORN,7613666001,CDM,761,RC,,,facility,both,,,,233,233,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVC FILTER REPOSITIONING,7613719201,CDM,761,RC,,,facility,both,,,,5210,5210,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IVC FILTER REPOSITIONING,7613719201,CDM,761,RC,,,facility,both,,,,3073,3073,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBOLYTIC ART THER INITIAL,7613721101,CDM,761,RC,37211,HCPCS,facility,both,,,,6800,6800,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBOLYTIC VEN THER INITIAL,7613721201,CDM,761,RC,37212,HCPCS,facility,both,,,,3527,3527,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THROMBOLYTIC THER SUBSEQUENTIAL,7613721301,CDM,761,RC,37213,HCPCS,facility,both,,,,3403,3403,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ILIAC STENT EACH ADDTL,7613722301,CDM,761,RC,,,facility,both,,,,6595,6595,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FEM/POP STENT AND ATHRECTOMY,7613722701,CDM,761,RC,37227,HCPCS,facility,both,,,,24247,24247,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTERNAL CAROTID ANGIOGRAPHY W/O BSE PROCEDURE,7613779901,CDM,761,RC,37799,HCPCS,facility,both,,,,3653,3653,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTO TRNSPL CRYO/STORE CELL,7613820701,CDM,761,RC,38207,HCPCS,facility,both,,,,3047,3047,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTO TRNSPL THAW CELL WO WASH,7613820801,CDM,761,RC,38208,HCPCS,facility,both,,,,1630,1630,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTO TRNSPL PLASMA DEPLETN,7613821401,CDM,761,RC,38214,HCPCS,facility,both,,,,3446,3446,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC BONE MARROW ASPIRATION,7613822001,CDM,761,RC,38220,HCPCS,facility,both,,,,1440,1440,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAGNOSTIC BONE MARROW BIOPSY,7613822101,CDM,761,RC,38221,HCPCS,facility,both,,,,3193,3193,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRNSPL ALLO SCT BMT,7613824001,CDM,761,RC,38240,HCPCS,facility,both,,,,44370.34,44370.34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRNSPL AUTO SCT BMT,7613824101,CDM,761,RC,38241,HCPCS,facility,both,,,,5103.97,5103.97,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRNSPL ALLO SCT BMT LYMPH INF,7613824201,CDM,761,RC,38242,HCPCS,facility,both,,,,2751.65,2751.65,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXC BIOPSY LYMPH NODES,7613850001,CDM,761,RC,38500,HCPCS,facility,both,,,,3922,3922,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF LIP,7614049001,CDM,761,RC,40490,HCPCS,facility,both,,,,294,294,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR LIP FULL THICKNESS,7614065001,CDM,761,RC,,,facility,both,,,,835,835,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REPAIR LIP,7614065201,CDM,761,RC,,,facility,both,,,,718,718,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR LIP FULL/COMPLEX,7614065401,CDM,761,RC,,,facility,both,,,,1608,1608,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D ABSCESS DENTOALVEOLAR,7614080001,CDM,761,RC,40800,HCPCS,facility,both,,,,692,692,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN MOUTH ABSC/CYST/HEMAT,COMPLX",7614080101,CDM,761,RC,,,facility,both,,,,604,604,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REMVL IMBED FB MOUTH,7614080401,CDM,761,RC,,,facility,both,,,,1115,1115,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REMOVAL FOREIGN BODY MOUTH,7614080501,CDM,761,RC,,,facility,both,,,,730,730,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF MOUTH LESION,7614080801,CDM,761,RC,40808,HCPCS,facility,both,,,,650,650,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF MOUTH LESION,7614080802,CDM,761,RC,,,facility,both,,,,960,960,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISION OF MOUTH LESION,7614081001,CDM,761,RC,,,facility,both,,,,4716,4716,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXCISE/REPAIR MOUTH LESION,7614081201,CDM,761,RC,,,facility,both,,,,4716,4716,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC EXCISE/REPAIR MOUTH LESION, COMPLEX",7614081401,CDM,761,RC,,,facility,both,,,,4716,4716,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSURE LAC VEST<2.5CM,7614083001,CDM,761,RC,,,facility,both,,,,376,376,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSURE LAC VEST>2.5CM,7614083101,CDM,761,RC,,,facility,both,,,,974,974,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAORAL I&D ABSCESS,7614100001,CDM,761,RC,41000,HCPCS,facility,both,,,,719,719,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAINAGE OF MOUTH LESION, SUBLING DEEP",7614100601,CDM,761,RC,,,facility,both,,,,1797,1797,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAORAL I&D SUBMENTAL,7614100701,CDM,761,RC,,,facility,both,,,,2253,2253,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTRAORAL I&D SUBMANDIBULAR,7614100801,CDM,761,RC,41008,HCPCS,facility,both,,,,2790,2790,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS INTRAORAL I&D TONGUE,7614100901,CDM,761,RC,,,facility,both,,,,804,804,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INCISION OF TONGUE,7614101001,CDM,761,RC,41010,HCPCS,facility,both,,,,1886,1886,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF MOUTH LESION SUBLINGUAL,7614101501,CDM,761,RC,,,facility,both,,,,835,835,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXTRAORAL I&D SUBMENTAL,7614101601,CDM,761,RC,,,facility,both,,,,9202,9202,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF MOUTH LESION SUBMNDB,7614101701,CDM,761,RC,,,facility,both,,,,3459,3459,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF MOUTH LESION MASTICATOR SPACE,7614101801,CDM,761,RC,,,facility,both,,,,2407,2407,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC BIOPSY TONGUE, ANTER 2/3",7614110001,CDM,761,RC,41100,HCPCS,facility,both,,,,1238,1238,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY TONGUE POSTERIOR ONE-THIRD,7614110501,CDM,761,RC,41105,HCPCS,facility,both,,,,8716,8716,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BS BIOPSY FLOOR MOUTH,7614110801,CDM,761,RC,41108,HCPCS,facility,both,,,,5604,5604,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXC LESION TONGUE W/CLSR ANTERIOR TWO-THIRDS,7614111201,CDM,761,RC,,,facility,both,,,,3253,3253,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR LAC TONGUE,7614125001,CDM,761,RC,,,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR ONE-THIRD TONGUE,7614125101,CDM,761,RC,,,facility,both,,,,379,379,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR LAC TONGUE>2.6CM,7614125201,CDM,761,RC,,,facility,both,,,,322,322,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLOSED BIOPSY OF THE TONGUE,7614159901,CDM,761,RC,,,facility,both,,,,1383,1383,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,7614180001,CDM,761,RC,41800,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL OF GUM TISSUE,7614183001,CDM,761,RC,,,facility,both,,,,4662,4662,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALVEOLOPLASTY EACH QUADRANT SPECIFY,7614187401,CDM,761,RC,41874,HCPCS,facility,both,,,,10122,10122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED TOOTH 1-3 EXTRACTIONS,7614189901,CDM,761,RC,41899,HCPCS,facility,both,,,,465,465,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED TOOTH 10-12 EXTRACTIONS,7614189902,CDM,761,RC,41899,HCPCS,facility,both,,,,1832,1832,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED TOOTH 4-6 EXTRACTIONS,7614189903,CDM,761,RC,41899,HCPCS,facility,both,,,,698,698,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED TOOTH 7-9 EXTRACTIONS,7614189904,CDM,761,RC,41899,HCPCS,facility,both,,,,1047,1047,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAIN ABSCESS PALATE,7614200001,CDM,761,RC,,,facility,both,,,,251,251,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY PALATE/UVULA,7614210001,CDM,761,RC,,,facility,both,,,,3065,3065,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR PALATE LAC UP TO 2CM,7614218001,CDM,761,RC,,,facility,both,,,,634,634,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REPAIR LACERATION PALATE,7614218201,CDM,761,RC,,,facility,both,,,,8109,8109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC DRAIN ABSCESS PAROTID,SIMPLE",7614230001,CDM,761,RC,,,facility,both,,,,3109,3109,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL OF SALIVARY STONE,7614233001,CDM,761,RC,42330,HCPCS,facility,both,,,,3253,3253,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY SALIVARY GLAND INCISIONAL,7614240501,CDM,761,RC,,,facility,both,,,,1829,1829,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX I&D PERITONSILLAR ABSC,7614270001,CDM,761,RC,42700,HCPCS,facility,both,,,,600,600,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE THROAT ABSCESS,7614272001,CDM,761,RC,,,facility,both,,,,4389,4389,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC  BIOPSY OROPHARYNX,7614280001,CDM,761,RC,42800,HCPCS,facility,both,,,,1391,1391,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ASPIRATION PERITONSILLAR ABSCESS,7614299901,CDM,761,RC,,,facility,both,,,,895,895,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS PRESSURE TREATMENT ESOPHAGUS,7614346001,CDM,761,RC,,,facility,both,,,,683,683,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,7614376201,CDM,761,RC,,,facility,both,,,,581,581,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX STOMACH SURGERY PROCEDURE,7614399901,CDM,761,RC,,,facility,both,,,,1899,1899,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IR-GI TUBE PLACE FECAL TRANPLT,7614479901,CDM,761,RC,,,facility,both,,,,1118,1118,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX GI COLONIC STENT PLACEMENT,7614479902,CDM,761,RC,,,facility,both,,,,1571,1571,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF RECTUM,7614510001,CDM,761,RC,,,facility,both,,,,6614,6614,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CLS COLCUT FIST TISSEEL INJ,7614539901,CDM,761,RC,,,facility,both,,,,2857,2857,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX I&D OF PERIANAL ABSCESS,7614605001,CDM,761,RC,46050,HCPCS,facility,both,,,,922,922,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX INCISION THROMB HEMORROID,7614608301,CDM,761,RC,46083,HCPCS,facility,both,,,,432,432,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX ANOSCOPY DX W OR WO SPEC,7614660001,CDM,761,RC,46600,HCPCS,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TPA INSTALLATION IN AN ABDOMINAL DRAIN,7614999901,CDM,761,RC,,,facility,both,,,,2714,2714,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ ILEAL COND/URETEROPYELGM,7615069001,CDM,761,RC,,,facility,both,,,,450,450,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS DRAIN BLADDER BY TROCAR/CATH,7615110101,CDM,761,RC,,,facility,both,,,,1268,1268,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BLDR IRRIGATION SMPL LAVAGE &/INSTLJ,7615170001,CDM,761,RC,51700,HCPCS,facility,both,,,,264,264,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERMITTENT CATH PROCEDURE,7615170101,CDM,761,RC,51701,HCPCS,facility,both,,,,175,175,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERMITTENT CATH PROCEDURE,7615170101,CDM,761,RC,51701,HCPCS,facility,both,,,,193,193,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FOLEY CATH INSERT,7615170201,CDM,761,RC,51702,HCPCS,facility,both,,,,144,144,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHANGE OF BLADDER TUBE,7615171001,CDM,761,RC,,,facility,both,,,,1003,1003,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTOURETHROSCOPY,7615200001,CDM,761,RC,,,facility,both,,,,1447,1447,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTOURETHROSCOPY,7615200002,CDM,761,RC,52000,HCPCS,facility,both,,,,1321,1321,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,7615228101,CDM,761,RC,,,facility,both,,,,2482,2482,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTO W/SIMPLE REMOVAL STONE & STENT,7615231001,CDM,761,RC,,,facility,both,,,,2320,2320,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYSTO W/INSERT URETERAL STENT,7615233201,CDM,761,RC,52332,HCPCS,facility,both,,,,10765,10765,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTRJ LESION PENIS SIMPLE CRYOSURGERY,7615405601,CDM,761,RC,54056,HCPCS,facility,both,,,,598,598,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS REMOVAL OF SCROTUM LESION,7615512001,CDM,761,RC,,,facility,both,,,,2482,2482,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TRANSPERINEAL PLMT OF  BIODEGRABLE MATERIAL,7615587401,CDM,761,RC,,,facility,both,,,,9744,9744,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SPLIT BILLED I&D VULVA/PERINEAL ABS,7615640501,CDM,761,RC,56405,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC I&D BARTHOLIN GLAND ABCESS,7615642001,CDM,761,RC,56420,HCPCS,facility,both,,,,404,404,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DSTRCT VULVA LESION SIMPLE,7615650101,CDM,761,RC,56501,HCPCS,facility,both,,,,3458,3458,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF VULVA LESION SINGLE,7615660501,CDM,761,RC,56605,HCPCS,facility,both,,,,882,882,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BX VULVA EACH ADDTL LESION,7615660601,CDM,761,RC,56606,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXAM OF VULVA WITH SCOPE,7615682001,CDM,761,RC,56820,HCPCS,facility,both,,,,174,174,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EXAM BIOPSY VULVA WITH SCOPE,7615682101,CDM,761,RC,56821,HCPCS,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEST VAGINAL LESION SINGLE,7615706101,CDM,761,RC,,,facility,both,,,,5951,5951,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY VAGINA SIMPLE,7615710001,CDM,761,RC,57100,HCPCS,facility,both,,,,789,789,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIOPSY OF VAGINA EXTENSIVE,7615710501,CDM,761,RC,,,facility,both,,,,9433,9433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT VAG RAD APPARATUS BRACH,7615715601,CDM,761,RC,57156,HCPCS,facility,both,,,,988,988,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INSERT PESSARY OTHER DEVICE,7615716001,CDM,761,RC,57160,HCPCS,facility,both,,,,228,228,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FITTING DIAPHRAGM CAP,7615717001,CDM,761,RC,,,facility,both,,,,234,234,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLPOSCOPY ENTIRE VAG WITH CERVI,7615742001,CDM,761,RC,57420,HCPCS,facility,both,,,,567,567,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLP OF VAGINA WITH CERVIX WITH BIO,7615742101,CDM,761,RC,57421,HCPCS,facility,both,,,,677,677,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLP CERVIX INCLUDE UP VAGINA,7615745201,CDM,761,RC,57452,HCPCS,facility,both,,,,229,229,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLP CERVIX WITH BX CUT,7615745401,CDM,761,RC,57454,HCPCS,facility,both,,,,351,351,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLP CERVIX WITH VAGINA AND BX,7615745501,CDM,761,RC,57455,HCPCS,facility,both,,,,405,405,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLPOSCOPY  ENDOCERV CURRETT,7615745601,CDM,761,RC,57456,HCPCS,facility,both,,,,516,516,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLP CERV UP VAG WITH BX,7615746001,CDM,761,RC,57460,HCPCS,facility,both,,,,9656,9656,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COLP CERVIX UP WITH LOOP,7615746101,CDM,761,RC,57461,HCPCS,facility,both,,,,3418,3418,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CERVIX BIOPSY SINGLE/MULTIPLE,7615750001,CDM,761,RC,57500,HCPCS,facility,both,,,,882,882,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOCERVICAL CURETTAGE,7615750501,CDM,761,RC,57505,HCPCS,facility,both,,,,882,882,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CYROCAUTERY CERVIX INTL REPEAT,7615751101,CDM,761,RC,,,facility,both,,,,433,433,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CONIZATION CERVIX LOOP ELECT,7615752201,CDM,761,RC,,,facility,both,,,,8184,8184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOMETRIAL BIOPSY,7615810001,CDM,761,RC,58100,HCPCS,facility,both,,,,237,237,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENDOMETRIAL SAMPLING,7615811001,CDM,761,RC,,,facility,both,,,,304,304,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IUD INSERTION,7615830001,CDM,761,RC,58300,HCPCS,facility,both,,,,59,59,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOVAL IUD,7615830101,CDM,761,RC,58301,HCPCS,facility,both,,,,327,327,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HYSTEROSCOPY BIOPSY,7615855801,CDM,761,RC,58558,HCPCS,facility,both,,,,8813,8813,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HYSTEROSCOPY REMOVAL IMPACTED FOREIGN BODY,7615856201,CDM,761,RC,58562,HCPCS,facility,both,,,,628,628,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CERCLAGE REMOVAL WITHOUT ANES,7615899901,CDM,761,RC,58999,HCPCS,facility,both,,,,2518,2518,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EPISIOTOMY OR VAGINAL REPAIR,7615930001,CDM,761,RC,59300,HCPCS,facility,both,,,,3306,3306,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX MISSED ABORTION FIRST TRIMESTER SURGICAL,7615982001,CDM,761,RC,,,facility,both,,,,3195,3195,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX MISSED ABORTION SECOND TRIMESTER SURGICAL,7615982101,CDM,761,RC,,,facility,both,,,,3727,3727,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS ASP AND/OR INJECT THYROID CYST,7616030001,CDM,761,RC,,,facility,both,,,,2089,2089,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
BURR HOLE W/ASPIR HEMATOMA/CYST INTRACEREBRAL,7616115601,CDM,761,RC,,,facility,both,,,,12862,12862,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX LUMBAR PUNCTURE DIAGNOSTIC,7616227001,CDM,761,RC,62270,HCPCS,facility,both,,,,871,871,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THERAPEUTIC SPINAL PUNCTURE,7616227201,CDM,761,RC,62272,HCPCS,facility,both,,,,761,761,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ NEUROLYTIC CERVICAL THORACIC,7616228101,CDM,761,RC,,,facility,both,,,,2827,2827,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ NEUROLYTIC LUMBAR SACRAL,7616228201,CDM,761,RC,,,facility,both,,,,1938,1938,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE",7616440501,CDM,761,RC,64405,HCPCS,facility,both,,,,657,657,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE",7616440501,CDM,761,RC,64405,HCPCS,facility,both,,,,730,730,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS N BLOCK INJ VAGUS,7616440801,CDM,761,RC,,,facility,both,,,,359,359,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS N BLOCK INJ BRACHIAL PLEXUS,7616441501,CDM,761,RC,,,facility,both,,,,2383,2383,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS",7616441502,CDM,761,RC,,,facility,both,,,,1768,1768,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS N BLOCK INJ AXILLARY,7616441701,CDM,761,RC,,,facility,both,,,,2331,2331,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS N BLOCK INJ ILIO-ING/HYPOGI,7616442501,CDM,761,RC,,,facility,both,,,,2349,2349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS N BLOCK INJ PUDENDAL,7616443001,CDM,761,RC,,,facility,both,,,,1288,1288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",7616445001,CDM,761,RC,64450,HCPCS,facility,both,,,,885,885,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX AA&/STRD TFRML EPI CERVICAL/THORACIC 1 LEVEL,7616447901,CDM,761,RC,64479,HCPCS,facility,both,,,,1114,1114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS INJ FORAMEN EPIDURAL L/S,7616448301,CDM,761,RC,,,facility,both,,,,1288,1288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL,7616448302,CDM,761,RC,64483,HCPCS,facility,both,,,,1114,1114,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV,7616448401,CDM,761,RC,64484,HCPCS,facility,both,,,,1048,1048,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL,7616449001,CDM,761,RC,,,facility,both,,,,3259,3259,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX INJ FACET JT LUMB SACR SINGLE,7616449301,CDM,761,RC,,,facility,both,,,,3387,3387,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX INJ FACET JT LUMB SACR EA ADDTL,7616449401,CDM,761,RC,,,facility,both,,,,3323,3323,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INJ ANESTHETIC AGENT STELLATE GANGLION BLOCK,7616451001,CDM,761,RC,,,facility,both,,,,2521,2521,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERQ ELEC NRV FIELD STIMJ CRANIAL NRV W/O IMPLTJ,7616456701,CDM,761,RC,,,facility,both,,,,2711,2711,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERV SALIV GLANDS,7616461101,CDM,761,RC,64611,HCPCS,facility,both,,,,667,667,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL,7616461201,CDM,761,RC,64612,HCPCS,facility,both,,,,512,512,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE,7616461501,CDM,761,RC,64615,HCPCS,facility,both,,,,512,512,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA,7616461601,CDM,761,RC,64616,HCPCS,facility,both,,,,369,369,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE,7616464201,CDM,761,RC,64642,HCPCS,facility,both,,,,652,652,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE,7616464301,CDM,761,RC,64643,HCPCS,facility,both,,,,115,115,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES,7616464401,CDM,761,RC,64644,HCPCS,facility,both,,,,734,734,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES,7616464501,CDM,761,RC,64645,HCPCS,facility,both,,,,208,208,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES,7616464601,CDM,761,RC,64646,HCPCS,facility,both,,,,1258,1258,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL,7616472102,CDM,761,RC,64721,HCPCS,facility,both,,,,549.67,549.67,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNLISTED CHEMODENERVATION ECCRINE GLANDS OF EXTREMITIES,7616499905,CDM,761,RC,64999,HCPCS,facility,both,,,,868,868,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DRAINAGE OF EYELID ABSCESS,7616770001,CDM,761,RC,,,facility,both,,,,498,498,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX REMOVAL FOREIGN BODY EAR,7616920001,CDM,761,RC,69200,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX REMOVE IMPACT CERUMEN W INSTR,7616921001,CDM,761,RC,69210,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX GUIDE NEEDLE PLACE S&I,7617694201,CDM,761,RC,76942,HCPCS,facility,both,,,,530,530,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC GERD TST W/ MUCOS IMPEDE ELECTROD,>1HR",7619103801,CDM,761,RC,91038,HCPCS,facility,both,,,,1300,1300,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FUNDUS PHOTOGRAPHY W/INTERPRETATION & REPORT,7619225001,CDM,761,RC,,,facility,both,,,,400,400,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NASOPHARYNGOSCOPY W/ENDOSCOPE,7619251101,CDM,761,RC,92511,HCPCS,facility,both,,,,212,212,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CPR,7619295001,CDM,761,RC,92950,HCPCS,facility,both,,,,308,308,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX CARDIOVERSION,7619296001,CDM,761,RC,,,facility,both,,,,1016,1016,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX US ART PHYSIO EXAM LIMITED,7619392201,CDM,761,RC,,,facility,both,,,,349,349,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX US ART DOPPLER LOW EXTREMITY COMPLETE BILATERAL,7619392501,CDM,761,RC,,,facility,both,,,,612,612,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX US ART DOPPLER LOW EXTREMITY LIMITED OR UNILATERAL,7619392601,CDM,761,RC,,,facility,both,,,,846,846,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX US EXTREMITY DOPPLER COMPLETE BILATERAL,7619397001,CDM,761,RC,,,facility,both,,,,444,444,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX US VENOUS EXTREMITY LIMITED OR UNILATERAL,7619397101,CDM,761,RC,,,facility,both,,,,338,338,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TCOM WITHOUT ABI,7619399801,CDM,761,RC,,,facility,both,,,,110,110,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ANALYZE NEUROSTIM NO PROG,7619597001,CDM,761,RC,95970,HCPCS,facility,both,,,,380,380,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELEC ALYS IMPLT SMPL CN NPGT PRGRMG,7619597601,CDM,761,RC,95976,HCPCS,facility,both,,,,54,54,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELEC ALYS IMPLT CPLX CN NPGT PRGRMG,7619597701,CDM,761,RC,95977,HCPCS,facility,both,,,,154,154,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC ED OBS IV HYDRATION, INITIAL, 31 MIN TO 1 HR",7619636001,CDM,761,RC,,,facility,both,,,,314,314,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS IV INF THER/PROPH/DIAG INIT TO 1 HR,7619636501,CDM,761,RC,96365,HCPCS,facility,both,,,,561,561,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED OBS THER/PROPH/DIAG INJECTION SC/IM,7619637201,CDM,761,RC,,,facility,both,,,,152,152,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IRRIGATION IMPLANTED DEVICE,7619652301,CDM,761,RC,96523,HCPCS,facility,both,,,,93,93,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MCHNL SCLP COOL CAP SPLY HEAD MEAS FIT & EDU,7619700701,CDM,761,RC,,,facility,both,,,,5305,5305,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MCHNL SCLP COOL PREP PLMT,7619700801,CDM,761,RC,,,facility,both,,,,3183,3183,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MCHNL SCLP COOL AFTER CHEMO EACH 30 MINUTES,7619700901,CDM,761,RC,,,facility,both,,,,2122,2122,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEBRIDEMENT OPEN WOUND EA ADDL 20 SQ CM,7619759801,CDM,761,RC,97598,HCPCS,facility,both,,,,57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS,7619760201,CDM,761,RC,97602,HCPCS,facility,both,,,,214,214,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LOW FREQ NON CONTR/THERMAL,7619761001,CDM,761,RC,97610,HCPCS,facility,both,,,,578,578,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSTEOPATHIC MANIPULATIVE TX 1-2 BODY REGIONS,7619892501,CDM,761,RC,98925,HCPCS,facility,both,,,,58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OSTEOPATHIC MANIPULATIVE TX 3-4 BODY REGIONS,7619892601,CDM,761,RC,,,facility,both,,,,78,78,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLY TOPICAL FLUORIDE,7619918801,CDM,761,RC,99188,HCPCS,facility,both,,,,56,56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX EST PT OV BRIEF,7619921101,CDM,761,RC,,,facility,both,,,,284,284,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX EST PT OV PROB FOCUSED,7619921201,CDM,761,RC,,,facility,both,,,,408,408,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX EST PT OV LOW COMPLEX,7619921301,CDM,761,RC,99213,HCPCS,facility,both,,,,488,488,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX EST PT OV MOD COMPLEX,7619921401,CDM,761,RC,,,facility,both,,,,541,541,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX EST PT OV HIGH COMPLEX,7619921501,CDM,761,RC,,,facility,both,,,,692,692,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LOW COST SKIN SUB TRNK ARMS LEGS 1ST 25 SQ CM OR LESS,761C527101,CDM,761,RC,C5271,HCPCS,facility,both,,,,1112,1112,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LOW COST SKIN SUB TRNK, ARMS LEGS EACH ADD 25 SQ CM",761C527201,CDM,761,RC,,,facility,both,,,,1080,1080,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LOW COST SKIN SUB FACE, SCALP, NECK, GENITALIA, HANDS,  FEET  1ST M",761C527501,CDM,761,RC,,,facility,both,,,,1260,1260,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
"HC LOW COST SKIN SUB FACE, SCALP, NECK, GENITALIA, HANDS,  FEET  2ND M",761C527601,CDM,761,RC,,,facility,both,,,,1260,1260,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OBSTETRIC EST PT VISIT,761G046301,CDM,761,RC,G0463,HCPCS,facility,both,,,,594,594,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC AUTOLOGOUS PRP FOR DIABETIC CHRONIC WOUND/ULCERS PER TREATMENT,761G046501,CDM,761,RC,G0465,HCPCS,facility,both,,,,2195,2195,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BURN OBSERVATION PER HOUR,762G037801,CDM,762,RC,,,facility,both,,,,362,362,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BURN OBSERVATION PER HOUR CARVE OUT,762G037802,CDM,762,RC,G0378,HCPCS,facility,both,,,,362,362,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOSPITAL OBSERVATION PER HOUR,762G037805,CDM,762,RC,G0378,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOSPITAL OBSERVATION PER HOUR CARVE OUT,762G037806,CDM,762,RC,G0378,HCPCS,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERMEDIATE OBSERVATION PER HR,762G037807,CDM,762,RC,G0378,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERMEDIATE OBSERVATION PER HR CARVE OUT,762G037808,CDM,762,RC,G0378,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OBSTETRIC OBSERVATION PER HOUR,762G037809,CDM,762,RC,G0378,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OBSTETRIC OBSERVATION PER HOUR CARVE OUT,762G037810,CDM,762,RC,G0378,HCPCS,facility,both,,,,89,89,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PEDS INTERMEDIATE OBSERVATION PER HR,762G037811,CDM,762,RC,G0378,HCPCS,facility,both,,,,204,204,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PEDS INTERMEDIATE OBSERVATION PER HR CARVE OUT,762G037812,CDM,762,RC,G0378,HCPCS,facility,both,,,,204,204,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PEDS OBSERVATION PER HOUR,762G037813,CDM,762,RC,G0378,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PEDS OBSERVATION PER HOUR CARVE OUT,762G037814,CDM,762,RC,G0378,HCPCS,facility,both,,,,205,205,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOSPITAL AT HOME OBSERVATION PER HOUR,762G037815,CDM,762,RC,,,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HOSPITAL AT HOME OBSERVATION PER HOUR CARVE OUT,762G037816,CDM,762,RC,,,facility,both,,,,104,104,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OBSERVATION DIRECT ADMIT INITIAL,762G037901,CDM,762,RC,,,facility,both,,,,610,610,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRNCHSC REVJ TRACHEAL/BRNCL STENT INS PREV SESS,7690000005,CDM,769,RC,,,facility,both,,,,17337,17337,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH APC CNTRL BLEED,7690000006,CDM,769,RC,,,facility,both,,,,5365,5365,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH APC DEBULK TUMOR,7690000007,CDM,769,RC,,,facility,both,,,,5398,5398,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH DILATE W STENT,7690000008,CDM,769,RC,,,facility,both,,,,17337,17337,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH EBUS 1 TO 2 NODE,7690000009,CDM,769,RC,,,facility,both,,,,8881,8881,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH EBUS 3 OR MORE NODES,7690000010,CDM,769,RC,,,facility,both,,,,13322,13322,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH EBUS IVNTJ PERPH LES,7690000011,CDM,769,RC,,,facility,both,,,,3508,3508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH LUNG BX ADDTL,7690000012,CDM,769,RC,,,facility,both,,,,1920,1920,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH LUNG BX EACH,7690000013,CDM,769,RC,,,facility,both,,,,1898,1898,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH NEEDL BX ADDTL,7690000014,CDM,769,RC,,,facility,both,,,,1920,1920,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH NEEDLE BX EACH,7690000015,CDM,769,RC,,,facility,both,,,,1910,1910,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH THERMOPLASTY 1 LOBE,7690000016,CDM,769,RC,,,facility,both,,,,12676,12676,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH THRMOPLSTY 2 OR MORE LOBES,7690000017,CDM,769,RC,,,facility,both,,,,19013,19013,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH W/IBV ADDTL INSERT,7690000018,CDM,769,RC,,,facility,both,,,,2371,2371,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH W/IBV ADDTL REMOVAL,7690000019,CDM,769,RC,,,facility,both,,,,2471,2471,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH W/IBV INITIAL INSERT,7690000020,CDM,769,RC,,,facility,both,,,,12676,12676,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH W/IBV INITIAL REMOVAL,7690000021,CDM,769,RC,,,facility,both,,,,5199,5199,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH WITH BAL,7690000022,CDM,769,RC,,,facility,both,,,,1979,1979,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH WITH BIOPSY,7690000023,CDM,769,RC,,,facility,both,,,,1876,1876,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH WITH BRONCHIAL STENT,7690000024,CDM,769,RC,,,facility,both,,,,17337,17337,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH WITH BRONCHIAL STENT ADD ON,7690000025,CDM,769,RC,,,facility,both,,,,3467,3467,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH WITH BRUSHING,7690000026,CDM,769,RC,,,facility,both,,,,1876,1876,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH WITH FOREIGN BODY REMOVAL,7690000027,CDM,769,RC,,,facility,both,,,,2893,2893,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH WITH TRACH/BRONCH DIL,7690000028,CDM,769,RC,,,facility,both,,,,9661,9661,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCH WITH/WO FLUOR CELWASH,7690000029,CDM,769,RC,,,facility,both,,,,1991,1991,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCHOSCOPY BALLOON OCCLUSION,7690000030,CDM,769,RC,,,facility,both,,,,12676,12676,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCHOSCOPY LEVEL I PER MINUTE,7690000031,CDM,769,RC,,,facility,both,,,,61,61,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCHOSCOPY LEVEL II PER MINUTE,7690000032,CDM,769,RC,,,facility,both,,,,124,124,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCHOSCOPY LEVEL III PER MINUTE,7690000033,CDM,769,RC,,,facility,both,,,,149,149,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCHOSCOPY LEVEL IV PER MINUTE,7690000034,CDM,769,RC,,,facility,both,,,,179,179,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BRONCHOSCOPY W/EXCISION TUMOR,7690000035,CDM,769,RC,,,facility,both,,,,9254,9254,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ENB PROCEDURE,7690000036,CDM,769,RC,,,facility,both,,,,4067,4067,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PULM - BRONCH W/FIDUCIAL MARK PL,7690000041,CDM,769,RC,,,facility,both,,,,12676,12676,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN MODERNA SARSCOV2 50MCG/0.25ML VACCINE BOOSTER,7710064A01,CDM,771,RC,,,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IP ADMIN MODERNA SARSCOV2 50MCG/0.25ML VACCINE BOOSTER,7710064A02,CDM,771,RC,,,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ADMIN MODERNA SARSCOV2 50MCG/0.25ML VACCINE BOOSTER,7710064A03,CDM,771,RC,,,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN PFIZER SARSCOV2 10MCG/0.2ML TRIS-SUCROSE VACCINE PEDIATRIC 2E,7710072A01,CDM,771,RC,,,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN PFIZER SARSCOV2 10MCG/0.2ML TRIS-SUCROSE VACCINE PEDIATRIC 3E,7710073A01,CDM,771,RC,,,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IP ADMIN PFIZER SARSCOV2 10MCG/0.2ML TRIS-SUCROSE VACCINE PEDIATRIC BOOSTER,7710074A03,CDM,771,RC,,,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE ADMIN THRU 18YR INITIAL,7719046001,CDM,771,RC,90460,HCPCS,facility,both,,,,81,81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC VACCINE ADMIN THRU 18YR INITIAL,7719046002,CDM,771,RC,90460,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE ADMIN THRU 18YR EA ADDL,7719046101,CDM,771,RC,90461,HCPCS,facility,both,,,,30.28,30.28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC VACCINE ADMIN THRU 18YR EA ADDL,7719046102,CDM,771,RC,90461,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VACCINE ADMIN THRU 18 YR EA ADDL,7719046103,CDM,771,RC,,,facility,both,,,,35,35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN HEP B VACCINE,7719047101,CDM,771,RC,90471,HCPCS,facility,both,,,,66,66,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN INFLUENZA VACCINE,7719047102,CDM,771,RC,90471,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMIN PNEUMONIA VACCINE,7719047103,CDM,771,RC,90471,HCPCS,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED HEP B VACCINE ADMIN,7719047104,CDM,771,RC,90471,HCPCS,facility,both,,,,74,74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED INFLUENZA VACCINE ADMIN,7719047105,CDM,771,RC,90471,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED PNEUMOCOCCAL VACCINE ADMIN,7719047106,CDM,771,RC,90471,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VACCINE ADMIN SINGLE,7719047107,CDM,771,RC,90471,HCPCS,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PNEUMOCOCCAL VACCINE ADMIN,7719047108,CDM,771,RC,90471,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE ADMIN SINGLE,7719047109,CDM,771,RC,90471,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC ADMIN FLU VACCINE,7719047110,CDM,771,RC,90471,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC ADMIN HEP B VACCINE,7719047111,CDM,771,RC,,,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC ADMIN OF PNEUMO VACCINE,7719047113,CDM,771,RC,90471,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC VACCINE ADMIN SINGLE,7719047114,CDM,771,RC,90471,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED VACCINE ADMIN EACH ADDTL,7719047201,CDM,771,RC,90472,HCPCS,facility,both,,,,60.56,60.56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE ADMIN EACH ADDTL,7719047202,CDM,771,RC,90472,HCPCS,facility,both,,,,18,18,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC VACCINE ADMIN EACH ADDTL,7719047203,CDM,771,RC,90472,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VACCINE ADMIN INTRANASAL/ORAL SINGLE,7719047301,CDM,771,RC,90473,HCPCS,facility,both,,,,66,66,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC VACCINE ADMIN INTRANASAL/ORAL SINGLE,7719047302,CDM,771,RC,90473,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMM ADMN SARSCOV2 VACCINE SINGLE DOSE,7719048001,CDM,771,RC,90480,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IMM ADMN SARSCOV2 VACCINE SINGLE DOSE,7719048002,CDM,771,RC,90480,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IP IMM ADMN SARSCOV2 VACCINE SINGLE DOSE,7719048003,CDM,771,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC IMM ADMN SARSCOV2 VACCINE SINGLE DOSE,7719048004,CDM,771,RC,,,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC ED IMM ADMN SARSCOV2 VACCINE SINGLE DOSE,7719048005,CDM,771,RC,,,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMM ADMN SARSCOV2 VACCINE EACH ADDL COMPONENT,7719048101,CDM,771,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED IMM ADMN SARSCOV2 VACCINE EACH ADDL COMPONENT,7719048102,CDM,771,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IP IMM ADMN SARSCOV2 VACCINE EACH ADDL COMPONENT,7719048103,CDM,771,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC IMM ADMN SARSCOV2 VACCINE EACH ADDL COMPONENT,7719048104,CDM,771,RC,,,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX,7719638101,CDM,771,RC,96381,HCPCS,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ED ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX,7719638102,CDM,771,RC,96381,HCPCS,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IP ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX,7719638103,CDM,771,RC,,,facility,both,,,,90,90,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX,7719638104,CDM,771,RC,96381,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC ED ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX,7719638105,CDM,771,RC,96381,HCPCS,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VFC IP ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX,7719638106,CDM,771,RC,,,facility,both,,,,23.03,23.03,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC COVID-19 VACCINE HOME ADMIN,771M020101,CDM,771,RC,,,facility,both,,,,53,53,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TELEHEALTH FACILITY FEE,780Q301401,CDM,780,RC,Q3014,HCPCS,facility,both,,,,82,82,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEMODIALYSIS ADULT/PEDS INPATIENT,8019093501,CDM,801,RC,90935,HCPCS,facility,both,,,,939,939,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IP PD DIALYSIS CAPD,8030000001,CDM,803,RC,,,facility,both,,,,298,298,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IP PD DIALYSIS CCPD,8040000001,CDM,804,RC,90945,HCPCS,facility,both,,,,310,310,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC KIDNEY ACQUISITION LIVE DONOR,8110000001,CDM,811,RC,,,facility,both,,,NTX,135360,135360,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CADAVERIC KIDNEY ACQUISITION,8120000001,CDM,812,RC,,,facility,both,,,NTX,155157,155157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEART ACQUISITION,8120000002,CDM,812,RC,,,facility,both,,,,350357,350357,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LUNG ACQUISITION,8120000003,CDM,812,RC,,,facility,both,,,,256402,256402,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEART AND LUNG  ACQUISITION,8120000004,CDM,812,RC,,,facility,both,,,,107803.39,107803.39,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLO TRNSPL FRESH/STORE CELL,8150000001,CDM,815,RC,,,facility,both,,,,1759.5,1759.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT VENIPUNCTURE,8153641501,CDM,815,RC,,,facility,both,,,,11.74,11.74,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT BLOOD DRAW EXT CVA DEVICE,8153659201,CDM,815,RC,,,facility,both,,,,121.92,121.92,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT DECLOTTING CATH/ACCESS DEVICE,8153659301,CDM,815,RC,,,facility,both,,,,464.81,464.81,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLO TRNSPL CRYO/STORE CELL,8153820701,CDM,815,RC,38207,HCPCS,facility,both,,,,2497.5,2497.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT TRANSPL THAW CELL WO WASH,8153820801,CDM,815,RC,38208,HCPCS,facility,both,,,,1233,1233,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT ALLO TRNSPL THAW  WASH CELLS,8153820901,CDM,815,RC,,,facility,both,,,,1233,1233,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLO CD 3 ENUMERATION,8158635901,CDM,815,RC,86359,HCPCS,facility,both,,,,318,318,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLO STEM CELLS TOTAL CD34,8158636701,CDM,815,RC,86367,HCPCS,facility,both,,,,284.9,284.9,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT IV HYDRATION INFUSION INITIAL HOUR,8159636001,CDM,815,RC,,,facility,both,,,,216.9,216.9,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT IV HYDRATE ADDTL HOURS,8159636101,CDM,815,RC,,,facility,both,,,,121.35,121.35,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT IV INFUSION THERAPY UP TO 1 HR,8159636501,CDM,815,RC,,,facility,both,,,,318.71,318.71,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT IV INFUSION THERAPY EACH ADDTL HR,8159636601,CDM,815,RC,,,facility,both,,,,121.56,121.56,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT IV INFUSION ADDTL SEQUENTUAL UP TO 1 HR,8159636701,CDM,815,RC,,,facility,both,,,,197.13,197.13,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT ADMIN OF INJECTION SUBQ OR IM,8159637201,CDM,815,RC,,,facility,both,,,,152.44,152.44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT IV PUSH EACH ADDTL NEW SUBSTANCE,8159637501,CDM,815,RC,,,facility,both,,,,181.28,181.28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT IV PUSH SAME DRUG 30 MIN AFTER,8159637601,CDM,815,RC,,,facility,both,,,,181.28,181.28,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BMT OUTPT CLINIC VISIT,815G046303,CDM,815,RC,,,facility,both,,,,145,145,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC HEMODIALYSIS ADULT OUTPATIENT,829G025701,CDM,829,RC,G0257,HCPCS,facility,both,,,,939,939,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CAR-T THERAPY AUTOLOGOUS CELL ADMINISTRATION,8743822801,CDM,874,RC,38228,HCPCS,facility,both,,,,2843,2843,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NON ESRD DIALYSIS TREATMENT,8809093502,CDM,880,RC,,,facility,both,,,,938.36,938.36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCL/NRPSYCL TST ELEC PLATFORM AUTO RESULT,9059614601,CDM,905,RC,96146,HCPCS,facility,both,,,,96,96,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEUROBEHAVORIAL STATUS EX 1ST HOUR,9189611601,CDM,918,RC,96116,HCPCS,facility,both,,,,906,906,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT,9189612701,CDM,918,RC,96127,HCPCS,facility,both,,,,88,88,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP 1ST HOUR,9189613201,CDM,918,RC,96132,HCPCS,facility,both,,,,1529,1529,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP EA ADDL HR,9189613301,CDM,918,RC,96133,HCPCS,facility,both,,,,765,765,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYL/NRPSYCL TST PHYS/QHP 2+ TST 1ST 30 MIN,9189613601,CDM,918,RC,96136,HCPCS,facility,both,,,,367,367,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCL/NRPSYCL TST PHYS/QHP 2+ TST EA ADDL 30 MIN,9189613701,CDM,918,RC,96137,HCPCS,facility,both,,,,178,178,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCHL/NRPSYCL TST TECH 2+TST 1ST 30 MIN,9189613801,CDM,918,RC,96138,HCPCS,facility,both,,,,330,330,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PSYCHL/NRPSYCL TST TECH 2+TST EA ADDL 30 MIN,9189613901,CDM,918,RC,96139,HCPCS,facility,both,,,,85,85,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC URINARY REFLEX STUDY,9205179201,CDM,920,RC,51792,HCPCS,facility,both,,,,152,152,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC FETAL NON STRESS TEST,9205902501,CDM,920,RC,59025,HCPCS,facility,both,,,,191,191,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC GASTROESOPHO REFLX PROLON,9209103401,CDM,920,RC,91034,HCPCS,facility,both,,,,714,714,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LAB HYDROGEN BREATH TEST,9209106501,CDM,920,RC,91065,HCPCS,facility,both,,,,462,462,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC IMG RETINA DETCJ/MNTR DS REM PHYS/QHP I&R UNI/BI,9209222801,CDM,920,RC,92228,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMG EYE,9209226501,CDM,920,RC,92265,HCPCS,facility,both,,,,157,157,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THER ACTIVATION IMPL PHRENIC NRV STIMULATOR SYS,9209315001,CDM,920,RC,,,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROG&PRGRMG IMPL PHRENIC NRV STIMULATOR SYS,9209315101,CDM,920,RC,,,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROG&PRGRMG IPNSS DURING POLYSOMNOGRAPHY,9209315201,CDM,920,RC,,,facility,both,,,,807,807,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTERROGATION WITHOUT PROGRAMMING IPNSS,9209315301,CDM,920,RC,,,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC BIS EXTRACELLULAR FLUID ALYS LYMPHEDEMA ASSMNT,9209370201,CDM,920,RC,93702,HCPCS,facility,both,,,,235,235,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVAL THICKNESS CAROTID BILATERAL,9209389501,CDM,920,RC,,,facility,both,,,,412,412,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EVAL THICKNESS CAROTID BILATERAL,9209389501,CDM,920,RC,,,facility,both,,,,552,552,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SLEEP STUDY UNATTENDED,9209580001,CDM,920,RC,95800,HCPCS,facility,both,,,,237,237,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MULTIPLE SLEEP LATENCY TEST,9209580501,CDM,920,RC,95805,HCPCS,facility,both,,,,5143,5143,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PORTABLE HOME SLEEP TESTING,9209580601,CDM,920,RC,95806,HCPCS,facility,both,,,,627,627,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PORTABLE HOME SLEEP TESTING,9209580601,CDM,920,RC,95806,HCPCS,facility,both,,,,564,564,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NERVE CONDUCTION STUDIES 1-2 STUDIES,9209590701,CDM,920,RC,95907,HCPCS,facility,both,,,,489,489,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NERVE CONDUCTION STUDIES 3-4 STUDIES,9209590801,CDM,920,RC,95908,HCPCS,facility,both,,,,908,908,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NERVE CONDUCTION STUDIES 5-6 STUDIES,9209590901,CDM,920,RC,95909,HCPCS,facility,both,,,,908,908,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NERVE CONDUCTION STUDIES 7-8 STUDIES,9209591001,CDM,920,RC,95910,HCPCS,facility,both,,,,908,908,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VISUAL EVOKED RESPONSE,9209593001,CDM,920,RC,,,facility,both,,,,669,669,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEVELOPMENTAL SCREEN W/SCORING & DOC STD INSTRM,9209611001,CDM,920,RC,96110,HCPCS,facility,both,,,,24,24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DEVELOPMENTAL SCREEN W/SCORING & DOC STD INSTRM,9209611001,CDM,920,RC,96110,HCPCS,facility,both,,,,34,34,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US CAROTID DOPPLER COMPLETE BILATERAL,9219388001,CDM,921,RC,93880,HCPCS,facility,both,,,,373,373,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US CAROTID DOPPLER COMPLETE BILATERAL,9219388001,CDM,921,RC,93880,HCPCS,facility,both,,,,292,292,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US CAROTID DUPLEX LIMITED OR UNILATERAL,9219388201,CDM,921,RC,93882,HCPCS,facility,both,,,,302,302,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US CAROTID DUPLEX LIMITED OR UNILATERAL,9219388201,CDM,921,RC,93882,HCPCS,facility,both,,,,370,370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US TRANSCRANIAL DOPPLER COMPLETE,9219388601,CDM,921,RC,93886,HCPCS,facility,both,,,,377,377,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US TRANSCRANIAL DOPPLER LIMITED,9219388801,CDM,921,RC,93888,HCPCS,facility,both,,,,274,274,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART PHYSIO EXAM LIMITED,9219392201,CDM,921,RC,93922,HCPCS,facility,both,,,,297,297,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART PHYSIO EXAM LIMITED,9219392201,CDM,921,RC,93922,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART PHYSIO EXAM COMPLETE,9219392301,CDM,921,RC,93923,HCPCS,facility,both,,,,283,283,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART PHYSIO EXAM COMPLETE,9219392301,CDM,921,RC,93923,HCPCS,facility,both,,,,342,342,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART PHYSIO EXAM W EXERCISE,9219392401,CDM,921,RC,93924,HCPCS,facility,both,,,,296,296,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART PHYSIO EXAM W EXERCISE,9219392401,CDM,921,RC,93924,HCPCS,facility,both,,,,329,329,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART DOPPLER LOW EXTREMITY COMPLETE BILATERAL,9219392501,CDM,921,RC,93925,HCPCS,facility,both,,,,693,693,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART DOPPLER LOW EXTREMITY COMPLETE BILATERAL,9219392501,CDM,921,RC,93925,HCPCS,facility,both,,,,945,945,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART DOPPLER LOW EXTREMITY LIMITED OR UNILATERAL,9219392601,CDM,921,RC,93926,HCPCS,facility,both,,,,668,668,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART DOPPLER LOW EXTREMITY LIMITED OR UNILATERAL,9219392601,CDM,921,RC,93926,HCPCS,facility,both,,,,956,956,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART DOPPLER UP EXTREMITY COMPLETE BILATERAL,9219393001,CDM,921,RC,93930,HCPCS,facility,both,,,,688,688,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART DOPPLER UP EXTREMITY COMPLETE BILATERAL,9219393001,CDM,921,RC,93930,HCPCS,facility,both,,,,769,769,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART DOPPLER UP EXTREMITY LIMITED OR UNILATERAL,9219393101,CDM,921,RC,93931,HCPCS,facility,both,,,,570,570,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ART DOPPLER UP EXTREMITY LIMITED OR UNILATERAL,9219393101,CDM,921,RC,93931,HCPCS,facility,both,,,,702,702,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US EXTREMITY DOPPLER COMPLETE BILATERAL,9219397001,CDM,921,RC,93970,HCPCS,facility,both,,,,1134,1134,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US EXTREMITY DOPPLER COMPLETE BILATERAL,9219397001,CDM,921,RC,93970,HCPCS,facility,both,,,,800,800,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US VENOUS EXTREMITY LIMITED OR UNILATERAL,9219397101,CDM,921,RC,93971,HCPCS,facility,both,,,,611,611,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US VENOUS EXTREMITY LIMITED OR UNILATERAL,9219397101,CDM,921,RC,93971,HCPCS,facility,both,,,,940,940,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ABD RETRO ART/VEN DOP COMPLETE,9219397501,CDM,921,RC,93975,HCPCS,facility,both,,,,800,800,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US ABD RETRO ART/VEN DOP COMPLETE,9219397501,CDM,921,RC,93975,HCPCS,facility,both,,,,1121,1121,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DUPLEX ABD PELV RETRO LIMITED,9219397601,CDM,921,RC,93976,HCPCS,facility,both,,,,611,611,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DUPLEX ABD PELV RETRO LIMITED,9219397601,CDM,921,RC,93976,HCPCS,facility,both,,,,936,936,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DUPLEX AORTA IVC ILI BYPASS COMPLETE,9219397801,CDM,921,RC,93978,HCPCS,facility,both,,,,800,800,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DUPLEX AORTA IVC ILI BYPASS COMPLETE,9219397801,CDM,921,RC,93978,HCPCS,facility,both,,,,1099,1099,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DUPLEX AORTA IVC BYPASS LIMITED,9219397901,CDM,921,RC,93979,HCPCS,facility,both,,,,1267,1267,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US DUPLEX AORTA IVC BYPASS LIMITED,9219397901,CDM,921,RC,93979,HCPCS,facility,both,,,,754,754,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL,9219398001,CDM,921,RC,,,facility,both,,,,370,370,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DUPLEX SCAN ARTL INFL&VEN O/F HEMO COMPL BI STD,9219398501,CDM,921,RC,93985,HCPCS,facility,both,,,,508,508,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DUPLEX SCAN ARTL INFL&VEN O/F HEMO COMPL UNI STD,9219398601,CDM,921,RC,93986,HCPCS,facility,both,,,,227,227,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US HEMODIAL ACCESS DUPLEX DOPPLER,9219399001,CDM,921,RC,93990,HCPCS,facility,both,,,,288,288,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC US HEMODIAL ACCESS DUPLEX DOPPLER,9219399001,CDM,921,RC,93990,HCPCS,facility,both,,,,273,273,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMG-ANAL/URINA MUS SDY ANY TEQ,9225178501,CDM,922,RC,51785,HCPCS,facility,both,,,,618,618,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST ONE LIMB,9229586001,CDM,922,RC,95860,HCPCS,facility,both,,,,259,259,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST 2 LIMBS,9229586101,CDM,922,RC,95861,HCPCS,facility,both,,,,390,390,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST 3 LIMBS,9229586301,CDM,922,RC,,,facility,both,,,,442,442,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST 4 LIMBS,9229586401,CDM,922,RC,95864,HCPCS,facility,both,,,,477,477,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST LARYNX,9229586501,CDM,922,RC,95865,HCPCS,facility,both,,,,310,310,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST HEMIDIAPHRAGM,9229586601,CDM,922,RC,,,facility,both,,,,276,276,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST CRAN NERV UNILATERAL,9229586701,CDM,922,RC,95867,HCPCS,facility,both,,,,701,701,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST CRAN NERV BILATERAL,9229586801,CDM,922,RC,95868,HCPCS,facility,both,,,,921,921,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST THOR PARASPINAL,9229586901,CDM,922,RC,95869,HCPCS,facility,both,,,,701,701,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSCLE TEST NONPARASPINAL,9229587001,CDM,922,RC,95870,HCPCS,facility,both,,,,259,259,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEEDLE EMG GUID W/CHEMODENERVATION,9229587401,CDM,922,RC,95874,HCPCS,facility,both,,,,84,84,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSC TEST DONE WITH NERVE TEST LIMITED,9229588501,CDM,922,RC,,,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEEDLE EMG EA EXTREMITY W/PARASPINL AREA LIMITED,9229588502,CDM,922,RC,95885,HCPCS,facility,both,,,,94,94,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSC TEST DONE WITH NERVE TEST COMPLETE,9229588601,CDM,922,RC,95886,HCPCS,facility,both,,,,246,246,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MUSC TEST DONE WITH NERVE TEST NONEXT,9229588701,CDM,922,RC,95887,HCPCS,facility,both,,,,130,130,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ELECTRO-OCULOGRAPY W/INTERPRETATION & REPORT,9229590701,CDM,922,RC,,,facility,both,,,,417,417,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NERVE CONDUCTION STUDIES 3-4 STUDIES,9229590801,CDM,922,RC,,,facility,both,,,,987,987,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMG SER UPPER LIMB,9229592501,CDM,922,RC,95925,HCPCS,facility,both,,,,733,733,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMG EVOKED RESPONSE LOWER LIMB,9229592601,CDM,922,RC,,,facility,both,,,,733,733,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC EMG EVOKED RESPONSE TRUNK/HEAD,9229592701,CDM,922,RC,,,facility,both,,,,835,835,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CENT MOTOR EVOK POT UPPER LIMB,9229592801,CDM,922,RC,95928,HCPCS,facility,both,,,,1927,1927,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CENT MOTOR EVOK POT LOWER LIMB,9229592901,CDM,922,RC,,,facility,both,,,,1022,1022,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC SOMATOSENSORY UPPER AND LOWER LIMB,9229593801,CDM,922,RC,95938,HCPCS,facility,both,,,,1082,1082,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC C MOTOR EVOKD UPPER AND LOWER LIMB,9229593901,CDM,922,RC,95939,HCPCS,facility,both,,,,2040,2040,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METHACHOLINE INHALATION,9249507001,CDM,924,RC,95070,HCPCS,facility,both,,,,666,666,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLERGEN INJECTION SINGLE,9249511502,CDM,924,RC,,,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ALLERGEN INJECTION MULTIPLE,9249511702,CDM,924,RC,95117,HCPCS,facility,both,,,,106,106,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES,9402056001,CDM,940,RC,20560,HCPCS,facility,both,,,,42,42,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEEDLE INSERTION W/O INJECTION 3 OR MORE MUSCLES,9402056101,CDM,940,RC,20561,HCPCS,facility,both,,,,63,63,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PAD REHABILITATION PER SESSION,9409366801,CDM,940,RC,,,facility,both,,,,25,25,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RFL&MAIN IMPLT PMP/RSVR DLVR SPI/BRN PHY/QHP,9409599101,CDM,940,RC,,,facility,both,,,,1334,1334,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC APPLICATION OF BODY INJECTOR,9409637701,CDM,940,RC,96377,HCPCS,facility,both,,,,198,198,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OTH DEBRIDEMENT 20 SQ CM OR LESS,9409759701,CDM,940,RC,97597,HCPCS,facility,both,,,,184,184,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC RMVL DEVITAL TIS ADDL 20CM,9409759801,CDM,940,RC,97598,HCPCS,facility,both,,,,169,169,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEG PRESS WOUND TX LESS THAN OR EQUAL TO 50 SQ CM WITH DME,9409760501,CDM,940,RC,97605,HCPCS,facility,both,,,,266,266,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TX NEG PRESS WOUND TX GREATER THAN 50 SQ CM WITH DME,9409760601,CDM,940,RC,97606,HCPCS,facility,both,,,,404,404,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEG PRESS WOUND TX LESS THAN OR EQUAL TO 50 SQ CM WITH DISP,9409760701,CDM,940,RC,97607,HCPCS,facility,both,,,,351,351,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC NEG PRESS WOUND TX GREATER THAN 50 SQ CM WITH DISP,9409760801,CDM,940,RC,97608,HCPCS,facility,both,,,,439,439,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACUPUNCTURE W/O STIMUL 15 MIN,9409781001,CDM,940,RC,,,facility,both,,,,32,32,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACUPUNCTURE W/O STIMUL ADDL 15,9409781101,CDM,940,RC,,,facility,both,,,,22,22,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACUPUNCTURE W/STIMUL 15 MIN,9409781301,CDM,940,RC,,,facility,both,,,,30,30,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC ACUPUNCTURE W/ STIMUL ADDL 15,9409781401,CDM,940,RC,,,facility,both,,,,24,24,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC THERAPUTIC PHLEBOTOMY,9409919501,CDM,940,RC,99195,HCPCS,facility,both,,,,295,295,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRINCIPAL ILLNESS NAVIGATION 60 MINUTES PER MONTH,940G002301,CDM,940,RC,G0023,HCPCS,facility,both,,,,137,137,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRINCIPAL ILLNESS NAVIGATION ADDITIONAL 30 MINUTES PER MONTH,940G002401,CDM,940,RC,G0024,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METABOLIC WELLNESS 12 WEEKS,9420000001,CDM,942,RC,,,facility,both,,,,275,275,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC METABOLIC WELLNESS 6 WEEKS,9420000002,CDM,942,RC,,,facility,both,,,,137.5,137.5,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC POTS PROGRAM 12 WEEKS,9420000003,CDM,942,RC,,,facility,both,,,,350,350,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MNT INITIAL ASSMT EA 15 MINUTE,9429780201,CDM,942,RC,97802,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL MNT INITIAL ASSMT EA 15 MINUTES,9429780202,CDM,942,RC,97802,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MNT REASSESSMENT EA 15 MINUTES,9429780301,CDM,942,RC,97803,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL MNT REASSESSMENT EA 15 MINUTES,9429780302,CDM,942,RC,97803,HCPCS,facility,both,,,,45,45,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC MNT GROUP EACH 30 MINUTES,9429780401,CDM,942,RC,97804,HCPCS,facility,both,,,,40,40,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL MNT GROUP EACH 30 MINUTES,9429780402,CDM,942,RC,97804,HCPCS,facility,both,,,"PN,CR",37,37,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC REMOTE THERAPEUTIC MNTR 1ST SETUP&PT EDUCAJ EQP,9429897501,CDM,942,RC,,,facility,both,,,,295,295,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LACTATION COUNSELING 15 MINUTE,9429940101,CDM,942,RC,99401,HCPCS,facility,both,,,,186,186,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LACTATION COUNSELING 30 MINUTE,9429940201,CDM,942,RC,99402,HCPCS,facility,both,,,,207,207,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LACTATION COUNSELING 45 MINUTE,9429940301,CDM,942,RC,99403,HCPCS,facility,both,,,,228,228,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LACTATION COUNSELING 60 MINUTE,9429940401,CDM,942,RC,99404,HCPCS,facility,both,,,,249,249,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,9429940601,CDM,942,RC,99406,HCPCS,facility,both,,,,41,41,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC TOBACCO USE CESSATION INTENSIVE >10 MINUTES,9429940701,CDM,942,RC,99407,HCPCS,facility,both,,,,83,83,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC DIAB INST INDIVIDUAL PER 30 MIN,942G010801,CDM,942,RC,G0108,HCPCS,facility,both,,,,108,108,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INITIAL CHNG DX EACH 15 MIN,942G027001,CDM,942,RC,,,facility,both,,,,62,62,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL MNT SUBSQ TX FOR CHANGE DX EACH 15 MINUTES,942G027002,CDM,942,RC,,,facility,both,,,"PN,CR",57,57,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL MNT SUBSQ TX FOR CHANGE DX EACH 15 MINUTES,942G027002,CDM,942,RC,,,facility,both,,,"PN,CR",58,58,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRENATAL CLASS-REFRESHER,942S943701,CDM,942,RC,,,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL PRENATAL CLASS- REFRESHER,942S943702,CDM,942,RC,S9437,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CESAREAN BIRTH CLASS NON PHY,942S943801,CDM,942,RC,S9438,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL CESAREAN BIRTH CLASS NON PHY,942S943802,CDM,942,RC,S9438,HCPCS,facility,both,,,,70,70,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PRENATAL CLASS-COMPREHENSIVE,942S944201,CDM,942,RC,S9442,HCPCS,facility,both,,,,170,170,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL PRENATAL CLASS-COMPREHENSIVE,942S944202,CDM,942,RC,S9442,HCPCS,facility,both,,,"PN,CR",170,170,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC LACTATION CLASS NONPHYSICIAN,942S944301,CDM,942,RC,S9443,HCPCS,facility,both,,,,80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL LACTATION CLASSS NONPHYSICIAN,942S944302,CDM,942,RC,S9443,HCPCS,facility,both,,,"PN,CR",80,80,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PARENTING CLASS NONPHYSICIAN,942S944401,CDM,942,RC,,,facility,both,,,,44,44,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC PERIPHERAL ARTERIAL DISEASE REHAB PER SESSION,9439366801,CDM,943,RC,93668,HCPCS,facility,both,,,,160,160,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARDIAC REHAB II WO EKG,9439379701,CDM,943,RC,93797,HCPCS,facility,both,,,,265,265,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL CARDIAC REHAB II WO EKG,9439379702,CDM,943,RC,,,facility,both,,,"CR,PN",273.11,273.11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC CARDIAC REHAB II WITH EKG,9439379801,CDM,943,RC,93798,HCPCS,facility,both,,,,265,265,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC VIRTUAL CARDIAC REHAB II WITH EKG,9439379802,CDM,943,RC,,,facility,both,,,"CR,PN",273.11,273.11,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTENS CARDIAC REHAB W/WO EKG WITH EXERCISE,943G042201,CDM,943,RC,G0422,HCPCS,facility,both,,,,356,356,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC INTENS CARDIAC REHAB W/WO EKG WITHOUT EXERCISE,943G042301,CDM,943,RC,G0423,HCPCS,facility,both,,,,356,356,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OP PULM REHAB WO CONT OXIMTRY MNTR,9489462501,CDM,948,RC,94625,HCPCS,facility,both,,,,231,231,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC OP PULM REHAB W/CONT OXIMTRY MNTR,9489462601,CDM,948,RC,,,facility,both,,,,261,261,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNRETURNED HOLTER MONITOR,9990000001,CDM,999,RC,,,facility,both,,,,2395,2395,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
HC UNRETURNED HOME SLEEP MONITOR,9990000002,CDM,999,RC,,,facility,both,,,,4025,4025,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
PR EAR MOLD/INSERT,V5264,CDM,NULL,RC,,,facility,both,,,,215.36,215.36,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
PR EAR IMPRESSION,V5275,CDM,NULL,RC,,,facility,both,,,,67.3,67.3,,,,,,,,,,,,,Gross Charge Type: SH BUTTERWORTH AND BLODGETT FEE SCHEDULE (NO REF-LAB)
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.49,,,,,,,fee schedule,168.15,1296,
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.94,,,,,,,fee schedule,168.15,1296,
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.15,,,,,,,fee schedule,168.15,1296,
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.96,,,,,,,fee schedule,168.15,1296,
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,756,,,,,,,fee schedule,168.15,1296,APC
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,720,,,,,,,fee schedule,168.15,1296,APC
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1296,,,,,,,fee schedule,168.15,1296,APC
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,528.57,,,,,,,fee schedule,503.4,906.12,APC
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,503.4,,,,,,,fee schedule,503.4,906.12,APC
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,906.12,,,,,,,fee schedule,503.4,906.12,APC
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.62,,,,,,,fee schedule,25,50.16,
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.7,,,,,,,fee schedule,25,50.16,
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.6,,,,,,,fee schedule,25,50.16,
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.16,,,,,,,fee schedule,25,50.16,
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.25,,,,,,,fee schedule,25,50.16,APC
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25,,,,,,,fee schedule,25,50.16,APC
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45,,,,,,,fee schedule,25,50.16,APC
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,528.57,,,,,,,fee schedule,503.4,906.12,APC
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,503.4,,,,,,,fee schedule,503.4,906.12,APC
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,906.12,,,,,,,fee schedule,503.4,906.12,APC
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2054.86,,,,,,,fee schedule,950,2363.09,
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1681.9,,,,,,,fee schedule,950,2363.09,
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1347.17,,,,,,,fee schedule,950,2363.09,
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2363.09,,,,,,,fee schedule,950,2363.09,
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,997.5,,,,,,,fee schedule,950,2363.09,APC
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,950,,,,,,,fee schedule,950,2363.09,APC
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1710,,,,,,,fee schedule,950,2363.09,APC
Scoliosis dna alys,0004M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.95,,,,,,,fee schedule,79,142.2,APC
Scoliosis dna alys,0004M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79,,,,,,,fee schedule,79,142.2,APC
Scoliosis dna alys,0004M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,142.2,,,,,,,fee schedule,79,142.2,APC
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.89,,,,,,,fee schedule,760,1890.47,
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1345.52,,,,,,,fee schedule,760,1890.47,
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1077.73,,,,,,,fee schedule,760,1890.47,
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.47,,,,,,,fee schedule,760,1890.47,
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1890.47,APC
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1890.47,APC
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1890.47,APC
Onc hep gene risk classifier,0006M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.5,,,,,,,fee schedule,150,270,APC
Onc hep gene risk classifier,0006M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150,,,,,,,fee schedule,150,270,APC
Onc hep gene risk classifier,0006M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270,,,,,,,fee schedule,150,270,APC
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,393.75,,,,,,,fee schedule,375,675,APC
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,375,,,,,,,fee schedule,375,675,APC
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,675,,,,,,,fee schedule,375,675,APC
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,207.24,,,,,,,fee schedule,114.43,238.33,
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.63,,,,,,,fee schedule,114.43,238.33,
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.87,,,,,,,fee schedule,114.43,238.33,
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,238.33,,,,,,,fee schedule,114.43,238.33,
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,114.43,238.33,APC
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,114.43,,,,,,,fee schedule,114.43,238.33,APC
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,205.97,,,,,,,fee schedule,114.43,238.33,APC
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.89,,,,,,,fee schedule,597.91,1890.47,
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1345.52,,,,,,,fee schedule,597.91,1890.47,
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1077.73,,,,,,,fee schedule,597.91,1890.47,
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.47,,,,,,,fee schedule,597.91,1890.47,
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,597.91,1890.47,APC
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,597.91,,,,,,,fee schedule,597.91,1890.47,APC
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1076.24,,,,,,,fee schedule,597.91,1890.47,APC
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.95,,,,,,,fee schedule,55.04,192.6,
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.71,,,,,,,fee schedule,55.04,192.6,
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.04,,,,,,,fee schedule,55.04,192.6,
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.54,,,,,,,fee schedule,55.04,192.6,
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.35,,,,,,,fee schedule,55.04,192.6,APC
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,107,,,,,,,fee schedule,55.04,192.6,APC
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,192.6,,,,,,,fee schedule,55.04,192.6,APC
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,432.02,,,,,,,fee schedule,283.23,769.07,
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.61,,,,,,,fee schedule,283.23,769.07,
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.23,,,,,,,fee schedule,283.23,769.07,
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.82,,,,,,,fee schedule,283.23,769.07,
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,448.62,,,,,,,fee schedule,283.23,769.07,APC
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,427.26,,,,,,,fee schedule,283.23,769.07,APC
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,769.07,,,,,,,fee schedule,283.23,769.07,APC
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,207.24,,,,,,,fee schedule,114.43,238.33,
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.63,,,,,,,fee schedule,114.43,238.33,
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.87,,,,,,,fee schedule,114.43,238.33,
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,238.33,,,,,,,fee schedule,114.43,238.33,
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,114.43,238.33,APC
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,114.43,,,,,,,fee schedule,114.43,238.33,APC
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,205.97,,,,,,,fee schedule,114.43,238.33,APC
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1370.64,,,,,,,fee schedule,1305.37,2349.67,APC
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1305.37,,,,,,,fee schedule,1305.37,2349.67,APC
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2349.67,,,,,,,fee schedule,1305.37,2349.67,APC
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.11,,,,,,,fee schedule,3489.63,6281.33,APC
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3489.63,,,,,,,fee schedule,3489.63,6281.33,APC
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6281.33,,,,,,,fee schedule,3489.63,6281.33,APC
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,614.05,,,,,,,fee schedule,163.96,706.16,
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,502.6,,,,,,,fee schedule,163.96,706.16,
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,402.57,,,,,,,fee schedule,163.96,706.16,
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,706.16,,,,,,,fee schedule,163.96,706.16,
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,172.16,,,,,,,fee schedule,163.96,706.16,APC
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,163.96,,,,,,,fee schedule,163.96,706.16,APC
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,295.13,,,,,,,fee schedule,163.96,706.16,APC
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2635.72,,,,,,,fee schedule,2510.21,4518.38,APC
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2510.21,,,,,,,fee schedule,2510.21,4518.38,APC
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4518.38,,,,,,,fee schedule,2510.21,4518.38,APC
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,343.32,,,,,,,fee schedule,91.66,394.82,
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,281.01,,,,,,,fee schedule,91.66,394.82,
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,225.08,,,,,,,fee schedule,91.66,394.82,
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,394.82,,,,,,,fee schedule,91.66,394.82,
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.24,,,,,,,fee schedule,91.66,394.82,APC
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,91.66,,,,,,,fee schedule,91.66,394.82,APC
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,164.99,,,,,,,fee schedule,91.66,394.82,APC
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672.77,,,,,,,fee schedule,640.73,1153.31,APC
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,640.73,,,,,,,fee schedule,640.73,1153.31,APC
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1153.31,,,,,,,fee schedule,640.73,1153.31,APC
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8180.25,,,,,,,fee schedule,3002.09,9407.29,
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6695.53,,,,,,,fee schedule,3002.09,9407.29,
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5362.97,,,,,,,fee schedule,3002.09,9407.29,
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9407.29,,,,,,,fee schedule,3002.09,9407.29,
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3152.19,,,,,,,fee schedule,3002.09,9407.29,APC
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3002.09,,,,,,,fee schedule,3002.09,9407.29,APC
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5403.76,,,,,,,fee schedule,3002.09,9407.29,APC
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,748.02,,,,,,,fee schedule,712.4,1282.32,APC
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,712.4,,,,,,,fee schedule,712.4,1282.32,APC
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1282.32,,,,,,,fee schedule,712.4,1282.32,APC
Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12548.68,,,,,,,fee schedule,3675,14430.98,
Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10271.09,,,,,,,fee schedule,3675,14430.98,
Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8226.91,,,,,,,fee schedule,3675,14430.98,
Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14430.98,,,,,,,fee schedule,3675,14430.98,
Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3858.75,,,,,,,fee schedule,3675,14430.98,APC
Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3675,,,,,,,fee schedule,3675,14430.98,APC
Onc rna tiss predict alg,0019U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6615,,,,,,,fee schedule,3675,14430.98,APC
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2206.91,,,,,,,fee schedule,760,2537.95,
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1806.36,,,,,,,fee schedule,760,2537.95,
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1446.85,,,,,,,fee schedule,760,2537.95,
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2537.95,,,,,,,fee schedule,760,2537.95,
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,2537.95,APC
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,2537.95,APC
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,2537.95,APC
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1569.67,,,,,,,fee schedule,1029.08,3510,
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1284.77,,,,,,,fee schedule,1029.08,3510,
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1029.08,,,,,,,fee schedule,1029.08,3510,
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1805.12,,,,,,,fee schedule,1029.08,3510,
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1029.08,3510,APC
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1950,,,,,,,fee schedule,1029.08,3510,APC
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3510,,,,,,,fee schedule,1029.08,3510,APC
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,652.39,,,,,,,fee schedule,248.51,750.25,
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,533.98,,,,,,,fee schedule,248.51,750.25,
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,427.71,,,,,,,fee schedule,248.51,750.25,
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,750.25,,,,,,,fee schedule,248.51,750.25,
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,260.94,,,,,,,fee schedule,248.51,750.25,APC
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.51,,,,,,,fee schedule,248.51,750.25,APC
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,447.32,,,,,,,fee schedule,248.51,750.25,APC
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.23,,,,,,,fee schedule,34.19,117.56,
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.68,,,,,,,fee schedule,34.19,117.56,
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.02,,,,,,,fee schedule,34.19,117.56,
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.56,,,,,,,fee schedule,34.19,117.56,
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.9,,,,,,,fee schedule,34.19,117.56,APC
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.19,,,,,,,fee schedule,34.19,117.56,APC
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.54,,,,,,,fee schedule,34.19,117.56,APC
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,300.39,,,,,,,fee schedule,114.43,345.45,
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,245.87,,,,,,,fee schedule,114.43,345.45,
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,196.94,,,,,,,fee schedule,114.43,345.45,
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,345.45,,,,,,,fee schedule,114.43,345.45,
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,114.43,345.45,APC
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,114.43,,,,,,,fee schedule,114.43,345.45,APC
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,205.97,,,,,,,fee schedule,114.43,345.45,APC
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9450.88,,,,,,,fee schedule,3600,10868.51,
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7735.55,,,,,,,fee schedule,3600,10868.51,
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6196,,,,,,,fee schedule,3600,10868.51,
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10868.51,,,,,,,fee schedule,3600,10868.51,
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3600,10868.51,APC
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3600,,,,,,,fee schedule,3600,10868.51,APC
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6480,,,,,,,fee schedule,3600,10868.51,APC
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.14,,,,,,,fee schedule,121.91,454.41,
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,323.42,,,,,,,fee schedule,121.91,454.41,
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.05,,,,,,,fee schedule,121.91,454.41,
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.41,,,,,,,fee schedule,121.91,454.41,
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.01,,,,,,,fee schedule,121.91,454.41,APC
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,121.91,,,,,,,fee schedule,121.91,454.41,APC
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,219.44,,,,,,,fee schedule,121.91,454.41,APC
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2221.66,,,,,,,fee schedule,1456.52,2554.91,
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1818.43,,,,,,,fee schedule,1456.52,2554.91,
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1456.52,,,,,,,fee schedule,1456.52,2554.91,
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2554.91,,,,,,,fee schedule,1456.52,2554.91,
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1153.56,,,,,,,fee schedule,134.13,1326.59,
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,944.19,,,,,,,fee schedule,134.13,1326.59,
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,756.27,,,,,,,fee schedule,134.13,1326.59,
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1326.59,,,,,,,fee schedule,134.13,1326.59,
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.84,,,,,,,fee schedule,134.13,1326.59,APC
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,134.13,,,,,,,fee schedule,134.13,1326.59,APC
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.43,,,,,,,fee schedule,134.13,1326.59,APC
Cyp1a2 gene,0031U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,458.9,,,,,,,fee schedule,300.85,527.74,
Cyp1a2 gene,0031U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.61,,,,,,,fee schedule,300.85,527.74,
Cyp1a2 gene,0031U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.85,,,,,,,fee schedule,300.85,527.74,
Cyp1a2 gene,0031U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,527.74,,,,,,,fee schedule,300.85,527.74,
Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,458.9,,,,,,,fee schedule,174.81,527.74,
Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.61,,,,,,,fee schedule,174.81,527.74,
Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.85,,,,,,,fee schedule,174.81,527.74,
Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,527.74,,,,,,,fee schedule,174.81,527.74,
Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,174.81,527.74,APC
Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,174.81,527.74,APC
Comt gene,0032U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,174.81,527.74,APC
Htr2a htr2c genes,0033U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,917.82,,,,,,,fee schedule,601.72,1055.49,
Htr2a htr2c genes,0033U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,751.24,,,,,,,fee schedule,601.72,1055.49,
Htr2a htr2c genes,0033U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,601.72,,,,,,,fee schedule,601.72,1055.49,
Htr2a htr2c genes,0033U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1055.49,,,,,,,fee schedule,601.72,1055.49,
Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1223.8,,,,,,,fee schedule,466.17,1407.37,
Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1001.68,,,,,,,fee schedule,466.17,1407.37,
Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,802.32,,,,,,,fee schedule,466.17,1407.37,
Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1407.37,,,,,,,fee schedule,466.17,1407.37,
Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,489.48,,,,,,,fee schedule,466.17,1407.37,APC
Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,466.17,,,,,,,fee schedule,466.17,1407.37,APC
Tpmt nudt15 genes,0034U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,839.11,,,,,,,fee schedule,466.17,1407.37,APC
Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1223.8,,,,,,,fee schedule,540.99,1407.37,
Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1001.68,,,,,,,fee schedule,540.99,1407.37,
Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,802.32,,,,,,,fee schedule,540.99,1407.37,
Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1407.37,,,,,,,fee schedule,540.99,1407.37,
Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.04,,,,,,,fee schedule,540.99,1407.37,APC
Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,540.99,,,,,,,fee schedule,540.99,1407.37,APC
Neuro csf prion prtn qual,0035U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.78,,,,,,,fee schedule,540.99,1407.37,APC
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12548.68,,,,,,,fee schedule,4780,14430.98,
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10271.09,,,,,,,fee schedule,4780,14430.98,
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8226.91,,,,,,,fee schedule,4780,14430.98,
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14430.98,,,,,,,fee schedule,4780,14430.98,
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5019,,,,,,,fee schedule,4780,14430.98,APC
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4780,,,,,,,fee schedule,4780,14430.98,APC
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8604,,,,,,,fee schedule,4780,14430.98,APC
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9188.36,,,,,,,fee schedule,3500,10566.61,
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7520.67,,,,,,,fee schedule,3500,10566.61,
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6023.89,,,,,,,fee schedule,3500,10566.61,
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10566.61,,,,,,,fee schedule,3500,10566.61,
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3500,10566.61,APC
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3500,,,,,,,fee schedule,3500,10566.61,APC
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6300,,,,,,,fee schedule,3500,10566.61,APC
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.93,,,,,,,fee schedule,29.6,110.32,
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.52,,,,,,,fee schedule,29.6,110.32,
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.89,,,,,,,fee schedule,29.6,110.32,
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,110.32,,,,,,,fee schedule,29.6,110.32,
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.08,,,,,,,fee schedule,29.6,110.32,APC
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.6,,,,,,,fee schedule,29.6,110.32,APC
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.28,,,,,,,fee schedule,29.6,110.32,APC
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.53,,,,,,,fee schedule,13.74,51.21,
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.45,,,,,,,fee schedule,13.74,51.21,
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.19,,,,,,,fee schedule,13.74,51.21,
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.21,,,,,,,fee schedule,13.74,51.21,
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.43,,,,,,,fee schedule,13.74,51.21,APC
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.74,,,,,,,fee schedule,13.74,51.21,APC
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.73,,,,,,,fee schedule,13.74,51.21,APC
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1328.5,,,,,,,fee schedule,409.9,1527.78,
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1087.38,,,,,,,fee schedule,409.9,1527.78,
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,870.96,,,,,,,fee schedule,409.9,1527.78,
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1527.78,,,,,,,fee schedule,409.9,1527.78,
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,430.4,,,,,,,fee schedule,409.9,1527.78,APC
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,409.9,,,,,,,fee schedule,409.9,1527.78,APC
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,737.82,,,,,,,fee schedule,409.9,1527.78,APC
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.43,,,,,,,fee schedule,17.21,115.49,
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.2,,,,,,,fee schedule,17.21,115.49,
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.84,,,,,,,fee schedule,17.21,115.49,
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.49,,,,,,,fee schedule,17.21,115.49,
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.07,,,,,,,fee schedule,17.21,115.49,APC
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.21,,,,,,,fee schedule,17.21,115.49,APC
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.98,,,,,,,fee schedule,17.21,115.49,APC
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.43,,,,,,,fee schedule,17.21,115.49,
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.2,,,,,,,fee schedule,17.21,115.49,
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.84,,,,,,,fee schedule,17.21,115.49,
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.49,,,,,,,fee schedule,17.21,115.49,
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.07,,,,,,,fee schedule,17.21,115.49,APC
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.21,,,,,,,fee schedule,17.21,115.49,APC
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.98,,,,,,,fee schedule,17.21,115.49,APC
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.43,,,,,,,fee schedule,14.86,115.49,
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.2,,,,,,,fee schedule,14.86,115.49,
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.84,,,,,,,fee schedule,14.86,115.49,
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.49,,,,,,,fee schedule,14.86,115.49,
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.6,,,,,,,fee schedule,14.86,115.49,APC
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.86,,,,,,,fee schedule,14.86,115.49,APC
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.75,,,,,,,fee schedule,14.86,115.49,APC
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.43,,,,,,,fee schedule,14.86,115.49,
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.2,,,,,,,fee schedule,14.86,115.49,
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.84,,,,,,,fee schedule,14.86,115.49,
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.49,,,,,,,fee schedule,14.86,115.49,
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.6,,,,,,,fee schedule,14.86,115.49,APC
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.86,,,,,,,fee schedule,14.86,115.49,APC
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.75,,,,,,,fee schedule,14.86,115.49,APC
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10167.59,,,,,,,fee schedule,3873,11692.73,
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8322.17,,,,,,,fee schedule,3873,11692.73,
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6665.87,,,,,,,fee schedule,3873,11692.73,
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11692.73,,,,,,,fee schedule,3873,11692.73,
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3873,11692.73,APC
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3873,11692.73,APC
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3873,11692.73,APC
Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,434.5,,,,,,,fee schedule,284.86,733.37,
Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,355.64,,,,,,,fee schedule,284.86,733.37,
Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,284.86,,,,,,,fee schedule,284.86,733.37,
Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,499.68,,,,,,,fee schedule,284.86,733.37,
Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,427.8,,,,,,,fee schedule,284.86,733.37,APC
Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,407.43,,,,,,,fee schedule,284.86,733.37,APC
Flt3 gene itd variants quan,0046U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,733.37,,,,,,,fee schedule,284.86,733.37,APC
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10167.59,,,,,,,fee schedule,3873,11692.73,
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6665.87,,,,,,,fee schedule,3873,11692.73,
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8322.17,,,,,,,fee schedule,3873,11692.73,
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11692.73,,,,,,,fee schedule,3873,11692.73,
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3873,11692.73,APC
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3873,11692.73,APC
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3873,11692.73,APC
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7664.66,,,,,,,fee schedule,2919.6,8814.36,
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5024.95,,,,,,,fee schedule,2919.6,8814.36,
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6273.52,,,,,,,fee schedule,2919.6,8814.36,
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8814.36,,,,,,,fee schedule,2919.6,8814.36,
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,8814.36,APC
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,8814.36,APC
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,8814.36,APC
Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,647.15,,,,,,,fee schedule,407.43,744.22,
Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,424.27,,,,,,,fee schedule,407.43,744.22,
Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,529.69,,,,,,,fee schedule,407.43,744.22,
Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,744.22,,,,,,,fee schedule,407.43,744.22,
Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,427.8,,,,,,,fee schedule,407.43,744.22,APC
Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,407.43,,,,,,,fee schedule,407.43,744.22,APC
Npm1 gene analysis quan,0049U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,733.37,,,,,,,fee schedule,407.43,744.22,APC
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7664.66,,,,,,,fee schedule,2916.6,8814.36,
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5024.95,,,,,,,fee schedule,2916.6,8814.36,
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6273.52,,,,,,,fee schedule,2916.6,8814.36,
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8814.36,,,,,,,fee schedule,2916.6,8814.36,
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3062.43,,,,,,,fee schedule,2916.6,8814.36,APC
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2916.6,,,,,,,fee schedule,2916.6,8814.36,APC
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5249.88,,,,,,,fee schedule,2916.6,8814.36,APC
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.21,,,,,,,fee schedule,246.92,745.44,
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,424.97,,,,,,,fee schedule,246.92,745.44,
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,530.56,,,,,,,fee schedule,246.92,745.44,
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.44,,,,,,,fee schedule,246.92,745.44,
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,246.92,745.44,APC
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.92,,,,,,,fee schedule,246.92,745.44,APC
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.46,,,,,,,fee schedule,246.92,745.44,APC
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.89,,,,,,,fee schedule,33.86,102.22,
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.76,,,,,,,fee schedule,33.86,102.22,
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.28,,,,,,,fee schedule,33.86,102.22,
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.22,,,,,,,fee schedule,33.86,102.22,
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.55,,,,,,,fee schedule,33.86,102.22,APC
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.86,,,,,,,fee schedule,33.86,102.22,APC
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,60.95,,,,,,,fee schedule,33.86,102.22,APC
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,521.74,,,,,,,fee schedule,198.74,600,
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,427.04,,,,,,,fee schedule,198.74,600,
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,342.05,,,,,,,fee schedule,198.74,600,
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,600,,,,,,,fee schedule,198.74,600,
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,198.74,600,APC
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.74,,,,,,,fee schedule,198.74,600,APC
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,357.73,,,,,,,fee schedule,198.74,600,APC
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8505.8,,,,,,,fee schedule,3240,9781.67,
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6962,,,,,,,fee schedule,3240,9781.67,
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5576.4,,,,,,,fee schedule,3240,9781.67,
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9781.67,,,,,,,fee schedule,3240,9781.67,
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3402,,,,,,,fee schedule,3240,9781.67,APC
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3240,,,,,,,fee schedule,3240,9781.67,APC
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5832,,,,,,,fee schedule,3240,9781.67,APC
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.74,,,,,,,fee schedule,322.96,1203.75,
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.76,,,,,,,fee schedule,322.96,1203.75,
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,686.24,,,,,,,fee schedule,322.96,1203.75,
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.75,,,,,,,fee schedule,322.96,1203.75,
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.11,,,,,,,fee schedule,322.96,1203.75,APC
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,322.96,,,,,,,fee schedule,322.96,1203.75,APC
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,581.33,,,,,,,fee schedule,322.96,1203.75,APC
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.74,,,,,,,fee schedule,322.96,1203.75,
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.76,,,,,,,fee schedule,322.96,1203.75,
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,686.24,,,,,,,fee schedule,322.96,1203.75,
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.75,,,,,,,fee schedule,322.96,1203.75,
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.11,,,,,,,fee schedule,322.96,1203.75,APC
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,322.96,,,,,,,fee schedule,322.96,1203.75,APC
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,581.33,,,,,,,fee schedule,322.96,1203.75,APC
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1992.68,,,,,,,fee schedule,759.05,2291.58,
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1631.01,,,,,,,fee schedule,759.05,2291.58,
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1306.4,,,,,,,fee schedule,759.05,2291.58,
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2291.58,,,,,,,fee schedule,759.05,2291.58,
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,759.05,2291.58,APC
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,759.05,2291.58,APC
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,759.05,2291.58,APC
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.24,,,,,,,fee schedule,10.65,45.18,
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.29,,,,,,,fee schedule,10.65,45.18,
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.65,,,,,,,fee schedule,10.65,45.18,
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.68,,,,,,,fee schedule,10.65,45.18,
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.36,,,,,,,fee schedule,10.65,45.18,APC
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.1,,,,,,,fee schedule,10.65,45.18,APC
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.18,,,,,,,fee schedule,10.65,45.18,APC
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,399.76,,,,,,,fee schedule,380.72,685.3,APC
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,380.72,,,,,,,fee schedule,380.72,685.3,APC
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,685.3,,,,,,,fee schedule,380.72,685.3,APC
Neuro autism 32 amines alg,0063U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,750,1350,APC
Neuro autism 32 amines alg,0063U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,750,,,,,,,fee schedule,750,1350,APC
Neuro autism 32 amines alg,0063U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1350,,,,,,,fee schedule,750,1350,APC
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.9,,,,,,,fee schedule,31.33,56.39,APC
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.33,,,,,,,fee schedule,31.33,56.39,APC
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56.39,,,,,,,fee schedule,31.33,56.39,APC
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.99,,,,,,,fee schedule,18.09,32.56,APC
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.09,,,,,,,fee schedule,18.09,32.56,APC
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.56,,,,,,,fee schedule,18.09,32.56,APC
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1991.85,,,,,,,fee schedule,1897,3414.6,APC
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1897,,,,,,,fee schedule,1897,3414.6,APC
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3414.6,,,,,,,fee schedule,1897,3414.6,APC
Candida species pnl amp prb,0068U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,142.63,256.73,APC
Candida species pnl amp prb,0068U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,142.63,256.73,APC
Candida species pnl amp prb,0068U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,142.63,256.73,APC
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,399,,,,,,,fee schedule,380,684,APC
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,380,,,,,,,fee schedule,380,684,APC
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,684,,,,,,,fee schedule,380,684,APC
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.19,,,,,,,fee schedule,676.37,1217.47,APC
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,676.37,,,,,,,fee schedule,676.37,1217.47,APC
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1217.47,,,,,,,fee schedule,676.37,1217.47,APC
Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,5805.87,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,5805.87,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,5805.87,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,5805.87,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2044.76,5805.87,APC
Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2044.76,5805.87,APC
Us leiomyomata ablate <200,0071T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2044.76,5805.87,APC
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,600,1080,APC
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,600,,,,,,,fee schedule,600,1080,APC
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1080,,,,,,,fee schedule,600,1080,APC
Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,5805.87,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,5805.87,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,5805.87,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,5805.87,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2044.76,5805.87,APC
Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2044.76,5805.87,APC
Us leiomyomata ablate >200,0072T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2044.76,5805.87,APC
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,450.91,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,811.64,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,450.91,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,811.64,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,450.91,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,811.64,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,450.91,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,811.64,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,450.91,,,,,,,fee schedule,450.91,811.64,APC
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,811.64,,,,,,,fee schedule,450.91,811.64,APC
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.6,,,,,,,fee schedule,43.43,78.17,APC
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.43,,,,,,,fee schedule,43.43,78.17,APC
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78.17,,,,,,,fee schedule,43.43,78.17,APC
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3696,,,,,,,fee schedule,3520,6336,APC
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3520,,,,,,,fee schedule,3520,6336,APC
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6336,,,,,,,fee schedule,3520,6336,APC
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,246.92,444.46,APC
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.92,,,,,,,fee schedule,246.92,444.46,APC
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.46,,,,,,,fee schedule,246.92,444.46,APC
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,175.72,,,,,,,fee schedule,167.35,301.23,APC
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,167.35,,,,,,,fee schedule,167.35,301.23,APC
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,301.23,,,,,,,fee schedule,167.35,301.23,APC
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,756,,,,,,,fee schedule,720,1296,APC
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,720,,,,,,,fee schedule,720,1296,APC
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1296,,,,,,,fee schedule,720,1296,APC
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210,,,,,,,fee schedule,200,360,APC
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,200,,,,,,,fee schedule,200,360,APC
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,360,,,,,,,fee schedule,200,360,APC
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.39,,,,,,,fee schedule,3159.42,5686.96,APC
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3159.42,,,,,,,fee schedule,3159.42,5686.96,APC
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5686.96,,,,,,,fee schedule,3159.42,5686.96,APC
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.39,,,,,,,fee schedule,3159.42,5686.96,APC
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3159.42,,,,,,,fee schedule,3159.42,5686.96,APC
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5686.96,,,,,,,fee schedule,3159.42,5686.96,APC
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1950,3510,APC
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1950,,,,,,,fee schedule,1950,3510,APC
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3510,,,,,,,fee schedule,1950,3510,APC
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2612.4,,,,,,,fee schedule,2488,4478.4,APC
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2488,,,,,,,fee schedule,2488,4478.4,APC
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4478.4,,,,,,,fee schedule,2488,4478.4,APC
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,62.14,111.85,APC
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.14,,,,,,,fee schedule,62.14,111.85,APC
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,111.85,,,,,,,fee schedule,62.14,111.85,APC
Genome rapid sequence alys,0094U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7961.31,,,,,,,fee schedule,7582.2,13647.96,APC
Genome rapid sequence alys,0094U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7582.2,,,,,,,fee schedule,7582.2,13647.96,APC
Genome rapid sequence alys,0094U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13647.96,,,,,,,fee schedule,7582.2,13647.96,APC
Inflm ee elisa alys alg,0095U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,810.58,,,,,,,fee schedule,771.98,1389.56,APC
Inflm ee elisa alys alg,0095U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,771.98,,,,,,,fee schedule,771.98,1389.56,APC
Inflm ee elisa alys alg,0095U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1389.56,,,,,,,fee schedule,771.98,1389.56,APC
Hpv hi risk types male urine,0096U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,63.16,APC
Hpv hi risk types male urine,0096U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,63.16,APC
Hpv hi risk types male urine,0096U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,63.16,APC
Prosth Retina Receive&Gen,0100T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,4137.79,4758.46,
Prosth Retina Receive&Gen,0100T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,4137.79,4758.46,
Prosth Retina Receive&Gen,0100T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,4137.79,4758.46,
Prosth Retina Receive&Gen,0100T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,4137.79,4758.46,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5352.02,,,,,,,fee schedule,245.78,6154.82,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,245.78,6154.82,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,245.78,6154.82,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3508.78,,,,,,,fee schedule,245.78,6154.82,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4380.63,,,,,,,fee schedule,245.78,6154.82,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,245.78,6154.82,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6154.82,,,,,,,fee schedule,245.78,6154.82,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,245.78,6154.82,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,6154.82,APC
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,6154.82,APC
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,6154.82,APC
Hered colon ca do 15 genes,0101U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1831.15,,,,,,,fee schedule,1743.95,3139.11,APC
Hered colon ca do 15 genes,0101U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1743.95,,,,,,,fee schedule,1743.95,3139.11,APC
Hered colon ca do 15 genes,0101U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3139.11,,,,,,,fee schedule,1743.95,3139.11,APC
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1303.95,2347.11,APC
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1303.95,,,,,,,fee schedule,1303.95,2347.11,APC
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2347.11,,,,,,,fee schedule,1303.95,2347.11,APC
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1831.15,,,,,,,fee schedule,1743.95,3139.11,APC
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1743.95,,,,,,,fee schedule,1743.95,3139.11,APC
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3139.11,,,,,,,fee schedule,1743.95,3139.11,APC
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,997.5,,,,,,,fee schedule,950,1710,APC
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,950,,,,,,,fee schedule,950,1710,APC
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1710,,,,,,,fee schedule,950,1710,APC
Touch Quant Sensory Test,0106T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Touch Quant Sensory Test,0106T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Touch Quant Sensory Test,0106T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Touch Quant Sensory Test,0106T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Touch Quant Sensory Test,0106T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Touch Quant Sensory Test,0106T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Touch Quant Sensory Test,0106T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,918.21,,,,,,,fee schedule,874.49,1574.08,APC
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,874.49,,,,,,,fee schedule,874.49,1574.08,APC
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1574.08,,,,,,,fee schedule,874.49,1574.08,APC
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.8,,,,,,,fee schedule,16,28.8,APC
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16,,,,,,,fee schedule,16,28.8,APC
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.8,,,,,,,fee schedule,16,28.8,APC
Cool Quant Sensory Test,0108T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Cool Quant Sensory Test,0108T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Cool Quant Sensory Test,0108T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Cool Quant Sensory Test,0108T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Cool Quant Sensory Test,0108T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Cool Quant Sensory Test,0108T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Cool Quant Sensory Test,0108T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5197.5,,,,,,,fee schedule,4950,8910,APC
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4950,,,,,,,fee schedule,4950,8910,APC
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8910,,,,,,,fee schedule,4950,8910,APC
Heat Quant Sensory Test,0109T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Heat Quant Sensory Test,0109T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Heat Quant Sensory Test,0109T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Heat Quant Sensory Test,0109T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Heat Quant Sensory Test,0109T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Heat Quant Sensory Test,0109T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Heat Quant Sensory Test,0109T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Id aspergillus dna 4 species,0109U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,142.63,256.73,APC
Id aspergillus dna 4 species,0109U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,142.63,256.73,APC
Id aspergillus dna 4 species,0109U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,142.63,256.73,APC
Nos Quant Sensory Test,0110T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Nos Quant Sensory Test,0110T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Nos Quant Sensory Test,0110T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Nos Quant Sensory Test,0110T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Nos Quant Sensory Test,0110T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Nos Quant Sensory Test,0110T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Nos Quant Sensory Test,0110T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,27.11,48.8,APC
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.11,,,,,,,fee schedule,27.11,48.8,APC
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.8,,,,,,,fee schedule,27.11,48.8,APC
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,716.4,,,,,,,fee schedule,682.29,1228.12,APC
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,682.29,,,,,,,fee schedule,682.29,1228.12,APC
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1228.12,,,,,,,fee schedule,682.29,1228.12,APC
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,373.94,,,,,,,fee schedule,356.13,641.03,APC
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,356.13,,,,,,,fee schedule,356.13,641.03,APC
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,641.03,,,,,,,fee schedule,356.13,641.03,APC
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2034.91,,,,,,,fee schedule,1938.01,3488.42,APC
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1938.01,,,,,,,fee schedule,1938.01,3488.42,APC
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3488.42,,,,,,,fee schedule,1938.01,3488.42,APC
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,289.12,,,,,,,fee schedule,275.35,495.63,APC
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,275.35,,,,,,,fee schedule,275.35,495.63,APC
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,495.63,,,,,,,fee schedule,275.35,495.63,APC
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,246.92,444.46,APC
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.92,,,,,,,fee schedule,246.92,444.46,APC
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.46,,,,,,,fee schedule,246.92,444.46,APC
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,840.65,1513.17,APC
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,840.65,,,,,,,fee schedule,840.65,1513.17,APC
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1513.17,,,,,,,fee schedule,840.65,1513.17,APC
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2890.91,,,,,,,fee schedule,2753.25,4955.85,APC
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2753.25,,,,,,,fee schedule,2753.25,4955.85,APC
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4955.85,,,,,,,fee schedule,2753.25,4955.85,APC
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.95,,,,,,,fee schedule,83.76,150.77,APC
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,83.76,,,,,,,fee schedule,83.76,150.77,APC
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,150.77,,,,,,,fee schedule,83.76,150.77,APC
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2635.72,,,,,,,fee schedule,2510.21,4518.38,APC
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2510.21,,,,,,,fee schedule,2510.21,4518.38,APC
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4518.38,,,,,,,fee schedule,2510.21,4518.38,APC
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,534.66,,,,,,,fee schedule,509.2,916.56,APC
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,509.2,,,,,,,fee schedule,509.2,916.56,APC
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,916.56,,,,,,,fee schedule,509.2,916.56,APC
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,552.54,,,,,,,fee schedule,526.23,947.21,APC
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,526.23,,,,,,,fee schedule,526.23,947.21,APC
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,947.21,,,,,,,fee schedule,526.23,947.21,APC
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.51,,,,,,,fee schedule,357.63,643.73,APC
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.63,,,,,,,fee schedule,357.63,643.73,APC
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,643.73,,,,,,,fee schedule,357.63,643.73,APC
Hered brst ca rltd do panel,0129U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1303.95,2347.11,APC
Hered brst ca rltd do panel,0129U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1303.95,,,,,,,fee schedule,1303.95,2347.11,APC
Hered brst ca rltd do panel,0129U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2347.11,,,,,,,fee schedule,1303.95,2347.11,APC
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,584.9,1052.82,APC
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.9,,,,,,,fee schedule,584.9,1052.82,APC
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1052.82,,,,,,,fee schedule,584.9,1052.82,APC
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.8,,,,,,,fee schedule,690.29,1242.52,APC
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,690.29,,,,,,,fee schedule,690.29,1242.52,APC
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1242.52,,,,,,,fee schedule,690.29,1242.52,APC
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,785.81,,,,,,,fee schedule,748.39,1347.1,APC
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,748.39,,,,,,,fee schedule,748.39,1347.1,APC
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1347.1,,,,,,,fee schedule,748.39,1347.1,APC
Atm mrna seq alys,0136U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,427.8,,,,,,,fee schedule,407.43,733.37,APC
Atm mrna seq alys,0136U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,407.43,,,,,,,fee schedule,407.43,733.37,APC
Atm mrna seq alys,0136U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,733.37,,,,,,,fee schedule,407.43,733.37,APC
Palb2 mrna seq alys,0137U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Palb2 mrna seq alys,0137U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Palb2 mrna seq alys,0137U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,491.75,,,,,,,fee schedule,468.33,842.99,APC
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,468.33,,,,,,,fee schedule,468.33,842.99,APC
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,842.99,,,,,,,fee schedule,468.33,842.99,APC
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.59,,,,,,,fee schedule,156.75,282.15,APC
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,156.75,,,,,,,fee schedule,156.75,282.15,APC
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,282.15,,,,,,,fee schedule,156.75,282.15,APC
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.59,,,,,,,fee schedule,156.75,282.15,APC
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,156.75,,,,,,,fee schedule,156.75,282.15,APC
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,282.15,,,,,,,fee schedule,156.75,282.15,APC
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.59,,,,,,,fee schedule,156.75,282.15,APC
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,156.75,,,,,,,fee schedule,156.75,282.15,APC
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,282.15,,,,,,,fee schedule,156.75,282.15,APC
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2232.51,,,,,,,fee schedule,2126.2,3827.16,APC
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2126.2,,,,,,,fee schedule,2126.2,3827.16,APC
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3827.16,,,,,,,fee schedule,2126.2,3827.16,APC
Onc breast mrna 101 genes,0153U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.39,,,,,,,fee schedule,3159.42,5686.96,APC
Onc breast mrna 101 genes,0153U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3159.42,,,,,,,fee schedule,3159.42,5686.96,APC
Onc breast mrna 101 genes,0153U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5686.96,,,,,,,fee schedule,3159.42,5686.96,APC
Fgfr3 gene analysis,0154U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,506.25,,,,,,,fee schedule,482.14,867.85,APC
Fgfr3 gene analysis,0154U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,482.14,,,,,,,fee schedule,482.14,867.85,APC
Fgfr3 gene analysis,0154U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,867.85,,,,,,,fee schedule,482.14,867.85,APC
Pik3ca gene analysis,0155U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Pik3ca gene analysis,0155U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Pik3ca gene analysis,0155U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Copy number sequence alys,0156U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1827,,,,,,,fee schedule,1740,3132,APC
Copy number sequence alys,0156U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1740,,,,,,,fee schedule,1740,3132,APC
Copy number sequence alys,0156U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3132,,,,,,,fee schedule,1740,3132,APC
Apc mrna seq alys,0157U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Apc mrna seq alys,0157U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Apc mrna seq alys,0157U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Mlh1 mrna seq alys,0158U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Mlh1 mrna seq alys,0158U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Mlh1 mrna seq alys,0158U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Msh2 mrna seq alys,0159U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Msh2 mrna seq alys,0159U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Msh2 mrna seq alys,0159U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Msh6 mrna seq alys,0160U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Msh6 mrna seq alys,0160U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Msh6 mrna seq alys,0160U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Pms2 mrna seq alys,0161U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Pms2 mrna seq alys,0161U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Pms2 mrna seq alys,0161U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,510.87,,,,,,,fee schedule,486.54,875.77,APC
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,486.54,,,,,,,fee schedule,486.54,875.77,APC
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,875.77,,,,,,,fee schedule,486.54,875.77,APC
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,117.62,,,,,,,fee schedule,112.02,201.64,APC
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,112.02,,,,,,,fee schedule,112.02,201.64,APC
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,201.64,,,,,,,fee schedule,112.02,201.64,APC
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,486.95,,,,,,,fee schedule,463.76,834.77,APC
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,463.76,,,,,,,fee schedule,463.76,834.77,APC
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,834.77,,,,,,,fee schedule,463.76,834.77,APC
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,528.57,,,,,,,fee schedule,503.4,906.12,APC
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,503.4,,,,,,,fee schedule,503.4,906.12,APC
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,906.12,,,,,,,fee schedule,503.4,906.12,APC
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,489.48,,,,,,,fee schedule,466.17,839.11,APC
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,466.17,,,,,,,fee schedule,466.17,839.11,APC
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,839.11,,,,,,,fee schedule,466.17,839.11,APC
Neuro asd rna next gen seq,0170U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1950,3510,APC
Neuro asd rna next gen seq,0170U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1950,,,,,,,fee schedule,1950,3510,APC
Neuro asd rna next gen seq,0170U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3510,,,,,,,fee schedule,1950,3510,APC
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1595.01,,,,,,,fee schedule,1519.06,2734.31,APC
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1519.06,,,,,,,fee schedule,1519.06,2734.31,APC
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2734.31,,,,,,,fee schedule,1519.06,2734.31,APC
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3181.5,,,,,,,fee schedule,3030,5454,APC
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3030,,,,,,,fee schedule,3030,5454,APC
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5454,,,,,,,fee schedule,3030,5454,APC
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,489.48,,,,,,,fee schedule,466.17,839.11,APC
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,466.17,,,,,,,fee schedule,466.17,839.11,APC
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,839.11,,,,,,,fee schedule,466.17,839.11,APC
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1370.64,,,,,,,fee schedule,1305.37,2349.67,APC
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1305.37,,,,,,,fee schedule,1305.37,2349.67,APC
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2349.67,,,,,,,fee schedule,1305.37,2349.67,APC
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1336.09,2404.96,APC
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1336.09,,,,,,,fee schedule,1336.09,2404.96,APC
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2404.96,,,,,,,fee schedule,1336.09,2404.96,APC
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.4,,,,,,,fee schedule,64.19,115.54,APC
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.19,,,,,,,fee schedule,64.19,115.54,APC
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.54,,,,,,,fee schedule,64.19,115.54,APC
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,482.85,,,,,,,fee schedule,459.86,827.75,APC
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,459.86,,,,,,,fee schedule,459.86,827.75,APC
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,827.75,,,,,,,fee schedule,459.86,827.75,APC
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2040.37,,,,,,,fee schedule,1943.21,3497.78,APC
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1943.21,,,,,,,fee schedule,1943.21,3497.78,APC
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3497.78,,,,,,,fee schedule,1943.21,3497.78,APC
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,301.35,542.43,APC
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,301.35,,,,,,,fee schedule,301.35,542.43,APC
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,542.43,,,,,,,fee schedule,301.35,542.43,APC
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7056.45,,,,,,,fee schedule,4626.21,10888.32,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4626.21,,,,,,,fee schedule,4626.21,10888.32,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5775.7,,,,,,,fee schedule,4626.21,10888.32,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8114.92,,,,,,,fee schedule,4626.21,10888.32,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,4626.21,10888.32,APC
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,4626.21,10888.32,APC
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,4626.21,10888.32,APC
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Klf1 targeted sequencing,0195U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,375.25,675.45,APC
Klf1 targeted sequencing,0195U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,375.25,,,,,,,fee schedule,375.25,675.45,APC
Klf1 targeted sequencing,0195U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,675.45,,,,,,,fee schedule,375.25,675.45,APC
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Ocular blood flow measure,0198T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Ocular blood flow measure,0198T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Ocular blood flow measure,0198T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Ocular blood flow measure,0198T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Ocular blood flow measure,0198T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Ocular blood flow measure,0198T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Ocular blood flow measure,0198T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,185.2,333.36,APC
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,185.2,333.36,APC
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,185.2,333.36,APC
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.35,,,,,,,fee schedule,47,84.6,APC
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47,,,,,,,fee schedule,47,84.6,APC
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84.6,,,,,,,fee schedule,47,84.6,APC
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2326.17,,,,,,,fee schedule,2215.4,3987.72,APC
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2215.4,,,,,,,fee schedule,2215.4,3987.72,APC
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3987.72,,,,,,,fee schedule,2215.4,3987.72,APC
Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Clear eyelid gland w/heat,0207T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Audiometry air only,0208T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Audiometry air only,0208T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Audiometry air only,0208T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Audiometry air only,0208T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Audiometry air only,0208T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Audiometry air only,0208T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Audiometry air only,0208T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Audiometry air & bone,0209T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Audiometry air & bone,0209T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Audiometry air & bone,0209T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Audiometry air & bone,0209T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Audiometry air & bone,0209T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Audiometry air & bone,0209T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Audiometry air & bone,0209T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Cytog const alys interrog,0209U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,826.51,,,,,,,fee schedule,787.15,1416.87,APC
Cytog const alys interrog,0209U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,787.15,,,,,,,fee schedule,787.15,1416.87,APC
Cytog const alys interrog,0209U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1416.87,,,,,,,fee schedule,787.15,1416.87,APC
Speech audiometry threshold,0210T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Speech audiometry threshold,0210T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Speech audiometry threshold,0210T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Speech audiometry threshold,0210T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Speech audiometry threshold,0210T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Speech audiometry threshold,0210T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Speech audiometry threshold,0210T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Syphilis tst antb ia quan,0210U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.56,,,,,,,fee schedule,18.63,33.53,APC
Syphilis tst antb ia quan,0210U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.63,,,,,,,fee schedule,18.63,33.53,APC
Syphilis tst antb ia quan,0210U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.53,,,,,,,fee schedule,18.63,33.53,APC
Speech audiom thresh & recog,0211T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Speech audiom thresh & recog,0211T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Speech audiom thresh & recog,0211T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Speech audiom thresh & recog,0211T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Speech audiom thresh & recog,0211T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Speech audiom thresh & recog,0211T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Speech audiom thresh & recog,0211T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8877.75,,,,,,,fee schedule,8455,15219,APC
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8455,,,,,,,fee schedule,8455,15219,APC
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15219,,,,,,,fee schedule,8455,15219,APC
Compre audiometry evaluation,0212T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Compre audiometry evaluation,0212T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Compre audiometry evaluation,0212T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Compre audiometry evaluation,0212T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Compre audiometry evaluation,0212T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Compre audiometry evaluation,0212T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Compre audiometry evaluation,0212T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Rare ds gen dna alys proband,0212U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5748.96,,,,,,,fee schedule,5475.2,9855.36,APC
Rare ds gen dna alys proband,0212U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5475.2,,,,,,,fee schedule,5475.2,9855.36,APC
Rare ds gen dna alys proband,0212U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9855.36,,,,,,,fee schedule,5475.2,9855.36,APC
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2845.45,,,,,,,fee schedule,2709.95,4877.91,APC
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2709.95,,,,,,,fee schedule,2709.95,4877.91,APC
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4877.91,,,,,,,fee schedule,2709.95,4877.91,APC
Rare ds xom dna alys proband,0214U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5485.83,,,,,,,fee schedule,5224.6,9404.28,APC
Rare ds xom dna alys proband,0214U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5224.6,,,,,,,fee schedule,5224.6,9404.28,APC
Rare ds xom dna alys proband,0214U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9404.28,,,,,,,fee schedule,5224.6,9404.28,APC
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2703.38,,,,,,,fee schedule,2574.65,4634.37,APC
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2574.65,,,,,,,fee schedule,2574.65,4634.37,APC
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4634.37,,,,,,,fee schedule,2574.65,4634.37,APC
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1613.87,,,,,,,fee schedule,1537.02,2766.64,APC
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1537.02,,,,,,,fee schedule,1537.02,2766.64,APC
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2766.64,,,,,,,fee schedule,1537.02,2766.64,APC
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2308.27,,,,,,,fee schedule,2198.35,3957.03,APC
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2198.35,,,,,,,fee schedule,2198.35,3957.03,APC
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3957.03,,,,,,,fee schedule,2198.35,3957.03,APC
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2392.95,,,,,,,fee schedule,2279,4102.2,APC
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2279,,,,,,,fee schedule,2279,4102.2,APC
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4102.2,,,,,,,fee schedule,2279,4102.2,APC
Plmt post facet implt cerv,0219T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Plmt post facet implt cerv,0219T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Plmt post facet implt cerv,0219T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,761.25,,,,,,,fee schedule,725,1305,APC
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,725,,,,,,,fee schedule,725,1305,APC
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1305,,,,,,,fee schedule,725,1305,APC
Plmt post facet implt thor,0220T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Plmt post facet implt thor,0220T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Plmt post facet implt thor,0220T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,706.25,1271.25,APC
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.25,,,,,,,fee schedule,706.25,1271.25,APC
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1271.25,,,,,,,fee schedule,706.25,1271.25,APC
Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Plmt post facet implt lumb,0221T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,282.88,509.18,APC
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,282.88,509.18,APC
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,282.88,509.18,APC
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.58,,,,,,,fee schedule,35.78,92.57,
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.67,,,,,,,fee schedule,35.78,92.57,
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.78,,,,,,,fee schedule,35.78,92.57,
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.77,,,,,,,fee schedule,35.78,92.57,
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54,,,,,,,fee schedule,35.78,92.57,APC
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.43,,,,,,,fee schedule,35.78,92.57,APC
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.57,,,,,,,fee schedule,35.78,92.57,APC
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.76,,,,,,,fee schedule,35.9,76.1,
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.82,,,,,,,fee schedule,35.9,76.1,
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.9,,,,,,,fee schedule,35.9,76.1,
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.97,,,,,,,fee schedule,35.9,76.1,
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.39,,,,,,,fee schedule,35.9,76.1,APC
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.28,,,,,,,fee schedule,35.9,76.1,APC
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,76.1,,,,,,,fee schedule,35.9,76.1,APC
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,62.14,111.85,APC
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.14,,,,,,,fee schedule,62.14,111.85,APC
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,111.85,,,,,,,fee schedule,62.14,111.85,APC
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.68,,,,,,,fee schedule,173.03,311.45,APC
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,173.03,,,,,,,fee schedule,173.03,311.45,APC
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,311.45,,,,,,,fee schedule,173.03,311.45,APC
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.2,,,,,,,fee schedule,384,691.2,APC
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,384,,,,,,,fee schedule,384,691.2,APC
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,691.2,,,,,,,fee schedule,384,691.2,APC
Ar full sequence analysis,0230U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,301.35,542.43,APC
Ar full sequence analysis,0230U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,301.35,,,,,,,fee schedule,301.35,542.43,APC
Ar full sequence analysis,0230U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,542.43,,,,,,,fee schedule,301.35,542.43,APC
Cacna1a full gene analysis,0231U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,888.58,,,,,,,fee schedule,846.27,1523.29,APC
Cacna1a full gene analysis,0231U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,846.27,,,,,,,fee schedule,846.27,1523.29,APC
Cacna1a full gene analysis,0231U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1523.29,,,,,,,fee schedule,846.27,1523.29,APC
Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Njx platelet plasma,0232T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Cstb full gene analysis,0232U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Cstb full gene analysis,0232U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Cstb full gene analysis,0232U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Fxn gene analysis,0233U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,274.83,494.69,APC
Fxn gene analysis,0233U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,274.83,494.69,APC
Fxn gene analysis,0233U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,274.83,494.69,APC
Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Trluml perip athrc renal art,0234T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Mecp2 full gene analysis,0234U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,554.26,,,,,,,fee schedule,527.87,950.17,APC
Mecp2 full gene analysis,0234U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,527.87,,,,,,,fee schedule,527.87,950.17,APC
Mecp2 full gene analysis,0234U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,950.17,,,,,,,fee schedule,527.87,950.17,APC
Pten full gene analysis,0235U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,600,1080,APC
Pten full gene analysis,0235U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,600,,,,,,,fee schedule,600,1080,APC
Pten full gene analysis,0235U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1080,,,,,,,fee schedule,600,1080,APC
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,632.84,,,,,,,fee schedule,602.7,1084.86,APC
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,602.7,,,,,,,fee schedule,602.7,1084.86,APC
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1084.86,,,,,,,fee schedule,602.7,1084.86,APC
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,584.9,1052.82,APC
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.9,,,,,,,fee schedule,584.9,1052.82,APC
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1052.82,,,,,,,fee schedule,584.9,1052.82,APC
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27231.15,,,,,,,fee schedule,17852.74,32878.29,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23558.75,,,,,,,fee schedule,17852.74,32878.29,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23558.75,,,,,,,fee schedule,17852.74,32878.29,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22288.7,,,,,,,fee schedule,17852.74,32878.29,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17852.74,,,,,,,fee schedule,17852.74,32878.29,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27092.56,,,,,,,fee schedule,17852.74,32878.29,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31315.82,,,,,,,fee schedule,17852.74,32878.29,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23558.75,,,,,,,fee schedule,17852.74,32878.29,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,17852.74,32878.29,APC
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,17852.74,32878.29,APC
Trluml perip athrc iliac art,0238T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,17852.74,32878.29,APC
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,584.9,1052.82,APC
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.9,,,,,,,fee schedule,584.9,1052.82,APC
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1052.82,,,,,,,fee schedule,584.9,1052.82,APC
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3500,6300,APC
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3500,,,,,,,fee schedule,3500,6300,APC
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6300,,,,,,,fee schedule,3500,6300,APC
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5250,,,,,,,fee schedule,5000,9000,APC
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5000,,,,,,,fee schedule,5000,9000,APC
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9000,,,,,,,fee schedule,5000,9000,APC
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,64.41,115.94,APC
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.41,,,,,,,fee schedule,64.41,115.94,APC
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.94,,,,,,,fee schedule,64.41,115.94,APC
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3500,6300,APC
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3500,,,,,,,fee schedule,3500,6300,APC
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6300,,,,,,,fee schedule,3500,6300,APC
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1329.37,,,,,,,fee schedule,1266.07,2278.93,APC
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1266.07,,,,,,,fee schedule,1266.07,2278.93,APC
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2278.93,,,,,,,fee schedule,1266.07,2278.93,APC
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,756,,,,,,,fee schedule,720,1296,APC
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,720,,,,,,,fee schedule,720,1296,APC
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1296,,,,,,,fee schedule,720,1296,APC
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,750,1350,APC
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,750,,,,,,,fee schedule,750,1350,APC
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1350,,,,,,,fee schedule,750,1350,APC
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.55,,,,,,,fee schedule,3033.86,5460.95,APC
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3033.86,,,,,,,fee schedule,3033.86,5460.95,APC
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5460.95,,,,,,,fee schedule,3033.86,5460.95,APC
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2330.09,,,,,,,fee schedule,2219.13,3994.43,APC
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2219.13,,,,,,,fee schedule,2219.13,3994.43,APC
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3994.43,,,,,,,fee schedule,2219.13,3994.43,APC
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,17.27,31.09,APC
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,17.27,31.09,APC
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,17.27,31.09,APC
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,759.05,1366.29,APC
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,759.05,1366.29,APC
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,759.05,1366.29,APC
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5882.4,,,,,,,fee schedule,3856.5,7413.41,
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3856.5,7413.41,
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3856.5,7413.41,
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4814.74,,,,,,,fee schedule,3856.5,7413.41,
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3856.5,,,,,,,fee schedule,3856.5,7413.41,
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3856.5,7413.41,
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6764.76,,,,,,,fee schedule,3856.5,7413.41,
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3856.5,7413.41,
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3856.5,7413.41,APC
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3856.5,7413.41,APC
Insert aqueous drain device,0253T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3856.5,7413.41,APC
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.39,,,,,,,fee schedule,3159.42,5686.96,APC
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3159.42,,,,,,,fee schedule,3159.42,5686.96,APC
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5686.96,,,,,,,fee schedule,3159.42,5686.96,APC
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,759.05,1366.29,APC
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,759.05,1366.29,APC
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,759.05,1366.29,APC
Andrology infertility assmt,0255U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.18,,,,,,,fee schedule,31.6,56.88,APC
Andrology infertility assmt,0255U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.6,,,,,,,fee schedule,31.6,56.88,APC
Andrology infertility assmt,0255U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56.88,,,,,,,fee schedule,31.6,56.88,APC
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,167.95,,,,,,,fee schedule,159.95,287.91,APC
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,159.95,,,,,,,fee schedule,159.95,287.91,APC
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,287.91,,,,,,,fee schedule,159.95,287.91,APC
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,748.09,,,,,,,fee schedule,712.47,1282.45,APC
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,712.47,,,,,,,fee schedule,712.47,1282.45,APC
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1282.45,,,,,,,fee schedule,712.47,1282.45,APC
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3858.75,,,,,,,fee schedule,3675,6615,APC
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3675,,,,,,,fee schedule,3675,6615,APC
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6615,,,,,,,fee schedule,3675,6615,APC
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.35,,,,,,,fee schedule,52.71,94.88,APC
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52.71,,,,,,,fee schedule,52.71,94.88,APC
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,94.88,,,,,,,fee schedule,52.71,94.88,APC
Rare ds id opt genome mapg,0260U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1263.53,2274.35,APC
Rare ds id opt genome mapg,0260U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1263.53,,,,,,,fee schedule,1263.53,2274.35,APC
Rare ds id opt genome mapg,0260U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2274.35,,,,,,,fee schedule,1263.53,2274.35,APC
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2638.91,,,,,,,fee schedule,2513.25,4523.85,APC
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2513.25,,,,,,,fee schedule,2513.25,4523.85,APC
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4523.85,,,,,,,fee schedule,2513.25,4523.85,APC
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3360,,,,,,,fee schedule,3200,5760,APC
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3200,,,,,,,fee schedule,3200,5760,APC
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5760,,,,,,,fee schedule,3200,5760,APC
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4705.9,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3851.78,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3085.19,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5411.79,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4556.83,,,,,,,fee schedule,3085.19,7811.71,APC
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4339.84,,,,,,,fee schedule,3085.19,7811.71,APC
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7811.71,,,,,,,fee schedule,3085.19,7811.71,APC
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,750,1350,APC
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,750,,,,,,,fee schedule,750,1350,APC
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1350,,,,,,,fee schedule,750,1350,APC
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4705.9,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3851.78,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3085.19,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5411.79,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4556.83,,,,,,,fee schedule,3085.19,7811.71,APC
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4339.84,,,,,,,fee schedule,3085.19,7811.71,APC
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7811.71,,,,,,,fee schedule,3085.19,7811.71,APC
Rare ds id opt genome mapg,0264U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1263.53,2274.35,APC
Rare ds id opt genome mapg,0264U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1263.53,,,,,,,fee schedule,1263.53,2274.35,APC
Rare ds id opt genome mapg,0264U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2274.35,,,,,,,fee schedule,1263.53,2274.35,APC
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4705.9,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3085.19,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3851.78,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5411.79,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4556.83,,,,,,,fee schedule,3085.19,7811.71,APC
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4339.84,,,,,,,fee schedule,3085.19,7811.71,APC
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7811.71,,,,,,,fee schedule,3085.19,7811.71,APC
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5749.59,,,,,,,fee schedule,5475.8,9856.44,APC
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5475.8,,,,,,,fee schedule,5475.8,9856.44,APC
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9856.44,,,,,,,fee schedule,5475.8,9856.44,APC
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3360,,,,,,,fee schedule,3200,5760,APC
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3200,,,,,,,fee schedule,3200,5760,APC
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5760,,,,,,,fee schedule,3200,5760,APC
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4023.71,,,,,,,fee schedule,2637.94,4627.27,
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2637.94,,,,,,,fee schedule,2637.94,4627.27,
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3293.41,,,,,,,fee schedule,2637.94,4627.27,
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4627.27,,,,,,,fee schedule,2637.94,4627.27,
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7076.3,,,,,,,fee schedule,6739.33,12130.79,APC
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6739.33,,,,,,,fee schedule,6739.33,12130.79,APC
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12130.79,,,,,,,fee schedule,6739.33,12130.79,APC
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26625.8,,,,,,,fee schedule,17455.87,30619.67,
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17455.87,,,,,,,fee schedule,17455.87,30619.67,
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21793.22,,,,,,,fee schedule,17455.87,30619.67,
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30619.67,,,,,,,fee schedule,17455.87,30619.67,
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,5927.15,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,5927.15,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,5927.15,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,5927.15,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,5927.15,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,5927.15,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,5927.15,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,5927.15,
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3971.69,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2820.94,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2820.94,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2603.84,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3250.83,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3244.08,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.44,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2820.94,,,,,,,fee schedule,2603.84,4567.44,
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3971.69,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2820.94,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2820.94,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2603.84,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3250.83,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3244.08,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.44,,,,,,,fee schedule,2603.84,4567.44,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2820.94,,,,,,,fee schedule,2603.84,4567.44,
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Interrogate crtd sns dev,0272T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,218.58,
Interrogate crtd sns dev,0272T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,218.58,
Interrogate crtd sns dev,0272T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,218.58,
Interrogate crtd sns dev,0272T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,218.58,
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Interrogate crtd sns w/pgrmg,0273T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,218.58,
Interrogate crtd sns w/pgrmg,0273T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,218.58,
Interrogate crtd sns w/pgrmg,0273T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,218.58,
Interrogate crtd sns w/pgrmg,0273T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,218.58,
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4745.33,13014.22,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,8323.87,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,8323.87,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4745.33,8323.87,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,8323.87,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,8323.87,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4745.33,8323.87,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,8323.87,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,8323.87,
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.29,,,,,,,fee schedule,18.37,33.07,APC
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.37,,,,,,,fee schedule,18.37,33.07,APC
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.07,,,,,,,fee schedule,18.37,33.07,APC
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2448.56,4407.41,APC
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2448.56,,,,,,,fee schedule,2448.56,4407.41,APC
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4407.41,,,,,,,fee schedule,2448.56,4407.41,APC
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Tempr,0278T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,608.17,1094.71,APC
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.17,,,,,,,fee schedule,608.17,1094.71,APC
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1094.71,,,,,,,fee schedule,608.17,1094.71,APC
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,11.53,20.75,APC
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.53,,,,,,,fee schedule,11.53,20.75,APC
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.75,,,,,,,fee schedule,11.53,20.75,APC
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,17.27,31.09,APC
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,17.27,31.09,APC
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,17.27,31.09,APC
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,17.27,31.09,APC
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,17.27,31.09,APC
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,17.27,31.09,APC
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,756,,,,,,,fee schedule,720,1296,APC
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,720,,,,,,,fee schedule,720,1296,APC
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1296,,,,,,,fee schedule,720,1296,APC
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,18.4,33.12,APC
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.4,,,,,,,fee schedule,18.4,33.12,APC
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.12,,,,,,,fee schedule,18.4,33.12,APC
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,17.27,31.09,APC
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,17.27,31.09,APC
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,17.27,31.09,APC
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,465.48,,,,,,,fee schedule,443.31,797.96,APC
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,443.31,,,,,,,fee schedule,443.31,797.96,APC
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,797.96,,,,,,,fee schedule,443.31,797.96,APC
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.84,,,,,,,fee schedule,134.13,241.43,APC
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,134.13,,,,,,,fee schedule,134.13,241.43,APC
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.43,,,,,,,fee schedule,134.13,241.43,APC
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3600,6480,APC
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3600,,,,,,,fee schedule,3600,6480,APC
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6480,,,,,,,fee schedule,3600,6480,APC
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3873,6971.4,APC
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3873,6971.4,APC
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3873,6971.4,APC
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1842.75,,,,,,,fee schedule,1755,3159,APC
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1755,,,,,,,fee schedule,1755,3159,APC
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3159,,,,,,,fee schedule,1755,3159,APC
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1842.75,,,,,,,fee schedule,1755,3159,APC
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1755,,,,,,,fee schedule,1755,3159,APC
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3159,,,,,,,fee schedule,1755,3159,APC
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5706.75,,,,,,,fee schedule,5435,9783,APC
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5435,,,,,,,fee schedule,5435,9783,APC
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9783,,,,,,,fee schedule,5435,9783,APC
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1950,3510,APC
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1950,,,,,,,fee schedule,1950,3510,APC
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3510,,,,,,,fee schedule,1950,3510,APC
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1956.38,,,,,,,fee schedule,1863.22,3353.8,APC
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1863.22,,,,,,,fee schedule,1863.22,3353.8,APC
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3353.8,,,,,,,fee schedule,1863.22,3353.8,APC
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4392.29,,,,,,,fee schedule,4183.13,7529.63,APC
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4183.13,,,,,,,fee schedule,4183.13,7529.63,APC
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7529.63,,,,,,,fee schedule,4183.13,7529.63,APC
Iadna bartonella ddpcr,0301U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,275.86,,,,,,,fee schedule,262.72,472.9,APC
Iadna bartonella ddpcr,0301U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,262.72,,,,,,,fee schedule,262.72,472.9,APC
Iadna bartonella ddpcr,0301U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,472.9,,,,,,,fee schedule,262.72,472.9,APC
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,379.44,,,,,,,fee schedule,361.37,650.47,APC
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,361.37,,,,,,,fee schedule,361.37,650.47,APC
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,650.47,,,,,,,fee schedule,361.37,650.47,APC
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2311.7,,,,,,,fee schedule,2201.62,3962.92,APC
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2201.62,,,,,,,fee schedule,2201.62,3962.92,APC
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3962.92,,,,,,,fee schedule,2201.62,3962.92,APC
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2179.59,,,,,,,fee schedule,2075.8,3736.44,APC
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2075.8,,,,,,,fee schedule,2075.8,3736.44,APC
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3736.44,,,,,,,fee schedule,2075.8,3736.44,APC
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,695.71,,,,,,,fee schedule,662.58,1192.64,APC
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,662.58,,,,,,,fee schedule,662.58,1192.64,APC
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1192.64,,,,,,,fee schedule,662.58,1192.64,APC
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4072.37,,,,,,,fee schedule,3878.45,6981.21,APC
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3878.45,,,,,,,fee schedule,3878.45,6981.21,APC
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6981.21,,,,,,,fee schedule,3878.45,6981.21,APC
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.21,,,,,,,fee schedule,794.49,1430.08,APC
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,794.49,,,,,,,fee schedule,794.49,1430.08,APC
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1430.08,,,,,,,fee schedule,794.49,1430.08,APC
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41837.47,,,,,,,fee schedule,16401.63,63082.15,
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54854.04,,,,,,,fee schedule,16401.63,63082.15,
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54854.04,,,,,,,fee schedule,16401.63,63082.15,
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27428.65,,,,,,,fee schedule,16401.63,63082.15,
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34243.97,,,,,,,fee schedule,16401.63,63082.15,
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63082.15,,,,,,,fee schedule,16401.63,63082.15,
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48113.09,,,,,,,fee schedule,16401.63,63082.15,
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54854.04,,,,,,,fee schedule,16401.63,63082.15,
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17221.72,,,,,,,fee schedule,16401.63,63082.15,APC
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16401.63,,,,,,,fee schedule,16401.63,63082.15,APC
Insj ocular telescope prosth,0308T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29522.94,,,,,,,fee schedule,16401.63,63082.15,APC
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,390.75,703.35,APC
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,390.75,,,,,,,fee schedule,390.75,703.35,APC
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,703.35,,,,,,,fee schedule,390.75,703.35,APC
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,390.75,703.35,APC
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,390.75,,,,,,,fee schedule,390.75,703.35,APC
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,703.35,,,,,,,fee schedule,390.75,703.35,APC
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,390.75,703.35,APC
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,390.75,,,,,,,fee schedule,390.75,703.35,APC
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,703.35,,,,,,,fee schedule,390.75,703.35,APC
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.48,,,,,,,fee schedule,8.08,14.54,APC
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.08,,,,,,,fee schedule,8.08,14.54,APC
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.54,,,,,,,fee schedule,8.08,14.54,APC
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,840.65,1513.17,APC
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,840.65,,,,,,,fee schedule,840.65,1513.17,APC
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1513.17,,,,,,,fee schedule,840.65,1513.17,APC
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3600,6480,APC
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3600,,,,,,,fee schedule,3600,6480,APC
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6480,,,,,,,fee schedule,3600,6480,APC
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1950,3510,APC
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1950,,,,,,,fee schedule,1950,3510,APC
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3510,,,,,,,fee schedule,1950,3510,APC
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8925,,,,,,,fee schedule,8500,15300,APC
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8500,,,,,,,fee schedule,8500,15300,APC
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15300,,,,,,,fee schedule,8500,15300,APC
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.59,,,,,,,fee schedule,18.66,33.59,APC
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.66,,,,,,,fee schedule,18.66,33.59,APC
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.59,,,,,,,fee schedule,18.66,33.59,APC
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2131.5,,,,,,,fee schedule,2030,3654,APC
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2030,,,,,,,fee schedule,2030,3654,APC
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3654,,,,,,,fee schedule,2030,3654,APC
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1859,,,,,,,fee schedule,1770.48,3186.86,APC
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1770.48,,,,,,,fee schedule,1770.48,3186.86,APC
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3186.86,,,,,,,fee schedule,1770.48,3186.86,APC
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2782.5,,,,,,,fee schedule,2650,4770,APC
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2650,,,,,,,fee schedule,2650,4770,APC
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4770,,,,,,,fee schedule,2650,4770,APC
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2782.5,,,,,,,fee schedule,2650,4770,APC
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2650,,,,,,,fee schedule,2650,4770,APC
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4770,,,,,,,fee schedule,2650,4770,APC
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.58,,,,,,,fee schedule,634.84,1142.71,APC
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,634.84,,,,,,,fee schedule,634.84,1142.71,APC
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1142.71,,,,,,,fee schedule,634.84,1142.71,APC
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,750,1350,APC
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,750,,,,,,,fee schedule,750,1350,APC
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1350,,,,,,,fee schedule,750,1350,APC
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2232.51,,,,,,,fee schedule,2126.2,3827.16,APC
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2126.2,,,,,,,fee schedule,2126.2,3827.16,APC
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3827.16,,,,,,,fee schedule,2126.2,3827.16,APC
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5250,,,,,,,fee schedule,5000,9000,APC
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5000,,,,,,,fee schedule,5000,9000,APC
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9000,,,,,,,fee schedule,5000,9000,APC
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.75,,,,,,,fee schedule,795,1431,APC
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,795,,,,,,,fee schedule,795,1431,APC
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1431,,,,,,,fee schedule,795,1431,APC
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,114.43,205.97,APC
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,114.43,,,,,,,fee schedule,114.43,205.97,APC
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,205.97,,,,,,,fee schedule,114.43,205.97,APC
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3609.88,,,,,,,fee schedule,3437.98,6188.36,APC
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3437.98,,,,,,,fee schedule,3437.98,6188.36,APC
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6188.36,,,,,,,fee schedule,3437.98,6188.36,APC
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1681.31,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1511.35,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1511.35,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1102.27,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1376.15,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1738.05,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1933.51,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1511.35,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,1102.27,2321.99,APC
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,1102.27,2321.99,APC
Heart symp image plnr,0331T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,1102.27,2321.99,APC
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1956.38,,,,,,,fee schedule,1863.22,3353.8,APC
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1863.22,,,,,,,fee schedule,1863.22,3353.8,APC
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3353.8,,,,,,,fee schedule,1863.22,3353.8,APC
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1681.31,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1511.35,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1511.35,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1376.15,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1102.27,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1738.05,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1933.51,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1511.35,,,,,,,fee schedule,1102.27,2321.99,
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,1102.27,2321.99,APC
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,1102.27,2321.99,APC
Heart symp image plnr spect,0332T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,1102.27,2321.99,APC
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1199.16,,,,,,,fee schedule,1142.06,2055.71,APC
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1142.06,,,,,,,fee schedule,1142.06,2055.71,APC
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2055.71,,,,,,,fee schedule,1142.06,2055.71,APC
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,695.44,,,,,,,fee schedule,662.32,1192.18,APC
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,662.32,,,,,,,fee schedule,662.32,1192.18,APC
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1192.18,,,,,,,fee schedule,662.32,1192.18,APC
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3500,6300,APC
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3500,,,,,,,fee schedule,3500,6300,APC
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6300,,,,,,,fee schedule,3500,6300,APC
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11456.8,,,,,,,fee schedule,2706.78,13175.32,
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13175.32,
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13175.32,
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9377.39,,,,,,,fee schedule,2706.78,13175.32,
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7511.08,,,,,,,fee schedule,2706.78,13175.32,
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13175.32,
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13175.32,,,,,,,fee schedule,2706.78,13175.32,
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13175.32,
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13175.32,APC
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13175.32,APC
Extraosseous joint stblztion,0335T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13175.32,APC
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5485.83,,,,,,,fee schedule,5224.6,9404.28,APC
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5224.6,,,,,,,fee schedule,5224.6,9404.28,APC
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9404.28,,,,,,,fee schedule,5224.6,9404.28,APC
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2703.38,,,,,,,fee schedule,2574.65,4634.37,APC
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2574.65,,,,,,,fee schedule,2574.65,4634.37,APC
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4634.37,,,,,,,fee schedule,2574.65,4634.37,APC
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2435,4383,APC
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2435,,,,,,,fee schedule,2435,4383,APC
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4383,,,,,,,fee schedule,2435,4383,APC
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6041.29,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3392.91,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3392.91,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4944.8,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3960.67,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3901.85,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6947.48,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3392.91,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,3392.91,10207.97,APC
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,3392.91,10207.97,APC
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,3392.91,10207.97,APC
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2435,4383,APC
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2435,,,,,,,fee schedule,2435,4383,APC
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4383,,,,,,,fee schedule,2435,4383,APC
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6041.29,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3392.91,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3392.91,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4944.8,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3960.67,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3901.85,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6947.48,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3392.91,,,,,,,fee schedule,3392.91,10207.97,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,3392.91,10207.97,APC
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,3392.91,10207.97,APC
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,3392.91,10207.97,APC
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3769.5,,,,,,,fee schedule,3590,6462,APC
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3590,,,,,,,fee schedule,3590,6462,APC
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6462,,,,,,,fee schedule,3590,6462,APC
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1995.21,,,,,,,fee schedule,1900.2,3420.36,APC
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1900.2,,,,,,,fee schedule,1900.2,3420.36,APC
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3420.36,,,,,,,fee schedule,1900.2,3420.36,APC
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4705.9,,,,,,,fee schedule,3085.19,7811.71,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3085.19,,,,,,,fee schedule,3085.19,7811.71,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3851.78,,,,,,,fee schedule,3085.19,7811.71,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,3085.19,7811.71,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5411.79,,,,,,,fee schedule,3085.19,7811.71,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4556.83,,,,,,,fee schedule,3085.19,7811.71,APC
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4339.84,,,,,,,fee schedule,3085.19,7811.71,APC
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7811.71,,,,,,,fee schedule,3085.19,7811.71,APC
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,831.78,,,,,,,fee schedule,792.17,1425.91,APC
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,792.17,,,,,,,fee schedule,792.17,1425.91,APC
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1425.91,,,,,,,fee schedule,792.17,1425.91,APC
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1336.09,2404.96,APC
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1336.09,,,,,,,fee schedule,1336.09,2404.96,APC
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2404.96,,,,,,,fee schedule,1336.09,2404.96,APC
Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Ins bone device for rsa,0347T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1336.09,2404.96,APC
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1336.09,,,,,,,fee schedule,1336.09,2404.96,APC
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2404.96,,,,,,,fee schedule,1336.09,2404.96,APC
RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,168.59,,,,,,,fee schedule,104.17,193.88,
RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.99,,,,,,,fee schedule,104.17,193.88,
RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.53,,,,,,,fee schedule,104.17,193.88,
RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,193.88,,,,,,,fee schedule,104.17,193.88,
RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,193.88,APC
RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,193.88,APC
RSA spine exam,0348T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,193.88,APC
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,779.38,,,,,,,fee schedule,742.27,1336.09,APC
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,742.27,,,,,,,fee schedule,742.27,1336.09,APC
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1336.09,,,,,,,fee schedule,742.27,1336.09,APC
RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,168.59,,,,,,,fee schedule,104.17,193.88,
RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.99,,,,,,,fee schedule,104.17,193.88,
RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.53,,,,,,,fee schedule,104.17,193.88,
RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,193.88,,,,,,,fee schedule,104.17,193.88,
RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,193.88,APC
RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,193.88,APC
RSA upper extr exam,0349T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,193.88,APC
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,779.38,,,,,,,fee schedule,742.27,1336.09,APC
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,742.27,,,,,,,fee schedule,742.27,1336.09,APC
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1336.09,,,,,,,fee schedule,742.27,1336.09,APC
RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.51,,,,,,,fee schedule,58.68,156.08,
RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.26,,,,,,,fee schedule,58.68,156.08,
RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.68,,,,,,,fee schedule,58.68,156.08,
RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.94,,,,,,,fee schedule,58.68,156.08,
RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,58.68,156.08,APC
RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,58.68,156.08,APC
RSA lower extr exam,0350T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,58.68,156.08,APC
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1336.09,2404.96,APC
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1336.09,,,,,,,fee schedule,1336.09,2404.96,APC
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2404.96,,,,,,,fee schedule,1336.09,2404.96,APC
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.52,,,,,,,fee schedule,260.5,468.9,APC
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.5,,,,,,,fee schedule,260.5,468.9,APC
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,468.9,,,,,,,fee schedule,260.5,468.9,APC
Apol1 risk variants,0355U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,137,246.6,APC
Apol1 risk variants,0355U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,137,246.6,APC
Apol1 risk variants,0355U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,137,246.6,APC
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1890,,,,,,,fee schedule,1800,3240,APC
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1800,,,,,,,fee schedule,1800,3240,APC
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3240,,,,,,,fee schedule,1800,3240,APC
BIA whole body,0358T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,51.88,
BIA whole body,0358T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,51.88,
BIA whole body,0358T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,51.88,
BIA whole body,0358T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,51.88,
BIA whole body,0358T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,27.82,51.88,APC
BIA whole body,0358T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,27.82,51.88,APC
BIA whole body,0358T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,27.82,51.88,APC
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.52,,,,,,,fee schedule,260.5,468.9,APC
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.5,,,,,,,fee schedule,260.5,468.9,APC
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,468.9,,,,,,,fee schedule,260.5,468.9,APC
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,840.65,1513.17,APC
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,840.65,,,,,,,fee schedule,840.65,1513.17,APC
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1513.17,,,,,,,fee schedule,840.65,1513.17,APC
Expose behav assessment,0362T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,37.33,120.85,
Expose behav assessment,0362T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,37.33,120.85,
Expose behav assessment,0362T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,37.33,120.85,
Expose behav assessment,0362T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,37.33,120.85,
Expose behav assessment,0362T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,120.85,APC
Expose behav assessment,0362T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,120.85,APC
Expose behav assessment,0362T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,120.85,APC
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3600,6480,APC
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3600,,,,,,,fee schedule,3600,6480,APC
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6480,,,,,,,fee schedule,3600,6480,APC
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2107.61,,,,,,,fee schedule,2007.25,3613.05,APC
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2007.25,,,,,,,fee schedule,2007.25,3613.05,APC
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3613.05,,,,,,,fee schedule,2007.25,3613.05,APC
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,897,1614.6,APC
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,897,,,,,,,fee schedule,897,1614.6,APC
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1614.6,,,,,,,fee schedule,897,1614.6,APC
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,897,1614.6,APC
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,897,,,,,,,fee schedule,897,1614.6,APC
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1614.6,,,,,,,fee schedule,897,1614.6,APC
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,947.29,,,,,,,fee schedule,902.18,1623.92,APC
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,902.18,,,,,,,fee schedule,902.18,1623.92,APC
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1623.92,,,,,,,fee schedule,902.18,1623.92,APC
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Exposure behavior treatment,0373T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,37.33,216.74,
Exposure behavior treatment,0373T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,37.33,216.74,
Exposure behavior treatment,0373T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,37.33,216.74,
Exposure behavior treatment,0373T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,37.33,216.74,
Exposure behavior treatment,0373T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,216.74,APC
Exposure behavior treatment,0373T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,216.74,APC
Exposure behavior treatment,0373T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,216.74,APC
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,897,1614.6,APC
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,897,,,,,,,fee schedule,897,1614.6,APC
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1614.6,,,,,,,fee schedule,897,1614.6,APC
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,706.25,1271.25,APC
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.25,,,,,,,fee schedule,706.25,1271.25,APC
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1271.25,,,,,,,fee schedule,706.25,1271.25,APC
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.96,,,,,,,fee schedule,47.58,85.64,APC
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.58,,,,,,,fee schedule,47.58,85.64,APC
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,85.64,,,,,,,fee schedule,47.58,85.64,APC
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,137,246.6,APC
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,137,246.6,APC
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,137,246.6,APC
Vis field assmnt tech suppt,0379T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Vis field assmnt tech suppt,0379T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Vis field assmnt tech suppt,0379T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Vis field assmnt tech suppt,0379T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Vis field assmnt tech suppt,0379T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Vis field assmnt tech suppt,0379T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Vis field assmnt tech suppt,0379T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3452.94,,,,,,,fee schedule,3288.51,5919.32,APC
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3288.51,,,,,,,fee schedule,3288.51,5919.32,APC
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5919.32,,,,,,,fee schedule,3288.51,5919.32,APC
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.33,,,,,,,fee schedule,44.12,79.42,APC
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,44.12,,,,,,,fee schedule,44.12,79.42,APC
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,79.42,,,,,,,fee schedule,44.12,79.42,APC
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.22,,,,,,,fee schedule,51.64,92.95,APC
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.64,,,,,,,fee schedule,51.64,92.95,APC
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.95,,,,,,,fee schedule,51.64,92.95,APC
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.65,,,,,,,fee schedule,52.05,93.69,APC
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52.05,,,,,,,fee schedule,52.05,93.69,APC
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.69,,,,,,,fee schedule,52.05,93.69,APC
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,750,1350,APC
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,750,,,,,,,fee schedule,750,1350,APC
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1350,,,,,,,fee schedule,750,1350,APC
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,390.75,703.35,APC
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,390.75,,,,,,,fee schedule,390.75,703.35,APC
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,703.35,,,,,,,fee schedule,390.75,703.35,APC
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,995.92,,,,,,,fee schedule,948.5,1707.3,APC
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,948.5,,,,,,,fee schedule,948.5,1707.3,APC
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1707.3,,,,,,,fee schedule,948.5,1707.3,APC
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3500,6300,APC
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3500,,,,,,,fee schedule,3500,6300,APC
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6300,,,,,,,fee schedule,3500,6300,APC
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.71,,,,,,,fee schedule,70.2,126.36,APC
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.2,,,,,,,fee schedule,70.2,126.36,APC
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,126.36,,,,,,,fee schedule,70.2,126.36,APC
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,64.41,115.94,APC
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.41,,,,,,,fee schedule,64.41,115.94,APC
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.94,,,,,,,fee schedule,64.41,115.94,APC
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3600,6480,APC
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3600,,,,,,,fee schedule,3600,6480,APC
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6480,,,,,,,fee schedule,3600,6480,APC
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1336.09,2404.96,APC
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1336.09,,,,,,,fee schedule,1336.09,2404.96,APC
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2404.96,,,,,,,fee schedule,1336.09,2404.96,APC
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.04,,,,,,,fee schedule,540.99,973.78,APC
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,540.99,,,,,,,fee schedule,540.99,973.78,APC
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.78,,,,,,,fee schedule,540.99,973.78,APC
Hdr elctrnc skn surf brchytx,0394T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,301.89,,,,,,,fee schedule,197.92,347.17,
Hdr elctrnc skn surf brchytx,0394T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,247.1,,,,,,,fee schedule,197.92,347.17,
Hdr elctrnc skn surf brchytx,0394T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.92,,,,,,,fee schedule,197.92,347.17,
Hdr elctrnc skn surf brchytx,0394T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,347.17,,,,,,,fee schedule,197.92,347.17,
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,198.74,357.73,APC
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.74,,,,,,,fee schedule,198.74,357.73,APC
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,357.73,,,,,,,fee schedule,198.74,357.73,APC
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1090.38,,,,,,,fee schedule,693.97,1253.94,
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,892.48,,,,,,,fee schedule,693.97,1253.94,
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,714.85,,,,,,,fee schedule,693.97,1253.94,
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1253.94,,,,,,,fee schedule,693.97,1253.94,
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.67,,,,,,,fee schedule,693.97,1253.94,APC
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.97,,,,,,,fee schedule,693.97,1253.94,APC
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1249.15,,,,,,,fee schedule,693.97,1253.94,APC
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.32,,,,,,,fee schedule,797.45,1435.41,APC
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,797.45,,,,,,,fee schedule,797.45,1435.41,APC
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1435.41,,,,,,,fee schedule,797.45,1435.41,APC
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1842.75,,,,,,,fee schedule,1755,3159,APC
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1755,,,,,,,fee schedule,1755,3159,APC
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3159,,,,,,,fee schedule,1755,3159,APC
Neuro cere folate defncy srm,0399U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315,,,,,,,fee schedule,300,540,APC
Neuro cere folate defncy srm,0399U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,300,,,,,,,fee schedule,300,540,APC
Neuro cere folate defncy srm,0399U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,540,,,,,,,fee schedule,300,540,APC
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,514.16,,,,,,,fee schedule,489.68,881.42,APC
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,489.68,,,,,,,fee schedule,489.68,881.42,APC
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,881.42,,,,,,,fee schedule,489.68,881.42,APC
Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1143.41,,,,,,,fee schedule,749.62,4264.08,
Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,935.88,,,,,,,fee schedule,749.62,4264.08,
Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,749.62,,,,,,,fee schedule,749.62,4264.08,
Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1314.92,,,,,,,fee schedule,749.62,4264.08,
Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,749.62,4264.08,APC
Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,749.62,4264.08,APC
Collagen crosslinking cornea,0402T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,749.62,4264.08,APC
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,142.63,256.73,APC
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,142.63,256.73,APC
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,142.63,256.73,APC
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.11,,,,,,,fee schedule,322.96,581.33,APC
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,322.96,,,,,,,fee schedule,322.96,581.33,APC
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,581.33,,,,,,,fee schedule,322.96,581.33,APC
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1859,,,,,,,fee schedule,1770.48,3186.86,APC
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1770.48,,,,,,,fee schedule,1770.48,3186.86,APC
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3186.86,,,,,,,fee schedule,1770.48,3186.86,APC
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,997.5,,,,,,,fee schedule,950,1710,APC
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,950,,,,,,,fee schedule,950,1710,APC
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1710,,,,,,,fee schedule,950,1710,APC
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43102.23,,,,,,,fee schedule,28257.82,56296.78,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35279.18,,,,,,,fee schedule,28257.82,56296.78,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28257.82,,,,,,,fee schedule,28257.82,56296.78,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49567.56,,,,,,,fee schedule,28257.82,56296.78,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32839.79,,,,,,,fee schedule,28257.82,56296.78,APC
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31275.99,,,,,,,fee schedule,28257.82,56296.78,APC
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56296.78,,,,,,,fee schedule,28257.82,56296.78,APC
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.84,,,,,,,fee schedule,14.13,25.43,APC
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.13,,,,,,,fee schedule,14.13,25.43,APC
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.43,,,,,,,fee schedule,14.13,25.43,APC
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43102.23,,,,,,,fee schedule,22163.59,49567.56,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35279.18,,,,,,,fee schedule,22163.59,49567.56,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28257.82,,,,,,,fee schedule,22163.59,49567.56,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49567.56,,,,,,,fee schedule,22163.59,49567.56,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,22163.59,49567.56,APC
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,22163.59,49567.56,APC
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,22163.59,49567.56,APC
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13520.97,,,,,,,fee schedule,8245.63,15549.12,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11066.91,,,,,,,fee schedule,8245.63,15549.12,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8864.35,,,,,,,fee schedule,8245.63,15549.12,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15549.12,,,,,,,fee schedule,8245.63,15549.12,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,15549.12,APC
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,15549.12,APC
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,15549.12,APC
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1160,2088,APC
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1160,,,,,,,fee schedule,1160,2088,APC
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2088,,,,,,,fee schedule,1160,2088,APC
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13520.97,,,,,,,fee schedule,8245.63,15549.12,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11066.91,,,,,,,fee schedule,8245.63,15549.12,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8864.35,,,,,,,fee schedule,8245.63,15549.12,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15549.12,,,,,,,fee schedule,8245.63,15549.12,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,15549.12,APC
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,15549.12,APC
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,15549.12,APC
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1336.09,2404.96,APC
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1336.09,,,,,,,fee schedule,1336.09,2404.96,APC
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2404.96,,,,,,,fee schedule,1336.09,2404.96,APC
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3778.52,,,,,,,fee schedule,2477.2,6702.34,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3092.72,,,,,,,fee schedule,2477.2,6702.34,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2477.2,,,,,,,fee schedule,2477.2,6702.34,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4345.3,,,,,,,fee schedule,2477.2,6702.34,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2477.2,6702.34,APC
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2477.2,6702.34,APC
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2477.2,6702.34,APC
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,750,1350,APC
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,750,,,,,,,fee schedule,750,1350,APC
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1350,,,,,,,fee schedule,750,1350,APC
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3778.52,,,,,,,fee schedule,2477.2,6702.34,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3092.72,,,,,,,fee schedule,2477.2,6702.34,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2477.2,,,,,,,fee schedule,2477.2,6702.34,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4345.3,,,,,,,fee schedule,2477.2,6702.34,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2477.2,6702.34,APC
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2477.2,6702.34,APC
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2477.2,6702.34,APC
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1263.53,2274.35,APC
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1263.53,,,,,,,fee schedule,1263.53,2274.35,APC
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2274.35,,,,,,,fee schedule,1263.53,2274.35,APC
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43102.23,,,,,,,fee schedule,22163.59,49567.56,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35279.18,,,,,,,fee schedule,22163.59,49567.56,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28257.82,,,,,,,fee schedule,22163.59,49567.56,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49567.56,,,,,,,fee schedule,22163.59,49567.56,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,22163.59,49567.56,APC
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,22163.59,49567.56,APC
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,22163.59,49567.56,APC
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,706.25,1271.25,APC
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.25,,,,,,,fee schedule,706.25,1271.25,APC
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1271.25,,,,,,,fee schedule,706.25,1271.25,APC
Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,625.05,1161.41,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,625.05,1161.41,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,625.05,1161.41,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,625.05,1161.41,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1161.41,APC
Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1161.41,APC
Repos car modulj tranvns elt,0415T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1161.41,APC
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,390.75,703.35,APC
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,390.75,,,,,,,fee schedule,390.75,703.35,APC
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,703.35,,,,,,,fee schedule,390.75,703.35,APC
Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Reloc skin pocket pls gen,0416T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.56,,,,,,,fee schedule,34.46,66.94,
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.02,,,,,,,fee schedule,34.46,66.94,
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.46,,,,,,,fee schedule,34.46,66.94,
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.44,,,,,,,fee schedule,34.46,66.94,
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,34.46,66.94,APC
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,34.46,66.94,APC
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,34.46,66.94,APC
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2984.66,,,,,,,fee schedule,2842.53,5116.55,APC
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2842.53,,,,,,,fee schedule,2842.53,5116.55,APC
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5116.55,,,,,,,fee schedule,2842.53,5116.55,APC
Interro eval cardiac modulj,0418T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.56,,,,,,,fee schedule,34.46,66.94,
Interro eval cardiac modulj,0418T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.02,,,,,,,fee schedule,34.46,66.94,
Interro eval cardiac modulj,0418T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.46,,,,,,,fee schedule,34.46,66.94,
Interro eval cardiac modulj,0418T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.44,,,,,,,fee schedule,34.46,66.94,
Interro eval cardiac modulj,0418T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,34.46,66.94,APC
Interro eval cardiac modulj,0418T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,34.46,66.94,APC
Interro eval cardiac modulj,0418T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,34.46,66.94,APC
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,706.25,1271.25,APC
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.25,,,,,,,fee schedule,706.25,1271.25,APC
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1271.25,,,,,,,fee schedule,706.25,1271.25,APC
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1336.09,2404.96,APC
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1336.09,,,,,,,fee schedule,1336.09,2404.96,APC
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2404.96,,,,,,,fee schedule,1336.09,2404.96,APC
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1394.74,,,,,,,fee schedule,1328.32,2390.98,APC
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1328.32,,,,,,,fee schedule,1328.32,2390.98,APC
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2390.98,,,,,,,fee schedule,1328.32,2390.98,APC
Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.37,,,,,,,fee schedule,57.94,156.08,
Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.33,,,,,,,fee schedule,57.94,156.08,
Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.94,,,,,,,fee schedule,57.94,156.08,
Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.63,,,,,,,fee schedule,57.94,156.08,
Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.94,156.08,APC
Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.94,156.08,APC
Tactile breast img uni/bi,0422T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.94,156.08,APC
Onc pan solid tum alys dna,0422U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2040.37,,,,,,,fee schedule,1943.21,3497.78,APC
Onc pan solid tum alys dna,0422U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1943.21,,,,,,,fee schedule,1943.21,3497.78,APC
Onc pan solid tum alys dna,0422U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3497.78,,,,,,,fee schedule,1943.21,3497.78,APC
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4299.11,,,,,,,fee schedule,4094.39,7369.9,APC
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4094.39,,,,,,,fee schedule,4094.39,7369.9,APC
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7369.9,,,,,,,fee schedule,4094.39,7369.9,APC
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7961.31,,,,,,,fee schedule,7582.2,13647.96,APC
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7582.2,,,,,,,fee schedule,7582.2,13647.96,APC
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13647.96,,,,,,,fee schedule,7582.2,13647.96,APC
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.7,,,,,,,fee schedule,4.48,8.06,APC
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.48,8.06,APC
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.06,,,,,,,fee schedule,4.48,8.06,APC
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,63.16,APC
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,63.16,APC
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,63.16,APC
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.62,,,,,,,fee schedule,61.54,110.77,APC
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,61.54,,,,,,,fee schedule,61.54,110.77,APC
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,110.77,,,,,,,fee schedule,61.54,110.77,APC
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.4,,,,,,,fee schedule,36.57,65.83,APC
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.57,,,,,,,fee schedule,36.57,65.83,APC
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.83,,,,,,,fee schedule,36.57,65.83,APC
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.4,,,,,,,fee schedule,36.57,65.83,APC
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.57,,,,,,,fee schedule,36.57,65.83,APC
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.83,,,,,,,fee schedule,36.57,65.83,APC
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.55,,,,,,,fee schedule,3033.86,5460.95,APC
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3033.86,,,,,,,fee schedule,3033.86,5460.95,APC
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5460.95,,,,,,,fee schedule,3033.86,5460.95,APC
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1579.45,,,,,,,fee schedule,1504.24,2707.63,APC
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1504.24,,,,,,,fee schedule,1504.24,2707.63,APC
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2707.63,,,,,,,fee schedule,1504.24,2707.63,APC
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,896.7,,,,,,,fee schedule,854,1537.2,APC
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,854,,,,,,,fee schedule,854,1537.2,APC
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1537.2,,,,,,,fee schedule,854,1537.2,APC
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,1945.7,5927.15,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,1945.7,5927.15,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,1945.7,5927.15,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,1945.7,5927.15,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,5927.15,APC
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,5927.15,APC
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,5927.15,APC
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,896.7,,,,,,,fee schedule,854,1537.2,APC
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,854,,,,,,,fee schedule,854,1537.2,APC
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1537.2,,,,,,,fee schedule,854,1537.2,APC
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,1945.7,5927.15,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,1945.7,5927.15,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,1945.7,5927.15,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,1945.7,5927.15,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,5927.15,APC
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,5927.15,APC
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,5927.15,APC
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,466.28,,,,,,,fee schedule,444.08,799.34,APC
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,444.08,,,,,,,fee schedule,444.08,799.34,APC
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,799.34,,,,,,,fee schedule,444.08,799.34,APC
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.45,,,,,,,fee schedule,41.38,74.48,APC
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.38,,,,,,,fee schedule,41.38,74.48,APC
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74.48,,,,,,,fee schedule,41.38,74.48,APC
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,116.23,209.21,APC
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.23,,,,,,,fee schedule,116.23,209.21,APC
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,209.21,,,,,,,fee schedule,116.23,209.21,APC
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.52,,,,,,,fee schedule,260.5,468.9,APC
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.5,,,,,,,fee schedule,260.5,468.9,APC
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,468.9,,,,,,,fee schedule,260.5,468.9,APC
Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,901.83,,,,,,,fee schedule,591.24,7461.77,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,738.15,,,,,,,fee schedule,591.24,7461.77,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,591.24,,,,,,,fee schedule,591.24,7461.77,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1037.1,,,,,,,fee schedule,591.24,7461.77,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4352.7,,,,,,,fee schedule,591.24,7461.77,APC
Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4145.43,,,,,,,fee schedule,591.24,7461.77,APC
Insj impltbl glucose sensor,0446T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7461.77,,,,,,,fee schedule,591.24,7461.77,APC
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,840.65,1513.17,APC
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,840.65,,,,,,,fee schedule,840.65,1513.17,APC
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1513.17,,,,,,,fee schedule,840.65,1513.17,APC
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,840.65,1513.17,APC
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,840.65,,,,,,,fee schedule,840.65,1513.17,APC
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1513.17,,,,,,,fee schedule,840.65,1513.17,APC
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,7461.77,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,7461.77,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,7461.77,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,7461.77,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4352.7,,,,,,,fee schedule,438.5,7461.77,APC
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4145.43,,,,,,,fee schedule,438.5,7461.77,APC
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7461.77,,,,,,,fee schedule,438.5,7461.77,APC
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6442.1,,,,,,,fee schedule,4223.44,9543.9,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5272.86,,,,,,,fee schedule,4223.44,9543.9,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4223.44,,,,,,,fee schedule,4223.44,9543.9,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7408.42,,,,,,,fee schedule,4223.44,9543.9,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,4223.44,9543.9,APC
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,4223.44,9543.9,APC
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,4223.44,9543.9,APC
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.6,,,,,,,fee schedule,192,345.6,APC
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,192,,,,,,,fee schedule,192,345.6,APC
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,345.6,,,,,,,fee schedule,192,345.6,APC
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.6,,,,,,,fee schedule,192,345.6,APC
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,192,,,,,,,fee schedule,192,345.6,APC
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,345.6,,,,,,,fee schedule,192,345.6,APC
U rare ds id opt genome mapg,0454U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1263.53,2274.35,APC
U rare ds id opt genome mapg,0454U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1263.53,,,,,,,fee schedule,1263.53,2274.35,APC
U rare ds id opt genome mapg,0454U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2274.35,,,,,,,fee schedule,1263.53,2274.35,APC
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,142.63,256.73,APC
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,142.63,256.73,APC
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,142.63,256.73,APC
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,198.74,357.73,APC
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.74,,,,,,,fee schedule,198.74,357.73,APC
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,357.73,,,,,,,fee schedule,198.74,357.73,APC
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.52,,,,,,,fee schedule,260.5,468.9,APC
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.5,,,,,,,fee schedule,260.5,468.9,APC
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,468.9,,,,,,,fee schedule,260.5,468.9,APC
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.52,,,,,,,fee schedule,260.5,468.9,APC
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.5,,,,,,,fee schedule,260.5,468.9,APC
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,468.9,,,,,,,fee schedule,260.5,468.9,APC
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,962.93,,,,,,,fee schedule,917.08,1650.74,APC
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.08,,,,,,,fee schedule,917.08,1650.74,APC
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1650.74,,,,,,,fee schedule,917.08,1650.74,APC
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,962.93,,,,,,,fee schedule,917.08,1650.74,APC
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.08,,,,,,,fee schedule,917.08,1650.74,APC
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1650.74,,,,,,,fee schedule,917.08,1650.74,APC
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,17.27,31.09,APC
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,17.27,31.09,APC
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,17.27,31.09,APC
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Visual ep test for glaucoma,0464T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Visual ep test for glaucoma,0464T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Visual ep test for glaucoma,0464T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Visual ep test for glaucoma,0464T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Visual ep test for glaucoma,0464T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Visual ep test for glaucoma,0464T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Visual ep test for glaucoma,0464T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,621.52,,,,,,,fee schedule,591.92,1065.46,APC
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,591.92,,,,,,,fee schedule,591.92,1065.46,APC
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1065.46,,,,,,,fee schedule,591.92,1065.46,APC
Autolog prp diab wound ulcer,0465?,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,3700.55,APC
Autolog prp diab wound ulcer,0465?,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,3700.55,APC
Autolog prp diab wound ulcer,0465?,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,3700.55,APC
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2034.91,,,,,,,fee schedule,1938.01,3488.42,APC
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1938.01,,,,,,,fee schedule,1938.01,3488.42,APC
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3488.42,,,,,,,fee schedule,1938.01,3488.42,APC
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.7,,,,,,,fee schedule,345.43,621.77,APC
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,345.43,,,,,,,fee schedule,345.43,621.77,APC
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,621.77,,,,,,,fee schedule,345.43,621.77,APC
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1595.01,,,,,,,fee schedule,1519.06,2734.31,APC
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1519.06,,,,,,,fee schedule,1519.06,2734.31,APC
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2734.31,,,,,,,fee schedule,1519.06,2734.31,APC
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,264.28,,,,,,,fee schedule,251.7,453.06,APC
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,251.7,,,,,,,fee schedule,251.7,453.06,APC
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,453.06,,,,,,,fee schedule,251.7,453.06,APC
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1257.84,,,,,,,fee schedule,1197.94,2156.29,APC
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1197.94,,,,,,,fee schedule,1197.94,2156.29,APC
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2156.29,,,,,,,fee schedule,1197.94,2156.29,APC
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,597.91,1076.24,APC
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,597.91,,,,,,,fee schedule,597.91,1076.24,APC
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1076.24,,,,,,,fee schedule,597.91,1076.24,APC
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,714.96,,,,,,,fee schedule,306.03,822.2,
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,585.19,,,,,,,fee schedule,306.03,822.2,
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,468.73,,,,,,,fee schedule,306.03,822.2,
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,822.2,,,,,,,fee schedule,306.03,822.2,
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,306.03,822.2,APC
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,306.03,822.2,APC
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,306.03,822.2,APC
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.3,,,,,,,fee schedule,27.9,50.22,APC
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.9,,,,,,,fee schedule,27.9,50.22,APC
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.22,,,,,,,fee schedule,27.9,50.22,APC
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,314.44,,,,,,,fee schedule,94.73,361.61,
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,257.37,,,,,,,fee schedule,94.73,361.61,
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.15,,,,,,,fee schedule,94.73,361.61,
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,361.61,,,,,,,fee schedule,94.73,361.61,
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,361.61,APC
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,361.61,APC
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,361.61,APC
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4725,,,,,,,fee schedule,4500,8100,APC
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4500,,,,,,,fee schedule,4500,8100,APC
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8100,,,,,,,fee schedule,4500,8100,APC
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9857.58,,,,,,,fee schedule,4075.83,11336.22,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4075.83,,,,,,,fee schedule,4075.83,11336.22,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4075.83,,,,,,,fee schedule,4075.83,11336.22,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8068.43,,,,,,,fee schedule,4075.83,11336.22,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6462.63,,,,,,,fee schedule,4075.83,11336.22,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4687.2,,,,,,,fee schedule,4075.83,11336.22,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11336.22,,,,,,,fee schedule,4075.83,11336.22,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4075.83,,,,,,,fee schedule,4075.83,11336.22,
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1303.95,2347.11,APC
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1303.95,,,,,,,fee schedule,1303.95,2347.11,APC
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2347.11,,,,,,,fee schedule,1303.95,2347.11,APC
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1303.95,2347.11,APC
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1303.95,,,,,,,fee schedule,1303.95,2347.11,APC
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2347.11,,,,,,,fee schedule,1303.95,2347.11,APC
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,580.64,,,,,,,fee schedule,552.99,995.38,APC
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,552.99,,,,,,,fee schedule,552.99,995.38,APC
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,995.38,,,,,,,fee schedule,552.99,995.38,APC
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,848.5,,,,,,,fee schedule,270.41,1325.55,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.41,,,,,,,fee schedule,270.41,1325.55,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,270.41,,,,,,,fee schedule,270.41,1325.55,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,694.5,,,,,,,fee schedule,270.41,1325.55,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,556.28,,,,,,,fee schedule,270.41,1325.55,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,310.97,,,,,,,fee schedule,270.41,1325.55,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,975.78,,,,,,,fee schedule,270.41,1325.55,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,270.41,,,,,,,fee schedule,270.41,1325.55,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,270.41,1325.55,APC
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,270.41,1325.55,APC
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,270.41,1325.55,APC
Tau phosphorylated ptau217,0479U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,17.27,31.09,APC
Tau phosphorylated ptau217,0479U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,17.27,31.09,APC
Tau phosphorylated ptau217,0479U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,17.27,31.09,APC
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2232.51,,,,,,,fee schedule,2126.2,3827.16,APC
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2126.2,,,,,,,fee schedule,2126.2,3827.16,APC
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3827.16,,,,,,,fee schedule,2126.2,3827.16,APC
Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,900.96,,,,,,,fee schedule,445.12,1036.1,
Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,737.44,,,,,,,fee schedule,445.12,1036.1,
Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,590.67,,,,,,,fee schedule,445.12,1036.1,
Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1036.1,,,,,,,fee schedule,445.12,1036.1,
Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,445.12,1036.1,APC
Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,445.12,1036.1,APC
Njx autol wbc concentrate,0481T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,445.12,1036.1,APC
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,707.95,,,,,,,fee schedule,674.24,1213.63,APC
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,674.24,,,,,,,fee schedule,674.24,1213.63,APC
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1213.63,,,,,,,fee schedule,674.24,1213.63,APC
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.26,,,,,,,fee schedule,128.82,231.88,APC
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.82,,,,,,,fee schedule,128.82,231.88,APC
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.88,,,,,,,fee schedule,128.82,231.88,APC
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,63.16,APC
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,63.16,APC
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,63.16,APC
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,63.16,APC
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,63.16,APC
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,63.16,APC
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.82,,,,,,,fee schedule,37.22,99.84,
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.06,,,,,,,fee schedule,37.22,99.84,
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.92,,,,,,,fee schedule,37.22,99.84,
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.84,,,,,,,fee schedule,37.22,99.84,
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,99.84,APC
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,99.84,APC
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,99.84,APC
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3831.95,,,,,,,fee schedule,3649.48,6569.06,APC
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3649.48,,,,,,,fee schedule,3649.48,6569.06,APC
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6569.06,,,,,,,fee schedule,3649.48,6569.06,APC
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.82,,,,,,,fee schedule,37.22,99.84,
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.06,,,,,,,fee schedule,37.22,99.84,
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.92,,,,,,,fee schedule,37.22,99.84,
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.84,,,,,,,fee schedule,37.22,99.84,
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,99.84,APC
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,99.84,APC
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,99.84,APC
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1726.46,,,,,,,fee schedule,1644.25,2959.65,APC
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1644.25,,,,,,,fee schedule,1644.25,2959.65,APC
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2959.65,,,,,,,fee schedule,1644.25,2959.65,APC
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2435,4383,APC
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2435,,,,,,,fee schedule,2435,4383,APC
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4383,,,,,,,fee schedule,2435,4383,APC
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2435,4383,APC
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2435,,,,,,,fee schedule,2435,4383,APC
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4383,,,,,,,fee schedule,2435,4383,APC
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2435,4383,APC
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2435,,,,,,,fee schedule,2435,4383,APC
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4383,,,,,,,fee schedule,2435,4383,APC
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2890.91,,,,,,,fee schedule,2753.25,4955.85,APC
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2753.25,,,,,,,fee schedule,2753.25,4955.85,APC
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4955.85,,,,,,,fee schedule,2753.25,4955.85,APC
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,759.05,1366.29,APC
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,759.05,1366.29,APC
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,759.05,1366.29,APC
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,510.15,,,,,,,fee schedule,485.86,874.55,APC
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,485.86,,,,,,,fee schedule,485.86,874.55,APC
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,874.55,,,,,,,fee schedule,485.86,874.55,APC
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3873,6971.4,APC
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3873,6971.4,APC
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3873,6971.4,APC
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1412.58,,,,,,,fee schedule,1345.31,2421.56,APC
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1345.31,,,,,,,fee schedule,1345.31,2421.56,APC
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2421.56,,,,,,,fee schedule,1345.31,2421.56,APC
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,597.91,1076.24,APC
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,597.91,,,,,,,fee schedule,597.91,1076.24,APC
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1076.24,,,,,,,fee schedule,597.91,1076.24,APC
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,175.4,315.72,APC
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,175.4,,,,,,,fee schedule,175.4,315.72,APC
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,315.72,,,,,,,fee schedule,175.4,315.72,APC
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,63.16,APC
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,63.16,APC
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,63.16,APC
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,750,1350,APC
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,750,,,,,,,fee schedule,750,1350,APC
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1350,,,,,,,fee schedule,750,1350,APC
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Ev fempop artl revsc,0505T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Ev fempop artl revsc,0505T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Ev fempop artl revsc,0505T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.76,,,,,,,fee schedule,679.77,1223.59,APC
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,679.77,,,,,,,fee schedule,679.77,1223.59,APC
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1223.59,,,,,,,fee schedule,679.77,1223.59,APC
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,105.8,APC
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,105.8,APC
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,105.8,APC
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2034.91,,,,,,,fee schedule,1938.01,3488.42,APC
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1938.01,,,,,,,fee schedule,1938.01,3488.42,APC
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3488.42,,,,,,,fee schedule,1938.01,3488.42,APC
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,105.8,APC
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,105.8,APC
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,105.8,APC
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1160,2088,APC
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1160,,,,,,,fee schedule,1160,2088,APC
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2088,,,,,,,fee schedule,1160,2088,APC
Pattern erg w/i&r,0509T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,356.91,,,,,,,fee schedule,215.15,410.45,
Pattern erg w/i&r,0509T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,292.13,,,,,,,fee schedule,215.15,410.45,
Pattern erg w/i&r,0509T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.99,,,,,,,fee schedule,215.15,410.45,
Pattern erg w/i&r,0509T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.45,,,,,,,fee schedule,215.15,410.45,
Pattern erg w/i&r,0509T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,410.45,APC
Pattern erg w/i&r,0509T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,410.45,APC
Pattern erg w/i&r,0509T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,410.45,APC
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6886.93,,,,,,,fee schedule,2014.25,7919.97,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2014.25,,,,,,,fee schedule,2014.25,7919.97,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2014.25,,,,,,,fee schedule,2014.25,7919.97,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5636.95,,,,,,,fee schedule,2014.25,7919.97,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4515.07,,,,,,,fee schedule,2014.25,7919.97,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2316.39,,,,,,,fee schedule,2014.25,7919.97,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7919.97,,,,,,,fee schedule,2014.25,7919.97,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2014.25,,,,,,,fee schedule,2014.25,7919.97,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2014.25,7919.97,APC
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2014.25,7919.97,APC
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2014.25,7919.97,APC
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,497.61,,,,,,,fee schedule,473.91,853.04,APC
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,473.91,,,,,,,fee schedule,473.91,853.04,APC
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,853.04,,,,,,,fee schedule,473.91,853.04,APC
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14962.81,,,,,,,fee schedule,5683.02,17207.23,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5683.02,,,,,,,fee schedule,5683.02,17207.23,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5683.02,,,,,,,fee schedule,5683.02,17207.23,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12247.06,,,,,,,fee schedule,5683.02,17207.23,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9809.62,,,,,,,fee schedule,5683.02,17207.23,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6535.47,,,,,,,fee schedule,5683.02,17207.23,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17207.23,,,,,,,fee schedule,5683.02,17207.23,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5683.02,,,,,,,fee schedule,5683.02,17207.23,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5683.02,17207.23,APC
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5683.02,17207.23,APC
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5683.02,17207.23,APC
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.55,,,,,,,fee schedule,3033.86,5460.95,APC
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3033.86,,,,,,,fee schedule,3033.86,5460.95,APC
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5460.95,,,,,,,fee schedule,3033.86,5460.95,APC
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,824.53,,,,,,,fee schedule,199.91,948.21,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,259.3,,,,,,,fee schedule,199.91,948.21,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.3,,,,,,,fee schedule,199.91,948.21,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,674.88,,,,,,,fee schedule,199.91,948.21,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,540.56,,,,,,,fee schedule,199.91,948.21,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.2,,,,,,,fee schedule,199.91,948.21,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,948.21,,,,,,,fee schedule,199.91,948.21,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.3,,,,,,,fee schedule,199.91,948.21,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,948.21,APC
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,948.21,APC
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,948.21,APC
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,706.25,1271.25,APC
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.25,,,,,,,fee schedule,706.25,1271.25,APC
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1271.25,,,,,,,fee schedule,706.25,1271.25,APC
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,706.25,1271.25,APC
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.25,,,,,,,fee schedule,706.25,1271.25,APC
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1271.25,,,,,,,fee schedule,706.25,1271.25,APC
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,38.57,69.43,APC
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.57,,,,,,,fee schedule,38.57,69.43,APC
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.43,,,,,,,fee schedule,38.57,69.43,APC
Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57746.11,,,,,,,fee schedule,22163.59,66408.03,
Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47265.19,,,,,,,fee schedule,22163.59,66408.03,
Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37858.35,,,,,,,fee schedule,22163.59,66408.03,
Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66408.03,,,,,,,fee schedule,22163.59,66408.03,
Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,22163.59,66408.03,APC
Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,22163.59,66408.03,APC
Insj wcs lv compl sys,0515T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,22163.59,66408.03,APC
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,38.57,69.43,APC
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.57,,,,,,,fee schedule,38.57,69.43,APC
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.43,,,,,,,fee schedule,38.57,69.43,APC
Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19437.6,,,,,,,fee schedule,10414.41,22353.24,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15909.68,,,,,,,fee schedule,10414.41,22353.24,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12743.29,,,,,,,fee schedule,10414.41,22353.24,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22353.24,,,,,,,fee schedule,10414.41,22353.24,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,22353.24,APC
Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,22353.24,APC
Insj wcs lv eltrd only,0516T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,22353.24,APC
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19437.6,,,,,,,fee schedule,10414.41,22353.24,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15909.68,,,,,,,fee schedule,10414.41,22353.24,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12743.29,,,,,,,fee schedule,10414.41,22353.24,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22353.24,,,,,,,fee schedule,10414.41,22353.24,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,22353.24,APC
Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,22353.24,APC
Insj wcs lv pg compnt,0517T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,22353.24,APC
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,246.92,444.46,APC
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.92,,,,,,,fee schedule,246.92,444.46,APC
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.46,,,,,,,fee schedule,246.92,444.46,APC
Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8218.4,,,,,,,fee schedule,3723.52,9451.16,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6726.76,,,,,,,fee schedule,3723.52,9451.16,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5387.98,,,,,,,fee schedule,3723.52,9451.16,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9451.16,,,,,,,fee schedule,3723.52,9451.16,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,9451.16,APC
Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,9451.16,APC
Rmvl pg compnt wcs,0518T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,9451.16,APC
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,246.92,444.46,APC
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.92,,,,,,,fee schedule,246.92,444.46,APC
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.46,,,,,,,fee schedule,246.92,444.46,APC
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8218.4,,,,,,,fee schedule,5387.98,18745.94,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6726.76,,,,,,,fee schedule,5387.98,18745.94,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5387.98,,,,,,,fee schedule,5387.98,18745.94,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9451.16,,,,,,,fee schedule,5387.98,18745.94,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,5387.98,18745.94,APC
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,5387.98,18745.94,APC
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,5387.98,18745.94,APC
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,246.92,444.46,APC
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.92,,,,,,,fee schedule,246.92,444.46,APC
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.46,,,,,,,fee schedule,246.92,444.46,APC
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57746.11,,,,,,,fee schedule,10414.41,66408.03,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47265.19,,,,,,,fee schedule,10414.41,66408.03,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37858.35,,,,,,,fee schedule,10414.41,66408.03,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66408.03,,,,,,,fee schedule,10414.41,66408.03,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,66408.03,APC
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,66408.03,APC
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,66408.03,APC
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,246.92,444.46,APC
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.92,,,,,,,fee schedule,246.92,444.46,APC
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.46,,,,,,,fee schedule,246.92,444.46,APC
Interrog dev eval wcs ip,0521T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,28.82,51.88,
Interrog dev eval wcs ip,0521T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,28.82,51.88,
Interrog dev eval wcs ip,0521T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,28.82,51.88,
Interrog dev eval wcs ip,0521T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,28.82,51.88,
Interrog dev eval wcs ip,0521T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Interrog dev eval wcs ip,0521T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Interrog dev eval wcs ip,0521T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.39,,,,,,,fee schedule,51.8,93.24,APC
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.8,,,,,,,fee schedule,51.8,93.24,APC
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.24,,,,,,,fee schedule,51.8,93.24,APC
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.56,,,,,,,fee schedule,37.19,112.19,
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.85,,,,,,,fee schedule,37.19,112.19,
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.96,,,,,,,fee schedule,37.19,112.19,
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.19,,,,,,,fee schedule,37.19,112.19,
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,112.19,APC
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,112.19,APC
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,112.19,APC
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.52,,,,,,,fee schedule,260.5,468.9,APC
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.5,,,,,,,fee schedule,260.5,468.9,APC
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,468.9,,,,,,,fee schedule,260.5,468.9,APC
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1419.69,,,,,,,fee schedule,1352.09,2433.76,APC
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1352.09,,,,,,,fee schedule,1352.09,2433.76,APC
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2433.76,,,,,,,fee schedule,1352.09,2433.76,APC
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6934.65,,,,,,,fee schedule,2093.27,7974.85,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2093.27,,,,,,,fee schedule,2093.27,7974.85,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2093.27,,,,,,,fee schedule,2093.27,7974.85,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5676.01,,,,,,,fee schedule,2093.27,7974.85,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4546.36,,,,,,,fee schedule,2093.27,7974.85,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2407.26,,,,,,,fee schedule,2093.27,7974.85,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7974.85,,,,,,,fee schedule,2093.27,7974.85,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2093.27,,,,,,,fee schedule,2093.27,7974.85,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2093.27,7974.85,APC
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2093.27,7974.85,APC
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2093.27,7974.85,APC
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.26,,,,,,,fee schedule,128.82,231.88,APC
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.82,,,,,,,fee schedule,128.82,231.88,APC
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.88,,,,,,,fee schedule,128.82,231.88,APC
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25935.7,,,,,,,fee schedule,10195.83,34546.37,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10195.83,,,,,,,fee schedule,10195.83,34546.37,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10195.83,,,,,,,fee schedule,10195.83,34546.37,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21228.37,,,,,,,fee schedule,10195.83,34546.37,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17003.44,,,,,,,fee schedule,10195.83,34546.37,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11725.2,,,,,,,fee schedule,10195.83,34546.37,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29826.06,,,,,,,fee schedule,10195.83,34546.37,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10195.83,,,,,,,fee schedule,10195.83,34546.37,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,10195.83,34546.37,APC
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,10195.83,34546.37,APC
Insj/rplcmt compl iims,0525T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,10195.83,34546.37,APC
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.55,,,,,,,fee schedule,3033.86,5460.95,APC
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3033.86,,,,,,,fee schedule,3033.86,5460.95,APC
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5460.95,,,,,,,fee schedule,3033.86,5460.95,APC
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19437.6,,,,,,,fee schedule,7668.68,22353.24,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7668.68,,,,,,,fee schedule,7668.68,22353.24,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7668.68,,,,,,,fee schedule,7668.68,22353.24,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15909.68,,,,,,,fee schedule,7668.68,22353.24,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12743.29,,,,,,,fee schedule,7668.68,22353.24,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8818.98,,,,,,,fee schedule,7668.68,22353.24,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22353.24,,,,,,,fee schedule,7668.68,22353.24,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7668.68,,,,,,,fee schedule,7668.68,22353.24,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,7668.68,22353.24,APC
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,7668.68,22353.24,APC
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,7668.68,22353.24,APC
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19437.6,,,,,,,fee schedule,5935.12,22353.24,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5935.12,,,,,,,fee schedule,5935.12,22353.24,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5935.12,,,,,,,fee schedule,5935.12,22353.24,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15909.68,,,,,,,fee schedule,5935.12,22353.24,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12743.29,,,,,,,fee schedule,5935.12,22353.24,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6825.39,,,,,,,fee schedule,5935.12,22353.24,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22353.24,,,,,,,fee schedule,5935.12,22353.24,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5935.12,,,,,,,fee schedule,5935.12,22353.24,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,5935.12,22353.24,APC
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,5935.12,22353.24,APC
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,5935.12,22353.24,APC
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,142.63,256.73,APC
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,142.63,256.73,APC
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,142.63,256.73,APC
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.56,,,,,,,fee schedule,37.19,112.19,
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.85,,,,,,,fee schedule,37.19,112.19,
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.96,,,,,,,fee schedule,37.19,112.19,
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.19,,,,,,,fee schedule,37.19,112.19,
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,112.19,APC
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,112.19,APC
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,112.19,APC
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.58,,,,,,,fee schedule,634.84,1142.71,APC
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,634.84,,,,,,,fee schedule,634.84,1142.71,APC
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1142.71,,,,,,,fee schedule,634.84,1142.71,APC
Interrog dev eval iims ip,0529T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.56,,,,,,,fee schedule,37.19,112.19,
Interrog dev eval iims ip,0529T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.85,,,,,,,fee schedule,37.19,112.19,
Interrog dev eval iims ip,0529T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.96,,,,,,,fee schedule,37.19,112.19,
Interrog dev eval iims ip,0529T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.19,,,,,,,fee schedule,37.19,112.19,
Interrog dev eval iims ip,0529T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,112.19,APC
Interrog dev eval iims ip,0529T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,112.19,APC
Interrog dev eval iims ip,0529T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,112.19,APC
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8218.4,,,,,,,fee schedule,2584.61,9451.16,
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6726.76,,,,,,,fee schedule,2584.61,9451.16,
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5387.98,,,,,,,fee schedule,2584.61,9451.16,
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2972.3,,,,,,,fee schedule,2584.61,9451.16,
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9451.16,,,,,,,fee schedule,2584.61,9451.16,
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2584.61,9451.16,APC
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2584.61,9451.16,APC
Removal complete iims,0530T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2584.61,9451.16,APC
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8218.4,,,,,,,fee schedule,2584.61,9451.16,
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6726.76,,,,,,,fee schedule,2584.61,9451.16,
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5387.98,,,,,,,fee schedule,2584.61,9451.16,
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2972.3,,,,,,,fee schedule,2584.61,9451.16,
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9451.16,,,,,,,fee schedule,2584.61,9451.16,
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2584.61,9451.16,APC
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2584.61,9451.16,APC
Removal iims electrode only,0531T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2584.61,9451.16,APC
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8218.4,,,,,,,fee schedule,2584.61,9451.16,
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6726.76,,,,,,,fee schedule,2584.61,9451.16,
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5387.98,,,,,,,fee schedule,2584.61,9451.16,
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2972.3,,,,,,,fee schedule,2584.61,9451.16,
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9451.16,,,,,,,fee schedule,2584.61,9451.16,
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2584.61,,,,,,,fee schedule,2584.61,9451.16,
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2584.61,9451.16,APC
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2584.61,9451.16,APC
Removal iims implt mntr only,0532T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2584.61,9451.16,APC
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5282.76,,,,,,,fee schedule,5031.2,9056.16,APC
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5031.2,,,,,,,fee schedule,5031.2,9056.16,APC
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9056.16,,,,,,,fee schedule,5031.2,9056.16,APC
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,62.14,111.85,APC
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.14,,,,,,,fee schedule,62.14,111.85,APC
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,111.85,,,,,,,fee schedule,62.14,111.85,APC
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.6,,,,,,,fee schedule,192,345.6,APC
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,192,,,,,,,fee schedule,192,345.6,APC
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,345.6,,,,,,,fee schedule,192,345.6,APC
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1569.75,,,,,,,fee schedule,1495,2691,APC
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1495,,,,,,,fee schedule,1495,2691,APC
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2691,,,,,,,fee schedule,1495,2691,APC
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3139.03,,,,,,,fee schedule,2989.55,5381.19,APC
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2989.55,,,,,,,fee schedule,2989.55,5381.19,APC
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5381.19,,,,,,,fee schedule,2989.55,5381.19,APC
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3452.94,,,,,,,fee schedule,3288.51,5919.32,APC
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3288.51,,,,,,,fee schedule,3288.51,5919.32,APC
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5919.32,,,,,,,fee schedule,3288.51,5919.32,APC
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2890.91,,,,,,,fee schedule,2753.25,4955.85,APC
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2753.25,,,,,,,fee schedule,2753.25,4955.85,APC
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4955.85,,,,,,,fee schedule,2753.25,4955.85,APC
Myocardial imaging mcg,0541T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,669.27,APC
Myocardial imaging mcg,0541T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,669.27,APC
Myocardial imaging mcg,0541T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,669.27,APC
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3139.03,,,,,,,fee schedule,2989.55,5381.19,APC
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2989.55,,,,,,,fee schedule,2989.55,5381.19,APC
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5381.19,,,,,,,fee schedule,2989.55,5381.19,APC
Achr antb id imfluor livecll,0545U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,37.73,67.91,APC
Achr antb id imfluor livecll,0545U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.73,,,,,,,fee schedule,37.73,67.91,APC
Achr antb id imfluor livecll,0545U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.91,,,,,,,fee schedule,37.73,67.91,APC
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,37.73,67.91,APC
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.73,,,,,,,fee schedule,37.73,67.91,APC
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.91,,,,,,,fee schedule,37.73,67.91,APC
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,116.23,209.21,APC
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.23,,,,,,,fee schedule,116.23,209.21,APC
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,209.21,,,,,,,fee schedule,116.23,209.21,APC
Gfap cleia plasma,0548U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,116.23,209.21,APC
Gfap cleia plasma,0548U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.23,,,,,,,fee schedule,116.23,209.21,APC
Gfap cleia plasma,0548U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,209.21,,,,,,,fee schedule,116.23,209.21,APC
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Repr med pga embry te strux,0553U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,759.05,1366.29,APC
Repr med pga embry te strux,0553U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,759.05,1366.29,APC
Repr med pga embry te strux,0553U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,759.05,1366.29,APC
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,759.05,1366.29,APC
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,759.05,1366.29,APC
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,759.05,1366.29,APC
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Repr med pga embryonic te qc,0555U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,759.05,1366.29,APC
Repr med pga embryonic te qc,0555U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,759.05,1366.29,APC
Repr med pga embryonic te qc,0555U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,759.05,1366.29,APC
B1 str & fx rsk assessment,0556T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
B1 str & fx rsk assessment,0556T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
B1 str & fx rsk assessment,0556T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,142.63,256.73,APC
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,142.63,256.73,APC
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,142.63,256.73,APC
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,262.99,473.38,APC
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,262.99,,,,,,,fee schedule,262.99,473.38,APC
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,473.38,,,,,,,fee schedule,262.99,473.38,APC
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,20.81,37.46,APC
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.81,,,,,,,fee schedule,20.81,37.46,APC
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.46,,,,,,,fee schedule,20.81,37.46,APC
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,20.81,37.46,APC
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.81,,,,,,,fee schedule,20.81,37.46,APC
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.46,,,,,,,fee schedule,20.81,37.46,APC
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4072.37,,,,,,,fee schedule,3878.45,6981.21,APC
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3878.45,,,,,,,fee schedule,3878.45,6981.21,APC
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6981.21,,,,,,,fee schedule,3878.45,6981.21,APC
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.21,,,,,,,fee schedule,794.49,1430.08,APC
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,794.49,,,,,,,fee schedule,794.49,1430.08,APC
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1430.08,,,,,,,fee schedule,794.49,1430.08,APC
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,597.91,1076.24,APC
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,597.91,,,,,,,fee schedule,597.91,1076.24,APC
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1076.24,,,,,,,fee schedule,597.91,1076.24,APC
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.86,,,,,,,fee schedule,58.78,122.89,
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.46,,,,,,,fee schedule,58.78,122.89,
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.06,,,,,,,fee schedule,58.78,122.89,
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.89,,,,,,,fee schedule,58.78,122.89,
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,122.89,APC
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,122.89,APC
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,122.89,APC
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Autol cell implt adps hrvg,0565T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.86,,,,,,,fee schedule,70.06,122.89,
Autol cell implt adps hrvg,0565T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.46,,,,,,,fee schedule,70.06,122.89,
Autol cell implt adps hrvg,0565T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.06,,,,,,,fee schedule,70.06,122.89,
Autol cell implt adps hrvg,0565T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.89,,,,,,,fee schedule,70.06,122.89,
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1160,2088,APC
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1160,,,,,,,fee schedule,1160,2088,APC
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2088,,,,,,,fee schedule,1160,2088,APC
Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,508.49,,,,,,,fee schedule,211.31,584.76,
Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.31,,,,,,,fee schedule,211.31,584.76,
Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.31,,,,,,,fee schedule,211.31,584.76,
Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.2,,,,,,,fee schedule,211.31,584.76,
Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,333.37,,,,,,,fee schedule,211.31,584.76,
Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.01,,,,,,,fee schedule,211.31,584.76,
Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,584.76,,,,,,,fee schedule,211.31,584.76,
Autol cell implt adps njx,0566T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.31,,,,,,,fee schedule,211.31,584.76,
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,416.78,750.2,APC
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,416.78,750.2,APC
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,416.78,750.2,APC
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5282.76,,,,,,,fee schedule,5031.2,9056.16,APC
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5031.2,,,,,,,fee schedule,5031.2,9056.16,APC
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9056.16,,,,,,,fee schedule,5031.2,9056.16,APC
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,897,1614.6,APC
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,897,,,,,,,fee schedule,897,1614.6,APC
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1614.6,,,,,,,fee schedule,897,1614.6,APC
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.52,,,,,,,fee schedule,260.5,468.9,APC
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.5,,,,,,,fee schedule,260.5,468.9,APC
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,468.9,,,,,,,fee schedule,260.5,468.9,APC
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32839.79,,,,,,,fee schedule,31275.99,56296.78,APC
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31275.99,,,,,,,fee schedule,31275.99,56296.78,APC
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56296.78,,,,,,,fee schedule,31275.99,56296.78,APC
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Insertion ss dfb electrode,0572T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,14842.14,APC
Insertion ss dfb electrode,0572T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,14842.14,APC
Insertion ss dfb electrode,0572T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,14842.14,APC
Removal ss dfb electrode,0573T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,6702.34,APC
Removal ss dfb electrode,0573T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,6702.34,APC
Removal ss dfb electrode,0573T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,6702.34,APC
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,6702.34,APC
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,6702.34,APC
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,6702.34,APC
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,399,,,,,,,fee schedule,380,684,APC
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,380,,,,,,,fee schedule,380,684,APC
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,684,,,,,,,fee schedule,380,684,APC
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3402,,,,,,,fee schedule,3240,5832,APC
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3240,,,,,,,fee schedule,3240,5832,APC
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5832,,,,,,,fee schedule,3240,5832,APC
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3873,6971.4,APC
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3873,6971.4,APC
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3873,6971.4,APC
Rem interrog dev icds tech,0579T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Rem interrog dev icds tech,0579T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Rem interrog dev icds tech,0579T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,390.75,703.35,APC
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,390.75,,,,,,,fee schedule,390.75,703.35,APC
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,703.35,,,,,,,fee schedule,390.75,703.35,APC
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,6702.34,APC
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,6702.34,APC
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,6702.34,APC
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.07,,,,,,,fee schedule,17.21,30.98,APC
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.21,,,,,,,fee schedule,17.21,30.98,APC
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.98,,,,,,,fee schedule,17.21,30.98,APC
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,3901.35,7022.44,APC
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,3901.35,7022.44,APC
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,3901.35,7022.44,APC
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,342.09,,,,,,,fee schedule,325.8,586.44,APC
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,325.8,,,,,,,fee schedule,325.8,586.44,APC
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,586.44,,,,,,,fee schedule,325.8,586.44,APC
Trurl abltj mal prst8 tiss,0582T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13803.31,,,,,,,fee schedule,13146.01,23662.82,APC
Trurl abltj mal prst8 tiss,0582T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13146.01,,,,,,,fee schedule,13146.01,23662.82,APC
Trurl abltj mal prst8 tiss,0582T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23662.82,,,,,,,fee schedule,13146.01,23662.82,APC
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7961.31,,,,,,,fee schedule,7582.2,13647.96,APC
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7582.2,,,,,,,fee schedule,7582.2,13647.96,APC
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13647.96,,,,,,,fee schedule,7582.2,13647.96,APC
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1546,2782.81,APC
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1546,2782.81,APC
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1546,2782.81,APC
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3980.66,,,,,,,fee schedule,3791.1,6823.98,APC
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3791.1,,,,,,,fee schedule,3791.1,6823.98,APC
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6823.98,,,,,,,fee schedule,3791.1,6823.98,APC
Neuro csf prion prtn qual,0584U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.04,,,,,,,fee schedule,540.99,973.78,APC
Neuro csf prion prtn qual,0584U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,540.99,,,,,,,fee schedule,540.99,973.78,APC
Neuro csf prion prtn qual,0584U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.78,,,,,,,fee schedule,540.99,973.78,APC
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1214.15,,,,,,,fee schedule,657.65,11430.14,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,657.65,,,,,,,fee schedule,657.65,11430.14,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,657.65,,,,,,,fee schedule,657.65,11430.14,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,993.78,,,,,,,fee schedule,657.65,11430.14,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,796,,,,,,,fee schedule,657.65,11430.14,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,756.3,,,,,,,fee schedule,657.65,11430.14,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1396.27,,,,,,,fee schedule,657.65,11430.14,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,657.65,,,,,,,fee schedule,657.65,11430.14,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6667.58,,,,,,,fee schedule,657.65,11430.14,APC
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6350.08,,,,,,,fee schedule,657.65,11430.14,APC
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11430.14,,,,,,,fee schedule,657.65,11430.14,APC
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,114.43,205.97,APC
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,114.43,,,,,,,fee schedule,114.43,205.97,APC
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,205.97,,,,,,,fee schedule,114.43,205.97,APC
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,508.49,,,,,,,fee schedule,211.31,6270.36,
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.31,,,,,,,fee schedule,211.31,6270.36,
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.31,,,,,,,fee schedule,211.31,6270.36,
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.2,,,,,,,fee schedule,211.31,6270.36,
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,333.37,,,,,,,fee schedule,211.31,6270.36,
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.01,,,,,,,fee schedule,211.31,6270.36,
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,584.76,,,,,,,fee schedule,211.31,6270.36,
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.31,,,,,,,fee schedule,211.31,6270.36,
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,211.31,6270.36,APC
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,211.31,6270.36,APC
Revision/removal isdns ptn,0588T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,211.31,6270.36,APC
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.33,,,,,,,fee schedule,94.73,253.38,
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.34,,,,,,,fee schedule,94.73,253.38,
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,144.45,,,,,,,fee schedule,94.73,253.38,
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,253.38,,,,,,,fee schedule,94.73,253.38,
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,253.38,APC
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,253.38,APC
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,253.38,APC
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,198.74,357.73,APC
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.74,,,,,,,fee schedule,198.74,357.73,APC
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,357.73,,,,,,,fee schedule,198.74,357.73,APC
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.33,,,,,,,fee schedule,94.73,253.38,
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.34,,,,,,,fee schedule,94.73,253.38,
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,144.45,,,,,,,fee schedule,94.73,253.38,
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,253.38,,,,,,,fee schedule,94.73,253.38,
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,253.38,APC
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,253.38,APC
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,253.38,APC
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,760,1368,APC
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,760,1368,APC
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,760,1368,APC
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2919.6,5255.28,APC
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2919.6,5255.28,APC
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2919.6,5255.28,APC
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.58,,,,,,,fee schedule,634.84,1142.71,APC
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,634.84,,,,,,,fee schedule,634.84,1142.71,APC
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1142.71,,,,,,,fee schedule,634.84,1142.71,APC
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.27,,,,,,,fee schedule,127.27,13014.22,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.27,,,,,,,fee schedule,127.27,13014.22,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.36,,,,,,,fee schedule,127.27,13014.22,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.27,,,,,,,fee schedule,127.27,13014.22,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,127.27,13014.22,APC
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,127.27,13014.22,APC
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,127.27,13014.22,APC
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,262.99,473.38,APC
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,262.99,,,,,,,fee schedule,262.99,473.38,APC
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,473.38,,,,,,,fee schedule,262.99,473.38,APC
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.69,,,,,,,fee schedule,9.69,1250.62,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.69,,,,,,,fee schedule,9.69,1250.62,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.14,,,,,,,fee schedule,9.69,1250.62,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.69,,,,,,,fee schedule,9.69,1250.62,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,9.69,1250.62,APC
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,9.69,1250.62,APC
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,9.69,1250.62,APC
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.69,,,,,,,fee schedule,9.69,1250.62,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.69,,,,,,,fee schedule,9.69,1250.62,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.14,,,,,,,fee schedule,9.69,1250.62,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.69,,,,,,,fee schedule,9.69,1250.62,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,9.69,1250.62,APC
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,9.69,1250.62,APC
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,9.69,1250.62,APC
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,387.26,APC
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,387.26,APC
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,387.26,APC
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315,,,,,,,fee schedule,300,540,APC
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,300,,,,,,,fee schedule,300,540,APC
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,540,,,,,,,fee schedule,300,540,APC
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,897,1614.6,APC
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,897,,,,,,,fee schedule,897,1614.6,APC
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1614.6,,,,,,,fee schedule,897,1614.6,APC
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.83,,,,,,,fee schedule,164.83,19064.9,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.83,,,,,,,fee schedule,164.83,19064.9,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.55,,,,,,,fee schedule,164.83,19064.9,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.83,,,,,,,fee schedule,164.83,19064.9,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,164.83,19064.9,APC
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,164.83,19064.9,APC
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,164.83,19064.9,APC
Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.83,,,,,,,fee schedule,164.83,19064.9,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.83,,,,,,,fee schedule,164.83,19064.9,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.55,,,,,,,fee schedule,164.83,19064.9,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.83,,,,,,,fee schedule,164.83,19064.9,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,164.83,19064.9,APC
Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,164.83,19064.9,APC
Ire abltj 1+tumors open,0601T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,164.83,19064.9,APC
Mrs disc pain acquisj data,0609T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mrs disc pain acquisj data,0609T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mrs disc pain acquisj data,0609T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mrs disc pain alg alys data,0611T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mrs disc pain alg alys data,0611T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mrs disc pain alg alys data,0611T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,501.26,,,,,,,fee schedule,501.26,39894.46,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,501.26,,,,,,,fee schedule,501.26,39894.46,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,576.45,,,,,,,fee schedule,501.26,39894.46,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,501.26,,,,,,,fee schedule,501.26,39894.46,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,501.26,39894.46,APC
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,501.26,39894.46,APC
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,501.26,39894.46,APC
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.65,,,,,,,fee schedule,89.65,103.1,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.65,,,,,,,fee schedule,89.65,103.1,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.1,,,,,,,fee schedule,89.65,103.1,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.65,,,,,,,fee schedule,89.65,103.1,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31207.65,,,,,,,fee schedule,306.58,78998.56,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,306.58,,,,,,,fee schedule,306.58,78998.56,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,306.58,,,,,,,fee schedule,306.58,78998.56,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25543.46,,,,,,,fee schedule,306.58,78998.56,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20459.74,,,,,,,fee schedule,306.58,78998.56,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,352.57,,,,,,,fee schedule,306.58,78998.56,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35888.8,,,,,,,fee schedule,306.58,78998.56,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,306.58,,,,,,,fee schedule,306.58,78998.56,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46082.49,,,,,,,fee schedule,306.58,78998.56,APC
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43888.09,,,,,,,fee schedule,306.58,78998.56,APC
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78998.56,,,,,,,fee schedule,306.58,78998.56,APC
Trabeculostomy interno laser,0621T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,4118.56,7413.41,APC
Trabeculostomy interno laser,0621T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,4118.56,7413.41,APC
Trabeculostomy interno laser,0621T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,4118.56,7413.41,APC
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.98,,,,,,,fee schedule,195.98,23026.52,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.98,,,,,,,fee schedule,195.98,23026.52,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.38,,,,,,,fee schedule,195.98,23026.52,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.98,,,,,,,fee schedule,195.98,23026.52,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,195.98,23026.52,APC
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,195.98,23026.52,APC
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,195.98,23026.52,APC
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.98,,,,,,,fee schedule,195.98,23026.52,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.98,,,,,,,fee schedule,195.98,23026.52,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.38,,,,,,,fee schedule,195.98,23026.52,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.98,,,,,,,fee schedule,195.98,23026.52,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,195.98,23026.52,APC
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,195.98,23026.52,APC
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,195.98,23026.52,APC
Tc vis lit hyperspectral img,0631T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.94,,,,,,,fee schedule,31.43,55.13,
Tc vis lit hyperspectral img,0631T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.24,,,,,,,fee schedule,31.43,55.13,
Tc vis lit hyperspectral img,0631T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.43,,,,,,,fee schedule,31.43,55.13,
Tc vis lit hyperspectral img,0631T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.13,,,,,,,fee schedule,31.43,55.13,
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.7,,,,,,,fee schedule,104.17,243.46,
Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.28,,,,,,,fee schedule,104.17,243.46,
Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.79,,,,,,,fee schedule,104.17,243.46,
Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.46,,,,,,,fee schedule,104.17,243.46,
Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,243.46,APC
Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,243.46,APC
Ct breast w/3d uni c-,0633T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,243.46,APC
Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,346.87,,,,,,,fee schedule,174.77,398.9,
Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.91,,,,,,,fee schedule,174.77,398.9,
Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.41,,,,,,,fee schedule,174.77,398.9,
Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,398.9,,,,,,,fee schedule,174.77,398.9,
Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,398.9,APC
Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,398.9,APC
Ct breast w/3d uni c+,0634T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,398.9,APC
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,346.87,,,,,,,fee schedule,174.77,398.9,
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.91,,,,,,,fee schedule,174.77,398.9,
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.41,,,,,,,fee schedule,174.77,398.9,
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,398.9,,,,,,,fee schedule,174.77,398.9,
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,398.9,APC
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,398.9,APC
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,398.9,APC
Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,447.09,,,,,,,fee schedule,237.74,514.15,
Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,365.94,,,,,,,fee schedule,237.74,514.15,
Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,293.11,,,,,,,fee schedule,237.74,514.15,
Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,514.15,,,,,,,fee schedule,237.74,514.15,
Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,514.15,APC
Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,514.15,APC
Ct breast w/3d bi c-,0636T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,514.15,APC
Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,715.15,,,,,,,fee schedule,347.62,822.42,
Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,585.35,,,,,,,fee schedule,347.62,822.42,
Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,468.85,,,,,,,fee schedule,347.62,822.42,
Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,822.42,,,,,,,fee schedule,347.62,822.42,
Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,822.42,APC
Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,822.42,APC
Ct breast w/3d bi c+,0637T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,822.42,APC
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,715.15,,,,,,,fee schedule,347.62,822.42,
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,585.35,,,,,,,fee schedule,347.62,822.42,
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,468.85,,,,,,,fee schedule,347.62,822.42,
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,822.42,,,,,,,fee schedule,347.62,822.42,
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,822.42,APC
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,822.42,APC
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,822.42,APC
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,66.99,APC
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,66.99,APC
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,66.99,APC
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4606.29,,,,,,,fee schedule,4606.29,10207.97,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4606.29,,,,,,,fee schedule,4606.29,10207.97,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5297.23,,,,,,,fee schedule,4606.29,10207.97,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4606.29,,,,,,,fee schedule,4606.29,10207.97,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,4606.29,10207.97,APC
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,4606.29,10207.97,APC
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,4606.29,10207.97,APC
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1474.52,,,,,,,fee schedule,1474.52,3441.61,
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1474.52,,,,,,,fee schedule,1474.52,3441.61,
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1695.7,,,,,,,fee schedule,1474.52,3441.61,
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1474.52,,,,,,,fee schedule,1474.52,3441.61,
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1474.52,3441.61,APC
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1474.52,3441.61,APC
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1474.52,3441.61,APC
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,973.35,,,,,,,fee schedule,927,1668.61,APC
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,927,,,,,,,fee schedule,927,1668.61,APC
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1668.61,,,,,,,fee schedule,927,1668.61,APC
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,973.35,,,,,,,fee schedule,927,1668.61,APC
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,927,,,,,,,fee schedule,927,1668.61,APC
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1668.61,,,,,,,fee schedule,927,1668.61,APC
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,874.21,,,,,,,fee schedule,874.21,1626.7,
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,874.21,,,,,,,fee schedule,874.21,1626.7,
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1005.34,,,,,,,fee schedule,874.21,1626.7,
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,874.21,,,,,,,fee schedule,874.21,1626.7,
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,874.21,1626.7,APC
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,874.21,1626.7,APC
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,874.21,1626.7,APC
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,874.21,,,,,,,fee schedule,874.21,3441.61,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,874.21,,,,,,,fee schedule,874.21,3441.61,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1005.34,,,,,,,fee schedule,874.21,3441.61,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,874.21,,,,,,,fee schedule,874.21,3441.61,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,874.21,3441.61,APC
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,874.21,3441.61,APC
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,874.21,3441.61,APC
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,874.21,,,,,,,fee schedule,874.21,3441.61,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,874.21,,,,,,,fee schedule,874.21,3441.61,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1005.34,,,,,,,fee schedule,874.21,3441.61,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,874.21,,,,,,,fee schedule,874.21,3441.61,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,874.21,3441.61,APC
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,874.21,3441.61,APC
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,874.21,3441.61,APC
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1474.52,,,,,,,fee schedule,1474.52,6914.9,
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1474.52,,,,,,,fee schedule,1474.52,6914.9,
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1695.7,,,,,,,fee schedule,1474.52,6914.9,
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1474.52,,,,,,,fee schedule,1474.52,6914.9,
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,1474.52,6914.9,APC
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,1474.52,6914.9,APC
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,1474.52,6914.9,APC
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2292.26,,,,,,,fee schedule,2292.26,9616.53,
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2292.26,,,,,,,fee schedule,2292.26,9616.53,
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2636.1,,,,,,,fee schedule,2292.26,9616.53,
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2292.26,,,,,,,fee schedule,2292.26,9616.53,
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2292.26,9616.53,APC
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2292.26,9616.53,APC
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2292.26,9616.53,APC
Vrt bdy tethering ant,0656T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Vrt bdy tethering ant,0656T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Vrt bdy tethering ant,0656T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,105.8,APC
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,105.8,APC
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,105.8,APC
Implt ant sgm io nbio rx sys,0660T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,4118.56,7413.41,APC
Implt ant sgm io nbio rx sys,0660T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,4118.56,7413.41,APC
Implt ant sgm io nbio rx sys,0660T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,4118.56,7413.41,APC
Rmvl&Rimpltj ant sgm implt,0661T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,4118.56,7413.41,APC
Rmvl&Rimpltj ant sgm implt,0661T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,4118.56,7413.41,APC
Rmvl&Rimpltj ant sgm implt,0661T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,4118.56,7413.41,APC
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4120.2,,,,,,,fee schedule,2566.74,9543.9,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2566.74,,,,,,,fee schedule,2566.74,9543.9,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2566.74,,,,,,,fee schedule,2566.74,9543.9,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3372.38,,,,,,,fee schedule,2566.74,9543.9,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2701.2,,,,,,,fee schedule,2566.74,9543.9,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2951.75,,,,,,,fee schedule,2566.74,9543.9,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4738.23,,,,,,,fee schedule,2566.74,9543.9,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2566.74,,,,,,,fee schedule,2566.74,9543.9,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,2566.74,9543.9,APC
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,2566.74,9543.9,APC
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,2566.74,9543.9,APC
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2791.66,,,,,,,fee schedule,975.64,3210.41,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,975.64,,,,,,,fee schedule,975.64,3210.41,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,975.64,,,,,,,fee schedule,975.64,3210.41,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2284.97,,,,,,,fee schedule,975.64,3210.41,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1830.21,,,,,,,fee schedule,975.64,3210.41,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1121.99,,,,,,,fee schedule,975.64,3210.41,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3210.41,,,,,,,fee schedule,975.64,3210.41,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,975.64,,,,,,,fee schedule,975.64,3210.41,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,975.64,3210.41,APC
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,975.64,3210.41,APC
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,975.64,3210.41,APC
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,30746.74,55344.12,APC
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,30746.74,55344.12,APC
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,30746.74,55344.12,APC
Laps insj nw/rpcmt isdss 1ld,0675T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,19984.73,APC
Laps insj nw/rpcmt isdss 1ld,0675T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,19984.73,APC
Laps insj nw/rpcmt isdss 1ld,0675T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,19984.73,APC
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Laps rmvl lead isdss,0679T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Laps rmvl lead isdss,0679T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Laps rmvl lead isdss,0679T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20296.87,,,,,,,fee schedule,19330.35,34794.63,APC
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19330.35,,,,,,,fee schedule,19330.35,34794.63,APC
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34794.63,,,,,,,fee schedule,19330.35,34794.63,APC
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,3483.53,6270.36,APC
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,3483.53,6270.36,APC
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,3483.53,6270.36,APC
Removal pulse gen only isdss,0682T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,3483.53,6270.36,APC
Removal pulse gen only isdss,0682T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,3483.53,6270.36,APC
Removal pulse gen only isdss,0682T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,3483.53,6270.36,APC
Prgrmg dev eval isdss ip,0683T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Prgrmg dev eval isdss ip,0683T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Prgrmg dev eval isdss ip,0683T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Interrog dev eval isdss ip,0685T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Interrog dev eval isdss ip,0685T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Interrog dev eval isdss ip,0685T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24284.82,,,,,,,fee schedule,10162.1,30722.2,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10162.1,,,,,,,fee schedule,10162.1,30722.2,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10162.1,,,,,,,fee schedule,10162.1,30722.2,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15921.13,,,,,,,fee schedule,10162.1,30722.2,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19877.13,,,,,,,fee schedule,10162.1,30722.2,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11686.42,,,,,,,fee schedule,10162.1,30722.2,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27927.54,,,,,,,fee schedule,10162.1,30722.2,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10162.1,,,,,,,fee schedule,10162.1,30722.2,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17921.28,,,,,,,fee schedule,10162.1,30722.2,APC
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17067.89,,,,,,,fee schedule,10162.1,30722.2,APC
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30722.2,,,,,,,fee schedule,10162.1,30722.2,APC
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.49,,,,,,,fee schedule,86.71,184.56,
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.22,,,,,,,fee schedule,86.71,184.56,
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.36,,,,,,,fee schedule,86.71,184.56,
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.56,,,,,,,fee schedule,86.71,184.56,
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,184.56,APC
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,184.56,APC
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,184.56,APC
Therapeutic ultrafiltration,0692T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,787.51,,,,,,,fee schedule,516.29,2793.29,
Therapeutic ultrafiltration,0692T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,516.29,,,,,,,fee schedule,516.29,2793.29,
Therapeutic ultrafiltration,0692T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,644.58,,,,,,,fee schedule,516.29,2793.29,
Therapeutic ultrafiltration,0692T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,905.64,,,,,,,fee schedule,516.29,2793.29,
Therapeutic ultrafiltration,0692T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,516.29,2793.29,APC
Therapeutic ultrafiltration,0692T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,516.29,2793.29,APC
Therapeutic ultrafiltration,0692T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,516.29,2793.29,APC
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,680.91,,,,,,,fee schedule,341.84,783.05,
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,446.4,,,,,,,fee schedule,341.84,783.05,
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,557.32,,,,,,,fee schedule,341.84,783.05,
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,783.05,,,,,,,fee schedule,341.84,783.05,
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,358.93,,,,,,,fee schedule,341.84,783.05,APC
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,341.84,,,,,,,fee schedule,341.84,783.05,APC
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,615.3,,,,,,,fee schedule,341.84,783.05,APC
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.89,,,,,,,fee schedule,37.19,84.97,
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.44,,,,,,,fee schedule,37.19,84.97,
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.48,,,,,,,fee schedule,37.19,84.97,
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.97,,,,,,,fee schedule,37.19,84.97,
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,84.97,APC
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,84.97,APC
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,84.97,APC
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,456.54,,,,,,,fee schedule,299.31,1668.61,
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.31,,,,,,,fee schedule,299.31,1668.61,
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,373.68,,,,,,,fee schedule,299.31,1668.61,
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,525.02,,,,,,,fee schedule,299.31,1668.61,
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,973.35,,,,,,,fee schedule,299.31,1668.61,APC
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,927,,,,,,,fee schedule,299.31,1668.61,APC
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1668.61,,,,,,,fee schedule,299.31,1668.61,APC
Quan mr tiss w/mri mlt orgn,0698T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,973.35,,,,,,,fee schedule,927,1668.61,APC
Quan mr tiss w/mri mlt orgn,0698T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,927,,,,,,,fee schedule,927,1668.61,APC
Quan mr tiss w/mri mlt orgn,0698T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1668.61,,,,,,,fee schedule,927,1668.61,APC
Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1704.71,,,,,,,fee schedule,1704.71,4139.14,
Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1704.71,,,,,,,fee schedule,1704.71,4139.14,
Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1960.42,,,,,,,fee schedule,1704.71,4139.14,
Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1704.71,,,,,,,fee schedule,1704.71,4139.14,
Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1704.71,4139.14,APC
Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1704.71,4139.14,APC
Njx pst chmbr eye medication,0699T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1704.71,4139.14,APC
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2840.32,,,,,,,fee schedule,2840.32,5868.42,
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2840.32,,,,,,,fee schedule,2840.32,5868.42,
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3266.37,,,,,,,fee schedule,2840.32,5868.42,
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2840.32,,,,,,,fee schedule,2840.32,5868.42,
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2840.32,5868.42,APC
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2840.32,5868.42,APC
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2840.32,5868.42,APC
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.49,,,,,,,fee schedule,105.22,387.26,
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.22,,,,,,,fee schedule,105.22,387.26,
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.36,,,,,,,fee schedule,105.22,387.26,
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.56,,,,,,,fee schedule,105.22,387.26,
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,105.22,387.26,APC
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,105.22,387.26,APC
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,105.22,387.26,APC
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3553.9,,,,,,,fee schedule,3553.9,9616.53,
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3553.9,,,,,,,fee schedule,3553.9,9616.53,
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4086.99,,,,,,,fee schedule,3553.9,9616.53,
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3553.9,,,,,,,fee schedule,3553.9,9616.53,
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3553.9,9616.53,APC
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3553.9,9616.53,APC
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3553.9,9616.53,APC
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,105.8,APC
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,105.8,APC
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,105.8,APC
Adrc ther prtl rc tear,0717T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3530.98,6355.77,APC
Adrc ther prtl rc tear,0717T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3530.98,6355.77,APC
Adrc ther prtl rc tear,0717T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3530.98,6355.77,APC
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3530.98,6355.77,APC
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3530.98,6355.77,APC
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3530.98,6355.77,APC
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.14,,,,,,,fee schedule,634.42,1141.96,APC
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,634.42,,,,,,,fee schedule,634.42,1141.96,APC
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1141.96,,,,,,,fee schedule,634.42,1141.96,APC
Quan ct tiss charac w/ct,0722T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.14,,,,,,,fee schedule,634.42,1141.96,APC
Quan ct tiss charac w/ct,0722T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,634.42,,,,,,,fee schedule,634.42,1141.96,APC
Quan ct tiss charac w/ct,0722T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1141.96,,,,,,,fee schedule,634.42,1141.96,APC
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,973.35,,,,,,,fee schedule,927,1668.61,APC
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,927,,,,,,,fee schedule,927,1668.61,APC
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1668.61,,,,,,,fee schedule,927,1668.61,APC
Qmrcp w/dx mri same anatomy,0724T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,973.35,,,,,,,fee schedule,927,1668.61,APC
Qmrcp w/dx mri same anatomy,0724T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,927,,,,,,,fee schedule,927,1668.61,APC
Qmrcp w/dx mri same anatomy,0724T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1668.61,,,,,,,fee schedule,927,1668.61,APC
Trabeculotomy lsr w/oct gdn,0730T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,5302.17,9543.9,APC
Trabeculotomy lsr w/oct gdn,0730T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,5302.17,9543.9,APC
Trabeculotomy lsr w/oct gdn,0730T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,5302.17,9543.9,APC
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,105.8,APC
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,105.8,APC
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,105.8,APC
Colonic lavage 35+l water,0736T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Colonic lavage 35+l water,0736T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Colonic lavage 35+l water,0736T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Xenograft impltj artclr surf,0737T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Xenograft impltj artclr surf,0737T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Xenograft impltj artclr surf,0737T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.86,,,,,,,fee schedule,58.78,126.34,
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.02,,,,,,,fee schedule,58.78,126.34,
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.92,,,,,,,fee schedule,58.78,126.34,
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.34,,,,,,,fee schedule,58.78,126.34,
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,126.34,APC
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,126.34,APC
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,126.34,APC
Rem auton alg nsln data coll,0741T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.9,,,,,,,fee schedule,37.19,76.94,
Rem auton alg nsln data coll,0741T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.86,,,,,,,fee schedule,37.19,76.94,
Rem auton alg nsln data coll,0741T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.76,,,,,,,fee schedule,37.19,76.94,
Rem auton alg nsln data coll,0741T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.94,,,,,,,fee schedule,37.19,76.94,
Rem auton alg nsln data coll,0741T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,76.94,APC
Rem auton alg nsln data coll,0741T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,76.94,APC
Rem auton alg nsln data coll,0741T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,76.94,APC
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9823.94,,,,,,,fee schedule,5544.48,11297.53,
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6440.58,,,,,,,fee schedule,5544.48,11297.53,
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8040.89,,,,,,,fee schedule,5544.48,11297.53,
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11297.53,,,,,,,fee schedule,5544.48,11297.53,
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,5544.48,11297.53,APC
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,5544.48,11297.53,APC
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,5544.48,11297.53,APC
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,277.98,,,,,,,fee schedule,182.24,387.26,
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.24,,,,,,,fee schedule,182.24,387.26,
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.53,,,,,,,fee schedule,182.24,387.26,
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.68,,,,,,,fee schedule,182.24,387.26,
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,182.24,387.26,APC
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,182.24,387.26,APC
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,182.24,387.26,APC
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,277.98,,,,,,,fee schedule,128.21,319.68,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.24,,,,,,,fee schedule,128.21,319.68,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.53,,,,,,,fee schedule,128.21,319.68,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.68,,,,,,,fee schedule,128.21,319.68,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,319.68,APC
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,319.68,APC
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,319.68,APC
Gi myoelectrical actv study,0779T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,924,,,,,,,fee schedule,371.82,1062.6,
Gi myoelectrical actv study,0779T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,605.77,,,,,,,fee schedule,371.82,1062.6,
Gi myoelectrical actv study,0779T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,756.29,,,,,,,fee schedule,371.82,1062.6,
Gi myoelectrical actv study,0779T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1062.6,,,,,,,fee schedule,371.82,1062.6,
Gi myoelectrical actv study,0779T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1062.6,APC
Gi myoelectrical actv study,0779T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1062.6,APC
Gi myoelectrical actv study,0779T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1062.6,APC
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Tc auriculr neurostimulation,0783T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,277.98,,,,,,,fee schedule,128.21,319.68,
Tc auriculr neurostimulation,0783T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.24,,,,,,,fee schedule,128.21,319.68,
Tc auriculr neurostimulation,0783T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.53,,,,,,,fee schedule,128.21,319.68,
Tc auriculr neurostimulation,0783T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.68,,,,,,,fee schedule,128.21,319.68,
Tc auriculr neurostimulation,0783T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,319.68,APC
Tc auriculr neurostimulation,0783T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,319.68,APC
Tc auriculr neurostimulation,0783T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,319.68,APC
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23449.76,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15373.66,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19193.63,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14632.85,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26967.22,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,26967.22,APC
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,26967.22,APC
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,26967.22,APC
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3009.69,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2617.12,6735.91,APC
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23449.76,,,,,,,fee schedule,11102.63,26967.22,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15373.66,,,,,,,fee schedule,11102.63,26967.22,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19193.63,,,,,,,fee schedule,11102.63,26967.22,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14632.85,,,,,,,fee schedule,11102.63,26967.22,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26967.22,,,,,,,fee schedule,11102.63,26967.22,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,26967.22,APC
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,26967.22,APC
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,26967.22,APC
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3009.69,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2617.12,6735.91,APC
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.65,,,,,,,fee schedule,94.73,191.65,
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.26,,,,,,,fee schedule,94.73,191.65,
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.4,,,,,,,fee schedule,94.73,191.65,
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,191.65,,,,,,,fee schedule,94.73,191.65,
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,191.65,APC
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,191.65,APC
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,191.65,APC
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.65,,,,,,,fee schedule,94.73,191.65,
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.26,,,,,,,fee schedule,94.73,191.65,
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.4,,,,,,,fee schedule,94.73,191.65,
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,191.65,,,,,,,fee schedule,94.73,191.65,
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,191.65,APC
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,191.65,APC
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,191.65,APC
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13663.83,,,,,,,fee schedule,13663.83,32878.29,
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13663.83,,,,,,,fee schedule,13663.83,32878.29,
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15713.4,,,,,,,fee schedule,13663.83,32878.29,
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13663.83,,,,,,,fee schedule,13663.83,32878.29,
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,13663.83,32878.29,APC
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,13663.83,32878.29,APC
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,13663.83,32878.29,APC
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,105.8,APC
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,105.8,APC
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,105.8,APC
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14588.03,,,,,,,fee schedule,14588.03,34546.37,
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14588.03,,,,,,,fee schedule,14588.03,34546.37,
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16776.23,,,,,,,fee schedule,14588.03,34546.37,
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14588.03,,,,,,,fee schedule,14588.03,34546.37,
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,14588.03,34546.37,APC
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,14588.03,34546.37,APC
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,14588.03,34546.37,APC
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,3146.13,5663.03,APC
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,3146.13,5663.03,APC
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,3146.13,5663.03,APC
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,3146.13,5663.03,APC
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,3146.13,5663.03,APC
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,3146.13,5663.03,APC
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2689.2,,,,,,,fee schedule,2689.2,5663.03,
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2689.2,,,,,,,fee schedule,2689.2,5663.03,
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3092.58,,,,,,,fee schedule,2689.2,5663.03,
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2689.2,,,,,,,fee schedule,2689.2,5663.03,
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2689.2,5663.03,APC
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2689.2,5663.03,APC
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2689.2,5663.03,APC
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,19192.43,34546.37,APC
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14588.03,,,,,,,fee schedule,14588.03,34546.37,
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14588.03,,,,,,,fee schedule,14588.03,34546.37,
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16776.23,,,,,,,fee schedule,14588.03,34546.37,
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14588.03,,,,,,,fee schedule,14588.03,34546.37,
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,14588.03,34546.37,APC
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,14588.03,34546.37,APC
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,14588.03,34546.37,APC
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,387.26,APC
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,387.26,APC
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,387.26,APC
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,387.26,APC
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,387.26,APC
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,387.26,APC
Rem mlt day uroflow setup,0811T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.55,,,,,,,fee schedule,132.66,261.68,
Rem mlt day uroflow setup,0811T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.18,,,,,,,fee schedule,132.66,261.68,
Rem mlt day uroflow setup,0811T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.25,,,,,,,fee schedule,132.66,261.68,
Rem mlt day uroflow setup,0811T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.68,,,,,,,fee schedule,132.66,261.68,
Rem mlt day uroflow setup,0811T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,261.68,APC
Rem mlt day uroflow setup,0811T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,261.68,APC
Rem mlt day uroflow setup,0811T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,261.68,APC
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.94,,,,,,,fee schedule,42.57,230.78,
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.57,,,,,,,fee schedule,42.57,230.78,
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.15,,,,,,,fee schedule,42.57,230.78,
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.68,,,,,,,fee schedule,42.57,230.78,
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,42.57,230.78,APC
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,42.57,230.78,APC
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,42.57,230.78,APC
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1560.49,,,,,,,fee schedule,648.33,1794.56,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.33,,,,,,,fee schedule,648.33,1794.56,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.33,,,,,,,fee schedule,648.33,1794.56,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1023.06,,,,,,,fee schedule,648.33,1794.56,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1277.26,,,,,,,fee schedule,648.33,1794.56,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.58,,,,,,,fee schedule,648.33,1794.56,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1794.56,,,,,,,fee schedule,648.33,1794.56,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.33,,,,,,,fee schedule,648.33,1794.56,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,648.33,1794.56,APC
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,648.33,1794.56,APC
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,648.33,1794.56,APC
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37657.82,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19481.46,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19481.46,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24688.47,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30822.93,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22403.68,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43306.49,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19481.46,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20296.87,,,,,,,fee schedule,19330.35,43306.49,APC
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19330.35,,,,,,,fee schedule,19330.35,43306.49,APC
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34794.63,,,,,,,fee schedule,19330.35,43306.49,APC
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37657.82,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19481.46,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19481.46,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24688.47,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30822.93,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22403.68,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43306.49,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19481.46,,,,,,,fee schedule,19330.35,43306.49,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20296.87,,,,,,,fee schedule,19330.35,43306.49,APC
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19330.35,,,,,,,fee schedule,19330.35,43306.49,APC
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34794.63,,,,,,,fee schedule,19330.35,43306.49,APC
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3009.69,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3009.69,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2617.12,6735.91,APC
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33543,,,,,,,fee schedule,19192.43,38574.45,
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27454.95,,,,,,,fee schedule,19192.43,38574.45,
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21990.79,,,,,,,fee schedule,19192.43,38574.45,
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38574.45,,,,,,,fee schedule,19192.43,38574.45,
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,19192.43,38574.45,APC
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,19192.43,38574.45,APC
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,19192.43,38574.45,APC
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5487.14,,,,,,,fee schedule,3146.13,6310.21,
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4491.22,,,,,,,fee schedule,3146.13,6310.21,
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3597.37,,,,,,,fee schedule,3146.13,6310.21,
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6310.21,,,,,,,fee schedule,3146.13,6310.21,
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,3146.13,6310.21,APC
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,3146.13,6310.21,APC
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,3146.13,6310.21,APC
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33543,,,,,,,fee schedule,19192.43,38574.45,
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27454.95,,,,,,,fee schedule,19192.43,38574.45,
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21990.79,,,,,,,fee schedule,19192.43,38574.45,
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38574.45,,,,,,,fee schedule,19192.43,38574.45,
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,19192.43,38574.45,APC
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,19192.43,38574.45,APC
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,19192.43,38574.45,APC
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.94,,,,,,,fee schedule,37.19,74.68,
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.15,,,,,,,fee schedule,37.19,74.68,
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.57,,,,,,,fee schedule,37.19,74.68,
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.68,,,,,,,fee schedule,37.19,74.68,
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,74.68,APC
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,74.68,APC
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,74.68,APC
Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.28,,,,,,,fee schedule,104.17,217.67,
Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.93,,,,,,,fee schedule,104.17,217.67,
Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.09,,,,,,,fee schedule,104.17,217.67,
Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.67,,,,,,,fee schedule,104.17,217.67,
Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,217.67,APC
Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,217.67,APC
Opto-acoustic img breast uni,0857T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,217.67,APC
Ext trnscranl mag stimj meas,0858T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,669.27,APC
Ext trnscranl mag stimj meas,0858T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,669.27,APC
Ext trnscranl mag stimj meas,0858T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,669.27,APC
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6760.19,,,,,,,fee schedule,3723.52,7774.22,
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5533.22,,,,,,,fee schedule,3723.52,7774.22,
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4431.98,,,,,,,fee schedule,3723.52,7774.22,
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7774.22,,,,,,,fee schedule,3723.52,7774.22,
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,7774.22,APC
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,7774.22,APC
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,7774.22,APC
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3139.28,,,,,,,fee schedule,2055.86,3700.55,
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2569.5,,,,,,,fee schedule,2055.86,3700.55,
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2058.11,,,,,,,fee schedule,2055.86,3700.55,
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3610.17,,,,,,,fee schedule,2055.86,3700.55,
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,3700.55,APC
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,3700.55,APC
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,3700.55,APC
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3139.28,,,,,,,fee schedule,2055.86,3700.55,
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2569.5,,,,,,,fee schedule,2055.86,3700.55,
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2058.11,,,,,,,fee schedule,2055.86,3700.55,
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3610.17,,,,,,,fee schedule,2055.86,3700.55,
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,3700.55,APC
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,3700.55,APC
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,3700.55,APC
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,425.44,,,,,,,fee schedule,176.75,489.26,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,176.75,,,,,,,fee schedule,176.75,489.26,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.75,,,,,,,fee schedule,176.75,489.26,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,348.22,,,,,,,fee schedule,176.75,489.26,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,278.92,,,,,,,fee schedule,176.75,489.26,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,203.26,,,,,,,fee schedule,176.75,489.26,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,489.26,,,,,,,fee schedule,176.75,489.26,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,176.75,,,,,,,fee schedule,176.75,489.26,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,176.75,489.26,APC
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,176.75,489.26,APC
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,176.75,489.26,APC
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,421.83,,,,,,,fee schedule,237.74,485.1,
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,345.27,,,,,,,fee schedule,237.74,485.1,
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,276.55,,,,,,,fee schedule,237.74,485.1,
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,485.1,,,,,,,fee schedule,237.74,485.1,
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,485.1,APC
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,485.1,APC
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,485.1,APC
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,421.83,,,,,,,fee schedule,237.74,485.1,
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,345.27,,,,,,,fee schedule,237.74,485.1,
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,276.55,,,,,,,fee schedule,237.74,485.1,
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,485.1,,,,,,,fee schedule,237.74,485.1,
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,485.1,APC
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,485.1,APC
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,485.1,APC
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,5342.52,9616.53,APC
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,5342.52,9616.53,APC
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,5342.52,9616.53,APC
Hi-res gastric ep mapping,0868T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,669.27,APC
Hi-res gastric ep mapping,0868T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,669.27,APC
Hi-res gastric ep mapping,0868T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,669.27,APC
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3567.53,6421.55,APC
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3567.53,6421.55,APC
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3567.53,6421.55,APC
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3567.53,6421.55,APC
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3567.53,6421.55,APC
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3567.53,6421.55,APC
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3567.53,6421.55,APC
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3567.53,6421.55,APC
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3567.53,6421.55,APC
Prgrm subq prtl asct pmp sys,0875T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Prgrm subq prtl asct pmp sys,0875T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Prgrm subq prtl asct pmp sys,0875T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Augmnt alys ch ct ild w/o ct,0877T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.14,,,,,,,fee schedule,634.42,1141.96,APC
Augmnt alys ch ct ild w/o ct,0877T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,634.42,,,,,,,fee schedule,634.42,1141.96,APC
Augmnt alys ch ct ild w/o ct,0877T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1141.96,,,,,,,fee schedule,634.42,1141.96,APC
Augmnt alys ch ct ild w/ct,0878T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.14,,,,,,,fee schedule,634.42,1141.96,APC
Augmnt alys ch ct ild w/ct,0878T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,634.42,,,,,,,fee schedule,634.42,1141.96,APC
Augmnt alys ch ct ild w/ct,0878T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1141.96,,,,,,,fee schedule,634.42,1141.96,APC
Cryotherapy oral cavity,0881T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,445.12,801.21,APC
Cryotherapy oral cavity,0881T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,445.12,801.21,APC
Cryotherapy oral cavity,0881T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,445.12,801.21,APC
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,6049.07,10888.32,APC
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,6049.07,10888.32,APC
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,6049.07,10888.32,APC
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,6049.07,10888.32,APC
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,6049.07,10888.32,APC
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,6049.07,10888.32,APC
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,6049.07,10888.32,APC
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,6049.07,10888.32,APC
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,6049.07,10888.32,APC
Prsnlz trgt dvl arhfcmrigtbs,0889T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,973.35,,,,,,,fee schedule,927,1668.61,APC
Prsnlz trgt dvl arhfcmrigtbs,0889T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,927,,,,,,,fee schedule,927,1668.61,APC
Prsnlz trgt dvl arhfcmrigtbs,0889T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1668.61,,,,,,,fee schedule,927,1668.61,APC
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,1540.17,APC
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,1540.17,APC
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,1540.17,APC
N-invas prst8 cancer est map,0898T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,1540.17,APC
N-invas prst8 cancer est map,0898T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,1540.17,APC
N-invas prst8 cancer est map,0898T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,1540.17,APC
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,210.75,,,,,,,fee schedule,132.57,242.36,
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,172.5,,,,,,,fee schedule,132.57,242.36,
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.17,,,,,,,fee schedule,132.57,242.36,
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,242.36,,,,,,,fee schedule,132.57,242.36,
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,242.36,APC
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,242.36,APC
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,242.36,APC
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.12,,,,,,,fee schedule,58.78,111.69,
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.49,,,,,,,fee schedule,58.78,111.69,
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.67,,,,,,,fee schedule,58.78,111.69,
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.69,,,,,,,fee schedule,58.78,111.69,
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,111.69,APC
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,111.69,APC
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,111.69,APC
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.87,,,,,,,fee schedule,199.91,373.6,
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.91,,,,,,,fee schedule,199.91,373.6,
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.98,,,,,,,fee schedule,199.91,373.6,
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,373.6,,,,,,,fee schedule,199.91,373.6,
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,373.6,APC
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,373.6,APC
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,373.6,APC
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,30746.74,55344.12,APC
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,30746.74,55344.12,APC
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,30746.74,55344.12,APC
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,30746.74,55344.12,APC
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,30746.74,55344.12,APC
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,30746.74,55344.12,APC
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,3483.53,6270.36,APC
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,3483.53,6270.36,APC
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,3483.53,6270.36,APC
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,105.8,APC
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,105.8,APC
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,105.8,APC
Elec alys nstim sys vgs smpl,0912T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,170.51,APC
Elec alys nstim sys vgs smpl,0912T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,170.51,APC
Elec alys nstim sys vgs smpl,0912T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,170.51,APC
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9321.99,,,,,,,fee schedule,6111.5,20704.82,
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7630.05,,,,,,,fee schedule,6111.5,20704.82,
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6111.5,,,,,,,fee schedule,6111.5,20704.82,
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10720.29,,,,,,,fee schedule,6111.5,20704.82,
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,6111.5,20704.82,APC
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,6111.5,20704.82,APC
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,6111.5,20704.82,APC
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52420.68,,,,,,,fee schedule,31275.99,60283.78,
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42906.33,,,,,,,fee schedule,31275.99,60283.78,
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34367,,,,,,,fee schedule,31275.99,60283.78,
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60283.78,,,,,,,fee schedule,31275.99,60283.78,
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32839.79,,,,,,,fee schedule,31275.99,60283.78,APC
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31275.99,,,,,,,fee schedule,31275.99,60283.78,APC
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56296.78,,,,,,,fee schedule,31275.99,60283.78,APC
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36699.53,,,,,,,fee schedule,22163.59,42204.46,
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30038.57,,,,,,,fee schedule,22163.59,42204.46,
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24060.21,,,,,,,fee schedule,22163.59,42204.46,
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42204.46,,,,,,,fee schedule,22163.59,42204.46,
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,22163.59,42204.46,APC
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,22163.59,42204.46,APC
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,22163.59,42204.46,APC
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13531.23,,,,,,,fee schedule,8245.63,15560.91,
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11075.31,,,,,,,fee schedule,8245.63,15560.91,
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8871.07,,,,,,,fee schedule,8245.63,15560.91,
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15560.91,,,,,,,fee schedule,8245.63,15560.91,
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,15560.91,APC
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,15560.91,APC
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,15560.91,APC
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13531.23,,,,,,,fee schedule,8245.63,15560.91,
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11075.31,,,,,,,fee schedule,8245.63,15560.91,
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8871.07,,,,,,,fee schedule,8245.63,15560.91,
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15560.91,,,,,,,fee schedule,8245.63,15560.91,
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,15560.91,APC
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,15560.91,APC
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,15560.91,APC
Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5950.26,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4870.29,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3900.99,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6842.8,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys pg only,0919T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5950.26,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4870.29,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3900.99,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6842.8,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys 1 pac ld,0920T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5950.26,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4870.29,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3900.99,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6842.8,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys 1 dfb ld,0921T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5950.26,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4870.29,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3900.99,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6842.8,,,,,,,fee schedule,3723.52,6842.8,
Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl perm ccm-d sys dual ld,0922T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3723.52,6842.8,APC
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36699.53,,,,,,,fee schedule,22163.59,42204.46,
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30038.57,,,,,,,fee schedule,22163.59,42204.46,
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24060.21,,,,,,,fee schedule,22163.59,42204.46,
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42204.46,,,,,,,fee schedule,22163.59,42204.46,
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,22163.59,42204.46,APC
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,22163.59,42204.46,APC
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,22163.59,42204.46,APC
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1010.86,,,,,,,fee schedule,625.05,1162.49,
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,827.39,,,,,,,fee schedule,625.05,1162.49,
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.72,,,,,,,fee schedule,625.05,1162.49,
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1162.49,,,,,,,fee schedule,625.05,1162.49,
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1162.49,APC
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1162.49,APC
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1162.49,APC
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2990.8,,,,,,,fee schedule,1960.77,3700.55,
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2447.97,,,,,,,fee schedule,1960.77,3700.55,
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1960.77,,,,,,,fee schedule,1960.77,3700.55,
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3439.42,,,,,,,fee schedule,1960.77,3700.55,
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1960.77,3700.55,APC
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1960.77,3700.55,APC
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1960.77,3700.55,APC
Prgrmg dev eval ccm-d ip,0926T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.97,,,,,,,fee schedule,37.19,70.12,
Prgrmg dev eval ccm-d ip,0926T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.9,,,,,,,fee schedule,37.19,70.12,
Prgrmg dev eval ccm-d ip,0926T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.97,,,,,,,fee schedule,37.19,70.12,
Prgrmg dev eval ccm-d ip,0926T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.12,,,,,,,fee schedule,37.19,70.12,
Prgrmg dev eval ccm-d ip,0926T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,70.12,APC
Prgrmg dev eval ccm-d ip,0926T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,70.12,APC
Prgrmg dev eval ccm-d ip,0926T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,70.12,APC
Interrog dev eval ccm-d ip,0927T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.97,,,,,,,fee schedule,37.19,70.12,
Interrog dev eval ccm-d ip,0927T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.9,,,,,,,fee schedule,37.19,70.12,
Interrog dev eval ccm-d ip,0927T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.97,,,,,,,fee schedule,37.19,70.12,
Interrog dev eval ccm-d ip,0927T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.12,,,,,,,fee schedule,37.19,70.12,
Interrog dev eval ccm-d ip,0927T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,70.12,APC
Interrog dev eval ccm-d ip,0927T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,70.12,APC
Interrog dev eval ccm-d ip,0927T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,70.12,APC
Rem interrog dev ccm-d tech,0929T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.97,,,,,,,fee schedule,37.19,70.12,
Rem interrog dev ccm-d tech,0929T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.9,,,,,,,fee schedule,37.19,70.12,
Rem interrog dev ccm-d tech,0929T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.97,,,,,,,fee schedule,37.19,70.12,
Rem interrog dev ccm-d tech,0929T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.12,,,,,,,fee schedule,37.19,70.12,
Rem interrog dev ccm-d tech,0929T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,70.12,APC
Rem interrog dev ccm-d tech,0929T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,70.12,APC
Rem interrog dev ccm-d tech,0929T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,70.12,APC
Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1984.88,,,,,,,fee schedule,1213.16,2282.61,
Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1624.62,,,,,,,fee schedule,1213.16,2282.61,
Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1301.29,,,,,,,fee schedule,1213.16,2282.61,
Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2282.61,,,,,,,fee schedule,1213.16,2282.61,
Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1273.82,,,,,,,fee schedule,1213.16,2282.61,APC
Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1213.16,,,,,,,fee schedule,1213.16,2282.61,APC
Ephys eval ccm-d ld 1st impl,0930T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2183.69,,,,,,,fee schedule,1213.16,2282.61,APC
Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1984.88,,,,,,,fee schedule,1213.16,2282.61,
Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1624.62,,,,,,,fee schedule,1213.16,2282.61,
Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1301.29,,,,,,,fee schedule,1213.16,2282.61,
Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2282.61,,,,,,,fee schedule,1213.16,2282.61,
Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1273.82,,,,,,,fee schedule,1213.16,2282.61,APC
Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1213.16,,,,,,,fee schedule,1213.16,2282.61,APC
Ephys eval ccm-d ld separate,0931T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2183.69,,,,,,,fee schedule,1213.16,2282.61,APC
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,490.36,,,,,,,fee schedule,306.03,563.91,
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,401.36,,,,,,,fee schedule,306.03,563.91,
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,321.48,,,,,,,fee schedule,306.03,563.91,
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,563.91,,,,,,,fee schedule,306.03,563.91,
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,306.03,563.91,APC
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,306.03,563.91,APC
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,306.03,563.91,APC
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5258.84,,,,,,,fee schedule,3230.27,6047.67,
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4304.36,,,,,,,fee schedule,3230.27,6047.67,
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3447.7,,,,,,,fee schedule,3230.27,6047.67,
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6047.67,,,,,,,fee schedule,3230.27,6047.67,
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,6047.67,APC
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,6047.67,APC
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,6047.67,APC
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,3749.16,APC
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,3749.16,APC
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,3749.16,APC
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.21,,,,,,,fee schedule,237.74,454.49,
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,323.48,,,,,,,fee schedule,237.74,454.49,
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.1,,,,,,,fee schedule,237.74,454.49,
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.49,,,,,,,fee schedule,237.74,454.49,
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,454.49,APC
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,454.49,APC
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,454.49,APC
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.87,,,,,,,fee schedule,104.17,199.95,
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.31,,,,,,,fee schedule,104.17,199.95,
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.99,,,,,,,fee schedule,104.17,199.95,
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.95,,,,,,,fee schedule,104.17,199.95,
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,199.95,APC
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,199.95,APC
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,199.95,APC
Rem interrog dev ccm tech,0949T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Rem interrog dev ccm tech,0949T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Rem interrog dev ccm tech,0949T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,16978.36,APC
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,16978.36,APC
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,16978.36,APC
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,2962.18,APC
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,2962.18,APC
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,2962.18,APC
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1192.34,2146.21,APC
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1192.34,2146.21,APC
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1192.34,2146.21,APC
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,3303.54,5946.37,APC
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,3303.54,5946.37,APC
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,3303.54,5946.37,APC
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,3303.54,5946.37,APC
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,3303.54,5946.37,APC
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,3303.54,5946.37,APC
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,3303.54,5946.37,APC
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,3303.54,5946.37,APC
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,3303.54,5946.37,APC
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1192.34,2146.21,APC
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1192.34,2146.21,APC
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1192.34,2146.21,APC
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,3901.35,7022.44,APC
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,3901.35,7022.44,APC
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,3901.35,7022.44,APC
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,3901.35,7022.44,APC
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,3901.35,7022.44,APC
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,3901.35,7022.44,APC
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,405.05,729.1,APC
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,405.05,729.1,APC
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,405.05,729.1,APC
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,405.05,729.1,APC
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,405.05,729.1,APC
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,405.05,729.1,APC
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,238.78,APC
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,238.78,APC
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,238.78,APC
Rem mntr impl ivc snr phys,0983T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Rem mntr impl ivc snr phys,0983T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Rem mntr impl ivc snr phys,0983T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,3483.53,6270.36,APC
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,3483.53,6270.36,APC
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,3483.53,6270.36,APC
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,16978.36,APC
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1520.91,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1244.86,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,997.11,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1749.05,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1520.91,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1244.86,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,997.11,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1749.05,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1520.91,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1244.86,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,997.11,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1749.05,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1520.91,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1244.86,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,997.11,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1749.05,,,,,,,fee schedule,705.59,1749.05,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,705.59,1749.05,APC
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,705.59,1749.05,APC
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2369.9,,,,,,,fee schedule,240.36,2725.39,
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,240.36,,,,,,,fee schedule,240.36,2725.39,
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,240.36,,,,,,,fee schedule,240.36,2725.39,
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1939.76,,,,,,,fee schedule,240.36,2725.39,
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1553.71,,,,,,,fee schedule,240.36,2725.39,
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,276.41,,,,,,,fee schedule,240.36,2725.39,
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2725.39,,,,,,,fee schedule,240.36,2725.39,
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,240.36,,,,,,,fee schedule,240.36,2725.39,
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,240.36,2725.39,APC
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,240.36,2725.39,APC
Fna w/o image,10021,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,240.36,2725.39,APC
Air displacmnt plethysmograp,1002T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Air displacmnt plethysmograp,1002T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Air displacmnt plethysmograp,1002T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,309.6,,,,,,,fee schedule,202.97,1319.63,
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1147.5,,,,,,,fee schedule,202.97,1319.63,
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1147.5,,,,,,,fee schedule,202.97,1319.63,
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,253.41,,,,,,,fee schedule,202.97,1319.63,
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.97,,,,,,,fee schedule,202.97,1319.63,
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1319.63,,,,,,,fee schedule,202.97,1319.63,
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,356.04,,,,,,,fee schedule,202.97,1319.63,
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1147.5,,,,,,,fee schedule,202.97,1319.63,
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,202.97,1319.63,APC
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,202.97,1319.63,APC
Guide cathet fluid drainage,10030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,202.97,1319.63,APC
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1485.36,,,,,,,fee schedule,705.59,1708.16,
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1215.77,,,,,,,fee schedule,705.59,1708.16,
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,973.8,,,,,,,fee schedule,705.59,1708.16,
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1708.16,,,,,,,fee schedule,705.59,1708.16,
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,705.59,1708.16,APC
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,705.59,1708.16,APC
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,705.59,1708.16,APC
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Acne surgery,10040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Elec alys s-scl eeg prgr 1st,1005T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,170.51,APC
Elec alys s-scl eeg prgr 1st,1005T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,170.51,APC
Elec alys s-scl eeg prgr 1st,1005T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,170.51,APC
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3048.46,,,,,,,fee schedule,169.69,3505.73,
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.69,,,,,,,fee schedule,169.69,3505.73,
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.69,,,,,,,fee schedule,169.69,3505.73,
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2495.16,,,,,,,fee schedule,169.69,3505.73,
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1998.57,,,,,,,fee schedule,169.69,3505.73,
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.14,,,,,,,fee schedule,169.69,3505.73,
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3505.73,,,,,,,fee schedule,169.69,3505.73,
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.69,,,,,,,fee schedule,169.69,3505.73,
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,169.69,3505.73,APC
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,169.69,3505.73,APC
Drainage of skin abscess,10060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,169.69,3505.73,APC
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,304.72,,,,,,,fee schedule,199.77,729.1,
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,199.77,729.1,
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,199.77,729.1,
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,249.41,,,,,,,fee schedule,199.77,729.1,
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.77,,,,,,,fee schedule,199.77,729.1,
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,199.77,729.1,
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,350.43,,,,,,,fee schedule,199.77,729.1,
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,199.77,729.1,
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,199.77,729.1,APC
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,199.77,729.1,APC
Drainage of skin abscess,10061,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,199.77,729.1,APC
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,360.59,,,,,,,fee schedule,214.62,1270.05,
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,214.62,1270.05,
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.14,,,,,,,fee schedule,214.62,1270.05,
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,236.4,,,,,,,fee schedule,214.62,1270.05,
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,214.62,1270.05,
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,414.68,,,,,,,fee schedule,214.62,1270.05,
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,214.62,1270.05,APC
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,214.62,1270.05,APC
Drainage of pilonidal cyst,10080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,214.62,1270.05,APC
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,468.36,,,,,,,fee schedule,307.06,1270.05,
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,411.57,,,,,,,fee schedule,307.06,1270.05,
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,411.57,,,,,,,fee schedule,307.06,1270.05,
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,383.35,,,,,,,fee schedule,307.06,1270.05,
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,307.06,,,,,,,fee schedule,307.06,1270.05,
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,473.31,,,,,,,fee schedule,307.06,1270.05,
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,538.61,,,,,,,fee schedule,307.06,1270.05,
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,411.57,,,,,,,fee schedule,307.06,1270.05,
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,307.06,1270.05,APC
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,307.06,1270.05,APC
Drainage of pilonidal cyst,10081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,307.06,1270.05,APC
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,238.78,APC
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,238.78,APC
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,238.78,APC
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8630.4,,,,,,,fee schedule,255.05,9924.96,
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,255.05,,,,,,,fee schedule,255.05,9924.96,
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255.05,,,,,,,fee schedule,255.05,9924.96,
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7063.98,,,,,,,fee schedule,255.05,9924.96,
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5658.09,,,,,,,fee schedule,255.05,9924.96,
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,293.31,,,,,,,fee schedule,255.05,9924.96,
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9924.96,,,,,,,fee schedule,255.05,9924.96,
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.05,,,,,,,fee schedule,255.05,9924.96,
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,255.05,9924.96,APC
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,255.05,9924.96,APC
Remove foreign body,10120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,255.05,9924.96,APC
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13658.99,,,,,,,fee schedule,1645.66,15707.84,
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,15707.84,
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,15707.84,
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11179.88,,,,,,,fee schedule,1645.66,15707.84,
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8954.83,,,,,,,fee schedule,1645.66,15707.84,
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,15707.84,
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15707.84,,,,,,,fee schedule,1645.66,15707.84,
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,15707.84,
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,15707.84,APC
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,15707.84,APC
Remove foreign body,10121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,15707.84,APC
Mtrz ab ntrno trph scl/tr mw,1012T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,4118.56,7413.41,APC
Mtrz ab ntrno trph scl/tr mw,1012T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,4118.56,7413.41,APC
Mtrz ab ntrno trph scl/tr mw,1012T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,4118.56,7413.41,APC
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4831.19,,,,,,,fee schedule,246.41,5555.87,
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,246.41,,,,,,,fee schedule,246.41,5555.87,
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.41,,,,,,,fee schedule,246.41,5555.87,
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3954.33,,,,,,,fee schedule,246.41,5555.87,
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3167.33,,,,,,,fee schedule,246.41,5555.87,
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.37,,,,,,,fee schedule,246.41,5555.87,
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5555.87,,,,,,,fee schedule,246.41,5555.87,
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.41,,,,,,,fee schedule,246.41,5555.87,
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,246.41,5555.87,APC
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,246.41,5555.87,APC
Drainage of hematoma/fluid,10140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,246.41,5555.87,APC
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.14,,,,,,,fee schedule,102.37,729.1,
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,197.15,,,,,,,fee schedule,102.37,729.1,
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.15,,,,,,,fee schedule,102.37,729.1,
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.8,,,,,,,fee schedule,102.37,729.1,
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.37,,,,,,,fee schedule,102.37,729.1,
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,226.72,,,,,,,fee schedule,102.37,729.1,
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.56,,,,,,,fee schedule,102.37,729.1,
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,197.15,,,,,,,fee schedule,102.37,729.1,
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,102.37,729.1,APC
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,102.37,729.1,APC
Puncture drainage of lesion,10160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,102.37,729.1,APC
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,1847.27,5209.69,
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Complex drainage wound,10180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,6616.29,11909.32,APC
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,6616.29,11909.32,APC
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,6616.29,11909.32,APC
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,105.8,APC
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,105.8,APC
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,105.8,APC
Active thrc irrigation spx,1021T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1125.08,APC
Active thrc irrigation spx,1021T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1125.08,APC
Active thrc irrigation spx,1021T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1125.08,APC
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,241.07,APC
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,241.07,APC
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,241.07,APC
Crtj dig 3d mdl surf mesh 1,1030T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Crtj dig 3d mdl surf mesh 1,1030T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Crtj dig 3d mdl surf mesh 1,1030T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Crtj dig 3d mdl mesh&sim 1,1032T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Crtj dig 3d mdl mesh&sim 1,1032T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Crtj dig 3d mdl mesh&sim 1,1032T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Crt dig 3d mdl msh sim&aly 1,1034T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Crt dig 3d mdl msh sim&aly 1,1034T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Crt dig 3d mdl msh sim&aly 1,1034T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Augmnt alg alys enceph wvfrm,1041T,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Augmnt alg alys enceph wvfrm,1041T,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Augmnt alg alys enceph wvfrm,1041T,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.2,,,,,,,fee schedule,57.17,729.1,
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.93,,,,,,,fee schedule,57.17,729.1,
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.93,,,,,,,fee schedule,57.17,729.1,
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.17,729.1,
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.17,,,,,,,fee schedule,57.17,729.1,
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.47,,,,,,,fee schedule,57.17,729.1,
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.28,,,,,,,fee schedule,57.17,729.1,
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.93,,,,,,,fee schedule,57.17,729.1,
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,57.17,729.1,APC
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,57.17,729.1,APC
Debride infected skin,11000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,57.17,729.1,APC
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.84,,,,,,,fee schedule,521.75,1270.05,
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,695.74,,,,,,,fee schedule,521.75,1270.05,
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,695.74,,,,,,,fee schedule,521.75,1270.05,
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.4,,,,,,,fee schedule,521.75,1270.05,
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.75,,,,,,,fee schedule,521.75,1270.05,
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,800.1,,,,,,,fee schedule,521.75,1270.05,
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,915.22,,,,,,,fee schedule,521.75,1270.05,
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,695.74,,,,,,,fee schedule,521.75,1270.05,
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,521.75,1270.05,APC
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,521.75,1270.05,APC
Debride skin at fx site,11010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,521.75,1270.05,APC
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.84,,,,,,,fee schedule,501.61,1270.05,
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,501.61,,,,,,,fee schedule,501.61,1270.05,
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,501.61,,,,,,,fee schedule,501.61,1270.05,
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.4,,,,,,,fee schedule,501.61,1270.05,
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.75,,,,,,,fee schedule,501.61,1270.05,
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,576.85,,,,,,,fee schedule,501.61,1270.05,
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,915.22,,,,,,,fee schedule,501.61,1270.05,
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,501.61,,,,,,,fee schedule,501.61,1270.05,
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,501.61,1270.05,APC
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,501.61,1270.05,APC
Debride skin musc at fx site,11011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,501.61,1270.05,APC
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1095.32,5209.69,
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1095.32,5209.69,
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1095.32,5209.69,
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,1095.32,5209.69,
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1095.32,5209.69,
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1095.32,5209.69,APC
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1095.32,5209.69,APC
Deb skin bone at fx site,11012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1095.32,5209.69,APC
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4384.46,,,,,,,fee schedule,375.19,5042.13,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,5042.13,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,375.19,5042.13,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3588.68,,,,,,,fee schedule,375.19,5042.13,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2874.45,,,,,,,fee schedule,375.19,5042.13,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,375.19,5042.13,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5042.13,,,,,,,fee schedule,375.19,5042.13,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,5042.13,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,375.19,5042.13,APC
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,375.19,5042.13,APC
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,375.19,5042.13,APC
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,375.19,1325.55,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,1325.55,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,375.19,1325.55,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,375.19,1325.55,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,375.19,1325.55,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,375.19,1325.55,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,375.19,1325.55,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,1325.55,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,375.19,1325.55,APC
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,375.19,1325.55,APC
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,375.19,1325.55,APC
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5081.6,,,,,,,fee schedule,1095.32,5843.84,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,5843.84,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,1095.32,5843.84,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4159.29,,,,,,,fee schedule,1095.32,5843.84,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3331.5,,,,,,,fee schedule,1095.32,5843.84,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,1095.32,5843.84,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5843.84,,,,,,,fee schedule,1095.32,5843.84,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,5843.84,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1095.32,5843.84,APC
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1095.32,5843.84,APC
Deb bone 20 sq cm/<,11044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1095.32,5843.84,APC
Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Trim skin lesion,11055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,96.85,359.84,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.85,,,,,,,fee schedule,96.85,359.84,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.85,,,,,,,fee schedule,96.85,359.84,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,96.85,359.84,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,96.85,359.84,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.38,,,,,,,fee schedule,96.85,359.84,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,96.85,359.84,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.85,,,,,,,fee schedule,96.85,359.84,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,96.85,359.84,APC
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,96.85,359.84,APC
Trim skin lesions 2 to 4,11056,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,96.85,359.84,APC
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.64,,,,,,,fee schedule,74.5,359.84,
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.31,,,,,,,fee schedule,74.5,359.84,
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.31,,,,,,,fee schedule,74.5,359.84,
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.01,,,,,,,fee schedule,74.5,359.84,
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.5,,,,,,,fee schedule,74.5,359.84,
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.36,,,,,,,fee schedule,74.5,359.84,
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.69,,,,,,,fee schedule,74.5,359.84,
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.31,,,,,,,fee schedule,74.5,359.84,
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,74.5,359.84,APC
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,74.5,359.84,APC
Trim skin lesions over 4,11057,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,74.5,359.84,APC
Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,463.22,,,,,,,fee schedule,303.69,729.1,
Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,379.15,,,,,,,fee schedule,303.69,729.1,
Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,303.69,,,,,,,fee schedule,303.69,729.1,
Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,532.7,,,,,,,fee schedule,303.69,729.1,
Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,303.69,729.1,APC
Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,303.69,729.1,APC
Tangntl bx skin single les,11102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,303.69,729.1,APC
Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,463.22,,,,,,,fee schedule,303.69,729.1,
Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,379.15,,,,,,,fee schedule,303.69,729.1,
Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,303.69,,,,,,,fee schedule,303.69,729.1,
Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,532.7,,,,,,,fee schedule,303.69,729.1,
Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,303.69,729.1,APC
Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,303.69,729.1,APC
Punch bx skin single lesion,11104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,303.69,729.1,APC
Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,824.53,,,,,,,fee schedule,540.56,1325.55,
Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,674.88,,,,,,,fee schedule,540.56,1325.55,
Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,540.56,,,,,,,fee schedule,540.56,1325.55,
Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,948.21,,,,,,,fee schedule,540.56,1325.55,
Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,540.56,1325.55,APC
Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,540.56,1325.55,APC
Incal bx skn single les,11106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,540.56,1325.55,APC
Removal of skin tags <w/15,11200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4004.33,,,,,,,fee schedule,199.91,4604.98,
Removal of skin tags <w/15,11200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3277.54,,,,,,,fee schedule,199.91,4604.98,
Removal of skin tags <w/15,11200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2625.24,,,,,,,fee schedule,199.91,4604.98,
Removal of skin tags <w/15,11200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4604.98,,,,,,,fee schedule,199.91,4604.98,
Removal of skin tags <w/15,11200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,4604.98,APC
Removal of skin tags <w/15,11200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,4604.98,APC
Removal of skin tags <w/15,11200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,4604.98,APC
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,729.1,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.99,,,,,,,fee schedule,150.12,729.1,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,178.99,,,,,,,fee schedule,150.12,729.1,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,729.1,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,729.1,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.84,,,,,,,fee schedule,150.12,729.1,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,729.1,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.99,,,,,,,fee schedule,150.12,729.1,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,150.12,729.1,APC
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,150.12,729.1,APC
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,150.12,729.1,APC
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,186.18,,,,,,,fee schedule,122.06,359.84,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.23,,,,,,,fee schedule,122.06,359.84,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.23,,,,,,,fee schedule,122.06,359.84,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.06,,,,,,,fee schedule,122.06,359.84,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,152.39,,,,,,,fee schedule,122.06,359.84,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.86,,,,,,,fee schedule,122.06,359.84,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,214.11,,,,,,,fee schedule,122.06,359.84,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.23,,,,,,,fee schedule,122.06,359.84,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,122.06,359.84,APC
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,122.06,359.84,APC
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,122.06,359.84,APC
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,301.78,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.85,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,247.01,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,347.05,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.19,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,216.47,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.26,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,379.72,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,243.97,,,,,,,fee schedule,159.95,1270.05,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.02,,,,,,,fee schedule,159.95,1270.05,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,210.02,,,,,,,fee schedule,159.95,1270.05,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.69,,,,,,,fee schedule,159.95,1270.05,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.95,,,,,,,fee schedule,159.95,1270.05,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,241.52,,,,,,,fee schedule,159.95,1270.05,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,280.57,,,,,,,fee schedule,159.95,1270.05,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,210.02,,,,,,,fee schedule,159.95,1270.05,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,159.95,1270.05,APC
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,159.95,1270.05,APC
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,159.95,1270.05,APC
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4430.49,,,,,,,fee schedule,237.77,5095.06,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,237.77,,,,,,,fee schedule,237.77,5095.06,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,237.77,,,,,,,fee schedule,237.77,5095.06,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3626.36,,,,,,,fee schedule,237.77,5095.06,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2904.63,,,,,,,fee schedule,237.77,5095.06,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,273.44,,,,,,,fee schedule,237.77,5095.06,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5095.06,,,,,,,fee schedule,237.77,5095.06,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,237.77,,,,,,,fee schedule,237.77,5095.06,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,237.77,5095.06,APC
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,237.77,5095.06,APC
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,237.77,5095.06,APC
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,260.25,6124.23,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,260.25,,,,,,,fee schedule,260.25,6124.23,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.25,,,,,,,fee schedule,260.25,6124.23,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,260.25,6124.23,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,260.25,6124.23,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,299.29,,,,,,,fee schedule,260.25,6124.23,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,260.25,6124.23,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,260.25,,,,,,,fee schedule,260.25,6124.23,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,260.25,6124.23,APC
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,260.25,6124.23,APC
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,260.25,6124.23,APC
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5732.88,,,,,,,fee schedule,282.71,6592.81,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,282.71,,,,,,,fee schedule,282.71,6592.81,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,282.71,,,,,,,fee schedule,282.71,6592.81,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3758.48,,,,,,,fee schedule,282.71,6592.81,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4692.36,,,,,,,fee schedule,282.71,6592.81,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.12,,,,,,,fee schedule,282.71,6592.81,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6592.81,,,,,,,fee schedule,282.71,6592.81,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,282.71,,,,,,,fee schedule,282.71,6592.81,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,282.71,6592.81,APC
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,282.71,6592.81,APC
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,282.71,6592.81,APC
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5355.31,,,,,,,fee schedule,1275.58,6158.61,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,6158.61,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,1275.58,6158.61,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3510.94,,,,,,,fee schedule,1275.58,6158.61,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.32,,,,,,,fee schedule,1275.58,6158.61,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,1275.58,6158.61,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6158.61,,,,,,,fee schedule,1275.58,6158.61,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,6158.61,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1275.58,6158.61,APC
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1275.58,6158.61,APC
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1275.58,6158.61,APC
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7287.2,,,,,,,fee schedule,1275.58,8380.28,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,8380.28,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,1275.58,8380.28,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4777.49,,,,,,,fee schedule,1275.58,8380.28,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5964.57,,,,,,,fee schedule,1275.58,8380.28,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,1275.58,8380.28,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8380.28,,,,,,,fee schedule,1275.58,8380.28,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,8380.28,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1275.58,8380.28,APC
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1275.58,8380.28,APC
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1275.58,8380.28,APC
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7370.26,,,,,,,fee schedule,200.59,8475.8,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,200.59,,,,,,,fee schedule,200.59,8475.8,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,200.59,,,,,,,fee schedule,200.59,8475.8,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4831.94,,,,,,,fee schedule,200.59,8475.8,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6032.56,,,,,,,fee schedule,200.59,8475.8,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,230.68,,,,,,,fee schedule,200.59,8475.8,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8475.8,,,,,,,fee schedule,200.59,8475.8,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,200.59,,,,,,,fee schedule,200.59,8475.8,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,200.59,8475.8,APC
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,200.59,8475.8,APC
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,200.59,8475.8,APC
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5963.91,,,,,,,fee schedule,236.91,6858.5,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,236.91,,,,,,,fee schedule,236.91,6858.5,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,236.91,,,,,,,fee schedule,236.91,6858.5,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3909.94,,,,,,,fee schedule,236.91,6858.5,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4881.46,,,,,,,fee schedule,236.91,6858.5,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,272.45,,,,,,,fee schedule,236.91,6858.5,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6858.5,,,,,,,fee schedule,236.91,6858.5,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.91,,,,,,,fee schedule,236.91,6858.5,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,236.91,6858.5,APC
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,236.91,6858.5,APC
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,236.91,6858.5,APC
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5052.46,,,,,,,fee schedule,262.84,5810.33,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.84,,,,,,,fee schedule,262.84,5810.33,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.84,,,,,,,fee schedule,262.84,5810.33,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3312.39,,,,,,,fee schedule,262.84,5810.33,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4135.44,,,,,,,fee schedule,262.84,5810.33,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,302.27,,,,,,,fee schedule,262.84,5810.33,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5810.33,,,,,,,fee schedule,262.84,5810.33,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,262.84,,,,,,,fee schedule,262.84,5810.33,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,262.84,5810.33,APC
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,262.84,5810.33,APC
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,262.84,5810.33,APC
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,326.28,,,,,,,fee schedule,213.91,2962.18,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.8,,,,,,,fee schedule,213.91,2962.18,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,284.8,,,,,,,fee schedule,213.91,2962.18,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.91,,,,,,,fee schedule,213.91,2962.18,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,267.06,,,,,,,fee schedule,213.91,2962.18,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,327.52,,,,,,,fee schedule,213.91,2962.18,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,375.22,,,,,,,fee schedule,213.91,2962.18,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.8,,,,,,,fee schedule,213.91,2962.18,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,213.91,2962.18,APC
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,213.91,2962.18,APC
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,213.91,2962.18,APC
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,2962.18,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8210.93,,,,,,,fee schedule,2417.43,9442.57,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,9442.57,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,9442.57,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5383.09,,,,,,,fee schedule,2417.43,9442.57,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6720.65,,,,,,,fee schedule,2417.43,9442.57,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,9442.57,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9442.57,,,,,,,fee schedule,2417.43,9442.57,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,9442.57,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,9442.57,APC
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,9442.57,APC
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,9442.57,APC
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,227.4,4948.46,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.4,,,,,,,fee schedule,227.4,4948.46,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.4,,,,,,,fee schedule,227.4,4948.46,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,227.4,4948.46,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,227.4,4948.46,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.51,,,,,,,fee schedule,227.4,4948.46,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,227.4,4948.46,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.4,,,,,,,fee schedule,227.4,4948.46,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,227.4,4948.46,APC
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,227.4,4948.46,APC
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,227.4,4948.46,APC
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.85,,,,,,,fee schedule,260.25,7300.03,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,260.25,,,,,,,fee schedule,260.25,7300.03,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.25,,,,,,,fee schedule,260.25,7300.03,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.72,,,,,,,fee schedule,260.25,7300.03,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.65,,,,,,,fee schedule,260.25,7300.03,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,299.29,,,,,,,fee schedule,260.25,7300.03,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.03,,,,,,,fee schedule,260.25,7300.03,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,260.25,,,,,,,fee schedule,260.25,7300.03,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,260.25,7300.03,APC
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,260.25,7300.03,APC
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,260.25,7300.03,APC
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,281.43,6124.23,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,281.43,,,,,,,fee schedule,281.43,6124.23,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,281.43,,,,,,,fee schedule,281.43,6124.23,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,281.43,6124.23,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,281.43,6124.23,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,323.64,,,,,,,fee schedule,281.43,6124.23,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,281.43,6124.23,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,281.43,,,,,,,fee schedule,281.43,6124.23,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,281.43,6124.23,APC
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,281.43,6124.23,APC
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,281.43,6124.23,APC
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6493.3,,,,,,,fee schedule,311.66,7467.3,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,311.66,,,,,,,fee schedule,311.66,7467.3,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,311.66,,,,,,,fee schedule,311.66,7467.3,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5314.77,,,,,,,fee schedule,311.66,7467.3,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4257.01,,,,,,,fee schedule,311.66,7467.3,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,358.41,,,,,,,fee schedule,311.66,7467.3,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7467.3,,,,,,,fee schedule,311.66,7467.3,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,311.66,,,,,,,fee schedule,311.66,7467.3,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,311.66,7467.3,APC
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,311.66,7467.3,APC
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,311.66,7467.3,APC
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12161.33,,,,,,,fee schedule,1095.32,13985.53,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,13985.53,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,1095.32,13985.53,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9954.05,,,,,,,fee schedule,1095.32,13985.53,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7972.97,,,,,,,fee schedule,1095.32,13985.53,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,1095.32,13985.53,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13985.53,,,,,,,fee schedule,1095.32,13985.53,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,13985.53,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1095.32,13985.53,APC
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1095.32,13985.53,APC
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1095.32,13985.53,APC
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9025.64,,,,,,,fee schedule,2417.43,10379.49,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,10379.49,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,10379.49,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7387.49,,,,,,,fee schedule,2417.43,10379.49,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5917.21,,,,,,,fee schedule,2417.43,10379.49,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,10379.49,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10379.49,,,,,,,fee schedule,2417.43,10379.49,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,10379.49,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,10379.49,APC
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,10379.49,APC
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,10379.49,APC
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11462,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11463,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Removal sweat gland lesion,11471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,352.75,,,,,,,fee schedule,231.26,1270.05,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,308.64,,,,,,,fee schedule,231.26,1270.05,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,308.64,,,,,,,fee schedule,231.26,1270.05,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,288.73,,,,,,,fee schedule,231.26,1270.05,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,231.26,,,,,,,fee schedule,231.26,1270.05,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,354.94,,,,,,,fee schedule,231.26,1270.05,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,405.66,,,,,,,fee schedule,231.26,1270.05,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,308.64,,,,,,,fee schedule,231.26,1270.05,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,231.26,1270.05,APC
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,231.26,1270.05,APC
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,231.26,1270.05,APC
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,403.69,,,,,,,fee schedule,264.66,1270.05,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,347.79,,,,,,,fee schedule,264.66,1270.05,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.79,,,,,,,fee schedule,264.66,1270.05,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,330.42,,,,,,,fee schedule,264.66,1270.05,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.66,,,,,,,fee schedule,264.66,1270.05,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.96,,,,,,,fee schedule,264.66,1270.05,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,464.24,,,,,,,fee schedule,264.66,1270.05,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.79,,,,,,,fee schedule,264.66,1270.05,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,264.66,1270.05,APC
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,264.66,1270.05,APC
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,264.66,1270.05,APC
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6388.47,,,,,,,fee schedule,373.84,7346.74,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,373.84,,,,,,,fee schedule,373.84,7346.74,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,373.84,,,,,,,fee schedule,373.84,7346.74,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5228.96,,,,,,,fee schedule,373.84,7346.74,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4188.28,,,,,,,fee schedule,373.84,7346.74,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,429.92,,,,,,,fee schedule,373.84,7346.74,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7346.74,,,,,,,fee schedule,373.84,7346.74,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,373.84,,,,,,,fee schedule,373.84,7346.74,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,373.84,7346.74,APC
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,373.84,7346.74,APC
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,373.84,7346.74,APC
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7064.48,,,,,,,fee schedule,404.92,8124.15,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,404.92,,,,,,,fee schedule,404.92,8124.15,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,404.92,,,,,,,fee schedule,404.92,8124.15,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5782.28,,,,,,,fee schedule,404.92,8124.15,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4631.47,,,,,,,fee schedule,404.92,8124.15,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,465.66,,,,,,,fee schedule,404.92,8124.15,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8124.15,,,,,,,fee schedule,404.92,8124.15,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,404.92,,,,,,,fee schedule,404.92,8124.15,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,404.92,8124.15,APC
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,404.92,8124.15,APC
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,404.92,8124.15,APC
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.84,,,,,,,fee schedule,521.75,1270.05,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,695.74,,,,,,,fee schedule,521.75,1270.05,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,695.74,,,,,,,fee schedule,521.75,1270.05,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.4,,,,,,,fee schedule,521.75,1270.05,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.75,,,,,,,fee schedule,521.75,1270.05,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,800.1,,,,,,,fee schedule,521.75,1270.05,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,915.22,,,,,,,fee schedule,521.75,1270.05,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,695.74,,,,,,,fee schedule,521.75,1270.05,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,521.75,1270.05,APC
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,521.75,1270.05,APC
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,521.75,1270.05,APC
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6035.12,,,,,,,fee schedule,1645.66,6940.39,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,6940.39,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,6940.39,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4939.75,,,,,,,fee schedule,1645.66,6940.39,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3956.62,,,,,,,fee schedule,1645.66,6940.39,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,6940.39,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6940.39,,,,,,,fee schedule,1645.66,6940.39,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,6940.39,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,6940.39,APC
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,6940.39,APC
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,6940.39,APC
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,354.7,,,,,,,fee schedule,232.54,2962.18,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312.13,,,,,,,fee schedule,232.54,2962.18,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,312.13,,,,,,,fee schedule,232.54,2962.18,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,290.32,,,,,,,fee schedule,232.54,2962.18,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,232.54,,,,,,,fee schedule,232.54,2962.18,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,358.95,,,,,,,fee schedule,232.54,2962.18,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,407.91,,,,,,,fee schedule,232.54,2962.18,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,312.13,,,,,,,fee schedule,232.54,2962.18,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,232.54,2962.18,APC
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,232.54,2962.18,APC
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,232.54,2962.18,APC
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4418.82,,,,,,,fee schedule,348.64,5081.64,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,348.64,,,,,,,fee schedule,348.64,5081.64,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,348.64,,,,,,,fee schedule,348.64,5081.64,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3616.8,,,,,,,fee schedule,348.64,5081.64,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2896.98,,,,,,,fee schedule,348.64,5081.64,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,400.94,,,,,,,fee schedule,348.64,5081.64,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5081.64,,,,,,,fee schedule,348.64,5081.64,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,348.64,,,,,,,fee schedule,348.64,5081.64,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,348.64,5081.64,APC
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,348.64,5081.64,APC
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,348.64,5081.64,APC
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,441.92,,,,,,,fee schedule,289.72,1270.05,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,379.7,,,,,,,fee schedule,289.72,1270.05,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,379.7,,,,,,,fee schedule,289.72,1270.05,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,361.71,,,,,,,fee schedule,289.72,1270.05,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,289.72,,,,,,,fee schedule,289.72,1270.05,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,436.66,,,,,,,fee schedule,289.72,1270.05,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,508.21,,,,,,,fee schedule,289.72,1270.05,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,379.7,,,,,,,fee schedule,289.72,1270.05,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,289.72,1270.05,APC
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,289.72,1270.05,APC
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,289.72,1270.05,APC
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,485.02,,,,,,,fee schedule,317.98,2962.18,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.69,,,,,,,fee schedule,317.98,2962.18,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.69,,,,,,,fee schedule,317.98,2962.18,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,396.99,,,,,,,fee schedule,317.98,2962.18,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,317.98,,,,,,,fee schedule,317.98,2962.18,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,479.19,,,,,,,fee schedule,317.98,2962.18,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,557.77,,,,,,,fee schedule,317.98,2962.18,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,416.69,,,,,,,fee schedule,317.98,2962.18,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,317.98,2962.18,APC
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,317.98,2962.18,APC
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,317.98,2962.18,APC
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7806.72,,,,,,,fee schedule,1645.66,8977.73,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,8977.73,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,8977.73,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6389.8,,,,,,,fee schedule,1645.66,8977.73,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5118.09,,,,,,,fee schedule,1645.66,8977.73,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,8977.73,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8977.73,,,,,,,fee schedule,1645.66,8977.73,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,8977.73,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,8977.73,APC
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,8977.73,APC
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,8977.73,APC
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6322.24,,,,,,,fee schedule,2417.43,7270.58,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,7270.58,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,7270.58,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5174.75,,,,,,,fee schedule,2417.43,7270.58,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4144.86,,,,,,,fee schedule,2417.43,7270.58,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,7270.58,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7270.58,,,,,,,fee schedule,2417.43,7270.58,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,7270.58,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,7270.58,APC
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,7270.58,APC
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,7270.58,APC
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,369.38,,,,,,,fee schedule,242.17,1270.05,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,323.38,,,,,,,fee schedule,242.17,1270.05,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,323.38,,,,,,,fee schedule,242.17,1270.05,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,302.34,,,,,,,fee schedule,242.17,1270.05,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,242.17,,,,,,,fee schedule,242.17,1270.05,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,371.89,,,,,,,fee schedule,242.17,1270.05,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,424.79,,,,,,,fee schedule,242.17,1270.05,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,323.38,,,,,,,fee schedule,242.17,1270.05,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,242.17,1270.05,APC
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,242.17,1270.05,APC
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,242.17,1270.05,APC
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.43,,,,,,,fee schedule,273.67,1270.05,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,359.55,,,,,,,fee schedule,273.67,1270.05,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,359.55,,,,,,,fee schedule,273.67,1270.05,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,341.67,,,,,,,fee schedule,273.67,1270.05,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.67,,,,,,,fee schedule,273.67,1270.05,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.48,,,,,,,fee schedule,273.67,1270.05,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.04,,,,,,,fee schedule,273.67,1270.05,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.55,,,,,,,fee schedule,273.67,1270.05,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,273.67,1270.05,APC
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,273.67,1270.05,APC
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,273.67,1270.05,APC
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,459.55,,,,,,,fee schedule,301.28,1270.05,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,394.84,,,,,,,fee schedule,301.28,1270.05,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,394.84,,,,,,,fee schedule,301.28,1270.05,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.14,,,,,,,fee schedule,301.28,1270.05,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.28,,,,,,,fee schedule,301.28,1270.05,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.07,,,,,,,fee schedule,301.28,1270.05,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,528.48,,,,,,,fee schedule,301.28,1270.05,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.84,,,,,,,fee schedule,301.28,1270.05,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,301.28,1270.05,APC
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,301.28,1270.05,APC
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,301.28,1270.05,APC
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,503.65,,,,,,,fee schedule,330.19,2962.18,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,441.86,,,,,,,fee schedule,330.19,2962.18,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,441.86,,,,,,,fee schedule,330.19,2962.18,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,412.24,,,,,,,fee schedule,330.19,2962.18,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,330.19,,,,,,,fee schedule,330.19,2962.18,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,508.14,,,,,,,fee schedule,330.19,2962.18,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,579.2,,,,,,,fee schedule,330.19,2962.18,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,441.86,,,,,,,fee schedule,330.19,2962.18,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,330.19,2962.18,APC
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,330.19,2962.18,APC
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,330.19,2962.18,APC
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8548.96,,,,,,,fee schedule,1275.58,9831.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,9831.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,1275.58,9831.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6997.32,,,,,,,fee schedule,1275.58,9831.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5604.7,,,,,,,fee schedule,1275.58,9831.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,1275.58,9831.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9831.3,,,,,,,fee schedule,1275.58,9831.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,9831.3,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1275.58,9831.3,APC
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1275.58,9831.3,APC
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1275.58,9831.3,APC
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.47,,,,,,,fee schedule,2417.43,9651.34,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,9651.34,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,9651.34,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.24,,,,,,,fee schedule,2417.43,9651.34,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.1,,,,,,,fee schedule,2417.43,9651.34,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,9651.34,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.34,,,,,,,fee schedule,2417.43,9651.34,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,9651.34,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,9651.34,APC
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,9651.34,APC
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,9651.34,APC
Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Trim nail(s) any number,11719,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Debride nail 1-5,11720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Debride nail 6 or more,11721,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,140.04,359.84,
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.04,,,,,,,fee schedule,140.04,359.84,
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.04,,,,,,,fee schedule,140.04,359.84,
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,140.04,359.84,
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,140.04,359.84,
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.05,,,,,,,fee schedule,140.04,359.84,
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,140.04,359.84,
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.04,,,,,,,fee schedule,140.04,359.84,
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,140.04,359.84,APC
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,140.04,359.84,APC
Removal of nail plate,11730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,140.04,359.84,APC
Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Drain blood from under nail,11740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,258.69,,,,,,,fee schedule,169.6,729.1,
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.67,,,,,,,fee schedule,169.6,729.1,
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.67,,,,,,,fee schedule,169.6,729.1,
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.6,,,,,,,fee schedule,169.6,729.1,
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.74,,,,,,,fee schedule,169.6,729.1,
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.82,,,,,,,fee schedule,169.6,729.1,
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,297.49,,,,,,,fee schedule,169.6,729.1,
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.67,,,,,,,fee schedule,169.6,729.1,
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,169.6,729.1,APC
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,169.6,729.1,APC
Removal of nail bed,11750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,169.6,729.1,APC
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,231.25,,,,,,,fee schedule,151.61,1270.05,
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,204.04,,,,,,,fee schedule,151.61,1270.05,
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,204.04,,,,,,,fee schedule,151.61,1270.05,
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.61,,,,,,,fee schedule,151.61,1270.05,
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.28,,,,,,,fee schedule,151.61,1270.05,
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,234.65,,,,,,,fee schedule,151.61,1270.05,
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.94,,,,,,,fee schedule,151.61,1270.05,
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.04,,,,,,,fee schedule,151.61,1270.05,
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,151.61,1270.05,APC
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,151.61,1270.05,APC
Biopsy nail unit,11755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,151.61,1270.05,APC
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,291.41,1325.55,
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,1325.55,
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,291.41,1325.55,
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,291.41,1325.55,
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,291.41,1325.55,
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,291.41,1325.55,
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,291.41,1325.55,
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,1325.55,
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,291.41,1325.55,APC
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,291.41,1325.55,APC
Repair of nail bed,11760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,291.41,1325.55,APC
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,460.51,,,,,,,fee schedule,301.91,3700.55,
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,412.46,,,,,,,fee schedule,301.91,3700.55,
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.46,,,,,,,fee schedule,301.91,3700.55,
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.91,,,,,,,fee schedule,301.91,3700.55,
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.93,,,,,,,fee schedule,301.91,3700.55,
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,474.33,,,,,,,fee schedule,301.91,3700.55,
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,529.59,,,,,,,fee schedule,301.91,3700.55,
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,412.46,,,,,,,fee schedule,301.91,3700.55,
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,301.91,3700.55,APC
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,301.91,3700.55,APC
Reconstruction of nail bed,11762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,301.91,3700.55,APC
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,193.65,729.1,
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,193.65,729.1,
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,193.65,729.1,
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,193.65,729.1,
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Excision of nail fold toe,11765,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.85,,,,,,,fee schedule,2417.43,7300.03,
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,7300.03,
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,7300.03,
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.65,,,,,,,fee schedule,2417.43,7300.03,
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.72,,,,,,,fee schedule,2417.43,7300.03,
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,7300.03,
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.03,,,,,,,fee schedule,2417.43,7300.03,
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,7300.03,
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,7300.03,APC
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,7300.03,APC
Remove pilonidal cyst simple,11770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,7300.03,APC
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5579.99,,,,,,,fee schedule,2417.43,6416.99,
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6416.99,
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,6416.99,
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.24,,,,,,,fee schedule,2417.43,6416.99,
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.22,,,,,,,fee schedule,2417.43,6416.99,
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,6416.99,
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6416.99,,,,,,,fee schedule,2417.43,6416.99,
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6416.99,
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,6416.99,APC
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,6416.99,APC
Remove pilonidal cyst exten,11771,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,6416.99,APC
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5688.56,,,,,,,fee schedule,2417.43,6541.84,
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6541.84,
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,6541.84,
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3729.42,,,,,,,fee schedule,2417.43,6541.84,
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4656.09,,,,,,,fee schedule,2417.43,6541.84,
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,6541.84,
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6541.84,,,,,,,fee schedule,2417.43,6541.84,
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6541.84,
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,6541.84,APC
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,6541.84,APC
Remove pilonidal cyst compl,11772,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,6541.84,APC
Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Inject skin lesions <=w 7,11900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Inject skin lesions >7,11901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,290.03,,,,,,,fee schedule,190.14,1325.55,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,256.79,,,,,,,fee schedule,190.14,1325.55,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.79,,,,,,,fee schedule,190.14,1325.55,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,190.14,,,,,,,fee schedule,190.14,1325.55,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,237.39,,,,,,,fee schedule,190.14,1325.55,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,295.31,,,,,,,fee schedule,190.14,1325.55,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,333.53,,,,,,,fee schedule,190.14,1325.55,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.79,,,,,,,fee schedule,190.14,1325.55,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,190.14,1325.55,APC
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,190.14,1325.55,APC
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,190.14,1325.55,APC
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.19,,,,,,,fee schedule,216.47,1325.55,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,290.52,,,,,,,fee schedule,216.47,1325.55,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,290.52,,,,,,,fee schedule,216.47,1325.55,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,216.47,,,,,,,fee schedule,216.47,1325.55,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.26,,,,,,,fee schedule,216.47,1325.55,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,334.1,,,,,,,fee schedule,216.47,1325.55,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,379.72,,,,,,,fee schedule,216.47,1325.55,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,290.52,,,,,,,fee schedule,216.47,1325.55,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,216.47,1325.55,APC
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,216.47,1325.55,APC
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,216.47,1325.55,APC
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,359.84,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.36,,,,,,,fee schedule,79.01,359.84,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.36,,,,,,,fee schedule,79.01,359.84,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,359.84,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,359.84,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.31,,,,,,,fee schedule,79.01,359.84,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,359.84,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.36,,,,,,,fee schedule,79.01,359.84,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,79.01,359.84,APC
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,79.01,359.84,APC
Tx contour defects 1 cc/<,11950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,79.01,359.84,APC
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.08,,,,,,,fee schedule,93.15,1325.55,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.21,,,,,,,fee schedule,93.15,1325.55,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.21,,,,,,,fee schedule,93.15,1325.55,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.15,,,,,,,fee schedule,93.15,1325.55,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,116.29,,,,,,,fee schedule,93.15,1325.55,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.09,,,,,,,fee schedule,93.15,1325.55,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,163.39,,,,,,,fee schedule,93.15,1325.55,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.21,,,,,,,fee schedule,93.15,1325.55,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,93.15,1325.55,APC
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,93.15,1325.55,APC
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,93.15,1325.55,APC
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.77,,,,,,,fee schedule,102.78,1325.55,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.86,,,,,,,fee schedule,102.78,1325.55,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.86,,,,,,,fee schedule,102.78,1325.55,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.78,,,,,,,fee schedule,102.78,1325.55,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.32,,,,,,,fee schedule,102.78,1325.55,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.04,,,,,,,fee schedule,102.78,1325.55,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.29,,,,,,,fee schedule,102.78,1325.55,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.86,,,,,,,fee schedule,102.78,1325.55,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,102.78,1325.55,APC
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,102.78,1325.55,APC
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,102.78,1325.55,APC
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.3,,,,,,,fee schedule,149.67,1325.55,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.34,,,,,,,fee schedule,149.67,1325.55,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.34,,,,,,,fee schedule,149.67,1325.55,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.67,,,,,,,fee schedule,149.67,1325.55,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.86,,,,,,,fee schedule,149.67,1325.55,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,232.69,,,,,,,fee schedule,149.67,1325.55,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,262.55,,,,,,,fee schedule,149.67,1325.55,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,202.34,,,,,,,fee schedule,149.67,1325.55,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,149.67,1325.55,APC
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,149.67,1325.55,APC
Tx contour defects >10.0 cc,11954,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,149.67,1325.55,APC
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Insert tissue expander(s),11960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12328.89,,,,,,,fee schedule,4986.47,14178.22,
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,14178.22,
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,14178.22,
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8082.82,,,,,,,fee schedule,4986.47,14178.22,
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10091.2,,,,,,,fee schedule,4986.47,14178.22,
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,14178.22,
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14178.22,,,,,,,fee schedule,4986.47,14178.22,
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,14178.22,
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,14178.22,APC
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,14178.22,APC
Replace tissue expander,11970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,14178.22,APC
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Remove tissue expander(s),11971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.85,,,,,,,fee schedule,132.33,1270.05,
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.26,,,,,,,fee schedule,132.33,1270.05,
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.26,,,,,,,fee schedule,132.33,1270.05,
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.33,,,,,,,fee schedule,132.33,1270.05,
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,165.21,,,,,,,fee schedule,132.33,1270.05,
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,203.85,,,,,,,fee schedule,132.33,1270.05,
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,232.13,,,,,,,fee schedule,132.33,1270.05,
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.26,,,,,,,fee schedule,132.33,1270.05,
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,132.33,1270.05,APC
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,132.33,1270.05,APC
Remove contraceptive capsule,11976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,132.33,1270.05,APC
Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Implant hormone pellet(s),11980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Insert drug implant device,11981,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Remove drug implant device,11982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,445.12,4572.08,
Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,445.12,4572.08,
Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,445.12,4572.08,
Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,445.12,4572.08,
Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,445.12,4572.08,APC
Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,445.12,4572.08,APC
Remove/insert drug implant,11983,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,445.12,4572.08,APC
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,193.65,729.1,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,193.65,729.1,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,193.65,729.1,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,193.65,729.1,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,729.1,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,729.1,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,729.1,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,729.1,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,729.1,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,729.1,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,729.1,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,729.1,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,148.19,729.1,APC
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,148.19,729.1,APC
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,148.19,729.1,APC
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,193.65,729.1,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,193.65,729.1,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,193.65,729.1,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,193.65,729.1,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Closure of split wound,12020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Closure of split wound,12021,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,569.96,4252.09,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,4252.09,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,569.96,4252.09,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,569.96,4252.09,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,569.96,4252.09,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,569.96,4252.09,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,569.96,4252.09,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,4252.09,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,569.96,4252.09,APC
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,569.96,4252.09,APC
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,569.96,4252.09,APC
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.29,,,,,,,fee schedule,277.51,729.1,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,277.51,729.1,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,277.51,729.1,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.51,,,,,,,fee schedule,277.51,729.1,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.46,,,,,,,fee schedule,277.51,729.1,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,277.51,729.1,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.78,,,,,,,fee schedule,277.51,729.1,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,277.51,729.1,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,277.51,729.1,APC
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,277.51,729.1,APC
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,277.51,729.1,APC
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,291.41,1325.55,APC
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,291.41,1325.55,APC
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,291.41,1325.55,APC
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,1325.55,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,291.41,1325.55,APC
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,291.41,1325.55,APC
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,291.41,1325.55,APC
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,1325.55,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,1325.55,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,1325.55,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,1325.55,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,1325.55,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,1325.55,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,1325.55,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,1325.55,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,283.19,1325.55,APC
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,283.19,1325.55,APC
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,283.19,1325.55,APC
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,569.96,3700.55,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,3700.55,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,569.96,3700.55,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,569.96,3700.55,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,569.96,3700.55,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,569.96,3700.55,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,569.96,3700.55,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,3700.55,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,569.96,3700.55,APC
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,569.96,3700.55,APC
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,569.96,3700.55,APC
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,148.19,729.1,APC
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,148.19,729.1,APC
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,148.19,729.1,APC
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,148.19,729.1,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,148.19,729.1,APC
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,148.19,729.1,APC
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,148.19,729.1,APC
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,291.41,769.19,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,769.19,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,291.41,769.19,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,291.41,769.19,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,291.41,769.19,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,291.41,769.19,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,291.41,769.19,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,769.19,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,291.41,769.19,APC
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,291.41,769.19,APC
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,291.41,769.19,APC
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,405.05,769.19,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,405.05,769.19,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,405.05,769.19,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,405.05,769.19,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,405.05,769.19,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,405.05,769.19,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,405.05,769.19,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,405.05,769.19,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,405.05,769.19,APC
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,405.05,769.19,APC
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,405.05,769.19,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5720.47,,,,,,,fee schedule,291.41,6578.54,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,6578.54,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,291.41,6578.54,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3750.34,,,,,,,fee schedule,291.41,6578.54,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4682.2,,,,,,,fee schedule,291.41,6578.54,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,291.41,6578.54,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6578.54,,,,,,,fee schedule,291.41,6578.54,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,291.41,6578.54,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,291.41,6578.54,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,291.41,6578.54,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,291.41,6578.54,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7098.04,,,,,,,fee schedule,405.05,8162.75,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,405.05,8162.75,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,405.05,8162.75,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4653.48,,,,,,,fee schedule,405.05,8162.75,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5809.75,,,,,,,fee schedule,405.05,8162.75,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,405.05,8162.75,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8162.75,,,,,,,fee schedule,405.05,8162.75,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,405.05,8162.75,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,405.05,8162.75,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,405.05,8162.75,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,405.05,8162.75,APC
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,6355.77,
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,6355.77,
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1860.17,,,,,,,fee schedule,1381.8,6355.77,
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,6355.77,
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,6355.77,
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2139.2,,,,,,,fee schedule,1381.8,6355.77,
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,6355.77,
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,6355.77,
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,1381.8,6355.77,APC
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,1381.8,6355.77,APC
Late closure of wound,13160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,1381.8,6355.77,APC
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5794.76,,,,,,,fee schedule,1865.01,6663.97,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6663.97,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,6663.97,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3799.04,,,,,,,fee schedule,1865.01,6663.97,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4743.01,,,,,,,fee schedule,1865.01,6663.97,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,6663.97,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6663.97,,,,,,,fee schedule,1865.01,6663.97,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6663.97,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,6663.97,APC
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,6663.97,APC
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,6663.97,APC
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4814.21,,,,,,,fee schedule,1865.01,5536.34,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,5536.34,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,5536.34,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3156.2,,,,,,,fee schedule,1865.01,5536.34,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3940.43,,,,,,,fee schedule,1865.01,5536.34,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,5536.34,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5536.34,,,,,,,fee schedule,1865.01,5536.34,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,5536.34,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,5536.34,APC
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,5536.34,APC
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,5536.34,APC
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.84,,,,,,,fee schedule,1865.01,7300.02,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7300.02,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,7300.02,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.64,,,,,,,fee schedule,1865.01,7300.02,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.71,,,,,,,fee schedule,1865.01,7300.02,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,7300.02,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.02,,,,,,,fee schedule,1865.01,7300.02,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7300.02,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,7300.02,APC
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,7300.02,APC
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,7300.02,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.07,,,,,,,fee schedule,1865.01,10827.33,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,10827.33,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,10827.33,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.23,,,,,,,fee schedule,1865.01,10827.33,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.52,,,,,,,fee schedule,1865.01,10827.33,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,10827.33,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.33,,,,,,,fee schedule,1865.01,10827.33,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,10827.33,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,10827.33,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,10827.33,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,10827.33,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6704.27,,,,,,,fee schedule,1865.01,7709.91,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7709.91,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,7709.91,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5487.44,,,,,,,fee schedule,1865.01,7709.91,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4395.32,,,,,,,fee schedule,1865.01,7709.91,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,7709.91,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7709.91,,,,,,,fee schedule,1865.01,7709.91,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7709.91,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,7709.91,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,7709.91,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,7709.91,APC
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6704.26,,,,,,,fee schedule,1865.01,7709.9,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7709.9,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,7709.9,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5487.44,,,,,,,fee schedule,1865.01,7709.9,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4395.31,,,,,,,fee schedule,1865.01,7709.9,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,7709.9,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7709.9,,,,,,,fee schedule,1865.01,7709.9,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7709.9,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,7709.9,APC
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,7709.9,APC
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,7709.9,APC
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6322.24,,,,,,,fee schedule,1865.01,7270.58,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7270.58,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,7270.58,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5174.75,,,,,,,fee schedule,1865.01,7270.58,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4144.86,,,,,,,fee schedule,1865.01,7270.58,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,7270.58,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7270.58,,,,,,,fee schedule,1865.01,7270.58,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7270.58,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,7270.58,APC
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,7270.58,APC
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,7270.58,APC
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6513.26,,,,,,,fee schedule,3049.82,7490.25,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,3049.82,7490.25,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,3049.82,7490.25,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5331.1,,,,,,,fee schedule,3049.82,7490.25,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4270.09,,,,,,,fee schedule,3049.82,7490.25,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,3049.82,7490.25,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7490.25,,,,,,,fee schedule,3049.82,7490.25,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,3049.82,7490.25,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3049.82,7490.25,APC
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3049.82,7490.25,APC
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3049.82,7490.25,APC
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,4252.09,
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,4252.09,
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,4252.09,
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,4252.09,
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,4252.09,
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,4252.09,APC
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,4252.09,APC
Filleted finger/toe flap,14350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,4252.09,APC
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,569.96,2423.84,
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,2423.84,
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,569.96,2423.84,
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,569.96,2423.84,
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,569.96,2423.84,
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,569.96,2423.84,
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,569.96,2423.84,
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,2423.84,
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,569.96,2423.84,APC
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,569.96,2423.84,APC
Wound prep trk/arm/leg,15002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,569.96,2423.84,APC
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11517.9,,,,,,,fee schedule,405.05,13245.59,
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,405.05,13245.59,
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,405.05,13245.59,
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9427.4,,,,,,,fee schedule,405.05,13245.59,
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7551.14,,,,,,,fee schedule,405.05,13245.59,
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,405.05,13245.59,
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13245.59,,,,,,,fee schedule,405.05,13245.59,
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,405.05,13245.59,
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,405.05,13245.59,APC
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,405.05,13245.59,APC
Wound prep f/n/hf/g,15004,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,405.05,13245.59,APC
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2990.8,,,,,,,fee schedule,1960.77,3700.55,
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2447.97,,,,,,,fee schedule,1960.77,3700.55,
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1960.77,,,,,,,fee schedule,1960.77,3700.55,
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3439.42,,,,,,,fee schedule,1960.77,3700.55,
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1960.77,3700.55,APC
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1960.77,3700.55,APC
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1960.77,3700.55,APC
Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10219.57,,,,,,,fee schedule,6699.95,12728.28,
Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8364.72,,,,,,,fee schedule,6699.95,12728.28,
Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6699.95,,,,,,,fee schedule,6699.95,12728.28,
Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11752.51,,,,,,,fee schedule,6699.95,12728.28,
Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7424.83,,,,,,,fee schedule,6699.95,12728.28,APC
Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7071.27,,,,,,,fee schedule,6699.95,12728.28,APC
Prepj skn cll ssp agrft 1st,15013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12728.28,,,,,,,fee schedule,6699.95,12728.28,APC
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2990.8,,,,,,,fee schedule,1960.77,3700.55,
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2447.97,,,,,,,fee schedule,1960.77,3700.55,
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1960.77,,,,,,,fee schedule,1960.77,3700.55,
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3439.42,,,,,,,fee schedule,1960.77,3700.55,
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1960.77,3700.55,APC
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1960.77,3700.55,APC
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1960.77,3700.55,APC
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2990.8,,,,,,,fee schedule,1960.77,3700.55,
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2447.97,,,,,,,fee schedule,1960.77,3700.55,
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1960.77,,,,,,,fee schedule,1960.77,3700.55,
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3439.42,,,,,,,fee schedule,1960.77,3700.55,
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1960.77,3700.55,APC
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1960.77,3700.55,APC
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1960.77,3700.55,APC
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,569.96,3700.55,
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,3700.55,
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,569.96,3700.55,
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,569.96,3700.55,
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,569.96,3700.55,
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,569.96,3700.55,
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,569.96,3700.55,
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,3700.55,
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,569.96,3700.55,APC
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,569.96,3700.55,APC
Harvest cultured skin graft,15040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,569.96,3700.55,APC
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Skin pinch graft,15050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5720.46,,,,,,,fee schedule,2055.86,6578.53,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,6578.53,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2055.86,6578.53,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4682.2,,,,,,,fee schedule,2055.86,6578.53,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3750.33,,,,,,,fee schedule,2055.86,6578.53,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2055.86,6578.53,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6578.53,,,,,,,fee schedule,2055.86,6578.53,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,6578.53,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,6578.53,APC
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,6578.53,APC
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,6578.53,APC
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,569.96,3700.55,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,3700.55,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,569.96,3700.55,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,569.96,3700.55,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,569.96,3700.55,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,569.96,3700.55,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,569.96,3700.55,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,3700.55,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,569.96,3700.55,APC
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,569.96,3700.55,APC
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,569.96,3700.55,APC
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6800.64,,,,,,,fee schedule,3049.82,7820.74,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,3049.82,7820.74,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,3049.82,7820.74,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5566.32,,,,,,,fee schedule,3049.82,7820.74,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.5,,,,,,,fee schedule,3049.82,7820.74,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,3049.82,7820.74,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7820.74,,,,,,,fee schedule,3049.82,7820.74,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,3049.82,7820.74,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3049.82,7820.74,APC
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3049.82,7820.74,APC
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3049.82,7820.74,APC
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2055.86,4252.09,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2055.86,4252.09,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2055.86,4252.09,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2055.86,4252.09,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2055.86,4252.09,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,4252.09,APC
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,4252.09,APC
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,4252.09,APC
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,6355.77,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,6355.77,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,6355.77,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,6355.77,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,6355.77,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,1865.01,6355.77,APC
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,1865.01,6355.77,APC
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,1865.01,6355.77,APC
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,4252.09,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,4252.09,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,4252.09,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,4252.09,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,4252.09,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,4252.09,APC
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,4252.09,APC
Cult skin grft t/arm/leg,15150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,4252.09,APC
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2055.86,4252.09,
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2055.86,4252.09,
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2055.86,4252.09,
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2055.86,4252.09,
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2055.86,4252.09,
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,4252.09,APC
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,4252.09,APC
Skin full graft trunk,15200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,4252.09,APC
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2139.2,,,,,,,fee schedule,1381.8,3700.55,
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Skin full grft face/genit/hf,15240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Skin full graft een & lips,15260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,736.41,2423.84,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,736.41,2423.84,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,736.41,2423.84,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,736.41,2423.84,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,736.41,2423.84,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,736.41,2423.84,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,736.41,2423.84,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,736.41,2423.84,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,736.41,2423.84,APC
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,736.41,2423.84,APC
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,736.41,2423.84,APC
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2055.86,4252.09,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2055.86,4252.09,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2055.86,4252.09,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2055.86,4252.09,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2055.86,4252.09,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,4252.09,APC
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,4252.09,APC
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,4252.09,APC
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6322.24,,,,,,,fee schedule,736.41,7270.58,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,736.41,7270.58,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,736.41,7270.58,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5174.75,,,,,,,fee schedule,736.41,7270.58,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4144.86,,,,,,,fee schedule,736.41,7270.58,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,736.41,7270.58,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7270.58,,,,,,,fee schedule,736.41,7270.58,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,736.41,7270.58,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,736.41,7270.58,APC
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,736.41,7270.58,APC
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,736.41,7270.58,APC
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Skin pedicle flap trunk,15570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,6355.77,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,6355.77,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,6355.77,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,6355.77,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,6355.77,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,1865.01,6355.77,APC
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,1865.01,6355.77,APC
Skin pedicle flap arms/legs,15572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,1865.01,6355.77,APC
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2139.2,,,,,,,fee schedule,1381.8,3700.55,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Delay flap trunk,15600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2055.86,4252.09,
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2055.86,4252.09,
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2055.86,4252.09,
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2055.86,4252.09,
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2055.86,4252.09,
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,4252.09,APC
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,4252.09,APC
Delay flap arms/legs,15610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,4252.09,APC
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6704.27,,,,,,,fee schedule,1865.01,7709.91,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7709.91,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,7709.91,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5487.44,,,,,,,fee schedule,1865.01,7709.91,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4395.32,,,,,,,fee schedule,1865.01,7709.91,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,7709.91,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7709.91,,,,,,,fee schedule,1865.01,7709.91,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,7709.91,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,7709.91,APC
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,7709.91,APC
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,7709.91,APC
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5794.76,,,,,,,fee schedule,1865.01,6663.97,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6663.97,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,6663.97,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4743.01,,,,,,,fee schedule,1865.01,6663.97,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3799.04,,,,,,,fee schedule,1865.01,6663.97,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,6663.97,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6663.97,,,,,,,fee schedule,1865.01,6663.97,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6663.97,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,6663.97,APC
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,6663.97,APC
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,6663.97,APC
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2139.2,,,,,,,fee schedule,1381.8,3700.55,
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Transfer skin pedicle flap,15650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7399.8,,,,,,,fee schedule,2358.38,8509.77,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2358.38,,,,,,,fee schedule,2358.38,8509.77,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2358.38,,,,,,,fee schedule,2358.38,8509.77,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6056.74,,,,,,,fee schedule,2358.38,8509.77,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4851.31,,,,,,,fee schedule,2358.38,8509.77,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2712.14,,,,,,,fee schedule,2358.38,8509.77,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8509.77,,,,,,,fee schedule,2358.38,8509.77,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2358.38,,,,,,,fee schedule,2358.38,8509.77,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2358.38,8509.77,APC
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2358.38,8509.77,APC
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2358.38,8509.77,APC
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7399.8,,,,,,,fee schedule,2358.38,8509.77,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2358.38,,,,,,,fee schedule,2358.38,8509.77,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2358.38,,,,,,,fee schedule,2358.38,8509.77,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6056.74,,,,,,,fee schedule,2358.38,8509.77,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4851.31,,,,,,,fee schedule,2358.38,8509.77,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2712.14,,,,,,,fee schedule,2358.38,8509.77,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8509.77,,,,,,,fee schedule,2358.38,8509.77,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2358.38,,,,,,,fee schedule,2358.38,8509.77,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2358.38,8509.77,APC
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2358.38,8509.77,APC
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2358.38,8509.77,APC
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Muscle-skin graft trunk,15734,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1860.17,4252.09,
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1860.17,,,,,,,fee schedule,1860.17,4252.09,
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1860.17,,,,,,,fee schedule,1860.17,4252.09,
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1860.17,4252.09,
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1860.17,4252.09,
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2139.2,,,,,,,fee schedule,1860.17,4252.09,
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1860.17,4252.09,
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1860.17,,,,,,,fee schedule,1860.17,4252.09,
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1860.17,4252.09,APC
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1860.17,4252.09,APC
Muscle-skin graft arm,15736,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1860.17,4252.09,APC
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Muscle-skin graft leg,15738,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Island pedicle flap graft,15740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,6355.77,
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,6355.77,
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,6355.77,
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,6355.77,
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,6355.77,
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,1865.01,6355.77,APC
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,1865.01,6355.77,APC
Neurovascular pedicle flap,15750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,1865.01,6355.77,APC
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Composite skin graft,15760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5783.37,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5783.37,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5783.37,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4733.69,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3791.58,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6650.88,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3530.98,6650.88,APC
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3530.98,6650.88,APC
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3530.98,6650.88,APC
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Derma-fat-fascia graft,15770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5783.37,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5783.37,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5783.37,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4733.69,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3791.58,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6650.88,,,,,,,fee schedule,3530.98,6650.88,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3530.98,6650.88,APC
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3530.98,6650.88,APC
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3530.98,6650.88,APC
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.69,,,,,,,fee schedule,315.8,553.94,
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.69,,,,,,,fee schedule,315.8,553.94,
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.69,,,,,,,fee schedule,315.8,553.94,
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,394.26,,,,,,,fee schedule,315.8,553.94,
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.8,,,,,,,fee schedule,315.8,553.94,
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.94,,,,,,,fee schedule,315.8,553.94,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3152.15,,,,,,,fee schedule,2055.86,3700.55,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3152.15,,,,,,,fee schedule,2055.86,3700.55,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3152.15,,,,,,,fee schedule,2055.86,3700.55,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2580.03,,,,,,,fee schedule,2055.86,3700.55,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2066.55,,,,,,,fee schedule,2055.86,3700.55,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3624.97,,,,,,,fee schedule,2055.86,3700.55,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,3700.55,APC
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,3700.55,APC
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,3700.55,APC
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,473.25,,,,,,,fee schedule,310.26,544.24,
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,473.25,,,,,,,fee schedule,310.26,544.24,
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.25,,,,,,,fee schedule,310.26,544.24,
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,387.36,,,,,,,fee schedule,310.26,544.24,
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.26,,,,,,,fee schedule,310.26,544.24,
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,544.24,,,,,,,fee schedule,310.26,544.24,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.41,,,,,,,fee schedule,283.19,729.1,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.12,,,,,,,fee schedule,283.19,729.1,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.41,,,,,,,fee schedule,283.19,729.1,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Impl absrb msh/prsth dly cls,15778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,536.48,,,,,,,fee schedule,351.72,616.95,
Impl absrb msh/prsth dly cls,15778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,439.11,,,,,,,fee schedule,351.72,616.95,
Impl absrb msh/prsth dly cls,15778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,351.72,,,,,,,fee schedule,351.72,616.95,
Impl absrb msh/prsth dly cls,15778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,616.95,,,,,,,fee schedule,351.72,616.95,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1429.61,,,,,,,fee schedule,937.25,5209.69,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1226.96,,,,,,,fee schedule,937.25,5209.69,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1226.96,,,,,,,fee schedule,937.25,5209.69,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1170.14,,,,,,,fee schedule,937.25,5209.69,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,937.25,,,,,,,fee schedule,937.25,5209.69,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1411,,,,,,,fee schedule,937.25,5209.69,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1644.05,,,,,,,fee schedule,937.25,5209.69,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1226.96,,,,,,,fee schedule,937.25,5209.69,
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,937.25,5209.69,APC
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,937.25,5209.69,APC
Dermabrasion total face,15780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,937.25,5209.69,APC
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.84,,,,,,,fee schedule,521.75,1270.05,
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,852.54,,,,,,,fee schedule,521.75,1270.05,
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,852.54,,,,,,,fee schedule,521.75,1270.05,
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.4,,,,,,,fee schedule,521.75,1270.05,
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.75,,,,,,,fee schedule,521.75,1270.05,
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,980.42,,,,,,,fee schedule,521.75,1270.05,
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,915.22,,,,,,,fee schedule,521.75,1270.05,
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,852.54,,,,,,,fee schedule,521.75,1270.05,
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,521.75,1270.05,APC
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,521.75,1270.05,APC
Dermabrasion segmental face,15781,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,521.75,1270.05,APC
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1261.06,,,,,,,fee schedule,501.61,5209.69,
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,501.61,,,,,,,fee schedule,501.61,5209.69,
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,501.61,,,,,,,fee schedule,501.61,5209.69,
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1032.18,,,,,,,fee schedule,501.61,5209.69,
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,826.75,,,,,,,fee schedule,501.61,5209.69,
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,576.85,,,,,,,fee schedule,501.61,5209.69,
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1450.22,,,,,,,fee schedule,501.61,5209.69,
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,501.61,,,,,,,fee schedule,501.61,5209.69,
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,501.61,5209.69,APC
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,501.61,5209.69,APC
Dermabrasion other than face,15782,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,501.61,5209.69,APC
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,729.1,
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,148.19,729.1,
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,148.19,729.1,
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,729.1,
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,729.1,
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,148.19,729.1,
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,729.1,
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,148.19,729.1,
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,148.19,729.1,APC
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,148.19,729.1,APC
Dermabrasion suprfl any site,15783,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,148.19,729.1,APC
Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Abrasion lesion single,15786,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,729.1,
Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,729.1,
Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,729.1,
Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,729.1,
Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,150.12,729.1,APC
Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,150.12,729.1,APC
Chemical peel face epiderm,15788,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,150.12,729.1,APC
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,193.65,1325.55,
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,1325.55,
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,1325.55,
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,193.65,1325.55,
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,193.65,1325.55,
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,1325.55,
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,193.65,1325.55,
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,1325.55,
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,193.65,1325.55,APC
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,193.65,1325.55,APC
Chemical peel face dermal,15789,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,193.65,1325.55,APC
Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,286.88,1325.55,
Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,286.88,1325.55,
Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,286.88,1325.55,
Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,286.88,1325.55,
Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,286.88,1325.55,APC
Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,286.88,1325.55,APC
Chemical peel nonfacial,15792,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,286.88,1325.55,APC
Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,286.88,729.1,
Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,286.88,729.1,
Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,286.88,729.1,
Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,286.88,729.1,
Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,286.88,729.1,APC
Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,286.88,729.1,APC
Chemical peel nonfacial,15793,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,286.88,729.1,APC
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Revision of lower eyelid,15820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,4252.09,
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,4252.09,
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,4252.09,
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,4252.09,
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,4252.09,
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,4252.09,
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1865.01,4252.09,APC
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1865.01,4252.09,APC
Revision of lower eyelid,15821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1865.01,4252.09,APC
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Revision of upper eyelid,15822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2139.2,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1860.17,,,,,,,fee schedule,1381.8,3700.55,
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Revision of upper eyelid,15823,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Removal of forehead wrinkles,15824,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,6355.77,
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,6355.77,
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,6355.77,
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,6355.77,
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,6355.77,
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,1865.01,6355.77,APC
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,1865.01,6355.77,APC
Removal of neck wrinkles,15825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,1865.01,6355.77,APC
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of brow wrinkles,15826,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of face wrinkles,15828,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of skin wrinkles,15829,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12734.47,,,,,,,fee schedule,5499.9,14644.64,
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5499.9,,,,,,,fee schedule,5499.9,14644.64,
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5499.9,,,,,,,fee schedule,5499.9,14644.64,
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10423.16,,,,,,,fee schedule,5499.9,14644.64,
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8348.72,,,,,,,fee schedule,5499.9,14644.64,
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6324.89,,,,,,,fee schedule,5499.9,14644.64,
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14644.64,,,,,,,fee schedule,5499.9,14644.64,
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5499.9,,,,,,,fee schedule,5499.9,14644.64,
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,5499.9,14644.64,APC
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,5499.9,14644.64,APC
Exc Skin Abd,15830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,5499.9,14644.64,APC
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin thigh,15832,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin leg,15833,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin hip,15834,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin buttck,15835,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excessive skin arm,15836,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin arm/hand,15837,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin fat pad,15838,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Excise excess skin & tissue,15839,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Nerve palsy fascial graft,15840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Nerve palsy muscle graft,15841,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,1381.8,3700.55,
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Nerve palsy microsurg graft,15842,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Skin and muscle repair face,15845,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3098.23,,,,,,,fee schedule,159.98,3700.55,
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,159.98,,,,,,,fee schedule,159.98,3700.55,
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.98,,,,,,,fee schedule,159.98,3700.55,
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2535.9,,,,,,,fee schedule,159.98,3700.55,
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2031.2,,,,,,,fee schedule,159.98,3700.55,
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.98,,,,,,,fee schedule,159.98,3700.55,
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3562.96,,,,,,,fee schedule,159.98,3700.55,
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.98,,,,,,,fee schedule,159.98,3700.55,
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,159.98,3700.55,APC
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,159.98,3700.55,APC
Remove sutures diff surgeon,15851,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,159.98,3700.55,APC
Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,736.41,4572.08,
Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,736.41,4572.08,
Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,736.41,4572.08,
Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,736.41,4572.08,
Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,736.41,4572.08,APC
Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,736.41,4572.08,APC
Dressing change not for burn,15852,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,736.41,4572.08,APC
Removal sutr/stapl xreq anes,15853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.58,,,,,,,fee schedule,41.03,71.97,
Removal sutr/stapl xreq anes,15853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.22,,,,,,,fee schedule,41.03,71.97,
Removal sutr/stapl xreq anes,15853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.03,,,,,,,fee schedule,41.03,71.97,
Removal sutr/stapl xreq anes,15853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.97,,,,,,,fee schedule,41.03,71.97,
Removal sutr&stapl xreq anes,15854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.22,,,,,,,fee schedule,57.18,100.3,
Removal sutr&stapl xreq anes,15854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.39,,,,,,,fee schedule,57.18,100.3,
Removal sutr&stapl xreq anes,15854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.18,,,,,,,fee schedule,57.18,100.3,
Removal sutr&stapl xreq anes,15854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.3,,,,,,,fee schedule,57.18,100.3,
Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Test for blood flow in graft,15860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Suction lipectomy head&neck,15876,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Suction lipectomy trunk,15877,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,1381.8,3700.55,
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Suction lipectomy upr extrem,15878,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Suction lipectomy lwr extrem,15879,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1095.32,5209.69,
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1095.32,5209.69,
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1095.32,5209.69,
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,1095.32,5209.69,
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1095.32,5209.69,
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1095.32,5209.69,APC
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1095.32,5209.69,APC
Removal of tail bone ulcer,15920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1095.32,5209.69,APC
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,6355.77,
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,6355.77,
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,6355.77,
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,6355.77,
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,6355.77,
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,1865.01,6355.77,APC
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,1865.01,6355.77,APC
Removal of tail bone ulcer,15922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,1865.01,6355.77,APC
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,5209.69,
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,5209.69,
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,933.69,5209.69,
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,5209.69,
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,5209.69,
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,933.69,5209.69,
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,5209.69,
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,5209.69,
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,933.69,5209.69,APC
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,933.69,5209.69,APC
Remove sacrum pressure sore,15931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,933.69,5209.69,APC
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Remove sacrum pressure sore,15933,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Remove sacrum pressure sore,15934,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Remove sacrum pressure sore,15935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Remove sacrum pressure sore,15936,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Remove sacrum pressure sore,15937,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Remove hip pressure sore,15940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Remove hip pressure sore,15941,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,1865.01,6355.77,
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,1865.01,6355.77,
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,1865.01,6355.77,
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1865.01,6355.77,
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,1865.01,6355.77,
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1865.01,6355.77,
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,1865.01,6355.77,APC
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,1865.01,6355.77,APC
Remove hip pressure sore,15944,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,1865.01,6355.77,APC
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,569.96,4252.09,
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,4252.09,
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,569.96,4252.09,
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,569.96,4252.09,
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,569.96,4252.09,
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,569.96,4252.09,
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,569.96,4252.09,
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,569.96,4252.09,
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,569.96,4252.09,APC
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,569.96,4252.09,APC
Remove hip pressure sore,15945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,569.96,4252.09,APC
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2055.86,4252.09,
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2055.86,4252.09,
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2055.86,4252.09,
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2055.86,4252.09,
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2055.86,4252.09,
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,4252.09,APC
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,4252.09,APC
Remove hip pressure sore,15946,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,4252.09,APC
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,2962.18,
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,933.69,2962.18,
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,933.69,2962.18,
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,2962.18,
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Remove thigh pressure sore,15950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Remove thigh pressure sore,15951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2055.86,4252.09,
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2055.86,4252.09,
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2055.86,4252.09,
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2055.86,4252.09,
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2055.86,4252.09,
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,4252.09,APC
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,4252.09,APC
Remove thigh pressure sore,15952,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,4252.09,APC
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Remove thigh pressure sore,15953,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Remove thigh pressure sore,15956,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Remove thigh pressure sore,15958,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of pressure sore,15999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,705.59,1270.05,APC
Removal of pressure sore,15999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,705.59,1270.05,APC
Removal of pressure sore,15999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,705.59,1270.05,APC
Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Initial treatment of burn(s),16000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,131.42,359.84,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.42,,,,,,,fee schedule,131.42,359.84,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.42,,,,,,,fee schedule,131.42,359.84,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,131.42,359.84,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,131.42,359.84,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,131.42,359.84,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,131.42,359.84,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,131.42,359.84,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,131.42,359.84,APC
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,131.42,359.84,APC
Dress/debrid p-thick burn s,16020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,131.42,359.84,APC
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Dress/debrid p-thick burn m,16025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,283.19,729.1,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,283.19,729.1,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,283.19,729.1,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,283.19,729.1,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Dress/debrid p-thick burn l,16030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,283.19,729.1,
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,283.19,729.1,
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,283.19,729.1,
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,283.19,729.1,
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Incision of burn scab initi,16035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,101.41,359.84,
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.41,,,,,,,fee schedule,101.41,359.84,
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.41,,,,,,,fee schedule,101.41,359.84,
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,101.41,359.84,
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,101.41,359.84,
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.62,,,,,,,fee schedule,101.41,359.84,
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,101.41,359.84,
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.41,,,,,,,fee schedule,101.41,359.84,
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,101.41,359.84,APC
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,101.41,359.84,APC
Destruct premalg lesion,17000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,101.41,359.84,APC
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,264.55,,,,,,,fee schedule,173.44,729.1,
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.57,,,,,,,fee schedule,173.44,729.1,
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,232.57,,,,,,,fee schedule,173.44,729.1,
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.44,,,,,,,fee schedule,173.44,729.1,
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,216.53,,,,,,,fee schedule,173.44,729.1,
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,267.46,,,,,,,fee schedule,173.44,729.1,
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,304.23,,,,,,,fee schedule,173.44,729.1,
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,232.57,,,,,,,fee schedule,173.44,729.1,
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,173.44,729.1,APC
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,173.44,729.1,APC
Destroy premal lesions 15/>,17004,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,173.44,729.1,APC
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,375.19,4948.46,
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,4948.46,
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,375.19,4948.46,
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,375.19,4948.46,
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,375.19,4948.46,
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,375.19,4948.46,
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,375.19,4948.46,
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,4948.46,
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,375.19,4948.46,APC
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,375.19,4948.46,APC
Destruction of skin lesions,17106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,375.19,4948.46,APC
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4139.38,,,,,,,fee schedule,375.19,4760.29,
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,4760.29,
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,375.19,4760.29,
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2713.78,,,,,,,fee schedule,375.19,4760.29,
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3388.08,,,,,,,fee schedule,375.19,4760.29,
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,375.19,4760.29,
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4760.29,,,,,,,fee schedule,375.19,4760.29,
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,4760.29,
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,375.19,4760.29,APC
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,375.19,4760.29,APC
Destruction of skin lesions,17107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,375.19,4760.29,APC
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,950.46,,,,,,,fee schedule,375.19,3700.55,
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,3700.55,
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,375.19,3700.55,
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,623.12,,,,,,,fee schedule,375.19,3700.55,
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,777.95,,,,,,,fee schedule,375.19,3700.55,
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,375.19,3700.55,
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1093.03,,,,,,,fee schedule,375.19,3700.55,
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,3700.55,
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,375.19,3700.55,APC
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,375.19,3700.55,APC
Destruction of skin lesions,17108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,375.19,3700.55,APC
Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,199.91,4948.46,
Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,199.91,4948.46,
Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,199.91,4948.46,
Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,199.91,4948.46,
Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,4948.46,APC
Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,4948.46,APC
Destruct b9 lesion 1-14,17110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,4948.46,APC
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3758.54,,,,,,,fee schedule,193.65,4322.32,
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,4322.32,
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,4322.32,
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2464.1,,,,,,,fee schedule,193.65,4322.32,
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3076.36,,,,,,,fee schedule,193.65,4322.32,
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,4322.32,
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4322.32,,,,,,,fee schedule,193.65,4322.32,
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,4322.32,
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,193.65,4322.32,APC
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,193.65,4322.32,APC
Destruct lesion 15 or more,17111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,193.65,4322.32,APC
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,145.26,359.84,
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.26,,,,,,,fee schedule,145.26,359.84,
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.26,,,,,,,fee schedule,145.26,359.84,
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,145.26,359.84,
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,145.26,359.84,
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.05,,,,,,,fee schedule,145.26,359.84,
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,145.26,359.84,
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.26,,,,,,,fee schedule,145.26,359.84,
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,145.26,359.84,APC
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,145.26,359.84,APC
Chemical cautery tissue,17250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,145.26,359.84,APC
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,137.48,359.84,
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.48,,,,,,,fee schedule,137.48,359.84,
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.48,,,,,,,fee schedule,137.48,359.84,
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,137.48,359.84,
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,137.48,359.84,
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,158.1,,,,,,,fee schedule,137.48,359.84,
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,137.48,359.84,
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.48,,,,,,,fee schedule,137.48,359.84,
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,137.48,359.84,APC
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,137.48,359.84,APC
Destruction of skin lesions,17260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,137.48,359.84,APC
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,344.92,,,,,,,fee schedule,193.65,729.1,
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,226.13,,,,,,,fee schedule,193.65,729.1,
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,282.32,,,,,,,fee schedule,193.65,729.1,
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,396.66,,,,,,,fee schedule,193.65,729.1,
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Destruction of skin lesions,17264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,379.2,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.89,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.89,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,248.6,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,310.38,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,382.82,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,436.08,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.89,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,248.6,729.1,APC
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,248.6,729.1,APC
Destruction of skin lesions,17266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,248.6,729.1,APC
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Destruction of skin lesions,17270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Destruction of skin lesions,17271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,342.95,,,,,,,fee schedule,224.84,729.1,
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,300.89,,,,,,,fee schedule,224.84,729.1,
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.89,,,,,,,fee schedule,224.84,729.1,
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.84,,,,,,,fee schedule,224.84,729.1,
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,280.7,,,,,,,fee schedule,224.84,729.1,
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,346.02,,,,,,,fee schedule,224.84,729.1,
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,394.39,,,,,,,fee schedule,224.84,729.1,
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,300.89,,,,,,,fee schedule,224.84,729.1,
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,224.84,729.1,APC
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,224.84,729.1,APC
Destruction of skin lesions,17273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,224.84,729.1,APC
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,388.03,,,,,,,fee schedule,254.39,729.1,
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,338.94,,,,,,,fee schedule,254.39,729.1,
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,338.94,,,,,,,fee schedule,254.39,729.1,
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,254.39,,,,,,,fee schedule,254.39,729.1,
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,317.6,,,,,,,fee schedule,254.39,729.1,
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,389.78,,,,,,,fee schedule,254.39,729.1,
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,446.23,,,,,,,fee schedule,254.39,729.1,
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,338.94,,,,,,,fee schedule,254.39,729.1,
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,254.39,729.1,APC
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,254.39,729.1,APC
Destruction of skin lesions,17274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,254.39,729.1,APC
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,427.2,,,,,,,fee schedule,280.07,729.1,
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,373.55,,,,,,,fee schedule,280.07,729.1,
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,373.55,,,,,,,fee schedule,280.07,729.1,
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,280.07,,,,,,,fee schedule,280.07,729.1,
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,349.66,,,,,,,fee schedule,280.07,729.1,
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,429.58,,,,,,,fee schedule,280.07,729.1,
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,491.28,,,,,,,fee schedule,280.07,729.1,
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,373.55,,,,,,,fee schedule,280.07,729.1,
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,280.07,729.1,APC
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,280.07,729.1,APC
Destruction of skin lesions,17276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,280.07,729.1,APC
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,359.84,
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.9,,,,,,,fee schedule,193.65,359.84,
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,359.84,
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,359.84,
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.99,,,,,,,fee schedule,193.65,359.84,
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.19,,,,,,,fee schedule,193.65,359.84,
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,359.84,
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.29,,,,,,,fee schedule,193.65,359.84,
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,359.84,
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,193.65,359.84,APC
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,193.65,359.84,APC
Destruction of skin lesions,17281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,193.65,359.84,APC
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,334.12,,,,,,,fee schedule,199.91,384.24,
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,293.11,,,,,,,fee schedule,199.91,384.24,
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,293.11,,,,,,,fee schedule,199.91,384.24,
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,219.05,,,,,,,fee schedule,199.91,384.24,
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,273.48,,,,,,,fee schedule,199.91,384.24,
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,337.08,,,,,,,fee schedule,199.91,384.24,
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,384.24,,,,,,,fee schedule,199.91,384.24,
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,293.11,,,,,,,fee schedule,199.91,384.24,
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,384.24,APC
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,384.24,APC
Destruction of skin lesions,17282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,384.24,APC
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,379.2,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.01,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.01,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,248.6,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,310.38,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,381.81,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,436.08,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.01,,,,,,,fee schedule,248.6,729.1,
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,248.6,729.1,APC
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,248.6,729.1,APC
Destruction of skin lesions,17283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,248.6,729.1,APC
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,419.37,,,,,,,fee schedule,274.94,1325.55,
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,367.5,,,,,,,fee schedule,274.94,1325.55,
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,367.5,,,,,,,fee schedule,274.94,1325.55,
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,274.94,,,,,,,fee schedule,274.94,1325.55,
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,343.25,,,,,,,fee schedule,274.94,1325.55,
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,422.63,,,,,,,fee schedule,274.94,1325.55,
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,482.28,,,,,,,fee schedule,274.94,1325.55,
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,367.5,,,,,,,fee schedule,274.94,1325.55,
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,274.94,1325.55,APC
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,274.94,1325.55,APC
Destruction of skin lesions,17284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,274.94,1325.55,APC
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,492.85,,,,,,,fee schedule,323.11,1325.55,
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,323.11,1325.55,
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,323.11,1325.55,
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,323.11,,,,,,,fee schedule,323.11,1325.55,
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,403.4,,,,,,,fee schedule,323.11,1325.55,
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,323.11,1325.55,
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,566.78,,,,,,,fee schedule,323.11,1325.55,
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,323.11,1325.55,
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,323.11,1325.55,APC
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,323.11,1325.55,APC
Destruction of skin lesions,17286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,323.11,1325.55,APC
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Mohs 1 stage t/a/l,17313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,105.8,
Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,105.8,
Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,105.8,
Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,105.8,
Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,27.82,105.8,APC
Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,27.82,105.8,APC
Cryotherapy of skin,17340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,27.82,105.8,APC
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.2,,,,,,,fee schedule,150.12,359.84,
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.2,,,,,,,fee schedule,150.12,359.84,
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.88,,,,,,,fee schedule,150.12,359.84,
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.2,,,,,,,fee schedule,150.12,359.84,
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Skin peel therapy,17360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,375.19,1325.55,
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,1325.55,
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,375.19,1325.55,
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,375.19,1325.55,
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,375.19,1325.55,
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,375.19,1325.55,
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,375.19,1325.55,
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,375.19,1325.55,
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,375.19,1325.55,APC
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,375.19,1325.55,APC
Hair removal by electrolysis,17380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,375.19,1325.55,APC
Skin tissue procedure,17999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,359.84,APC
Skin tissue procedure,17999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,359.84,APC
Skin tissue procedure,17999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,359.84,APC
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,460.2,,,,,,,fee schedule,195.39,1270.05,
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.39,,,,,,,fee schedule,195.39,1270.05,
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.39,,,,,,,fee schedule,195.39,1270.05,
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.71,,,,,,,fee schedule,195.39,1270.05,
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.67,,,,,,,fee schedule,195.39,1270.05,
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,224.7,,,,,,,fee schedule,195.39,1270.05,
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,529.23,,,,,,,fee schedule,195.39,1270.05,
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.39,,,,,,,fee schedule,195.39,1270.05,
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,195.39,1270.05,APC
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,195.39,1270.05,APC
Drainage of breast lesion,19000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,195.39,1270.05,APC
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,933.69,2962.18,
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,933.69,2962.18,
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Incision of breast lesion,19020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Injection for breast x-ray,19030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.58,,,,,,,fee schedule,191.82,336.47,
Injection for breast x-ray,19030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.82,,,,,,,fee schedule,191.82,336.47,
Injection for breast x-ray,19030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.48,,,,,,,fee schedule,191.82,336.47,
Injection for breast x-ray,19030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,336.47,,,,,,,fee schedule,191.82,336.47,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2713.64,,,,,,,fee schedule,1645.66,3580.7,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3113.65,,,,,,,fee schedule,1645.66,3580.7,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3113.65,,,,,,,fee schedule,1645.66,3580.7,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1779.06,,,,,,,fee schedule,1645.66,3580.7,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2221.11,,,,,,,fee schedule,1645.66,3580.7,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3580.7,,,,,,,fee schedule,1645.66,3580.7,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3120.69,,,,,,,fee schedule,1645.66,3580.7,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3113.65,,,,,,,fee schedule,1645.66,3580.7,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,3580.7,APC
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,3580.7,APC
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,3580.7,APC
Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3025.06,,,,,,,fee schedule,1645.66,3478.82,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3025.06,,,,,,,fee schedule,1645.66,3478.82,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3478.82,,,,,,,fee schedule,1645.66,3478.82,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3025.06,,,,,,,fee schedule,1645.66,3478.82,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,3478.82,APC
Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,3478.82,APC
Bx breast 1st lesion us imag,19083,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,3478.82,APC
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,3580.7,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3113.65,,,,,,,fee schedule,933.69,3580.7,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3113.65,,,,,,,fee schedule,933.69,3580.7,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,3580.7,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,3580.7,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3580.7,,,,,,,fee schedule,933.69,3580.7,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,3580.7,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3113.65,,,,,,,fee schedule,933.69,3580.7,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,3580.7,APC
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,3580.7,APC
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,3580.7,APC
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4384.46,,,,,,,fee schedule,645.78,5042.13,
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,645.78,,,,,,,fee schedule,645.78,5042.13,
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.78,,,,,,,fee schedule,645.78,5042.13,
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2874.45,,,,,,,fee schedule,645.78,5042.13,
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3588.68,,,,,,,fee schedule,645.78,5042.13,
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.65,,,,,,,fee schedule,645.78,5042.13,
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5042.13,,,,,,,fee schedule,645.78,5042.13,
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,645.78,,,,,,,fee schedule,645.78,5042.13,
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,645.78,5042.13,APC
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,645.78,5042.13,APC
Bx breast percut w/o image,19100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,645.78,5042.13,APC
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5720.46,,,,,,,fee schedule,2465.17,7022.44,
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3750.33,,,,,,,fee schedule,2465.17,7022.44,
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4682.2,,,,,,,fee schedule,2465.17,7022.44,
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2834.95,,,,,,,fee schedule,2465.17,7022.44,
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6578.53,,,,,,,fee schedule,2465.17,7022.44,
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy of breast open,19101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,2465.17,7022.44,APC
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,1802.57,7022.44,
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Cryosurg ablate fa each,19105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3303.28,,,,,,,fee schedule,1802.57,7022.44,
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Nipple exploration,19110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3303.28,,,,,,,fee schedule,1802.57,7022.44,
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Excise breast duct fistula,19112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5031.25,,,,,,,fee schedule,2465.17,7022.44,
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4118.08,,,,,,,fee schedule,2465.17,7022.44,
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3298.49,,,,,,,fee schedule,2465.17,7022.44,
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2834.95,,,,,,,fee schedule,2465.17,7022.44,
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5785.94,,,,,,,fee schedule,2465.17,7022.44,
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,2465.17,7022.44,APC
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,2465.17,7022.44,APC
Removal of breast lesion,19120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,2465.17,7022.44,APC
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6265.56,,,,,,,fee schedule,2872.42,7205.39,
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2872.42,,,,,,,fee schedule,2872.42,7205.39,
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2872.42,,,,,,,fee schedule,2872.42,7205.39,
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5128.36,,,,,,,fee schedule,2872.42,7205.39,
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4107.7,,,,,,,fee schedule,2872.42,7205.39,
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3303.28,,,,,,,fee schedule,2872.42,7205.39,
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7205.39,,,,,,,fee schedule,2872.42,7205.39,
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2872.42,,,,,,,fee schedule,2872.42,7205.39,
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,2872.42,7205.39,APC
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,2872.42,7205.39,APC
Excision breast lesion,19125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,2872.42,7205.39,APC
Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,623.41,,,,,,,fee schedule,408.71,2962.18,
Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,510.26,,,,,,,fee schedule,408.71,2962.18,
Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,408.71,,,,,,,fee schedule,408.71,2962.18,
Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,716.92,,,,,,,fee schedule,408.71,2962.18,
Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,408.71,2962.18,APC
Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,408.71,2962.18,APC
Perq device breast 1st imag,19281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,408.71,2962.18,APC
Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,489.39,,,,,,,fee schedule,320.84,1270.05,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,400.57,,,,,,,fee schedule,320.84,1270.05,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,320.84,,,,,,,fee schedule,320.84,1270.05,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,562.8,,,,,,,fee schedule,320.84,1270.05,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,320.84,1270.05,APC
Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,320.84,1270.05,APC
Perq dev breast 1st strtctc,19283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,320.84,1270.05,APC
Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,489.38,,,,,,,fee schedule,320.84,1270.05,
Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,400.56,,,,,,,fee schedule,320.84,1270.05,
Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,320.84,,,,,,,fee schedule,320.84,1270.05,
Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,562.79,,,,,,,fee schedule,320.84,1270.05,
Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,320.84,1270.05,APC
Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,320.84,1270.05,APC
Perq dev breast 1st us imag,19285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,320.84,1270.05,APC
Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,806.26,,,,,,,fee schedule,528.58,1270.05,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,659.92,,,,,,,fee schedule,528.58,1270.05,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,528.58,,,,,,,fee schedule,528.58,1270.05,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,927.2,,,,,,,fee schedule,528.58,1270.05,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,528.58,1270.05,APC
Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,528.58,1270.05,APC
Perq dev breast 1st mr guide,19287,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,528.58,1270.05,APC
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9237.29,,,,,,,fee schedule,6055.97,14659.2,
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7192.38,,,,,,,fee schedule,6055.97,14659.2,
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7192.38,,,,,,,fee schedule,6055.97,14659.2,
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7560.72,,,,,,,fee schedule,6055.97,14659.2,
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6055.97,,,,,,,fee schedule,6055.97,14659.2,
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8271.24,,,,,,,fee schedule,6055.97,14659.2,
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10622.88,,,,,,,fee schedule,6055.97,14659.2,
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7192.38,,,,,,,fee schedule,6055.97,14659.2,
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8551.2,,,,,,,fee schedule,6055.97,14659.2,APC
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8144,,,,,,,fee schedule,6055.97,14659.2,APC
Place po breast cath for rad,19296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14659.2,,,,,,,fee schedule,6055.97,14659.2,APC
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5287.16,,,,,,,fee schedule,3466.26,24716.51,
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9807.8,,,,,,,fee schedule,3466.26,24716.51,
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9807.8,,,,,,,fee schedule,3466.26,24716.51,
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4327.54,,,,,,,fee schedule,3466.26,24716.51,
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3466.26,,,,,,,fee schedule,3466.26,24716.51,
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11278.97,,,,,,,fee schedule,3466.26,24716.51,
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6080.23,,,,,,,fee schedule,3466.26,24716.51,
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9807.8,,,,,,,fee schedule,3466.26,24716.51,
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14417.97,,,,,,,fee schedule,3466.26,24716.51,APC
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13731.4,,,,,,,fee schedule,3466.26,24716.51,APC
Place breast rad tube/caths,19298,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24716.51,,,,,,,fee schedule,3466.26,24716.51,APC
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3303.28,,,,,,,fee schedule,1802.57,7022.44,
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Removal of Breast Tissue,19300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5810.23,,,,,,,fee schedule,2465.17,7022.44,
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4755.67,,,,,,,fee schedule,2465.17,7022.44,
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3809.19,,,,,,,fee schedule,2465.17,7022.44,
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2834.95,,,,,,,fee schedule,2465.17,7022.44,
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6681.76,,,,,,,fee schedule,2465.17,7022.44,
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,2465.17,7022.44,APC
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,2465.17,7022.44,APC
Partial Mastectomy,19301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,2465.17,7022.44,APC
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9662.32,,,,,,,fee schedule,4881.78,11909.32,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4881.78,,,,,,,fee schedule,4881.78,11909.32,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4881.78,,,,,,,fee schedule,4881.78,11909.32,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7908.61,,,,,,,fee schedule,4881.78,11909.32,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6334.62,,,,,,,fee schedule,4881.78,11909.32,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5614.05,,,,,,,fee schedule,4881.78,11909.32,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11111.67,,,,,,,fee schedule,4881.78,11909.32,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4881.78,,,,,,,fee schedule,4881.78,11909.32,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,4881.78,11909.32,APC
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,4881.78,11909.32,APC
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,4881.78,11909.32,APC
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13587.79,,,,,,,fee schedule,3992.3,15625.96,
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,3992.3,15625.96,
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,3992.3,15625.96,
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11121.61,,,,,,,fee schedule,3992.3,15625.96,
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8908.16,,,,,,,fee schedule,3992.3,15625.96,
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,3992.3,15625.96,
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15625.96,,,,,,,fee schedule,3992.3,15625.96,
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,3992.3,15625.96,
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,3992.3,15625.96,APC
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,3992.3,15625.96,APC
Mast simple complete,19303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,3992.3,15625.96,APC
Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6609.5,,,,,,,fee schedule,4333.19,11909.32,
Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5409.88,,,,,,,fee schedule,4333.19,11909.32,
Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4333.19,,,,,,,fee schedule,4333.19,11909.32,
Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7600.93,,,,,,,fee schedule,4333.19,11909.32,
Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,4333.19,11909.32,APC
Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,4333.19,11909.32,APC
Mast mod rad,19307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,4333.19,11909.32,APC
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5287.16,,,,,,,fee schedule,3466.26,11909.32,
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,3466.26,11909.32,
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,3466.26,11909.32,
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4327.54,,,,,,,fee schedule,3466.26,11909.32,
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3466.26,,,,,,,fee schedule,3466.26,11909.32,
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,3466.26,11909.32,
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6080.23,,,,,,,fee schedule,3466.26,11909.32,
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,3466.26,11909.32,
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,3466.26,11909.32,APC
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,3466.26,11909.32,APC
Suspension of breast,19316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,3466.26,11909.32,APC
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18319.51,,,,,,,fee schedule,4881.78,21067.44,
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4881.78,,,,,,,fee schedule,4881.78,21067.44,
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4881.78,,,,,,,fee schedule,4881.78,21067.44,
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14994.52,,,,,,,fee schedule,4881.78,21067.44,
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12010.27,,,,,,,fee schedule,4881.78,21067.44,
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5614.05,,,,,,,fee schedule,4881.78,21067.44,
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21067.44,,,,,,,fee schedule,4881.78,21067.44,
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4881.78,,,,,,,fee schedule,4881.78,21067.44,
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,4881.78,21067.44,APC
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,4881.78,21067.44,APC
Reduction of large breast,19318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,4881.78,21067.44,APC
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6218.04,,,,,,,fee schedule,4076.55,14659.2,
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9807.8,,,,,,,fee schedule,4076.55,14659.2,
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9807.8,,,,,,,fee schedule,4076.55,14659.2,
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5089.47,,,,,,,fee schedule,4076.55,14659.2,
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4076.55,,,,,,,fee schedule,4076.55,14659.2,
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11278.97,,,,,,,fee schedule,4076.55,14659.2,
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7150.75,,,,,,,fee schedule,4076.55,14659.2,
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9807.8,,,,,,,fee schedule,4076.55,14659.2,
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8551.2,,,,,,,fee schedule,4076.55,14659.2,APC
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8144,,,,,,,fee schedule,4076.55,14659.2,APC
Enlarge breast with implant,19325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14659.2,,,,,,,fee schedule,4076.55,14659.2,APC
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,1802.57,7022.44,
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Removal of breast implant,19328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,1802.57,7022.44,
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Removal of implant material,19330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5287.16,,,,,,,fee schedule,3466.26,14659.2,
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5499.9,,,,,,,fee schedule,3466.26,14659.2,
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5499.9,,,,,,,fee schedule,3466.26,14659.2,
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4327.54,,,,,,,fee schedule,3466.26,14659.2,
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3466.26,,,,,,,fee schedule,3466.26,14659.2,
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6324.89,,,,,,,fee schedule,3466.26,14659.2,
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6080.23,,,,,,,fee schedule,3466.26,14659.2,
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5499.9,,,,,,,fee schedule,3466.26,14659.2,
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8551.2,,,,,,,fee schedule,3466.26,14659.2,APC
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8144,,,,,,,fee schedule,3466.26,14659.2,APC
Immediate breast prosthesis,19340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14659.2,,,,,,,fee schedule,3466.26,14659.2,APC
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9796.79,,,,,,,fee schedule,5749.63,14659.2,
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5749.63,,,,,,,fee schedule,5749.63,14659.2,
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5749.63,,,,,,,fee schedule,5749.63,14659.2,
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8018.67,,,,,,,fee schedule,5749.63,14659.2,
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6422.78,,,,,,,fee schedule,5749.63,14659.2,
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6612.07,,,,,,,fee schedule,5749.63,14659.2,
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11266.31,,,,,,,fee schedule,5749.63,14659.2,
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5749.63,,,,,,,fee schedule,5749.63,14659.2,
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8551.2,,,,,,,fee schedule,5749.63,14659.2,APC
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8144,,,,,,,fee schedule,5749.63,14659.2,APC
Delayed breast prosthesis,19342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14659.2,,,,,,,fee schedule,5749.63,14659.2,APC
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3303.28,,,,,,,fee schedule,1802.57,7022.44,
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2872.42,,,,,,,fee schedule,1802.57,7022.44,
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Breast reconstruction,19350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,1802.57,7022.44,
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Correct inverted nipple(s),19355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7724.45,,,,,,,fee schedule,5064.15,24716.51,
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9807.8,,,,,,,fee schedule,5064.15,24716.51,
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9807.8,,,,,,,fee schedule,5064.15,24716.51,
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5064.15,,,,,,,fee schedule,5064.15,24716.51,
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6322.46,,,,,,,fee schedule,5064.15,24716.51,
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11278.97,,,,,,,fee schedule,5064.15,24716.51,
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8883.12,,,,,,,fee schedule,5064.15,24716.51,
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9807.8,,,,,,,fee schedule,5064.15,24716.51,
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14417.97,,,,,,,fee schedule,5064.15,24716.51,APC
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13731.4,,,,,,,fee schedule,5064.15,24716.51,APC
Breast reconstruction,19357,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24716.51,,,,,,,fee schedule,5064.15,24716.51,APC
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4598.45,,,,,,,fee schedule,3014.74,7022.44,
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,3014.74,7022.44,
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,3014.74,7022.44,
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3014.74,,,,,,,fee schedule,3014.74,7022.44,
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3763.83,,,,,,,fee schedule,3014.74,7022.44,
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,3014.74,7022.44,
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5288.22,,,,,,,fee schedule,3014.74,7022.44,
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,3014.74,7022.44,
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,3014.74,7022.44,APC
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,3014.74,7022.44,APC
Surgery of breast capsule,19370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,3014.74,7022.44,APC
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7056.44,,,,,,,fee schedule,3901.35,8114.91,
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,3901.35,8114.91,
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,3901.35,8114.91,
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4626.2,,,,,,,fee schedule,3901.35,8114.91,
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5775.7,,,,,,,fee schedule,3901.35,8114.91,
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,3901.35,8114.91,
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8114.91,,,,,,,fee schedule,3901.35,8114.91,
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,3901.35,8114.91,
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,3901.35,8114.91,APC
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,3901.35,8114.91,APC
Removal of breast capsule,19371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,3901.35,8114.91,APC
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8941.79,,,,,,,fee schedule,4881.78,11909.32,
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4881.78,,,,,,,fee schedule,4881.78,11909.32,
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4881.78,,,,,,,fee schedule,4881.78,11909.32,
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5862.24,,,,,,,fee schedule,4881.78,11909.32,
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7318.86,,,,,,,fee schedule,4881.78,11909.32,
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5614.05,,,,,,,fee schedule,4881.78,11909.32,
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10283.06,,,,,,,fee schedule,4881.78,11909.32,
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4881.78,,,,,,,fee schedule,4881.78,11909.32,
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,4881.78,11909.32,APC
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,4881.78,11909.32,APC
Revise breast reconstruction,19380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,4881.78,11909.32,APC
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4591.15,,,,,,,fee schedule,1802.57,7022.44,
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3992.3,,,,,,,fee schedule,1802.57,7022.44,
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Design custom breast implant,19396,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Breast surgery procedure,19499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,3901.35,7022.44,APC
Breast surgery procedure,19499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,3901.35,7022.44,APC
Breast surgery procedure,19499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,3901.35,7022.44,APC
Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,661.95,,,,,,,fee schedule,433.97,967.3,
Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,433.97,,,,,,,fee schedule,433.97,967.3,
Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,541.81,,,,,,,fee schedule,433.97,967.3,
Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,761.24,,,,,,,fee schedule,433.97,967.3,
Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,433.97,967.3,APC
Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,433.97,967.3,APC
Explore wound neck,20100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,433.97,967.3,APC
Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2135.29,,,,,,,fee schedule,1399.9,3700.55,
Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1399.9,,,,,,,fee schedule,1399.9,3700.55,
Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1747.73,,,,,,,fee schedule,1399.9,3700.55,
Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2455.58,,,,,,,fee schedule,1399.9,3700.55,
Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1399.9,3700.55,APC
Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1399.9,3700.55,APC
Explore wound chest,20101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1399.9,3700.55,APC
Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2135.29,,,,,,,fee schedule,1399.9,3700.55,
Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1399.9,,,,,,,fee schedule,1399.9,3700.55,
Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1747.73,,,,,,,fee schedule,1399.9,3700.55,
Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2455.58,,,,,,,fee schedule,1399.9,3700.55,
Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1399.9,3700.55,APC
Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1399.9,3700.55,APC
Explore wound abdomen,20102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1399.9,3700.55,APC
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5794.76,,,,,,,fee schedule,1147.5,6663.97,
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1147.5,,,,,,,fee schedule,1147.5,6663.97,
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1147.5,,,,,,,fee schedule,1147.5,6663.97,
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3799.04,,,,,,,fee schedule,1147.5,6663.97,
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4743.01,,,,,,,fee schedule,1147.5,6663.97,
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1319.63,,,,,,,fee schedule,1147.5,6663.97,
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6663.97,,,,,,,fee schedule,1147.5,6663.97,
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1147.5,,,,,,,fee schedule,1147.5,6663.97,
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1147.5,6663.97,APC
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1147.5,6663.97,APC
Explore wound extremity,20103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1147.5,6663.97,APC
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Excise epiphyseal bar,20150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,2962.18,
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,2962.18,
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Muscle biopsy,20200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6048.31,,,,,,,fee schedule,1777.52,6955.56,
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,6955.56,
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,6955.56,
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3965.27,,,,,,,fee schedule,1777.52,6955.56,
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4950.54,,,,,,,fee schedule,1777.52,6955.56,
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,6955.56,
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6955.56,,,,,,,fee schedule,1777.52,6955.56,
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,6955.56,
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,6955.56,APC
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,6955.56,APC
Deep muscle biopsy,20205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,6955.56,APC
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1173.31,,,,,,,fee schedule,769.22,2962.18,
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,769.22,2962.18,
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,769.22,2962.18,
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,769.22,,,,,,,fee schedule,769.22,2962.18,
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,960.35,,,,,,,fee schedule,769.22,2962.18,
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,769.22,2962.18,
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1349.31,,,,,,,fee schedule,769.22,2962.18,
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,769.22,2962.18,
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,769.22,2962.18,APC
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,769.22,2962.18,APC
Needle biopsy muscle,20206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,769.22,2962.18,APC
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,907.13,,,,,,,fee schedule,594.71,2962.18,
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,594.71,2962.18,
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,594.71,2962.18,
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,594.71,,,,,,,fee schedule,594.71,2962.18,
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,742.49,,,,,,,fee schedule,594.71,2962.18,
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,594.71,2962.18,
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1043.2,,,,,,,fee schedule,594.71,2962.18,
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,594.71,2962.18,
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,594.71,2962.18,APC
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,594.71,2962.18,APC
Bone biopsy trocar/needle,20220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,594.71,2962.18,APC
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1363.12,,,,,,,fee schedule,893.66,2962.18,
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,893.66,2962.18,
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,893.66,2962.18,
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,893.66,,,,,,,fee schedule,893.66,2962.18,
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1115.71,,,,,,,fee schedule,893.66,2962.18,
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,893.66,2962.18,
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1567.59,,,,,,,fee schedule,893.66,2962.18,
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,893.66,2962.18,
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,893.66,2962.18,APC
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,893.66,2962.18,APC
Bone biopsy trocar/needle,20225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,893.66,2962.18,APC
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8523.29,,,,,,,fee schedule,2417.43,9801.78,
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,9801.78,
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,9801.78,
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5587.87,,,,,,,fee schedule,2417.43,9801.78,
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6976.31,,,,,,,fee schedule,2417.43,9801.78,
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,9801.78,
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9801.78,,,,,,,fee schedule,2417.43,9801.78,
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,9801.78,
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,9801.78,APC
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,9801.78,APC
Bone biopsy open superficial,20240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,9801.78,APC
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5409.28,,,,,,,fee schedule,2417.43,6220.67,
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6220.67,
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,6220.67,
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3546.32,,,,,,,fee schedule,2417.43,6220.67,
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4427.5,,,,,,,fee schedule,2417.43,6220.67,
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,6220.67,
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6220.67,,,,,,,fee schedule,2417.43,6220.67,
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6220.67,
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,6220.67,APC
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,6220.67,APC
Bone biopsy open deep,20245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,6220.67,APC
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Open bone biopsy,20250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Open bone biopsy,20251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,521.42,,,,,,,fee schedule,134.89,2782.81,
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.89,,,,,,,fee schedule,134.89,2782.81,
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.89,,,,,,,fee schedule,134.89,2782.81,
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,341.84,,,,,,,fee schedule,134.89,2782.81,
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,426.78,,,,,,,fee schedule,134.89,2782.81,
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.12,,,,,,,fee schedule,134.89,2782.81,
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,599.63,,,,,,,fee schedule,134.89,2782.81,
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.89,,,,,,,fee schedule,134.89,2782.81,
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,134.89,2782.81,APC
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,134.89,2782.81,APC
Injection of sinus tract,20500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,134.89,2782.81,APC
Inject sinus tract for x-ray,20501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.92,,,,,,,fee schedule,161.88,283.96,
Inject sinus tract for x-ray,20501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.88,,,,,,,fee schedule,161.88,283.96,
Inject sinus tract for x-ray,20501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.1,,,,,,,fee schedule,161.88,283.96,
Inject sinus tract for x-ray,20501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.96,,,,,,,fee schedule,161.88,283.96,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,355.68,,,,,,,fee schedule,233.18,2962.18,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312.13,,,,,,,fee schedule,233.18,2962.18,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,312.13,,,,,,,fee schedule,233.18,2962.18,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.18,,,,,,,fee schedule,233.18,2962.18,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.12,,,,,,,fee schedule,233.18,2962.18,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,358.95,,,,,,,fee schedule,233.18,2962.18,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,409.03,,,,,,,fee schedule,233.18,2962.18,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,312.13,,,,,,,fee schedule,233.18,2962.18,
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,233.18,2962.18,APC
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,233.18,2962.18,APC
Removal of foreign body,20520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,233.18,2962.18,APC
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Removal of foreign body,20525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.77,,,,,,,fee schedule,70.65,550.53,
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95.08,,,,,,,fee schedule,70.65,550.53,
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.08,,,,,,,fee schedule,70.65,550.53,
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.65,,,,,,,fee schedule,70.65,550.53,
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.21,,,,,,,fee schedule,70.65,550.53,
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.34,,,,,,,fee schedule,70.65,550.53,
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.94,,,,,,,fee schedule,70.65,550.53,
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.08,,,,,,,fee schedule,70.65,550.53,
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,70.65,550.53,APC
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,70.65,550.53,APC
Ther injection carp tunnel,20526,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,70.65,550.53,APC
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.51,,,,,,,fee schedule,78.35,550.53,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.48,,,,,,,fee schedule,78.35,550.53,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.48,,,,,,,fee schedule,78.35,550.53,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.82,,,,,,,fee schedule,78.35,550.53,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.35,,,,,,,fee schedule,78.35,550.53,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.3,,,,,,,fee schedule,78.35,550.53,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.44,,,,,,,fee schedule,78.35,550.53,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.48,,,,,,,fee schedule,78.35,550.53,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,78.35,550.53,APC
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,78.35,550.53,APC
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,78.35,550.53,APC
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.67,,,,,,,fee schedule,42.4,550.53,
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.6,,,,,,,fee schedule,42.4,550.53,
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.6,,,,,,,fee schedule,42.4,550.53,
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.93,,,,,,,fee schedule,42.4,550.53,
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.4,,,,,,,fee schedule,42.4,550.53,
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.49,,,,,,,fee schedule,42.4,550.53,
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.37,,,,,,,fee schedule,42.4,550.53,
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.6,,,,,,,fee schedule,42.4,550.53,
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,42.4,550.53,APC
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,42.4,550.53,APC
Inj tendon sheath/ligament,20550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,42.4,550.53,APC
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.2,,,,,,,fee schedule,57.17,550.53,
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.06,,,,,,,fee schedule,57.17,550.53,
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.06,,,,,,,fee schedule,57.17,550.53,
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.17,550.53,
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.17,,,,,,,fee schedule,57.17,550.53,
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.47,,,,,,,fee schedule,57.17,550.53,
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.28,,,,,,,fee schedule,57.17,550.53,
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.06,,,,,,,fee schedule,57.17,550.53,
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,57.17,550.53,APC
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,57.17,550.53,APC
Inj tendon origin/insertion,20551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,57.17,550.53,APC
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.3,,,,,,,fee schedule,53.96,550.53,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.6,,,,,,,fee schedule,53.96,550.53,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.6,,,,,,,fee schedule,53.96,550.53,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.36,,,,,,,fee schedule,53.96,550.53,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.96,,,,,,,fee schedule,53.96,550.53,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.49,,,,,,,fee schedule,53.96,550.53,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.65,,,,,,,fee schedule,53.96,550.53,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.6,,,,,,,fee schedule,53.96,550.53,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,53.96,550.53,APC
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,53.96,550.53,APC
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,53.96,550.53,APC
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.51,,,,,,,fee schedule,82.31,4709.84,
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.31,,,,,,,fee schedule,82.31,4709.84,
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.31,,,,,,,fee schedule,82.31,4709.84,
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.17,,,,,,,fee schedule,82.31,4709.84,
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,82.31,4709.84,
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.66,,,,,,,fee schedule,82.31,4709.84,
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.84,,,,,,,fee schedule,82.31,4709.84,
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.31,,,,,,,fee schedule,82.31,4709.84,
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,82.31,4709.84,APC
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,82.31,4709.84,APC
Inject trigger points 3/>,20553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,82.31,4709.84,APC
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Place ndl musc/tis for rt,20555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.01,,,,,,,fee schedule,28.82,94.31,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.01,,,,,,,fee schedule,28.82,94.31,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.01,,,,,,,fee schedule,28.82,94.31,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.13,,,,,,,fee schedule,28.82,94.31,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.77,,,,,,,fee schedule,28.82,94.31,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.31,,,,,,,fee schedule,28.82,94.31,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,94.31,APC
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,94.31,APC
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,94.31,APC
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.9,,,,,,,fee schedule,28.82,137.89,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.9,,,,,,,fee schedule,28.82,137.89,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.9,,,,,,,fee schedule,28.82,137.89,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.14,,,,,,,fee schedule,28.82,137.89,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.61,,,,,,,fee schedule,28.82,137.89,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.89,,,,,,,fee schedule,28.82,137.89,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,137.89,APC
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,137.89,APC
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,137.89,APC
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.11,,,,,,,fee schedule,53.61,550.53,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.61,,,,,,,fee schedule,53.61,550.53,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.61,,,,,,,fee schedule,53.61,550.53,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.12,,,,,,,fee schedule,53.61,550.53,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.41,,,,,,,fee schedule,53.61,550.53,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.65,,,,,,,fee schedule,53.61,550.53,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.78,,,,,,,fee schedule,53.61,550.53,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.61,,,,,,,fee schedule,53.61,550.53,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,53.61,550.53,APC
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,53.61,550.53,APC
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,53.61,550.53,APC
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.83,,,,,,,fee schedule,68.73,550.53,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.64,,,,,,,fee schedule,68.73,550.53,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.64,,,,,,,fee schedule,68.73,550.53,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.8,,,,,,,fee schedule,68.73,550.53,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.73,,,,,,,fee schedule,68.73,550.53,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.39,,,,,,,fee schedule,68.73,550.53,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.55,,,,,,,fee schedule,68.73,550.53,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.64,,,,,,,fee schedule,68.73,550.53,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,68.73,550.53,APC
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,68.73,550.53,APC
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,68.73,550.53,APC
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.11,,,,,,,fee schedule,57.04,550.53,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.04,,,,,,,fee schedule,57.04,550.53,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.04,,,,,,,fee schedule,57.04,550.53,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.12,,,,,,,fee schedule,57.04,550.53,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.41,,,,,,,fee schedule,57.04,550.53,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.6,,,,,,,fee schedule,57.04,550.53,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.78,,,,,,,fee schedule,57.04,550.53,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.04,,,,,,,fee schedule,57.04,550.53,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,57.04,550.53,APC
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,57.04,550.53,APC
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,57.04,550.53,APC
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.64,,,,,,,fee schedule,74.5,1266.02,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.44,,,,,,,fee schedule,74.5,1266.02,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.44,,,,,,,fee schedule,74.5,1266.02,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.01,,,,,,,fee schedule,74.5,1266.02,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.5,,,,,,,fee schedule,74.5,1266.02,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.36,,,,,,,fee schedule,74.5,1266.02,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.69,,,,,,,fee schedule,74.5,1266.02,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.44,,,,,,,fee schedule,74.5,1266.02,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,74.5,1266.02,APC
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,74.5,1266.02,APC
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,74.5,1266.02,APC
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,553.02,,,,,,,fee schedule,305.85,635.97,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,553.02,,,,,,,fee schedule,305.85,635.97,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,635.97,,,,,,,fee schedule,305.85,635.97,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,553.02,,,,,,,fee schedule,305.85,635.97,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,305.85,635.97,APC
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,305.85,635.97,APC
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,305.85,635.97,APC
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1227.85,,,,,,,fee schedule,116.73,1412.03,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,116.73,,,,,,,fee schedule,116.73,1412.03,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.73,,,,,,,fee schedule,116.73,1412.03,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1005,,,,,,,fee schedule,116.73,1412.03,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,804.98,,,,,,,fee schedule,116.73,1412.03,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,134.24,,,,,,,fee schedule,116.73,1412.03,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1412.03,,,,,,,fee schedule,116.73,1412.03,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,116.73,,,,,,,fee schedule,116.73,1412.03,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,116.73,1412.03,APC
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,116.73,1412.03,APC
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,116.73,1412.03,APC
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.12,,,,,,,fee schedule,59.74,550.53,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.26,,,,,,,fee schedule,59.74,550.53,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.26,,,,,,,fee schedule,59.74,550.53,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.58,,,,,,,fee schedule,59.74,550.53,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.74,,,,,,,fee schedule,59.74,550.53,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.45,,,,,,,fee schedule,59.74,550.53,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,104.79,,,,,,,fee schedule,59.74,550.53,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.26,,,,,,,fee schedule,59.74,550.53,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,59.74,550.53,APC
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,59.74,550.53,APC
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,59.74,550.53,APC
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,414.47,,,,,,,fee schedule,271.73,1270.05,
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,378.76,,,,,,,fee schedule,271.73,1270.05,
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,378.76,,,,,,,fee schedule,271.73,1270.05,
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,339.24,,,,,,,fee schedule,271.73,1270.05,
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,271.73,,,,,,,fee schedule,271.73,1270.05,
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,435.57,,,,,,,fee schedule,271.73,1270.05,
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,476.64,,,,,,,fee schedule,271.73,1270.05,
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,378.76,,,,,,,fee schedule,271.73,1270.05,
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,271.73,1270.05,APC
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,271.73,1270.05,APC
Treatment of bone cyst,20615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,271.73,1270.05,APC
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Insert and remove bone pin,20650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1820.68,,,,,,,fee schedule,1193.64,2883.98,
Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1490.23,,,,,,,fee schedule,1193.64,2883.98,
Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1193.64,,,,,,,fee schedule,1193.64,2883.98,
Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2093.78,,,,,,,fee schedule,1193.64,2883.98,
Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1193.64,2883.98,APC
Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1193.64,2883.98,APC
Apply rem fixation device,20660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1193.64,2883.98,APC
Application of head brace,20661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Application of head brace,20661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Application of head brace,20661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,2883.98,
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Application of pelvis brace,20662,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Application of thigh brace,20663,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Application of halo,20664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Application of halo,20664,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Application of halo,20664,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,389.14,,,,,,,fee schedule,174.57,801.21,
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.57,,,,,,,fee schedule,174.57,801.21,
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.57,,,,,,,fee schedule,174.57,801.21,
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,318.51,,,,,,,fee schedule,174.57,801.21,
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255.12,,,,,,,fee schedule,174.57,801.21,
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,200.76,,,,,,,fee schedule,174.57,801.21,
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,447.51,,,,,,,fee schedule,174.57,801.21,
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,174.57,,,,,,,fee schedule,174.57,801.21,
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,174.57,801.21,APC
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,174.57,801.21,APC
Removal of fixation device,20665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,174.57,801.21,APC
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4384.46,,,,,,,fee schedule,1645.66,5042.13,
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,5042.13,
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,5042.13,
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3588.68,,,,,,,fee schedule,1645.66,5042.13,
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2874.45,,,,,,,fee schedule,1645.66,5042.13,
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,5042.13,
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5042.13,,,,,,,fee schedule,1645.66,5042.13,
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,5042.13,
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,5042.13,APC
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,5042.13,APC
Removal of support implant,20670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,5042.13,APC
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2417.43,5563.42,
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,5563.42,
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,5563.42,
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2417.43,5563.42,
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2417.43,5563.42,
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,5563.42,
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2417.43,5563.42,
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,5563.42,
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,5563.42,APC
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,5563.42,APC
Removal of support implant,20680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,5563.42,APC
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Apply bone fixation device,20690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19608.41,,,,,,,fee schedule,3448.15,23026.52,
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,23026.52,
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,23026.52,
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12855.27,,,,,,,fee schedule,3448.15,23026.52,
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16049.48,,,,,,,fee schedule,3448.15,23026.52,
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,23026.52,
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22549.67,,,,,,,fee schedule,3448.15,23026.52,
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,23026.52,
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,3448.15,23026.52,APC
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,3448.15,23026.52,APC
Apply bone fixation device,20692,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,3448.15,23026.52,APC
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6986.34,,,,,,,fee schedule,3448.15,13014.22,
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4580.24,,,,,,,fee schedule,3448.15,13014.22,
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5718.32,,,,,,,fee schedule,3448.15,13014.22,
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8034.29,,,,,,,fee schedule,3448.15,13014.22,
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Adjust bone fixation device,20693,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4404.26,,,,,,,fee schedule,1602.21,5064.9,
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,5064.9,
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1602.21,5064.9,
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2887.43,,,,,,,fee schedule,1602.21,5064.9,
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3604.89,,,,,,,fee schedule,1602.21,5064.9,
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1602.21,5064.9,
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5064.9,,,,,,,fee schedule,1602.21,5064.9,
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,5064.9,
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,5064.9,APC
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,5064.9,APC
Remove bone fixation device,20694,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,5064.9,APC
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21305.84,,,,,,,fee schedule,3448.15,48665.61,
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,48665.61,
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,48665.61,
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13968.11,,,,,,,fee schedule,3448.15,48665.61,
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17438.83,,,,,,,fee schedule,3448.15,48665.61,
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,48665.61,
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24501.72,,,,,,,fee schedule,3448.15,48665.61,
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,48665.61,
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28388.27,,,,,,,fee schedule,3448.15,48665.61,APC
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27036.45,,,,,,,fee schedule,3448.15,48665.61,APC
Comp multiplane ext fixation,20696,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48665.61,,,,,,,fee schedule,3448.15,48665.61,APC
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5852.66,,,,,,,fee schedule,945.14,6730.56,
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,6730.56,
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,6730.56,
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3837,,,,,,,fee schedule,945.14,6730.56,
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4790.4,,,,,,,fee schedule,945.14,6730.56,
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,6730.56,
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6730.56,,,,,,,fee schedule,945.14,6730.56,
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,6730.56,
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,6730.56,APC
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,6730.56,APC
Comp ext fixate strut change,20697,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,6730.56,APC
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.92,,,,,,,fee schedule,92.39,162.06,
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.92,,,,,,,fee schedule,92.39,162.06,
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.92,,,,,,,fee schedule,92.39,162.06,
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.39,,,,,,,fee schedule,92.39,162.06,
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.34,,,,,,,fee schedule,92.39,162.06,
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.06,,,,,,,fee schedule,92.39,162.06,
Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.14,,,,,,,fee schedule,68.93,120.91,
Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.14,,,,,,,fee schedule,68.93,120.91,
Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.14,,,,,,,fee schedule,68.93,120.91,
Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.93,,,,,,,fee schedule,68.93,120.91,
Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.06,,,,,,,fee schedule,68.93,120.91,
Rmvl deep rx delivery device,20701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.91,,,,,,,fee schedule,68.93,120.91,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,231.37,,,,,,,fee schedule,151.69,266.08,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,231.37,,,,,,,fee schedule,151.69,266.08,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,231.37,,,,,,,fee schedule,151.69,266.08,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.69,,,,,,,fee schedule,151.69,266.08,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.38,,,,,,,fee schedule,151.69,266.08,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,266.08,,,,,,,fee schedule,151.69,266.08,
Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,168.26,,,,,,,fee schedule,110.31,193.5,
Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,168.26,,,,,,,fee schedule,110.31,193.5,
Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.26,,,,,,,fee schedule,110.31,193.5,
Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.31,,,,,,,fee schedule,110.31,193.5,
Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.72,,,,,,,fee schedule,110.31,193.5,
Rmvl imed rx delivery device,20703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,193.5,,,,,,,fee schedule,110.31,193.5,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,241.87,,,,,,,fee schedule,158.57,278.15,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.87,,,,,,,fee schedule,158.57,278.15,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,241.87,,,,,,,fee schedule,158.57,278.15,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.57,,,,,,,fee schedule,158.57,278.15,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,197.97,,,,,,,fee schedule,158.57,278.15,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.15,,,,,,,fee schedule,158.57,278.15,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.85,,,,,,,fee schedule,131.02,229.83,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.85,,,,,,,fee schedule,131.02,229.83,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.85,,,,,,,fee schedule,131.02,229.83,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.02,,,,,,,fee schedule,131.02,229.83,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.58,,,,,,,fee schedule,131.02,229.83,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.83,,,,,,,fee schedule,131.02,229.83,
Replantation arm complete,20802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Replantation arm complete,20802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Replantation arm complete,20802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Replant forearm complete,20805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Replant forearm complete,20805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Replant forearm complete,20805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Replantation hand complete,20808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Replantation hand complete,20808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Replantation hand complete,20808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Replantation digit complete,20816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation digit complete,20816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation digit complete,20816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,1602.21,3829.09,
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,1602.21,3829.09,
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,1602.21,3829.09,
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,1602.21,3829.09,
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Replantation digit complete,20822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Replantation thumb complete,20824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation thumb complete,20824,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation thumb complete,20824,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation thumb complete,20827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation thumb complete,20827,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation thumb complete,20827,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Replantation foot complete,20838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Replantation foot complete,20838,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Replantation foot complete,20838,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of bone for graft,20900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of bone for graft,20902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,1325.55,
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.96,,,,,,,fee schedule,438.5,1325.55,
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,1325.55,
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,1325.55,
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.45,,,,,,,fee schedule,438.5,1325.55,
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,1325.55,
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.96,,,,,,,fee schedule,438.5,1325.55,
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,773.24,,,,,,,fee schedule,438.5,1325.55,APC
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,736.41,,,,,,,fee schedule,438.5,1325.55,APC
Remove cartilage for graft,20910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1325.55,,,,,,,fee schedule,438.5,1325.55,APC
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Remove cartilage for graft,20912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,1381.8,3700.55,
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Removal of fascia for graft,20920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2055.86,4252.09,
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2055.86,4252.09,
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2055.86,4252.09,
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2055.86,4252.09,
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2055.86,4252.09,
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2055.86,4252.09,
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,2055.86,4252.09,APC
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,2055.86,4252.09,APC
Removal of fascia for graft,20922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,2055.86,4252.09,APC
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of tendon for graft,20924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Osteoart algrft w/surf & b1,20932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1555.38,,,,,,,fee schedule,1019.71,1788.69,
Osteoart algrft w/surf & b1,20932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1273.08,,,,,,,fee schedule,1019.71,1788.69,
Osteoart algrft w/surf & b1,20932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.71,,,,,,,fee schedule,1019.71,1788.69,
Osteoart algrft w/surf & b1,20932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.69,,,,,,,fee schedule,1019.71,1788.69,
Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1427.71,,,,,,,fee schedule,936.01,1641.87,
Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1168.58,,,,,,,fee schedule,936.01,1641.87,
Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,936.01,,,,,,,fee schedule,936.01,1641.87,
Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1641.87,,,,,,,fee schedule,936.01,1641.87,
Intercalary algrft compl,20934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1555.38,,,,,,,fee schedule,1019.71,1788.69,
Intercalary algrft compl,20934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1273.08,,,,,,,fee schedule,1019.71,1788.69,
Intercalary algrft compl,20934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.71,,,,,,,fee schedule,1019.71,1788.69,
Intercalary algrft compl,20934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.69,,,,,,,fee schedule,1019.71,1788.69,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.84,,,,,,,fee schedule,214.62,1270.05,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,214.62,1270.05,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.4,,,,,,,fee schedule,214.62,1270.05,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.75,,,,,,,fee schedule,214.62,1270.05,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,214.62,1270.05,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,915.22,,,,,,,fee schedule,214.62,1270.05,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,214.62,1270.05,APC
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,214.62,1270.05,APC
Fluid pressure muscle,20950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,214.62,1270.05,APC
Fibula bone graft microvasc,20955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Fibula bone graft microvasc,20955,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Fibula bone graft microvasc,20955,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Iliac bone graft microvasc,20956,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Iliac bone graft microvasc,20956,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Iliac bone graft microvasc,20956,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Mt bone graft microvasc,20957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Mt bone graft microvasc,20957,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Mt bone graft microvasc,20957,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Other bone graft microvasc,20962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Other bone graft microvasc,20962,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Other bone graft microvasc,20962,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Bone/skin graft microvasc,20969,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Bone/skin graft microvasc,20969,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Bone/skin graft microvasc,20969,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Bone/skin graft iliac crest,20970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Bone/skin graft iliac crest,20970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Bone/skin graft iliac crest,20970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Bone/skin graft metatarsal,20972,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Bone/skin graft great toe,20973,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.1,,,,,,,fee schedule,49.25,162.27,
Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.49,,,,,,,fee schedule,49.25,162.27,
Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.51,,,,,,,fee schedule,49.25,162.27,
Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.27,,,,,,,fee schedule,49.25,162.27,
Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.71,,,,,,,fee schedule,49.25,162.27,APC
Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.25,,,,,,,fee schedule,49.25,162.27,APC
Electrical bone stimulation,20974,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88.65,,,,,,,fee schedule,49.25,162.27,APC
Electrical bone stimulation,20975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,186.18,,,,,,,fee schedule,122.06,214.11,
Electrical bone stimulation,20975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.06,,,,,,,fee schedule,122.06,214.11,
Electrical bone stimulation,20975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,152.39,,,,,,,fee schedule,122.06,214.11,
Electrical bone stimulation,20975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,214.11,,,,,,,fee schedule,122.06,214.11,
Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,51.88,
Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,51.88,
Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,51.88,
Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,51.88,
Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,27.82,51.88,APC
Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,27.82,51.88,APC
Us bone stimulation,20979,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,27.82,51.88,APC
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13895.7,,,,,,,fee schedule,4986.47,31447.38,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,31447.38,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,31447.38,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9110.02,,,,,,,fee schedule,4986.47,31447.38,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11373.63,,,,,,,fee schedule,4986.47,31447.38,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,31447.38,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15980.06,,,,,,,fee schedule,4986.47,31447.38,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,31447.38,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,4986.47,31447.38,APC
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,4986.47,31447.38,APC
Ablate bone tumor(s) perq,20982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,4986.47,31447.38,APC
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Ablate bone tumor(s) perq,20983,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Musculoskeletal surgery,20999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Musculoskeletal surgery,20999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Musculoskeletal surgery,20999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Incision of jaw joint,21010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,626.13,,,,,,,fee schedule,410.49,2962.18,
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,554.25,,,,,,,fee schedule,410.49,2962.18,
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,554.25,,,,,,,fee schedule,410.49,2962.18,
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,410.49,,,,,,,fee schedule,410.49,2962.18,
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,512.49,,,,,,,fee schedule,410.49,2962.18,
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,637.39,,,,,,,fee schedule,410.49,2962.18,
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,720.05,,,,,,,fee schedule,410.49,2962.18,
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,554.25,,,,,,,fee schedule,410.49,2962.18,
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,410.49,2962.18,APC
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,410.49,2962.18,APC
Exc face les sc <2 cm,21011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,410.49,2962.18,APC
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,933.69,2962.18,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,933.69,2962.18,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,731.49,6124.23,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,731.49,,,,,,,fee schedule,731.49,6124.23,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,731.49,,,,,,,fee schedule,731.49,6124.23,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,731.49,6124.23,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,731.49,6124.23,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,841.21,,,,,,,fee schedule,731.49,6124.23,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,731.49,6124.23,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,731.49,,,,,,,fee schedule,731.49,6124.23,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,731.49,6124.23,APC
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,731.49,6124.23,APC
Exc face tum deep < 2 cm,21013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,731.49,6124.23,APC
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1095.32,5209.69,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1095.32,5209.69,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1095.32,5209.69,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,1095.32,5209.69,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1095.32,5209.69,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,1095.32,5209.69,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1095.32,5209.69,APC
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1095.32,5209.69,APC
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1095.32,5209.69,APC
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Excision of bone lower jaw,21025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Excision of facial bone(s),21026,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Contour of face bone lesion,21029,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,904.39,,,,,,,fee schedule,592.92,10617.38,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,799.8,,,,,,,fee schedule,592.92,10617.38,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,799.8,,,,,,,fee schedule,592.92,10617.38,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,592.92,,,,,,,fee schedule,592.92,10617.38,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,740.24,,,,,,,fee schedule,592.92,10617.38,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,919.77,,,,,,,fee schedule,592.92,10617.38,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1040.05,,,,,,,fee schedule,592.92,10617.38,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,799.8,,,,,,,fee schedule,592.92,10617.38,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,592.92,10617.38,APC
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,592.92,10617.38,APC
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,592.92,10617.38,APC
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,738.81,,,,,,,fee schedule,484.36,5946.37,
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,653.71,,,,,,,fee schedule,484.36,5946.37,
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,653.71,,,,,,,fee schedule,484.36,5946.37,
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,484.36,,,,,,,fee schedule,484.36,5946.37,
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,604.72,,,,,,,fee schedule,484.36,5946.37,
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.77,,,,,,,fee schedule,484.36,5946.37,
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,849.63,,,,,,,fee schedule,484.36,5946.37,
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.71,,,,,,,fee schedule,484.36,5946.37,
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,484.36,5946.37,APC
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,484.36,5946.37,APC
Remove exostosis mandible,21031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,484.36,5946.37,APC
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,747.62,,,,,,,fee schedule,490.14,5946.37,
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.21,,,,,,,fee schedule,490.14,5946.37,
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,663.21,,,,,,,fee schedule,490.14,5946.37,
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.14,,,,,,,fee schedule,490.14,5946.37,
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,611.93,,,,,,,fee schedule,490.14,5946.37,
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,762.69,,,,,,,fee schedule,490.14,5946.37,
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,859.76,,,,,,,fee schedule,490.14,5946.37,
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,663.21,,,,,,,fee schedule,490.14,5946.37,
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,490.14,5946.37,APC
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,490.14,5946.37,APC
Remove exostosis maxilla,21032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,490.14,5946.37,APC
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Excise max/zygoma mal tumor,21034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excise mandible lesion,21040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of jaw bone lesion,21044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Extensive jaw surgery,21045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Extensive jaw surgery,21045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Extensive jaw surgery,21045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove mandible cyst complex,21046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove maxilla cyst complex,21048,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of jaw joint,21050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove jaw joint cartilage,21060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove coronoid process,21070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,726.07,,,,,,,fee schedule,476.01,2782.81,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,635.55,,,,,,,fee schedule,476.01,2782.81,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,635.55,,,,,,,fee schedule,476.01,2782.81,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,476.01,,,,,,,fee schedule,476.01,2782.81,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,594.29,,,,,,,fee schedule,476.01,2782.81,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,730.88,,,,,,,fee schedule,476.01,2782.81,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,834.98,,,,,,,fee schedule,476.01,2782.81,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,635.55,,,,,,,fee schedule,476.01,2782.81,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,476.01,2782.81,APC
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,476.01,2782.81,APC
Mnpj of tmj w/anesth,21073,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,476.01,2782.81,APC
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1282.61,,,,,,,fee schedule,840.88,2782.81,
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1161.26,,,,,,,fee schedule,840.88,2782.81,
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1161.26,,,,,,,fee schedule,840.88,2782.81,
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,840.88,,,,,,,fee schedule,840.88,2782.81,
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1049.82,,,,,,,fee schedule,840.88,2782.81,
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1335.45,,,,,,,fee schedule,840.88,2782.81,
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1475,,,,,,,fee schedule,840.88,2782.81,
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1161.26,,,,,,,fee schedule,840.88,2782.81,
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,840.88,2782.81,APC
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,840.88,2782.81,APC
Prepare face/oral prosthesis,21076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,840.88,2782.81,APC
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3254.09,,,,,,,fee schedule,2133.38,10617.38,
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2911.32,,,,,,,fee schedule,2133.38,10617.38,
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2911.32,,,,,,,fee schedule,2133.38,10617.38,
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.47,,,,,,,fee schedule,2133.38,10617.38,
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2133.38,,,,,,,fee schedule,2133.38,10617.38,
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3348.02,,,,,,,fee schedule,2133.38,10617.38,
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3742.2,,,,,,,fee schedule,2133.38,10617.38,
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2911.32,,,,,,,fee schedule,2133.38,10617.38,
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2133.38,10617.38,APC
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2133.38,10617.38,APC
Prepare face/oral prosthesis,21077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2133.38,10617.38,APC
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2227.2,,,,,,,fee schedule,1460.15,5946.37,
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1993.89,,,,,,,fee schedule,1460.15,5946.37,
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1993.89,,,,,,,fee schedule,1460.15,5946.37,
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.96,,,,,,,fee schedule,1460.15,5946.37,
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1460.15,,,,,,,fee schedule,1460.15,5946.37,
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2292.97,,,,,,,fee schedule,1460.15,5946.37,
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2561.28,,,,,,,fee schedule,1460.15,5946.37,
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1993.89,,,,,,,fee schedule,1460.15,5946.37,
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1460.15,5946.37,APC
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1460.15,5946.37,APC
Prepare face/oral prosthesis,21079,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1460.15,5946.37,APC
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2506.43,,,,,,,fee schedule,1643.22,5946.37,
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2231.68,,,,,,,fee schedule,1643.22,5946.37,
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2231.68,,,,,,,fee schedule,1643.22,5946.37,
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2051.51,,,,,,,fee schedule,1643.22,5946.37,
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.22,,,,,,,fee schedule,1643.22,5946.37,
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2566.43,,,,,,,fee schedule,1643.22,5946.37,
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2882.39,,,,,,,fee schedule,1643.22,5946.37,
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2231.68,,,,,,,fee schedule,1643.22,5946.37,
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1643.22,5946.37,APC
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1643.22,5946.37,APC
Prepare face/oral prosthesis,21080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1643.22,5946.37,APC
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2336.96,,,,,,,fee schedule,1532.11,10617.38,
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2092.48,,,,,,,fee schedule,1532.11,10617.38,
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2092.48,,,,,,,fee schedule,1532.11,10617.38,
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1912.8,,,,,,,fee schedule,1532.11,10617.38,
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1532.11,,,,,,,fee schedule,1532.11,10617.38,
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2406.35,,,,,,,fee schedule,1532.11,10617.38,
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2687.5,,,,,,,fee schedule,1532.11,10617.38,
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2092.48,,,,,,,fee schedule,1532.11,10617.38,
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,1532.11,10617.38,APC
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,1532.11,10617.38,APC
Prepare face/oral prosthesis,21081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,1532.11,10617.38,APC
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2284.05,,,,,,,fee schedule,1497.42,5946.37,
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2063.96,,,,,,,fee schedule,1497.42,5946.37,
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2063.96,,,,,,,fee schedule,1497.42,5946.37,
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1869.49,,,,,,,fee schedule,1497.42,5946.37,
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1497.42,,,,,,,fee schedule,1497.42,5946.37,
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2373.55,,,,,,,fee schedule,1497.42,5946.37,
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2626.66,,,,,,,fee schedule,1497.42,5946.37,
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2063.96,,,,,,,fee schedule,1497.42,5946.37,
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1497.42,5946.37,APC
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1497.42,5946.37,APC
Prepare face/oral prosthesis,21082,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1497.42,5946.37,APC
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2249.73,,,,,,,fee schedule,1474.92,5946.37,
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2025.05,,,,,,,fee schedule,1474.92,5946.37,
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2025.05,,,,,,,fee schedule,1474.92,5946.37,
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1841.4,,,,,,,fee schedule,1474.92,5946.37,
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1474.92,,,,,,,fee schedule,1474.92,5946.37,
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2328.81,,,,,,,fee schedule,1474.92,5946.37,
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2587.19,,,,,,,fee schedule,1474.92,5946.37,
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2025.05,,,,,,,fee schedule,1474.92,5946.37,
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1474.92,5946.37,APC
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1474.92,5946.37,APC
Prepare face/oral prosthesis,21083,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1474.92,5946.37,APC
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2533.91,,,,,,,fee schedule,1661.23,5946.37,
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2273.17,,,,,,,fee schedule,1661.23,5946.37,
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2273.17,,,,,,,fee schedule,1661.23,5946.37,
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2074.01,,,,,,,fee schedule,1661.23,5946.37,
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1661.23,,,,,,,fee schedule,1661.23,5946.37,
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2614.15,,,,,,,fee schedule,1661.23,5946.37,
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2914,,,,,,,fee schedule,1661.23,5946.37,
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2273.17,,,,,,,fee schedule,1661.23,5946.37,
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1661.23,5946.37,APC
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1661.23,5946.37,APC
Prepare face/oral prosthesis,21084,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1661.23,5946.37,APC
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,236,985.44,
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,236,985.44,
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,236,985.44,
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,236,985.44,
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,236,985.44,
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,236,985.44,
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,236,985.44,
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,236,985.44,
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,985.44,APC
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,985.44,APC
Prepare face/oral prosthesis,21085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,985.44,APC
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2422.19,,,,,,,fee schedule,1587.99,5946.37,
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2180.66,,,,,,,fee schedule,1587.99,5946.37,
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2180.66,,,,,,,fee schedule,1587.99,5946.37,
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1982.56,,,,,,,fee schedule,1587.99,5946.37,
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1587.99,,,,,,,fee schedule,1587.99,5946.37,
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2507.76,,,,,,,fee schedule,1587.99,5946.37,
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2785.52,,,,,,,fee schedule,1587.99,5946.37,
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2180.66,,,,,,,fee schedule,1587.99,5946.37,
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1587.99,5946.37,APC
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1587.99,5946.37,APC
Prepare face/oral prosthesis,21086,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1587.99,5946.37,APC
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2399.64,,,,,,,fee schedule,1573.2,10617.38,
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2180.66,,,,,,,fee schedule,1573.2,10617.38,
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2180.66,,,,,,,fee schedule,1573.2,10617.38,
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1964.11,,,,,,,fee schedule,1573.2,10617.38,
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1573.2,,,,,,,fee schedule,1573.2,10617.38,
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2507.76,,,,,,,fee schedule,1573.2,10617.38,
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2759.59,,,,,,,fee schedule,1573.2,10617.38,
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2180.66,,,,,,,fee schedule,1573.2,10617.38,
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,1573.2,10617.38,APC
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,1573.2,10617.38,APC
Prepare face/oral prosthesis,21087,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,1573.2,10617.38,APC
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Prepare face/oral prosthesis,21088,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Prepare face/oral prosthesis,21089,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Prepare face/oral prosthesis,21089,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Prepare face/oral prosthesis,21089,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Maxillofacial fixation,21100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Interdental fixation,21110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Injection jaw joint x-ray,21116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,320.43,,,,,,,fee schedule,210.07,368.49,
Injection jaw joint x-ray,21116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.27,,,,,,,fee schedule,210.07,368.49,
Injection jaw joint x-ray,21116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,210.07,,,,,,,fee schedule,210.07,368.49,
Injection jaw joint x-ray,21116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,368.49,,,,,,,fee schedule,210.07,368.49,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7687.56,,,,,,,fee schedule,4942.79,10617.38,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6292.27,,,,,,,fee schedule,4942.79,10617.38,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5039.96,,,,,,,fee schedule,4942.79,10617.38,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8840.69,,,,,,,fee schedule,4942.79,10617.38,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Reconstruction of chin,21120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruction of chin,21121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of chin,21122,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruction of chin,21123,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Augmentation lower jaw bone,21125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Augmentation lower jaw bone,21127,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Reduction of forehead,21137,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12328.96,,,,,,,fee schedule,4942.79,14178.3,
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,14178.3,
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,14178.3,
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10091.25,,,,,,,fee schedule,4942.79,14178.3,
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8082.87,,,,,,,fee schedule,4942.79,14178.3,
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,14178.3,
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14178.3,,,,,,,fee schedule,4942.79,14178.3,
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,14178.3,
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,14178.3,APC
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,14178.3,APC
Reduction of forehead,21138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,14178.3,APC
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reduction of forehead,21139,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Lefort ii anterior intrusion,21150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Lefort ii w/bone grafts,21151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort ii w/bone grafts,21151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort ii w/bone grafts,21151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/o lefort i,21154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/o lefort i,21154,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/o lefort i,21154,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/ lefort i,21155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/ lefort i,21155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/ lefort i,21155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Reconstruct orbit/forehead,21172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Reconstruct orbit/forehead,21175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Reconstruct entire forehead,21179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct entire forehead,21179,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct entire forehead,21179,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct entire forehead,21180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct entire forehead,21180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct entire forehead,21180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Contour cranial bone lesion,21181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cranial bone,21182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct cranial bone,21182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct cranial bone,21182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct cranial bone,21183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct cranial bone,21183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct cranial bone,21183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct cranial bone,21184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct cranial bone,21184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct cranial bone,21184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruction of midface,21188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruction of midface,21188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruction of midface,21188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Reconst lwr jaw w/graft,21194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconst lwr jaw w/graft,21194,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconst lwr jaw w/graft,21194,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstr lwr jaw segment,21198,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct upper jaw bone,21206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Augmentation of facial bones,21208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reduction of facial bones,21209,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Face bone graft,21210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Lower jaw bone graft,21215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Rib cartilage graft,21230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11241.77,,,,,,,fee schedule,1678.74,12928.04,
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,12928.04,
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,12928.04,
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9201.39,,,,,,,fee schedule,1678.74,12928.04,
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7370.1,,,,,,,fee schedule,1678.74,12928.04,
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,12928.04,
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12928.04,,,,,,,fee schedule,1678.74,12928.04,
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,12928.04,
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,1678.74,12928.04,APC
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,1678.74,12928.04,APC
Ear cartilage graft,21235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,1678.74,12928.04,APC
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw joint,21240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw joint,21242,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30932.79,,,,,,,fee schedule,4942.79,48665.61,
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,48665.61,
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,48665.61,
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25318.49,,,,,,,fee schedule,4942.79,48665.61,
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20279.54,,,,,,,fee schedule,4942.79,48665.61,
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,48665.61,
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35572.71,,,,,,,fee schedule,4942.79,48665.61,
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,48665.61,
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28388.27,,,,,,,fee schedule,4942.79,48665.61,APC
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27036.45,,,,,,,fee schedule,4942.79,48665.61,APC
Reconstruction of jaw joint,21243,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48665.61,,,,,,,fee schedule,4942.79,48665.61,APC
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of lower jaw,21244,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct lower jaw bone,21247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct lower jaw bone,21247,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct lower jaw bone,21247,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of jaw,21249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct lower jaw bone,21255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct lower jaw bone,21255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruct lower jaw bone,21255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Reconstruction of orbit,21256,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revise eye sockets,21260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Revise eye sockets,21261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Revise eye sockets,21263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revise eye sockets,21267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Revise eye sockets,21268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Revise eye sockets,21268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Revise eye sockets,21268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Augmentation cheek bone,21270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5927.86,,,,,,,fee schedule,3886.31,10617.38,
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3886.31,10617.38,
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3886.31,10617.38,
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4851.95,,,,,,,fee schedule,3886.31,10617.38,
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3886.31,,,,,,,fee schedule,3886.31,10617.38,
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3886.31,10617.38,
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6817.04,,,,,,,fee schedule,3886.31,10617.38,
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3886.31,10617.38,
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3886.31,10617.38,APC
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3886.31,10617.38,APC
Revision orbitofacial bones,21275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3886.31,10617.38,APC
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of eyelid,21280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Revision of eyelid,21282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Revision of jaw muscle/bone,21295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of jaw muscle/bone,21296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Cranio/maxillofacial surgery,21299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Cranio/maxillofacial surgery,21299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Cranio/maxillofacial surgery,21299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,1546,4572.08,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1546,4572.08,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1546,4572.08,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,1546,4572.08,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,1546,4572.08,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1546,4572.08,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,1546,4572.08,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1546,4572.08,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1546,4572.08,APC
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1546,4572.08,APC
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1546,4572.08,APC
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4321.9,,,,,,,fee schedule,1678.74,5946.37,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3537.48,,,,,,,fee schedule,1678.74,5946.37,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2833.44,,,,,,,fee schedule,1678.74,5946.37,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4970.19,,,,,,,fee schedule,1678.74,5946.37,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5794.76,,,,,,,fee schedule,2578.99,10617.38,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4743.01,,,,,,,fee schedule,2578.99,10617.38,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3799.04,,,,,,,fee schedule,2578.99,10617.38,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6663.97,,,,,,,fee schedule,2578.99,10617.38,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Open tx nose & septal fx,21335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Closed tx septal&nose fx,21337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Perq tx nasoethmoid fx,21340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Open tx dprsd front sinus fx,21343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Open tx dprsd front sinus fx,21343,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Open tx dprsd front sinus fx,21343,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Open tx compl front sinus fx,21344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Open tx compl front sinus fx,21344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Open tx compl front sinus fx,21344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Closed tx nose/jaw fx,21345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx nasomax fx multple,21347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Opn tx nasomax fx multple,21347,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Opn tx nasomax fx multple,21347,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Perq tx malar fracture,21355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx dprsd malar fracture,21360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18526.78,,,,,,,fee schedule,5898.54,21305.8,
Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15164.17,,,,,,,fee schedule,5898.54,21305.8,
Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12146.16,,,,,,,fee schedule,5898.54,21305.8,
Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21305.8,,,,,,,fee schedule,5898.54,21305.8,
Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,21305.8,APC
Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,21305.8,APC
Opn tx complx malar fx,21365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,21305.8,APC
Opn tx complx malar w/grft,21366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Opn tx complx malar w/grft,21366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Opn tx complx malar w/grft,21366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx transantral,21385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx periorbital,21386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx combined,21387,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14070.46,,,,,,,fee schedule,4942.79,16181.03,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,16181.03,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,16181.03,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11516.67,,,,,,,fee schedule,4942.79,16181.03,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9224.59,,,,,,,fee schedule,4942.79,16181.03,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,16181.03,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16181.03,,,,,,,fee schedule,4942.79,16181.03,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,16181.03,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,16181.03,APC
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,16181.03,APC
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,16181.03,APC
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,985.44,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,428.37,985.44,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,985.44,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,985.44,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,428.37,985.44,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,985.44,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,985.44,APC
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,985.44,APC
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,985.44,APC
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Closed tx orbit w/manipulj,21401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx orbit fx w/implant,21407,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Treat mouth roof fracture,21421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Treat mouth roof fracture,21422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Treat mouth roof fracture,21422,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Treat mouth roof fracture,21422,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Treat mouth roof fracture,21423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Treat mouth roof fracture,21423,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Treat mouth roof fracture,21423,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21431,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21431,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21432,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21432,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21433,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21433,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Treat craniofacial fracture,21436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1235.59,,,,,,,fee schedule,810.05,5946.37,
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1094.63,,,,,,,fee schedule,810.05,5946.37,
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1094.63,,,,,,,fee schedule,810.05,5946.37,
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1011.33,,,,,,,fee schedule,810.05,5946.37,
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,810.05,,,,,,,fee schedule,810.05,5946.37,
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1258.82,,,,,,,fee schedule,810.05,5946.37,
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1420.93,,,,,,,fee schedule,810.05,5946.37,
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1094.63,,,,,,,fee schedule,810.05,5946.37,
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,810.05,5946.37,APC
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,810.05,5946.37,APC
Treat dental ridge fracture,21440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,810.05,5946.37,APC
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Treat dental ridge fracture,21445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,967.3,
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,428.37,967.3,
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,967.3,
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,967.3,
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,428.37,967.3,
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,967.3,
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,967.3,APC
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,967.3,APC
Treat lower jaw fracture,21450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,967.3,APC
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2782.81,
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2782.81,
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2782.81,
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1005.11,2782.81,
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2782.81,
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2782.81,APC
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2782.81,APC
Treat lower jaw fracture,21451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2782.81,APC
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,1678.74,10617.38,
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,10617.38,
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,10617.38,
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,1678.74,10617.38,
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,1678.74,10617.38,
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,10617.38,
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,1678.74,10617.38,
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,10617.38,
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,1678.74,10617.38,APC
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,1678.74,10617.38,APC
Treat lower jaw fracture,21452,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,1678.74,10617.38,APC
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7806.72,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6389.8,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5118.09,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8977.73,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Treat lower jaw fracture,21453,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Treat lower jaw fracture,21454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,3171.64,10617.38,
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3171.64,10617.38,
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3171.64,10617.38,
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,3171.64,10617.38,
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,3171.64,10617.38,
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3171.64,10617.38,
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,3171.64,10617.38,
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3171.64,10617.38,
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3171.64,10617.38,APC
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3171.64,10617.38,APC
Treat lower jaw fracture,21461,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3171.64,10617.38,APC
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7806.72,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6389.8,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5118.09,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8977.73,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Treat lower jaw fracture,21462,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Treat lower jaw fracture,21465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9291.17,,,,,,,fee schedule,5898.54,10684.85,
Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6091.29,,,,,,,fee schedule,5898.54,10684.85,
Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7604.82,,,,,,,fee schedule,5898.54,10684.85,
Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10684.85,,,,,,,fee schedule,5898.54,10684.85,
Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10684.85,APC
Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10684.85,APC
Treat lower jaw fracture,21470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10684.85,APC
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,171.91,442.4,
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,171.91,442.4,
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,171.91,442.4,
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,171.91,442.4,
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,171.91,442.4,
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,171.91,442.4,
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,171.91,442.4,
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,171.91,442.4,
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,171.91,442.4,APC
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,171.91,442.4,APC
Reset dislocated jaw,21480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,171.91,442.4,APC
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Reset dislocated jaw,21485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Repair dislocated jaw,21490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Interdental wiring,21497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Head surgery procedure,21499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Head surgery procedure,21499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Head surgery procedure,21499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5052.46,,,,,,,fee schedule,2167.63,5810.33,
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,2167.63,5810.33,
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,2167.63,5810.33,
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3312.39,,,,,,,fee schedule,2167.63,5810.33,
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4135.44,,,,,,,fee schedule,2167.63,5810.33,
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,2167.63,5810.33,
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5810.33,,,,,,,fee schedule,2167.63,5810.33,
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,2167.63,5810.33,
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2167.63,5810.33,APC
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2167.63,5810.33,APC
Drain neck/chest lesion,21501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2167.63,5810.33,APC
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Drain chest lesion,21502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Drainage of bone lesion,21510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Drainage of bone lesion,21510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Drainage of bone lesion,21510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,1645.66,6124.23,
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,6124.23,
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,6124.23,
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,1645.66,6124.23,
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,1645.66,6124.23,
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,6124.23,
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,1645.66,6124.23,
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,6124.23,
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,6124.23,APC
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,6124.23,APC
Biopsy of neck/chest,21550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,6124.23,APC
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4844.43,,,,,,,fee schedule,2417.43,5571.09,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,5571.09,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,5571.09,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3176.01,,,,,,,fee schedule,2417.43,5571.09,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3965.17,,,,,,,fee schedule,2417.43,5571.09,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,5571.09,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5571.09,,,,,,,fee schedule,2417.43,5571.09,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,5571.09,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,5571.09,APC
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,5571.09,APC
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,5571.09,APC
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7842.43,,,,,,,fee schedule,2417.43,9018.79,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,9018.79,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,9018.79,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5141.5,,,,,,,fee schedule,2417.43,9018.79,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6419.03,,,,,,,fee schedule,2417.43,9018.79,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,9018.79,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9018.79,,,,,,,fee schedule,2417.43,9018.79,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,9018.79,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,9018.79,APC
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,9018.79,APC
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,9018.79,APC
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5032.15,,,,,,,fee schedule,1645.66,5786.97,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,5786.97,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,5786.97,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3299.08,,,,,,,fee schedule,1645.66,5786.97,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4118.81,,,,,,,fee schedule,1645.66,5786.97,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,5786.97,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5786.97,,,,,,,fee schedule,1645.66,5786.97,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,5786.97,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,5786.97,APC
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,5786.97,APC
Exc neck les sc < 3 cm,21555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,5786.97,APC
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,2417.43,6124.23,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6124.23,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,6124.23,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,2417.43,6124.23,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,2417.43,6124.23,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,6124.23,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,2417.43,6124.23,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6124.23,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,6124.23,APC
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,6124.23,APC
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,6124.23,APC
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal of rib,21600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4504.41,,,,,,,fee schedule,2894.27,5209.69,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4504.41,,,,,,,fee schedule,2894.27,5209.69,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4504.41,,,,,,,fee schedule,2894.27,5209.69,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2953.09,,,,,,,fee schedule,2894.27,5209.69,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3686.86,,,,,,,fee schedule,2894.27,5209.69,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5180.07,,,,,,,fee schedule,2894.27,5209.69,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2894.27,5209.69,APC
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2894.27,5209.69,APC
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2894.27,5209.69,APC
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3912.26,,,,,,,fee schedule,2564.88,13014.22,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3912.26,,,,,,,fee schedule,2564.88,13014.22,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3912.26,,,,,,,fee schedule,2564.88,13014.22,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2564.88,,,,,,,fee schedule,2564.88,13014.22,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3202.18,,,,,,,fee schedule,2564.88,13014.22,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4499.1,,,,,,,fee schedule,2564.88,13014.22,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2564.88,13014.22,APC
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2564.88,13014.22,APC
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2564.88,13014.22,APC
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4145.73,,,,,,,fee schedule,2717.94,13014.22,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4145.73,,,,,,,fee schedule,2717.94,13014.22,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4145.73,,,,,,,fee schedule,2717.94,13014.22,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2717.94,,,,,,,fee schedule,2717.94,13014.22,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3393.28,,,,,,,fee schedule,2717.94,13014.22,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4767.59,,,,,,,fee schedule,2717.94,13014.22,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2717.94,13014.22,APC
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2717.94,13014.22,APC
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2717.94,13014.22,APC
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of rib,21610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of rib,21615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of rib,21615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of rib,21615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of rib and nerves,21616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of rib and nerves,21616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of rib and nerves,21616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Partial removal of sternum,21620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Partial removal of sternum,21620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Partial removal of sternum,21620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Sternal debridement,21627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Sternal debridement,21627,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Sternal debridement,21627,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Extensive sternum surgery,21630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Extensive sternum surgery,21630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Extensive sternum surgery,21630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Hyoid myotomy & suspension,21685,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,13014.22,
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of neck muscle,21700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of neck muscle/rib,21705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of neck muscle/rib,21705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of neck muscle/rib,21705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of neck muscle,21720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.84,,,,,,,fee schedule,214.62,1270.05,
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,214.62,1270.05,
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.75,,,,,,,fee schedule,214.62,1270.05,
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.4,,,,,,,fee schedule,214.62,1270.05,
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,214.62,1270.05,
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,915.22,,,,,,,fee schedule,214.62,1270.05,
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,214.62,1270.05,APC
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,214.62,1270.05,APC
Revision of neck muscle,21725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,214.62,1270.05,APC
Reconstruction of sternum,21740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Reconstruction of sternum,21740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Reconstruction of sternum,21740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,5868.42,
Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,5868.42,
Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,5868.42,
Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,5868.42,
Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2390.75,5868.42,APC
Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2390.75,5868.42,APC
Repair stern/nuss w/o scope,21742,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2390.75,5868.42,APC
Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,5868.42,
Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,5868.42,
Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,5868.42,
Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,5868.42,
Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2390.75,5868.42,APC
Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2390.75,5868.42,APC
Repair sternum/nuss w/scope,21743,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2390.75,5868.42,APC
Repair of sternum separation,21750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of sternum separation,21750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of sternum separation,21750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,13014.22,
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,13014.22,
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,13014.22,
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,13014.22,
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2390.75,13014.22,APC
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2390.75,13014.22,APC
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2390.75,13014.22,APC
Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1820.68,,,,,,,fee schedule,1193.64,13014.22,
Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1193.64,,,,,,,fee schedule,1193.64,13014.22,
Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1490.23,,,,,,,fee schedule,1193.64,13014.22,
Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2093.78,,,,,,,fee schedule,1193.64,13014.22,
Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,1193.64,13014.22,APC
Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,1193.64,13014.22,APC
Treatment of rib fracture,21812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,1193.64,13014.22,APC
Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1820.68,,,,,,,fee schedule,1193.64,2883.98,
Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1193.64,,,,,,,fee schedule,1193.64,2883.98,
Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1490.23,,,,,,,fee schedule,1193.64,2883.98,
Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2093.78,,,,,,,fee schedule,1193.64,2883.98,
Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1193.64,2883.98,APC
Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1193.64,2883.98,APC
Treatment of rib fracture,21813,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1193.64,2883.98,APC
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat sternum fracture,21820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat sternum fracture,21825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat sternum fracture,21825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat sternum fracture,21825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Neck/chest surgery procedure,21899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Neck/chest surgery procedure,21899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Neck/chest surgery procedure,21899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.09,,,,,,,fee schedule,315.4,2962.18,
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,421.1,,,,,,,fee schedule,315.4,2962.18,
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,421.1,,,,,,,fee schedule,315.4,2962.18,
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.4,,,,,,,fee schedule,315.4,2962.18,
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.77,,,,,,,fee schedule,315.4,2962.18,
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,484.27,,,,,,,fee schedule,315.4,2962.18,
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.25,,,,,,,fee schedule,315.4,2962.18,
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,421.1,,,,,,,fee schedule,315.4,2962.18,
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,315.4,2962.18,APC
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,315.4,2962.18,APC
Biopsy soft tissue of back,21920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,315.4,2962.18,APC
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,2962.18,
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,933.69,2962.18,
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,933.69,2962.18,
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,2962.18,
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy soft tissue of back,21925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,933.69,2962.18,
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc back les sc < 3 cm,21930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6704.26,,,,,,,fee schedule,1275.58,7709.9,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,7709.9,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,1275.58,7709.9,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4395.31,,,,,,,fee schedule,1275.58,7709.9,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5487.44,,,,,,,fee schedule,1275.58,7709.9,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,1275.58,7709.9,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7709.9,,,,,,,fee schedule,1275.58,7709.9,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,7709.9,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1275.58,7709.9,APC
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1275.58,7709.9,APC
Exc back les sc 3 cm/>,21931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1275.58,7709.9,APC
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Exc back tum deep < 5 cm,21932,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7060.03,,,,,,,fee schedule,2417.43,8119.03,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,8119.03,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,8119.03,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4628.56,,,,,,,fee schedule,2417.43,8119.03,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5778.63,,,,,,,fee schedule,2417.43,8119.03,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,8119.03,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8119.03,,,,,,,fee schedule,2417.43,8119.03,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,8119.03,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,8119.03,APC
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,8119.03,APC
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,8119.03,APC
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect back tum < 5 cm,21935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect back tum 5 cm/>,21936,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Remove part of neck vertebra,22100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,13014.22,
Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,13014.22,
Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,13014.22,
Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,13014.22,
Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2390.75,13014.22,APC
Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2390.75,13014.22,APC
Remove part thorax vertebra,22101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2390.75,13014.22,APC
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4745.33,13014.22,
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Remove part lumbar vertebra,22102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Remove part of neck vertebra,22110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part of neck vertebra,22110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part of neck vertebra,22110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part thorax vertebra,22112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part thorax vertebra,22112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part thorax vertebra,22112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part lumbar vertebra,22114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part lumbar vertebra,22114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Remove part lumbar vertebra,22114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incis spine 3 column thorac,22206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incis spine 3 column thorac,22206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incis spine 3 column thorac,22206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incis spine 3 column lumbar,22207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incis spine 3 column lumbar,22207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incis spine 3 column lumbar,22207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy cervical,22220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy cervical,22220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy cervical,22220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy thoracic,22222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy thoracic,22222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy thoracic,22222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy lumbar,22224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy lumbar,22224,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incis w/discectomy lumbar,22224,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Closed tx vert fx w/o manj,22310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,5868.42,
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,5868.42,
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,5868.42,
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,5868.42,
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Closed tx vert fx w/manj,22315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Treat odontoid fx w/o graft,22318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Treat odontoid fx w/o graft,22318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Treat odontoid fx w/o graft,22318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Treat odontoid fx w/graft,22319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Treat odontoid fx w/graft,22319,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Treat odontoid fx w/graft,22319,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Treat spine fracture,22325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Treat spine fracture,22325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Treat spine fracture,22325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Treat neck spine fracture,22326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Treat neck spine fracture,22326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Treat neck spine fracture,22326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Treat thorax spine fracture,22327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Treat thorax spine fracture,22327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Treat thorax spine fracture,22327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Manipulation of spine,22505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.56,,,,,,,fee schedule,1942.91,5868.42,
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1942.91,5868.42,
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1942.91,5868.42,
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2425.67,,,,,,,fee schedule,1942.91,5868.42,
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1942.91,,,,,,,fee schedule,1942.91,5868.42,
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1942.91,5868.42,
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3408.09,,,,,,,fee schedule,1942.91,5868.42,
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1942.91,5868.42,
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1942.91,5868.42,APC
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1942.91,5868.42,APC
Perq cervicothoracic inject,22510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1942.91,5868.42,APC
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2788.62,,,,,,,fee schedule,1828.22,5868.42,
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1828.22,5868.42,
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1828.22,5868.42,
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2282.49,,,,,,,fee schedule,1828.22,5868.42,
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1828.22,,,,,,,fee schedule,1828.22,5868.42,
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1828.22,5868.42,
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3206.91,,,,,,,fee schedule,1828.22,5868.42,
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1828.22,5868.42,
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1828.22,5868.42,APC
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1828.22,5868.42,APC
Perq lumbosacral injection,22511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1828.22,5868.42,APC
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5319.07,,,,,,,fee schedule,3487.18,13014.22,
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,3487.18,13014.22,
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,3487.18,13014.22,
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4353.66,,,,,,,fee schedule,3487.18,13014.22,
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3487.18,,,,,,,fee schedule,3487.18,13014.22,
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,3487.18,13014.22,
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6116.93,,,,,,,fee schedule,3487.18,13014.22,
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,3487.18,13014.22,
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3487.18,13014.22,APC
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3487.18,13014.22,APC
Perq vertebral augmentation,22513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3487.18,13014.22,APC
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Perq vertebral augmentation,22514,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Idet single level,22526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5777.22,,,,,,,fee schedule,3787.55,6643.8,
Idet single level,22526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4728.65,,,,,,,fee schedule,3787.55,6643.8,
Idet single level,22526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3787.55,,,,,,,fee schedule,3787.55,6643.8,
Idet single level,22526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6643.8,,,,,,,fee schedule,3787.55,6643.8,
Lat thorax spine fusion,22532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Lat thorax spine fusion,22532,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Lat thorax spine fusion,22532,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Lat lumbar spine fusion,22533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Lat lumbar spine fusion,22533,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Lat lumbar spine fusion,22533,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Neck spine fusion,22548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Neck spine fusion,22548,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Neck spine fusion,22548,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9262.12,,,,,,,fee schedule,6072.25,23026.52,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,6072.25,23026.52,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,6072.25,23026.52,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7581.05,,,,,,,fee schedule,6072.25,23026.52,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6072.25,,,,,,,fee schedule,6072.25,23026.52,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,6072.25,23026.52,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10651.44,,,,,,,fee schedule,6072.25,23026.52,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,6072.25,23026.52,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6072.25,23026.52,APC
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6072.25,23026.52,APC
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6072.25,23026.52,APC
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12685.41,,,,,,,fee schedule,8316.55,23026.52,
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,8316.55,23026.52,
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,8316.55,23026.52,
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10383.01,,,,,,,fee schedule,8316.55,23026.52,
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8316.55,,,,,,,fee schedule,8316.55,23026.52,
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,8316.55,23026.52,
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14588.22,,,,,,,fee schedule,8316.55,23026.52,
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,8316.55,23026.52,
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8316.55,23026.52,APC
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8316.55,23026.52,APC
Neck spine fusion,22554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8316.55,23026.52,APC
Thorax spine fusion,22556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Thorax spine fusion,22556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Thorax spine fusion,22556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Spine & skull spinal fusion,22590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Spine & skull spinal fusion,22590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Spine & skull spinal fusion,22590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Neck spinal fusion,22595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Neck spinal fusion,22595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Neck spinal fusion,22595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Neck spine fusion,22600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Neck spine fusion,22600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Neck spine fusion,22600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Thorax spine fusion,22610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Thorax spine fusion,22610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Thorax spine fusion,22610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6843.97,,,,,,,fee schedule,4486.91,31447.38,
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,4486.91,31447.38,
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,4486.91,31447.38,
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5601.79,,,,,,,fee schedule,4486.91,31447.38,
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4486.91,,,,,,,fee schedule,4486.91,31447.38,
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,4486.91,31447.38,
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7870.57,,,,,,,fee schedule,4486.91,31447.38,
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,4486.91,31447.38,
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,4486.91,31447.38,APC
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,4486.91,31447.38,APC
Lumbar spine fusion,22612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,4486.91,31447.38,APC
Post fusion <=6 vert seg,22800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Post fusion <=6 vert seg,22800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Post fusion <=6 vert seg,22800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Post fusion 7-12 vert seg,22802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Post fusion 7-12 vert seg,22802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Post fusion 7-12 vert seg,22802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Post fusion 13/> vert seg,22804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Post fusion 13/> vert seg,22804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Post fusion 13/> vert seg,22804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 8/> vert seg,22812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 8/> vert seg,22812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Ant fusion 8/> vert seg,22812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Kyphectomy 1-2 segments,22818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Kyphectomy 1-2 segments,22818,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Kyphectomy 1-2 segments,22818,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Kyphectomy 3 or more,22819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Kyphectomy 3 or more,22819,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Kyphectomy 3 or more,22819,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Exploration of spinal fusion,22830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Exploration of spinal fusion,22830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Exploration of spinal fusion,22830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2849.17,,,,,,,fee schedule,1867.92,31447.38,
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2332.05,,,,,,,fee schedule,1867.92,31447.38,
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1867.92,,,,,,,fee schedule,1867.92,31447.38,
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3276.55,,,,,,,fee schedule,1867.92,31447.38,
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,1867.92,31447.38,APC
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,1867.92,31447.38,APC
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,1867.92,31447.38,APC
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3090.29,,,,,,,fee schedule,2025.99,31447.38,
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2529.4,,,,,,,fee schedule,2025.99,31447.38,
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2025.99,,,,,,,fee schedule,2025.99,31447.38,
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3553.83,,,,,,,fee schedule,2025.99,31447.38,
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,2025.99,31447.38,APC
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,2025.99,31447.38,APC
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,2025.99,31447.38,APC
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3123.97,,,,,,,fee schedule,2048.07,31447.38,
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2556.97,,,,,,,fee schedule,2048.07,31447.38,
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2048.07,,,,,,,fee schedule,2048.07,31447.38,
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3592.57,,,,,,,fee schedule,2048.07,31447.38,
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,2048.07,31447.38,APC
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,2048.07,31447.38,APC
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,2048.07,31447.38,APC
Reinsert spinal fixation,22849,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Reinsert spinal fixation,22849,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Reinsert spinal fixation,22849,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Remove spine fixation device,22850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spine fixation device,22850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spine fixation device,22850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spine fixation device,22852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spine fixation device,22852,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spine fixation device,22852,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spine fixation device,22855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spine fixation device,22855,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spine fixation device,22855,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21990.73,,,,,,,fee schedule,14417.12,31447.38,
Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17999.41,,,,,,,fee schedule,14417.12,31447.38,
Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14417.12,,,,,,,fee schedule,14417.12,31447.38,
Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25289.34,,,,,,,fee schedule,14417.12,31447.38,
Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,14417.12,31447.38,APC
Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,14417.12,31447.38,APC
Cerv artific diskectomy,22856,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,14417.12,31447.38,APC
Lumbar Artif Diskectomy,22857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Lumbar Artif Diskectomy,22857,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Lumbar Artif Diskectomy,22857,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Revise cerv artific disc,22861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Revise cerv artific disc,22861,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Revise cerv artific disc,22861,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Revise Lumbar Artif Disc,22862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Revise Lumbar Artif Disc,22862,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Revise Lumbar Artif Disc,22862,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Remove cerv artif disc,22864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Remove cerv artif disc,22864,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Remove cerv artif disc,22864,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Remove Lumb Artif Disc,22865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Remove Lumb Artif Disc,22865,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Remove Lumb Artif Disc,22865,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28726.51,,,,,,,fee schedule,17470.77,33035.49,
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23512.65,,,,,,,fee schedule,17470.77,33035.49,
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18833.1,,,,,,,fee schedule,17470.77,33035.49,
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33035.49,,,,,,,fee schedule,17470.77,33035.49,
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,33035.49,APC
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,33035.49,APC
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,33035.49,APC
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28726.51,,,,,,,fee schedule,12792.51,33035.49,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23512.65,,,,,,,fee schedule,12792.51,33035.49,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18833.1,,,,,,,fee schedule,12792.51,33035.49,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33035.49,,,,,,,fee schedule,12792.51,33035.49,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,33035.49,APC
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,33035.49,APC
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,33035.49,APC
Spine surgery procedure,22899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Spine surgery procedure,22899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Spine surgery procedure,22899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5231.42,,,,,,,fee schedule,1645.66,6016.13,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,6016.13,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,6016.13,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3429.72,,,,,,,fee schedule,1645.66,6016.13,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4281.92,,,,,,,fee schedule,1645.66,6016.13,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,6016.13,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6016.13,,,,,,,fee schedule,1645.66,6016.13,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,6016.13,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,6016.13,APC
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,6016.13,APC
Exc abd les sc < 3 cm,22902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,6016.13,APC
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Radical resect abd tumor<5cm,22904,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Abdomen surgery procedure,22999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Abdomen surgery procedure,22999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Abdomen surgery procedure,22999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Removal of calcium deposits,23000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release shoulder joint,23020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,1847.27,5209.69,
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Drain shoulder lesion,23030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,5209.69,
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,933.69,5209.69,
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,933.69,5209.69,
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,5209.69,
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,5209.69,
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,933.69,5209.69,
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,5209.69,
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,933.69,5209.69,
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,933.69,5209.69,APC
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,933.69,5209.69,APC
Drain shoulder bursa,23031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,933.69,5209.69,APC
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,2883.98,
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Drain shoulder bone lesion,23035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Exploratory shoulder surgery,23040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Exploratory shoulder surgery,23044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.81,,,,,,,fee schedule,228.02,2962.18,
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,302.62,,,,,,,fee schedule,228.02,2962.18,
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,302.62,,,,,,,fee schedule,228.02,2962.18,
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,228.02,,,,,,,fee schedule,228.02,2962.18,
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.68,,,,,,,fee schedule,228.02,2962.18,
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,348.01,,,,,,,fee schedule,228.02,2962.18,
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.98,,,,,,,fee schedule,228.02,2962.18,
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,302.62,,,,,,,fee schedule,228.02,2962.18,
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,228.02,2962.18,APC
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,228.02,2962.18,APC
Biopsy shoulder tissues,23065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,228.02,2962.18,APC
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy shoulder tissues,23066,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3758.54,,,,,,,fee schedule,1645.66,4322.32,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1645.66,4322.32,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1645.66,4322.32,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2464.1,,,,,,,fee schedule,1645.66,4322.32,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3076.36,,,,,,,fee schedule,1645.66,4322.32,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1645.66,4322.32,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4322.32,,,,,,,fee schedule,1645.66,4322.32,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1645.66,4322.32,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,4322.32,APC
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,4322.32,APC
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,4322.32,APC
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,2962.18,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4418.82,,,,,,,fee schedule,1777.52,5209.69,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2896.98,,,,,,,fee schedule,1777.52,5209.69,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3616.8,,,,,,,fee schedule,1777.52,5209.69,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5081.64,,,,,,,fee schedule,1777.52,5209.69,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,5868.42,
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Biopsy of shoulder joint,23100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder joint surgery,23101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove shoulder joint lining,23105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of collarbone joint,23106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Explore treat shoulder joint,23107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7720.48,,,,,,,fee schedule,3260.23,8878.55,
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,8878.55,
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3260.23,8878.55,
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6319.21,,,,,,,fee schedule,3260.23,8878.55,
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5061.55,,,,,,,fee schedule,3260.23,8878.55,
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3260.23,8878.55,
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8878.55,,,,,,,fee schedule,3260.23,8878.55,
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,8878.55,
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,8878.55,APC
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,8878.55,APC
Partial removal collar bone,23120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,8878.55,APC
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of collar bone,23125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove shoulder bone part,23130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of bone lesion,23140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of bone lesion,23145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of bone lesion,23146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of humerus lesion,23150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of humerus lesion,23155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of humerus lesion,23156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,5868.42,
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1245.6,5868.42,
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1245.6,5868.42,
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,5868.42,
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Remove collar bone lesion,23170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove shoulder blade lesion,23172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Remove humerus lesion,23174,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Remove collar bone lesion,23180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Remove shoulder blade lesion,23182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove humerus lesion,23184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of scapula,23190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of head of humerus,23195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Resect clavicle tumor,23200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Resect clavicle tumor,23200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Resect clavicle tumor,23200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Resect scapula tumor,23210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Resect scapula tumor,23210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Resect scapula tumor,23210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Resect prox humerus tumor,23220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Resect prox humerus tumor,23220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Resect prox humerus tumor,23220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.84,,,,,,,fee schedule,521.75,2962.18,
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,521.75,2962.18,
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,521.75,2962.18,
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.4,,,,,,,fee schedule,521.75,2962.18,
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.75,,,,,,,fee schedule,521.75,2962.18,
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,521.75,2962.18,
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,915.22,,,,,,,fee schedule,521.75,2962.18,
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,521.75,2962.18,
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,521.75,2962.18,APC
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,521.75,2962.18,APC
Remove shoulder foreign body,23330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,521.75,2962.18,APC
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,5209.69,
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,5209.69,
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,933.69,5209.69,
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,5209.69,
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,5209.69,
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,933.69,5209.69,
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,5209.69,
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,5209.69,
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,933.69,5209.69,APC
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,933.69,5209.69,APC
Remove shoulder fb deep,23333,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,933.69,5209.69,APC
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,13014.22,
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,13014.22,
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,13014.22,
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,13014.22,
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,13014.22,
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,13014.22,
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,13014.22,
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,13014.22,
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,1847.27,13014.22,APC
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,1847.27,13014.22,APC
Shoulder prosthesis removal,23334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,1847.27,13014.22,APC
Shoulder prosthesis removal,23335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Shoulder prosthesis removal,23335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Shoulder prosthesis removal,23335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Injection for shoulder x-ray,23350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,836.06,,,,,,,fee schedule,548.12,961.47,
Injection for shoulder x-ray,23350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,684.32,,,,,,,fee schedule,548.12,961.47,
Injection for shoulder x-ray,23350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,548.12,,,,,,,fee schedule,548.12,961.47,
Injection for shoulder x-ray,23350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,961.47,,,,,,,fee schedule,548.12,961.47,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Muscle transfer shoulder/arm,23395,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Muscle transfers,23397,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Fixation of shoulder blade,23400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Incision of tendon & muscle,23405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5219.11,,,,,,,fee schedule,3421.65,13014.22,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3421.65,13014.22,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3421.65,13014.22,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4271.84,,,,,,,fee schedule,3421.65,13014.22,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3421.65,,,,,,,fee schedule,3421.65,13014.22,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3421.65,13014.22,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6001.98,,,,,,,fee schedule,3421.65,13014.22,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3421.65,13014.22,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3421.65,13014.22,APC
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3421.65,13014.22,APC
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3421.65,13014.22,APC
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair rotator cuff acute,23410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7732.11,,,,,,,fee schedule,4986.47,13014.22,
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6328.73,,,,,,,fee schedule,4986.47,13014.22,
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5069.17,,,,,,,fee schedule,4986.47,13014.22,
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,13014.22,
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8891.93,,,,,,,fee schedule,4986.47,13014.22,
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,13014.22,APC
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,13014.22,APC
Repair rotator cuff chronic,23412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,13014.22,APC
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Release of shoulder ligament,23415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of shoulder,23420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6369.4,,,,,,,fee schedule,4175.78,13014.22,
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4175.78,13014.22,
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4175.78,13014.22,
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5213.35,,,,,,,fee schedule,4175.78,13014.22,
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4175.78,,,,,,,fee schedule,4175.78,13014.22,
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4175.78,13014.22,
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7324.81,,,,,,,fee schedule,4175.78,13014.22,
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4175.78,13014.22,
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4175.78,13014.22,APC
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4175.78,13014.22,APC
Repair biceps tendon,23430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4175.78,13014.22,APC
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Remove/transplant tendon,23440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7357.36,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23462,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair shoulder capsule,23466,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14299.31,,,,,,,fee schedule,9374.63,23026.52,
Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9374.63,,,,,,,fee schedule,9374.63,23026.52,
Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11703.99,,,,,,,fee schedule,9374.63,23026.52,
Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16444.21,,,,,,,fee schedule,9374.63,23026.52,
Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,9374.63,23026.52,APC
Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,9374.63,23026.52,APC
Reconstruct shoulder joint,23470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,9374.63,23026.52,APC
Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19306.54,,,,,,,fee schedule,17470.77,31447.38,
Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19306.54,,,,,,,fee schedule,17470.77,31447.38,
Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22202.52,,,,,,,fee schedule,17470.77,31447.38,
Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19306.54,,,,,,,fee schedule,17470.77,31447.38,
Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Reconstruct shoulder joint,23472,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14299.31,,,,,,,fee schedule,9374.63,23026.52,
Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9374.63,,,,,,,fee schedule,9374.63,23026.52,
Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11703.99,,,,,,,fee schedule,9374.63,23026.52,
Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16444.21,,,,,,,fee schedule,9374.63,23026.52,
Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,9374.63,23026.52,APC
Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,9374.63,23026.52,APC
Revis reconst shoulder joint,23473,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,9374.63,23026.52,APC
Revis reconst shoulder joint,23474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Revis reconst shoulder joint,23474,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Revis reconst shoulder joint,23474,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of collar bone,23480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13002.38,,,,,,,fee schedule,8378.58,23026.52,
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8524.36,,,,,,,fee schedule,8378.58,23026.52,
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10642.45,,,,,,,fee schedule,8378.58,23026.52,
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14952.74,,,,,,,fee schedule,8378.58,23026.52,
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Revision of collar bone,23485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Reinforce clavicle,23490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8378.58,23026.52,
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8378.58,23026.52,
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8378.58,23026.52,
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8378.58,23026.52,
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Reinforce shoulder bones,23491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle fracture,23500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,945.14,2883.98,
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,945.14,2883.98,
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,945.14,2883.98,
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,2883.98,
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,945.14,2883.98,
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,2883.98,APC
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,2883.98,APC
Treat clavicle fracture,23505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,2883.98,APC
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9698.87,,,,,,,fee schedule,6358.58,13014.22,
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8625.72,,,,,,,fee schedule,6358.58,13014.22,
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8625.72,,,,,,,fee schedule,6358.58,13014.22,
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7938.53,,,,,,,fee schedule,6358.58,13014.22,
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6358.58,,,,,,,fee schedule,6358.58,13014.22,
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9919.58,,,,,,,fee schedule,6358.58,13014.22,
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11153.7,,,,,,,fee schedule,6358.58,13014.22,
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8625.72,,,,,,,fee schedule,6358.58,13014.22,
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6358.58,13014.22,APC
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6358.58,13014.22,APC
Treat clavicle fracture,23515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6358.58,13014.22,APC
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat clavicle dislocation,23520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat clavicle dislocation,23530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2706.78,13014.22,
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2706.78,13014.22,
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2706.78,13014.22,
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2706.78,13014.22,
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treat clavicle dislocation,23532,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat clavicle dislocation,23550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat clavicle dislocation,23552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat shoulder blade fx,23570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat shoulder blade fx,23575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,4745.33,13014.22,
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat scapula fracture,23585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,23600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat humerus fracture,23605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10000.44,,,,,,,fee schedule,6556.29,23026.52,
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,6556.29,23026.52,
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,6556.29,23026.52,
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8185.36,,,,,,,fee schedule,6556.29,23026.52,
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6556.29,,,,,,,fee schedule,6556.29,23026.52,
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,6556.29,23026.52,
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11500.51,,,,,,,fee schedule,6556.29,23026.52,
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,6556.29,23026.52,
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6556.29,23026.52,APC
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6556.29,23026.52,APC
Treat humerus fracture,23615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6556.29,23026.52,APC
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31008.83,,,,,,,fee schedule,10009.92,35660.15,
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,10009.92,35660.15,
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,10009.92,35660.15,
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25380.73,,,,,,,fee schedule,10009.92,35660.15,
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20329.39,,,,,,,fee schedule,10009.92,35660.15,
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,10009.92,35660.15,
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35660.15,,,,,,,fee schedule,10009.92,35660.15,
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,10009.92,35660.15,
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,10009.92,35660.15,APC
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,10009.92,35660.15,APC
Treat humerus fracture,23616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,10009.92,35660.15,APC
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,23620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat humerus fracture,23625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,4745.33,13014.22,
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat humerus fracture,23630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat shoulder dislocation,23650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat shoulder dislocation,23655,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat shoulder dislocation,23660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,945.14,2883.98,
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,945.14,2883.98,
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,945.14,2883.98,
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,2883.98,
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,945.14,2883.98,
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,2883.98,APC
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,2883.98,APC
Treat dislocation/fracture,23665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,2883.98,APC
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7357.36,,,,,,,fee schedule,4745.33,13014.22,
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat dislocation/fracture,23670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat dislocation/fracture,23675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,5603.18,23026.52,
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,5603.18,23026.52,
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,5603.18,23026.52,
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5603.18,23026.52,
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,5603.18,23026.52,
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,5603.18,23026.52,APC
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,5603.18,23026.52,APC
Treat dislocation/fracture,23680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,5603.18,23026.52,APC
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Fixation of shoulder,23700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of shoulder joint,23800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8378.58,23026.52,
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8378.58,23026.52,
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8378.58,23026.52,
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8378.58,23026.52,
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion of shoulder joint,23802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Amputation of arm & girdle,23900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation of arm & girdle,23900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation of arm & girdle,23900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation at shoulder joint,23920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation at shoulder joint,23920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation at shoulder joint,23920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Amputation follow-up surgery,23921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Shoulder surgery procedure,23929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Shoulder surgery procedure,23929,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Shoulder surgery procedure,23929,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.07,,,,,,,fee schedule,2167.63,10827.33,
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,2167.63,10827.33,
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,2167.63,10827.33,
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.52,,,,,,,fee schedule,2167.63,10827.33,
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.23,,,,,,,fee schedule,2167.63,10827.33,
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,2167.63,10827.33,
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.33,,,,,,,fee schedule,2167.63,10827.33,
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,2167.63,10827.33,
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2167.63,10827.33,APC
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2167.63,10827.33,APC
Drainage of arm lesion,23930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2167.63,10827.33,APC
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1319.63,,,,,,,fee schedule,933.69,2962.18,
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Drainage of arm bursa,23931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Drain arm/elbow bone lesion,23935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Exploratory elbow surgery,24000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release elbow joint,24006,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,474.25,,,,,,,fee schedule,310.92,2962.18,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.78,,,,,,,fee schedule,310.92,2962.18,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.78,,,,,,,fee schedule,310.92,2962.18,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,388.17,,,,,,,fee schedule,310.92,2962.18,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.92,,,,,,,fee schedule,310.92,2962.18,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,479.3,,,,,,,fee schedule,310.92,2962.18,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,545.39,,,,,,,fee schedule,310.92,2962.18,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,416.78,,,,,,,fee schedule,310.92,2962.18,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,310.92,2962.18,APC
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,310.92,2962.18,APC
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,310.92,2962.18,APC
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.84,,,,,,,fee schedule,1645.66,7300.02,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,7300.02,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,7300.02,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.71,,,,,,,fee schedule,1645.66,7300.02,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.64,,,,,,,fee schedule,1645.66,7300.02,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,7300.02,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.02,,,,,,,fee schedule,1645.66,7300.02,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,7300.02,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,7300.02,APC
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,7300.02,APC
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,7300.02,APC
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy elbow joint lining,24100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat elbow joint,24101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow joint lining,24102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of elbow bursa,24105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove humerus lesion,24110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft bone lesion,24115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft bone lesion,24116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow lesion,24120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft bone lesion,24125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9101.63,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7449.68,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5967.03,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10466.87,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft bone lesion,24126,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.07,,,,,,,fee schedule,3260.23,10827.33,
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,10827.33,
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3260.23,10827.33,
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.23,,,,,,,fee schedule,3260.23,10827.33,
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.52,,,,,,,fee schedule,3260.23,10827.33,
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3260.23,10827.33,
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.33,,,,,,,fee schedule,3260.23,10827.33,
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,10827.33,
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,10827.33,APC
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,10827.33,APC
Removal of head of radius,24130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,10827.33,APC
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Removal of arm bone lesion,24134,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove radius bone lesion,24136,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove elbow bone lesion,24138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of arm bone,24140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal of radius,24145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of elbow,24147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Radical resection of elbow,24149,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Resect distal humerus tumor,24150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Resect radius tumor,24152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of elbow joint,24155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove elbow joint implant,24160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove radius head implant,24164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,371.34,,,,,,,fee schedule,243.45,2962.18,
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,327.7,,,,,,,fee schedule,243.45,2962.18,
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,327.7,,,,,,,fee schedule,243.45,2962.18,
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,243.45,,,,,,,fee schedule,243.45,2962.18,
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,303.94,,,,,,,fee schedule,243.45,2962.18,
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,376.86,,,,,,,fee schedule,243.45,2962.18,
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,427.04,,,,,,,fee schedule,243.45,2962.18,
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,327.7,,,,,,,fee schedule,243.45,2962.18,
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,243.45,2962.18,APC
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,243.45,2962.18,APC
Removal of arm foreign body,24200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,243.45,2962.18,APC
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Removal of arm foreign body,24201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Injection for elbow x-ray,24220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,913.91,,,,,,,fee schedule,599.16,1051,
Injection for elbow x-ray,24220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,748.04,,,,,,,fee schedule,599.16,1051,
Injection for elbow x-ray,24220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,599.16,,,,,,,fee schedule,599.16,1051,
Injection for elbow x-ray,24220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1051,,,,,,,fee schedule,599.16,1051,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Manipulate elbow w/anesth,24300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Muscle/tendon transfer,24301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Arm tendon lengthening,24305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of arm tendon,24310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of arm tendon,24320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,2182.91,13014.22,
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,2182.91,13014.22,
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,2182.91,13014.22,
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,2182.91,13014.22,
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of arm muscles,24330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of arm muscles,24331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Tenolysis triceps,24332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of biceps tendon,24340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9041.4,,,,,,,fee schedule,4986.47,13014.22,
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7400.39,,,,,,,fee schedule,4986.47,13014.22,
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5927.54,,,,,,,fee schedule,4986.47,13014.22,
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,13014.22,
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10397.61,,,,,,,fee schedule,4986.47,13014.22,
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,13014.22,APC
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,13014.22,APC
Repair arm tendon/muscle,24341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,13014.22,APC
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of ruptured tendon,24342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,4986.47,23026.52,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,4986.47,23026.52,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,4986.47,23026.52,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,23026.52,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,4986.47,23026.52,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,4986.47,23026.52,APC
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,4986.47,23026.52,APC
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,4986.47,23026.52,APC
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair elbow perc,24357,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair elbow w/deb open,24358,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair elbow deb/attch open,24359,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruct elbow joint,24360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34167.15,,,,,,,fee schedule,17470.77,39292.22,
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,39292.22,
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,17470.77,39292.22,
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27965.81,,,,,,,fee schedule,17470.77,39292.22,
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22399.98,,,,,,,fee schedule,17470.77,39292.22,
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,17470.77,39292.22,
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39292.22,,,,,,,fee schedule,17470.77,39292.22,
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,39292.22,
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,39292.22,APC
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,39292.22,APC
Reconstruct elbow joint,24361,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,39292.22,APC
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19490.54,,,,,,,fee schedule,4458.15,23026.52,
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,23026.52,
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,23026.52,
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15953.01,,,,,,,fee schedule,4458.15,23026.52,
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12778,,,,,,,fee schedule,4458.15,23026.52,
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,23026.52,
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22414.12,,,,,,,fee schedule,4458.15,23026.52,
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,23026.52,
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,4458.15,23026.52,APC
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,4458.15,23026.52,APC
Reconstruct elbow joint,24362,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,4458.15,23026.52,APC
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33097.45,,,,,,,fee schedule,17470.77,38062.07,
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,38062.07,
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,17470.77,38062.07,
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27090.26,,,,,,,fee schedule,17470.77,38062.07,
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21698.69,,,,,,,fee schedule,17470.77,38062.07,
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,17470.77,38062.07,
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38062.07,,,,,,,fee schedule,17470.77,38062.07,
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,38062.07,
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,38062.07,APC
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,38062.07,APC
Replace elbow joint,24363,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,38062.07,APC
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19859.14,,,,,,,fee schedule,12792.51,23026.52,
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,12792.51,23026.52,
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,12792.51,23026.52,
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16254.71,,,,,,,fee schedule,12792.51,23026.52,
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13019.65,,,,,,,fee schedule,12792.51,23026.52,
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,12792.51,23026.52,
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22838.01,,,,,,,fee schedule,12792.51,23026.52,
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,12792.51,23026.52,
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Reconstruct head of radius,24365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20380.18,,,,,,,fee schedule,12792.51,23437.21,
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,12792.51,23437.21,
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,12792.51,23437.21,
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16681.18,,,,,,,fee schedule,12792.51,23437.21,
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13361.25,,,,,,,fee schedule,12792.51,23437.21,
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,12792.51,23437.21,
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23437.21,,,,,,,fee schedule,12792.51,23437.21,
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,12792.51,23437.21,
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23437.21,APC
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23437.21,APC
Reconstruct head of radius,24366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23437.21,APC
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18804.28,,,,,,,fee schedule,12328.09,23026.52,
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,12328.09,23026.52,
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,12328.09,23026.52,
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15391.3,,,,,,,fee schedule,12328.09,23026.52,
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12328.09,,,,,,,fee schedule,12328.09,23026.52,
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,12328.09,23026.52,
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21624.92,,,,,,,fee schedule,12328.09,23026.52,
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,12328.09,23026.52,
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12328.09,23026.52,APC
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12328.09,23026.52,APC
Revise reconst elbow joint,24370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12328.09,23026.52,APC
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31899.31,,,,,,,fee schedule,17470.77,36684.21,
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,36684.21,
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,17470.77,36684.21,
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26109.59,,,,,,,fee schedule,17470.77,36684.21,
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20913.19,,,,,,,fee schedule,17470.77,36684.21,
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,17470.77,36684.21,
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36684.21,,,,,,,fee schedule,17470.77,36684.21,
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,36684.21,
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,36684.21,APC
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,36684.21,APC
Revise reconst elbow joint,24371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,36684.21,APC
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of humerus,24400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,4986.47,23026.52,
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,4986.47,23026.52,
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,4986.47,23026.52,
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,23026.52,
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,4986.47,23026.52,
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,4986.47,23026.52,APC
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,4986.47,23026.52,APC
Revision of humerus,24410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,4986.47,23026.52,APC
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9034.08,,,,,,,fee schedule,4986.47,13014.22,
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7394.39,,,,,,,fee schedule,4986.47,13014.22,
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5922.74,,,,,,,fee schedule,4986.47,13014.22,
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,13014.22,
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10389.19,,,,,,,fee schedule,4986.47,13014.22,
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,13014.22,APC
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,13014.22,APC
Revision of humerus,24420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,13014.22,APC
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18700.3,,,,,,,fee schedule,8378.58,23026.52,
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15306.2,,,,,,,fee schedule,8378.58,23026.52,
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12259.92,,,,,,,fee schedule,8378.58,23026.52,
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21505.35,,,,,,,fee schedule,8378.58,23026.52,
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Repair of humerus,24430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18605.55,,,,,,,fee schedule,12197.8,23026.52,
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,12197.8,23026.52,
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,12197.8,23026.52,
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15228.64,,,,,,,fee schedule,12197.8,23026.52,
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12197.8,,,,,,,fee schedule,12197.8,23026.52,
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,12197.8,23026.52,
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21396.38,,,,,,,fee schedule,12197.8,23026.52,
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,12197.8,23026.52,
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12197.8,23026.52,APC
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12197.8,23026.52,APC
Repair humerus with graft,24435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12197.8,23026.52,APC
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of elbow joint,24470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Decompression of forearm,24495,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14380.03,,,,,,,fee schedule,9427.55,23026.52,
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,9427.55,23026.52,
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,9427.55,23026.52,
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11770.05,,,,,,,fee schedule,9427.55,23026.52,
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9427.55,,,,,,,fee schedule,9427.55,23026.52,
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,9427.55,23026.52,
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16537.03,,,,,,,fee schedule,9427.55,23026.52,
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,9427.55,23026.52,
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,9427.55,23026.52,APC
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,9427.55,23026.52,APC
Reinforce humerus,24498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,9427.55,23026.52,APC
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9269.99,,,,,,,fee schedule,6077.41,23026.52,
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,6077.41,23026.52,
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,6077.41,23026.52,
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6077.41,,,,,,,fee schedule,6077.41,23026.52,
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7587.49,,,,,,,fee schedule,6077.41,23026.52,
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,6077.41,23026.52,
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10660.49,,,,,,,fee schedule,6077.41,23026.52,
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,6077.41,23026.52,
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6077.41,23026.52,APC
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6077.41,23026.52,APC
Treat humerus fracture,24515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6077.41,23026.52,APC
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8916.51,23026.52,APC
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8916.51,23026.52,APC
Treat humerus fracture,24516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8916.51,23026.52,APC
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6603.46,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4329.23,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5404.93,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7593.98,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treat humerus fracture,24538,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.84,,,,,,,fee schedule,4161.64,23026.52,
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,4161.64,23026.52,
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,4161.64,23026.52,
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.64,,,,,,,fee schedule,4161.64,23026.52,
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.71,,,,,,,fee schedule,4161.64,23026.52,
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,4161.64,23026.52,
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.02,,,,,,,fee schedule,4161.64,23026.52,
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,4161.64,23026.52,
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,4161.64,23026.52,APC
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,4161.64,23026.52,APC
Treat humerus fracture,24545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,4161.64,23026.52,APC
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10033.43,,,,,,,fee schedule,6577.92,23026.52,
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,6577.92,23026.52,
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,6577.92,23026.52,
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6577.92,,,,,,,fee schedule,6577.92,23026.52,
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8212.36,,,,,,,fee schedule,6577.92,23026.52,
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,6577.92,23026.52,
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11538.44,,,,,,,fee schedule,6577.92,23026.52,
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,6577.92,23026.52,
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6577.92,23026.52,APC
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6577.92,23026.52,APC
Treat humerus fracture,24546,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6577.92,23026.52,APC
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,1602.21,3829.09,
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,1602.21,3829.09,
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,1602.21,3829.09,
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,1602.21,3829.09,
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Treat humerus fracture,24566,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.07,,,,,,,fee schedule,6172.52,23026.52,
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,6172.52,23026.52,
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,6172.52,23026.52,
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.52,,,,,,,fee schedule,6172.52,23026.52,
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.23,,,,,,,fee schedule,6172.52,23026.52,
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,6172.52,23026.52,
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.33,,,,,,,fee schedule,6172.52,23026.52,
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,6172.52,23026.52,
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6172.52,23026.52,APC
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6172.52,23026.52,APC
Treat humerus fracture,24575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6172.52,23026.52,APC
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24577,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8916.51,23026.52,APC
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8916.51,23026.52,APC
Treat humerus fracture,24579,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8916.51,23026.52,APC
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.66,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.23,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.39,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.56,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treat humerus fracture,24582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10377.42,,,,,,,fee schedule,6803.44,23026.52,
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,6803.44,23026.52,
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,6803.44,23026.52,
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6803.44,,,,,,,fee schedule,6803.44,23026.52,
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8493.92,,,,,,,fee schedule,6803.44,23026.52,
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,6803.44,23026.52,
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11934.03,,,,,,,fee schedule,6803.44,23026.52,
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,6803.44,23026.52,
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6803.44,23026.52,APC
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6803.44,23026.52,APC
Treat elbow fracture,24586,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6803.44,23026.52,APC
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19546,,,,,,,fee schedule,10009.92,23026.52,
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,10009.92,23026.52,
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,10009.92,23026.52,
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12814.36,,,,,,,fee schedule,10009.92,23026.52,
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15998.4,,,,,,,fee schedule,10009.92,23026.52,
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,10009.92,23026.52,
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22477.9,,,,,,,fee schedule,10009.92,23026.52,
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,10009.92,23026.52,
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,10009.92,23026.52,APC
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,10009.92,23026.52,APC
Treat elbow fracture,24587,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,10009.92,23026.52,APC
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat elbow dislocation,24600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat elbow dislocation,24605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat elbow dislocation,24615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat elbow fracture,24620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat elbow fracture,24635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.13,,,,,,,fee schedule,123.34,442.4,
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,217.02,,,,,,,fee schedule,123.34,442.4,
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.02,,,,,,,fee schedule,123.34,442.4,
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.34,,,,,,,fee schedule,123.34,442.4,
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.98,,,,,,,fee schedule,123.34,442.4,
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,249.57,,,,,,,fee schedule,123.34,442.4,
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.35,,,,,,,fee schedule,123.34,442.4,
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.02,,,,,,,fee schedule,123.34,442.4,
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,123.34,442.4,APC
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,123.34,442.4,APC
Treat elbow dislocation,24640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,123.34,442.4,APC
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat radius fracture,24650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.85,,,,,,,fee schedule,283.36,7300.03,
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,7300.03,
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,7300.03,
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.72,,,,,,,fee schedule,283.36,7300.03,
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.65,,,,,,,fee schedule,283.36,7300.03,
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,7300.03,
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.03,,,,,,,fee schedule,283.36,7300.03,
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,7300.03,
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,7300.03,APC
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,7300.03,APC
Treat radius fracture,24655,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,7300.03,APC
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat radius fracture,24665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20144.5,,,,,,,fee schedule,10009.92,23166.18,
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,10009.92,23166.18,
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,10009.92,23166.18,
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16488.27,,,,,,,fee schedule,10009.92,23166.18,
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13206.73,,,,,,,fee schedule,10009.92,23166.18,
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,10009.92,23166.18,
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23166.18,,,,,,,fee schedule,10009.92,23166.18,
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,10009.92,23166.18,
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,10009.92,23166.18,APC
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,10009.92,23166.18,APC
Treat radius fracture,24666,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,10009.92,23166.18,APC
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat ulnar fracture,24670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat ulnar fracture,24675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12260.13,,,,,,,fee schedule,5603.18,14099.15,
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,14099.15,
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5603.18,14099.15,
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10034.92,,,,,,,fee schedule,5603.18,14099.15,
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8037.74,,,,,,,fee schedule,5603.18,14099.15,
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5603.18,14099.15,
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14099.15,,,,,,,fee schedule,5603.18,14099.15,
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,14099.15,
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5603.18,14099.15,APC
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5603.18,14099.15,APC
Treat ulnar fracture,24685,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5603.18,14099.15,APC
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of elbow joint,24800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion/graft of elbow joint,24802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Amputation of upper arm,24900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation of upper arm,24900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation of upper arm,24900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation of upper arm,24920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation of upper arm,24920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation of upper arm,24920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,24925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,24930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation follow-up surgery,24930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation follow-up surgery,24930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Amputate upper arm & implant,24931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Amputate upper arm & implant,24931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Amputate upper arm & implant,24931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Revision of amputation,24935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Revision of upper arm,24940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Revision of upper arm,24940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Revision of upper arm,24940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Upper arm/elbow surgery,24999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Upper arm/elbow surgery,24999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Upper arm/elbow surgery,24999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1245.6,2883.98,
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of tendon sheath,25000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,5868.42,
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Incise flexor carpi radialis,25001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,3965.37,
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,3965.37,
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,3965.37,
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1245.6,3965.37,
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,3965.37,
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,3965.37,APC
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,3965.37,APC
Decompress forearm 1 space,25020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,3965.37,APC
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Decompress forearm 1 space,25023,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Decompress forearm 2 spaces,25024,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3965.37,
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1602.21,3965.37,
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1602.21,3965.37,
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3965.37,
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3965.37,
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1602.21,3965.37,
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3965.37,
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1602.21,3965.37,
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3965.37,APC
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3965.37,APC
Decompress forearm 2 spaces,25025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3965.37,APC
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Drainage of forearm lesion,25028,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,2883.98,
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Drainage of forearm bursa,25031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2200.83,13014.22,
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2200.83,13014.22,
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2200.83,13014.22,
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2200.83,13014.22,
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2200.83,13014.22,
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2200.83,13014.22,
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2200.83,13014.22,
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2200.83,13014.22,
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2200.83,13014.22,APC
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2200.83,13014.22,APC
Treat forearm bone lesion,25035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2200.83,13014.22,APC
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat wrist joint,25040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,477.17,,,,,,,fee schedule,312.83,2962.18,
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,422.82,,,,,,,fee schedule,312.83,2962.18,
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,422.82,,,,,,,fee schedule,312.83,2962.18,
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,390.56,,,,,,,fee schedule,312.83,2962.18,
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,312.83,,,,,,,fee schedule,312.83,2962.18,
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.24,,,,,,,fee schedule,312.83,2962.18,
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,548.75,,,,,,,fee schedule,312.83,2962.18,
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,422.82,,,,,,,fee schedule,312.83,2962.18,
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,312.83,2962.18,APC
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,312.83,2962.18,APC
Biopsy forearm soft tissues,25065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,312.83,2962.18,APC
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy forearm soft tissues,25066,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7043.29,,,,,,,fee schedule,1645.66,8099.78,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,8099.78,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1645.66,8099.78,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5764.93,,,,,,,fee schedule,1645.66,8099.78,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4617.58,,,,,,,fee schedule,1645.66,8099.78,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1645.66,8099.78,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8099.78,,,,,,,fee schedule,1645.66,8099.78,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1645.66,8099.78,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,8099.78,APC
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,8099.78,APC
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,8099.78,APC
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,5209.69,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,5209.69,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,5209.69,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,5209.69,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,5209.69,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,5209.69,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,5209.69,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,5209.69,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,933.69,5209.69,APC
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,933.69,5209.69,APC
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,933.69,5209.69,APC
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of wrist capsule,25085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of wrist joint,25100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat wrist joint,25101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist joint lining,25105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist joint cartilage,25107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Excise tendon forearm/wrist,25109,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Remove wrist tendon lesion,25110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Remove wrist tendon lesion,25111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3716.46,,,,,,,fee schedule,1602.21,4273.93,
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,4273.93,
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1602.21,4273.93,
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3041.92,,,,,,,fee schedule,1602.21,4273.93,
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2436.51,,,,,,,fee schedule,1602.21,4273.93,
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1602.21,4273.93,
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4273.93,,,,,,,fee schedule,1602.21,4273.93,
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,4273.93,
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,4273.93,APC
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,4273.93,APC
Reremove wrist tendon lesion,25112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,4273.93,APC
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Remove wrist/forearm lesion,25115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist/forearm lesion,25116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3965.37,
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1602.21,3965.37,
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1602.21,3965.37,
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3965.37,
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3965.37,
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1602.21,3965.37,
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3965.37,
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1602.21,3965.37,
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3965.37,APC
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3965.37,APC
Excise wrist tendon sheath,25118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3965.37,APC
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of ulna,25119,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of forearm lesion,25120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1602.21,3829.09,
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1602.21,3829.09,
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1602.21,3829.09,
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1602.21,3829.09,
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Remove/graft forearm lesion,25125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft forearm lesion,25126,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist lesion,25130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Remove & graft wrist lesion,25135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove & graft wrist lesion,25136,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove forearm bone lesion,25145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of ulna,25150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of radius,25151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Resect radius/ulnar tumor,25170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist bone,25210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist bones,25215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of radius,25230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of ulna,25240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Injection for wrist x-ray,25246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,966.05,,,,,,,fee schedule,633.34,1110.96,
Injection for wrist x-ray,25246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,790.71,,,,,,,fee schedule,633.34,1110.96,
Injection for wrist x-ray,25246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,633.34,,,,,,,fee schedule,633.34,1110.96,
Injection for wrist x-ray,25246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1110.96,,,,,,,fee schedule,633.34,1110.96,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1602.21,3829.09,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Remove forearm foreign body,25248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,3965.37,
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,3965.37,
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,3965.37,
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1245.6,3965.37,
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,3965.37,
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,3965.37,APC
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,3965.37,APC
Removal of wrist prosthesis,25250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,3965.37,APC
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of wrist prosthesis,25251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1245.6,2883.98,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Manipulate wrist w/anesthes,25259,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Repair forearm tendon/muscle,25263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon/muscle,25274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair forearm tendon sheath,25275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revise wrist/forearm tendon,25280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incise wrist/forearm tendon,25290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release wrist/forearm tendon,25295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of tendons at wrist,25300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of tendons at wrist,25301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant forearm tendon,25310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant forearm tendon,25312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Revise palsy hand tendon(s),25315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revise palsy hand tendon(s),25316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/revise wrist joint,25320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6044.93,,,,,,,fee schedule,3260.23,6951.67,
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,3260.23,6951.67,
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,3260.23,6951.67,
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3963.06,,,,,,,fee schedule,3260.23,6951.67,
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4947.78,,,,,,,fee schedule,3260.23,6951.67,
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,3260.23,6951.67,
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6951.67,,,,,,,fee schedule,3260.23,6951.67,
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,3260.23,6951.67,
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,6951.67,APC
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,6951.67,APC
Revise wrist joint,25332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,6951.67,APC
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Realignment of hand,25335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13504.75,,,,,,,fee schedule,4986.47,15530.46,
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,15530.46,
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,15530.46,
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11053.64,,,,,,,fee schedule,4986.47,15530.46,
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8853.71,,,,,,,fee schedule,4986.47,15530.46,
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,15530.46,
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15530.46,,,,,,,fee schedule,4986.47,15530.46,
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,15530.46,
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,15530.46,APC
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,15530.46,APC
Revision of radius,25350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,15530.46,APC
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of radius,25355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6369.4,,,,,,,fee schedule,4175.78,13014.22,
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4175.78,13014.22,
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4175.78,13014.22,
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5213.35,,,,,,,fee schedule,4175.78,13014.22,
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4175.78,,,,,,,fee schedule,4175.78,13014.22,
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4175.78,13014.22,
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7324.81,,,,,,,fee schedule,4175.78,13014.22,
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4175.78,13014.22,
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4175.78,13014.22,APC
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4175.78,13014.22,APC
Revision of ulna,25360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4175.78,13014.22,APC
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,4986.47,23026.52,
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,4986.47,23026.52,
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,4986.47,23026.52,
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,23026.52,
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,4986.47,23026.52,
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,4986.47,23026.52,APC
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,4986.47,23026.52,APC
Revise radius & ulna,25365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,4986.47,23026.52,APC
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revise radius or ulna,25370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revise radius & ulna,25375,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Shorten radius or ulna,25390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18662.16,,,,,,,fee schedule,4986.47,23026.52,
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15274.98,,,,,,,fee schedule,4986.47,23026.52,
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12234.91,,,,,,,fee schedule,4986.47,23026.52,
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,23026.52,
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21461.48,,,,,,,fee schedule,4986.47,23026.52,
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,4986.47,23026.52,APC
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,4986.47,23026.52,APC
Lengthen radius or ulna,25391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,4986.47,23026.52,APC
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Shorten radius & ulna,25392,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,13014.22,
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,13014.22,
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,13014.22,
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,13014.22,
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Lengthen radius & ulna,25393,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair carpal bone shorten,25394,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13049.39,,,,,,,fee schedule,7230.12,15006.8,
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,7230.12,15006.8,
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,7230.12,15006.8,
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10680.93,,,,,,,fee schedule,7230.12,15006.8,
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8555.18,,,,,,,fee schedule,7230.12,15006.8,
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,7230.12,15006.8,
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15006.8,,,,,,,fee schedule,7230.12,15006.8,
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,7230.12,15006.8,
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,15006.8,APC
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,15006.8,APC
Repair radius or ulna,25400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,15006.8,APC
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft radius or ulna,25405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair radius & ulna,25415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10038.3,,,,,,,fee schedule,6581.11,13014.22,
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,6581.11,13014.22,
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,6581.11,13014.22,
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8216.35,,,,,,,fee schedule,6581.11,13014.22,
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6581.11,,,,,,,fee schedule,6581.11,13014.22,
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,6581.11,13014.22,
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11544.05,,,,,,,fee schedule,6581.11,13014.22,
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,6581.11,13014.22,
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6581.11,13014.22,APC
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6581.11,13014.22,APC
Repair/graft radius & ulna,25420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6581.11,13014.22,APC
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9192.21,,,,,,,fee schedule,4986.47,13014.22,
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7523.82,,,,,,,fee schedule,4986.47,13014.22,
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6026.41,,,,,,,fee schedule,4986.47,13014.22,
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,13014.22,
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10571.04,,,,,,,fee schedule,4986.47,13014.22,
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,13014.22,APC
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,13014.22,APC
Repair/graft radius or ulna,25425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,13014.22,APC
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4508.85,,,,,,,fee schedule,2956,5868.42,
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2956,5868.42,
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2956,5868.42,
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3690.49,,,,,,,fee schedule,2956,5868.42,
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2956,,,,,,,fee schedule,2956,5868.42,
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2956,5868.42,
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5185.18,,,,,,,fee schedule,2956,5868.42,
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2956,5868.42,
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2956,5868.42,APC
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2956,5868.42,APC
Repair/graft radius & ulna,25426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2956,5868.42,APC
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Vasc graft into carpal bone,25430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair nonunion carpal bone,25431,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft wrist bone,25440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21080.32,,,,,,,fee schedule,12792.51,24242.37,
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,12792.51,24242.37,
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,12792.51,24242.37,
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17254.24,,,,,,,fee schedule,12792.51,24242.37,
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13820.26,,,,,,,fee schedule,12792.51,24242.37,
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,12792.51,24242.37,
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24242.37,,,,,,,fee schedule,12792.51,24242.37,
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,12792.51,24242.37,
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,24242.37,APC
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,24242.37,APC
Reconstruct wrist joint,25441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,24242.37,APC
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33054.05,,,,,,,fee schedule,17470.77,38012.16,
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,38012.16,
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,17470.77,38012.16,
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27054.74,,,,,,,fee schedule,17470.77,38012.16,
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21670.24,,,,,,,fee schedule,17470.77,38012.16,
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,17470.77,38012.16,
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38012.16,,,,,,,fee schedule,17470.77,38012.16,
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,38012.16,
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,38012.16,APC
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,38012.16,APC
Reconstruct wrist joint,25442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,38012.16,APC
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10421.98,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8530.39,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6832.65,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11985.28,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruct wrist joint,25443,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20682.88,,,,,,,fee schedule,12792.51,23785.31,
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,12792.51,23785.31,
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,12792.51,23785.31,
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16928.94,,,,,,,fee schedule,12792.51,23785.31,
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13559.7,,,,,,,fee schedule,12792.51,23785.31,
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,12792.51,23785.31,
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23785.31,,,,,,,fee schedule,12792.51,23785.31,
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,12792.51,23785.31,
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23785.31,APC
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23785.31,APC
Reconstruct wrist joint,25444,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23785.31,APC
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9853.84,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6460.18,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8065.37,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11331.92,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruct wrist joint,25445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33616.92,,,,,,,fee schedule,17470.77,38659.46,
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,38659.46,
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,17470.77,38659.46,
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22039.25,,,,,,,fee schedule,17470.77,38659.46,
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27515.45,,,,,,,fee schedule,17470.77,38659.46,
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,17470.77,38659.46,
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38659.46,,,,,,,fee schedule,17470.77,38659.46,
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,38659.46,
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,38659.46,APC
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,38659.46,APC
Wrist replacement,25446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,38659.46,APC
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair wrist joints,25447,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5304.94,,,,,,,fee schedule,3260.23,6100.68,
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3477.92,,,,,,,fee schedule,3260.23,6100.68,
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4342.09,,,,,,,fee schedule,3260.23,6100.68,
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6100.68,,,,,,,fee schedule,3260.23,6100.68,
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,6100.68,APC
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,6100.68,APC
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,6100.68,APC
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4458.15,13014.22,
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4458.15,13014.22,
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4458.15,13014.22,
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4458.15,13014.22,
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Remove wrist joint implant,25449,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10437.49,,,,,,,fee schedule,2929.89,12003.11,
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,12003.11,
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2929.89,12003.11,
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6842.82,,,,,,,fee schedule,2929.89,12003.11,
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8543.09,,,,,,,fee schedule,2929.89,12003.11,
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2929.89,12003.11,
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12003.11,,,,,,,fee schedule,2929.89,12003.11,
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,12003.11,
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2929.89,12003.11,APC
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2929.89,12003.11,APC
Revision of wrist joint,25450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2929.89,12003.11,APC
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of wrist joint,25455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Reinforce radius,25490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,4986.47,23026.52,
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,4986.47,23026.52,
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,4986.47,23026.52,
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,23026.52,
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,4986.47,23026.52,
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,23026.52,
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,4986.47,23026.52,APC
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,4986.47,23026.52,APC
Reinforce ulna,25491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,4986.47,23026.52,APC
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Reinforce radius and ulna,25492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of radius,25500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.84,,,,,,,fee schedule,945.14,7300.02,
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,7300.02,
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,7300.02,
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.64,,,,,,,fee schedule,945.14,7300.02,
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.71,,,,,,,fee schedule,945.14,7300.02,
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,7300.02,
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.02,,,,,,,fee schedule,945.14,7300.02,
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,7300.02,
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,7300.02,APC
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,7300.02,APC
Treat fracture of radius,25505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,7300.02,APC
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture of radius,25515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat fracture of radius,25520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11064.47,,,,,,,fee schedule,5603.18,13014.22,
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7253.87,,,,,,,fee schedule,5603.18,13014.22,
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9056.27,,,,,,,fee schedule,5603.18,13014.22,
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5603.18,13014.22,
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12724.14,,,,,,,fee schedule,5603.18,13014.22,
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5603.18,13014.22,APC
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5603.18,13014.22,APC
Treat fracture of radius,25525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5603.18,13014.22,APC
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture of radius,25526,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of ulna,25530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of ulna,25535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture of ulna,25545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture radius & ulna,25560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.66,,,,,,,fee schedule,283.36,9651.56,
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,9651.56,
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,9651.56,
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.23,,,,,,,fee schedule,283.36,9651.56,
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.39,,,,,,,fee schedule,283.36,9651.56,
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,9651.56,
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.56,,,,,,,fee schedule,283.36,9651.56,
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,9651.56,
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,9651.56,APC
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,9651.56,APC
Treat fracture radius & ulna,25565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,9651.56,APC
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture radius & ulna,25574,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.47,,,,,,,fee schedule,5502.1,13014.22,
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,5502.1,13014.22,
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,5502.1,13014.22,
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.1,,,,,,,fee schedule,5502.1,13014.22,
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.24,,,,,,,fee schedule,5502.1,13014.22,
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,5502.1,13014.22,
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.34,,,,,,,fee schedule,5502.1,13014.22,
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,5502.1,13014.22,
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5502.1,13014.22,APC
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5502.1,13014.22,APC
Treat fracture radius/ulna,25575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5502.1,13014.22,APC
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture radius/ulna,25600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.38,,,,,,,fee schedule,945.14,6124.19,
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,6124.19,
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,6124.19,
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.82,,,,,,,fee schedule,945.14,6124.19,
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.32,,,,,,,fee schedule,945.14,6124.19,
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,6124.19,
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.19,,,,,,,fee schedule,945.14,6124.19,
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,6124.19,
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,6124.19,APC
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,6124.19,APC
Treat fracture radius/ulna,25605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,6124.19,APC
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat Fx Distal Radial,25606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9991.05,,,,,,,fee schedule,6550.13,13014.22,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9054.46,,,,,,,fee schedule,6550.13,13014.22,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9054.46,,,,,,,fee schedule,6550.13,13014.22,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8177.67,,,,,,,fee schedule,6550.13,13014.22,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6550.13,,,,,,,fee schedule,6550.13,13014.22,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10412.63,,,,,,,fee schedule,6550.13,13014.22,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11489.71,,,,,,,fee schedule,6550.13,13014.22,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9054.46,,,,,,,fee schedule,6550.13,13014.22,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6550.13,13014.22,APC
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6550.13,13014.22,APC
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6550.13,13014.22,APC
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10686.95,,,,,,,fee schedule,7006.36,13014.22,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9055.68,,,,,,,fee schedule,7006.36,13014.22,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9055.68,,,,,,,fee schedule,7006.36,13014.22,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8747.27,,,,,,,fee schedule,7006.36,13014.22,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7006.36,,,,,,,fee schedule,7006.36,13014.22,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10414.03,,,,,,,fee schedule,7006.36,13014.22,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12289.99,,,,,,,fee schedule,7006.36,13014.22,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9055.68,,,,,,,fee schedule,7006.36,13014.22,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7006.36,13014.22,APC
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7006.36,13014.22,APC
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7006.36,13014.22,APC
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9269.98,,,,,,,fee schedule,6077.4,13014.22,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9128.53,,,,,,,fee schedule,6077.4,13014.22,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9128.53,,,,,,,fee schedule,6077.4,13014.22,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7587.48,,,,,,,fee schedule,6077.4,13014.22,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6077.4,,,,,,,fee schedule,6077.4,13014.22,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10497.81,,,,,,,fee schedule,6077.4,13014.22,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10660.48,,,,,,,fee schedule,6077.4,13014.22,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9128.53,,,,,,,fee schedule,6077.4,13014.22,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6077.4,13014.22,APC
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6077.4,13014.22,APC
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6077.4,13014.22,APC
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist bone fracture,25622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,945.14,2883.98,
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,945.14,2883.98,
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,945.14,2883.98,
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,2883.98,
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,945.14,2883.98,
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,2883.98,APC
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,2883.98,APC
Treat wrist bone fracture,25624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,2883.98,APC
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat wrist bone fracture,25628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist bone fracture,25630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat wrist bone fracture,25635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat wrist bone fracture,25645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist bone fracture,25650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Pin ulnar styloid fracture,25651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat fracture ulnar styloid,25652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist dislocation,25660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Treat wrist dislocation,25670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Pin radioulnar dislocation,25671,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist dislocation,25675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treat wrist dislocation,25676,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist fracture,25680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,13014.22,
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Treat wrist fracture,25685,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat wrist dislocation,25690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treat wrist dislocation,25695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10086.87,,,,,,,fee schedule,6612.95,13014.22,
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,6612.95,13014.22,
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,6612.95,13014.22,
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8256.1,,,,,,,fee schedule,6612.95,13014.22,
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6612.95,,,,,,,fee schedule,6612.95,13014.22,
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,6612.95,13014.22,
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11599.9,,,,,,,fee schedule,6612.95,13014.22,
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,6612.95,13014.22,
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6612.95,13014.22,APC
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6612.95,13014.22,APC
Fusion of wrist joint,25800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6612.95,13014.22,APC
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,4745.33,13014.22,
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,4745.33,13014.22,
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion/graft of wrist joint,25805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion/graft of wrist joint,25810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of hand bones,25820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13205.18,,,,,,,fee schedule,7230.12,15185.96,
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,7230.12,15185.96,
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,7230.12,15185.96,
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8657.32,,,,,,,fee schedule,7230.12,15185.96,
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10808.44,,,,,,,fee schedule,7230.12,15185.96,
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,7230.12,15185.96,
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15185.96,,,,,,,fee schedule,7230.12,15185.96,
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,7230.12,15185.96,
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,15185.96,APC
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,15185.96,APC
Fuse hand bones with graft,25825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,15185.96,APC
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Amputation of forearm,25900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of forearm,25900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of forearm,25900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of forearm,25905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of forearm,25905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of forearm,25905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,25907,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,13014.22,
Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,13014.22,
Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,13014.22,
Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,13014.22,
Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2390.75,13014.22,APC
Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2390.75,13014.22,APC
Amputation follow-up surgery,25909,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2390.75,13014.22,APC
Amputation of forearm,25915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of forearm,25915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of forearm,25915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Amputate hand at wrist,25920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate hand at wrist,25920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate hand at wrist,25920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,2883.98,
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Amputate hand at wrist,25922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Amputation follow-up surgery,25924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,25924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,25924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of hand,25927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of hand,25927,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of hand,25927,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Amputation follow-up surgery,25929,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,25931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Forearm or wrist surgery,25999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Forearm or wrist surgery,25999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Forearm or wrist surgery,25999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,148.19,359.84,
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,148.19,359.84,
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,148.19,359.84,
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,148.19,359.84,
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Drainage of finger abscess,26010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1319.63,,,,,,,fee schedule,933.69,2962.18,
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Drainage of finger abscess,26011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Drain hand tendon sheath,26020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Drainage of palm bursa,26025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Drainage of palm bursas,26030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat hand bone lesion,26034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Decompress fingers/hand,26035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Decompress fingers/hand,26037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Release palm contracture,26040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm contracture,26045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4526.52,,,,,,,fee schedule,1602.21,5205.5,
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,5205.5,
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1602.21,5205.5,
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2967.59,,,,,,,fee schedule,1602.21,5205.5,
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3704.96,,,,,,,fee schedule,1602.21,5205.5,
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1602.21,5205.5,
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5205.5,,,,,,,fee schedule,1602.21,5205.5,
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,5205.5,
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,5205.5,APC
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,5205.5,APC
Incise finger tendon sheath,26055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,5205.5,APC
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of finger tendon,26060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Explore/treat hand joint,26070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Explore/treat finger joint,26075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Explore/treat finger joint,26080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Biopsy hand joint lining,26100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Biopsy finger joint lining,26105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Biopsy finger joint lining,26110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm contracture,26121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm contracture,26123,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Remove wrist joint lining,26130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revise finger joint each,26135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Revise finger joint each,26140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Tendon excision palm/finger,26145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Remove tendon sheath lesion,26160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of palm tendon each,26170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of finger tendon,26180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Remove finger bone,26185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1602.21,3829.09,
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Remove hand bone lesion,26200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Remove/graft bone lesion,26205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of finger lesion,26210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Remove/graft finger lesion,26215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Partial removal of hand bone,26230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Partial removal finger bone,26235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Partial removal finger bone,26236,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Extensive hand surgery,26250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Resect prox finger tumor,26260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1602.21,3829.09,
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Resect distal finger tumor,26262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,933.69,2962.18,
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,933.69,2962.18,
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Removal of implant from hand,26320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Manipulate finger w/anesth,26340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.52,,,,,,,fee schedule,111.14,442.4,
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.42,,,,,,,fee schedule,111.14,442.4,
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.42,,,,,,,fee schedule,111.14,442.4,
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.14,,,,,,,fee schedule,111.14,442.4,
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.75,,,,,,,fee schedule,111.14,442.4,
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.98,,,,,,,fee schedule,111.14,442.4,
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.95,,,,,,,fee schedule,111.14,442.4,
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.42,,,,,,,fee schedule,111.14,442.4,
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,111.14,442.4,APC
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,111.14,442.4,APC
Manipulat palm cord post inj,26341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,111.14,442.4,APC
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Repair/graft hand tendon,26352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26357,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Repair/graft hand tendon,26358,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Repair/graft hand tendon,26372,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26373,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7064.48,,,,,,,fee schedule,2928.69,13014.22,
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5782.28,,,,,,,fee schedule,2928.69,13014.22,
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4631.47,,,,,,,fee schedule,2928.69,13014.22,
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8124.15,,,,,,,fee schedule,2928.69,13014.22,
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Revise hand/finger tendon,26390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Repair/graft hand tendon,26392,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1602.21,3829.09,
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Repair hand tendon,26410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft hand tendon,26412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,1245.6,5868.42,
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,1245.6,5868.42,
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,1245.6,5868.42,
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,1245.6,5868.42,
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Excision hand/finger tendon,26415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Graft hand or finger tendon,26416,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1602.21,3829.09,
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Repair finger tendon,26418,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft finger tendon,26420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger/hand tendon,26426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft finger tendon,26428,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,1602.21,6124.23,
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,6124.23,
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1602.21,6124.23,
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,1602.21,6124.23,
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,1602.21,6124.23,
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1602.21,6124.23,
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,1602.21,6124.23,
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,6124.23,
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,6124.23,APC
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,6124.23,APC
Repair finger tendon,26432,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,6124.23,APC
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Repair finger tendon,26433,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft finger tendon,26434,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Realignment of tendons,26437,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Release palm/finger tendon,26440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release palm & finger tendon,26442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Release hand/finger tendon,26445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release forearm/hand tendon,26449,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Incision of palm tendon,26450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of finger tendon,26455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Incise hand/finger tendon,26460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Fusion of finger tendons,26471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1602.21,3829.09,
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Fusion of finger tendons,26474,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Tendon lengthening,26476,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Tendon shortening,26477,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Lengthening of hand tendon,26478,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,5868.42,
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,5868.42,
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,5868.42,
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,5868.42,
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Shortening of hand tendon,26479,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant hand tendon,26480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant/graft hand tendon,26483,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant palm tendon,26485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transplant/graft palm tendon,26489,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revise thumb tendon,26490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Tendon transfer with graft,26492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Hand tendon/muscle transfer,26494,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revise thumb tendon,26496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Finger tendon transfer,26497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Finger tendon transfer,26498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of finger,26499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,1627.71,13014.22,
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,13014.22,
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,13014.22,
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,1627.71,13014.22,
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,1627.71,13014.22,
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,13014.22,
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,1627.71,13014.22,
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,13014.22,
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,1627.71,13014.22,APC
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,1627.71,13014.22,APC
Hand tendon reconstruction,26500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,1627.71,13014.22,APC
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Hand tendon reconstruction,26502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14527.14,,,,,,,fee schedule,1627.71,16706.21,
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,16706.21,
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,16706.21,
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11890.46,,,,,,,fee schedule,1627.71,16706.21,
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9523.99,,,,,,,fee schedule,1627.71,16706.21,
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,16706.21,
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16706.21,,,,,,,fee schedule,1627.71,16706.21,
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,16706.21,
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,16706.21,APC
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,16706.21,APC
Release thumb contracture,26508,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,16706.21,APC
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Thumb tendon transfer,26510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of knuckle joint,26516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of knuckle joints,26517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,13014.22,
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,13014.22,
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Fusion of knuckle joints,26518,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Release knuckle contracture,26520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1602.21,3829.09,
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1602.21,3829.09,
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Release finger contracture,26525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,2182.91,13014.22,
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,2182.91,13014.22,
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,2182.91,13014.22,
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,2182.91,13014.22,
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Revise knuckle joint,26530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10057.95,,,,,,,fee schedule,4458.15,13014.22,
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8232.43,,,,,,,fee schedule,4458.15,13014.22,
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6593.99,,,,,,,fee schedule,4458.15,13014.22,
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11566.64,,,,,,,fee schedule,4458.15,13014.22,
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Revise knuckle with implant,26531,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,2182.91,5868.42,
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revise finger joint,26535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4458.15,13014.22,
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4458.15,13014.22,
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4458.15,13014.22,
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4458.15,13014.22,
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Revise/implant finger joint,26536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Repair hand joint,26540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair hand joint with graft,26541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Repair hand joint with graft,26542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruct finger joint,26545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Repair nonunion hand,26546,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruct finger joint,26548,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Construct thumb replacement,26550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Great toe-hand transfer,26551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Great toe-hand transfer,26551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Great toe-hand transfer,26551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Single transfer toe-hand,26553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Single transfer toe-hand,26553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Single transfer toe-hand,26553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Double transfer toe-hand,26554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Double transfer toe-hand,26554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Double transfer toe-hand,26554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Positional change of finger,26555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Toe joint transfer,26556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Toe joint transfer,26556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Toe joint transfer,26556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Repair of web finger,26560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of web finger,26561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31908.17,,,,,,,fee schedule,2928.69,36694.4,
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,36694.4,
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,36694.4,
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20919,,,,,,,fee schedule,2928.69,36694.4,
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26116.84,,,,,,,fee schedule,2928.69,36694.4,
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,36694.4,
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36694.4,,,,,,,fee schedule,2928.69,36694.4,
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,36694.4,
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2928.69,36694.4,APC
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2928.69,36694.4,APC
Repair of web finger,26562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2928.69,36694.4,APC
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Correct metacarpal flaw,26565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Correct finger deformity,26567,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10365.4,,,,,,,fee schedule,2928.69,13014.22,
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6795.56,,,,,,,fee schedule,2928.69,13014.22,
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8484.08,,,,,,,fee schedule,2928.69,13014.22,
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11920.21,,,,,,,fee schedule,2928.69,13014.22,
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Lengthen metacarpal/finger,26568,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Repair hand deformity,26580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Reconstruct extra finger,26587,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1245.6,2883.98,
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1245.6,2883.98,
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Repair finger deformity,26590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair muscles of hand,26591,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Release muscles of hand,26593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Excision constricting tissue,26596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat metacarpal fracture,26600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat metacarpal fracture,26605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1738.83,5868.42,
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1738.83,5868.42,
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1738.83,5868.42,
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1738.83,5868.42,
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1738.83,5868.42,
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1738.83,5868.42,APC
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1738.83,5868.42,APC
Treat metacarpal fracture,26607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1738.83,5868.42,APC
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4710.47,,,,,,,fee schedule,2706.78,5868.42,
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,5868.42,
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,5868.42,
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3855.52,,,,,,,fee schedule,2706.78,5868.42,
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3088.18,,,,,,,fee schedule,2706.78,5868.42,
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,5868.42,
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5417.04,,,,,,,fee schedule,2706.78,5868.42,
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,5868.42,
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2706.78,5868.42,APC
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2706.78,5868.42,APC
Treat metacarpal fracture,26608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2706.78,5868.42,APC
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5386.45,,,,,,,fee schedule,2929.89,6194.42,
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,6194.42,
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2929.89,6194.42,
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4408.81,,,,,,,fee schedule,2929.89,6194.42,
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3531.36,,,,,,,fee schedule,2929.89,6194.42,
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2929.89,6194.42,
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6194.42,,,,,,,fee schedule,2929.89,6194.42,
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,6194.42,
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2929.89,6194.42,APC
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2929.89,6194.42,APC
Treat metacarpal fracture,26615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2929.89,6194.42,APC
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat thumb dislocation,26641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat thumb fracture,26645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat thumb fracture,26650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat thumb fracture,26665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat hand dislocation,26670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat hand dislocation,26675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Pin hand dislocation,26676,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat hand dislocation,26685,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,11511.41,
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,2182.91,11511.41,
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,2182.91,11511.41,
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,11511.41,
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,11511.41,
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,2182.91,11511.41,
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,11511.41,
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,2182.91,11511.41,
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,11511.41,APC
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,11511.41,APC
Treat hand dislocation,26686,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,11511.41,APC
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat knuckle dislocation,26700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat knuckle dislocation,26705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1738.83,5868.42,
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1738.83,5868.42,
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1738.83,5868.42,
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1738.83,5868.42,
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1738.83,5868.42,
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1738.83,5868.42,APC
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1738.83,5868.42,APC
Pin knuckle dislocation,26706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1738.83,5868.42,APC
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat knuckle dislocation,26715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,2706.78,6124.23,
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,6124.23,
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,6124.23,
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,2706.78,6124.23,
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,2706.78,6124.23,
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,6124.23,
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,2706.78,6124.23,
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,6124.23,
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2706.78,6124.23,APC
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2706.78,6124.23,APC
Treat finger fracture each,26727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2706.78,6124.23,APC
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat finger fracture each,26735,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat finger fracture each,26742,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10437.49,,,,,,,fee schedule,2706.78,12003.11,
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,12003.11,
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,12003.11,
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8543.09,,,,,,,fee schedule,2706.78,12003.11,
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6842.82,,,,,,,fee schedule,2706.78,12003.11,
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,12003.11,
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12003.11,,,,,,,fee schedule,2706.78,12003.11,
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,12003.11,
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2706.78,12003.11,APC
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2706.78,12003.11,APC
Treat finger fracture each,26746,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2706.78,12003.11,APC
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat finger fracture each,26755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3716.46,,,,,,,fee schedule,2436.51,5868.42,
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2436.51,5868.42,
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2436.51,5868.42,
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3041.92,,,,,,,fee schedule,2436.51,5868.42,
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2436.51,,,,,,,fee schedule,2436.51,5868.42,
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2436.51,5868.42,
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4273.93,,,,,,,fee schedule,2436.51,5868.42,
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2436.51,5868.42,
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2436.51,5868.42,APC
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2436.51,5868.42,APC
Pin finger fracture each,26756,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2436.51,5868.42,APC
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.44,,,,,,,fee schedule,2706.78,9651.31,
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,9651.31,
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,9651.31,
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.21,,,,,,,fee schedule,2706.78,9651.31,
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.08,,,,,,,fee schedule,2706.78,9651.31,
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,9651.31,
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.31,,,,,,,fee schedule,2706.78,9651.31,
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,9651.31,
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2706.78,9651.31,APC
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2706.78,9651.31,APC
Treat finger fracture each,26765,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2706.78,9651.31,APC
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat finger dislocation,26770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,278.69,4948.46,
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,278.69,4948.46,
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,278.69,4948.46,
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,278.69,4948.46,
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,278.69,4948.46,
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,278.69,4948.46,
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,278.69,4948.46,
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,278.69,4948.46,
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,278.69,4948.46,APC
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,278.69,4948.46,APC
Treat finger dislocation,26775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,278.69,4948.46,APC
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Pin finger dislocation,26776,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat finger dislocation,26785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Thumb fusion with graft,26820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of thumb,26841,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Thumb fusion with graft,26842,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of hand joint,26843,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion/graft of hand joint,26844,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of knuckle,26850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2928.69,13014.22,
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of knuckle with graft,26852,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2928.69,13014.22,APC
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of finger joint,26860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion/graft of finger joint,26862,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Amputate metacarpal bone,26910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3716.46,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3041.92,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2436.51,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4273.93,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Amputation of finger/thumb,26951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.87,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.71,,,,,,,fee schedule,1627.71,5868.42,
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1627.71,5868.42,APC
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1627.71,5868.42,APC
Amputation of finger/thumb,26952,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1627.71,5868.42,APC
Hand/finger surgery,26989,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Hand/finger surgery,26989,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Hand/finger surgery,26989,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Drainage of pelvis lesion,26990,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1602.21,3829.09,
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Drainage of pelvis bursa,26991,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Drainage of bone lesion,26992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Drainage of bone lesion,26992,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Drainage of bone lesion,26992,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1602.21,3829.09,
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Incision of hip tendon,27000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of hip tendon,27001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Incision of hip tendon,27003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Incision of hip tendon,27005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Incision of hip tendon,27005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Incision of hip tendon,27005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,5868.42,
Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,5868.42,
Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,5868.42,
Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,5868.42,
Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2390.75,5868.42,APC
Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2390.75,5868.42,APC
Incision of hip tendons,27006,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2390.75,5868.42,APC
Incision of hip/thigh fascia,27025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Incision of hip/thigh fascia,27025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Incision of hip/thigh fascia,27025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Buttock fasciotomy,27027,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Drainage of hip joint,27030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Drainage of hip joint,27030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Drainage of hip joint,27030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,13014.22,
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,13014.22,
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,13014.22,
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,13014.22,
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Exploration of hip joint,27033,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Denervation of hip joint,27035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Excision of hip joint/muscle,27036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Excision of hip joint/muscle,27036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Excision of hip joint/muscle,27036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy of soft tissues,27040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy of soft tissues,27041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4885.25,,,,,,,fee schedule,1777.52,5618.04,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5618.04,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5618.04,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3202.77,,,,,,,fee schedule,1777.52,5618.04,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3998.58,,,,,,,fee schedule,1777.52,5618.04,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5618.04,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5618.04,,,,,,,fee schedule,1777.52,5618.04,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5618.04,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5618.04,APC
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5618.04,APC
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5618.04,APC
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Biopsy of sacroiliac joint,27050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,2883.98,
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Biopsy of hip joint,27052,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of hip joint lining,27054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Removal of hip joint lining,27054,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Removal of hip joint lining,27054,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1820.68,,,,,,,fee schedule,1193.64,2883.98,
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1193.64,,,,,,,fee schedule,1193.64,2883.98,
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1490.23,,,,,,,fee schedule,1193.64,2883.98,
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2093.78,,,,,,,fee schedule,1193.64,2883.98,
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1193.64,2883.98,APC
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1193.64,2883.98,APC
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1193.64,2883.98,APC
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,13014.22,
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of ischial bursa,27060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove femur lesion/bursa,27062,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,13014.22,
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,13014.22,
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Remove hip bone les super,27065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove hip bone les deep,27066,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft hip bone lesion,27067,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Part remove hip bone super,27070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Part remove hip bone super,27070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Part remove hip bone super,27070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Part removal hip bone deep,27071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Part removal hip bone deep,27071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Part removal hip bone deep,27071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Resect hip tumor,27075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Resect hip tumor,27075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Resect hip tumor,27075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Resect hip tum incl acetabul,27076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Resect hip tum incl acetabul,27076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Resect hip tum incl acetabul,27076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Resect hip tum w/innom bone,27077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Resect hip tum w/innom bone,27077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Resect hip tum w/innom bone,27077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Rsect hip tum incl femur,27078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Rsect hip tum incl femur,27078,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Rsect hip tum incl femur,27078,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7064.48,,,,,,,fee schedule,3260.23,8124.15,
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,8124.15,
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3260.23,8124.15,
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4631.47,,,,,,,fee schedule,3260.23,8124.15,
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5782.28,,,,,,,fee schedule,3260.23,8124.15,
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3260.23,8124.15,
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8124.15,,,,,,,fee schedule,3260.23,8124.15,
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,8124.15,
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,8124.15,APC
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,8124.15,APC
Removal of tail bone,27080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,8124.15,APC
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,5209.69,
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,5209.69,
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,933.69,5209.69,
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,5209.69,
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,5209.69,
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,933.69,5209.69,
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,5209.69,
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,5209.69,
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,933.69,5209.69,APC
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,933.69,5209.69,APC
Remove hip foreign body,27086,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,933.69,5209.69,APC
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove hip foreign body,27087,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of hip prosthesis,27090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of hip prosthesis,27090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of hip prosthesis,27090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Removal of hip prosthesis,27091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Removal of hip prosthesis,27091,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Removal of hip prosthesis,27091,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Injection for hip x-ray,27093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,850.65,,,,,,,fee schedule,557.69,978.25,
Injection for hip x-ray,27093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,696.26,,,,,,,fee schedule,557.69,978.25,
Injection for hip x-ray,27093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,557.69,,,,,,,fee schedule,557.69,978.25,
Injection for hip x-ray,27093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,978.25,,,,,,,fee schedule,557.69,978.25,
Injection for hip x-ray,27095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,510.5,,,,,,,fee schedule,334.68,587.08,
Injection for hip x-ray,27095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,417.84,,,,,,,fee schedule,334.68,587.08,
Injection for hip x-ray,27095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.68,,,,,,,fee schedule,334.68,587.08,
Injection for hip x-ray,27095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.08,,,,,,,fee schedule,334.68,587.08,
Inject sacroiliac joint,27096,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3538.26,,,,,,,fee schedule,2319.68,4069,
Inject sacroiliac joint,27096,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2896.07,,,,,,,fee schedule,2319.68,4069,
Inject sacroiliac joint,27096,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2319.68,,,,,,,fee schedule,2319.68,4069,
Inject sacroiliac joint,27096,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4069,,,,,,,fee schedule,2319.68,4069,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of hip tendon,27097,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer tendon to pelvis,27098,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Transfer of abdominal muscle,27100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer of spinal muscle,27105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Transfer of iliopsoas muscle,27110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Transfer of iliopsoas muscle,27111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruction of hip socket,27120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Reconstruction of hip socket,27120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Reconstruction of hip socket,27120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Reconstruction of hip socket,27122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Reconstruction of hip socket,27122,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Reconstruction of hip socket,27122,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Partial hip replacement,27125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Partial hip replacement,27125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Partial hip replacement,27125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20478.09,,,,,,,fee schedule,12792.51,23549.8,
Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20478.09,,,,,,,fee schedule,12792.51,23549.8,
Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23549.8,,,,,,,fee schedule,12792.51,23549.8,
Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20478.09,,,,,,,fee schedule,12792.51,23549.8,
Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23549.8,APC
Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23549.8,APC
Total hip arthroplasty,27130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23549.8,APC
Total hip arthroplasty,27132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Total hip arthroplasty,27132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Total hip arthroplasty,27132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27134,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27134,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27137,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27137,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Revise hip joint replacement,27138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Transplant femur ridge,27140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Transplant femur ridge,27140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Transplant femur ridge,27140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of hip bone,27146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of hip bone,27146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of hip bone,27146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of hip bone,27147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of hip bone,27147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of hip bone,27147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of hip bones,27151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of hip bones,27151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of hip bones,27151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of hip bones,27156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of hip bones,27156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of hip bones,27156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of pelvis,27158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of pelvis,27158,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of pelvis,27158,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of neck of femur,27161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of neck of femur,27161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of neck of femur,27161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incision/fixation of femur,27165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incision/fixation of femur,27165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incision/fixation of femur,27165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Repair/graft femur head/neck,27170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Repair/graft femur head/neck,27170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Repair/graft femur head/neck,27170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat slipped epiphysis,27175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27176,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27176,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27177,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27177,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27178,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Treat slipped epiphysis,27178,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Revise head/neck of femur,27179,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Treat slipped epiphysis,27181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat slipped epiphysis,27181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat slipped epiphysis,27181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of femur epiphysis,27185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Revision of femur epiphysis,27185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Revision of femur epiphysis,27185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Reinforce hip bones,27187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Reinforce hip bones,27187,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Reinforce hip bones,27187,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,397.75,,,,,,,fee schedule,245.78,457.41,
Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,325.56,,,,,,,fee schedule,245.78,457.41,
Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.76,,,,,,,fee schedule,245.78,457.41,
Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,457.41,,,,,,,fee schedule,245.78,457.41,
Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,457.41,APC
Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,457.41,APC
Clsd tx pelvic ring fx,27197,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,457.41,APC
Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,397.75,,,,,,,fee schedule,245.78,457.41,
Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,325.56,,,,,,,fee schedule,245.78,457.41,
Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.76,,,,,,,fee schedule,245.78,457.41,
Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,457.41,,,,,,,fee schedule,245.78,457.41,
Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,457.41,APC
Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,457.41,APC
Clsd tx pelvic ring fx,27198,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,457.41,APC
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.17,,,,,,,fee schedule,186.3,442.4,
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,186.3,442.4,
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,186.3,442.4,
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.59,,,,,,,fee schedule,186.3,442.4,
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.3,,,,,,,fee schedule,186.3,442.4,
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,186.3,442.4,
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.8,,,,,,,fee schedule,186.3,442.4,
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,186.3,442.4,
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,186.3,442.4,APC
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,186.3,442.4,APC
Treat tail bone fracture,27200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,186.3,442.4,APC
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,6443.66,
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,2182.91,6443.66,
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,2182.91,6443.66,
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,6443.66,
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,6443.66,
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,2182.91,6443.66,
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,6443.66,
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,2182.91,6443.66,
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,6443.66,APC
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,6443.66,APC
Treat tail bone fracture,27202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,6443.66,APC
Treat pelvic fracture(s),27215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6323.98,,,,,,,fee schedule,4146,7272.58,
Treat pelvic fracture(s),27215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5176.18,,,,,,,fee schedule,4146,7272.58,
Treat pelvic fracture(s),27215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4146,,,,,,,fee schedule,4146,7272.58,
Treat pelvic fracture(s),27215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7272.58,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6323.98,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5176.18,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4146,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7272.58,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6323.98,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5176.18,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4146,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7272.58,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6323.98,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5176.18,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4146,,,,,,,fee schedule,4146,7272.58,
Treat pelvic ring fracture,27218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7272.58,,,,,,,fee schedule,4146,7272.58,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat hip socket fracture,27220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat hip socket fracture,27222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Treat hip socket fracture,27222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Treat hip socket fracture,27222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Treat hip wall fracture,27226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip wall fracture,27226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip wall fracture,27226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip fracture(s),27227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip fracture(s),27227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip fracture(s),27227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip fracture(s),27228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip fracture(s),27228,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip fracture(s),27228,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fracture,27230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fracture,27232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Treat thigh fracture,27232,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Treat thigh fracture,27232,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5052.46,,,,,,,fee schedule,3312.39,13014.22,
Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4135.44,,,,,,,fee schedule,3312.39,13014.22,
Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3312.39,,,,,,,fee schedule,3312.39,13014.22,
Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5810.33,,,,,,,fee schedule,3312.39,13014.22,
Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3312.39,13014.22,APC
Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3312.39,13014.22,APC
Treat thigh fracture,27235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3312.39,13014.22,APC
Treat thigh fracture,27236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27236,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27236,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat thigh fracture,27238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat thigh fracture,27240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Treat thigh fracture,27240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Treat thigh fracture,27240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Treat thigh fracture,27244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27244,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27244,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fracture,27246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fracture,27248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fracture,27248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,2883.98,APC
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,2883.98,APC
Treat hip dislocation,27252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,2883.98,APC
Treat hip dislocation,27253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27253,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27253,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip dislocation,27254,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip dislocation,27254,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27256,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,2883.98,APC
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,2883.98,APC
Treat hip dislocation,27257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,2883.98,APC
Treat hip dislocation,27258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27258,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27258,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27259,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27259,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat hip dislocation,27266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1738.83,5868.42,
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1738.83,5868.42,
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1738.83,5868.42,
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1738.83,5868.42,
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1738.83,5868.42,
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1738.83,5868.42,APC
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1738.83,5868.42,APC
Cltx thigh fx,27267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1738.83,5868.42,APC
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,2883.98,APC
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,2883.98,APC
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,2883.98,APC
Optx thigh fx,27269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Optx thigh fx,27269,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Optx thigh fx,27269,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Manipulation of hip joint,27275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32081.2,,,,,,,fee schedule,16117.27,36893.38,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16117.27,,,,,,,fee schedule,16117.27,36893.38,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16117.27,,,,,,,fee schedule,16117.27,36893.38,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21032.43,,,,,,,fee schedule,16117.27,36893.38,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26258.46,,,,,,,fee schedule,16117.27,36893.38,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18534.86,,,,,,,fee schedule,16117.27,36893.38,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36893.38,,,,,,,fee schedule,16117.27,36893.38,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16117.27,,,,,,,fee schedule,16117.27,36893.38,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,16117.27,36893.38,APC
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,16117.27,36893.38,APC
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,16117.27,36893.38,APC
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34400.62,,,,,,,fee schedule,17470.77,39560.71,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,39560.71,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,17470.77,39560.71,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22553.05,,,,,,,fee schedule,17470.77,39560.71,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28156.91,,,,,,,fee schedule,17470.77,39560.71,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,17470.77,39560.71,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39560.71,,,,,,,fee schedule,17470.77,39560.71,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,17470.77,39560.71,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,39560.71,APC
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,39560.71,APC
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,39560.71,APC
Fusion of sacroiliac joint,27280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Fusion of sacroiliac joint,27280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Fusion of sacroiliac joint,27280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Fusion of pubic bones,27282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Fusion of pubic bones,27282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Fusion of pubic bones,27282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Fusion of hip joint,27284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Fusion of hip joint,27284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Fusion of hip joint,27284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Fusion of hip joint,27286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Fusion of hip joint,27286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Fusion of hip joint,27286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Amputation of leg at hip,27290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Amputation of leg at hip,27290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Amputation of leg at hip,27290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Amputation of leg at hip,27295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Amputation of leg at hip,27295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Amputation of leg at hip,27295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Pelvis/hip joint surgery,27299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Pelvis/hip joint surgery,27299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Pelvis/hip joint surgery,27299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,1847.27,5209.69,
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Drain thigh/knee lesion,27301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Drainage of bone lesion,27303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Drainage of bone lesion,27303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Drainage of bone lesion,27303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incise thigh tendon & fascia,27305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1245.6,5868.42,
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1245.6,5868.42,
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Incision of thigh tendon,27306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendons,27307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of knee joint,27310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,933.69,2962.18,
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy thigh soft tissues,27323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy thigh soft tissues,27324,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Neurectomy hamstring,27325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Neurectomy popliteal,27326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,2962.18,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,933.69,2962.18,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,933.69,2962.18,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,933.69,2962.18,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy knee joint lining,27330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat knee joint,27331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cartilage,27332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cartilage,27333,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove knee joint lining,27334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10733.28,,,,,,,fee schedule,3448.15,13014.22,
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7036.74,,,,,,,fee schedule,3448.15,13014.22,
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8785.19,,,,,,,fee schedule,3448.15,13014.22,
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12343.27,,,,,,,fee schedule,3448.15,13014.22,
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove knee joint lining,27335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4418.84,,,,,,,fee schedule,2417.43,5209.69,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,5209.69,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,5209.69,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2896.99,,,,,,,fee schedule,2417.43,5209.69,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3616.82,,,,,,,fee schedule,2417.43,5209.69,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,5209.69,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5081.67,,,,,,,fee schedule,2417.43,5209.69,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,5209.69,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,5209.69,APC
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,5209.69,APC
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,5209.69,APC
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of kneecap bursa,27340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of knee cyst,27345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove knee cyst,27347,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of kneecap,27350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5079.13,,,,,,,fee schedule,3260.23,5868.42,
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,5868.42,
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3260.23,5868.42,
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3329.88,,,,,,,fee schedule,3260.23,5868.42,
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4157.27,,,,,,,fee schedule,3260.23,5868.42,
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3260.23,5868.42,
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5841,,,,,,,fee schedule,3260.23,5868.42,
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,5868.42,
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Remove femur lesion,27355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20830.77,,,,,,,fee schedule,3448.15,23955.39,
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,23955.39,
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,23955.39,
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13656.65,,,,,,,fee schedule,3448.15,23955.39,
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17049.99,,,,,,,fee schedule,3448.15,23955.39,
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,23955.39,
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23955.39,,,,,,,fee schedule,3448.15,23955.39,
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,23955.39,
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,3448.15,23955.39,APC
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,3448.15,23955.39,APC
Remove femur lesion/graft,27356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,3448.15,23955.39,APC
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove femur lesion/graft,27357,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7806.72,,,,,,,fee schedule,3260.23,8977.73,
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,8977.73,
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3260.23,8977.73,
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5118.09,,,,,,,fee schedule,3260.23,8977.73,
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6389.8,,,,,,,fee schedule,3260.23,8977.73,
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3260.23,8977.73,
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8977.73,,,,,,,fee schedule,3260.23,8977.73,
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,8977.73,
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,8977.73,APC
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,8977.73,APC
Partial removal leg bone(s),27360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,8977.73,APC
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5794.76,,,,,,,fee schedule,2417.43,6663.97,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6663.97,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,6663.97,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3799.04,,,,,,,fee schedule,2417.43,6663.97,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4743.01,,,,,,,fee schedule,2417.43,6663.97,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,6663.97,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6663.97,,,,,,,fee schedule,2417.43,6663.97,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6663.97,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,6663.97,APC
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,6663.97,APC
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,6663.97,APC
Resect femur/knee tumor,27365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Resect femur/knee tumor,27365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Resect femur/knee tumor,27365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,908.31,,,,,,,fee schedule,595.49,1044.56,
Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,595.49,,,,,,,fee schedule,595.49,1044.56,
Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,743.45,,,,,,,fee schedule,595.49,1044.56,
Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1044.56,,,,,,,fee schedule,595.49,1044.56,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Removal of foreign body,27372,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8548.96,,,,,,,fee schedule,3448.15,13014.22,
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5604.7,,,,,,,fee schedule,3448.15,13014.22,
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6997.32,,,,,,,fee schedule,3448.15,13014.22,
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9831.3,,,,,,,fee schedule,3448.15,13014.22,
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of kneecap tendon,27380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair/graft kneecap tendon,27381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6369.4,,,,,,,fee schedule,3448.15,13014.22,
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4175.78,,,,,,,fee schedule,3448.15,13014.22,
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5213.35,,,,,,,fee schedule,3448.15,13014.22,
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7324.81,,,,,,,fee schedule,3448.15,13014.22,
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of thigh muscle,27385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair/graft of thigh muscle,27386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendon,27390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendons,27391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of thigh tendons,27392,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Lengthening of thigh tendon,27393,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Lengthening of thigh tendons,27394,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13504.75,,,,,,,fee schedule,3260.23,15530.46,
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,3260.23,15530.46,
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,3260.23,15530.46,
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11053.64,,,,,,,fee schedule,3260.23,15530.46,
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8853.71,,,,,,,fee schedule,3260.23,15530.46,
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,3260.23,15530.46,
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15530.46,,,,,,,fee schedule,3260.23,15530.46,
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,3260.23,15530.46,
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,15530.46,APC
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,15530.46,APC
Lengthening of thigh tendons,27395,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,15530.46,APC
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Transplant of thigh tendon,27396,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11312.31,,,,,,,fee schedule,4986.47,13014.22,
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9259.13,,,,,,,fee schedule,4986.47,13014.22,
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7416.35,,,,,,,fee schedule,4986.47,13014.22,
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,13014.22,
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13009.16,,,,,,,fee schedule,4986.47,13014.22,
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,13014.22,APC
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,13014.22,APC
Transplants of thigh tendons,27397,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,13014.22,APC
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revise thigh muscles/tendons,27400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Repair of knee cartilage,27403,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of knee ligament,27405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10377.42,,,,,,,fee schedule,6803.44,13014.22,
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,6803.44,13014.22,
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,6803.44,13014.22,
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8493.92,,,,,,,fee schedule,6803.44,13014.22,
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6803.44,,,,,,,fee schedule,6803.44,13014.22,
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,6803.44,13014.22,
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11934.03,,,,,,,fee schedule,6803.44,13014.22,
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,6803.44,13014.22,
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6803.44,13014.22,APC
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6803.44,13014.22,APC
Repair of knee ligament,27407,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6803.44,13014.22,APC
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of knee ligaments,27409,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Autochondrocyte implant knee,27412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10377.42,,,,,,,fee schedule,6803.44,23026.52,
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,6803.44,23026.52,
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,6803.44,23026.52,
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8493.92,,,,,,,fee schedule,6803.44,23026.52,
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6803.44,,,,,,,fee schedule,6803.44,23026.52,
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,6803.44,23026.52,
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11934.03,,,,,,,fee schedule,6803.44,23026.52,
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,6803.44,23026.52,
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6803.44,23026.52,APC
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6803.44,23026.52,APC
Osteochondral knee allograft,27415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6803.44,23026.52,APC
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10351.87,,,,,,,fee schedule,4986.47,13014.22,
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8473.01,,,,,,,fee schedule,4986.47,13014.22,
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6786.69,,,,,,,fee schedule,4986.47,13014.22,
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,13014.22,
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11904.65,,,,,,,fee schedule,4986.47,13014.22,
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,13014.22,APC
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,13014.22,APC
Osteochondral knee autograft,27416,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,13014.22,APC
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair degenerated kneecap,27418,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of unstable kneecap,27420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12482.32,,,,,,,fee schedule,4986.47,14354.67,
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,14354.67,
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,14354.67,
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10216.78,,,,,,,fee schedule,4986.47,14354.67,
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8183.41,,,,,,,fee schedule,4986.47,14354.67,
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,14354.67,
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14354.67,,,,,,,fee schedule,4986.47,14354.67,
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,14354.67,
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,14354.67,APC
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,14354.67,APC
Revision of unstable kneecap,27422,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,14354.67,APC
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revision/removal of kneecap,27424,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Lat retinacular release open,27425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11459.93,,,,,,,fee schedule,6397.7,13178.92,
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6397.7,,,,,,,fee schedule,6397.7,13178.92,
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6397.7,,,,,,,fee schedule,6397.7,13178.92,
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9379.95,,,,,,,fee schedule,6397.7,13178.92,
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7513.13,,,,,,,fee schedule,6397.7,13178.92,
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7357.36,,,,,,,fee schedule,6397.7,13178.92,
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13178.92,,,,,,,fee schedule,6397.7,13178.92,
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6397.7,,,,,,,fee schedule,6397.7,13178.92,
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6397.7,13178.92,APC
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6397.7,13178.92,APC
Reconstruction knee,27427,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6397.7,13178.92,APC
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8916.51,23026.52,
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,8916.51,23026.52,
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,8916.51,23026.52,
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8916.51,23026.52,
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8916.51,23026.52,
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,8916.51,23026.52,
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8916.51,23026.52,
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,8916.51,23026.52,
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8916.51,23026.52,APC
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8916.51,23026.52,APC
Reconstruction knee,27428,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8916.51,23026.52,APC
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8378.58,23026.52,
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8378.58,23026.52,
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8378.58,23026.52,
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8378.58,23026.52,
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Reconstruction knee,27429,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of thigh muscles,27430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of knee joint,27435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4458.15,13014.22,
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4458.15,13014.22,
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4458.15,13014.22,
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4458.15,13014.22,
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Revise kneecap,27437,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18711.84,,,,,,,fee schedule,12267.48,23026.52,
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,12267.48,23026.52,
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,12267.48,23026.52,
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15315.64,,,,,,,fee schedule,12267.48,23026.52,
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12267.48,,,,,,,fee schedule,12267.48,23026.52,
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,12267.48,23026.52,
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21518.62,,,,,,,fee schedule,12267.48,23026.52,
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,12267.48,23026.52,
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12267.48,23026.52,APC
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12267.48,23026.52,APC
Revise kneecap with implant,27438,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12267.48,23026.52,APC
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19125.47,,,,,,,fee schedule,12538.66,23026.52,
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,12538.66,23026.52,
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,12538.66,23026.52,
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15654.2,,,,,,,fee schedule,12538.66,23026.52,
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12538.66,,,,,,,fee schedule,12538.66,23026.52,
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,12538.66,23026.52,
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21994.29,,,,,,,fee schedule,12538.66,23026.52,
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,12538.66,23026.52,
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12538.66,23026.52,APC
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12538.66,23026.52,APC
Revision of knee joint,27440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12538.66,23026.52,APC
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,4458.15,23026.52,
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,23026.52,
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,23026.52,
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,4458.15,23026.52,
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,4458.15,23026.52,
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,23026.52,
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,4458.15,23026.52,
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,23026.52,
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,4458.15,23026.52,APC
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,4458.15,23026.52,APC
Revision of knee joint,27441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,4458.15,23026.52,APC
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12315.3,,,,,,,fee schedule,8073.91,23026.52,
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,8073.91,23026.52,
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,8073.91,23026.52,
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10080.07,,,,,,,fee schedule,8073.91,23026.52,
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8073.91,,,,,,,fee schedule,8073.91,23026.52,
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,8073.91,23026.52,
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14162.6,,,,,,,fee schedule,8073.91,23026.52,
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,8073.91,23026.52,
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8073.91,23026.52,APC
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8073.91,23026.52,APC
Revision of knee joint,27442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8073.91,23026.52,APC
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8916.51,23026.52,
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,8916.51,23026.52,
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,8916.51,23026.52,
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8916.51,23026.52,
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8916.51,23026.52,
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,8916.51,23026.52,
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8916.51,23026.52,
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,8916.51,23026.52,
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8916.51,23026.52,APC
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8916.51,23026.52,APC
Revision of knee joint,27443,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8916.51,23026.52,APC
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9660.75,,,,,,,fee schedule,6333.59,23026.52,
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,6333.59,23026.52,
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,6333.59,23026.52,
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7907.32,,,,,,,fee schedule,6333.59,23026.52,
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6333.59,,,,,,,fee schedule,6333.59,23026.52,
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,6333.59,23026.52,
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11109.86,,,,,,,fee schedule,6333.59,23026.52,
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,6333.59,23026.52,
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6333.59,23026.52,APC
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6333.59,23026.52,APC
Revision of knee joint,27446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6333.59,23026.52,APC
Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20478.09,,,,,,,fee schedule,12792.51,23549.8,
Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20478.09,,,,,,,fee schedule,12792.51,23549.8,
Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23549.8,,,,,,,fee schedule,12792.51,23549.8,
Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20478.09,,,,,,,fee schedule,12792.51,23549.8,
Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23549.8,APC
Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23549.8,APC
Total knee arthroplasty,27447,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23549.8,APC
Incision of thigh,27448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of thigh,27448,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of thigh,27448,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of thigh,27450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of thigh,27450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Incision of thigh,27450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of thigh bone,27454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of thigh bone,27454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of thigh bone,27454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of knee,27455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of knee,27455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of knee,27455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of knee,27457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of knee,27457,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Realignment of knee,27457,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Osteot femur imed lngth dev,27458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Osteot femur imed lngth dev,27458,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Osteot femur imed lngth dev,27458,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Shortening of thigh bone,27465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Shortening of thigh bone,27465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Shortening of thigh bone,27465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Lengthening of thigh bone,27466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Lengthening of thigh bone,27466,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Lengthening of thigh bone,27466,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of thigh,27470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of thigh,27470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of thigh,27470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Repair/graft of thigh,27472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Repair/graft of thigh,27472,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Repair/graft of thigh,27472,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Surgery to stop leg growth,27475,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,13014.22,
Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,13014.22,
Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,13014.22,
Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,13014.22,
Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2390.75,13014.22,APC
Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2390.75,13014.22,APC
Surgery to stop leg growth,27477,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2390.75,13014.22,APC
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10270.11,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8406.09,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6733.08,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11810.63,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Surgery to stop leg growth,27479,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,13014.22,
Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,13014.22,
Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,13014.22,
Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,13014.22,
Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2390.75,13014.22,APC
Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2390.75,13014.22,APC
Surgery to stop leg growth,27485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2390.75,13014.22,APC
Revise/replace knee joint,27486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Revise/replace knee joint,27486,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Revise/replace knee joint,27486,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Revise/replace knee joint,27487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Revise/replace knee joint,27487,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Revise/replace knee joint,27487,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Removal of knee prosthesis,27488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Removal of knee prosthesis,27488,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Removal of knee prosthesis,27488,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Reinforce thigh,27495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Reinforce thigh,27495,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Reinforce thigh,27495,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of thigh/knee,27496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of thigh/knee,27497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,3965.37,
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,3965.37,
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,3965.37,
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1245.6,3965.37,
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,3965.37,
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,3965.37,
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,3965.37,APC
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,3965.37,APC
Decompression of thigh/knee,27498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,3965.37,APC
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,13014.22,
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,13014.22,
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Decompression of thigh/knee,27499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of thigh fracture,27502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treatment of thigh fracture,27503,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treatment of thigh fracture,27506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treatment of thigh fracture,27506,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treatment of thigh fracture,27506,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treatment of thigh fracture,27507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treatment of thigh fracture,27507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treatment of thigh fracture,27507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27508,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9356.37,,,,,,,fee schedule,2706.78,13014.22,
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6134.04,,,,,,,fee schedule,2706.78,13014.22,
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7658.19,,,,,,,fee schedule,2706.78,13014.22,
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10759.83,,,,,,,fee schedule,2706.78,13014.22,
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of thigh fracture,27509,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treatment of thigh fracture,27510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treatment of thigh fracture,27511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Treatment of thigh fracture,27511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Treatment of thigh fracture,27511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Treatment of thigh fracture,27513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Treatment of thigh fracture,27513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Treatment of thigh fracture,27513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Treatment of thigh fracture,27514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Treatment of thigh fracture,27514,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Treatment of thigh fracture,27514,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fx growth plate,27516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,283.36,2883.98,
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,283.36,2883.98,APC
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,283.36,2883.98,APC
Treat thigh fx growth plate,27517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,283.36,2883.98,APC
Treat thigh fx growth plate,27519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fx growth plate,27519,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat thigh fx growth plate,27519,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat kneecap fracture,27520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat kneecap fracture,27524,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat knee fracture,27530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1738.83,5868.42,
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1738.83,5868.42,
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1738.83,5868.42,
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1738.83,5868.42,
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1738.83,5868.42,
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1738.83,5868.42,APC
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1738.83,5868.42,APC
Treat knee fracture,27532,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1738.83,5868.42,APC
Treat knee fracture,27535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee fracture,27535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee fracture,27535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee fracture,27536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee fracture,27536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee fracture,27536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat knee fracture(s),27538,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat knee fracture,27540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee fracture,27540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee fracture,27540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat knee dislocation,27550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat knee dislocation,27552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat knee dislocation,27556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Treat knee dislocation,27558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat kneecap dislocation,27560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,1086.91,
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,193.4,1086.91,
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,193.4,1086.91,
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,1086.91,
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,1086.91,
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,193.4,1086.91,
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,1086.91,
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,193.4,1086.91,
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,1086.91,APC
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,1086.91,APC
Treat kneecap dislocation,27562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,1086.91,APC
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat kneecap dislocation,27566,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3199.19,,,,,,,fee schedule,1524.79,3679.07,
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1524.79,3679.07,
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1524.79,3679.07,
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2097.39,,,,,,,fee schedule,1524.79,3679.07,
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2618.54,,,,,,,fee schedule,1524.79,3679.07,
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1524.79,3679.07,
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3679.07,,,,,,,fee schedule,1524.79,3679.07,
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1524.79,3679.07,
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1524.79,3679.07,APC
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1524.79,3679.07,APC
Fixation of knee joint,27570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1524.79,3679.07,APC
Fusion of knee,27580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Fusion of knee,27580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Fusion of knee,27580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Amputate leg at thigh,27590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate leg at thigh,27590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate leg at thigh,27590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate leg at thigh,27591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate leg at thigh,27591,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate leg at thigh,27591,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate leg at thigh,27592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate leg at thigh,27592,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate leg at thigh,27592,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,27594,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,27596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,27596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,27596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate lower leg at knee,27598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate lower leg at knee,27598,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputate lower leg at knee,27598,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Leg surgery procedure,27599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Leg surgery procedure,27599,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Leg surgery procedure,27599,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of lower leg,27600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of lower leg,27601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of lower leg,27602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,1847.27,5209.69,
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Drain lower leg lesion,27603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Drain lower leg bursa,27604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,2883.98,
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of achilles tendon,27605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7762.36,,,,,,,fee schedule,2200.83,8926.71,
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2200.83,8926.71,
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2200.83,8926.71,
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5089,,,,,,,fee schedule,2200.83,8926.71,
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6353.49,,,,,,,fee schedule,2200.83,8926.71,
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2200.83,8926.71,
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8926.71,,,,,,,fee schedule,2200.83,8926.71,
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2200.83,8926.71,
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2200.83,8926.71,APC
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2200.83,8926.71,APC
Incision of achilles tendon,27606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2200.83,8926.71,APC
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat lower leg bone lesion,27607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat ankle joint,27610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of ankle joint,27612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,459.55,,,,,,,fee schedule,301.28,2962.18,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,399.5,,,,,,,fee schedule,301.28,2962.18,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,399.5,,,,,,,fee schedule,301.28,2962.18,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.28,,,,,,,fee schedule,301.28,2962.18,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.14,,,,,,,fee schedule,301.28,2962.18,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,459.43,,,,,,,fee schedule,301.28,2962.18,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,528.48,,,,,,,fee schedule,301.28,2962.18,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,399.5,,,,,,,fee schedule,301.28,2962.18,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,301.28,2962.18,APC
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,301.28,2962.18,APC
Biopsy lower leg soft tissue,27613,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,301.28,2962.18,APC
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy lower leg soft tissue,27614,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,2962.18,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Explore/treat ankle joint,27620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove ankle joint lining,27625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove ankle joint lining,27626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of tendon lesion,27630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6071.8,,,,,,,fee schedule,2417.43,6982.57,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6982.57,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,2417.43,6982.57,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3980.67,,,,,,,fee schedule,2417.43,6982.57,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4969.77,,,,,,,fee schedule,2417.43,6982.57,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,2417.43,6982.57,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6982.57,,,,,,,fee schedule,2417.43,6982.57,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,2417.43,6982.57,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,2417.43,6982.57,APC
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,2417.43,6982.57,APC
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,2417.43,6982.57,APC
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove lower leg bone lesion,27635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft leg bone lesion,27637,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Remove/graft leg bone lesion,27638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5319.07,,,,,,,fee schedule,3260.23,6116.93,
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,6116.93,
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3260.23,6116.93,
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3487.18,,,,,,,fee schedule,3260.23,6116.93,
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4353.66,,,,,,,fee schedule,3260.23,6116.93,
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3260.23,6116.93,
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6116.93,,,,,,,fee schedule,3260.23,6116.93,
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3260.23,6116.93,
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,6116.93,APC
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,6116.93,APC
Partial removal of tibia,27640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,6116.93,APC
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of fibula,27641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Resect tibia tumor,27645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Resect tibia tumor,27645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Resect tibia tumor,27645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Resect fibula tumor,27646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Resect fibula tumor,27646,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Resect fibula tumor,27646,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Resect talus/calcaneus tum,27647,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Injection for ankle x-ray,27648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,354.7,,,,,,,fee schedule,232.54,407.91,
Injection for ankle x-ray,27648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,232.54,,,,,,,fee schedule,232.54,407.91,
Injection for ankle x-ray,27648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,290.32,,,,,,,fee schedule,232.54,407.91,
Injection for ankle x-ray,27648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,407.91,,,,,,,fee schedule,232.54,407.91,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5682.37,,,,,,,fee schedule,2929.89,13014.22,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,13014.22,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2929.89,13014.22,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3725.36,,,,,,,fee schedule,2929.89,13014.22,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4651.02,,,,,,,fee schedule,2929.89,13014.22,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2929.89,13014.22,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6534.73,,,,,,,fee schedule,2929.89,13014.22,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,13014.22,
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2929.89,13014.22,APC
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2929.89,13014.22,APC
Repair achilles tendon,27650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2929.89,13014.22,APC
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft achilles tendon,27652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of achilles tendon,27654,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair leg fascia defect,27656,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of leg tendon each,27658,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2200.83,13014.22,
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2200.83,13014.22,
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2200.83,13014.22,
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2200.83,13014.22,
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2200.83,13014.22,
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2200.83,13014.22,
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2200.83,13014.22,
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2200.83,13014.22,
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2200.83,13014.22,APC
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2200.83,13014.22,APC
Repair of leg tendon each,27659,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2200.83,13014.22,APC
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of leg tendon each,27664,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of leg tendon each,27665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair lower leg tendons,27675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair lower leg tendons,27676,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11874.37,,,,,,,fee schedule,2929.89,13655.53,
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,13655.53,
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2929.89,13655.53,
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7784.84,,,,,,,fee schedule,2929.89,13655.53,
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9719.17,,,,,,,fee schedule,2929.89,13655.53,
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2929.89,13655.53,
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13655.53,,,,,,,fee schedule,2929.89,13655.53,
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,13655.53,
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2929.89,13655.53,APC
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2929.89,13655.53,APC
Release of lower leg tendon,27680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2929.89,13655.53,APC
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release of lower leg tendons,27681,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of lower leg tendon,27685,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revise lower leg tendons,27686,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13504.79,,,,,,,fee schedule,2929.89,15530.51,
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,15530.51,
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2929.89,15530.51,
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8853.74,,,,,,,fee schedule,2929.89,15530.51,
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11053.67,,,,,,,fee schedule,2929.89,15530.51,
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2929.89,15530.51,
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15530.51,,,,,,,fee schedule,2929.89,15530.51,
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,15530.51,
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2929.89,15530.51,APC
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2929.89,15530.51,APC
Revision of calf tendon,27687,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2929.89,15530.51,APC
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revise lower leg tendon,27690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Revise lower leg tendon,27691,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of ankle ligament,27695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of ankle ligaments,27696,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Repair of ankle ligament,27698,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4458.15,13014.22,
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4458.15,13014.22,
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4458.15,13014.22,
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4458.15,13014.22,
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Revision of ankle joint,27700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Reconstruction ankle joint,27703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,31447.38,APC
Reconstruction ankle joint,27703,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,31447.38,APC
Reconstruction ankle joint,27703,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,31447.38,APC
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of ankle implant,27704,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10437.51,,,,,,,fee schedule,4986.47,13014.22,
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6842.83,,,,,,,fee schedule,4986.47,13014.22,
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8543.1,,,,,,,fee schedule,4986.47,13014.22,
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4986.47,13014.22,
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12003.14,,,,,,,fee schedule,4986.47,13014.22,
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4986.47,13014.22,
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4986.47,13014.22,APC
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4986.47,13014.22,APC
Incision of tibia,27705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4986.47,13014.22,APC
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of fibula,27707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18456.53,,,,,,,fee schedule,3448.15,23026.52,
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,23026.52,
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,23026.52,
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12100.1,,,,,,,fee schedule,3448.15,23026.52,
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15106.67,,,,,,,fee schedule,3448.15,23026.52,
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,23026.52,
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21225.01,,,,,,,fee schedule,3448.15,23026.52,
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,23026.52,
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,3448.15,23026.52,APC
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,3448.15,23026.52,APC
Incision of tibia & fibula,27709,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,3448.15,23026.52,APC
Realignment of lower leg,27712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Realignment of lower leg,27712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Realignment of lower leg,27712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Osteot tibia imed lngth dev,27713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Osteot tibia imed lngth dev,27713,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Osteot tibia imed lngth dev,27713,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Revision of lower leg,27715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Revision of lower leg,27715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Revision of lower leg,27715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair of tibia,27720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Repair/graft of tibia,27722,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Repair/graft of tibia,27724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Repair/graft of tibia,27724,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Repair/graft of tibia,27724,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of lower leg,27725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of lower leg,27725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Repair of lower leg,27725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7056.45,,,,,,,fee schedule,4626.21,13014.22,
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4626.21,13014.22,
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4626.21,13014.22,
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4626.21,,,,,,,fee schedule,4626.21,13014.22,
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5775.7,,,,,,,fee schedule,4626.21,13014.22,
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4626.21,13014.22,
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8114.92,,,,,,,fee schedule,4626.21,13014.22,
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4626.21,13014.22,
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4626.21,13014.22,APC
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4626.21,13014.22,APC
Repair fibula nonunion,27726,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4626.21,13014.22,APC
Repair of lower leg,27727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Repair of lower leg,27727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Repair of lower leg,27727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of tibia epiphysis,27730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of fibula epiphysis,27732,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair lower leg epiphyses,27734,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4537.69,,,,,,,fee schedule,2974.91,5868.42,
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2974.91,5868.42,
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2974.91,5868.42,
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2974.91,,,,,,,fee schedule,2974.91,5868.42,
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3714.1,,,,,,,fee schedule,2974.91,5868.42,
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2974.91,5868.42,
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5218.34,,,,,,,fee schedule,2974.91,5868.42,
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2974.91,5868.42,
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2974.91,5868.42,APC
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2974.91,5868.42,APC
Repair of leg epiphyses,27740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2974.91,5868.42,APC
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,2182.91,5868.42,
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of leg epiphyses,27742,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8244.72,,,,,,,fee schedule,5405.24,21813.84,
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,5405.24,21813.84,
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,5405.24,21813.84,
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5405.24,,,,,,,fee schedule,5405.24,21813.84,
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6748.3,,,,,,,fee schedule,5405.24,21813.84,
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,5405.24,21813.84,
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9481.43,,,,,,,fee schedule,5405.24,21813.84,
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,5405.24,21813.84,
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5405.24,21813.84,APC
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5405.24,21813.84,APC
Reinforce tibia,27745,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5405.24,21813.84,APC
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of tibia fracture,27750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of tibia fracture,27752,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2706.78,13014.22,
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2706.78,13014.22,
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2706.78,13014.22,
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2706.78,13014.22,
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of tibia fracture,27756,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12630.22,,,,,,,fee schedule,5603.18,23026.52,
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8280.37,,,,,,,fee schedule,5603.18,23026.52,
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10337.84,,,,,,,fee schedule,5603.18,23026.52,
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5603.18,23026.52,
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14524.75,,,,,,,fee schedule,5603.18,23026.52,
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,5603.18,23026.52,APC
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,5603.18,23026.52,APC
Treatment of tibia fracture,27758,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,5603.18,23026.52,APC
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8916.51,23026.52,
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8916.51,23026.52,
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8916.51,23026.52,
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,8916.51,23026.52,
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8916.51,23026.52,
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,8916.51,23026.52,
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8916.51,23026.52,APC
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8916.51,23026.52,APC
Treatment of tibia fracture,27759,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8916.51,23026.52,APC
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,245.78,6124.23,
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,245.78,6124.23,
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,245.78,6124.23,
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,245.78,6124.23,
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,245.78,6124.23,
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,245.78,6124.23,
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,245.78,6124.23,
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,245.78,6124.23,
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,6124.23,APC
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,6124.23,APC
Cltx medial ankle fx,27760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,6124.23,APC
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8398.02,,,,,,,fee schedule,5505.74,13014.22,
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5505.74,13014.22,
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5505.74,13014.22,
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5505.74,,,,,,,fee schedule,5505.74,13014.22,
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6873.78,,,,,,,fee schedule,5505.74,13014.22,
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5505.74,13014.22,
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9657.72,,,,,,,fee schedule,5505.74,13014.22,
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5505.74,13014.22,
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5505.74,13014.22,APC
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5505.74,13014.22,APC
Optx medial ankle fx,27766,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5505.74,13014.22,APC
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Cltx post ankle fx,27767,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,224.08,2883.98,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,224.08,2883.98,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,224.08,2883.98,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,224.08,2883.98,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,224.08,2883.98,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,224.08,2883.98,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,224.08,2883.98,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,224.08,2883.98,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,224.08,2883.98,APC
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,224.08,2883.98,APC
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,224.08,2883.98,APC
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Optx post ankle fx,27769,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of fibula fracture,27780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,945.14,2883.98,
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,945.14,2883.98,
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,945.14,2883.98,
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,2883.98,
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,945.14,2883.98,
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of fibula fracture,27781,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treatment of fibula fracture,27784,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27786,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27788,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7764.35,,,,,,,fee schedule,5090.31,13014.22,
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5090.31,13014.22,
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5090.31,13014.22,
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5090.31,,,,,,,fee schedule,5090.31,13014.22,
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6355.12,,,,,,,fee schedule,5090.31,13014.22,
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5090.31,13014.22,
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8929,,,,,,,fee schedule,5090.31,13014.22,
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5090.31,13014.22,
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5090.31,13014.22,APC
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5090.31,13014.22,APC
Treatment of ankle fracture,27792,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5090.31,13014.22,APC
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of ankle fracture,27810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10273.47,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6735.29,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8408.84,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11814.49,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5603.18,13014.22,APC
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5603.18,13014.22,APC
Treatment of ankle fracture,27814,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5603.18,13014.22,APC
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,2883.98,
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of ankle fracture,27818,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,945.14,2883.98,APC
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10354.37,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6788.32,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8475.05,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11907.53,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,13014.22,
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5603.18,13014.22,APC
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5603.18,13014.22,APC
Treatment of ankle fracture,27822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5603.18,13014.22,APC
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,4745.33,13014.22,
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,4745.33,13014.22,
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treatment of ankle fracture,27823,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat lower leg fracture,27824,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5579.99,,,,,,,fee schedule,1602.21,6416.99,
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1602.21,6416.99,
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1602.21,6416.99,
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.24,,,,,,,fee schedule,1602.21,6416.99,
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.22,,,,,,,fee schedule,1602.21,6416.99,
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1602.21,6416.99,
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6416.99,,,,,,,fee schedule,1602.21,6416.99,
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1602.21,6416.99,
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,6416.99,APC
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,6416.99,APC
Treat lower leg fracture,27825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,6416.99,APC
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg fracture,27826,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10928.55,,,,,,,fee schedule,7164.76,23026.52,
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,7164.76,23026.52,
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,7164.76,23026.52,
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7164.76,,,,,,,fee schedule,7164.76,23026.52,
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8945.02,,,,,,,fee schedule,7164.76,23026.52,
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,7164.76,23026.52,
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12567.83,,,,,,,fee schedule,7164.76,23026.52,
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,7164.76,23026.52,
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,7164.76,23026.52,APC
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,7164.76,23026.52,APC
Treat lower leg fracture,27827,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,7164.76,23026.52,APC
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14444.49,,,,,,,fee schedule,9469.81,23026.52,
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,9469.81,23026.52,
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,9469.81,23026.52,
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9469.81,,,,,,,fee schedule,9469.81,23026.52,
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11822.82,,,,,,,fee schedule,9469.81,23026.52,
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,9469.81,23026.52,
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16611.16,,,,,,,fee schedule,9469.81,23026.52,
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,9469.81,23026.52,
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,9469.81,23026.52,APC
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,9469.81,23026.52,APC
Treat lower leg fracture,27828,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,9469.81,23026.52,APC
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg joint,27829,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat lower leg dislocation,27830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,945.14,5868.42,
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,5868.42,
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,945.14,5868.42,
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,945.14,5868.42,
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,945.14,5868.42,
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,945.14,5868.42,
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,945.14,5868.42,
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,945.14,5868.42,
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,945.14,5868.42,APC
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,945.14,5868.42,APC
Treat lower leg dislocation,27831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,945.14,5868.42,APC
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat lower leg dislocation,27832,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat ankle dislocation,27840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1245.6,2883.98,
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1245.6,2883.98,
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat ankle dislocation,27842,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat ankle dislocation,27846,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat ankle dislocation,27848,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8506.58,,,,,,,fee schedule,1524.79,9782.57,
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1524.79,,,,,,,fee schedule,1524.79,9782.57,
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.79,,,,,,,fee schedule,1524.79,9782.57,
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5576.91,,,,,,,fee schedule,1524.79,9782.57,
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6962.64,,,,,,,fee schedule,1524.79,9782.57,
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1753.51,,,,,,,fee schedule,1524.79,9782.57,
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9782.57,,,,,,,fee schedule,1524.79,9782.57,
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1524.79,,,,,,,fee schedule,1524.79,9782.57,
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1524.79,9782.57,APC
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1524.79,9782.57,APC
Fixation of ankle joint,27860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1524.79,9782.57,APC
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12381.39,,,,,,,fee schedule,8117.24,23026.52,
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8117.24,23026.52,
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8117.24,23026.52,
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8117.24,,,,,,,fee schedule,8117.24,23026.52,
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10134.17,,,,,,,fee schedule,8117.24,23026.52,
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8117.24,23026.52,
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14238.6,,,,,,,fee schedule,8117.24,23026.52,
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8117.24,23026.52,
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8117.24,23026.52,APC
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8117.24,23026.52,APC
Fusion of ankle joint open,27870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8117.24,23026.52,APC
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18000.15,,,,,,,fee schedule,8378.58,23026.52,
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11800.9,,,,,,,fee schedule,8378.58,23026.52,
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14733.12,,,,,,,fee schedule,8378.58,23026.52,
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20700.17,,,,,,,fee schedule,8378.58,23026.52,
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Fusion of tibiofibular joint,27871,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Amputation of lower leg,27880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of lower leg,27880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of lower leg,27880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Amputation of lower leg,27881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of lower leg,27881,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of lower leg,27881,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of lower leg,27882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of lower leg,27882,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of lower leg,27882,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,27884,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation follow-up surgery,27886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,27886,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation follow-up surgery,27886,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of foot at ankle,27888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of foot at ankle,27888,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of foot at ankle,27888,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Amputation of foot at ankle,27889,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,2182.91,5868.42,
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,2182.91,5868.42,
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of leg,27892,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3448.15,13014.22,
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3448.15,13014.22,
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3448.15,13014.22,
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,3448.15,13014.22,
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3448.15,13014.22,
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,3448.15,13014.22,
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3448.15,13014.22,APC
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3448.15,13014.22,APC
Decompression of leg,27893,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3448.15,13014.22,APC
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,5868.42,
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3448.15,,,,,,,fee schedule,1245.6,5868.42,
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3965.37,,,,,,,fee schedule,1245.6,5868.42,
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3448.15,,,,,,,fee schedule,1245.6,5868.42,
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Decompression of leg,27894,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Leg/ankle surgery procedure,27899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Leg/ankle surgery procedure,27899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Leg/ankle surgery procedure,27899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,485.99,,,,,,,fee schedule,318.62,2962.18,
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434.94,,,,,,,fee schedule,318.62,2962.18,
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,434.94,,,,,,,fee schedule,318.62,2962.18,
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.62,,,,,,,fee schedule,318.62,2962.18,
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.78,,,,,,,fee schedule,318.62,2962.18,
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,500.18,,,,,,,fee schedule,318.62,2962.18,
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,558.89,,,,,,,fee schedule,318.62,2962.18,
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,434.94,,,,,,,fee schedule,318.62,2962.18,
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,318.62,2962.18,APC
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,318.62,2962.18,APC
Drainage of bursa of foot,28001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,318.62,2962.18,APC
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,1602.21,3829.09,
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,1602.21,3829.09,
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Treatment of foot infection,28002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2530.95,,,,,,,fee schedule,2182.91,5868.42,
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2200.83,,,,,,,fee schedule,2182.91,5868.42,
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treatment of foot infection,28003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat foot bone lesion,28005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6704.26,,,,,,,fee schedule,2310.4,7709.9,
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,7709.9,
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,7709.9,
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4395.31,,,,,,,fee schedule,2310.4,7709.9,
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5487.44,,,,,,,fee schedule,2310.4,7709.9,
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,7709.9,
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7709.9,,,,,,,fee schedule,2310.4,7709.9,
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,7709.9,
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2310.4,7709.9,APC
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2310.4,7709.9,APC
Incision of foot fascia,28008,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2310.4,7709.9,APC
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,338.05,,,,,,,fee schedule,221.63,2883.98,
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,297.44,,,,,,,fee schedule,221.63,2883.98,
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,297.44,,,,,,,fee schedule,221.63,2883.98,
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,221.63,,,,,,,fee schedule,221.63,2883.98,
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,276.69,,,,,,,fee schedule,221.63,2883.98,
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,342.06,,,,,,,fee schedule,221.63,2883.98,
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,388.76,,,,,,,fee schedule,221.63,2883.98,
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,297.44,,,,,,,fee schedule,221.63,2883.98,
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,221.63,2883.98,APC
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,221.63,2883.98,APC
Incision of toe tendon,28010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,221.63,2883.98,APC
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,2883.98,
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of toe tendons,28011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of foot joint,28020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of foot joint,28022,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1602.21,3829.09,
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1602.21,3829.09,
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1602.21,3829.09,
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1602.21,3829.09,
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Exploration of toe joint,28024,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Decompression of tibia nerve,28035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,933.69,2962.18,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of foot joint lining,28050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of foot joint lining,28052,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Biopsy of toe joint lining,28054,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Neurectomy foot,28055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal foot fascia,28060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot fascia,28062,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,13014.22,
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of foot joint lining,28070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot joint lining,28072,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1245.6,2883.98,
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1245.6,2883.98,
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of foot lesion,28080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Excise foot tendon sheath,28086,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,5868.42,
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Excise foot tendon sheath,28088,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1602.21,3829.09,
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1602.21,3829.09,
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1602.21,3829.09,
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1602.21,3829.09,
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Removal of foot lesion,28090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of toe lesions,28092,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of ankle/heel lesion,28100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Remove/graft foot lesion,28102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9022.37,,,,,,,fee schedule,5915.07,13014.22,
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,5915.07,13014.22,
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,5915.07,13014.22,
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7384.81,,,,,,,fee schedule,5915.07,13014.22,
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5915.07,,,,,,,fee schedule,5915.07,13014.22,
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,5915.07,13014.22,
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10375.73,,,,,,,fee schedule,5915.07,13014.22,
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,5915.07,13014.22,
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5915.07,13014.22,APC
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5915.07,13014.22,APC
Remove/graft foot lesion,28103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5915.07,13014.22,APC
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of foot lesion,28104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Remove/graft foot lesion,28106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11459.91,,,,,,,fee schedule,6916.07,13178.9,
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,13178.9,
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6916.07,13178.9,
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9379.94,,,,,,,fee schedule,6916.07,13178.9,
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7513.12,,,,,,,fee schedule,6916.07,13178.9,
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6916.07,13178.9,
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13178.9,,,,,,,fee schedule,6916.07,13178.9,
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,13178.9,
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6916.07,13178.9,APC
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6916.07,13178.9,APC
Remove/graft foot lesion,28107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6916.07,13178.9,APC
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of toe lesions,28108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10437.49,,,,,,,fee schedule,2310.4,12003.11,
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,12003.11,
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,12003.11,
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8543.09,,,,,,,fee schedule,2310.4,12003.11,
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6842.82,,,,,,,fee schedule,2310.4,12003.11,
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,12003.11,
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12003.11,,,,,,,fee schedule,2310.4,12003.11,
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,12003.11,
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2310.4,12003.11,APC
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2310.4,12003.11,APC
Part removal of metatarsal,28110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2310.4,12003.11,APC
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of metatarsal,28111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of metatarsal,28112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of metatarsal,28113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of metatarsal heads,28114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11459.91,,,,,,,fee schedule,2310.4,13178.9,
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13178.9,
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,13178.9,
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9379.94,,,,,,,fee schedule,2310.4,13178.9,
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7513.12,,,,,,,fee schedule,2310.4,13178.9,
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,13178.9,
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13178.9,,,,,,,fee schedule,2310.4,13178.9,
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13178.9,
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2310.4,13178.9,APC
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2310.4,13178.9,APC
Revision of foot,28116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2310.4,13178.9,APC
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7370.26,,,,,,,fee schedule,2310.4,8475.8,
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,8475.8,
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,8475.8,
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6032.56,,,,,,,fee schedule,2310.4,8475.8,
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4831.94,,,,,,,fee schedule,2310.4,8475.8,
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,8475.8,
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8475.8,,,,,,,fee schedule,2310.4,8475.8,
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,8475.8,
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2310.4,8475.8,APC
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2310.4,8475.8,APC
Removal of heel bone,28118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2310.4,8475.8,APC
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of heel spur,28119,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Part removal of ankle/heel,28120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3716.46,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3041.92,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2436.51,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4273.93,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2310.4,5868.42,APC
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2310.4,5868.42,APC
Partial removal of foot bone,28122,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2310.4,5868.42,APC
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,822.11,,,,,,,fee schedule,538.98,5868.42,
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,708.18,,,,,,,fee schedule,538.98,5868.42,
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,708.18,,,,,,,fee schedule,538.98,5868.42,
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,672.9,,,,,,,fee schedule,538.98,5868.42,
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,538.98,,,,,,,fee schedule,538.98,5868.42,
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,814.41,,,,,,,fee schedule,538.98,5868.42,
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,945.43,,,,,,,fee schedule,538.98,5868.42,
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,708.18,,,,,,,fee schedule,538.98,5868.42,
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,538.98,5868.42,APC
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,538.98,5868.42,APC
Partial removal of toe,28124,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,538.98,5868.42,APC
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of toe,28126,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,13014.22,
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of ankle bone,28130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of metatarsal,28140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of toe,28150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,5868.42,
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Partial removal of toe,28153,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of toe,28160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Resect tarsal tumor,28171,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Resect metatarsal tumor,28173,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,2883.98,
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Resect phalanx of toe tumor,28175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,433.47,6124.23,
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,433.47,,,,,,,fee schedule,433.47,6124.23,
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,433.47,,,,,,,fee schedule,433.47,6124.23,
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,433.47,6124.23,
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,433.47,6124.23,
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,498.49,,,,,,,fee schedule,433.47,6124.23,
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,433.47,6124.23,
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,433.47,,,,,,,fee schedule,433.47,6124.23,
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,433.47,6124.23,APC
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,433.47,6124.23,APC
Removal of foot foreign body,28190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,433.47,6124.23,APC
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Removal of foot foreign body,28192,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1095.32,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,933.69,2962.18,
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Removal of foot foreign body,28193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of foot tendon,28200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2310.4,13014.22,
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2310.4,13014.22,
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2310.4,13014.22,
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,13014.22,
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2310.4,13014.22,
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2310.4,13014.22,APC
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2310.4,13014.22,APC
Repair/graft of foot tendon,28202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2310.4,13014.22,APC
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of foot tendon,28208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair/graft of foot tendon,28210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,783.9,,,,,,,fee schedule,513.92,2883.98,
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,688.28,,,,,,,fee schedule,513.92,2883.98,
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,688.28,,,,,,,fee schedule,513.92,2883.98,
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,641.62,,,,,,,fee schedule,513.92,2883.98,
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,513.92,,,,,,,fee schedule,513.92,2883.98,
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,791.52,,,,,,,fee schedule,513.92,2883.98,
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,901.49,,,,,,,fee schedule,513.92,2883.98,
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,688.28,,,,,,,fee schedule,513.92,2883.98,
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,513.92,2883.98,APC
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,513.92,2883.98,APC
Release of foot tendon,28220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,513.92,2883.98,APC
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release of foot tendons,28222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release of foot tendon,28225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,5868.42,
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Release of foot tendons,28226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,769.19,,,,,,,fee schedule,504.28,2883.98,
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,681.35,,,,,,,fee schedule,504.28,2883.98,
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,681.35,,,,,,,fee schedule,504.28,2883.98,
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,629.58,,,,,,,fee schedule,504.28,2883.98,
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,504.28,,,,,,,fee schedule,504.28,2883.98,
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,783.55,,,,,,,fee schedule,504.28,2883.98,
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,884.57,,,,,,,fee schedule,504.28,2883.98,
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,681.35,,,,,,,fee schedule,504.28,2883.98,
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,504.28,2883.98,APC
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,504.28,2883.98,APC
Incision of foot tendon(s),28230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,504.28,2883.98,APC
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,619.97,6124.23,
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,619.97,,,,,,,fee schedule,619.97,6124.23,
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,619.97,,,,,,,fee schedule,619.97,6124.23,
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,619.97,6124.23,
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,619.97,6124.23,
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,712.97,,,,,,,fee schedule,619.97,6124.23,
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,619.97,6124.23,
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,619.97,,,,,,,fee schedule,619.97,6124.23,
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,619.97,6124.23,APC
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,619.97,6124.23,APC
Incision of toe tendon,28232,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,619.97,6124.23,APC
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,2883.98,
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,2883.98,
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Incision of foot tendon,28234,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7686.35,,,,,,,fee schedule,5039.17,13014.22,
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6397.7,,,,,,,fee schedule,5039.17,13014.22,
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6397.7,,,,,,,fee schedule,5039.17,13014.22,
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6291.28,,,,,,,fee schedule,5039.17,13014.22,
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5039.17,,,,,,,fee schedule,5039.17,13014.22,
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7357.36,,,,,,,fee schedule,5039.17,13014.22,
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8839.3,,,,,,,fee schedule,5039.17,13014.22,
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6397.7,,,,,,,fee schedule,5039.17,13014.22,
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5039.17,13014.22,APC
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5039.17,13014.22,APC
Revision of foot tendon,28238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5039.17,13014.22,APC
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release of big toe,28240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of foot fascia,28250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1245.6,5868.42,
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1245.6,5868.42,
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Release of midfoot joint,28260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1602.21,3829.09,
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1602.21,3829.09,
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1602.21,3829.09,
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1602.21,3829.09,
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1602.21,3829.09,
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1602.21,3829.09,
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1602.21,3829.09,
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1602.21,3829.09,
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3829.09,APC
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3829.09,APC
Revision of foot tendon,28261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3829.09,APC
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2310.4,13014.22,
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2310.4,13014.22,
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2310.4,13014.22,
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,13014.22,
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2310.4,13014.22,
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2310.4,13014.22,APC
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2310.4,13014.22,APC
Revision of foot and ankle,28262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2310.4,13014.22,APC
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,7953.48,
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,1245.6,7953.48,
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,1245.6,7953.48,
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,7953.48,
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,7953.48,
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,1245.6,7953.48,
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,7953.48,
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,1245.6,7953.48,
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,7953.48,APC
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,7953.48,APC
Release of midfoot joint,28264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,7953.48,APC
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Release of foot contracture,28270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,704.5,,,,,,,fee schedule,461.87,2883.98,
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,621.71,,,,,,,fee schedule,461.87,2883.98,
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,621.71,,,,,,,fee schedule,461.87,2883.98,
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,576.63,,,,,,,fee schedule,461.87,2883.98,
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,461.87,,,,,,,fee schedule,461.87,2883.98,
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,714.97,,,,,,,fee schedule,461.87,2883.98,
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,810.18,,,,,,,fee schedule,461.87,2883.98,
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,621.71,,,,,,,fee schedule,461.87,2883.98,
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,461.87,2883.98,APC
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,461.87,2883.98,APC
Release of toe joint each,28272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,461.87,2883.98,APC
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of toes,28280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3716.46,,,,,,,fee schedule,2310.4,5868.42,
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3041.92,,,,,,,fee schedule,2310.4,5868.42,
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2436.51,,,,,,,fee schedule,2310.4,5868.42,
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,5868.42,
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4273.93,,,,,,,fee schedule,2310.4,5868.42,
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2310.4,5868.42,APC
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2310.4,5868.42,APC
Repair of hammertoe,28285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2310.4,5868.42,APC
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of hammertoe,28286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3716.46,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3041.92,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2436.51,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4273.93,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2310.4,5868.42,APC
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2310.4,5868.42,APC
Partial removal of foot bone,28288,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2310.4,5868.42,APC
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9759.14,,,,,,,fee schedule,6398.09,13014.22,
Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6398.09,,,,,,,fee schedule,6398.09,13014.22,
Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7987.86,,,,,,,fee schedule,6398.09,13014.22,
Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11223.01,,,,,,,fee schedule,6398.09,13014.22,
Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6398.09,13014.22,APC
Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6398.09,13014.22,APC
Corrj halux rigdus w/implt,28291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6398.09,13014.22,APC
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Correction hallux valgus,28292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4489.36,,,,,,,fee schedule,2943.22,5868.42,
Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2943.22,,,,,,,fee schedule,2943.22,5868.42,
Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3674.54,,,,,,,fee schedule,2943.22,5868.42,
Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5162.76,,,,,,,fee schedule,2943.22,5868.42,
Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2943.22,5868.42,APC
Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2943.22,5868.42,APC
Correction hallux valgus,28295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2943.22,5868.42,APC
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Correction hallux valgus,28296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3546.67,23026.52,
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3546.67,,,,,,,fee schedule,3546.67,23026.52,
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3546.67,,,,,,,fee schedule,3546.67,23026.52,
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3546.67,23026.52,
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3546.67,23026.52,
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4078.67,,,,,,,fee schedule,3546.67,23026.52,
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3546.67,23026.52,
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3546.67,,,,,,,fee schedule,3546.67,23026.52,
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,3546.67,23026.52,APC
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,3546.67,23026.52,APC
Correction hallux valgus,28297,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,3546.67,23026.52,APC
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,3546.67,13014.22,
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3546.67,,,,,,,fee schedule,3546.67,13014.22,
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3546.67,,,,,,,fee schedule,3546.67,13014.22,
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,3546.67,13014.22,
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,3546.67,13014.22,
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4078.67,,,,,,,fee schedule,3546.67,13014.22,
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,3546.67,13014.22,
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3546.67,,,,,,,fee schedule,3546.67,13014.22,
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3546.67,13014.22,APC
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3546.67,13014.22,APC
Correction hallux valgus,28298,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3546.67,13014.22,APC
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,13014.22,
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,13014.22,
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,13014.22,
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,13014.22,
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Correction hallux valgus,28299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16041.63,,,,,,,fee schedule,6916.07,18447.87,
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,18447.87,
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6916.07,18447.87,
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10516.89,,,,,,,fee schedule,6916.07,18447.87,
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13130.07,,,,,,,fee schedule,6916.07,18447.87,
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6916.07,18447.87,
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18447.87,,,,,,,fee schedule,6916.07,18447.87,
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,18447.87,
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6916.07,18447.87,APC
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6916.07,18447.87,APC
Incision of heel bone,28300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6916.07,18447.87,APC
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2310.4,13014.22,
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2310.4,13014.22,
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2310.4,13014.22,
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,13014.22,
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2310.4,13014.22,
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2310.4,13014.22,APC
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2310.4,13014.22,APC
Incision of ankle bone,28302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2310.4,13014.22,APC
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7357.36,,,,,,,fee schedule,4745.33,13014.22,
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Incision of midfoot bones,28304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9816.93,,,,,,,fee schedule,6435.98,13014.22,
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6435.98,13014.22,
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6435.98,13014.22,
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6435.98,,,,,,,fee schedule,6435.98,13014.22,
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8035.16,,,,,,,fee schedule,6435.98,13014.22,
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6435.98,13014.22,
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11289.47,,,,,,,fee schedule,6435.98,13014.22,
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6435.98,13014.22,
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6435.98,13014.22,APC
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6435.98,13014.22,APC
Incise/graft midfoot bones,28305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6435.98,13014.22,APC
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2310.4,13014.22,
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2310.4,13014.22,
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2310.4,13014.22,
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,13014.22,
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2310.4,13014.22,
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2310.4,13014.22,APC
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2310.4,13014.22,APC
Incision of metatarsal,28306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2310.4,13014.22,APC
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,13014.22,
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Incision of metatarsal,28307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of metatarsal,28308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7357.36,,,,,,,fee schedule,4745.33,13014.22,
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6397.7,,,,,,,fee schedule,4745.33,13014.22,
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Incision of metatarsals,28309,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,13014.22,
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,13014.22,
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of big toe,28310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Revision of toe,28312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair deformity of toe,28313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Removal of sesamoid bone,28315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,6916.07,23026.52,
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,6916.07,23026.52,
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,6916.07,23026.52,
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6916.07,23026.52,
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,6916.07,23026.52,
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6916.07,23026.52,APC
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6916.07,23026.52,APC
Repair of foot bones,28320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6916.07,23026.52,APC
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2310.4,13014.22,
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2310.4,13014.22,
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2310.4,13014.22,
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,13014.22,
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2310.4,13014.22,
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2310.4,13014.22,APC
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2310.4,13014.22,APC
Repair of metatarsals,28322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2310.4,13014.22,APC
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Resect enlarged toe tissue,28340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Resect enlarged toe,28341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair extra toe(s),28344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17083.19,,,,,,,fee schedule,1602.21,19645.67,
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,1602.21,19645.67,
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,1602.21,19645.67,
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11199.74,,,,,,,fee schedule,1602.21,19645.67,
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13982.59,,,,,,,fee schedule,1602.21,19645.67,
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,1602.21,19645.67,
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19645.67,,,,,,,fee schedule,1602.21,19645.67,
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,1602.21,19645.67,
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,19645.67,APC
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,19645.67,APC
Repair webbed toe(s),28345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,19645.67,APC
Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Reconstruct cleft foot,28360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of heel fracture,28400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,1086.91,
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,945.14,,,,,,,fee schedule,193.4,1086.91,
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.14,,,,,,,fee schedule,193.4,1086.91,
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,1086.91,
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,1086.91,
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.91,,,,,,,fee schedule,193.4,1086.91,
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,1086.91,
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.14,,,,,,,fee schedule,193.4,1086.91,
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,1086.91,APC
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,1086.91,APC
Treatment of heel fracture,28405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,1086.91,APC
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2706.78,13014.22,
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2706.78,13014.22,
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2706.78,13014.22,
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2706.78,13014.22,
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of heel fracture,28406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7705.41,,,,,,,fee schedule,5051.67,13014.22,
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10009.92,,,,,,,fee schedule,5051.67,13014.22,
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10009.92,,,,,,,fee schedule,5051.67,13014.22,
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5051.67,,,,,,,fee schedule,5051.67,13014.22,
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6306.88,,,,,,,fee schedule,5051.67,13014.22,
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11511.41,,,,,,,fee schedule,5051.67,13014.22,
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8861.22,,,,,,,fee schedule,5051.67,13014.22,
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10009.92,,,,,,,fee schedule,5051.67,13014.22,
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5051.67,13014.22,APC
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5051.67,13014.22,APC
Treat heel fracture,28415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5051.67,13014.22,APC
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18309.8,,,,,,,fee schedule,5603.18,23026.52,
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12003.9,,,,,,,fee schedule,5603.18,23026.52,
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14986.57,,,,,,,fee schedule,5603.18,23026.52,
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5603.18,23026.52,
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21056.27,,,,,,,fee schedule,5603.18,23026.52,
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5603.18,23026.52,
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,5603.18,23026.52,APC
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,5603.18,23026.52,APC
Treat/graft heel fracture,28420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,5603.18,23026.52,APC
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,28430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of ankle fracture,28435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10169.87,,,,,,,fee schedule,2706.78,13014.22,
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6667.37,,,,,,,fee schedule,2706.78,13014.22,
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8324.04,,,,,,,fee schedule,2706.78,13014.22,
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11695.35,,,,,,,fee schedule,2706.78,13014.22,
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treatment of ankle fracture,28436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7764.36,,,,,,,fee schedule,5090.31,13014.22,
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5090.31,13014.22,
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5090.31,13014.22,
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5090.31,,,,,,,fee schedule,5090.31,13014.22,
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6355.13,,,,,,,fee schedule,5090.31,13014.22,
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5090.31,13014.22,
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8929.01,,,,,,,fee schedule,5090.31,13014.22,
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5090.31,13014.22,
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5090.31,13014.22,APC
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5090.31,13014.22,APC
Treat ankle fracture,28445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5090.31,13014.22,APC
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,4745.33,13014.22,
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Osteochondral talus autogrft,28446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat midfoot fracture each,28450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,452.69,,,,,,,fee schedule,224.08,2883.98,
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,224.08,2883.98,
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,224.08,2883.98,
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,296.78,,,,,,,fee schedule,224.08,2883.98,
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,370.53,,,,,,,fee schedule,224.08,2883.98,
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,224.08,2883.98,
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,520.59,,,,,,,fee schedule,224.08,2883.98,
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,224.08,2883.98,
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,224.08,2883.98,APC
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,224.08,2883.98,APC
Treat midfoot fracture each,28455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,224.08,2883.98,APC
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2706.78,13014.22,
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2706.78,13014.22,
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2706.78,13014.22,
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2706.78,13014.22,
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treat midfoot fracture,28456,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat midfoot fracture each,28465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat metatarsal fracture,28470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat metatarsal fracture,28475,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat metatarsal fracture,28476,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Treat metatarsal fracture,28485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,278.24,,,,,,,fee schedule,182.41,442.4,
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,182.41,442.4,
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,182.41,442.4,
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.41,,,,,,,fee schedule,182.41,442.4,
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.74,,,,,,,fee schedule,182.41,442.4,
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,182.41,442.4,
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.98,,,,,,,fee schedule,182.41,442.4,
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,182.41,442.4,
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,182.41,442.4,APC
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,182.41,442.4,APC
Treat big toe fracture,28490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,182.41,442.4,APC
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.36,,,,,,,fee schedule,193.4,442.4,
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.86,,,,,,,fee schedule,193.4,442.4,
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.36,,,,,,,fee schedule,193.4,442.4,
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat big toe fracture,28495,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7370.26,,,,,,,fee schedule,2706.78,8475.8,
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,8475.8,
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,8475.8,
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4831.94,,,,,,,fee schedule,2706.78,8475.8,
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6032.56,,,,,,,fee schedule,2706.78,8475.8,
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,8475.8,
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8475.8,,,,,,,fee schedule,2706.78,8475.8,
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,8475.8,
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2706.78,8475.8,APC
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2706.78,8475.8,APC
Treat big toe fracture,28496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2706.78,8475.8,APC
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat big toe fracture,28505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,219.47,,,,,,,fee schedule,143.88,442.4,
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.54,,,,,,,fee schedule,143.88,442.4,
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,194.54,,,,,,,fee schedule,143.88,442.4,
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.88,,,,,,,fee schedule,143.88,442.4,
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,179.64,,,,,,,fee schedule,143.88,442.4,
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,223.72,,,,,,,fee schedule,143.88,442.4,
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,252.39,,,,,,,fee schedule,143.88,442.4,
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194.54,,,,,,,fee schedule,143.88,442.4,
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,143.88,442.4,APC
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,143.88,442.4,APC
Treatment of toe fracture,28510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,143.88,442.4,APC
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.84,,,,,,,fee schedule,245.78,7300.02,
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.2,,,,,,,fee schedule,245.78,7300.02,
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,254.2,,,,,,,fee schedule,245.78,7300.02,
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.64,,,,,,,fee schedule,245.78,7300.02,
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.71,,,,,,,fee schedule,245.78,7300.02,
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.33,,,,,,,fee schedule,245.78,7300.02,
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.02,,,,,,,fee schedule,245.78,7300.02,
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.2,,,,,,,fee schedule,245.78,7300.02,
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,7300.02,APC
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,7300.02,APC
Treatment of toe fracture,28515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,7300.02,APC
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat toe fracture,28525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.78,,,,,,,fee schedule,134.25,442.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.71,,,,,,,fee schedule,134.25,442.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,180.71,,,,,,,fee schedule,134.25,442.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.25,,,,,,,fee schedule,134.25,442.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.61,,,,,,,fee schedule,134.25,442.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,207.82,,,,,,,fee schedule,134.25,442.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.5,,,,,,,fee schedule,134.25,442.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,180.71,,,,,,,fee schedule,134.25,442.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,134.25,442.4,APC
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,134.25,442.4,APC
Treat sesamoid bone fracture,28530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,134.25,442.4,APC
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2706.78,13014.22,
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2706.78,13014.22,
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2706.78,13014.22,
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2706.78,13014.22,
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Treat sesamoid bone fracture,28531,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4573.91,,,,,,,fee schedule,2706.78,5868.42,
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,5868.42,
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,5868.42,
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2998.66,,,,,,,fee schedule,2706.78,5868.42,
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3743.75,,,,,,,fee schedule,2706.78,5868.42,
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,5868.42,
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5260,,,,,,,fee schedule,2706.78,5868.42,
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,5868.42,
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2706.78,5868.42,APC
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2706.78,5868.42,APC
Treat foot dislocation,28545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2706.78,5868.42,APC
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,3112.8,
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,1245.6,3112.8,
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,1245.6,3112.8,
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,3112.8,
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,3112.8,
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,1245.6,3112.8,
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,3112.8,
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,1245.6,3112.8,
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,3112.8,APC
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,3112.8,APC
Treat foot dislocation,28546,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,3112.8,APC
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,4745.33,13014.22,
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,4745.33,13014.22,
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Repair foot dislocation,28555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.23,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,241.23,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,277.41,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,241.23,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,1738.83,5868.42,
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,1738.83,5868.42,
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,1738.83,5868.42,
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1738.83,5868.42,
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,1738.83,5868.42,
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1738.83,5868.42,
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1738.83,5868.42,APC
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1738.83,5868.42,APC
Treat foot dislocation,28575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1738.83,5868.42,APC
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,13014.22,
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,1245.6,13014.22,
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,1245.6,13014.22,
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,13014.22,
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,13014.22,
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,1245.6,13014.22,
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,13014.22,
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,1245.6,13014.22,
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,1245.6,13014.22,APC
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,1245.6,13014.22,APC
Treat foot dislocation,28576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,1245.6,13014.22,APC
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9835.38,,,,,,,fee schedule,2706.78,13014.22,
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6448.08,,,,,,,fee schedule,2706.78,13014.22,
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8050.26,,,,,,,fee schedule,2706.78,13014.22,
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2706.78,13014.22,
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11310.69,,,,,,,fee schedule,2706.78,13014.22,
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2706.78,13014.22,
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2706.78,13014.22,APC
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2706.78,13014.22,APC
Repair foot dislocation,28585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2706.78,13014.22,APC
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.4,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.46,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.69,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.25,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.08,,,,,,,fee schedule,193.4,442.4,
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,193.4,442.4,APC
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat foot dislocation,28606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7686.35,,,,,,,fee schedule,5039.17,13014.22,
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5603.18,,,,,,,fee schedule,5039.17,13014.22,
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5603.18,,,,,,,fee schedule,5039.17,13014.22,
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5039.17,,,,,,,fee schedule,5039.17,13014.22,
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6291.28,,,,,,,fee schedule,5039.17,13014.22,
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6443.66,,,,,,,fee schedule,5039.17,13014.22,
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8839.3,,,,,,,fee schedule,5039.17,13014.22,
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5603.18,,,,,,,fee schedule,5039.17,13014.22,
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5039.17,13014.22,APC
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5039.17,13014.22,APC
Repair foot dislocation,28615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5039.17,13014.22,APC
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.78,,,,,,,fee schedule,165.72,442.4,
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,217.88,,,,,,,fee schedule,165.72,442.4,
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.88,,,,,,,fee schedule,165.72,442.4,
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.72,,,,,,,fee schedule,165.72,442.4,
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.9,,,,,,,fee schedule,165.72,442.4,
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.56,,,,,,,fee schedule,165.72,442.4,
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.7,,,,,,,fee schedule,165.72,442.4,
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.88,,,,,,,fee schedule,165.72,442.4,
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,165.72,442.4,APC
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,165.72,442.4,APC
Treat toe dislocation,28630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,165.72,442.4,APC
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,2883.98,
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,2883.98,
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,2883.98,
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1999.65,,,,,,,fee schedule,1245.6,2883.98,
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,2883.98,
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1738.83,,,,,,,fee schedule,1245.6,2883.98,
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,2883.98,APC
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,2883.98,APC
Treat toe dislocation,28635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,2883.98,APC
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat toe dislocation,28636,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair toe dislocation,28645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,186.18,,,,,,,fee schedule,122.06,442.4,
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.23,,,,,,,fee schedule,122.06,442.4,
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.23,,,,,,,fee schedule,122.06,442.4,
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.06,,,,,,,fee schedule,122.06,442.4,
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,152.39,,,,,,,fee schedule,122.06,442.4,
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.86,,,,,,,fee schedule,122.06,442.4,
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,214.11,,,,,,,fee schedule,122.06,442.4,
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.23,,,,,,,fee schedule,122.06,442.4,
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,122.06,442.4,APC
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,122.06,442.4,APC
Treat toe dislocation,28660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,122.06,442.4,APC
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Treat toe dislocation,28665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Treat toe dislocation,28666,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3112.8,,,,,,,fee schedule,2182.91,5868.42,
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2706.78,,,,,,,fee schedule,2182.91,5868.42,
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Repair of toe dislocation,28675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30178.09,,,,,,,fee schedule,6916.07,34704.8,
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,34704.8,
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6916.07,34704.8,
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19784.76,,,,,,,fee schedule,6916.07,34704.8,
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24700.77,,,,,,,fee schedule,6916.07,34704.8,
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6916.07,34704.8,
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34704.8,,,,,,,fee schedule,6916.07,34704.8,
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,34704.8,
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,6916.07,34704.8,APC
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,6916.07,34704.8,APC
Fusion of foot bones,28705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,6916.07,34704.8,APC
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11452.71,,,,,,,fee schedule,7508.4,23026.52,
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18146.83,,,,,,,fee schedule,7508.4,23026.52,
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18146.83,,,,,,,fee schedule,7508.4,23026.52,
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7508.4,,,,,,,fee schedule,7508.4,23026.52,
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9374.04,,,,,,,fee schedule,7508.4,23026.52,
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20868.85,,,,,,,fee schedule,7508.4,23026.52,
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13170.62,,,,,,,fee schedule,7508.4,23026.52,
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18146.83,,,,,,,fee schedule,7508.4,23026.52,
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,7508.4,23026.52,APC
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,7508.4,23026.52,APC
Fusion of foot bones,28715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,7508.4,23026.52,APC
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13756.69,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9018.89,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11259.85,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15820.19,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6916.07,23026.52,APC
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6916.07,23026.52,APC
Fusion of foot bones,28725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6916.07,23026.52,APC
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8935.31,,,,,,,fee schedule,5857.99,23026.52,
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,5857.99,23026.52,
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,5857.99,23026.52,
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5857.99,,,,,,,fee schedule,5857.99,23026.52,
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7313.55,,,,,,,fee schedule,5857.99,23026.52,
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,5857.99,23026.52,
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10275.61,,,,,,,fee schedule,5857.99,23026.52,
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,5857.99,23026.52,
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,5857.99,23026.52,APC
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,5857.99,23026.52,APC
Fusion of foot bones,28730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,5857.99,23026.52,APC
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18937.16,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12415.2,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15500.07,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21777.73,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6916.07,23026.52,APC
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6916.07,23026.52,APC
Fusion of foot bones,28735,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6916.07,23026.52,APC
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19483.62,,,,,,,fee schedule,6916.07,23026.52,
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12773.46,,,,,,,fee schedule,6916.07,23026.52,
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15947.34,,,,,,,fee schedule,6916.07,23026.52,
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6916.07,23026.52,
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22406.16,,,,,,,fee schedule,6916.07,23026.52,
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6916.07,23026.52,
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,6916.07,23026.52,APC
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,6916.07,23026.52,APC
Revision of foot bones,28737,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,6916.07,23026.52,APC
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8506.58,,,,,,,fee schedule,5576.91,13014.22,
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,5576.91,13014.22,
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,5576.91,13014.22,
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5576.91,,,,,,,fee schedule,5576.91,13014.22,
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6962.64,,,,,,,fee schedule,5576.91,13014.22,
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,5576.91,13014.22,
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9782.57,,,,,,,fee schedule,5576.91,13014.22,
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,5576.91,13014.22,
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5576.91,13014.22,APC
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5576.91,13014.22,APC
Fusion of foot bones,28740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5576.91,13014.22,APC
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9866.12,,,,,,,fee schedule,6468.23,13014.22,
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,6468.23,13014.22,
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,6468.23,13014.22,
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6468.23,,,,,,,fee schedule,6468.23,13014.22,
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8075.42,,,,,,,fee schedule,6468.23,13014.22,
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,6468.23,13014.22,
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11346.04,,,,,,,fee schedule,6468.23,13014.22,
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,6468.23,13014.22,
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6468.23,13014.22,APC
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6468.23,13014.22,APC
Fusion of big toe joint,28750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6468.23,13014.22,APC
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,2310.4,13014.22,
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,2310.4,13014.22,
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,2310.4,13014.22,
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,13014.22,
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,2310.4,13014.22,
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,13014.22,
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2310.4,13014.22,APC
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2310.4,13014.22,APC
Fusion of big toe joint,28755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2310.4,13014.22,APC
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7953.48,,,,,,,fee schedule,4745.33,13014.22,
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6916.07,,,,,,,fee schedule,4745.33,13014.22,
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Fusion of big toe joint,28760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Amputation of midfoot,28800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of midfoot,28800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation of midfoot,28800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3646.66,,,,,,,fee schedule,2390.75,5868.42,
Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2390.75,,,,,,,fee schedule,2390.75,5868.42,
Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2984.79,,,,,,,fee schedule,2390.75,5868.42,
Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4193.66,,,,,,,fee schedule,2390.75,5868.42,
Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2390.75,5868.42,APC
Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2390.75,5868.42,APC
Amputation thru metatarsal,28805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2390.75,5868.42,APC
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation toe & metatarsal,28810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Amputation of toe,28820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.51,,,,,,,fee schedule,2310.4,5868.42,
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,2310.4,5868.42,
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.17,,,,,,,fee schedule,2310.4,5868.42,
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2310.4,5868.42,
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.84,,,,,,,fee schedule,2310.4,5868.42,
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2310.4,5868.42,
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2310.4,5868.42,APC
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2310.4,5868.42,APC
Partial amputation of toe,28825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2310.4,5868.42,APC
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,546.75,,,,,,,fee schedule,358.45,2883.98,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.63,,,,,,,fee schedule,358.45,2883.98,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.63,,,,,,,fee schedule,358.45,2883.98,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,358.45,,,,,,,fee schedule,358.45,2883.98,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,447.51,,,,,,,fee schedule,358.45,2883.98,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.87,,,,,,,fee schedule,358.45,2883.98,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,628.76,,,,,,,fee schedule,358.45,2883.98,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.63,,,,,,,fee schedule,358.45,2883.98,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,358.45,2883.98,APC
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,358.45,2883.98,APC
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,358.45,2883.98,APC
Foot/toes surgery procedure,28899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Foot/toes surgery procedure,28899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Foot/toes surgery procedure,28899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,184.74,,,,,,,fee schedule,121.12,291.45,
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.44,,,,,,,fee schedule,121.12,291.45,
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.44,,,,,,,fee schedule,121.12,291.45,
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.21,,,,,,,fee schedule,121.12,291.45,
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.12,,,,,,,fee schedule,121.12,291.45,
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.86,,,,,,,fee schedule,121.12,291.45,
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,212.45,,,,,,,fee schedule,121.12,291.45,
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.44,,,,,,,fee schedule,121.12,291.45,
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,121.12,291.45,APC
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,121.12,291.45,APC
Application of body cast,29044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,121.12,291.45,APC
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of body cast,29046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.81,,,,,,,fee schedule,69.37,501.64,
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.05,,,,,,,fee schedule,69.37,501.64,
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.05,,,,,,,fee schedule,69.37,501.64,
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.61,,,,,,,fee schedule,69.37,501.64,
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.37,,,,,,,fee schedule,69.37,501.64,
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.41,,,,,,,fee schedule,69.37,501.64,
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.68,,,,,,,fee schedule,69.37,501.64,
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.05,,,,,,,fee schedule,69.37,501.64,
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,69.37,501.64,APC
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,69.37,501.64,APC
Application of figure eight,29049,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,69.37,501.64,APC
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of shoulder cast,29055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.1,,,,,,,fee schedule,123.97,501.64,
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,172.06,,,,,,,fee schedule,123.97,501.64,
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.06,,,,,,,fee schedule,123.97,501.64,
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.78,,,,,,,fee schedule,123.97,501.64,
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.97,,,,,,,fee schedule,123.97,501.64,
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.87,,,,,,,fee schedule,123.97,501.64,
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.47,,,,,,,fee schedule,123.97,501.64,
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.06,,,,,,,fee schedule,123.97,501.64,
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,123.97,501.64,APC
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,123.97,501.64,APC
Application of shoulder cast,29058,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,123.97,501.64,APC
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,168.52,,,,,,,fee schedule,110.48,501.64,
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.57,,,,,,,fee schedule,110.48,501.64,
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.57,,,,,,,fee schedule,110.48,501.64,
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.93,,,,,,,fee schedule,110.48,501.64,
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.48,,,,,,,fee schedule,110.48,501.64,
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,110.48,501.64,
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,193.8,,,,,,,fee schedule,110.48,501.64,
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,110.48,501.64,
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,110.48,501.64,APC
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,110.48,501.64,APC
Application of long arm cast,29065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,110.48,501.64,APC
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.81,,,,,,,fee schedule,101.49,501.64,
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.59,,,,,,,fee schedule,101.49,501.64,
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.59,,,,,,,fee schedule,101.49,501.64,
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.71,,,,,,,fee schedule,101.49,501.64,
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.49,,,,,,,fee schedule,101.49,501.64,
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.08,,,,,,,fee schedule,101.49,501.64,
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.03,,,,,,,fee schedule,101.49,501.64,
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.59,,,,,,,fee schedule,101.49,501.64,
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,101.49,501.64,APC
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,101.49,501.64,APC
Application of forearm cast,29075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,101.49,501.64,APC
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,167.54,,,,,,,fee schedule,109.84,291.45,
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.71,,,,,,,fee schedule,109.84,291.45,
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.71,,,,,,,fee schedule,109.84,291.45,
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.13,,,,,,,fee schedule,109.84,291.45,
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.84,,,,,,,fee schedule,109.84,291.45,
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.02,,,,,,,fee schedule,109.84,291.45,
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,192.67,,,,,,,fee schedule,109.84,291.45,
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.71,,,,,,,fee schedule,109.84,291.45,
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,109.84,291.45,APC
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,109.84,291.45,APC
Apply hand/wrist cast,29085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,109.84,291.45,APC
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,291.45,
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.26,,,,,,,fee schedule,94.43,291.45,
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.26,,,,,,,fee schedule,94.43,291.45,
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,291.45,
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,291.45,
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,152.1,,,,,,,fee schedule,94.43,291.45,
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,291.45,
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,132.26,,,,,,,fee schedule,94.43,291.45,
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,94.43,291.45,APC
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,94.43,291.45,APC
Apply finger cast,29086,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,94.43,291.45,APC
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.95,,,,,,,fee schedule,97,291.45,
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.42,,,,,,,fee schedule,97,291.45,
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.42,,,,,,,fee schedule,97,291.45,
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.1,,,,,,,fee schedule,97,291.45,
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97,,,,,,,fee schedule,97,291.45,
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,97,291.45,
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.14,,,,,,,fee schedule,97,291.45,
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,97,291.45,
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,97,291.45,APC
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,97,291.45,APC
Apply long arm splint,29105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,97,291.45,APC
Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Apply forearm splint,29125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Apply forearm splint,29126,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Application of finger splint,29130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Application of finger splint,29131,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.11,,,,,,,fee schedule,28.26,291.45,
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.03,,,,,,,fee schedule,28.26,291.45,
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.03,,,,,,,fee schedule,28.26,291.45,
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.29,,,,,,,fee schedule,28.26,291.45,
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.26,,,,,,,fee schedule,28.26,291.45,
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.73,,,,,,,fee schedule,28.26,291.45,
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.58,,,,,,,fee schedule,28.26,291.45,
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.03,,,,,,,fee schedule,28.26,291.45,
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,28.26,291.45,APC
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,28.26,291.45,APC
Strapping of chest,29200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,28.26,291.45,APC
Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Strapping of shoulder,29240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,105.8,
Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,105.8,
Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,105.8,
Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,105.8,
Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,27.82,105.8,APC
Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,27.82,105.8,APC
Strapping of elbow or wrist,29260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,27.82,105.8,APC
Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,105.8,
Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,105.8,
Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,105.8,
Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,105.8,
Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,27.82,105.8,APC
Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,27.82,105.8,APC
Strapping of hand or finger,29280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,27.82,105.8,APC
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of hip cast,29305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.89,,,,,,,fee schedule,213.65,501.64,
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.89,,,,,,,fee schedule,213.65,501.64,
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.65,,,,,,,fee schedule,213.65,501.64,
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.74,,,,,,,fee schedule,213.65,501.64,
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.27,,,,,,,fee schedule,213.65,501.64,
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.77,,,,,,,fee schedule,213.65,501.64,
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.89,,,,,,,fee schedule,213.65,501.64,
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,213.65,501.64,APC
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,213.65,501.64,APC
Application of hip casts,29325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,213.65,501.64,APC
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,219.47,,,,,,,fee schedule,143.88,501.64,
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.54,,,,,,,fee schedule,143.88,501.64,
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,194.54,,,,,,,fee schedule,143.88,501.64,
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.88,,,,,,,fee schedule,143.88,501.64,
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,179.64,,,,,,,fee schedule,143.88,501.64,
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,223.72,,,,,,,fee schedule,143.88,501.64,
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,252.39,,,,,,,fee schedule,143.88,501.64,
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194.54,,,,,,,fee schedule,143.88,501.64,
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,143.88,501.64,APC
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,143.88,501.64,APC
Application of long leg cast,29345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,143.88,501.64,APC
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.5,,,,,,,fee schedule,142.59,501.64,
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,192.82,,,,,,,fee schedule,142.59,501.64,
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.82,,,,,,,fee schedule,142.59,501.64,
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.59,,,,,,,fee schedule,142.59,501.64,
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.02,,,,,,,fee schedule,142.59,501.64,
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.74,,,,,,,fee schedule,142.59,501.64,
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.13,,,,,,,fee schedule,142.59,501.64,
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.82,,,,,,,fee schedule,142.59,501.64,
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,142.59,501.64,APC
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,142.59,501.64,APC
Application of long leg cast,29355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,142.59,501.64,APC
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,281.21,,,,,,,fee schedule,184.36,501.64,
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,249.86,,,,,,,fee schedule,184.36,501.64,
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.86,,,,,,,fee schedule,184.36,501.64,
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,184.36,,,,,,,fee schedule,184.36,501.64,
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,230.17,,,,,,,fee schedule,184.36,501.64,
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,287.34,,,,,,,fee schedule,184.36,501.64,
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,323.39,,,,,,,fee schedule,184.36,501.64,
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,249.86,,,,,,,fee schedule,184.36,501.64,
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,184.36,501.64,APC
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,184.36,501.64,APC
Apply long leg cast brace,29358,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,184.36,501.64,APC
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,206.76,,,,,,,fee schedule,135.55,501.64,
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,183.31,,,,,,,fee schedule,135.55,501.64,
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,183.31,,,,,,,fee schedule,135.55,501.64,
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.55,,,,,,,fee schedule,135.55,501.64,
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.23,,,,,,,fee schedule,135.55,501.64,
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,210.81,,,,,,,fee schedule,135.55,501.64,
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,237.77,,,,,,,fee schedule,135.55,501.64,
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,183.31,,,,,,,fee schedule,135.55,501.64,
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,135.55,501.64,APC
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,135.55,501.64,APC
Application of long leg cast,29365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,135.55,501.64,APC
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.14,,,,,,,fee schedule,91.22,501.64,
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.76,,,,,,,fee schedule,91.22,501.64,
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.76,,,,,,,fee schedule,91.22,501.64,
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.22,,,,,,,fee schedule,91.22,501.64,
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.89,,,,,,,fee schedule,91.22,501.64,
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.17,,,,,,,fee schedule,91.22,501.64,
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.01,,,,,,,fee schedule,91.22,501.64,
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.76,,,,,,,fee schedule,91.22,501.64,
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,91.22,501.64,APC
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,91.22,501.64,APC
Apply short leg cast,29405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,91.22,501.64,APC
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.3,,,,,,,fee schedule,86.08,501.64,
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.85,,,,,,,fee schedule,86.08,501.64,
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,115.85,,,,,,,fee schedule,86.08,501.64,
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.08,,,,,,,fee schedule,86.08,501.64,
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.47,,,,,,,fee schedule,86.08,501.64,
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,133.23,,,,,,,fee schedule,86.08,501.64,
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151,,,,,,,fee schedule,86.08,501.64,
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.85,,,,,,,fee schedule,86.08,501.64,
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,86.08,501.64,APC
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,86.08,501.64,APC
Apply short leg cast,29425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,86.08,501.64,APC
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194,,,,,,,fee schedule,127.19,501.64,
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,172.94,,,,,,,fee schedule,127.19,501.64,
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.94,,,,,,,fee schedule,127.19,501.64,
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.19,,,,,,,fee schedule,127.19,501.64,
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.79,,,,,,,fee schedule,127.19,501.64,
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.88,,,,,,,fee schedule,127.19,501.64,
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,223.1,,,,,,,fee schedule,127.19,501.64,
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.94,,,,,,,fee schedule,127.19,501.64,
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,127.19,501.64,APC
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,127.19,501.64,APC
Apply short leg cast,29435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,127.19,501.64,APC
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.7,,,,,,,fee schedule,41.11,291.45,
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.32,,,,,,,fee schedule,41.11,291.45,
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.32,,,,,,,fee schedule,41.11,291.45,
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.11,,,,,,,fee schedule,41.11,291.45,
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.32,,,,,,,fee schedule,41.11,291.45,
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.62,,,,,,,fee schedule,41.11,291.45,
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.11,,,,,,,fee schedule,41.11,291.45,
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.32,,,,,,,fee schedule,41.11,291.45,
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,41.11,291.45,APC
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,41.11,291.45,APC
Addition of walker to cast,29440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,41.11,291.45,APC
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.25,,,,,,,fee schedule,119.48,501.64,
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.42,,,,,,,fee schedule,119.48,501.64,
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.42,,,,,,,fee schedule,119.48,501.64,
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.48,,,,,,,fee schedule,119.48,501.64,
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.17,,,,,,,fee schedule,119.48,501.64,
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.93,,,,,,,fee schedule,119.48,501.64,
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.59,,,,,,,fee schedule,119.48,501.64,
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.42,,,,,,,fee schedule,119.48,501.64,
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,119.48,501.64,APC
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,119.48,501.64,APC
Apply rigid leg cast,29445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,119.48,501.64,APC
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6704.26,,,,,,,fee schedule,159.98,7709.9,
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,159.98,,,,,,,fee schedule,159.98,7709.9,
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.98,,,,,,,fee schedule,159.98,7709.9,
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4395.31,,,,,,,fee schedule,159.98,7709.9,
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5487.44,,,,,,,fee schedule,159.98,7709.9,
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.98,,,,,,,fee schedule,159.98,7709.9,
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7709.9,,,,,,,fee schedule,159.98,7709.9,
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.98,,,,,,,fee schedule,159.98,7709.9,
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,159.98,7709.9,APC
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,159.98,7709.9,APC
Application of leg cast,29450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,159.98,7709.9,APC
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,157.74,,,,,,,fee schedule,103.41,291.45,
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.48,,,,,,,fee schedule,103.41,291.45,
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.48,,,,,,,fee schedule,103.41,291.45,
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.41,,,,,,,fee schedule,103.41,291.45,
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.11,,,,,,,fee schedule,103.41,291.45,
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,158.1,,,,,,,fee schedule,103.41,291.45,
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,181.4,,,,,,,fee schedule,103.41,291.45,
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.48,,,,,,,fee schedule,103.41,291.45,
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,103.41,291.45,APC
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,103.41,291.45,APC
Application long leg splint,29505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,103.41,291.45,APC
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.5,,,,,,,fee schedule,79.66,291.45,
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.36,,,,,,,fee schedule,79.66,291.45,
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.36,,,,,,,fee schedule,79.66,291.45,
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.66,,,,,,,fee schedule,79.66,291.45,
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.45,,,,,,,fee schedule,79.66,291.45,
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.31,,,,,,,fee schedule,79.66,291.45,
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.73,,,,,,,fee schedule,79.66,291.45,
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.36,,,,,,,fee schedule,79.66,291.45,
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,79.66,291.45,APC
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,79.66,291.45,APC
Application lower leg splint,29515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,79.66,291.45,APC
Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Strapping of hip,29520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Strapping of knee,29530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.35,,,,,,,fee schedule,20.55,291.45,
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.65,,,,,,,fee schedule,20.55,291.45,
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.65,,,,,,,fee schedule,20.55,291.45,
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.55,,,,,,,fee schedule,20.55,291.45,
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.66,,,,,,,fee schedule,20.55,291.45,
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.8,,,,,,,fee schedule,20.55,291.45,
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.05,,,,,,,fee schedule,20.55,291.45,
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.65,,,,,,,fee schedule,20.55,291.45,
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,20.55,291.45,APC
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,20.55,291.45,APC
Strapping of ankle and/or ft,29540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,20.55,291.45,APC
Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Strapping of toes,29550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.24,,,,,,,fee schedule,55.88,291.45,
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.06,,,,,,,fee schedule,55.88,291.45,
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.06,,,,,,,fee schedule,55.88,291.45,
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.88,,,,,,,fee schedule,55.88,291.45,
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.77,,,,,,,fee schedule,55.88,291.45,
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.47,,,,,,,fee schedule,55.88,291.45,
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.03,,,,,,,fee schedule,55.88,291.45,
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.06,,,,,,,fee schedule,55.88,291.45,
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,55.88,291.45,APC
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,55.88,291.45,APC
Application of paste boot,29580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,55.88,291.45,APC
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.31,,,,,,,fee schedule,99.85,291.45,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.81,,,,,,,fee schedule,99.85,291.45,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.81,,,,,,,fee schedule,99.85,291.45,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.85,,,,,,,fee schedule,99.85,291.45,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.67,,,,,,,fee schedule,99.85,291.45,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.13,,,,,,,fee schedule,99.85,291.45,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.16,,,,,,,fee schedule,99.85,291.45,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.81,,,,,,,fee schedule,99.85,291.45,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,99.85,291.45,APC
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,99.85,291.45,APC
Apply multlay comprs lwr leg,29581,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,99.85,291.45,APC
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.7,,,,,,,fee schedule,105.35,291.45,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.92,,,,,,,fee schedule,105.35,291.45,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.92,,,,,,,fee schedule,105.35,291.45,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.35,,,,,,,fee schedule,105.35,291.45,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.53,,,,,,,fee schedule,105.35,291.45,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.06,,,,,,,fee schedule,105.35,291.45,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.81,,,,,,,fee schedule,105.35,291.45,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.92,,,,,,,fee schedule,105.35,291.45,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,105.35,291.45,APC
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,105.35,291.45,APC
Appl multlay comprs arm/hand,29584,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,105.35,291.45,APC
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.67,,,,,,,fee schedule,73.21,501.64,
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.21,,,,,,,fee schedule,73.21,501.64,
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.21,,,,,,,fee schedule,73.21,501.64,
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.21,,,,,,,fee schedule,73.21,501.64,
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.4,,,,,,,fee schedule,73.21,501.64,
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.34,,,,,,,fee schedule,73.21,501.64,
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.42,,,,,,,fee schedule,73.21,501.64,
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.21,,,,,,,fee schedule,73.21,501.64,
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,73.21,501.64,APC
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,73.21,501.64,APC
Removal/revision of cast,29700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,73.21,501.64,APC
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.96,,,,,,,fee schedule,65.53,501.64,
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.05,,,,,,,fee schedule,65.53,501.64,
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.05,,,,,,,fee schedule,65.53,501.64,
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.53,,,,,,,fee schedule,65.53,501.64,
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.82,,,,,,,fee schedule,65.53,501.64,
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.41,,,,,,,fee schedule,65.53,501.64,
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.95,,,,,,,fee schedule,65.53,501.64,
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.05,,,,,,,fee schedule,65.53,501.64,
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,65.53,501.64,APC
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,65.53,501.64,APC
Removal/revision of cast,29705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,65.53,501.64,APC
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,183.22,,,,,,,fee schedule,120.12,501.64,
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.72,,,,,,,fee schedule,120.12,501.64,
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.72,,,,,,,fee schedule,120.12,501.64,
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,120.12,,,,,,,fee schedule,120.12,501.64,
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.97,,,,,,,fee schedule,120.12,501.64,
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,192.88,,,,,,,fee schedule,120.12,501.64,
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,210.7,,,,,,,fee schedule,120.12,501.64,
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,167.72,,,,,,,fee schedule,120.12,501.64,
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,120.12,501.64,APC
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,120.12,501.64,APC
Removal/revision of cast,29710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,120.12,501.64,APC
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,157.74,,,,,,,fee schedule,103.41,291.45,
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.04,,,,,,,fee schedule,103.41,291.45,
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.04,,,,,,,fee schedule,103.41,291.45,
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.41,,,,,,,fee schedule,103.41,291.45,
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.11,,,,,,,fee schedule,103.41,291.45,
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.05,,,,,,,fee schedule,103.41,291.45,
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,181.4,,,,,,,fee schedule,103.41,291.45,
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.04,,,,,,,fee schedule,103.41,291.45,
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,103.41,291.45,APC
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,103.41,291.45,APC
Repair of body cast,29720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,103.41,291.45,APC
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.03,,,,,,,fee schedule,62.3,291.45,
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.85,,,,,,,fee schedule,62.3,291.45,
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.85,,,,,,,fee schedule,62.3,291.45,
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.3,,,,,,,fee schedule,62.3,291.45,
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.78,,,,,,,fee schedule,62.3,291.45,
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.43,,,,,,,fee schedule,62.3,291.45,
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.28,,,,,,,fee schedule,62.3,291.45,
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.85,,,,,,,fee schedule,62.3,291.45,
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,62.3,291.45,APC
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,62.3,291.45,APC
Windowing of cast,29730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,62.3,291.45,APC
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.98,,,,,,,fee schedule,96.36,501.64,
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.66,,,,,,,fee schedule,96.36,501.64,
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.66,,,,,,,fee schedule,96.36,501.64,
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.36,,,,,,,fee schedule,96.36,501.64,
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.3,,,,,,,fee schedule,96.36,501.64,
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.11,,,,,,,fee schedule,96.36,501.64,
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.03,,,,,,,fee schedule,96.36,501.64,
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.66,,,,,,,fee schedule,96.36,501.64,
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,96.36,501.64,APC
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,96.36,501.64,APC
Wedging of cast,29740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,96.36,501.64,APC
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,501.64,
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.93,,,,,,,fee schedule,79.01,501.64,
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.93,,,,,,,fee schedule,79.01,501.64,
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,501.64,
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,501.64,
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.27,,,,,,,fee schedule,79.01,501.64,
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,501.64,
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.93,,,,,,,fee schedule,79.01,501.64,
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.62,,,,,,,fee schedule,79.01,501.64,APC
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.69,,,,,,,fee schedule,79.01,501.64,APC
Wedging of clubfoot cast,29750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.64,,,,,,,fee schedule,79.01,501.64,APC
Casting/strapping procedure,29799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.01,,,,,,,fee schedule,161.92,291.45,APC
Casting/strapping procedure,29799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.92,,,,,,,fee schedule,161.92,291.45,APC
Casting/strapping procedure,29799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.45,,,,,,,fee schedule,161.92,291.45,APC
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Jaw arthroscopy/surgery,29800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Jaw arthroscopy/surgery,29804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy dx,29805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5701.41,,,,,,,fee schedule,3737.84,13014.22,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5675.4,,,,,,,fee schedule,3737.84,13014.22,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5675.4,,,,,,,fee schedule,3737.84,13014.22,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3737.84,,,,,,,fee schedule,3737.84,13014.22,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4666.6,,,,,,,fee schedule,3737.84,13014.22,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6526.71,,,,,,,fee schedule,3737.84,13014.22,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6556.62,,,,,,,fee schedule,3737.84,13014.22,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5675.4,,,,,,,fee schedule,3737.84,13014.22,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3737.84,13014.22,APC
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3737.84,13014.22,APC
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3737.84,13014.22,APC
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9041.42,,,,,,,fee schedule,5675.4,13014.22,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5675.4,,,,,,,fee schedule,5675.4,13014.22,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5675.4,,,,,,,fee schedule,5675.4,13014.22,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5927.55,,,,,,,fee schedule,5675.4,13014.22,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7400.4,,,,,,,fee schedule,5675.4,13014.22,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6526.71,,,,,,,fee schedule,5675.4,13014.22,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10397.63,,,,,,,fee schedule,5675.4,13014.22,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5675.4,,,,,,,fee schedule,5675.4,13014.22,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5675.4,13014.22,APC
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5675.4,13014.22,APC
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5675.4,13014.22,APC
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6655.05,,,,,,,fee schedule,4745.33,13014.22,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6655.05,,,,,,,fee schedule,4745.33,13014.22,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7653.31,,,,,,,fee schedule,4745.33,13014.22,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6655.05,,,,,,,fee schedule,4745.33,13014.22,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,7653.31,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6655.05,,,,,,,fee schedule,2182.91,7653.31,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6655.05,,,,,,,fee schedule,2182.91,7653.31,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,7653.31,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,7653.31,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7653.31,,,,,,,fee schedule,2182.91,7653.31,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,7653.31,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6655.05,,,,,,,fee schedule,2182.91,7653.31,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,7653.31,APC
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,7653.31,APC
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,7653.31,APC
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6844.27,,,,,,,fee schedule,2929.89,7870.91,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,7870.91,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2929.89,7870.91,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4487.1,,,,,,,fee schedule,2929.89,7870.91,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5602.03,,,,,,,fee schedule,2929.89,7870.91,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2929.89,7870.91,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7870.91,,,,,,,fee schedule,2929.89,7870.91,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,7870.91,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2929.89,7870.91,APC
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2929.89,7870.91,APC
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2929.89,7870.91,APC
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6079.41,,,,,,,fee schedule,3260.23,6991.32,
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6079.41,,,,,,,fee schedule,3260.23,6991.32,
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6991.32,,,,,,,fee schedule,3260.23,6991.32,
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6079.41,,,,,,,fee schedule,3260.23,6991.32,
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,6991.32,APC
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,6991.32,APC
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,6991.32,APC
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9077.71,,,,,,,fee schedule,7230.12,13014.22,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9077.71,,,,,,,fee schedule,7230.12,13014.22,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10439.37,,,,,,,fee schedule,7230.12,13014.22,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9077.71,,,,,,,fee schedule,7230.12,13014.22,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Arthroscop rotator cuff repr,29827,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,4745.33,13014.22,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,6622.23,APC
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,6622.23,APC
Elbow arthroscopy,29830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,6622.23,APC
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Elbow arthroscopy/surgery,29834,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,6622.23,APC
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,6622.23,APC
Elbow arthroscopy/surgery,29835,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,6622.23,APC
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,4745.33,13014.22,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Elbow arthroscopy/surgery,29836,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Elbow arthroscopy/surgery,29837,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Elbow arthroscopy/surgery,29838,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy,29840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29843,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29844,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29845,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7037.41,,,,,,,fee schedule,2851.13,8093.02,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2851.13,8093.02,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2851.13,8093.02,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4613.73,,,,,,,fee schedule,2851.13,8093.02,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5760.12,,,,,,,fee schedule,2851.13,8093.02,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2851.13,8093.02,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8093.02,,,,,,,fee schedule,2851.13,8093.02,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2851.13,8093.02,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2851.13,8093.02,APC
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2851.13,8093.02,APC
Wrist arthroscopy/surgery,29846,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2851.13,8093.02,APC
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,4745.33,13014.22,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Wrist arthroscopy/surgery,29847,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3456.66,,,,,,,fee schedule,1602.21,3975.16,
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1643.7,,,,,,,fee schedule,1602.21,3975.16,
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.7,,,,,,,fee schedule,1602.21,3975.16,
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2266.19,,,,,,,fee schedule,1602.21,3975.16,
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2829.28,,,,,,,fee schedule,1602.21,3975.16,
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.26,,,,,,,fee schedule,1602.21,3975.16,
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3975.16,,,,,,,fee schedule,1602.21,3975.16,
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.7,,,,,,,fee schedule,1602.21,3975.16,
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1602.21,3975.16,APC
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1602.21,3975.16,APC
Wrist endoscopy/surgery,29848,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1602.21,3975.16,APC
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,3469.39,
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3016.86,,,,,,,fee schedule,1245.6,3469.39,
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3016.86,,,,,,,fee schedule,1245.6,3469.39,
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,3469.39,
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,3469.39,
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3469.39,,,,,,,fee schedule,1245.6,3469.39,
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,3469.39,
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3016.86,,,,,,,fee schedule,1245.6,3469.39,
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,3469.39,APC
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,3469.39,APC
Knee arthroscopy/surgery,29850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,3469.39,APC
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,6622.23,
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,1245.6,6622.23,
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,1245.6,6622.23,
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,6622.23,
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,6622.23,
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,1245.6,6622.23,
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,6622.23,
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,1245.6,6622.23,
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,6622.23,APC
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,6622.23,APC
Knee arthroscopy/surgery,29851,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,6622.23,APC
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8833.74,,,,,,,fee schedule,5758.46,13014.22,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,5758.46,13014.22,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,5758.46,13014.22,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5791.4,,,,,,,fee schedule,5758.46,13014.22,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7230.42,,,,,,,fee schedule,5758.46,13014.22,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,5758.46,13014.22,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10158.8,,,,,,,fee schedule,5758.46,13014.22,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,5758.46,13014.22,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5758.46,13014.22,APC
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5758.46,13014.22,APC
Tibial arthroscopy/surgery,29855,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5758.46,13014.22,APC
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19223.68,,,,,,,fee schedule,5758.46,23026.52,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,5758.46,23026.52,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,5758.46,23026.52,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12603.04,,,,,,,fee schedule,5758.46,23026.52,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15734.58,,,,,,,fee schedule,5758.46,23026.52,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,5758.46,23026.52,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22107.23,,,,,,,fee schedule,5758.46,23026.52,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,5758.46,23026.52,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,5758.46,23026.52,APC
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,5758.46,23026.52,APC
Tibial arthroscopy/surgery,29856,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,5758.46,23026.52,APC
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,4745.33,13014.22,
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Hip arthroscopy dx,29860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,2182.91,13014.22,
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,2182.91,13014.22,
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,2182.91,13014.22,
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,2182.91,13014.22,
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Hip arthro w/fb removal,29861,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7705.41,,,,,,,fee schedule,5051.67,13014.22,
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,5051.67,13014.22,
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,5051.67,13014.22,
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5051.67,,,,,,,fee schedule,5051.67,13014.22,
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6306.88,,,,,,,fee schedule,5051.67,13014.22,
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,5051.67,13014.22,
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8861.22,,,,,,,fee schedule,5051.67,13014.22,
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,5051.67,13014.22,
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5051.67,13014.22,APC
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5051.67,13014.22,APC
Hip arthr0 w/debridement,29862,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5051.67,13014.22,APC
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,4745.33,13014.22,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Autgrft implnt knee w/scope,29866,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14299.31,,,,,,,fee schedule,9374.63,23026.52,
Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9374.63,,,,,,,fee schedule,9374.63,23026.52,
Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11703.99,,,,,,,fee schedule,9374.63,23026.52,
Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16444.21,,,,,,,fee schedule,9374.63,23026.52,
Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,9374.63,23026.52,APC
Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,9374.63,23026.52,APC
Allgrft implnt knee w/scope,29867,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,9374.63,23026.52,APC
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy dx,29870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/drainage,29871,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29873,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29874,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8548.96,,,,,,,fee schedule,2810.02,9831.3,
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2810.02,,,,,,,fee schedule,2810.02,9831.3,
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2810.02,,,,,,,fee schedule,2810.02,9831.3,
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5604.7,,,,,,,fee schedule,2810.02,9831.3,
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6997.32,,,,,,,fee schedule,2810.02,9831.3,
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3231.52,,,,,,,fee schedule,2810.02,9831.3,
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9831.3,,,,,,,fee schedule,2810.02,9831.3,
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2810.02,,,,,,,fee schedule,2810.02,9831.3,
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2810.02,9831.3,APC
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2810.02,9831.3,APC
Knee arthroscopy/surgery,29875,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2810.02,9831.3,APC
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6322.24,,,,,,,fee schedule,2929.89,7270.58,
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,7270.58,
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2929.89,7270.58,
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4144.86,,,,,,,fee schedule,2929.89,7270.58,
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5174.75,,,,,,,fee schedule,2929.89,7270.58,
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2929.89,7270.58,
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7270.58,,,,,,,fee schedule,2929.89,7270.58,
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2929.89,7270.58,
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2929.89,7270.58,APC
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2929.89,7270.58,APC
Knee arthroscopy/surgery,29876,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2929.89,7270.58,APC
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29877,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29879,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4217.46,,,,,,,fee schedule,2764.97,5868.42,
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2764.97,5868.42,
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2764.97,5868.42,
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2764.97,,,,,,,fee schedule,2764.97,5868.42,
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3451.99,,,,,,,fee schedule,2764.97,5868.42,
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2764.97,5868.42,
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4850.08,,,,,,,fee schedule,2764.97,5868.42,
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2764.97,5868.42,
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2764.97,5868.42,APC
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2764.97,5868.42,APC
Knee arthroscopy/surgery,29880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2764.97,5868.42,APC
Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.53,,,,,,,fee schedule,3260.23,5868.42,
Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3352.53,,,,,,,fee schedule,3260.23,5868.42,
Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3855.41,,,,,,,fee schedule,3260.23,5868.42,
Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3352.53,,,,,,,fee schedule,3260.23,5868.42,
Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Knee arthroscopy/surgery,29881,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29882,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29883,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3369.37,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2929.89,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29884,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,4745.33,13014.22,
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Knee arthroscopy/surgery,29885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3016.86,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3016.86,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3469.39,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3016.86,,,,,,,fee schedule,2182.91,5868.42,
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29886,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14527.14,,,,,,,fee schedule,2851.13,16706.21,
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2851.13,16706.21,
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2851.13,16706.21,
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9523.99,,,,,,,fee schedule,2851.13,16706.21,
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11890.46,,,,,,,fee schedule,2851.13,16706.21,
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2851.13,16706.21,
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16706.21,,,,,,,fee schedule,2851.13,16706.21,
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2851.13,16706.21,
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2851.13,16706.21,APC
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2851.13,16706.21,APC
Knee arthroscopy/surgery,29887,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2851.13,16706.21,APC
Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10661.57,,,,,,,fee schedule,7230.12,13014.22,
Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10661.57,,,,,,,fee schedule,7230.12,13014.22,
Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12260.81,,,,,,,fee schedule,7230.12,13014.22,
Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10661.57,,,,,,,fee schedule,7230.12,13014.22,
Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Knee arthroscopy/surgery,29888,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,8378.58,23026.52,
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,8378.58,23026.52,
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,8378.58,23026.52,
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9635.37,,,,,,,fee schedule,8378.58,23026.52,
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,8378.58,23026.52,
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8378.58,,,,,,,fee schedule,8378.58,23026.52,
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,8378.58,23026.52,APC
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,8378.58,23026.52,APC
Knee arthroscopy/surgery,29889,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,8378.58,23026.52,APC
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3016.86,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3016.86,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3469.39,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3016.86,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29891,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5734.44,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4986.47,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Ankle arthroscopy/surgery,29892,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2656.96,,,,,,,fee schedule,2182.91,5868.42,
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2310.4,,,,,,,fee schedule,2182.91,5868.42,
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Scope plantar fasciotomy,29893,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29894,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29895,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29897,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29898,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,4745.33,13014.22,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Ankle arthroscopy/surgery,29899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Mcp joint arthroscopy dx,29900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,6622.23,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,6622.23,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,6622.23,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,2182.91,6622.23,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,6622.23,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,2182.91,6622.23,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,6622.23,APC
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,6622.23,APC
Mcp joint arthroscopy surg,29901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,6622.23,APC
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,3278.8,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,1245.6,3278.8,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,1245.6,3278.8,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,3278.8,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,3278.8,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,1245.6,3278.8,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,3278.8,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,1245.6,3278.8,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.32,,,,,,,fee schedule,1245.6,3278.8,APC
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1602.21,,,,,,,fee schedule,1245.6,3278.8,APC
Mcp joint arthroscopy surg,29902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2883.98,,,,,,,fee schedule,1245.6,3278.8,APC
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,13014.22,
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,13014.22,
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,13014.22,
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,13014.22,
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,13014.22,
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,13014.22,
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,13014.22,
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,13014.22,
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,2182.91,13014.22,APC
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,2182.91,13014.22,APC
Subtalar arthro w/exc,29905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,2182.91,13014.22,APC
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.8,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2851.13,,,,,,,fee schedule,2182.91,5868.42,
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Subtalar arthro w/deb,29906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13600.53,,,,,,,fee schedule,5758.46,23026.52,
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,5758.46,23026.52,
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,5758.46,23026.52,
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8916.51,,,,,,,fee schedule,5758.46,23026.52,
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11132.03,,,,,,,fee schedule,5758.46,23026.52,
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,5758.46,23026.52,
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15640.61,,,,,,,fee schedule,5758.46,23026.52,
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,5758.46,23026.52,
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,5758.46,23026.52,APC
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,5758.46,23026.52,APC
Subtalar arthro w/fusion,29907,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,5758.46,23026.52,APC
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5720.47,,,,,,,fee schedule,3750.34,13014.22,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,3750.34,13014.22,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,3750.34,13014.22,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3750.34,,,,,,,fee schedule,3750.34,13014.22,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4682.2,,,,,,,fee schedule,3750.34,13014.22,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,3750.34,13014.22,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6578.54,,,,,,,fee schedule,3750.34,13014.22,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,3750.34,13014.22,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,3750.34,13014.22,APC
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,3750.34,13014.22,APC
Hip arthro w/femoroplasty,29914,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,3750.34,13014.22,APC
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8853.27,,,,,,,fee schedule,5758.46,13014.22,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,5758.46,13014.22,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,5758.46,13014.22,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5804.2,,,,,,,fee schedule,5758.46,13014.22,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7246.4,,,,,,,fee schedule,5758.46,13014.22,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,5758.46,13014.22,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10181.26,,,,,,,fee schedule,5758.46,13014.22,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,5758.46,13014.22,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5758.46,13014.22,APC
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5758.46,13014.22,APC
Hip arthro acetabuloplasty,29915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5758.46,13014.22,APC
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7043.75,,,,,,,fee schedule,4617.88,13014.22,
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.46,,,,,,,fee schedule,4617.88,13014.22,
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5758.46,,,,,,,fee schedule,4617.88,13014.22,
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4617.88,,,,,,,fee schedule,4617.88,13014.22,
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5765.31,,,,,,,fee schedule,4617.88,13014.22,
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6622.23,,,,,,,fee schedule,4617.88,13014.22,
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8100.31,,,,,,,fee schedule,4617.88,13014.22,
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5758.46,,,,,,,fee schedule,4617.88,13014.22,
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4617.88,13014.22,APC
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4617.88,13014.22,APC
Hip arthro w/labral repair,29916,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4617.88,13014.22,APC
Arthroscopy of joint,29999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.07,,,,,,,fee schedule,245.78,442.4,APC
Arthroscopy of joint,29999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.78,,,,,,,fee schedule,245.78,442.4,APC
Arthroscopy of joint,29999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.4,,,,,,,fee schedule,245.78,442.4,APC
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,424.8,
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,171.38,424.8,
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,424.8,
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,424.8,
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,171.38,424.8,
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,424.8,
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,424.8,APC
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,424.8,APC
Drainage of nose lesion,30000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,424.8,APC
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,478.15,,,,,,,fee schedule,313.48,967.3,
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,427.17,,,,,,,fee schedule,313.48,967.3,
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,427.17,,,,,,,fee schedule,313.48,967.3,
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,313.48,,,,,,,fee schedule,313.48,967.3,
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,391.37,,,,,,,fee schedule,313.48,967.3,
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,491.25,,,,,,,fee schedule,313.48,967.3,
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,549.87,,,,,,,fee schedule,313.48,967.3,
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,427.17,,,,,,,fee schedule,313.48,967.3,
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,313.48,967.3,APC
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,313.48,967.3,APC
Drainage of nose lesion,30020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,313.48,967.3,APC
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,285.14,,,,,,,fee schedule,186.94,2782.81,
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,255.93,,,,,,,fee schedule,186.94,2782.81,
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255.93,,,,,,,fee schedule,186.94,2782.81,
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.94,,,,,,,fee schedule,186.94,2782.81,
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,233.39,,,,,,,fee schedule,186.94,2782.81,
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.32,,,,,,,fee schedule,186.94,2782.81,
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,327.91,,,,,,,fee schedule,186.94,2782.81,
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.93,,,,,,,fee schedule,186.94,2782.81,
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,186.94,2782.81,APC
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,186.94,2782.81,APC
Intranasal biopsy,30100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,186.94,2782.81,APC
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,449.76,,,,,,,fee schedule,294.86,2782.81,
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,401.2,,,,,,,fee schedule,294.86,2782.81,
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,401.2,,,,,,,fee schedule,294.86,2782.81,
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,294.86,,,,,,,fee schedule,294.86,2782.81,
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,368.13,,,,,,,fee schedule,294.86,2782.81,
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,461.38,,,,,,,fee schedule,294.86,2782.81,
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,517.22,,,,,,,fee schedule,294.86,2782.81,
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,401.2,,,,,,,fee schedule,294.86,2782.81,
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,294.86,2782.81,APC
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,294.86,2782.81,APC
Removal of nose polyp(s),30110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,294.86,2782.81,APC
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of nose polyp(s),30115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.1,,,,,,,fee schedule,1678.74,10827.37,
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,10827.37,
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,10827.37,
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.54,,,,,,,fee schedule,1678.74,10827.37,
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.26,,,,,,,fee schedule,1678.74,10827.37,
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,10827.37,
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.37,,,,,,,fee schedule,1678.74,10827.37,
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,10827.37,
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,10827.37,APC
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,10827.37,APC
Removal of intranasal lesion,30117,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,10827.37,APC
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,1684.24,5946.37,
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of intranasal lesion,30118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of nose,30120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Removal of nose lesion,30124,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of nose lesion,30125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,1684.24,5946.37,
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excise inferior turbinate,30130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4613.1,,,,,,,fee schedule,2258.7,5946.37,
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3024.35,,,,,,,fee schedule,2258.7,5946.37,
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3775.82,,,,,,,fee schedule,2258.7,5946.37,
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,2258.7,5946.37,
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5305.07,,,,,,,fee schedule,2258.7,5946.37,
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2258.7,5946.37,APC
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2258.7,5946.37,APC
Resect inferior turbinate,30140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2258.7,5946.37,APC
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Partial removal of nose,30150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of nose,30160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,225.34,,,,,,,fee schedule,147.73,967.3,
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,203.17,,,,,,,fee schedule,147.73,967.3,
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.17,,,,,,,fee schedule,147.73,967.3,
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.73,,,,,,,fee schedule,147.73,967.3,
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,184.44,,,,,,,fee schedule,147.73,967.3,
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.65,,,,,,,fee schedule,147.73,967.3,
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.14,,,,,,,fee schedule,147.73,967.3,
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.17,,,,,,,fee schedule,147.73,967.3,
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,147.73,967.3,APC
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,147.73,967.3,APC
Injection treatment of nose,30200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,147.73,967.3,APC
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,288.07,,,,,,,fee schedule,188.86,2782.81,
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.53,,,,,,,fee schedule,188.86,2782.81,
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.53,,,,,,,fee schedule,188.86,2782.81,
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,188.86,,,,,,,fee schedule,188.86,2782.81,
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,235.79,,,,,,,fee schedule,188.86,2782.81,
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,297.31,,,,,,,fee schedule,188.86,2782.81,
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,331.28,,,,,,,fee schedule,188.86,2782.81,
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,258.53,,,,,,,fee schedule,188.86,2782.81,
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,188.86,2782.81,APC
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,188.86,2782.81,APC
Nasal sinus therapy,30210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,188.86,2782.81,APC
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2782.81,
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2782.81,
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2782.81,
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1005.11,2782.81,
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2782.81,
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2782.81,APC
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2782.81,APC
Insert nasal septal button,30220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2782.81,APC
Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Remove nasal foreign body,30300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Remove nasal foreign body,30310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Remove nasal foreign body,30320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6014.56,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of nose,30400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6014.56,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of nose,30410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5730.25,,,,,,,fee schedule,5730.25,10617.38,
Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5730.25,,,,,,,fee schedule,5730.25,10617.38,
Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6589.79,,,,,,,fee schedule,5730.25,10617.38,
Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5730.25,,,,,,,fee schedule,5730.25,10617.38,
Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5730.25,10617.38,APC
Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5730.25,10617.38,APC
Reconstruction of nose,30420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5730.25,10617.38,APC
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Revision of nose,30430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of nose,30435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of nose,30450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.07,,,,,,,fee schedule,4942.79,10827.33,
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10827.33,
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10827.33,
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.52,,,,,,,fee schedule,4942.79,10827.33,
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.23,,,,,,,fee schedule,4942.79,10827.33,
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10827.33,
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.33,,,,,,,fee schedule,4942.79,10827.33,
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10827.33,
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10827.33,APC
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10827.33,APC
Revision of nose,30460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10827.33,APC
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19639.24,,,,,,,fee schedule,4942.79,22585.13,
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,22585.13,
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,22585.13,
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12875.49,,,,,,,fee schedule,4942.79,22585.13,
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16074.72,,,,,,,fee schedule,4942.79,22585.13,
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,22585.13,
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22585.13,,,,,,,fee schedule,4942.79,22585.13,
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,22585.13,
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,22585.13,APC
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,22585.13,APC
Revision of nose,30462,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,22585.13,APC
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21268.51,,,,,,,fee schedule,4942.79,24458.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,24458.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,24458.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17408.28,,,,,,,fee schedule,4942.79,24458.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13943.64,,,,,,,fee schedule,4942.79,24458.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,24458.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24458.79,,,,,,,fee schedule,4942.79,24458.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,24458.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,24458.79,APC
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,24458.79,APC
Repair Nasal Stenosis,30465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,24458.79,APC
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9880.72,,,,,,,fee schedule,115.83,11362.83,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.83,,,,,,,fee schedule,115.83,11362.83,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,115.83,,,,,,,fee schedule,115.83,11362.83,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8087.37,,,,,,,fee schedule,115.83,11362.83,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6477.8,,,,,,,fee schedule,115.83,11362.83,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,133.2,,,,,,,fee schedule,115.83,11362.83,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11362.83,,,,,,,fee schedule,115.83,11362.83,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.83,,,,,,,fee schedule,115.83,11362.83,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,115.83,11362.83,APC
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,115.83,11362.83,APC
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,115.83,11362.83,APC
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10206.05,,,,,,,fee schedule,5144.92,11736.96,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5144.92,,,,,,,fee schedule,5144.92,11736.96,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5144.92,,,,,,,fee schedule,5144.92,11736.96,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8353.65,,,,,,,fee schedule,5144.92,11736.96,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6691.09,,,,,,,fee schedule,5144.92,11736.96,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5916.66,,,,,,,fee schedule,5144.92,11736.96,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11736.96,,,,,,,fee schedule,5144.92,11736.96,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5144.92,,,,,,,fee schedule,5144.92,11736.96,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5144.92,11736.96,APC
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5144.92,11736.96,APC
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5144.92,11736.96,APC
Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5079.12,,,,,,,fee schedule,3303.54,5946.37,
Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5079.12,,,,,,,fee schedule,3303.54,5946.37,
Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5840.99,,,,,,,fee schedule,3303.54,5946.37,
Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5079.12,,,,,,,fee schedule,3303.54,5946.37,
Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,3303.54,5946.37,APC
Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,3303.54,5946.37,APC
Repair of nasal septum,30520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,3303.54,5946.37,APC
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair nasal defect,30540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair nasal defect,30545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,967.3,
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,428.37,967.3,
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,967.3,
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,967.3,
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,428.37,967.3,
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,967.3,
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,967.3,APC
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,967.3,APC
Release of nasal adhesions,30560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,967.3,APC
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11762.9,,,,,,,fee schedule,5230.05,13527.34,
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5230.05,,,,,,,fee schedule,5230.05,13527.34,
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5230.05,,,,,,,fee schedule,5230.05,13527.34,
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7711.76,,,,,,,fee schedule,5230.05,13527.34,
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9627.93,,,,,,,fee schedule,5230.05,13527.34,
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6014.56,,,,,,,fee schedule,5230.05,13527.34,
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13527.34,,,,,,,fee schedule,5230.05,13527.34,
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5230.05,,,,,,,fee schedule,5230.05,13527.34,
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5230.05,13527.34,APC
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5230.05,13527.34,APC
Repair upper jaw fistula,30580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5230.05,13527.34,APC
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6014.56,,,,,,,fee schedule,3650.62,10617.38,
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair mouth/nose fistula,30600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6014.56,,,,,,,fee schedule,3650.62,10617.38,
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5230.05,,,,,,,fee schedule,3650.62,10617.38,
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Intranasal reconstruction,30620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,6014.56,
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5230.05,,,,,,,fee schedule,1684.24,6014.56,
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5230.05,,,,,,,fee schedule,1684.24,6014.56,
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,6014.56,
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,6014.56,
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6014.56,,,,,,,fee schedule,1684.24,6014.56,
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,6014.56,
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5230.05,,,,,,,fee schedule,1684.24,6014.56,
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,6014.56,APC
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,6014.56,APC
Repair nasal septum defect,30630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,6014.56,APC
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Ablate inf turbinate superf,30801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2782.81,
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2782.81,
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2782.81,
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1005.11,2782.81,
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2782.81,
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2782.81,APC
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2782.81,APC
Ablate inf turbinate submuc,30802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2782.81,APC
Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,132.57,4572.08,
Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,132.57,4572.08,
Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,132.57,4572.08,
Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,132.57,4572.08,
Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,4572.08,APC
Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,4572.08,APC
Control of nosebleed,30901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,4572.08,APC
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4425.64,,,,,,,fee schedule,127.87,5089.49,
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.87,,,,,,,fee schedule,127.87,5089.49,
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.87,,,,,,,fee schedule,127.87,5089.49,
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2901.45,,,,,,,fee schedule,127.87,5089.49,
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3622.39,,,,,,,fee schedule,127.87,5089.49,
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.05,,,,,,,fee schedule,127.87,5089.49,
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5089.49,,,,,,,fee schedule,127.87,5089.49,
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.87,,,,,,,fee schedule,127.87,5089.49,
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,127.87,5089.49,APC
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,127.87,5089.49,APC
Control of nosebleed,30903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,127.87,5089.49,APC
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.65,,,,,,,fee schedule,96.8,238.63,
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,96.8,238.63,
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,96.8,238.63,
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.8,,,,,,,fee schedule,96.8,238.63,
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.85,,,,,,,fee schedule,96.8,238.63,
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,96.8,238.63,
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.8,,,,,,,fee schedule,96.8,238.63,
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,96.8,238.63,
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,96.8,238.63,APC
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,96.8,238.63,APC
Control of nosebleed,30905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,96.8,238.63,APC
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,424.8,
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,171.38,424.8,
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,424.8,
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,424.8,
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,171.38,424.8,
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,424.8,
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,424.8,APC
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,424.8,APC
Repeat control of nosebleed,30906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,424.8,APC
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Ligation nasal sinus artery,30915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Ligation upper jaw artery,30920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,2258.7,6124.23,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,6124.23,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,2258.7,6124.23,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,2258.7,6124.23,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,2258.7,6124.23,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,2258.7,6124.23,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,2258.7,6124.23,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,6124.23,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2258.7,6124.23,APC
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2258.7,6124.23,APC
Ther fx nasal inf turbinate,30930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2258.7,6124.23,APC
Nasal surgery procedure,30999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Nasal surgery procedure,30999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Nasal surgery procedure,30999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,424.8,
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,334.63,,,,,,,fee schedule,171.38,424.8,
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.63,,,,,,,fee schedule,171.38,424.8,
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,424.8,
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,424.8,
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,384.82,,,,,,,fee schedule,171.38,424.8,
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,424.8,
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,334.63,,,,,,,fee schedule,171.38,424.8,
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,424.8,APC
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,424.8,APC
Irrigation maxillary sinus,31000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,424.8,APC
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Irrigation sphenoid sinus,31002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,1684.24,5946.37,
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Exploration maxillary sinus,31020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration maxillary sinus,31030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Explore sinus remove polyps,31032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Exploration behind upper jaw,31040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration sphenoid sinus,31050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Sphenoid sinus surgery,31051,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of frontal sinus,31070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of frontal sinus,31075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31084,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31086,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of frontal sinus,31087,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Exploration of sinuses,31090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of ethmoid sinus,31200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11762.9,,,,,,,fee schedule,1546,13527.34,
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,1546,13527.34,
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,1546,13527.34,
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7711.76,,,,,,,fee schedule,1546,13527.34,
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9627.93,,,,,,,fee schedule,1546,13527.34,
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,1546,13527.34,
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13527.34,,,,,,,fee schedule,1546,13527.34,
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,1546,13527.34,
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1546,13527.34,APC
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1546,13527.34,APC
Removal of ethmoid sinus,31201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1546,13527.34,APC
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of ethmoid sinus,31205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,215.8,,,,,,,fee schedule,141.48,358,
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.64,,,,,,,fee schedule,141.48,358,
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.64,,,,,,,fee schedule,141.48,358,
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.48,,,,,,,fee schedule,141.48,358,
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,176.63,,,,,,,fee schedule,141.48,358,
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.59,,,,,,,fee schedule,141.48,358,
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,248.17,,,,,,,fee schedule,141.48,358,
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.64,,,,,,,fee schedule,141.48,358,
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.83,,,,,,,fee schedule,141.48,358,APC
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.89,,,,,,,fee schedule,141.48,358,APC
Nasal endoscopy dx,31231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,358,,,,,,,fee schedule,141.48,358,APC
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.3,,,,,,,fee schedule,350.29,701.48,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,512.02,,,,,,,fee schedule,350.29,701.48,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.29,,,,,,,fee schedule,350.29,701.48,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.32,,,,,,,fee schedule,350.29,701.48,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.82,,,,,,,fee schedule,350.29,701.48,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.45,,,,,,,fee schedule,350.29,701.48,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.2,,,,,,,fee schedule,350.29,701.48,APC
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.71,,,,,,,fee schedule,350.29,701.48,APC
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,701.48,,,,,,,fee schedule,350.29,701.48,APC
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1554.98,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.44,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1272.75,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.23,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1019.44,3192.3,APC
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1019.44,3192.3,APC
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1019.44,3192.3,APC
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5127.87,,,,,,,fee schedule,1669.08,5897.05,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,5897.05,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1669.08,5897.05,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3361.83,,,,,,,fee schedule,1669.08,5897.05,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4197.16,,,,,,,fee schedule,1669.08,5897.05,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1669.08,5897.05,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5897.05,,,,,,,fee schedule,1669.08,5897.05,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,5897.05,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1669.08,5897.05,APC
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1669.08,5897.05,APC
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1669.08,5897.05,APC
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5722.21,,,,,,,fee schedule,1407.9,6580.54,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1407.9,,,,,,,fee schedule,1407.9,6580.54,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1407.9,,,,,,,fee schedule,1407.9,6580.54,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3751.48,,,,,,,fee schedule,1407.9,6580.54,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4683.63,,,,,,,fee schedule,1407.9,6580.54,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1619.09,,,,,,,fee schedule,1407.9,6580.54,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6580.54,,,,,,,fee schedule,1407.9,6580.54,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1407.9,,,,,,,fee schedule,1407.9,6580.54,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1407.9,6580.54,APC
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1407.9,6580.54,APC
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1407.9,6580.54,APC
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,2001.79,6686.89,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,2001.79,6686.89,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,2001.79,6686.89,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2001.79,6686.89,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,2001.79,6686.89,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2001.79,6686.89,APC
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2001.79,6686.89,APC
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2001.79,6686.89,APC
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1554.98,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.44,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1272.75,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.23,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,1019.44,3192.3,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1019.44,3192.3,APC
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1019.44,3192.3,APC
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1019.44,3192.3,APC
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1064.46,,,,,,,fee schedule,697.86,3192.3,
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,697.86,,,,,,,fee schedule,697.86,3192.3,
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,871.26,,,,,,,fee schedule,697.86,3192.3,
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1224.13,,,,,,,fee schedule,697.86,3192.3,
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,697.86,3192.3,APC
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,697.86,3192.3,APC
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,697.86,3192.3,APC
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10081.15,,,,,,,fee schedule,4796.13,11593.32,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4796.13,,,,,,,fee schedule,4796.13,11593.32,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4796.13,,,,,,,fee schedule,4796.13,11593.32,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6609.2,,,,,,,fee schedule,4796.13,11593.32,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8251.42,,,,,,,fee schedule,4796.13,11593.32,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5515.55,,,,,,,fee schedule,4796.13,11593.32,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11593.32,,,,,,,fee schedule,4796.13,11593.32,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4796.13,,,,,,,fee schedule,4796.13,11593.32,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4796.13,11593.32,APC
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4796.13,11593.32,APC
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4796.13,11593.32,APC
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10081.15,,,,,,,fee schedule,5064.61,11593.32,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5064.61,,,,,,,fee schedule,5064.61,11593.32,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5064.61,,,,,,,fee schedule,5064.61,11593.32,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6609.2,,,,,,,fee schedule,5064.61,11593.32,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8251.42,,,,,,,fee schedule,5064.61,11593.32,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5824.3,,,,,,,fee schedule,5064.61,11593.32,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11593.32,,,,,,,fee schedule,5064.61,11593.32,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5064.61,,,,,,,fee schedule,5064.61,11593.32,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5064.61,11593.32,APC
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5064.61,11593.32,APC
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5064.61,11593.32,APC
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13279.49,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8706.03,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10869.26,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3396.12,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15271.41,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc total,31253,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2953.15,15271.41,APC
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7700.53,,,,,,,fee schedule,2663.84,12657.75,
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5048.47,,,,,,,fee schedule,2663.84,12657.75,
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6302.88,,,,,,,fee schedule,2663.84,12657.75,
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,12657.75,
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8855.61,,,,,,,fee schedule,2663.84,12657.75,
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2663.84,12657.75,APC
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2663.84,12657.75,APC
Revision of ethmoid sinus,31254,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2663.84,12657.75,APC
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8727.65,,,,,,,fee schedule,4069.17,12657.75,
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5721.85,,,,,,,fee schedule,4069.17,12657.75,
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7143.58,,,,,,,fee schedule,4069.17,12657.75,
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4679.55,,,,,,,fee schedule,4069.17,12657.75,
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10036.8,,,,,,,fee schedule,4069.17,12657.75,
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,4069.17,12657.75,APC
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,4069.17,12657.75,APC
Removal of ethmoid sinus,31255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,4069.17,12657.75,APC
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5764.89,,,,,,,fee schedule,2663.84,6686.89,
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3779.46,,,,,,,fee schedule,2663.84,6686.89,
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4718.56,,,,,,,fee schedule,2663.84,6686.89,
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,6686.89,
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6629.62,,,,,,,fee schedule,2663.84,6686.89,
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2663.84,6686.89,APC
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2663.84,6686.89,APC
Exploration maxillary sinus,31256,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2663.84,6686.89,APC
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13279.49,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8706.03,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10869.26,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3396.12,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15271.41,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13279.49,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8706.03,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10869.26,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3396.12,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15271.41,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2953.15,15271.41,APC
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8649.86,,,,,,,fee schedule,2663.84,12657.75,
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5670.85,,,,,,,fee schedule,2663.84,12657.75,
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7079.91,,,,,,,fee schedule,2663.84,12657.75,
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,12657.75,
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9947.34,,,,,,,fee schedule,2663.84,12657.75,
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2663.84,12657.75,APC
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2663.84,12657.75,APC
Endoscopy maxillary sinus,31267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2663.84,12657.75,APC
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9291.17,,,,,,,fee schedule,4069.17,12657.75,
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6091.29,,,,,,,fee schedule,4069.17,12657.75,
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7604.82,,,,,,,fee schedule,4069.17,12657.75,
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4679.55,,,,,,,fee schedule,4069.17,12657.75,
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10684.85,,,,,,,fee schedule,4069.17,12657.75,
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,4069.17,12657.75,APC
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,4069.17,12657.75,APC
Sinus endoscopy surgical,31276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,4069.17,12657.75,APC
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8789.6,,,,,,,fee schedule,4069.17,12657.75,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5762.46,,,,,,,fee schedule,4069.17,12657.75,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7194.29,,,,,,,fee schedule,4069.17,12657.75,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4679.55,,,,,,,fee schedule,4069.17,12657.75,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10108.04,,,,,,,fee schedule,4069.17,12657.75,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,4069.17,12657.75,APC
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,4069.17,12657.75,APC
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,4069.17,12657.75,APC
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,3062.14,12657.75,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,3062.14,12657.75,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,3062.14,12657.75,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4679.55,,,,,,,fee schedule,3062.14,12657.75,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,3062.14,12657.75,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,3062.14,12657.75,APC
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,3062.14,12657.75,APC
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,3062.14,12657.75,APC
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6524.99,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4277.78,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5340.7,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7503.74,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,4277.78,12657.75,APC
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,4277.78,12657.75,APC
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,4277.78,12657.75,APC
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6524.99,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4277.78,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5340.7,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7503.74,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,4277.78,12657.75,APC
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,4277.78,12657.75,APC
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,4277.78,12657.75,APC
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6524.99,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4277.78,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5340.7,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7503.74,,,,,,,fee schedule,4277.78,12657.75,
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,4277.78,12657.75,APC
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,4277.78,12657.75,APC
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,4277.78,12657.75,APC
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,3062.14,12657.75,
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,3062.14,12657.75,
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,3062.14,12657.75,
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4679.55,,,,,,,fee schedule,3062.14,12657.75,
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,3062.14,12657.75,
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,3062.14,12657.75,APC
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,3062.14,12657.75,APC
Sinus endo w/balloon dil,31295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,3062.14,12657.75,APC
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7370.26,,,,,,,fee schedule,4069.17,12657.75,
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4831.94,,,,,,,fee schedule,4069.17,12657.75,
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6032.56,,,,,,,fee schedule,4069.17,12657.75,
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4679.55,,,,,,,fee schedule,4069.17,12657.75,
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8475.8,,,,,,,fee schedule,4069.17,12657.75,
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4069.17,,,,,,,fee schedule,4069.17,12657.75,
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,4069.17,12657.75,APC
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,4069.17,12657.75,APC
Sinus endo w/balloon dil,31296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,4069.17,12657.75,APC
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,2663.84,12657.75,
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,2663.84,12657.75,
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,2663.84,12657.75,
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,12657.75,
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,2663.84,12657.75,
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2663.84,12657.75,APC
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2663.84,12657.75,APC
Sinus endo w/balloon dil,31297,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2663.84,12657.75,APC
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13279.49,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8706.03,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10869.26,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3396.12,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15271.41,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2953.15,,,,,,,fee schedule,2953.15,15271.41,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2953.15,15271.41,APC
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2953.15,15271.41,APC
Sinus surgery procedure,31299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Sinus surgery procedure,31299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Sinus surgery procedure,31299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of larynx lesion,31300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of larynx,31400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of epiglottis,31420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,424.8,
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,171.38,424.8,
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,424.8,
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,424.8,
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,171.38,424.8,
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,424.8,
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,424.8,APC
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,424.8,APC
Insert emergency airway,31500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,424.8,APC
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,424.8,
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,171.38,424.8,
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,424.8,
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,424.8,
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,171.38,424.8,
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,424.8,
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,424.8,APC
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,424.8,APC
Change of windpipe airway,31502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,424.8,APC
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.69,,,,,,,fee schedule,106,358,
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,143.65,,,,,,,fee schedule,106,358,
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.65,,,,,,,fee schedule,106,358,
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106,,,,,,,fee schedule,106,358,
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.34,,,,,,,fee schedule,106,358,
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.2,,,,,,,fee schedule,106,358,
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.94,,,,,,,fee schedule,106,358,
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.65,,,,,,,fee schedule,106,358,
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.83,,,,,,,fee schedule,106,358,APC
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.89,,,,,,,fee schedule,106,358,APC
Diagnostic laryngoscopy,31505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,358,,,,,,,fee schedule,106,358,APC
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscopy with biopsy,31510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,1669.08,6686.89,APC
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,215.8,,,,,,,fee schedule,141.48,358,
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.64,,,,,,,fee schedule,141.48,358,
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.64,,,,,,,fee schedule,141.48,358,
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.48,,,,,,,fee schedule,141.48,358,
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,176.63,,,,,,,fee schedule,141.48,358,
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.59,,,,,,,fee schedule,141.48,358,
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,248.17,,,,,,,fee schedule,141.48,358,
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.64,,,,,,,fee schedule,141.48,358,
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.83,,,,,,,fee schedule,141.48,358,APC
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.89,,,,,,,fee schedule,141.48,358,APC
Remove foreign body larynx,31511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,358,,,,,,,fee schedule,141.48,358,APC
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,2001.79,6686.89,
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,2001.79,6686.89,
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,2001.79,6686.89,
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2001.79,6686.89,
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,2001.79,6686.89,
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2001.79,6686.89,APC
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2001.79,6686.89,APC
Removal of larynx lesion,31512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2001.79,6686.89,APC
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.3,,,,,,,fee schedule,350.29,701.48,
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,512.02,,,,,,,fee schedule,350.29,701.48,
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.29,,,,,,,fee schedule,350.29,701.48,
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.32,,,,,,,fee schedule,350.29,701.48,
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.82,,,,,,,fee schedule,350.29,701.48,
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.45,,,,,,,fee schedule,350.29,701.48,
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.2,,,,,,,fee schedule,350.29,701.48,APC
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.71,,,,,,,fee schedule,350.29,701.48,APC
Injection into vocal cord,31513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,701.48,,,,,,,fee schedule,350.29,701.48,APC
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.3,,,,,,,fee schedule,350.29,1919.44,
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,350.29,1919.44,
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,350.29,1919.44,
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.29,,,,,,,fee schedule,350.29,1919.44,
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.32,,,,,,,fee schedule,350.29,1919.44,
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,350.29,1919.44,
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.45,,,,,,,fee schedule,350.29,1919.44,
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,350.29,1919.44,
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.2,,,,,,,fee schedule,350.29,1919.44,APC
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.71,,,,,,,fee schedule,350.29,1919.44,APC
Laryngoscopy for aspiration,31515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,701.48,,,,,,,fee schedule,350.29,1919.44,APC
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.3,,,,,,,fee schedule,350.29,701.48,
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,512.02,,,,,,,fee schedule,350.29,701.48,
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.29,,,,,,,fee schedule,350.29,701.48,
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.32,,,,,,,fee schedule,350.29,701.48,
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.82,,,,,,,fee schedule,350.29,701.48,
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.45,,,,,,,fee schedule,350.29,701.48,
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.2,,,,,,,fee schedule,350.29,701.48,APC
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.71,,,,,,,fee schedule,350.29,701.48,APC
Dx laryngoscopy newborn,31520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,701.48,,,,,,,fee schedule,350.29,701.48,APC
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1554.98,,,,,,,fee schedule,1019.44,3192.3,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.44,,,,,,,fee schedule,1019.44,3192.3,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1272.75,,,,,,,fee schedule,1019.44,3192.3,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1019.44,3192.3,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.23,,,,,,,fee schedule,1019.44,3192.3,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1019.44,3192.3,APC
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1019.44,3192.3,APC
Dx laryngoscopy excl nb,31525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1019.44,3192.3,APC
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,1669.08,4948.46,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,4948.46,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1669.08,4948.46,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,1669.08,4948.46,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,1669.08,4948.46,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1669.08,4948.46,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,1669.08,4948.46,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,4948.46,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1669.08,4948.46,APC
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1669.08,4948.46,APC
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1669.08,4948.46,APC
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscopy for treatment,31527,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4710.47,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3088.18,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3855.52,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5417.04,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy and dilation,31528,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy and dilation,31529,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4885.25,,,,,,,fee schedule,1669.08,5618.04,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,5618.04,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1669.08,5618.04,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3202.77,,,,,,,fee schedule,1669.08,5618.04,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3998.58,,,,,,,fee schedule,1669.08,5618.04,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1669.08,5618.04,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5618.04,,,,,,,fee schedule,1669.08,5618.04,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,5618.04,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1669.08,5618.04,APC
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1669.08,5618.04,APC
Laryngoscopy w/fb removal,31530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1669.08,5618.04,APC
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.51,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.17,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy w/biopsy,31535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2663.84,6686.89,APC
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2001.79,6686.89,APC
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2663.84,6686.89,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2663.84,6686.89,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2663.84,6686.89,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,6686.89,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2663.84,6686.89,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,6686.89,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2663.84,6686.89,APC
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2663.84,6686.89,APC
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2663.84,6686.89,APC
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,2001.79,6686.89,
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,2001.79,6686.89,
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,2001.79,6686.89,
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2001.79,6686.89,
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,2001.79,6686.89,
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2001.79,6686.89,APC
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2001.79,6686.89,APC
Remove vc lesion w/scope,31545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2001.79,6686.89,APC
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,3062.14,12657.75,
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,3062.14,12657.75,
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,3062.14,12657.75,
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4679.55,,,,,,,fee schedule,3062.14,12657.75,
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,3062.14,12657.75,
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,3062.14,12657.75,APC
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,3062.14,12657.75,APC
Remove vc lesion scope/graft,31546,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,3062.14,12657.75,APC
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,3062.14,12657.75,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,3062.14,12657.75,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,3062.14,12657.75,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4679.55,,,,,,,fee schedule,3062.14,12657.75,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,3062.14,12657.75,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4069.17,,,,,,,fee schedule,3062.14,12657.75,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,3062.14,12657.75,APC
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,3062.14,12657.75,APC
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,3062.14,12657.75,APC
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,2663.84,12657.75,
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,2663.84,12657.75,
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,2663.84,12657.75,
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2663.84,12657.75,
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,2663.84,12657.75,
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2663.84,12657.75,
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2663.84,12657.75,APC
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2663.84,12657.75,APC
Larynscop remve cart + scop,31561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2663.84,12657.75,APC
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.52,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.18,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.85,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscope w/vc inj,31570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3063.42,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2663.84,,,,,,,fee schedule,2001.79,6686.89,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2001.79,6686.89,APC
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2001.79,6686.89,APC
Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4116.86,,,,,,,fee schedule,2699.01,6686.89,
Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2699.01,,,,,,,fee schedule,2699.01,6686.89,
Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3369.65,,,,,,,fee schedule,2699.01,6686.89,
Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4734.39,,,,,,,fee schedule,2699.01,6686.89,
Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2699.01,6686.89,APC
Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2699.01,6686.89,APC
Largsc w/laser dstrj les,31572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2699.01,6686.89,APC
Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2096.59,,,,,,,fee schedule,1374.52,3192.3,
Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1374.52,,,,,,,fee schedule,1374.52,3192.3,
Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1716.06,,,,,,,fee schedule,1374.52,3192.3,
Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2411.08,,,,,,,fee schedule,1374.52,3192.3,
Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1374.52,3192.3,APC
Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1374.52,3192.3,APC
Largsc w/ther injection,31573,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1374.52,3192.3,APC
Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2096.59,,,,,,,fee schedule,1374.52,3192.3,
Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1374.52,,,,,,,fee schedule,1374.52,3192.3,
Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1716.06,,,,,,,fee schedule,1374.52,3192.3,
Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2411.08,,,,,,,fee schedule,1374.52,3192.3,
Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1374.52,3192.3,APC
Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1374.52,3192.3,APC
Largsc w/njx augmentation,31574,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1374.52,3192.3,APC
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.63,,,,,,,fee schedule,138.74,358,
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.78,,,,,,,fee schedule,138.74,358,
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.78,,,,,,,fee schedule,138.74,358,
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.74,,,,,,,fee schedule,138.74,358,
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.22,,,,,,,fee schedule,138.74,358,
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.85,,,,,,,fee schedule,138.74,358,
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.37,,,,,,,fee schedule,138.74,358,
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.78,,,,,,,fee schedule,138.74,358,
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.83,,,,,,,fee schedule,138.74,358,APC
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.89,,,,,,,fee schedule,138.74,358,APC
Diagnostic laryngoscopy,31575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,358,,,,,,,fee schedule,138.74,358,APC
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1554.98,,,,,,,fee schedule,1019.44,3192.3,
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.44,,,,,,,fee schedule,1019.44,3192.3,
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1272.75,,,,,,,fee schedule,1019.44,3192.3,
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1019.44,3192.3,
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.23,,,,,,,fee schedule,1019.44,3192.3,
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1019.44,3192.3,
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1019.44,3192.3,APC
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1019.44,3192.3,APC
Laryngoscopy with biopsy,31576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1019.44,3192.3,APC
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.3,,,,,,,fee schedule,350.29,701.48,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,512.02,,,,,,,fee schedule,350.29,701.48,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.29,,,,,,,fee schedule,350.29,701.48,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.32,,,,,,,fee schedule,350.29,701.48,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.82,,,,,,,fee schedule,350.29,701.48,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.45,,,,,,,fee schedule,350.29,701.48,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.2,,,,,,,fee schedule,350.29,701.48,APC
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.71,,,,,,,fee schedule,350.29,701.48,APC
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,701.48,,,,,,,fee schedule,350.29,701.48,APC
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,1669.08,6686.89,
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,1669.08,6686.89,
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,1669.08,6686.89,
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.44,,,,,,,fee schedule,1669.08,6686.89,
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,1669.08,6686.89,
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.08,,,,,,,fee schedule,1669.08,6686.89,
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,1669.08,6686.89,APC
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,1669.08,6686.89,APC
Largsc w/removal lesion,31578,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,1669.08,6686.89,APC
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.17,,,,,,,fee schedule,186.3,701.48,
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,259.58,,,,,,,fee schedule,186.3,701.48,
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.58,,,,,,,fee schedule,186.3,701.48,
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.3,,,,,,,fee schedule,186.3,701.48,
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.59,,,,,,,fee schedule,186.3,701.48,
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.52,,,,,,,fee schedule,186.3,701.48,
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.8,,,,,,,fee schedule,186.3,701.48,
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.58,,,,,,,fee schedule,186.3,701.48,
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.2,,,,,,,fee schedule,186.3,701.48,APC
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.71,,,,,,,fee schedule,186.3,701.48,APC
Laryngoscopy telescopic,31579,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,701.48,,,,,,,fee schedule,186.3,701.48,APC
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty laryngeal web,31580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Laryngoplasty cricoid split,31587,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reinnervate larynx,31590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Laryngoplasty medialization,31591,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Cricotracheal resection,31592,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Larynx surgery procedure,31599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Larynx surgery procedure,31599,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Larynx surgery procedure,31599,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3250.82,,,,,,,fee schedule,2131.24,5946.37,
Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2131.24,,,,,,,fee schedule,2131.24,5946.37,
Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2660.8,,,,,,,fee schedule,2131.24,5946.37,
Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3738.44,,,,,,,fee schedule,2131.24,5946.37,
Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2131.24,5946.37,APC
Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2131.24,5946.37,APC
Incision of windpipe,31600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2131.24,5946.37,APC
Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Incision of windpipe,31601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Incision of windpipe,31603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,236,985.44,
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,236,985.44,
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,236,985.44,
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,236,985.44,
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,236,985.44,
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,236,985.44,
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,236,985.44,
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,236,985.44,
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,985.44,APC
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,985.44,APC
Incision of windpipe,31605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,985.44,APC
Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Incision of windpipe,31610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Surgery/speech prosthesis,31611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Puncture/clear windpipe,31612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Repair windpipe opening,31613,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair windpipe opening,31614,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,985.44,
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,428.37,985.44,
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,985.44,
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,985.44,
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,428.37,985.44,
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,985.44,
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,985.44,APC
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,985.44,APC
Visualization of windpipe,31615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,985.44,APC
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1444.35,,,,,,,fee schedule,946.92,3192.3,
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,946.92,3192.3,
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,946.92,3192.3,
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,946.92,,,,,,,fee schedule,946.92,3192.3,
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1182.2,,,,,,,fee schedule,946.92,3192.3,
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,946.92,3192.3,
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1661,,,,,,,fee schedule,946.92,3192.3,
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,946.92,3192.3,
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,946.92,3192.3,APC
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,946.92,3192.3,APC
Dx bronchoscope/wash,31622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,946.92,3192.3,APC
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6910.89,,,,,,,fee schedule,1398.16,7947.52,
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,7947.52,
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,1398.16,7947.52,
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4530.78,,,,,,,fee schedule,1398.16,7947.52,
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5656.56,,,,,,,fee schedule,1398.16,7947.52,
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,1398.16,7947.52,
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7947.52,,,,,,,fee schedule,1398.16,7947.52,
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,7947.52,
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1398.16,7947.52,APC
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1398.16,7947.52,APC
Dx bronchoscope/brush,31623,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1398.16,7947.52,APC
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2166.52,,,,,,,fee schedule,1398.16,3192.3,
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,3192.3,
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,1398.16,3192.3,
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.37,,,,,,,fee schedule,1398.16,3192.3,
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1773.3,,,,,,,fee schedule,1398.16,3192.3,
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,1398.16,3192.3,
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2491.5,,,,,,,fee schedule,1398.16,3192.3,
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,3192.3,
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1398.16,3192.3,APC
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1398.16,3192.3,APC
Dx bronchoscope/lavage,31624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1398.16,3192.3,APC
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6794.46,,,,,,,fee schedule,1398.16,7813.63,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,7813.63,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,1398.16,7813.63,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4454.45,,,,,,,fee schedule,1398.16,7813.63,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5561.27,,,,,,,fee schedule,1398.16,7813.63,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,1398.16,7813.63,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7813.63,,,,,,,fee schedule,1398.16,7813.63,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,7813.63,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1398.16,7813.63,APC
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1398.16,7813.63,APC
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1398.16,7813.63,APC
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy w/markers,31626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8079.97,,,,,,,fee schedule,1398.16,9291.97,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,9291.97,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,1398.16,9291.97,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5297.23,,,,,,,fee schedule,1398.16,9291.97,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6613.46,,,,,,,fee schedule,1398.16,9291.97,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,1398.16,9291.97,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9291.97,,,,,,,fee schedule,1398.16,9291.97,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,9291.97,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,1398.16,9291.97,APC
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,1398.16,9291.97,APC
Bronchoscopy/lung bx each,31628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,1398.16,9291.97,APC
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5333.69,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3496.77,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4365.63,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6133.74,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2989.99,6686.89,APC
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2989.99,6686.89,APC
Bronchoscopy/needle bx each,31629,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2989.99,6686.89,APC
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.84,,,,,,,fee schedule,2989.99,7300.02,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,7300.02,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,7300.02,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.64,,,,,,,fee schedule,2989.99,7300.02,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.71,,,,,,,fee schedule,2989.99,7300.02,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,7300.02,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.02,,,,,,,fee schedule,2989.99,7300.02,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,7300.02,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2989.99,7300.02,APC
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2989.99,7300.02,APC
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2989.99,7300.02,APC
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2989.99,12657.75,APC
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,2989.99,12657.75,
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,2989.99,12657.75,
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,2989.99,12657.75,
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,12657.75,
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,2989.99,12657.75,
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2989.99,12657.75,APC
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2989.99,12657.75,APC
Bronch w/balloon occlusion,31634,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,1398.16,6124.23,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,6124.23,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,1398.16,6124.23,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,1398.16,6124.23,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,1398.16,6124.23,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,1398.16,6124.23,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,1398.16,6124.23,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,1398.16,6124.23,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1398.16,6124.23,APC
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1398.16,6124.23,APC
Bronchoscopy w/fb removal,31635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1398.16,6124.23,APC
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6513.37,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4270.17,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5331.19,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7490.38,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy bronch stents,31636,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy revise stent,31638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,2821.05,6686.89,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2821.05,6686.89,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2821.05,6686.89,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,2821.05,6686.89,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,2821.05,6686.89,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2821.05,6686.89,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,2821.05,6686.89,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2821.05,6686.89,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2821.05,6686.89,APC
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2821.05,6686.89,APC
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2821.05,6686.89,APC
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5325.42,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3491.35,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.86,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6124.23,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,6686.89,
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2989.99,6686.89,APC
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2989.99,6686.89,APC
Bronchoscopy treat blockage,31641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2989.99,6686.89,APC
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1554.98,,,,,,,fee schedule,1019.44,3192.3,
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.44,,,,,,,fee schedule,1019.44,3192.3,
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1272.75,,,,,,,fee schedule,1019.44,3192.3,
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,1019.44,3192.3,
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.23,,,,,,,fee schedule,1019.44,3192.3,
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1019.44,3192.3,APC
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1019.44,3192.3,APC
Diag bronchoscope/catheter,31643,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1019.44,3192.3,APC
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1554.98,,,,,,,fee schedule,1019.44,3192.3,
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.44,,,,,,,fee schedule,1019.44,3192.3,
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1272.75,,,,,,,fee schedule,1019.44,3192.3,
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,1019.44,3192.3,
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.23,,,,,,,fee schedule,1019.44,3192.3,
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1019.44,3192.3,APC
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1019.44,3192.3,APC
Bronchoscopy clear airways,31645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1019.44,3192.3,APC
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.3,,,,,,,fee schedule,350.29,1607.88,
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,350.29,1607.88,
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,350.29,1607.88,
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.29,,,,,,,fee schedule,350.29,1607.88,
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.32,,,,,,,fee schedule,350.29,1607.88,
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,350.29,1607.88,
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.45,,,,,,,fee schedule,350.29,1607.88,
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,350.29,1607.88,
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.2,,,,,,,fee schedule,350.29,1607.88,APC
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.71,,,,,,,fee schedule,350.29,1607.88,APC
Bronchoscopy reclear airway,31646,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,701.48,,,,,,,fee schedule,350.29,1607.88,APC
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4670.75,,,,,,,fee schedule,2989.99,12657.75,
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3062.14,,,,,,,fee schedule,2989.99,12657.75,
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3823.01,,,,,,,fee schedule,2989.99,12657.75,
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2989.99,12657.75,
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5371.36,,,,,,,fee schedule,2989.99,12657.75,
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2989.99,12657.75,
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchial valve init insert,31647,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,2989.99,12657.75,APC
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3053.37,,,,,,,fee schedule,2001.79,6686.89,
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2989.99,,,,,,,fee schedule,2001.79,6686.89,
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2989.99,,,,,,,fee schedule,2001.79,6686.89,
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2001.79,,,,,,,fee schedule,2001.79,6686.89,
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2499.18,,,,,,,fee schedule,2001.79,6686.89,
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3438.49,,,,,,,fee schedule,2001.79,6686.89,
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3511.38,,,,,,,fee schedule,2001.79,6686.89,
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2989.99,,,,,,,fee schedule,2001.79,6686.89,
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,2001.79,6686.89,APC
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,2001.79,6686.89,APC
Bronchial valve remov init,31648,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,2001.79,6686.89,APC
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1554.98,,,,,,,fee schedule,1019.44,3192.3,
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.44,,,,,,,fee schedule,1019.44,3192.3,
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1272.75,,,,,,,fee schedule,1019.44,3192.3,
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1607.88,,,,,,,fee schedule,1019.44,3192.3,
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.23,,,,,,,fee schedule,1019.44,3192.3,
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.16,,,,,,,fee schedule,1019.44,3192.3,
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,1019.44,3192.3,APC
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,1019.44,3192.3,APC
Bronchial valve remov addl,31649,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,1019.44,3192.3,APC
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6155.61,,,,,,,fee schedule,3714.94,7078.95,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4035.62,,,,,,,fee schedule,3714.94,7078.95,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5038.37,,,,,,,fee schedule,3714.94,7078.95,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7078.95,,,,,,,fee schedule,3714.94,7078.95,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,3714.94,7078.95,APC
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,3714.94,7078.95,APC
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,3714.94,7078.95,APC
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6689.99,,,,,,,fee schedule,3714.94,7693.49,
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4385.96,,,,,,,fee schedule,3714.94,7693.49,
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5475.76,,,,,,,fee schedule,3714.94,7693.49,
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7693.49,,,,,,,fee schedule,3714.94,7693.49,
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3900.69,,,,,,,fee schedule,3714.94,7693.49,APC
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3714.94,,,,,,,fee schedule,3714.94,7693.49,APC
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6686.89,,,,,,,fee schedule,3714.94,7693.49,APC
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2741.66,,,,,,,fee schedule,1797.43,12657.75,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1797.43,,,,,,,fee schedule,1797.43,12657.75,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2244.05,,,,,,,fee schedule,1797.43,12657.75,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3152.91,,,,,,,fee schedule,1797.43,12657.75,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,1797.43,12657.75,APC
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,1797.43,12657.75,APC
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,1797.43,12657.75,APC
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2741.66,,,,,,,fee schedule,1797.43,12657.75,
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1797.43,,,,,,,fee schedule,1797.43,12657.75,
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2244.05,,,,,,,fee schedule,1797.43,12657.75,
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3152.91,,,,,,,fee schedule,1797.43,12657.75,
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7383.68,,,,,,,fee schedule,1797.43,12657.75,APC
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7032.08,,,,,,,fee schedule,1797.43,12657.75,APC
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12657.75,,,,,,,fee schedule,1797.43,12657.75,APC
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.3,,,,,,,fee schedule,350.29,701.48,
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,512.02,,,,,,,fee schedule,350.29,701.48,
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.29,,,,,,,fee schedule,350.29,701.48,
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.32,,,,,,,fee schedule,350.29,701.48,
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.82,,,,,,,fee schedule,350.29,701.48,
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.45,,,,,,,fee schedule,350.29,701.48,
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,512.02,,,,,,,fee schedule,350.29,701.48,
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.2,,,,,,,fee schedule,350.29,701.48,APC
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.71,,,,,,,fee schedule,350.29,701.48,APC
Bronchial brush biopsy,31717,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,701.48,,,,,,,fee schedule,350.29,701.48,APC
Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.41,,,,,,,fee schedule,158.92,392.74,
Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.92,,,,,,,fee schedule,158.92,392.74,
Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.41,,,,,,,fee schedule,158.92,392.74,
Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.77,,,,,,,fee schedule,158.92,392.74,
Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,229.1,,,,,,,fee schedule,158.92,392.74,APC
Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.19,,,,,,,fee schedule,158.92,392.74,APC
Clearance of airways,31720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.74,,,,,,,fee schedule,158.92,392.74,APC
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1554.98,,,,,,,fee schedule,512.02,3192.3,
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,512.02,,,,,,,fee schedule,512.02,3192.3,
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,512.02,,,,,,,fee schedule,512.02,3192.3,
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1019.44,,,,,,,fee schedule,512.02,3192.3,
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1272.75,,,,,,,fee schedule,512.02,3192.3,
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.82,,,,,,,fee schedule,512.02,3192.3,
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1788.23,,,,,,,fee schedule,512.02,3192.3,
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,512.02,,,,,,,fee schedule,512.02,3192.3,
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,512.02,3192.3,APC
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,512.02,3192.3,APC
Intro windpipe wire/tube,31730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,512.02,3192.3,APC
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair of windpipe,31750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair of windpipe,31755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Remove windpipe lesion,31785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Closure of windpipe lesion,31820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Repair of windpipe defect,31825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Revise windpipe scar,31830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Airways surgical procedure,31899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.83,,,,,,,fee schedule,198.89,358,APC
Airways surgical procedure,31899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.89,,,,,,,fee schedule,198.89,358,APC
Airways surgical procedure,31899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,358,,,,,,,fee schedule,198.89,358,APC
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1235.07,,,,,,,fee schedule,809.71,2962.18,
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,809.71,2962.18,
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,809.71,2962.18,
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,809.71,,,,,,,fee schedule,809.71,2962.18,
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1010.9,,,,,,,fee schedule,809.71,2962.18,
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,809.71,2962.18,
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1420.33,,,,,,,fee schedule,809.71,2962.18,
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,809.71,2962.18,
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,809.71,2962.18,APC
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,809.71,2962.18,APC
Needle biopsy chest lining,32400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,809.71,2962.18,APC
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2733.38,,,,,,,fee schedule,19.86,3143.39,
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.86,,,,,,,fee schedule,19.86,3143.39,
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.86,,,,,,,fee schedule,19.86,3143.39,
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1792,,,,,,,fee schedule,19.86,3143.39,
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2237.27,,,,,,,fee schedule,19.86,3143.39,
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.84,,,,,,,fee schedule,19.86,3143.39,
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3143.39,,,,,,,fee schedule,19.86,3143.39,
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.86,,,,,,,fee schedule,19.86,3143.39,
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,19.86,3143.39,APC
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,19.86,3143.39,APC
Core ndl bx lng/med perq,32408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,19.86,3143.39,APC
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3487.06,,,,,,,fee schedule,2604.09,6421.55,
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Insert pleural cath,32550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,670.76,2823.29,
Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,670.76,2823.29,
Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,670.76,2823.29,
Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,670.76,2823.29,
Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,670.76,2823.29,APC
Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,670.76,2823.29,APC
Insertion of chest tube,32551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,670.76,2823.29,APC
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,625.05,1161.41,
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,625.05,1161.41,
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,625.05,1161.41,
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,625.05,1161.41,
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,625.05,1161.41,
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,625.05,1161.41,
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,625.05,1161.41,
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,625.05,1161.41,
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1161.41,APC
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1161.41,APC
Remove lung catheter,32552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1161.41,APC
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1574,,,,,,,fee schedule,1031.91,2482.48,
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1376.2,,,,,,,fee schedule,1031.91,2482.48,
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1376.2,,,,,,,fee schedule,1031.91,2482.48,
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1031.91,,,,,,,fee schedule,1031.91,2482.48,
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1288.32,,,,,,,fee schedule,1031.91,2482.48,
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1582.63,,,,,,,fee schedule,1031.91,2482.48,
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1810.1,,,,,,,fee schedule,1031.91,2482.48,
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1376.2,,,,,,,fee schedule,1031.91,2482.48,
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1448.11,,,,,,,fee schedule,1031.91,2482.48,APC
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1379.15,,,,,,,fee schedule,1031.91,2482.48,APC
Ins mark thor for rt perq,32553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2482.48,,,,,,,fee schedule,1031.91,2482.48,APC
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,625.05,1161.41,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,625.05,1161.41,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,625.05,1161.41,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,625.05,1161.41,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,625.05,1161.41,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,625.05,1161.41,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,625.05,1161.41,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,625.05,1161.41,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1161.41,APC
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1161.41,APC
Aspirate pleura w/o imaging,32554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1161.41,APC
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3442.81,,,,,,,fee schedule,625.05,3959.23,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,625.05,3959.23,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,625.05,3959.23,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2257.11,,,,,,,fee schedule,625.05,3959.23,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2817.94,,,,,,,fee schedule,625.05,3959.23,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,625.05,3959.23,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3959.23,,,,,,,fee schedule,625.05,3959.23,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,625.05,3959.23,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,3959.23,APC
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,3959.23,APC
Aspirate pleura w/ imaging,32555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,3959.23,APC
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,648.43,3441.61,
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,3441.61,
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,648.43,3441.61,
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,648.43,3441.61,
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,648.43,3441.61,
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,648.43,3441.61,
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,648.43,3441.61,
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,3441.61,
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,648.43,3441.61,APC
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,648.43,3441.61,APC
Insert cath pleura w/o image,32556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,648.43,3441.61,APC
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,648.43,2823.29,
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,2823.29,
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,648.43,2823.29,
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,648.43,2823.29,
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,648.43,2823.29,
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,648.43,2823.29,
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,648.43,2823.29,
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,2823.29,
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,648.43,2823.29,APC
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,648.43,2823.29,APC
Insert cath pleura w/ image,32557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,648.43,2823.29,APC
Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,625.05,1176.6,
Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,625.05,1176.6,
Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,625.05,1176.6,
Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,625.05,1176.6,
Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1176.6,APC
Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1176.6,APC
Treat pleurodesis w/agent,32560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1176.6,APC
Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,625.05,1176.6,
Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,625.05,1176.6,
Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,625.05,1176.6,
Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,625.05,1176.6,
Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1176.6,APC
Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1176.6,APC
Lyse chest fibrin init day,32561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1176.6,APC
Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,625.05,1176.6,
Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,625.05,1176.6,
Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,625.05,1176.6,
Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,625.05,1176.6,
Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1176.6,APC
Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1176.6,APC
Lyse chest fibrin subq day,32562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1176.6,APC
Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Thoracoscopy diagnostic,32601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy wbx sac,32604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Thoracoscopy w/bx med space,32606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,19064.9,
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,4117.16,19064.9,APC
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Thorax stereo rad targetw/tx,32701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.51,,,,,,,fee schedule,78.35,137.44,
Thorax stereo rad targetw/tx,32701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.35,,,,,,,fee schedule,78.35,137.44,
Thorax stereo rad targetw/tx,32701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.82,,,,,,,fee schedule,78.35,137.44,
Thorax stereo rad targetw/tx,32701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.44,,,,,,,fee schedule,78.35,137.44,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,625.05,1161.41,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,625.05,1161.41,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,625.05,1161.41,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,625.05,1161.41,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,625.05,1161.41,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,625.05,1161.41,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,625.05,1161.41,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,625.05,1161.41,
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1161.41,APC
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1161.41,APC
Therapeutic pneumothorax,32960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1161.41,APC
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12254.39,,,,,,,fee schedule,3502.79,19064.9,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3502.79,,,,,,,fee schedule,3502.79,19064.9,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3502.79,,,,,,,fee schedule,3502.79,19064.9,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8033.98,,,,,,,fee schedule,3502.79,19064.9,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10030.22,,,,,,,fee schedule,3502.79,19064.9,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4028.21,,,,,,,fee schedule,3502.79,19064.9,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14092.55,,,,,,,fee schedule,3502.79,19064.9,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3502.79,,,,,,,fee schedule,3502.79,19064.9,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,3502.79,19064.9,APC
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,3502.79,19064.9,APC
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,3502.79,19064.9,APC
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5427.63,,,,,,,fee schedule,3651.57,10842.82,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5427.63,,,,,,,fee schedule,3651.57,10842.82,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6241.77,,,,,,,fee schedule,3651.57,10842.82,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5427.63,,,,,,,fee schedule,3651.57,10842.82,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Chest surgery procedure,32999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1125.08,APC
Chest surgery procedure,32999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1125.08,APC
Chest surgery procedure,32999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1125.08,APC
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3168.47,,,,,,,fee schedule,1568.49,3643.74,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3168.47,,,,,,,fee schedule,1568.49,3643.74,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3168.47,,,,,,,fee schedule,1568.49,3643.74,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2077.25,,,,,,,fee schedule,1568.49,3643.74,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2593.39,,,,,,,fee schedule,1568.49,3643.74,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3643.74,,,,,,,fee schedule,1568.49,3643.74,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,1568.49,3643.74,APC
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,1568.49,3643.74,APC
Pericardiocentesis w/imaging,33016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,1568.49,3643.74,APC
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.33,,,,,,,fee schedule,217.88,382.18,
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.33,,,,,,,fee schedule,217.88,382.18,
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.33,,,,,,,fee schedule,217.88,382.18,
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.88,,,,,,,fee schedule,217.88,382.18,
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.01,,,,,,,fee schedule,217.88,382.18,
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,382.18,,,,,,,fee schedule,217.88,382.18,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,372.3,,,,,,,fee schedule,244.08,428.15,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,372.3,,,,,,,fee schedule,244.08,428.15,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,372.3,,,,,,,fee schedule,244.08,428.15,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,244.08,,,,,,,fee schedule,244.08,428.15,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,304.73,,,,,,,fee schedule,244.08,428.15,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,428.15,,,,,,,fee schedule,244.08,428.15,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,309.2,,,,,,,fee schedule,202.71,355.58,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,309.2,,,,,,,fee schedule,202.71,355.58,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,309.2,,,,,,,fee schedule,202.71,355.58,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.71,,,,,,,fee schedule,202.71,355.58,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,253.08,,,,,,,fee schedule,202.71,355.58,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,355.58,,,,,,,fee schedule,202.71,355.58,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16234.66,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18991.24,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10643.44,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13288.07,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21839.93,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18669.86,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,21839.93,APC
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,21839.93,APC
Insert heart pm atrial,33206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,21839.93,APC
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16234.66,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18991.24,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10643.44,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13288.07,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21839.93,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18669.86,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,21839.93,
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,21839.93,APC
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,21839.93,APC
Insert heart pm ventricular,33207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,21839.93,APC
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19931.88,,,,,,,fee schedule,10414.41,22921.66,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,22921.66,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18991.24,,,,,,,fee schedule,10414.41,22921.66,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13067.34,,,,,,,fee schedule,10414.41,22921.66,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16314.24,,,,,,,fee schedule,10414.41,22921.66,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21839.93,,,,,,,fee schedule,10414.41,22921.66,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22921.66,,,,,,,fee schedule,10414.41,22921.66,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,22921.66,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,22921.66,APC
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,22921.66,APC
Insrt heart pm atrial & vent,33208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,22921.66,APC
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10028.22,,,,,,,fee schedule,6574.5,15716.54,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13666.56,,,,,,,fee schedule,6574.5,15716.54,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13666.56,,,,,,,fee schedule,6574.5,15716.54,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6574.5,,,,,,,fee schedule,6574.5,15716.54,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8208.1,,,,,,,fee schedule,6574.5,15716.54,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15716.54,,,,,,,fee schedule,6574.5,15716.54,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11532.45,,,,,,,fee schedule,6574.5,15716.54,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13666.56,,,,,,,fee schedule,6574.5,15716.54,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,6574.5,15716.54,APC
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,6574.5,15716.54,APC
Insert electrd/pm cath sngl,33210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,6574.5,15716.54,APC
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15444.57,,,,,,,fee schedule,8245.63,17761.26,
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,17761.26,
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13666.56,,,,,,,fee schedule,8245.63,17761.26,
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10125.46,,,,,,,fee schedule,8245.63,17761.26,
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12641.38,,,,,,,fee schedule,8245.63,17761.26,
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15716.54,,,,,,,fee schedule,8245.63,17761.26,
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17761.26,,,,,,,fee schedule,8245.63,17761.26,
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,17761.26,
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,17761.26,APC
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,17761.26,APC
Insert card electrodes dual,33211,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,17761.26,APC
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15505.88,,,,,,,fee schedule,8245.63,17831.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,17831.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13666.56,,,,,,,fee schedule,8245.63,17831.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10165.65,,,,,,,fee schedule,8245.63,17831.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12691.56,,,,,,,fee schedule,8245.63,17831.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15716.54,,,,,,,fee schedule,8245.63,17831.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17831.76,,,,,,,fee schedule,8245.63,17831.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,17831.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,17831.76,APC
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,17831.76,APC
Insert pulse gen sngl lead,33212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,17831.76,APC
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20999.86,,,,,,,fee schedule,10414.41,24149.84,
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,24149.84,
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18991.24,,,,,,,fee schedule,10414.41,24149.84,
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13767.51,,,,,,,fee schedule,10414.41,24149.84,
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17188.39,,,,,,,fee schedule,10414.41,24149.84,
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21839.93,,,,,,,fee schedule,10414.41,24149.84,
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24149.84,,,,,,,fee schedule,10414.41,24149.84,
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,24149.84,
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,24149.84,APC
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,24149.84,APC
Insert pulse gen dual leads,33213,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,24149.84,APC
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20704.4,,,,,,,fee schedule,10414.41,23810.06,
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,23810.06,
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18991.24,,,,,,,fee schedule,10414.41,23810.06,
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13573.8,,,,,,,fee schedule,10414.41,23810.06,
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16946.55,,,,,,,fee schedule,10414.41,23810.06,
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21839.93,,,,,,,fee schedule,10414.41,23810.06,
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23810.06,,,,,,,fee schedule,10414.41,23810.06,
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,23810.06,
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,23810.06,APC
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,23810.06,APC
Upgrade of pacemaker system,33214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,23810.06,APC
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5671.86,,,,,,,fee schedule,2088.47,6522.64,
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2088.47,,,,,,,fee schedule,2088.47,6522.64,
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2088.47,,,,,,,fee schedule,2088.47,6522.64,
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3718.47,,,,,,,fee schedule,2088.47,6522.64,
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4642.42,,,,,,,fee schedule,2088.47,6522.64,
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2401.74,,,,,,,fee schedule,2088.47,6522.64,
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6522.64,,,,,,,fee schedule,2088.47,6522.64,
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2088.47,,,,,,,fee schedule,2088.47,6522.64,
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2088.47,6522.64,APC
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2088.47,6522.64,APC
Reposition pacing-defib lead,33215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2088.47,6522.64,APC
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8447.36,,,,,,,fee schedule,5538.09,15716.54,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13666.56,,,,,,,fee schedule,5538.09,15716.54,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13666.56,,,,,,,fee schedule,5538.09,15716.54,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5538.09,,,,,,,fee schedule,5538.09,15716.54,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6914.16,,,,,,,fee schedule,5538.09,15716.54,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15716.54,,,,,,,fee schedule,5538.09,15716.54,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9714.46,,,,,,,fee schedule,5538.09,15716.54,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13666.56,,,,,,,fee schedule,5538.09,15716.54,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,5538.09,15716.54,APC
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,5538.09,15716.54,APC
Insert 1 electrode pm-defib,33216,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,5538.09,15716.54,APC
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14922.35,,,,,,,fee schedule,8245.63,17160.7,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,17160.7,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13666.56,,,,,,,fee schedule,8245.63,17160.7,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9783.09,,,,,,,fee schedule,8245.63,17160.7,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12213.94,,,,,,,fee schedule,8245.63,17160.7,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15716.54,,,,,,,fee schedule,8245.63,17160.7,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17160.7,,,,,,,fee schedule,8245.63,17160.7,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,17160.7,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,17160.7,APC
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,17160.7,APC
Insert 2 electrode pm-defib,33217,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,17160.7,APC
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3778.52,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2477.2,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3092.72,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3576.97,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4345.3,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2477.2,6702.34,APC
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2477.2,6702.34,APC
Repair lead pace-defib one,33218,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2477.2,6702.34,APC
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3778.52,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2477.2,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3092.72,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3576.97,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4345.3,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2477.2,6702.34,APC
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2477.2,6702.34,APC
Repair lead pace-defib dual,33220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2477.2,6702.34,APC
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34746.2,,,,,,,fee schedule,19192.43,39958.13,
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30273.31,,,,,,,fee schedule,19192.43,39958.13,
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30273.31,,,,,,,fee schedule,19192.43,39958.13,
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22779.61,,,,,,,fee schedule,19192.43,39958.13,
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28439.76,,,,,,,fee schedule,19192.43,39958.13,
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34814.31,,,,,,,fee schedule,19192.43,39958.13,
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39958.13,,,,,,,fee schedule,19192.43,39958.13,
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30273.31,,,,,,,fee schedule,19192.43,39958.13,
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,19192.43,39958.13,APC
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,19192.43,39958.13,APC
Insert pulse gen mult leads,33221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,19192.43,39958.13,APC
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Relocation pocket pacemaker,33222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2575.75,,,,,,,fee schedule,1688.66,3700.55,
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1688.66,3700.55,
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1688.66,3700.55,
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1688.66,,,,,,,fee schedule,1688.66,3700.55,
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2108.25,,,,,,,fee schedule,1688.66,3700.55,
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1688.66,3700.55,
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2962.11,,,,,,,fee schedule,1688.66,3700.55,
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1688.66,3700.55,
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1688.66,3700.55,APC
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1688.66,3700.55,APC
Relocate pocket for defib,33223,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1688.66,3700.55,APC
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21077.97,,,,,,,fee schedule,10414.41,24239.67,
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,24239.67,
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18991.24,,,,,,,fee schedule,10414.41,24239.67,
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13818.72,,,,,,,fee schedule,10414.41,24239.67,
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17252.32,,,,,,,fee schedule,10414.41,24239.67,
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21839.93,,,,,,,fee schedule,10414.41,24239.67,
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24239.67,,,,,,,fee schedule,10414.41,24239.67,
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18991.24,,,,,,,fee schedule,10414.41,24239.67,
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,10414.41,24239.67,APC
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,10414.41,24239.67,APC
Insert pacing lead & connect,33224,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,10414.41,24239.67,APC
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5543.46,,,,,,,fee schedule,2088.47,6374.98,
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2088.47,,,,,,,fee schedule,2088.47,6374.98,
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2088.47,,,,,,,fee schedule,2088.47,6374.98,
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3634.29,,,,,,,fee schedule,2088.47,6374.98,
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4537.32,,,,,,,fee schedule,2088.47,6374.98,
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2401.74,,,,,,,fee schedule,2088.47,6374.98,
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6374.98,,,,,,,fee schedule,2088.47,6374.98,
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2088.47,,,,,,,fee schedule,2088.47,6374.98,
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2088.47,6374.98,APC
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2088.47,6374.98,APC
Reposition l ventric lead,33226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2088.47,6374.98,APC
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15440.3,,,,,,,fee schedule,8245.63,17756.35,
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,17756.35,
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13666.56,,,,,,,fee schedule,8245.63,17756.35,
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10122.66,,,,,,,fee schedule,8245.63,17756.35,
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12637.89,,,,,,,fee schedule,8245.63,17756.35,
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15716.54,,,,,,,fee schedule,8245.63,17756.35,
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17756.35,,,,,,,fee schedule,8245.63,17756.35,
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,17756.35,
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,17756.35,APC
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,17756.35,APC
Remove&replace pm gen singl,33227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,17756.35,APC
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14963.36,,,,,,,fee schedule,9809.98,21839.93,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18991.24,,,,,,,fee schedule,9809.98,21839.93,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18991.24,,,,,,,fee schedule,9809.98,21839.93,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9809.98,,,,,,,fee schedule,9809.98,21839.93,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12247.51,,,,,,,fee schedule,9809.98,21839.93,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21839.93,,,,,,,fee schedule,9809.98,21839.93,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17207.86,,,,,,,fee schedule,9809.98,21839.93,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18991.24,,,,,,,fee schedule,9809.98,21839.93,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10935.13,,,,,,,fee schedule,9809.98,21839.93,APC
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.41,,,,,,,fee schedule,9809.98,21839.93,APC
Remv&replc pm gen dual lead,33228,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.94,,,,,,,fee schedule,9809.98,21839.93,APC
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33808.04,,,,,,,fee schedule,19192.43,38879.25,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30273.31,,,,,,,fee schedule,19192.43,38879.25,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30273.31,,,,,,,fee schedule,19192.43,38879.25,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22164.55,,,,,,,fee schedule,19192.43,38879.25,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27671.88,,,,,,,fee schedule,19192.43,38879.25,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34814.31,,,,,,,fee schedule,19192.43,38879.25,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38879.25,,,,,,,fee schedule,19192.43,38879.25,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30273.31,,,,,,,fee schedule,19192.43,38879.25,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,19192.43,38879.25,APC
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,19192.43,38879.25,APC
Remv&replc pm gen mult leads,33229,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,19192.43,38879.25,APC
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53098.57,,,,,,,fee schedule,22163.59,61063.36,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49073.59,,,,,,,fee schedule,22163.59,61063.36,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49073.59,,,,,,,fee schedule,22163.59,61063.36,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34811.42,,,,,,,fee schedule,22163.59,61063.36,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43461.18,,,,,,,fee schedule,22163.59,61063.36,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56434.63,,,,,,,fee schedule,22163.59,61063.36,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61063.36,,,,,,,fee schedule,22163.59,61063.36,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49073.59,,,,,,,fee schedule,22163.59,61063.36,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,22163.59,61063.36,APC
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,22163.59,61063.36,APC
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,22163.59,61063.36,APC
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73073.47,,,,,,,fee schedule,31275.99,84034.49,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65807.74,,,,,,,fee schedule,31275.99,84034.49,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65807.74,,,,,,,fee schedule,31275.99,84034.49,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47906.97,,,,,,,fee schedule,31275.99,84034.49,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59810.64,,,,,,,fee schedule,31275.99,84034.49,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75678.9,,,,,,,fee schedule,31275.99,84034.49,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84034.49,,,,,,,fee schedule,31275.99,84034.49,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65807.74,,,,,,,fee schedule,31275.99,84034.49,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32839.79,,,,,,,fee schedule,31275.99,84034.49,APC
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31275.99,,,,,,,fee schedule,31275.99,84034.49,APC
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56296.78,,,,,,,fee schedule,31275.99,84034.49,APC
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10028.22,,,,,,,fee schedule,6574.5,15716.54,
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13666.56,,,,,,,fee schedule,6574.5,15716.54,
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13666.56,,,,,,,fee schedule,6574.5,15716.54,
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6574.5,,,,,,,fee schedule,6574.5,15716.54,
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8208.1,,,,,,,fee schedule,6574.5,15716.54,
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15716.54,,,,,,,fee schedule,6574.5,15716.54,
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11532.45,,,,,,,fee schedule,6574.5,15716.54,
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13666.56,,,,,,,fee schedule,6574.5,15716.54,
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,6574.5,15716.54,APC
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,6574.5,15716.54,APC
Removal of pm generator,33233,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,6574.5,15716.54,APC
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3778.52,,,,,,,fee schedule,2477.2,6702.34,
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2477.2,,,,,,,fee schedule,2477.2,6702.34,
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3092.72,,,,,,,fee schedule,2477.2,6702.34,
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3576.97,,,,,,,fee schedule,2477.2,6702.34,
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4345.3,,,,,,,fee schedule,2477.2,6702.34,
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2477.2,6702.34,APC
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2477.2,6702.34,APC
Removal of pacemaker system,33234,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2477.2,6702.34,APC
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1866.39,,,,,,,fee schedule,1223.61,6702.34,
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3110.41,,,,,,,fee schedule,1223.61,6702.34,
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3110.41,,,,,,,fee schedule,1223.61,6702.34,
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1223.61,,,,,,,fee schedule,1223.61,6702.34,
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1527.64,,,,,,,fee schedule,1223.61,6702.34,
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3576.97,,,,,,,fee schedule,1223.61,6702.34,
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2146.35,,,,,,,fee schedule,1223.61,6702.34,
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3110.41,,,,,,,fee schedule,1223.61,6702.34,
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,1223.61,6702.34,APC
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,1223.61,6702.34,APC
Removal pacemaker electrode,33235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,1223.61,6702.34,APC
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52824.29,,,,,,,fee schedule,22163.59,60747.93,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49073.59,,,,,,,fee schedule,22163.59,60747.93,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49073.59,,,,,,,fee schedule,22163.59,60747.93,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34631.6,,,,,,,fee schedule,22163.59,60747.93,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43236.68,,,,,,,fee schedule,22163.59,60747.93,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56434.63,,,,,,,fee schedule,22163.59,60747.93,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60747.93,,,,,,,fee schedule,22163.59,60747.93,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49073.59,,,,,,,fee schedule,22163.59,60747.93,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,22163.59,60747.93,APC
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,22163.59,60747.93,APC
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,22163.59,60747.93,APC
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3482.68,,,,,,,fee schedule,2283.25,6702.34,
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3110.41,,,,,,,fee schedule,2283.25,6702.34,
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3110.41,,,,,,,fee schedule,2283.25,6702.34,
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2283.25,,,,,,,fee schedule,2283.25,6702.34,
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2850.57,,,,,,,fee schedule,2283.25,6702.34,
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3576.97,,,,,,,fee schedule,2283.25,6702.34,
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4005.08,,,,,,,fee schedule,2283.25,6702.34,
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3110.41,,,,,,,fee schedule,2283.25,6702.34,
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2283.25,6702.34,APC
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2283.25,6702.34,APC
Remove pulse generator,33241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2283.25,6702.34,APC
Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1705.65,,,,,,,fee schedule,1118.22,6702.34,
Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1118.22,,,,,,,fee schedule,1118.22,6702.34,
Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1396.07,,,,,,,fee schedule,1118.22,6702.34,
Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1961.5,,,,,,,fee schedule,1118.22,6702.34,
Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,1118.22,6702.34,APC
Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,1118.22,6702.34,APC
Remove elctrd transvenously,33244,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,1118.22,6702.34,APC
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26914.12,,,,,,,fee schedule,17644.9,75678.9,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65807.74,,,,,,,fee schedule,17644.9,75678.9,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65807.74,,,,,,,fee schedule,17644.9,75678.9,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17644.9,,,,,,,fee schedule,17644.9,75678.9,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22029.21,,,,,,,fee schedule,17644.9,75678.9,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75678.9,,,,,,,fee schedule,17644.9,75678.9,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30951.24,,,,,,,fee schedule,17644.9,75678.9,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65807.74,,,,,,,fee schedule,17644.9,75678.9,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32839.79,,,,,,,fee schedule,17644.9,75678.9,APC
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31275.99,,,,,,,fee schedule,17644.9,75678.9,APC
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56296.78,,,,,,,fee schedule,17644.9,75678.9,APC
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14104.21,,,,,,,fee schedule,9246.72,56434.63,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49073.59,,,,,,,fee schedule,9246.72,56434.63,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49073.59,,,,,,,fee schedule,9246.72,56434.63,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9246.72,,,,,,,fee schedule,9246.72,56434.63,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11544.3,,,,,,,fee schedule,9246.72,56434.63,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56434.63,,,,,,,fee schedule,9246.72,56434.63,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16219.84,,,,,,,fee schedule,9246.72,56434.63,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49073.59,,,,,,,fee schedule,9246.72,56434.63,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,9246.72,56434.63,APC
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,9246.72,56434.63,APC
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,9246.72,56434.63,APC
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12373.21,,,,,,,fee schedule,8111.88,56434.63,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49073.59,,,,,,,fee schedule,8111.88,56434.63,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49073.59,,,,,,,fee schedule,8111.88,56434.63,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8111.88,,,,,,,fee schedule,8111.88,56434.63,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10127.47,,,,,,,fee schedule,8111.88,56434.63,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56434.63,,,,,,,fee schedule,8111.88,56434.63,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14229.19,,,,,,,fee schedule,8111.88,56434.63,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49073.59,,,,,,,fee schedule,8111.88,56434.63,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23271.77,,,,,,,fee schedule,8111.88,56434.63,APC
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22163.59,,,,,,,fee schedule,8111.88,56434.63,APC
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39894.46,,,,,,,fee schedule,8111.88,56434.63,APC
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21890.16,,,,,,,fee schedule,14351.19,75678.9,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65807.74,,,,,,,fee schedule,14351.19,75678.9,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65807.74,,,,,,,fee schedule,14351.19,75678.9,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14351.19,,,,,,,fee schedule,14351.19,75678.9,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17917.1,,,,,,,fee schedule,14351.19,75678.9,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75678.9,,,,,,,fee schedule,14351.19,75678.9,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25173.68,,,,,,,fee schedule,14351.19,75678.9,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65807.74,,,,,,,fee schedule,14351.19,75678.9,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32839.79,,,,,,,fee schedule,14351.19,75678.9,APC
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31275.99,,,,,,,fee schedule,14351.19,75678.9,APC
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56296.78,,,,,,,fee schedule,14351.19,75678.9,APC
Excl laa open any method,33267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1615.55,,,,,,,fee schedule,1059.15,1857.88,
Excl laa open any method,33267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1059.15,,,,,,,fee schedule,1059.15,1857.88,
Excl laa open any method,33267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1322.33,,,,,,,fee schedule,1059.15,1857.88,
Excl laa open any method,33267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1857.88,,,,,,,fee schedule,1059.15,1857.88,
Excl laa opn oth px any meth,33268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.34,,,,,,,fee schedule,101.84,178.64,
Excl laa opn oth px any meth,33268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.84,,,,,,,fee schedule,101.84,178.64,
Excl laa opn oth px any meth,33268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.84,178.64,
Excl laa opn oth px any meth,33268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.64,,,,,,,fee schedule,101.84,178.64,
Excl laa thrscp any method,33269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1355.33,,,,,,,fee schedule,888.55,1558.63,
Excl laa thrscp any method,33269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,888.55,,,,,,,fee schedule,888.55,1558.63,
Excl laa thrscp any method,33269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1109.34,,,,,,,fee schedule,888.55,1558.63,
Excl laa thrscp any method,33269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1558.63,,,,,,,fee schedule,888.55,1558.63,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9814.36,,,,,,,fee schedule,6434.29,75678.9,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65807.74,,,,,,,fee schedule,6434.29,75678.9,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65807.74,,,,,,,fee schedule,6434.29,75678.9,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6434.29,,,,,,,fee schedule,6434.29,75678.9,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8033.05,,,,,,,fee schedule,6434.29,75678.9,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75678.9,,,,,,,fee schedule,6434.29,75678.9,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11286.51,,,,,,,fee schedule,6434.29,75678.9,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65807.74,,,,,,,fee schedule,6434.29,75678.9,
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32839.79,,,,,,,fee schedule,6434.29,75678.9,APC
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31275.99,,,,,,,fee schedule,6434.29,75678.9,APC
Ins/rep subq defibrillator,33270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56296.78,,,,,,,fee schedule,6434.29,75678.9,APC
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16194.21,,,,,,,fee schedule,8245.63,18623.34,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,18623.34,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13666.56,,,,,,,fee schedule,8245.63,18623.34,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10616.92,,,,,,,fee schedule,8245.63,18623.34,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13254.96,,,,,,,fee schedule,8245.63,18623.34,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15716.54,,,,,,,fee schedule,8245.63,18623.34,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18623.34,,,,,,,fee schedule,8245.63,18623.34,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13666.56,,,,,,,fee schedule,8245.63,18623.34,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,8245.63,18623.34,APC
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,8245.63,18623.34,APC
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,8245.63,18623.34,APC
Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3827.96,,,,,,,fee schedule,2509.61,6702.34,
Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2509.61,,,,,,,fee schedule,2509.61,6702.34,
Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3133.19,,,,,,,fee schedule,2509.61,6702.34,
Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4402.15,,,,,,,fee schedule,2509.61,6702.34,
Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2509.61,6702.34,APC
Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2509.61,6702.34,APC
Rmvl of subq defibrillator,33272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2509.61,6702.34,APC
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3778.52,,,,,,,fee schedule,2477.2,6702.34,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2477.2,,,,,,,fee schedule,2477.2,6702.34,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3092.72,,,,,,,fee schedule,2477.2,6702.34,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3576.97,,,,,,,fee schedule,2477.2,6702.34,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4345.3,,,,,,,fee schedule,2477.2,6702.34,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2477.2,6702.34,APC
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2477.2,6702.34,APC
Repos prev impltbl subq dfb,33273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2477.2,6702.34,APC
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40309.34,,,,,,,fee schedule,10554.69,46355.74,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10554.69,,,,,,,fee schedule,10554.69,46355.74,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10554.69,,,,,,,fee schedule,10554.69,46355.74,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26426.8,,,,,,,fee schedule,10554.69,46355.74,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32993.19,,,,,,,fee schedule,10554.69,46355.74,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12137.89,,,,,,,fee schedule,10554.69,46355.74,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46355.74,,,,,,,fee schedule,10554.69,46355.74,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10554.69,,,,,,,fee schedule,10554.69,46355.74,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20152.05,,,,,,,fee schedule,10554.69,46355.74,APC
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19192.43,,,,,,,fee schedule,10554.69,46355.74,APC
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34546.37,,,,,,,fee schedule,10554.69,46355.74,APC
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6934.65,,,,,,,fee schedule,2093.27,7974.85,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2093.27,,,,,,,fee schedule,2093.27,7974.85,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2093.27,,,,,,,fee schedule,2093.27,7974.85,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4546.36,,,,,,,fee schedule,2093.27,7974.85,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5676.01,,,,,,,fee schedule,2093.27,7974.85,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2407.26,,,,,,,fee schedule,2093.27,7974.85,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7974.85,,,,,,,fee schedule,2093.27,7974.85,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2093.27,,,,,,,fee schedule,2093.27,7974.85,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2093.27,7974.85,APC
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2093.27,7974.85,APC
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2093.27,7974.85,APC
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81220.23,,,,,,,fee schedule,43888.09,93403.26,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55925.4,,,,,,,fee schedule,43888.09,93403.26,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55925.4,,,,,,,fee schedule,43888.09,93403.26,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53247.98,,,,,,,fee schedule,43888.09,93403.26,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66478.76,,,,,,,fee schedule,43888.09,93403.26,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64314.21,,,,,,,fee schedule,43888.09,93403.26,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93403.26,,,,,,,fee schedule,43888.09,93403.26,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55925.4,,,,,,,fee schedule,43888.09,93403.26,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46082.49,,,,,,,fee schedule,43888.09,93403.26,APC
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43888.09,,,,,,,fee schedule,43888.09,93403.26,APC
Insj phrnc nrv stim sys,33276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78998.56,,,,,,,fee schedule,43888.09,93403.26,APC
Insj phrnc nrv stim transvns,33277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,397.16,,,,,,,fee schedule,260.38,456.73,
Insj phrnc nrv stim transvns,33277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.38,,,,,,,fee schedule,260.38,456.73,
Insj phrnc nrv stim transvns,33277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,325.08,,,,,,,fee schedule,260.38,456.73,
Insj phrnc nrv stim transvns,33277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,456.73,,,,,,,fee schedule,260.38,456.73,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3009.69,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2617.12,6735.91,APC
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2617.12,6735.91,APC
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2617.12,6735.91,APC
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,3297.5,6735.91,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3297.5,,,,,,,fee schedule,3297.5,6735.91,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3297.5,,,,,,,fee schedule,3297.5,6735.91,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,3297.5,6735.91,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,3297.5,6735.91,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3792.13,,,,,,,fee schedule,3297.5,6735.91,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,3297.5,6735.91,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3297.5,,,,,,,fee schedule,3297.5,6735.91,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,3297.5,6735.91,APC
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,3297.5,6735.91,APC
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,3297.5,6735.91,APC
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3009.69,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2617.12,6735.91,APC
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2617.12,6735.91,APC
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2617.12,6735.91,APC
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,2617.12,6735.91,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,2617.12,6735.91,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,2617.12,6735.91,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3009.69,,,,,,,fee schedule,2617.12,6735.91,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,2617.12,6735.91,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2617.12,6735.91,APC
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2617.12,6735.91,APC
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2617.12,6735.91,APC
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19437.6,,,,,,,fee schedule,5935.12,22353.24,
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5935.12,,,,,,,fee schedule,5935.12,22353.24,
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5935.12,,,,,,,fee schedule,5935.12,22353.24,
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12743.29,,,,,,,fee schedule,5935.12,22353.24,
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15909.68,,,,,,,fee schedule,5935.12,22353.24,
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6825.39,,,,,,,fee schedule,5935.12,22353.24,
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22353.24,,,,,,,fee schedule,5935.12,22353.24,
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5935.12,,,,,,,fee schedule,5935.12,22353.24,
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.91,,,,,,,fee schedule,5935.12,22353.24,APC
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8245.63,,,,,,,fee schedule,5935.12,22353.24,APC
Insj subq car rhythm mntr,33285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14842.14,,,,,,,fee schedule,5935.12,22353.24,APC
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1520.91,,,,,,,fee schedule,478.3,1749.05,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,478.3,,,,,,,fee schedule,478.3,1749.05,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,478.3,,,,,,,fee schedule,478.3,1749.05,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,997.11,,,,,,,fee schedule,478.3,1749.05,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1244.86,,,,,,,fee schedule,478.3,1749.05,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,550.05,,,,,,,fee schedule,478.3,1749.05,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1749.05,,,,,,,fee schedule,478.3,1749.05,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,478.3,,,,,,,fee schedule,478.3,1749.05,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,478.3,1749.05,APC
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,478.3,1749.05,APC
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,478.3,1749.05,APC
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53455.08,,,,,,,fee schedule,30746.74,61473.34,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33340.65,,,,,,,fee schedule,30746.74,61473.34,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33340.65,,,,,,,fee schedule,30746.74,61473.34,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35045.15,,,,,,,fee schedule,30746.74,61473.34,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43752.98,,,,,,,fee schedule,30746.74,61473.34,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38341.75,,,,,,,fee schedule,30746.74,61473.34,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61473.34,,,,,,,fee schedule,30746.74,61473.34,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33340.65,,,,,,,fee schedule,30746.74,61473.34,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,30746.74,61473.34,APC
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,30746.74,61473.34,APC
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,30746.74,61473.34,APC
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23449.76,,,,,,,fee schedule,11102.63,26967.22,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15135.37,,,,,,,fee schedule,11102.63,26967.22,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15135.37,,,,,,,fee schedule,11102.63,26967.22,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15373.66,,,,,,,fee schedule,11102.63,26967.22,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19193.63,,,,,,,fee schedule,11102.63,26967.22,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17405.68,,,,,,,fee schedule,11102.63,26967.22,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26967.22,,,,,,,fee schedule,11102.63,26967.22,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15135.37,,,,,,,fee schedule,11102.63,26967.22,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,26967.22,APC
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,26967.22,APC
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,26967.22,APC
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77026.62,,,,,,,fee schedule,28580.21,88580.61,
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50498.65,,,,,,,fee schedule,28580.21,88580.61,
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63046.29,,,,,,,fee schedule,28580.21,88580.61,
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88580.61,,,,,,,fee schedule,28580.21,88580.61,
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30009.22,,,,,,,fee schedule,28580.21,88580.61,APC
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28580.21,,,,,,,fee schedule,28580.21,88580.61,APC
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51444.38,,,,,,,fee schedule,28580.21,88580.61,APC
Tcat plmt&rmvl cepd perq,33370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.56,,,,,,,fee schedule,119.03,208.79,
Tcat plmt&rmvl cepd perq,33370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.03,,,,,,,fee schedule,119.03,208.79,
Tcat plmt&rmvl cepd perq,33370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.61,,,,,,,fee schedule,119.03,208.79,
Tcat plmt&rmvl cepd perq,33370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.79,,,,,,,fee schedule,119.03,208.79,
Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5682.33,,,,,,,fee schedule,3725.34,6534.68,
Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3725.34,,,,,,,fee schedule,3725.34,6534.68,
Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4650.99,,,,,,,fee schedule,3725.34,6534.68,
Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6534.68,,,,,,,fee schedule,3725.34,6534.68,
Ndsc hrv uxtr art 1 sgm cab,33509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.63,,,,,,,fee schedule,125.63,220.37,
Ndsc hrv uxtr art 1 sgm cab,33509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.63,,,,,,,fee schedule,125.63,220.37,
Ndsc hrv uxtr art 1 sgm cab,33509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.85,,,,,,,fee schedule,125.63,220.37,
Ndsc hrv uxtr art 1 sgm cab,33509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.37,,,,,,,fee schedule,125.63,220.37,
Tas congenital car anomal,33741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1012.75,,,,,,,fee schedule,663.96,1164.66,
Tas congenital car anomal,33741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,663.96,,,,,,,fee schedule,663.96,1164.66,
Tas congenital car anomal,33741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,828.94,,,,,,,fee schedule,663.96,1164.66,
Tas congenital car anomal,33741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1164.66,,,,,,,fee schedule,663.96,1164.66,
Tis cgen car anomal 1st shnt,33745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1472.36,,,,,,,fee schedule,965.28,1693.21,
Tis cgen car anomal 1st shnt,33745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,965.28,,,,,,,fee schedule,965.28,1693.21,
Tis cgen car anomal 1st shnt,33745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1205.13,,,,,,,fee schedule,965.28,1693.21,
Tis cgen car anomal 1st shnt,33745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1693.21,,,,,,,fee schedule,965.28,1693.21,
Tis cgen car anomal ea addl,33746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,585.68,,,,,,,fee schedule,383.97,673.53,
Tis cgen car anomal ea addl,33746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,383.97,,,,,,,fee schedule,383.97,673.53,
Tis cgen car anomal ea addl,33746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,479.38,,,,,,,fee schedule,383.97,673.53,
Tis cgen car anomal ea addl,33746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,673.53,,,,,,,fee schedule,383.97,673.53,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4345.52,,,,,,,fee schedule,2848.92,4997.35,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4345.52,,,,,,,fee schedule,2848.92,4997.35,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4345.52,,,,,,,fee schedule,2848.92,4997.35,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2848.92,,,,,,,fee schedule,2848.92,4997.35,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3556.81,,,,,,,fee schedule,2848.92,4997.35,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4997.35,,,,,,,fee schedule,2848.92,4997.35,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3228.66,,,,,,,fee schedule,2116.71,3712.96,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3228.66,,,,,,,fee schedule,2116.71,3712.96,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3228.66,,,,,,,fee schedule,2116.71,3712.96,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2116.71,,,,,,,fee schedule,2116.71,3712.96,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2642.66,,,,,,,fee schedule,2116.71,3712.96,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3712.96,,,,,,,fee schedule,2116.71,3712.96,
Aortic hemiarch graft,33866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1717.22,,,,,,,fee schedule,1125.81,1974.8,
Aortic hemiarch graft,33866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1125.81,,,,,,,fee schedule,1125.81,1974.8,
Aortic hemiarch graft,33866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1405.54,,,,,,,fee schedule,1125.81,1974.8,
Aortic hemiarch graft,33866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1974.8,,,,,,,fee schedule,1125.81,1974.8,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4166.71,,,,,,,fee schedule,2731.7,4791.72,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4166.71,,,,,,,fee schedule,2731.7,4791.72,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4166.71,,,,,,,fee schedule,2731.7,4791.72,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2731.7,,,,,,,fee schedule,2731.7,4791.72,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3410.45,,,,,,,fee schedule,2731.7,4791.72,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4791.72,,,,,,,fee schedule,2731.7,4791.72,
Evasc st rpr thrc/aa acrs br,33894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1327.14,,,,,,,fee schedule,870.07,1526.21,
Evasc st rpr thrc/aa acrs br,33894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,870.07,,,,,,,fee schedule,870.07,1526.21,
Evasc st rpr thrc/aa acrs br,33894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1086.26,,,,,,,fee schedule,870.07,1526.21,
Evasc st rpr thrc/aa acrs br,33894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1526.21,,,,,,,fee schedule,870.07,1526.21,
Evasc st rpr thrc/aa x crsg,33895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1054.84,,,,,,,fee schedule,691.55,1213.07,
Evasc st rpr thrc/aa x crsg,33895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,691.55,,,,,,,fee schedule,691.55,1213.07,
Evasc st rpr thrc/aa x crsg,33895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,863.39,,,,,,,fee schedule,691.55,1213.07,
Evasc st rpr thrc/aa x crsg,33895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1213.07,,,,,,,fee schedule,691.55,1213.07,
Perq trluml angp nt/recr coa,33897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,784.58,,,,,,,fee schedule,514.37,902.27,
Perq trluml angp nt/recr coa,33897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,514.37,,,,,,,fee schedule,514.37,902.27,
Perq trluml angp nt/recr coa,33897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,642.18,,,,,,,fee schedule,514.37,902.27,
Perq trluml angp nt/recr coa,33897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,902.27,,,,,,,fee schedule,514.37,902.27,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20289.71,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16607.13,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13301.93,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10627.09,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23333.17,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20289.71,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16607.13,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13301.93,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10627.09,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23333.17,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32832.61,,,,,,,fee schedule,15357.04,37757.5,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15357.04,,,,,,,fee schedule,15357.04,37757.5,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15357.04,,,,,,,fee schedule,15357.04,37757.5,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26873.49,,,,,,,fee schedule,15357.04,37757.5,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21525.06,,,,,,,fee schedule,15357.04,37757.5,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17660.6,,,,,,,fee schedule,15357.04,37757.5,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37757.5,,,,,,,fee schedule,15357.04,37757.5,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15357.04,,,,,,,fee schedule,15357.04,37757.5,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,15357.04,37757.5,APC
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,15357.04,37757.5,APC
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,15357.04,37757.5,APC
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20289.71,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16607.13,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13301.93,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10627.09,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23333.17,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9240.95,,,,,,,fee schedule,9240.95,23333.17,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9240.95,23333.17,APC
Perq p-art revsc each addl,33904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,371.56,,,,,,,fee schedule,243.59,427.29,
Perq p-art revsc each addl,33904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,304.12,,,,,,,fee schedule,243.59,427.29,
Perq p-art revsc each addl,33904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,243.59,,,,,,,fee schedule,243.59,427.29,
Perq p-art revsc each addl,33904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,427.29,,,,,,,fee schedule,243.59,427.29,
Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3965.89,,,,,,,fee schedule,2600.04,4560.77,
Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3246.08,,,,,,,fee schedule,2600.04,4560.77,
Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2600.04,,,,,,,fee schedule,2600.04,4560.77,
Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4560.77,,,,,,,fee schedule,2600.04,4560.77,
Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3965.89,,,,,,,fee schedule,2600.04,4560.77,
Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3246.08,,,,,,,fee schedule,2600.04,4560.77,
Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2600.04,,,,,,,fee schedule,2600.04,4560.77,
Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4560.77,,,,,,,fee schedule,2600.04,4560.77,
Insj perq vad r hrt venous,33995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,496.21,,,,,,,fee schedule,325.32,570.64,
Insj perq vad r hrt venous,33995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,406.15,,,,,,,fee schedule,325.32,570.64,
Insj perq vad r hrt venous,33995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.32,,,,,,,fee schedule,325.32,570.64,
Insj perq vad r hrt venous,33995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,570.64,,,,,,,fee schedule,325.32,570.64,
Rmvl perq right heart vad,33997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.65,,,,,,,fee schedule,145.31,254.9,
Rmvl perq right heart vad,33997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.42,,,,,,,fee schedule,145.31,254.9,
Rmvl perq right heart vad,33997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.31,,,,,,,fee schedule,145.31,254.9,
Rmvl perq right heart vad,33997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,254.9,,,,,,,fee schedule,145.31,254.9,
Cardiac surgery procedure,33999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1125.08,APC
Cardiac surgery procedure,33999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1125.08,APC
Cardiac surgery procedure,33999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1125.08,APC
Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of artery clot,34101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of arm artery clot,34111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of artery clot,34201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of leg artery clot,34203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Removal of vein clot,34421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,625.05,1176.6,
Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,625.05,1176.6,
Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,625.05,1176.6,
Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,625.05,1176.6,
Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1176.6,APC
Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1176.6,APC
Removal of vein clot,34471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1176.6,APC
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,2284.6,5663.03,
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Removal of vein clot,34490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair valve femoral vein,34501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Transposition of vein valve,34510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Cross-over vein graft,34520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Leg vein fusion,34530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Evasc rpr a-ao ndgft,34701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2093.56,,,,,,,fee schedule,1372.54,2407.59,
Evasc rpr a-ao ndgft,34701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1713.58,,,,,,,fee schedule,1372.54,2407.59,
Evasc rpr a-ao ndgft,34701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1372.54,,,,,,,fee schedule,1372.54,2407.59,
Evasc rpr a-ao ndgft,34701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2407.59,,,,,,,fee schedule,1372.54,2407.59,
Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2981.1,,,,,,,fee schedule,1954.41,3428.27,
Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2440.03,,,,,,,fee schedule,1954.41,3428.27,
Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1954.41,,,,,,,fee schedule,1954.41,3428.27,
Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3428.27,,,,,,,fee schedule,1954.41,3428.27,
Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2294.06,,,,,,,fee schedule,1503.99,2638.17,
Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1877.69,,,,,,,fee schedule,1503.99,2638.17,
Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1503.99,,,,,,,fee schedule,1503.99,2638.17,
Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2638.17,,,,,,,fee schedule,1503.99,2638.17,
Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3606.22,,,,,,,fee schedule,2364.24,4147.15,
Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2951.69,,,,,,,fee schedule,2364.24,4147.15,
Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2364.24,,,,,,,fee schedule,2364.24,4147.15,
Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4147.15,,,,,,,fee schedule,2364.24,4147.15,
Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2524.05,,,,,,,fee schedule,1654.77,2902.66,
Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2065.93,,,,,,,fee schedule,1654.77,2902.66,
Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1654.77,,,,,,,fee schedule,1654.77,2902.66,
Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2902.66,,,,,,,fee schedule,1654.77,2902.66,
Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3638.68,,,,,,,fee schedule,2385.52,4184.48,
Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2978.26,,,,,,,fee schedule,2385.52,4184.48,
Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2385.52,,,,,,,fee schedule,2385.52,4184.48,
Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4184.48,,,,,,,fee schedule,2385.52,4184.48,
Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1893.04,,,,,,,fee schedule,1241.08,2177,
Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1241.08,,,,,,,fee schedule,1241.08,2177,
Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1549.45,,,,,,,fee schedule,1241.08,2177,
Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2177,,,,,,,fee schedule,1241.08,2177,
Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2857.25,,,,,,,fee schedule,1873.21,3285.84,
Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1873.21,,,,,,,fee schedule,1873.21,3285.84,
Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2338.66,,,,,,,fee schedule,1873.21,3285.84,
Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3285.84,,,,,,,fee schedule,1873.21,3285.84,
Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1497.93,,,,,,,fee schedule,982.04,1722.62,
Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,982.04,,,,,,,fee schedule,982.04,1722.62,
Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1226.06,,,,,,,fee schedule,982.04,1722.62,
Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1722.62,,,,,,,fee schedule,982.04,1722.62,
Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1618.8,,,,,,,fee schedule,1061.29,1861.62,
Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1061.29,,,,,,,fee schedule,1061.29,1861.62,
Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1324.99,,,,,,,fee schedule,1061.29,1861.62,
Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1861.62,,,,,,,fee schedule,1061.29,1861.62,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.24,,,,,,,fee schedule,256.5,449.93,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,391.24,,,,,,,fee schedule,256.5,449.93,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,391.24,,,,,,,fee schedule,256.5,449.93,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.5,,,,,,,fee schedule,256.5,449.93,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.23,,,,,,,fee schedule,256.5,449.93,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.93,,,,,,,fee schedule,256.5,449.93,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1369.27,,,,,,,fee schedule,897.69,1574.66,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1369.27,,,,,,,fee schedule,897.69,1574.66,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1369.27,,,,,,,fee schedule,897.69,1574.66,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,897.69,,,,,,,fee schedule,897.69,1574.66,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1120.75,,,,,,,fee schedule,897.69,1574.66,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1574.66,,,,,,,fee schedule,897.69,1574.66,
Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair defect of artery,35011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair defect of arm artery,35045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,670.76,2823.29,
Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,670.76,2823.29,
Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,670.76,2823.29,
Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,670.76,2823.29,
Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,670.76,2823.29,APC
Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,670.76,2823.29,APC
Repair blood vessel lesion,35180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,670.76,2823.29,APC
Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Repair blood vessel lesion,35188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,2284.6,5663.03,
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Repair blood vessel lesion,35207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,806.26,,,,,,,fee schedule,528.58,1270.05,
Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,528.58,,,,,,,fee schedule,528.58,1270.05,
Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,659.92,,,,,,,fee schedule,528.58,1270.05,
Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,927.2,,,,,,,fee schedule,528.58,1270.05,
Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,528.58,1270.05,APC
Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,528.58,1270.05,APC
Repair blood vessel lesion,35226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,528.58,1270.05,APC
Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35236,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35256,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Repair blood vessel lesion,35286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Rechanneling of artery,35321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Rechanneling of artery,35372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,5544.48,9980.06,APC
Rechanneling of artery,35372,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,5544.48,9980.06,APC
Rechanneling of artery,35372,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,5544.48,9980.06,APC
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.4,,,,,,,fee schedule,445.41,781.31,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,679.4,,,,,,,fee schedule,445.41,781.31,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,679.4,,,,,,,fee schedule,445.41,781.31,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.41,,,,,,,fee schedule,445.41,781.31,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,556.09,,,,,,,fee schedule,445.41,781.31,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.31,,,,,,,fee schedule,445.41,781.31,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,605.77,,,,,,,fee schedule,397.14,696.64,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,605.77,,,,,,,fee schedule,397.14,696.64,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,605.77,,,,,,,fee schedule,397.14,696.64,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,397.14,,,,,,,fee schedule,397.14,696.64,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,495.82,,,,,,,fee schedule,397.14,696.64,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,696.64,,,,,,,fee schedule,397.14,696.64,
Explore neck vessels,35800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,5544.48,9980.06,APC
Explore neck vessels,35800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,5544.48,9980.06,APC
Explore neck vessels,35800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,5544.48,9980.06,APC
Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Explore limb vessels,35860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Removal of clot in graft,35875,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Removal of clot in graft,35876,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Revise graft w/vein,35879,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Revise graft w/vein,35881,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Revise graft w/vein,35884,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Excision graft extremity,35903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Place needle in vein,36000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,710.92,,,,,,,fee schedule,466.08,817.56,
Place needle in vein,36000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,466.08,,,,,,,fee schedule,466.08,817.56,
Place needle in vein,36000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,581.89,,,,,,,fee schedule,466.08,817.56,
Place needle in vein,36000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,817.56,,,,,,,fee schedule,466.08,817.56,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,611.36,,,,,,,fee schedule,251.28,1125.08,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.28,,,,,,,fee schedule,251.28,1125.08,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.28,,,,,,,fee schedule,251.28,1125.08,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,400.81,,,,,,,fee schedule,251.28,1125.08,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,500.4,,,,,,,fee schedule,251.28,1125.08,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,288.97,,,,,,,fee schedule,251.28,1125.08,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,703.06,,,,,,,fee schedule,251.28,1125.08,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,251.28,,,,,,,fee schedule,251.28,1125.08,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,251.28,1125.08,APC
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,251.28,1125.08,APC
Pseudoaneurysm injection trt,36002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,251.28,1125.08,APC
Injection ext venography,36005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,678.84,,,,,,,fee schedule,445.05,780.67,
Injection ext venography,36005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.05,,,,,,,fee schedule,445.05,780.67,
Injection ext venography,36005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,555.63,,,,,,,fee schedule,445.05,780.67,
Injection ext venography,36005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,780.67,,,,,,,fee schedule,445.05,780.67,
Place catheter in vein,36010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1409.77,,,,,,,fee schedule,924.25,1621.24,
Place catheter in vein,36010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,924.25,,,,,,,fee schedule,924.25,1621.24,
Place catheter in vein,36010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1153.9,,,,,,,fee schedule,924.25,1621.24,
Place catheter in vein,36010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1621.24,,,,,,,fee schedule,924.25,1621.24,
Place catheter in vein,36011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1695.34,,,,,,,fee schedule,1111.46,1949.64,
Place catheter in vein,36011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1111.46,,,,,,,fee schedule,1111.46,1949.64,
Place catheter in vein,36011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1387.64,,,,,,,fee schedule,1111.46,1949.64,
Place catheter in vein,36011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1949.64,,,,,,,fee schedule,1111.46,1949.64,
Place catheter in vein,36012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1528.43,,,,,,,fee schedule,1002.04,1757.69,
Place catheter in vein,36012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1002.04,,,,,,,fee schedule,1002.04,1757.69,
Place catheter in vein,36012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1251.02,,,,,,,fee schedule,1002.04,1757.69,
Place catheter in vein,36012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1757.69,,,,,,,fee schedule,1002.04,1757.69,
Place catheter in artery,36013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1859.75,,,,,,,fee schedule,1219.25,2138.71,
Place catheter in artery,36013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1219.25,,,,,,,fee schedule,1219.25,2138.71,
Place catheter in artery,36013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1522.21,,,,,,,fee schedule,1219.25,2138.71,
Place catheter in artery,36013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2138.71,,,,,,,fee schedule,1219.25,2138.71,
Place catheter in artery,36014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1474.15,,,,,,,fee schedule,966.45,1695.27,
Place catheter in artery,36014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,966.45,,,,,,,fee schedule,966.45,1695.27,
Place catheter in artery,36014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1206.59,,,,,,,fee schedule,966.45,1695.27,
Place catheter in artery,36014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1695.27,,,,,,,fee schedule,966.45,1695.27,
Place catheter in artery,36015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2010.67,,,,,,,fee schedule,1318.2,2312.27,
Place catheter in artery,36015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1318.2,,,,,,,fee schedule,1318.2,2312.27,
Place catheter in artery,36015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1645.73,,,,,,,fee schedule,1318.2,2312.27,
Place catheter in artery,36015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2312.27,,,,,,,fee schedule,1318.2,2312.27,
Establish access to artery,36100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,970.03,,,,,,,fee schedule,635.95,1115.53,
Establish access to artery,36100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,635.95,,,,,,,fee schedule,635.95,1115.53,
Establish access to artery,36100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,793.97,,,,,,,fee schedule,635.95,1115.53,
Establish access to artery,36100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1115.53,,,,,,,fee schedule,635.95,1115.53,
Establish access to artery,36140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,968.08,,,,,,,fee schedule,634.67,1113.29,
Establish access to artery,36140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,634.67,,,,,,,fee schedule,634.67,1113.29,
Establish access to artery,36140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,792.37,,,,,,,fee schedule,634.67,1113.29,
Establish access to artery,36140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1113.29,,,,,,,fee schedule,634.67,1113.29,
Establish access to aorta,36160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1089.59,,,,,,,fee schedule,714.34,1253.03,
Establish access to aorta,36160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,714.34,,,,,,,fee schedule,714.34,1253.03,
Establish access to aorta,36160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,891.83,,,,,,,fee schedule,714.34,1253.03,
Establish access to aorta,36160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1253.03,,,,,,,fee schedule,714.34,1253.03,
Place catheter in aorta,36200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2023.8,,,,,,,fee schedule,1326.8,2327.37,
Place catheter in aorta,36200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1326.8,,,,,,,fee schedule,1326.8,2327.37,
Place catheter in aorta,36200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1656.48,,,,,,,fee schedule,1326.8,2327.37,
Place catheter in aorta,36200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2327.37,,,,,,,fee schedule,1326.8,2327.37,
Place catheter in artery,36215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7264.57,,,,,,,fee schedule,4762.65,8354.26,
Place catheter in artery,36215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4762.65,,,,,,,fee schedule,4762.65,8354.26,
Place catheter in artery,36215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5946.05,,,,,,,fee schedule,4762.65,8354.26,
Place catheter in artery,36215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8354.26,,,,,,,fee schedule,4762.65,8354.26,
Place catheter in artery,36216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1914.2,,,,,,,fee schedule,1254.95,2201.33,
Place catheter in artery,36216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1254.95,,,,,,,fee schedule,1254.95,2201.33,
Place catheter in artery,36216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1566.77,,,,,,,fee schedule,1254.95,2201.33,
Place catheter in artery,36216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2201.33,,,,,,,fee schedule,1254.95,2201.33,
Place catheter in artery,36217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4547.47,,,,,,,fee schedule,2981.32,5229.59,
Place catheter in artery,36217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2981.32,,,,,,,fee schedule,2981.32,5229.59,
Place catheter in artery,36217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3722.1,,,,,,,fee schedule,2981.32,5229.59,
Place catheter in artery,36217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5229.59,,,,,,,fee schedule,2981.32,5229.59,
Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath thoracic aorta,36221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath carotid/inom art,36222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7064.48,,,,,,,fee schedule,4631.47,9980.06,
Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4631.47,,,,,,,fee schedule,4631.47,9980.06,
Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5782.28,,,,,,,fee schedule,4631.47,9980.06,
Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8124.15,,,,,,,fee schedule,4631.47,9980.06,
Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,4631.47,9980.06,APC
Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,4631.47,9980.06,APC
Place cath carotid/inom art,36223,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,4631.47,9980.06,APC
Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Place cath carotd art,36224,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath subclavian art,36225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Place cath vertebral art,36226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Ins cath abd/l-ext art 1st,36245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3549.53,,,,,,,fee schedule,2327.07,4081.96,
Ins cath abd/l-ext art 1st,36245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2905.29,,,,,,,fee schedule,2327.07,4081.96,
Ins cath abd/l-ext art 1st,36245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2327.07,,,,,,,fee schedule,2327.07,4081.96,
Ins cath abd/l-ext art 1st,36245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4081.96,,,,,,,fee schedule,2327.07,4081.96,
Ins cath abd/l-ext art 2nd,36246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1977.33,,,,,,,fee schedule,1296.34,2273.93,
Ins cath abd/l-ext art 2nd,36246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1618.44,,,,,,,fee schedule,1296.34,2273.93,
Ins cath abd/l-ext art 2nd,36246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1296.34,,,,,,,fee schedule,1296.34,2273.93,
Ins cath abd/l-ext art 2nd,36246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2273.93,,,,,,,fee schedule,1296.34,2273.93,
Ins cath abd/l-ext art 3rd,36247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2728.67,,,,,,,fee schedule,1788.92,3137.97,
Ins cath abd/l-ext art 3rd,36247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2233.42,,,,,,,fee schedule,1788.92,3137.97,
Ins cath abd/l-ext art 3rd,36247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1788.92,,,,,,,fee schedule,1788.92,3137.97,
Ins cath abd/l-ext art 3rd,36247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3137.97,,,,,,,fee schedule,1788.92,3137.97,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Ins cath ren art 1st unilat,36251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Ins cath ren art 1st bilat,36252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9928.84,,,,,,,fee schedule,2963.35,11418.17,
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,11418.17,
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,11418.17,
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8126.76,,,,,,,fee schedule,2963.35,11418.17,
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6509.35,,,,,,,fee schedule,2963.35,11418.17,
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,11418.17,
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11418.17,,,,,,,fee schedule,2963.35,11418.17,
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,11418.17,
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,11418.17,APC
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,11418.17,APC
Insertion of infusion pump,36260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,11418.17,APC
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5877.75,,,,,,,fee schedule,3110.41,6759.41,
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3110.41,,,,,,,fee schedule,3110.41,6759.41,
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3110.41,,,,,,,fee schedule,3110.41,6759.41,
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4810.94,,,,,,,fee schedule,3110.41,6759.41,
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3853.45,,,,,,,fee schedule,3110.41,6759.41,
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3576.97,,,,,,,fee schedule,3110.41,6759.41,
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6759.41,,,,,,,fee schedule,3110.41,6759.41,
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3110.41,,,,,,,fee schedule,3110.41,6759.41,
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,3110.41,6759.41,APC
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,3110.41,6759.41,APC
Revision of infusion pump,36261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,3110.41,6759.41,APC
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3778.52,,,,,,,fee schedule,2477.2,6702.34,
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3092.72,,,,,,,fee schedule,2477.2,6702.34,
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2477.2,,,,,,,fee schedule,2477.2,6702.34,
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3576.97,,,,,,,fee schedule,2477.2,6702.34,
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4345.3,,,,,,,fee schedule,2477.2,6702.34,
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3110.41,,,,,,,fee schedule,2477.2,6702.34,
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.7,,,,,,,fee schedule,2477.2,6702.34,APC
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3723.52,,,,,,,fee schedule,2477.2,6702.34,APC
Removal of infusion pump,36262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6702.34,,,,,,,fee schedule,2477.2,6702.34,APC
Bl draw < 3 yrs fem/jugular,36400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,22.47,39.42,
Bl draw < 3 yrs fem/jugular,36400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,22.47,39.42,
Bl draw < 3 yrs fem/jugular,36400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,22.47,39.42,
Bl draw < 3 yrs fem/jugular,36400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,22.47,39.42,
Bl draw <3 yrs scalp vein,36405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,24.4,42.8,
Bl draw <3 yrs scalp vein,36405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,24.4,42.8,
Bl draw <3 yrs scalp vein,36405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,24.4,42.8,
Bl draw <3 yrs scalp vein,36405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,24.4,42.8,
Bl draw <3 yrs other vein,36406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,37.19,
Bl draw <3 yrs other vein,36406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,37.19,
Bl draw <3 yrs other vein,36406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,37.19,
Bl draw <3 yrs other vein,36406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,37.19,
Non-routine bl draw 3/> yrs,36410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,17.99,31.56,
Non-routine bl draw 3/> yrs,36410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,17.99,31.56,
Non-routine bl draw 3/> yrs,36410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,17.99,31.56,
Non-routine bl draw 3/> yrs,36410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,17.99,31.56,
Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.99,,,,,,,fee schedule,9.34,17.24,
Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.27,,,,,,,fee schedule,9.34,17.24,
Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.83,,,,,,,fee schedule,9.34,17.24,
Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.24,,,,,,,fee schedule,9.34,17.24,
Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.81,,,,,,,fee schedule,9.34,17.24,APC
Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.34,,,,,,,fee schedule,9.34,17.24,APC
Routine venipuncture,36415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.81,,,,,,,fee schedule,9.34,17.24,APC
Capillary blood draw,36416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.33,,,,,,,fee schedule,23.82,41.78,
Capillary blood draw,36416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.74,,,,,,,fee schedule,23.82,41.78,
Capillary blood draw,36416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.82,,,,,,,fee schedule,23.82,41.78,
Capillary blood draw,36416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.78,,,,,,,fee schedule,23.82,41.78,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Vein access cutdown < 1 yr,36420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Vein access cutdown > 1 yr,36425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,273.26,,,,,,,fee schedule,81.48,791.26,
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.48,,,,,,,fee schedule,81.48,791.26,
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.48,,,,,,,fee schedule,81.48,791.26,
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.15,,,,,,,fee schedule,81.48,791.26,
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,223.66,,,,,,,fee schedule,81.48,791.26,
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.7,,,,,,,fee schedule,81.48,791.26,
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,314.25,,,,,,,fee schedule,81.48,791.26,
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.48,,,,,,,fee schedule,81.48,791.26,
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,81.48,791.26,APC
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,81.48,791.26,APC
Blood transfusion service,36430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,81.48,791.26,APC
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.36,,,,,,,fee schedule,343.11,791.26,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.95,,,,,,,fee schedule,343.11,791.26,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,393.95,,,,,,,fee schedule,343.11,791.26,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.11,,,,,,,fee schedule,343.11,791.26,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,428.37,,,,,,,fee schedule,343.11,791.26,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.04,,,,,,,fee schedule,343.11,791.26,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,601.86,,,,,,,fee schedule,343.11,791.26,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,393.95,,,,,,,fee schedule,343.11,791.26,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,343.11,791.26,APC
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,343.11,791.26,APC
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,343.11,791.26,APC
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.36,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.95,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,393.95,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,428.37,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.11,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.04,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,601.86,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,393.95,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,343.11,791.26,APC
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,343.11,791.26,APC
Bl exchange/transfuse nb,36450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,343.11,791.26,APC
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.36,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.95,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,393.95,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,428.37,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.11,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.04,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,601.86,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,393.95,,,,,,,fee schedule,343.11,791.26,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,343.11,791.26,APC
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,343.11,791.26,APC
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,343.11,791.26,APC
Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Prtl exchange transfuse nb,36456,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Transfusion service fetal,36460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4281.9,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1364.68,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1364.68,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2807.21,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3504.74,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1569.38,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4924.19,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1364.68,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1364.68,4924.19,APC
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1364.68,4924.19,APC
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1364.68,4924.19,APC
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4281.9,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1364.68,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1364.68,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2807.21,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3504.74,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1569.38,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4924.19,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1364.68,,,,,,,fee schedule,1364.68,4924.19,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1364.68,4924.19,APC
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1364.68,4924.19,APC
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1364.68,4924.19,APC
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,729.1,
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,729.1,
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,150.12,729.1,
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,729.1,
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,729.1,
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,150.12,729.1,
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,729.1,
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,150.12,729.1,
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,150.12,729.1,APC
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,150.12,729.1,APC
Injection(s) spider veins,36468,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,150.12,729.1,APC
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.18,,,,,,,fee schedule,185.65,729.1,
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,255.93,,,,,,,fee schedule,185.65,729.1,
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255.93,,,,,,,fee schedule,185.65,729.1,
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.65,,,,,,,fee schedule,185.65,729.1,
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,231.78,,,,,,,fee schedule,185.65,729.1,
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.32,,,,,,,fee schedule,185.65,729.1,
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.66,,,,,,,fee schedule,185.65,729.1,
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.93,,,,,,,fee schedule,185.65,729.1,
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,185.65,729.1,APC
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,185.65,729.1,APC
Injection therapy of vein,36470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,185.65,729.1,APC
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.9,,,,,,,fee schedule,193.65,729.1,
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.99,,,,,,,fee schedule,193.65,729.1,
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.19,,,,,,,fee schedule,193.65,729.1,
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.29,,,,,,,fee schedule,193.65,729.1,
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Injection therapy of veins,36471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Endovenous rf 1st vein,36475,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Endovenous laser 1st vein,36478,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Insertion of catheter vein,36481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2013.09,,,,,,,fee schedule,1319.78,2315.05,
Insertion of catheter vein,36481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1319.78,,,,,,,fee schedule,1319.78,2315.05,
Insertion of catheter vein,36481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1647.71,,,,,,,fee schedule,1319.78,2315.05,
Insertion of catheter vein,36481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2315.05,,,,,,,fee schedule,1319.78,2315.05,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11643.62,,,,,,,fee schedule,3710.88,13390.16,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3710.88,,,,,,,fee schedule,3710.88,13390.16,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3710.88,,,,,,,fee schedule,3710.88,13390.16,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7633.56,,,,,,,fee schedule,3710.88,13390.16,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9530.3,,,,,,,fee schedule,3710.88,13390.16,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4267.51,,,,,,,fee schedule,3710.88,13390.16,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13390.16,,,,,,,fee schedule,3710.88,13390.16,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3710.88,,,,,,,fee schedule,3710.88,13390.16,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3710.88,13390.16,APC
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3710.88,13390.16,APC
Endoven ther chem adhes 1st,36482,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3710.88,13390.16,APC
Insertion of catheter vein,36500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.59,,,,,,,fee schedule,77.09,135.23,
Insertion of catheter vein,36500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.09,,,,,,,fee schedule,77.09,135.23,
Insertion of catheter vein,36500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.25,,,,,,,fee schedule,77.09,135.23,
Insertion of catheter vein,36500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.23,,,,,,,fee schedule,77.09,135.23,
Insertion of catheter vein,36510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.5,,,,,,,fee schedule,79.66,139.73,
Insertion of catheter vein,36510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.66,,,,,,,fee schedule,79.66,139.73,
Insertion of catheter vein,36510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.45,,,,,,,fee schedule,79.66,139.73,
Insertion of catheter vein,36510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.73,,,,,,,fee schedule,79.66,139.73,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.89,,,,,,,fee schedule,1063.31,2793.29,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1063.31,,,,,,,fee schedule,1063.31,2793.29,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1608.3,,,,,,,fee schedule,1063.31,2793.29,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1865.17,,,,,,,fee schedule,1063.31,2793.29,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis wbc,36511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.89,,,,,,,fee schedule,1063.31,2793.29,
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1063.31,,,,,,,fee schedule,1063.31,2793.29,
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1608.3,,,,,,,fee schedule,1063.31,2793.29,
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1865.17,,,,,,,fee schedule,1063.31,2793.29,
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis rbc,36512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.36,,,,,,,fee schedule,343.11,1608.3,
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.52,,,,,,,fee schedule,343.11,1608.3,
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.52,,,,,,,fee schedule,343.11,1608.3,
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.11,,,,,,,fee schedule,343.11,1608.3,
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,428.37,,,,,,,fee schedule,343.11,1608.3,
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1608.3,,,,,,,fee schedule,343.11,1608.3,
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,601.86,,,,,,,fee schedule,343.11,1608.3,
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.52,,,,,,,fee schedule,343.11,1608.3,
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,343.11,1608.3,APC
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,343.11,1608.3,APC
Apheresis platelets,36513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,343.11,1608.3,APC
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.89,,,,,,,fee schedule,1063.31,2793.29,
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1063.31,,,,,,,fee schedule,1063.31,2793.29,
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1608.3,,,,,,,fee schedule,1063.31,2793.29,
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1865.17,,,,,,,fee schedule,1063.31,2793.29,
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis plasma,36514,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,1063.31,2793.29,APC
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4705.9,,,,,,,fee schedule,3085.19,7811.71,
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3085.19,,,,,,,fee schedule,3085.19,7811.71,
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3851.78,,,,,,,fee schedule,3085.19,7811.71,
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,3085.19,7811.71,
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5411.79,,,,,,,fee schedule,3085.19,7811.71,
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4556.83,,,,,,,fee schedule,3085.19,7811.71,APC
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4339.84,,,,,,,fee schedule,3085.19,7811.71,APC
Apheresis selective,36516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7811.71,,,,,,,fee schedule,3085.19,7811.71,APC
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4705.9,,,,,,,fee schedule,3085.19,7811.71,
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3085.19,,,,,,,fee schedule,3085.19,7811.71,
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3851.78,,,,,,,fee schedule,3085.19,7811.71,
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,3085.19,7811.71,
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5411.79,,,,,,,fee schedule,3085.19,7811.71,
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,3085.19,7811.71,
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4556.83,,,,,,,fee schedule,3085.19,7811.71,APC
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4339.84,,,,,,,fee schedule,3085.19,7811.71,APC
Photopheresis,36522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7811.71,,,,,,,fee schedule,3085.19,7811.71,APC
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,662.1,5663.03,
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,5663.03,
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,662.1,5663.03,
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,662.1,5663.03,
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,662.1,5663.03,
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,662.1,5663.03,
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,662.1,5663.03,
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,5663.03,
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,662.1,5663.03,APC
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,662.1,5663.03,APC
Insert non-tunnel cv cath,36555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,662.1,5663.03,APC
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,936.82,,,,,,,fee schedule,614.18,5663.03,
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,614.18,5663.03,
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,614.18,5663.03,
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,614.18,,,,,,,fee schedule,614.18,5663.03,
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,766.79,,,,,,,fee schedule,614.18,5663.03,
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,614.18,5663.03,
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1077.34,,,,,,,fee schedule,614.18,5663.03,
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,614.18,5663.03,
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,614.18,5663.03,APC
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,614.18,5663.03,APC
Insert non-tunnel cv cath,36556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,614.18,5663.03,APC
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tunneled cv cath,36557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1573.44,,,,,,,fee schedule,1031.55,5663.03,
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,1031.55,5663.03,
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,1031.55,5663.03,
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1031.55,,,,,,,fee schedule,1031.55,5663.03,
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1287.86,,,,,,,fee schedule,1031.55,5663.03,
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,1031.55,5663.03,
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1809.46,,,,,,,fee schedule,1031.55,5663.03,
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,1031.55,5663.03,
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,1031.55,5663.03,APC
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,1031.55,5663.03,APC
Insert tunneled cv cath,36558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,1031.55,5663.03,APC
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Insert tunneled cv cath,36560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6438.5,,,,,,,fee schedule,2963.35,7404.28,
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,7404.28,
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,7404.28,
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4221.08,,,,,,,fee schedule,2963.35,7404.28,
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5269.91,,,,,,,fee schedule,2963.35,7404.28,
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,7404.28,
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7404.28,,,,,,,fee schedule,2963.35,7404.28,
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,7404.28,
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2963.35,7404.28,APC
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2963.35,7404.28,APC
Insert tunneled cv cath,36561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2963.35,7404.28,APC
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tunneled cv cath,36563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Insert tunneled cv cath,36565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tunneled cv cath,36566,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,9980.06,APC
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.66,,,,,,,fee schedule,1117.72,9651.56,
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,1117.72,9651.56,
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,1117.72,9651.56,
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.23,,,,,,,fee schedule,1117.72,9651.56,
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.39,,,,,,,fee schedule,1117.72,9651.56,
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,1117.72,9651.56,
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.56,,,,,,,fee schedule,1117.72,9651.56,
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,1117.72,9651.56,
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,1117.72,9651.56,APC
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,1117.72,9651.56,APC
Insert picc cath,36568,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,1117.72,9651.56,APC
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1337.09,,,,,,,fee schedule,876.6,2823.29,
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,876.6,2823.29,
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,876.6,2823.29,
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,876.6,,,,,,,fee schedule,876.6,2823.29,
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1094.41,,,,,,,fee schedule,876.6,2823.29,
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,876.6,2823.29,
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1537.65,,,,,,,fee schedule,876.6,2823.29,
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,876.6,2823.29,
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,876.6,2823.29,APC
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,876.6,2823.29,APC
Insert picc cath,36569,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,876.6,2823.29,APC
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Insert picvad cath,36570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Insert picvad cath,36571,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1627.66,,,,,,,fee schedule,511.87,1871.81,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,511.87,,,,,,,fee schedule,511.87,1871.81,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,511.87,,,,,,,fee schedule,511.87,1871.81,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1067.09,,,,,,,fee schedule,511.87,1871.81,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1332.24,,,,,,,fee schedule,511.87,1871.81,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.65,,,,,,,fee schedule,511.87,1871.81,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1871.81,,,,,,,fee schedule,511.87,1871.81,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,511.87,,,,,,,fee schedule,511.87,1871.81,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,511.87,1871.81,APC
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,511.87,1871.81,APC
Insj picc rs&i <5 yr,36572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,511.87,1871.81,APC
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2871.05,,,,,,,fee schedule,902.92,3301.71,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,902.92,,,,,,,fee schedule,902.92,3301.71,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,902.92,,,,,,,fee schedule,902.92,3301.71,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1882.26,,,,,,,fee schedule,902.92,3301.71,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2349.95,,,,,,,fee schedule,902.92,3301.71,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1038.36,,,,,,,fee schedule,902.92,3301.71,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3301.71,,,,,,,fee schedule,902.92,3301.71,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,902.92,,,,,,,fee schedule,902.92,3301.71,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,902.92,3301.71,APC
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,902.92,3301.71,APC
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,902.92,3301.71,APC
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,625.05,1161.41,
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,625.05,1161.41,
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,625.05,1161.41,
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,625.05,1161.41,
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,625.05,1161.41,
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,625.05,1161.41,
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,625.05,1161.41,
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,625.05,1161.41,
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1161.41,APC
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1161.41,APC
Repair tunneled cv cath,36575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1161.41,APC
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,662.1,2823.29,
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,2823.29,
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,662.1,2823.29,
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,662.1,2823.29,
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,662.1,2823.29,
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,662.1,2823.29,
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,662.1,2823.29,
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,2823.29,
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,662.1,2823.29,APC
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,662.1,2823.29,APC
Repair tunneled cv cath,36576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,662.1,2823.29,APC
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Replace tunneled cv cath,36578,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,662.1,2823.29,
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,2823.29,
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,662.1,2823.29,
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,662.1,2823.29,
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,662.1,2823.29,
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,662.1,2823.29,
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,662.1,2823.29,
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,2823.29,
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,662.1,2823.29,APC
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,662.1,2823.29,APC
Replace cvad cath,36580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,662.1,2823.29,APC
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3302.27,,,,,,,fee schedule,2164.97,5663.03,
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2164.97,5663.03,
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2164.97,5663.03,
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2164.97,,,,,,,fee schedule,2164.97,5663.03,
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2702.91,,,,,,,fee schedule,2164.97,5663.03,
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2164.97,5663.03,
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3797.61,,,,,,,fee schedule,2164.97,5663.03,
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2164.97,5663.03,
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2164.97,5663.03,APC
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2164.97,5663.03,APC
Replace tunneled cv cath,36581,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2164.97,5663.03,APC
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Replace tunneled cv cath,36582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9831.42,,,,,,,fee schedule,2963.35,11306.13,
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,11306.13,
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,11306.13,
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6445.48,,,,,,,fee schedule,2963.35,11306.13,
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8047.02,,,,,,,fee schedule,2963.35,11306.13,
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,11306.13,
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11306.13,,,,,,,fee schedule,2963.35,11306.13,
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,11306.13,
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,11306.13,APC
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,11306.13,APC
Replace tunneled cv cath,36583,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,11306.13,APC
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,789.18,,,,,,,fee schedule,517.39,2823.29,
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,517.39,2823.29,
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,517.39,2823.29,
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,517.39,,,,,,,fee schedule,517.39,2823.29,
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,645.94,,,,,,,fee schedule,517.39,2823.29,
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,517.39,2823.29,
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,907.56,,,,,,,fee schedule,517.39,2823.29,
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,517.39,2823.29,
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,517.39,2823.29,APC
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,517.39,2823.29,APC
Replace picc cath,36584,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,517.39,2823.29,APC
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Replace picvad cath,36585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1463.18,,,,,,,fee schedule,625.05,1682.66,
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,625.05,1682.66,
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,625.05,1682.66,
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,959.26,,,,,,,fee schedule,625.05,1682.66,
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1197.61,,,,,,,fee schedule,625.05,1682.66,
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,625.05,1682.66,
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1682.66,,,,,,,fee schedule,625.05,1682.66,
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,625.05,1682.66,
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1682.66,APC
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1682.66,APC
Removal tunneled cv cath,36589,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1682.66,APC
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1972.27,,,,,,,fee schedule,1117.72,2823.29,
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,1117.72,2823.29,
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,1117.72,2823.29,
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1293.02,,,,,,,fee schedule,1117.72,2823.29,
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1614.3,,,,,,,fee schedule,1117.72,2823.29,
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,1117.72,2823.29,
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2268.11,,,,,,,fee schedule,1117.72,2823.29,
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,1117.72,2823.29,
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,1117.72,2823.29,APC
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,1117.72,2823.29,APC
Removal tunneled cv cath,36590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,1117.72,2823.29,APC
Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.31,,,,,,,fee schedule,71.66,238.63,
Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.66,,,,,,,fee schedule,71.66,238.63,
Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.47,,,,,,,fee schedule,71.66,238.63,
Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.71,,,,,,,fee schedule,71.66,238.63,
Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,71.66,238.63,APC
Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,71.66,238.63,APC
Draw blood off venous device,36591,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,71.66,238.63,APC
Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.31,,,,,,,fee schedule,71.66,238.63,
Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.66,,,,,,,fee schedule,71.66,238.63,
Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.47,,,,,,,fee schedule,71.66,238.63,
Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.71,,,,,,,fee schedule,71.66,238.63,
Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,71.66,238.63,APC
Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,71.66,238.63,APC
Collect blood from picc,36592,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,71.66,238.63,APC
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.2,,,,,,,fee schedule,57.17,592.41,
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.35,,,,,,,fee schedule,57.17,592.41,
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.35,,,,,,,fee schedule,57.17,592.41,
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.17,,,,,,,fee schedule,57.17,592.41,
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.17,592.41,
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.5,,,,,,,fee schedule,57.17,592.41,
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.28,,,,,,,fee schedule,57.17,592.41,
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.35,,,,,,,fee schedule,57.17,592.41,
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,57.17,592.41,APC
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,57.17,592.41,APC
Declot vascular device,36593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,57.17,592.41,APC
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1059.49,,,,,,,fee schedule,694.6,5663.03,
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1093.82,,,,,,,fee schedule,694.6,5663.03,
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1093.82,,,,,,,fee schedule,694.6,5663.03,
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,694.6,,,,,,,fee schedule,694.6,5663.03,
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,867.19,,,,,,,fee schedule,694.6,5663.03,
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1257.89,,,,,,,fee schedule,694.6,5663.03,
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1218.41,,,,,,,fee schedule,694.6,5663.03,
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1093.82,,,,,,,fee schedule,694.6,5663.03,
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,694.6,5663.03,APC
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,694.6,5663.03,APC
Mech remov tunneled cv cath,36595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,694.6,5663.03,APC
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,662.1,2823.29,
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,2823.29,
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,662.1,2823.29,
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,662.1,2823.29,
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,662.1,2823.29,
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,662.1,2823.29,
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,662.1,2823.29,
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,2823.29,
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,662.1,2823.29,APC
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,662.1,2823.29,APC
Mech remov tunneled cv cath,36596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,662.1,2823.29,APC
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,662.1,2823.29,
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,2823.29,
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,662.1,2823.29,
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,662.1,2823.29,
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,662.1,2823.29,
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,662.1,2823.29,
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,662.1,2823.29,
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,662.1,2823.29,
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,662.1,2823.29,APC
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,662.1,2823.29,APC
Reposition venous catheter,36597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,662.1,2823.29,APC
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,580.8,,,,,,,fee schedule,201.46,667.92,
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.46,,,,,,,fee schedule,201.46,667.92,
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.46,,,,,,,fee schedule,201.46,667.92,
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,380.77,,,,,,,fee schedule,201.46,667.92,
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,475.38,,,,,,,fee schedule,201.46,667.92,
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.68,,,,,,,fee schedule,201.46,667.92,
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,667.92,,,,,,,fee schedule,201.46,667.92,
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.46,,,,,,,fee schedule,201.46,667.92,
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,201.46,667.92,APC
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,201.46,667.92,APC
Inj w/fluor eval cv device,36598,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,201.46,667.92,APC
Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.99,,,,,,,fee schedule,41.3,238.63,
Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.3,,,,,,,fee schedule,41.3,238.63,
Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.56,,,,,,,fee schedule,41.3,238.63,
Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.44,,,,,,,fee schedule,41.3,238.63,
Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,41.3,238.63,APC
Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,41.3,238.63,APC
Withdrawal of arterial blood,36600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,41.3,238.63,APC
Insertion catheter artery,36620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.56,,,,,,,fee schedule,14.13,24.79,
Insertion catheter artery,36620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.13,,,,,,,fee schedule,14.13,24.79,
Insertion catheter artery,36620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.65,,,,,,,fee schedule,14.13,24.79,
Insertion catheter artery,36620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.79,,,,,,,fee schedule,14.13,24.79,
Insertion catheter artery,36625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.87,,,,,,,fee schedule,36.63,64.25,
Insertion catheter artery,36625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.63,,,,,,,fee schedule,36.63,64.25,
Insertion catheter artery,36625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.73,,,,,,,fee schedule,36.63,64.25,
Insertion catheter artery,36625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.25,,,,,,,fee schedule,36.63,64.25,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Insertion catheter artery,36640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Insert needle bone cavity,36680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,9980.06,APC
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,9980.06,APC
Insertion of cannula,36800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,9980.06,APC
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Insertion of cannula,36810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,9980.06,APC
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,9980.06,APC
Insertion of cannula,36815,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,9980.06,APC
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14465.64,,,,,,,fee schedule,4268.07,16635.49,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,4268.07,16635.49,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,4268.07,16635.49,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9483.67,,,,,,,fee schedule,4268.07,16635.49,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11840.13,,,,,,,fee schedule,4268.07,16635.49,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,4268.07,16635.49,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16635.49,,,,,,,fee schedule,4268.07,16635.49,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,4268.07,16635.49,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,4268.07,16635.49,APC
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,4268.07,16635.49,APC
Av fuse uppr arm cephalic,36818,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,4268.07,16635.49,APC
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Av fuse uppr arm basilic,36819,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10754.47,,,,,,,fee schedule,4268.07,12367.64,
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,4268.07,12367.64,
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,4268.07,12367.64,
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8802.53,,,,,,,fee schedule,4268.07,12367.64,
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7050.63,,,,,,,fee schedule,4268.07,12367.64,
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,4268.07,12367.64,
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12367.64,,,,,,,fee schedule,4268.07,12367.64,
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,4268.07,12367.64,
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,4268.07,12367.64,APC
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,4268.07,12367.64,APC
Av fusion/forearm vein,36820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,4268.07,12367.64,APC
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11252.11,,,,,,,fee schedule,3146.13,12939.93,
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3146.13,12939.93,
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3146.13,12939.93,
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9209.85,,,,,,,fee schedule,3146.13,12939.93,
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7376.88,,,,,,,fee schedule,3146.13,12939.93,
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3146.13,12939.93,
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12939.93,,,,,,,fee schedule,3146.13,12939.93,
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3146.13,12939.93,
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,3146.13,12939.93,APC
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,3146.13,12939.93,APC
Av fusion direct any site,36821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,3146.13,12939.93,APC
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Artery-vein autograft,36825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Artery-vein nonautograft,36830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Open thrombect av fistula,36831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Av fistula revision open,36832,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,9980.06,
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3797.94,9980.06,APC
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3797.94,9980.06,APC
Av fistula revision,36833,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3797.94,9980.06,APC
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Artery to vein shunt,36835,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32832.61,,,,,,,fee schedule,16252.26,37757.5,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16252.26,,,,,,,fee schedule,16252.26,37757.5,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16252.26,,,,,,,fee schedule,16252.26,37757.5,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21525.06,,,,,,,fee schedule,16252.26,37757.5,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26873.49,,,,,,,fee schedule,16252.26,37757.5,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18690.1,,,,,,,fee schedule,16252.26,37757.5,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37757.5,,,,,,,fee schedule,16252.26,37757.5,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16252.26,,,,,,,fee schedule,16252.26,37757.5,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,16252.26,37757.5,APC
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,16252.26,37757.5,APC
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,16252.26,37757.5,APC
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32832.61,,,,,,,fee schedule,17980.1,37757.5,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17980.1,,,,,,,fee schedule,17980.1,37757.5,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17980.1,,,,,,,fee schedule,17980.1,37757.5,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21525.06,,,,,,,fee schedule,17980.1,37757.5,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26873.49,,,,,,,fee schedule,17980.1,37757.5,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20677.12,,,,,,,fee schedule,17980.1,37757.5,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37757.5,,,,,,,fee schedule,17980.1,37757.5,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17980.1,,,,,,,fee schedule,17980.1,37757.5,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,17980.1,37757.5,APC
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,17980.1,37757.5,APC
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,17980.1,37757.5,APC
Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Dist revas ligation hemo,36838,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,258.67,2823.29,
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.67,,,,,,,fee schedule,258.67,2823.29,
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.67,,,,,,,fee schedule,258.67,2823.29,
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,258.67,2823.29,
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,258.67,2823.29,
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,297.47,,,,,,,fee schedule,258.67,2823.29,
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,258.67,2823.29,
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,258.67,,,,,,,fee schedule,258.67,2823.29,
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,258.67,2823.29,APC
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,258.67,2823.29,APC
External cannula declotting,36860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,258.67,2823.29,APC
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2963.35,9980.06,
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2963.35,9980.06,
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2963.35,9980.06,
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,9980.06,
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2963.35,9980.06,
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,9980.06,APC
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,9980.06,APC
Cannula declotting,36861,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,9980.06,APC
Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,662.1,2823.29,
Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,662.1,2823.29,
Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,662.1,2823.29,
Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,662.1,2823.29,
Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,662.1,2823.29,APC
Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,662.1,2823.29,APC
Intro cath dialysis circuit,36901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,662.1,2823.29,APC
Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5579.99,,,,,,,fee schedule,3658.24,10207.97,
Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.22,,,,,,,fee schedule,3658.24,10207.97,
Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.24,,,,,,,fee schedule,3658.24,10207.97,
Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6416.99,,,,,,,fee schedule,3658.24,10207.97,
Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,3658.24,10207.97,APC
Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,3658.24,10207.97,APC
Intro cath dialysis circuit,36902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,3658.24,10207.97,APC
Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15434.29,,,,,,,fee schedule,10118.72,20704.82,
Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12632.97,,,,,,,fee schedule,10118.72,20704.82,
Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10118.72,,,,,,,fee schedule,10118.72,20704.82,
Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17749.43,,,,,,,fee schedule,10118.72,20704.82,
Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,10118.72,20704.82,APC
Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,10118.72,20704.82,APC
Intro cath dialysis circuit,36903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,10118.72,20704.82,APC
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8145.38,,,,,,,fee schedule,5340.11,10207.97,
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6666.99,,,,,,,fee schedule,5340.11,10207.97,
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5340.11,,,,,,,fee schedule,5340.11,10207.97,
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9367.19,,,,,,,fee schedule,5340.11,10207.97,
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,5340.11,10207.97,APC
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,5340.11,10207.97,APC
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,5340.11,10207.97,APC
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15434.29,,,,,,,fee schedule,10118.72,20704.82,
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12632.97,,,,,,,fee schedule,10118.72,20704.82,
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10118.72,,,,,,,fee schedule,10118.72,20704.82,
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17749.43,,,,,,,fee schedule,10118.72,20704.82,
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,10118.72,20704.82,APC
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,10118.72,20704.82,APC
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,10118.72,20704.82,APC
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24163.47,,,,,,,fee schedule,15841.57,32878.29,
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19777.8,,,,,,,fee schedule,15841.57,32878.29,
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15841.57,,,,,,,fee schedule,15841.57,32878.29,
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27787.99,,,,,,,fee schedule,15841.57,32878.29,
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,15841.57,32878.29,APC
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,15841.57,32878.29,APC
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,15841.57,32878.29,APC
Insert hepatic shunt (tips),37182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Insert hepatic shunt (tips),37182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Insert hepatic shunt (tips),37182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7216.3,,,,,,,fee schedule,4731.01,10207.97,
Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5906.54,,,,,,,fee schedule,4731.01,10207.97,
Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4731.01,,,,,,,fee schedule,4731.01,10207.97,
Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8298.75,,,,,,,fee schedule,4731.01,10207.97,
Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,4731.01,10207.97,APC
Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,4731.01,10207.97,APC
Remove hepatic shunt (tips),37183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,4731.01,10207.97,APC
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8056.36,,,,,,,fee schedule,4268.07,32878.29,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,4268.07,32878.29,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,4268.07,32878.29,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6594.13,,,,,,,fee schedule,4268.07,32878.29,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5281.75,,,,,,,fee schedule,4268.07,32878.29,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,4268.07,32878.29,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9264.81,,,,,,,fee schedule,4268.07,32878.29,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,4268.07,32878.29,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,4268.07,32878.29,APC
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,4268.07,32878.29,APC
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,4268.07,32878.29,APC
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,3797.94,20704.82,
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,20704.82,
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,3797.94,20704.82,
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,3797.94,20704.82,
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,3797.94,20704.82,
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,3797.94,20704.82,
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,3797.94,20704.82,
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,3797.94,20704.82,
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,3797.94,20704.82,APC
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,3797.94,20704.82,APC
Venous mech thrombectomy,37187,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,3797.94,20704.82,APC
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4908.28,,,,,,,fee schedule,2284.6,5663.03,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4268.07,,,,,,,fee schedule,2284.6,5663.03,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Venous m-thrombectomy add-on,37188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Ins endovas vena cava filtr,37191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Redo endovas vena cava filtr,37192,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Rem endovas vena cava filter,37193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,273.99,592.41,
Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,273.99,592.41,
Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,273.99,592.41,
Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,273.99,592.41,
Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,273.99,592.41,APC
Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,273.99,592.41,APC
Thrombolytic therapy stroke,37195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,273.99,592.41,APC
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2284.6,5663.03,
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2284.6,5663.03,
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Remove intrvas foreign body,37197,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2963.35,9980.06,
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2963.35,9980.06,
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2963.35,9980.06,
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,9980.06,
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2963.35,9980.06,
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,9980.06,APC
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,9980.06,APC
Transcatheter biopsy,37200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,9980.06,APC
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,1117.72,9980.06,
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,1117.72,9980.06,
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,1117.72,9980.06,
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,1117.72,9980.06,
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,1117.72,9980.06,
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,1117.72,9980.06,
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,1117.72,9980.06,
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,1117.72,9980.06,
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,1117.72,9980.06,APC
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,1117.72,9980.06,APC
Thrombolytic art therapy,37211,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,1117.72,9980.06,APC
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,1117.72,5663.03,
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1117.72,,,,,,,fee schedule,1117.72,5663.03,
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1117.72,,,,,,,fee schedule,1117.72,5663.03,
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,1117.72,5663.03,
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,1117.72,5663.03,
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1285.38,,,,,,,fee schedule,1117.72,5663.03,
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,1117.72,5663.03,
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1117.72,,,,,,,fee schedule,1117.72,5663.03,
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,1117.72,5663.03,APC
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,1117.72,5663.03,APC
Thrombolytic venous therapy,37212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,1117.72,5663.03,APC
Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,670.76,5663.03,
Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,670.76,5663.03,
Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,670.76,5663.03,
Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,670.76,5663.03,
Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,670.76,5663.03,APC
Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,670.76,5663.03,APC
Thromblytic art/ven therapy,37213,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,670.76,5663.03,APC
Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,670.76,5663.03,
Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,670.76,5663.03,
Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,670.76,5663.03,
Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,670.76,5663.03,
Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,670.76,5663.03,APC
Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,670.76,5663.03,APC
Cessj therapy cath removal,37214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,670.76,5663.03,APC
Transcath stent cca w/o eps,37216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14399.4,,,,,,,fee schedule,9440.25,16559.31,
Transcath stent cca w/o eps,37216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11785.91,,,,,,,fee schedule,9440.25,16559.31,
Transcath stent cca w/o eps,37216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9440.25,,,,,,,fee schedule,9440.25,16559.31,
Transcath stent cca w/o eps,37216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16559.31,,,,,,,fee schedule,9440.25,16559.31,
Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6041.29,,,,,,,fee schedule,3960.67,6947.48,
Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5367.78,,,,,,,fee schedule,3960.67,6947.48,
Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5367.78,,,,,,,fee schedule,3960.67,6947.48,
Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4944.8,,,,,,,fee schedule,3960.67,6947.48,
Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3960.67,,,,,,,fee schedule,3960.67,6947.48,
Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6172.95,,,,,,,fee schedule,3960.67,6947.48,
Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6947.48,,,,,,,fee schedule,3960.67,6947.48,
Iliac revasc,37220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5367.78,,,,,,,fee schedule,3960.67,6947.48,
Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10738.24,,,,,,,fee schedule,7039.99,16858.28,
Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14659.37,,,,,,,fee schedule,7039.99,16858.28,
Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14659.37,,,,,,,fee schedule,7039.99,16858.28,
Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8789.25,,,,,,,fee schedule,7039.99,16858.28,
Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7039.99,,,,,,,fee schedule,7039.99,16858.28,
Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16858.28,,,,,,,fee schedule,7039.99,16858.28,
Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12348.98,,,,,,,fee schedule,7039.99,16858.28,
Iliac revasc w/stent,37221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14659.37,,,,,,,fee schedule,7039.99,16858.28,
Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7311.91,,,,,,,fee schedule,4793.69,8408.7,
Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5367.78,,,,,,,fee schedule,4793.69,8408.7,
Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5367.78,,,,,,,fee schedule,4793.69,8408.7,
Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5984.8,,,,,,,fee schedule,4793.69,8408.7,
Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4793.69,,,,,,,fee schedule,4793.69,8408.7,
Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6172.95,,,,,,,fee schedule,4793.69,8408.7,
Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8408.7,,,,,,,fee schedule,4793.69,8408.7,
Fem/popl revas w/tla,37224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5367.78,,,,,,,fee schedule,4793.69,8408.7,
Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19595.37,,,,,,,fee schedule,12846.72,22534.68,
Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14659.37,,,,,,,fee schedule,12846.72,22534.68,
Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14659.37,,,,,,,fee schedule,12846.72,22534.68,
Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16038.81,,,,,,,fee schedule,12846.72,22534.68,
Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12846.72,,,,,,,fee schedule,12846.72,22534.68,
Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16858.28,,,,,,,fee schedule,12846.72,22534.68,
Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22534.68,,,,,,,fee schedule,12846.72,22534.68,
Fem/popl revas w/ather,37225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14659.37,,,,,,,fee schedule,12846.72,22534.68,
Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10033.43,,,,,,,fee schedule,6577.92,16858.28,
Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14659.37,,,,,,,fee schedule,6577.92,16858.28,
Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14659.37,,,,,,,fee schedule,6577.92,16858.28,
Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8212.36,,,,,,,fee schedule,6577.92,16858.28,
Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6577.92,,,,,,,fee schedule,6577.92,16858.28,
Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16858.28,,,,,,,fee schedule,6577.92,16858.28,
Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11538.44,,,,,,,fee schedule,6577.92,16858.28,
Fem/popl revasc w/stent,37226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14659.37,,,,,,,fee schedule,6577.92,16858.28,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28755.09,,,,,,,fee schedule,18851.84,33068.35,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23558.75,,,,,,,fee schedule,18851.84,33068.35,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23558.75,,,,,,,fee schedule,18851.84,33068.35,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23536.04,,,,,,,fee schedule,18851.84,33068.35,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18851.84,,,,,,,fee schedule,18851.84,33068.35,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27092.56,,,,,,,fee schedule,18851.84,33068.35,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33068.35,,,,,,,fee schedule,18851.84,33068.35,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23558.75,,,,,,,fee schedule,18851.84,33068.35,
Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11447.29,,,,,,,fee schedule,7504.84,16858.28,
Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14659.37,,,,,,,fee schedule,7504.84,16858.28,
Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14659.37,,,,,,,fee schedule,7504.84,16858.28,
Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9369.61,,,,,,,fee schedule,7504.84,16858.28,
Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7504.84,,,,,,,fee schedule,7504.84,16858.28,
Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16858.28,,,,,,,fee schedule,7504.84,16858.28,
Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13164.38,,,,,,,fee schedule,7504.84,16858.28,
Tib/per revasc w/tla,37228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14659.37,,,,,,,fee schedule,7504.84,16858.28,
Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8177.82,,,,,,,fee schedule,5361.38,27092.56,
Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23558.75,,,,,,,fee schedule,5361.38,27092.56,
Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23558.75,,,,,,,fee schedule,5361.38,27092.56,
Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6693.55,,,,,,,fee schedule,5361.38,27092.56,
Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5361.38,,,,,,,fee schedule,5361.38,27092.56,
Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27092.56,,,,,,,fee schedule,5361.38,27092.56,
Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9404.49,,,,,,,fee schedule,5361.38,27092.56,
Tib/per revasc w/ather,37229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23558.75,,,,,,,fee schedule,5361.38,27092.56,
Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25958.43,,,,,,,fee schedule,17018.35,29852.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23558.75,,,,,,,fee schedule,17018.35,29852.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23558.75,,,,,,,fee schedule,17018.35,29852.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21246.97,,,,,,,fee schedule,17018.35,29852.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17018.35,,,,,,,fee schedule,17018.35,29852.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27092.56,,,,,,,fee schedule,17018.35,29852.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29852.19,,,,,,,fee schedule,17018.35,29852.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23558.75,,,,,,,fee schedule,17018.35,29852.19,
Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25620.41,,,,,,,fee schedule,16796.74,29463.47,
Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23558.75,,,,,,,fee schedule,16796.74,29463.47,
Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23558.75,,,,,,,fee schedule,16796.74,29463.47,
Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20970.31,,,,,,,fee schedule,16796.74,29463.47,
Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16796.74,,,,,,,fee schedule,16796.74,29463.47,
Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27092.56,,,,,,,fee schedule,16796.74,29463.47,
Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29463.47,,,,,,,fee schedule,16796.74,29463.47,
Tib/per revasc stent & ather,37231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23558.75,,,,,,,fee schedule,16796.74,29463.47,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4979.07,,,,,,,fee schedule,3264.28,20704.82,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14659.37,,,,,,,fee schedule,3264.28,20704.82,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14659.37,,,,,,,fee schedule,3264.28,20704.82,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4075.37,,,,,,,fee schedule,3264.28,20704.82,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3264.28,,,,,,,fee schedule,3264.28,20704.82,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16858.28,,,,,,,fee schedule,3264.28,20704.82,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5725.93,,,,,,,fee schedule,3264.28,20704.82,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14659.37,,,,,,,fee schedule,3264.28,20704.82,
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,3264.28,20704.82,APC
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,3264.28,20704.82,APC
Open/perq place stent 1st,37236,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,3264.28,20704.82,APC
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2290.82,,,,,,,fee schedule,1501.86,20704.82,
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14659.37,,,,,,,fee schedule,1501.86,20704.82,
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14659.37,,,,,,,fee schedule,1501.86,20704.82,
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1875.04,,,,,,,fee schedule,1501.86,20704.82,
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1501.86,,,,,,,fee schedule,1501.86,20704.82,
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16858.28,,,,,,,fee schedule,1501.86,20704.82,
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2634.44,,,,,,,fee schedule,1501.86,20704.82,
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14659.37,,,,,,,fee schedule,1501.86,20704.82,
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,1501.86,20704.82,APC
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,1501.86,20704.82,APC
Open/perq place stent same,37238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,1501.86,20704.82,APC
Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9723.08,,,,,,,fee schedule,6374.45,20704.82,
Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7958.34,,,,,,,fee schedule,6374.45,20704.82,
Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6374.45,,,,,,,fee schedule,6374.45,20704.82,
Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11181.54,,,,,,,fee schedule,6374.45,20704.82,
Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,6374.45,20704.82,APC
Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,6374.45,20704.82,APC
Vasc embolize/occlude venous,37241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,6374.45,20704.82,APC
Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6155.59,,,,,,,fee schedule,4035.6,32878.29,
Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5038.35,,,,,,,fee schedule,4035.6,32878.29,
Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4035.6,,,,,,,fee schedule,4035.6,32878.29,
Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7078.93,,,,,,,fee schedule,4035.6,32878.29,
Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,4035.6,32878.29,APC
Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,4035.6,32878.29,APC
Vasc embolize/occlude artery,37242,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,4035.6,32878.29,APC
Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16815.17,,,,,,,fee schedule,11024.03,20704.82,
Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13763.22,,,,,,,fee schedule,11024.03,20704.82,
Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11024.03,,,,,,,fee schedule,11024.03,20704.82,
Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19337.45,,,,,,,fee schedule,11024.03,20704.82,
Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11024.03,20704.82,APC
Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11024.03,20704.82,APC
Vasc embolize/occlude organ,37243,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11024.03,20704.82,APC
Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Vasc embolize/occlude bleed,37244,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8145.38,,,,,,,fee schedule,5340.11,10207.97,
Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6666.99,,,,,,,fee schedule,5340.11,10207.97,
Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5340.11,,,,,,,fee schedule,5340.11,10207.97,
Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9367.19,,,,,,,fee schedule,5340.11,10207.97,
Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,5340.11,10207.97,APC
Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,5340.11,10207.97,APC
Trluml balo angiop 1st art,37246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,5340.11,10207.97,APC
Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6320.39,,,,,,,fee schedule,4143.65,10207.97,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4143.65,,,,,,,fee schedule,4143.65,10207.97,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5173.24,,,,,,,fee schedule,4143.65,10207.97,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7268.45,,,,,,,fee schedule,4143.65,10207.97,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,4143.65,10207.97,APC
Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,4143.65,10207.97,APC
Trluml balo angiop 1st vein,37248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,4143.65,10207.97,APC
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,5671.1,10207.97,APC
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2877.83,6662.04,
Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2877.83,6662.04,
Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2877.83,6662.04,
Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2877.83,6662.04,
Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2877.83,6662.04,
Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2877.83,6662.04,
Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2877.83,6662.04,
Endoscopy ligate perf veins,37500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2877.83,6662.04,
Vascular endoscopy procedure,37501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1125.08,APC
Vascular endoscopy procedure,37501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1125.08,APC
Vascular endoscopy procedure,37501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1125.08,APC
Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,670.76,5663.03,
Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,670.76,5663.03,
Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,670.76,5663.03,
Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,670.76,5663.03,
Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,670.76,5663.03,APC
Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,670.76,5663.03,APC
Ligation of neck vein,37565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,670.76,5663.03,APC
Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of neck artery,37600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of neck artery,37605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3530.36,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2314.5,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2889.6,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4059.91,,,,,,,fee schedule,2314.5,5663.03,
Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of neck artery,37606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2314.5,5663.03,APC
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Ligation of a-v fistula,37607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,2962.18,
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,2962.18,
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Temporal artery procedure,37609,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,670.76,5663.03,
Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,670.76,5663.03,
Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,670.76,5663.03,
Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,670.76,5663.03,
Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,670.76,5663.03,APC
Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,670.76,5663.03,APC
Ligation of neck artery,37615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,670.76,5663.03,APC
Ligation of abdomen artery,37617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,5544.48,9980.06,APC
Ligation of abdomen artery,37617,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,5544.48,9980.06,APC
Ligation of abdomen artery,37617,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,5544.48,9980.06,APC
Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5868.97,,,,,,,fee schedule,3847.7,9980.06,
Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4803.75,,,,,,,fee schedule,3847.7,9980.06,
Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3847.7,,,,,,,fee schedule,3847.7,9980.06,
Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6749.32,,,,,,,fee schedule,3847.7,9980.06,
Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,3847.7,9980.06,APC
Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,3847.7,9980.06,APC
Ligation of inf vena cava,37619,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,3847.7,9980.06,APC
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Revision of major vein,37650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Revise leg vein,37700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate/strip short leg vein,37718,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate/strip long leg vein,37722,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Removal of leg veins/lesion,37735,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate leg veins radical,37760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,662.1,5663.03,
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,662.1,5663.03,
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,662.1,5663.03,
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,662.1,5663.03,
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,662.1,5663.03,
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,662.1,5663.03,
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,662.1,5663.03,
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,662.1,5663.03,
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,662.1,5663.03,APC
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,662.1,5663.03,APC
Ligate leg veins open,37761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,662.1,5663.03,APC
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,920.07,,,,,,,fee schedule,603.2,5663.03,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,776.24,,,,,,,fee schedule,603.2,5663.03,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,776.24,,,,,,,fee schedule,603.2,5663.03,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,603.2,,,,,,,fee schedule,603.2,5663.03,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,753.08,,,,,,,fee schedule,603.2,5663.03,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,892.68,,,,,,,fee schedule,603.2,5663.03,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1058.08,,,,,,,fee schedule,603.2,5663.03,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,776.24,,,,,,,fee schedule,603.2,5663.03,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,603.2,5663.03,APC
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,603.2,5663.03,APC
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,603.2,5663.03,APC
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.76,,,,,,,fee schedule,677.73,5663.03,
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,931.23,,,,,,,fee schedule,677.73,5663.03,
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,931.23,,,,,,,fee schedule,677.73,5663.03,
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.73,,,,,,,fee schedule,677.73,5663.03,
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,846.13,,,,,,,fee schedule,677.73,5663.03,
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1070.91,,,,,,,fee schedule,677.73,5663.03,
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188.82,,,,,,,fee schedule,677.73,5663.03,
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,931.23,,,,,,,fee schedule,677.73,5663.03,
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,677.73,5663.03,APC
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,677.73,5663.03,APC
Phleb veins - extrem 20+,37766,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,677.73,5663.03,APC
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1009.92,,,,,,,fee schedule,662.1,5663.03,
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,662.1,5663.03,
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,662.1,5663.03,
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.1,,,,,,,fee schedule,662.1,5663.03,
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,826.62,,,,,,,fee schedule,662.1,5663.03,
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,662.1,5663.03,
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1161.41,,,,,,,fee schedule,662.1,5663.03,
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,662.1,5663.03,
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,662.1,5663.03,APC
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,662.1,5663.03,APC
Revision of leg vein,37780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,662.1,5663.03,APC
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2284.6,5663.03,
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2284.6,5663.03,
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2284.6,5663.03,
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3309.5,,,,,,,fee schedule,2284.6,5663.03,
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2284.6,5663.03,
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2877.83,,,,,,,fee schedule,2284.6,5663.03,
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2284.6,5663.03,APC
Ligate/divide/excise vein,37785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2284.6,5663.03,APC
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2114.87,6322.15,
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Penile venous occlusion,37790,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Vascular surgery procedure,37799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,625.05,1125.08,APC
Vascular surgery procedure,37799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,625.05,1125.08,APC
Vascular surgery procedure,37799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,625.05,1125.08,APC
Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10423.72,,,,,,,fee schedule,6833.79,19064.9,
Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6833.79,,,,,,,fee schedule,6833.79,19064.9,
Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8531.81,,,,,,,fee schedule,6833.79,19064.9,
Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11987.28,,,,,,,fee schedule,6833.79,19064.9,
Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,6833.79,19064.9,APC
Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,6833.79,19064.9,APC
Laparoscopy splenectomy,38120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,6833.79,19064.9,APC
Laparoscope proc spleen,38129,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc spleen,38129,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc spleen,38129,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Injection for spleen x-ray,38200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.83,,,,,,,fee schedule,68.07,119.4,
Injection for spleen x-ray,38200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.07,,,,,,,fee schedule,68.07,119.4,
Injection for spleen x-ray,38200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.98,,,,,,,fee schedule,68.07,119.4,
Injection for spleen x-ray,38200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.4,,,,,,,fee schedule,68.07,119.4,
Bl donor search management,38204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.44,,,,,,,fee schedule,49.46,86.76,
Bl donor search management,38204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.46,,,,,,,fee schedule,49.46,86.76,
Bl donor search management,38204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.75,,,,,,,fee schedule,49.46,86.76,
Bl donor search management,38204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.76,,,,,,,fee schedule,49.46,86.76,
Harvest allogeneic stem cell,38205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,90.13,
Harvest allogeneic stem cell,38205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,90.13,
Harvest allogeneic stem cell,38205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,90.13,
Harvest allogeneic stem cell,38205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,90.13,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.89,,,,,,,fee schedule,1063.31,2793.29,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1063.31,,,,,,,fee schedule,1063.31,2793.29,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.52,,,,,,,fee schedule,1063.31,2793.29,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1608.3,,,,,,,fee schedule,1063.31,2793.29,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1865.17,,,,,,,fee schedule,1063.31,2793.29,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,1063.31,2793.29,APC
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,1063.31,2793.29,APC
Harvest auto stem cells,38206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,1063.31,2793.29,APC
Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Cryopreserve stem cells,38207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Thaw preserved stem cells,38208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Wash harvest stem cells,38209,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
T-cell depletion of harvest,38210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Tumor cell deplete of harvst,38211,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Rbc depletion of harvest,38212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Platelet deplete of harvest,38213,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Volume deplete of harvest,38214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.24,,,,,,,fee schedule,347.63,791.26,
Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.63,,,,,,,fee schedule,347.63,791.26,
Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434,,,,,,,fee schedule,347.63,791.26,
Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.78,,,,,,,fee schedule,347.63,791.26,
Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,347.63,791.26,APC
Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,347.63,791.26,APC
Harvest stem cell concentrte,38215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,347.63,791.26,APC
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,346.86,,,,,,,fee schedule,227.4,2962.18,
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,298.28,,,,,,,fee schedule,227.4,2962.18,
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,298.28,,,,,,,fee schedule,227.4,2962.18,
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.4,,,,,,,fee schedule,227.4,2962.18,
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.9,,,,,,,fee schedule,227.4,2962.18,
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,343.02,,,,,,,fee schedule,227.4,2962.18,
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,398.89,,,,,,,fee schedule,227.4,2962.18,
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,298.28,,,,,,,fee schedule,227.4,2962.18,
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,227.4,2962.18,APC
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,227.4,2962.18,APC
Bone marrow aspiration,38220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,227.4,2962.18,APC
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1296.77,,,,,,,fee schedule,284.46,2962.18,
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.46,,,,,,,fee schedule,284.46,2962.18,
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,284.46,,,,,,,fee schedule,284.46,2962.18,
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,850.16,,,,,,,fee schedule,284.46,2962.18,
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1061.41,,,,,,,fee schedule,284.46,2962.18,
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,327.13,,,,,,,fee schedule,284.46,2962.18,
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1491.29,,,,,,,fee schedule,284.46,2962.18,
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.46,,,,,,,fee schedule,284.46,2962.18,
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,284.46,2962.18,APC
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,284.46,2962.18,APC
Bone marrow biopsy,38221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,284.46,2962.18,APC
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3680.22,,,,,,,fee schedule,198.41,5209.69,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.41,,,,,,,fee schedule,198.41,5209.69,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,198.41,,,,,,,fee schedule,198.41,5209.69,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2412.75,,,,,,,fee schedule,198.41,5209.69,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3012.26,,,,,,,fee schedule,198.41,5209.69,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.17,,,,,,,fee schedule,198.41,5209.69,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4232.25,,,,,,,fee schedule,198.41,5209.69,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.41,,,,,,,fee schedule,198.41,5209.69,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,198.41,5209.69,APC
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,198.41,5209.69,APC
Dx bone marrow bx & aspir,38222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,198.41,5209.69,APC
Car-t hrv bld-drv t lymphcyt,38225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.56,,,,,,,fee schedule,79.04,138.64,
Car-t hrv bld-drv t lymphcyt,38225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.04,,,,,,,fee schedule,79.04,138.64,
Car-t hrv bld-drv t lymphcyt,38225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.68,,,,,,,fee schedule,79.04,138.64,
Car-t hrv bld-drv t lymphcyt,38225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.64,,,,,,,fee schedule,79.04,138.64,
Car-t prep t lymphcyt f/trns,38226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.2,,,,,,,fee schedule,32.26,56.58,
Car-t prep t lymphcyt f/trns,38226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.26,,,,,,,fee schedule,32.26,56.58,
Car-t prep t lymphcyt f/trns,38226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.27,,,,,,,fee schedule,32.26,56.58,
Car-t prep t lymphcyt f/trns,38226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.58,,,,,,,fee schedule,32.26,56.58,
Car-t receipt&prepj admn,38227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.2,,,,,,,fee schedule,32.26,56.58,
Car-t receipt&prepj admn,38227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.26,,,,,,,fee schedule,32.26,56.58,
Car-t receipt&prepj admn,38227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.27,,,,,,,fee schedule,32.26,56.58,
Car-t receipt&prepj admn,38227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.58,,,,,,,fee schedule,32.26,56.58,
Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,542.32,,,,,,,fee schedule,329.12,623.67,
Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,355.54,,,,,,,fee schedule,329.12,623.67,
Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,443.89,,,,,,,fee schedule,329.12,623.67,
Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,623.67,,,,,,,fee schedule,329.12,623.67,
Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,329.12,623.67,APC
Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,329.12,623.67,APC
Car-t admn autologous,38228,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,329.12,623.67,APC
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.89,,,,,,,fee schedule,1063.31,4336.72,
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,1063.31,4336.72,
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,1063.31,4336.72,
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1063.31,,,,,,,fee schedule,1063.31,4336.72,
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.52,,,,,,,fee schedule,1063.31,4336.72,
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,1063.31,4336.72,
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1865.17,,,,,,,fee schedule,1063.31,4336.72,
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,1063.31,4336.72,
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,1063.31,4336.72,APC
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,1063.31,4336.72,APC
Bone marrow harvest allogen,38230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,1063.31,4336.72,APC
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6374.16,,,,,,,fee schedule,3771.06,7811.71,
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,3771.06,7811.71,
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,3771.06,7811.71,
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4178.9,,,,,,,fee schedule,3771.06,7811.71,
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5217.25,,,,,,,fee schedule,3771.06,7811.71,
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,3771.06,7811.71,
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7330.28,,,,,,,fee schedule,3771.06,7811.71,
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,3771.06,7811.71,
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4556.83,,,,,,,fee schedule,3771.06,7811.71,APC
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4339.84,,,,,,,fee schedule,3771.06,7811.71,APC
Bone marrow harvest autolog,38232,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7811.71,,,,,,,fee schedule,3771.06,7811.71,APC
Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41523.12,,,,,,,fee schedule,27222.56,112814.87,
Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27222.56,,,,,,,fee schedule,27222.56,112814.87,
Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33986.67,,,,,,,fee schedule,27222.56,112814.87,
Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47751.59,,,,,,,fee schedule,27222.56,112814.87,
Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65808.67,,,,,,,fee schedule,27222.56,112814.87,APC
Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62674.93,,,,,,,fee schedule,27222.56,112814.87,APC
Transplt allo hct/donor,38240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,112814.87,,,,,,,fee schedule,27222.56,112814.87,APC
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.89,,,,,,,fee schedule,1063.31,4336.72,
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3771.06,,,,,,,fee schedule,1063.31,4336.72,
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.06,,,,,,,fee schedule,1063.31,4336.72,
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1063.31,,,,,,,fee schedule,1063.31,4336.72,
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.52,,,,,,,fee schedule,1063.31,4336.72,
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4336.72,,,,,,,fee schedule,1063.31,4336.72,
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1865.17,,,,,,,fee schedule,1063.31,4336.72,
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.06,,,,,,,fee schedule,1063.31,4336.72,
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,1063.31,4336.72,APC
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,1063.31,4336.72,APC
Transplt autol hct/donor,38241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,1063.31,4336.72,APC
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.89,,,,,,,fee schedule,1063.31,2793.29,
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1063.31,,,,,,,fee schedule,1063.31,2793.29,
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.52,,,,,,,fee schedule,1063.31,2793.29,
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1608.3,,,,,,,fee schedule,1063.31,2793.29,
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1865.17,,,,,,,fee schedule,1063.31,2793.29,
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,1063.31,2793.29,APC
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,1063.31,2793.29,APC
Transplt allo lymphocytes,38242,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,1063.31,2793.29,APC
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.89,,,,,,,fee schedule,1063.31,2793.29,
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1063.31,,,,,,,fee schedule,1063.31,2793.29,
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.52,,,,,,,fee schedule,1063.31,2793.29,
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1608.3,,,,,,,fee schedule,1063.31,2793.29,
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1865.17,,,,,,,fee schedule,1063.31,2793.29,
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1398.52,,,,,,,fee schedule,1063.31,2793.29,
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1629.42,,,,,,,fee schedule,1063.31,2793.29,APC
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1551.83,,,,,,,fee schedule,1063.31,2793.29,APC
Transplj hematopoietic boost,38243,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2793.29,,,,,,,fee schedule,1063.31,2793.29,APC
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1147.5,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1147.5,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1319.63,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1147.5,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,933.69,5209.69,APC
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,933.69,5209.69,APC
Drainage lymph node lesion,38300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,933.69,5209.69,APC
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,933.69,5209.69,
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,933.69,5209.69,APC
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,933.69,5209.69,APC
Drainage lymph node lesion,38305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,933.69,5209.69,APC
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3572.8,,,,,,,fee schedule,1802.57,7022.44,
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Incision of lymph channels,38308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5739.43,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3762.77,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4697.72,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2834.95,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6600.34,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy/removal lymph nodes,38500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,2465.17,7022.44,APC
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,928.27,,,,,,,fee schedule,608.57,2962.18,
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,608.57,2962.18,
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,608.57,2962.18,
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,608.57,,,,,,,fee schedule,608.57,2962.18,
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,759.79,,,,,,,fee schedule,608.57,2962.18,
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,608.57,2962.18,
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1067.51,,,,,,,fee schedule,608.57,2962.18,
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,608.57,2962.18,
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,608.57,2962.18,APC
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,608.57,2962.18,APC
Needle biopsy lymph nodes,38505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,608.57,2962.18,APC
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5958.86,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3906.63,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4877.33,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2834.95,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6852.69,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy/removal lymph nodes,38510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3572.8,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Biopsy/removal lymph nodes,38520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4726.12,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3098.44,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3868.33,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2834.95,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5435.04,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2465.17,,,,,,,fee schedule,2465.17,7022.44,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy/removal lymph nodes,38525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,2465.17,7022.44,APC
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3572.8,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Biopsy/removal lymph nodes,38530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7392.72,,,,,,,fee schedule,3901.35,8501.63,
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4846.67,,,,,,,fee schedule,3901.35,8501.63,
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6050.94,,,,,,,fee schedule,3901.35,8501.63,
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8501.63,,,,,,,fee schedule,3901.35,8501.63,
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,3901.35,8501.63,APC
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,3901.35,8501.63,APC
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,3901.35,8501.63,APC
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,3651.57,10842.82,
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Explore deep node(s) neck,38542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2749.49,,,,,,,fee schedule,1802.57,7022.44,
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.57,,,,,,,fee schedule,1802.57,7022.44,
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2250.46,,,,,,,fee schedule,1802.57,7022.44,
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3572.8,,,,,,,fee schedule,1802.57,7022.44,
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3161.91,,,,,,,fee schedule,1802.57,7022.44,
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3106.78,,,,,,,fee schedule,1802.57,7022.44,
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4096.42,,,,,,,fee schedule,1802.57,7022.44,APC
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3901.35,,,,,,,fee schedule,1802.57,7022.44,APC
Removal neck/armpit lesion,38550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7022.44,,,,,,,fee schedule,1802.57,7022.44,APC
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5287.16,,,,,,,fee schedule,3106.78,11909.32,
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3106.78,,,,,,,fee schedule,3106.78,11909.32,
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3106.78,,,,,,,fee schedule,3106.78,11909.32,
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3466.26,,,,,,,fee schedule,3106.78,11909.32,
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4327.54,,,,,,,fee schedule,3106.78,11909.32,
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3572.8,,,,,,,fee schedule,3106.78,11909.32,
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6080.23,,,,,,,fee schedule,3106.78,11909.32,
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3106.78,,,,,,,fee schedule,3106.78,11909.32,
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,3106.78,11909.32,APC
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,3106.78,11909.32,APC
Removal neck/armpit lesion,38555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,3106.78,11909.32,APC
Removal pelvic lymph nodes,38562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8551.2,,,,,,,fee schedule,8144,14659.2,APC
Removal pelvic lymph nodes,38562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8144,,,,,,,fee schedule,8144,14659.2,APC
Removal pelvic lymph nodes,38562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14659.2,,,,,,,fee schedule,8144,14659.2,APC
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy lymph node biop,38570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8948.41,,,,,,,fee schedule,5866.58,19064.9,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7260.58,,,,,,,fee schedule,5866.58,19064.9,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7260.58,,,,,,,fee schedule,5866.58,19064.9,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5866.58,,,,,,,fee schedule,5866.58,19064.9,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7324.27,,,,,,,fee schedule,5866.58,19064.9,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8349.67,,,,,,,fee schedule,5866.58,19064.9,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10290.67,,,,,,,fee schedule,5866.58,19064.9,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7260.58,,,,,,,fee schedule,5866.58,19064.9,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5866.58,19064.9,APC
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5866.58,19064.9,APC
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5866.58,19064.9,APC
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8948.41,,,,,,,fee schedule,5008.21,19064.9,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5866.58,,,,,,,fee schedule,5008.21,19064.9,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7324.27,,,,,,,fee schedule,5008.21,19064.9,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,5008.21,19064.9,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10290.67,,,,,,,fee schedule,5008.21,19064.9,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5008.21,19064.9,APC
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5008.21,19064.9,APC
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5008.21,19064.9,APC
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20735.97,,,,,,,fee schedule,5626.09,23846.37,
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5626.09,,,,,,,fee schedule,5626.09,23846.37,
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5626.09,,,,,,,fee schedule,5626.09,23846.37,
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13594.5,,,,,,,fee schedule,5626.09,23846.37,
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16972.39,,,,,,,fee schedule,5626.09,23846.37,
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6470,,,,,,,fee schedule,5626.09,23846.37,
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23846.37,,,,,,,fee schedule,5626.09,23846.37,
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5626.09,,,,,,,fee schedule,5626.09,23846.37,
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5626.09,23846.37,APC
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5626.09,23846.37,APC
Laps pelvic lymphadec,38573,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5626.09,23846.37,APC
Laparoscope proc lymphatic,38589,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc lymphatic,38589,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc lymphatic,38589,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10361.46,,,,,,,fee schedule,3106.78,11915.68,
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3106.78,,,,,,,fee schedule,3106.78,11915.68,
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3106.78,,,,,,,fee schedule,3106.78,11915.68,
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6792.97,,,,,,,fee schedule,3106.78,11915.68,
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8480.86,,,,,,,fee schedule,3106.78,11915.68,
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3572.8,,,,,,,fee schedule,3106.78,11915.68,
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11915.68,,,,,,,fee schedule,3106.78,11915.68,
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3106.78,,,,,,,fee schedule,3106.78,11915.68,
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,3106.78,11915.68,APC
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,3106.78,11915.68,APC
Removal of lymph nodes neck,38700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,3106.78,11915.68,APC
Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9700.64,,,,,,,fee schedule,6359.74,11909.32,
Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6359.74,,,,,,,fee schedule,6359.74,11909.32,
Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7939.97,,,,,,,fee schedule,6359.74,11909.32,
Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11155.74,,,,,,,fee schedule,6359.74,11909.32,
Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,6359.74,11909.32,APC
Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,6359.74,11909.32,APC
Removal of lymph nodes neck,38720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,6359.74,11909.32,APC
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,3651.57,10842.82,
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Remove armpit lymph nodes,38740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8433.59,,,,,,,fee schedule,5529.06,10842.82,
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,5529.06,10842.82,
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,5529.06,10842.82,
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5529.06,,,,,,,fee schedule,5529.06,10842.82,
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6902.89,,,,,,,fee schedule,5529.06,10842.82,
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,5529.06,10842.82,
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9698.63,,,,,,,fee schedule,5529.06,10842.82,
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,5529.06,10842.82,
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5529.06,10842.82,APC
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5529.06,10842.82,APC
Remove armpit lymph nodes,38745,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5529.06,10842.82,APC
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5579.99,,,,,,,fee schedule,3106.78,11909.32,
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3106.78,,,,,,,fee schedule,3106.78,11909.32,
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3106.78,,,,,,,fee schedule,3106.78,11909.32,
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.24,,,,,,,fee schedule,3106.78,11909.32,
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.22,,,,,,,fee schedule,3106.78,11909.32,
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3572.8,,,,,,,fee schedule,3106.78,11909.32,
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6416.99,,,,,,,fee schedule,3106.78,11909.32,
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3106.78,,,,,,,fee schedule,3106.78,11909.32,
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6947.1,,,,,,,fee schedule,3106.78,11909.32,APC
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6616.29,,,,,,,fee schedule,3106.78,11909.32,APC
Remove groin lymph nodes,38760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11909.32,,,,,,,fee schedule,3106.78,11909.32,APC
Inject for lymphatic x-ray,38790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.2,,,,,,,fee schedule,57.17,100.28,
Inject for lymphatic x-ray,38790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.17,,,,,,,fee schedule,57.17,100.28,
Inject for lymphatic x-ray,38790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.17,100.28,
Inject for lymphatic x-ray,38790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.28,,,,,,,fee schedule,57.17,100.28,
Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,380.99,,,,,,,fee schedule,249.78,717,
Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.78,,,,,,,fee schedule,249.78,717,
Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,311.84,,,,,,,fee schedule,249.78,717,
Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.14,,,,,,,fee schedule,249.78,717,
Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,249.78,717,APC
Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,249.78,717,APC
Ra tracer id of sentinl node,38792,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,249.78,717,APC
Access thoracic lymph duct,38794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,356.65,,,,,,,fee schedule,233.82,410.15,
Access thoracic lymph duct,38794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.82,,,,,,,fee schedule,233.82,410.15,
Access thoracic lymph duct,38794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.92,,,,,,,fee schedule,233.82,410.15,
Access thoracic lymph duct,38794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.15,,,,,,,fee schedule,233.82,410.15,
Blood/lymph system procedure,38999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.57,,,,,,,fee schedule,439.59,791.26,APC
Blood/lymph system procedure,38999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.59,,,,,,,fee schedule,439.59,791.26,APC
Blood/lymph system procedure,38999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.26,,,,,,,fee schedule,439.59,791.26,APC
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7069.9,,,,,,,fee schedule,4635.03,10842.82,
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4635.03,,,,,,,fee schedule,4635.03,10842.82,
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5786.71,,,,,,,fee schedule,4635.03,10842.82,
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8130.39,,,,,,,fee schedule,4635.03,10842.82,
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4635.03,10842.82,APC
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4635.03,10842.82,APC
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4635.03,10842.82,APC
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,225.34,,,,,,,fee schedule,147.73,424.8,
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.87,,,,,,,fee schedule,147.73,424.8,
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,198.87,,,,,,,fee schedule,147.73,424.8,
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.73,,,,,,,fee schedule,147.73,424.8,
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,184.44,,,,,,,fee schedule,147.73,424.8,
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.7,,,,,,,fee schedule,147.73,424.8,
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.14,,,,,,,fee schedule,147.73,424.8,
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.87,,,,,,,fee schedule,147.73,424.8,
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,147.73,424.8,APC
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,147.73,424.8,APC
Biopsy of lip,40490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,147.73,424.8,APC
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7370.26,,,,,,,fee schedule,1678.74,8475.8,
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,8475.8,
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,8475.8,
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4831.94,,,,,,,fee schedule,1678.74,8475.8,
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6032.56,,,,,,,fee schedule,1678.74,8475.8,
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,8475.8,
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8475.8,,,,,,,fee schedule,1678.74,8475.8,
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,8475.8,
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,8475.8,APC
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,8475.8,APC
Partial excision of lip,40500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,8475.8,APC
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Partial excision of lip,40510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Partial excision of lip,40520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruct lip with flap,40525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct lip with flap,40527,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Partial removal of lip,40530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,985.44,
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,428.37,985.44,
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,985.44,
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,985.44,
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,428.37,985.44,
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,985.44,
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,985.44,APC
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,985.44,APC
Repair lip,40650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,985.44,APC
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,985.44,
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,428.37,985.44,
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,985.44,
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,985.44,
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,428.37,985.44,
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,985.44,
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,985.44,APC
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,985.44,APC
Repair lip,40652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,985.44,APC
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Repair lip,40654,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13504.75,,,,,,,fee schedule,4942.79,15530.46,
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,15530.46,
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,15530.46,
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8853.71,,,,,,,fee schedule,4942.79,15530.46,
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11053.64,,,,,,,fee schedule,4942.79,15530.46,
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,15530.46,
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15530.46,,,,,,,fee schedule,4942.79,15530.46,
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,15530.46,
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,15530.46,APC
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,15530.46,APC
Repair cleft lip/nasal,40700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,15530.46,APC
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair cleft lip/nasal,40701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair cleft lip/nasal,40702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13018.24,,,,,,,fee schedule,3303.54,14970.98,
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3303.54,14970.98,
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3303.54,14970.98,
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8534.76,,,,,,,fee schedule,3303.54,14970.98,
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10655.43,,,,,,,fee schedule,3303.54,14970.98,
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3303.54,14970.98,
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14970.98,,,,,,,fee schedule,3303.54,14970.98,
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3303.54,14970.98,
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,3303.54,14970.98,APC
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,3303.54,14970.98,APC
Repair cleft lip/nasal,40720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,3303.54,14970.98,APC
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair cleft lip/nasal,40761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Lip surgery procedure,40799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Lip surgery procedure,40799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Lip surgery procedure,40799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,463.46,,,,,,,fee schedule,214.62,1270.05,
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,214.62,1270.05,
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,303.84,,,,,,,fee schedule,214.62,1270.05,
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,379.34,,,,,,,fee schedule,214.62,1270.05,
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,214.62,1270.05,
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,532.98,,,,,,,fee schedule,214.62,1270.05,
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,214.62,1270.05,APC
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,214.62,1270.05,APC
Drainage of mouth lesion,40800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,214.62,1270.05,APC
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,985.44,
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,428.37,985.44,
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,985.44,
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,985.44,
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,428.37,985.44,
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,985.44,
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,985.44,APC
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,985.44,APC
Drainage of mouth lesion,40801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,985.44,APC
Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,1626.7,
Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,1626.7,
Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,1626.7,
Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,1626.7,
Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,258.44,1626.7,APC
Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,258.44,1626.7,APC
Removal foreign body mouth,40804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,258.44,1626.7,APC
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,594.75,,,,,,,fee schedule,389.92,967.3,
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,533.49,,,,,,,fee schedule,389.92,967.3,
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,533.49,,,,,,,fee schedule,389.92,967.3,
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,389.92,,,,,,,fee schedule,389.92,967.3,
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,486.8,,,,,,,fee schedule,389.92,967.3,
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,613.51,,,,,,,fee schedule,389.92,967.3,
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,683.96,,,,,,,fee schedule,389.92,967.3,
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,533.49,,,,,,,fee schedule,389.92,967.3,
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,389.92,967.3,APC
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,389.92,967.3,APC
Removal foreign body mouth,40805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,389.92,967.3,APC
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.67,,,,,,,fee schedule,170.24,967.3,
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.51,,,,,,,fee schedule,170.24,967.3,
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,239.51,,,,,,,fee schedule,170.24,967.3,
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.24,,,,,,,fee schedule,170.24,967.3,
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.54,,,,,,,fee schedule,170.24,967.3,
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,275.44,,,,,,,fee schedule,170.24,967.3,
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.62,,,,,,,fee schedule,170.24,967.3,
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,239.51,,,,,,,fee schedule,170.24,967.3,
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,170.24,967.3,APC
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,170.24,967.3,APC
Incision of lip fold,40806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,170.24,967.3,APC
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,413.5,,,,,,,fee schedule,271.09,967.3,
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,369.22,,,,,,,fee schedule,271.09,967.3,
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,369.22,,,,,,,fee schedule,271.09,967.3,
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,271.09,,,,,,,fee schedule,271.09,967.3,
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,338.45,,,,,,,fee schedule,271.09,967.3,
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,424.6,,,,,,,fee schedule,271.09,967.3,
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,475.53,,,,,,,fee schedule,271.09,967.3,
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,369.22,,,,,,,fee schedule,271.09,967.3,
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,271.09,967.3,APC
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,271.09,967.3,APC
Biopsy of mouth lesion,40808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,271.09,967.3,APC
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,383.02,5946.37,
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,383.02,,,,,,,fee schedule,383.02,5946.37,
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,383.02,,,,,,,fee schedule,383.02,5946.37,
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,383.02,5946.37,
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,383.02,5946.37,
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,440.47,,,,,,,fee schedule,383.02,5946.37,
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,383.02,5946.37,
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,383.02,,,,,,,fee schedule,383.02,5946.37,
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,383.02,5946.37,APC
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,383.02,5946.37,APC
Excision of mouth lesion,40810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,383.02,5946.37,APC
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4885.25,,,,,,,fee schedule,465.41,5618.04,
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,465.41,,,,,,,fee schedule,465.41,5618.04,
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,465.41,,,,,,,fee schedule,465.41,5618.04,
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3202.77,,,,,,,fee schedule,465.41,5618.04,
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3998.58,,,,,,,fee schedule,465.41,5618.04,
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,535.22,,,,,,,fee schedule,465.41,5618.04,
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5618.04,,,,,,,fee schedule,465.41,5618.04,
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,465.41,,,,,,,fee schedule,465.41,5618.04,
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,465.41,5618.04,APC
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,465.41,5618.04,APC
Excise/repair mouth lesion,40812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,465.41,5618.04,APC
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excise/repair mouth lesion,40814,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of mouth lesion,40816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,967.3,
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,428.37,967.3,
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,967.3,
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,967.3,
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,428.37,967.3,
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,967.3,
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,967.3,APC
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,967.3,APC
Excise oral mucosa for graft,40818,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,967.3,APC
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2782.81,
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2782.81,
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2782.81,
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1005.11,2782.81,
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2782.81,
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1005.11,2782.81,
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2782.81,APC
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2782.81,APC
Excise lip or cheek fold,40819,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2782.81,APC
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,601.64,,,,,,,fee schedule,394.44,5946.37,
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,536.96,,,,,,,fee schedule,394.44,5946.37,
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,536.96,,,,,,,fee schedule,394.44,5946.37,
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,394.44,,,,,,,fee schedule,394.44,5946.37,
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,492.44,,,,,,,fee schedule,394.44,5946.37,
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,617.5,,,,,,,fee schedule,394.44,5946.37,
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,691.89,,,,,,,fee schedule,394.44,5946.37,
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,536.96,,,,,,,fee schedule,394.44,5946.37,
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,394.44,5946.37,APC
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,394.44,5946.37,APC
Treatment of mouth lesion,40820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,394.44,5946.37,APC
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,553.62,
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,171.38,553.62,
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,553.62,
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,553.62,
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,171.38,553.62,
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,553.62,
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,553.62,APC
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,553.62,APC
Repair mouth laceration,40830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,553.62,APC
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,985.44,
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,428.37,985.44,
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,985.44,
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,985.44,
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,428.37,985.44,
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,985.44,
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,428.37,985.44,
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,985.44,APC
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,985.44,APC
Repair mouth laceration,40831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,985.44,APC
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of mouth,40840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of mouth,40842,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of mouth,40843,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of mouth,40844,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of mouth,40845,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Mouth surgery procedure,40899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Mouth surgery procedure,40899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Mouth surgery procedure,40899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,306.68,,,,,,,fee schedule,201.06,967.3,
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,274.94,,,,,,,fee schedule,201.06,967.3,
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,274.94,,,,,,,fee schedule,201.06,967.3,
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.02,,,,,,,fee schedule,201.06,967.3,
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.06,,,,,,,fee schedule,201.06,967.3,
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,316.18,,,,,,,fee schedule,201.06,967.3,
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,352.68,,,,,,,fee schedule,201.06,967.3,
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,274.94,,,,,,,fee schedule,201.06,967.3,
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,201.06,967.3,APC
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,201.06,967.3,APC
Drainage of mouth lesion,41000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,201.06,967.3,APC
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,553.62,
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,553.62,
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,553.62,
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,171.38,553.62,
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,553.62,
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,553.62,APC
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,553.62,APC
Drainage of mouth lesion,41005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,553.62,APC
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Drainage of mouth lesion,41006,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.52,,,,,,,fee schedule,1546,4709.85,
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1546,4709.85,
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1546,4709.85,
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.18,,,,,,,fee schedule,1546,4709.85,
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,1546,4709.85,
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1546,4709.85,
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.85,,,,,,,fee schedule,1546,4709.85,
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1546,4709.85,
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1546,4709.85,APC
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1546,4709.85,APC
Drainage of mouth lesion,41007,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1546,4709.85,APC
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of mouth lesion,41008,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,967.3,APC
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,967.3,APC
Drainage of mouth lesion,41009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,967.3,APC
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4430.49,,,,,,,fee schedule,856.9,5095.06,
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,5095.06,
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,5095.06,
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3626.36,,,,,,,fee schedule,856.9,5095.06,
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2904.63,,,,,,,fee schedule,856.9,5095.06,
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,5095.06,
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5095.06,,,,,,,fee schedule,856.9,5095.06,
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,5095.06,
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,5095.06,APC
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,5095.06,APC
Incision of tongue fold,41010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,5095.06,APC
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,967.3,APC
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,967.3,APC
Drainage of mouth lesion,41015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,967.3,APC
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Drainage of mouth lesion,41016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of mouth lesion,41017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Drainage of mouth lesion,41018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Place needles h&n for rt,41019,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.51,,,,,,,fee schedule,206.85,967.3,
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,280.99,,,,,,,fee schedule,206.85,967.3,
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,280.99,,,,,,,fee schedule,206.85,967.3,
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.85,,,,,,,fee schedule,206.85,967.3,
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.24,,,,,,,fee schedule,206.85,967.3,
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,323.14,,,,,,,fee schedule,206.85,967.3,
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,362.84,,,,,,,fee schedule,206.85,967.3,
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,280.99,,,,,,,fee schedule,206.85,967.3,
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,206.85,967.3,APC
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,206.85,967.3,APC
Biopsy of tongue,41100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,206.85,967.3,APC
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,317.47,,,,,,,fee schedule,208.13,5946.37,
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,282.71,,,,,,,fee schedule,208.13,5946.37,
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,282.71,,,,,,,fee schedule,208.13,5946.37,
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,208.13,,,,,,,fee schedule,208.13,5946.37,
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,259.85,,,,,,,fee schedule,208.13,5946.37,
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.12,,,,,,,fee schedule,208.13,5946.37,
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,365.09,,,,,,,fee schedule,208.13,5946.37,
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,282.71,,,,,,,fee schedule,208.13,5946.37,
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,208.13,5946.37,APC
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,208.13,5946.37,APC
Biopsy of tongue,41105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,208.13,5946.37,APC
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,294.91,,,,,,,fee schedule,193.34,2962.18,
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.84,,,,,,,fee schedule,193.34,2962.18,
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.84,,,,,,,fee schedule,193.34,2962.18,
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.34,,,,,,,fee schedule,193.34,2962.18,
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.38,,,,,,,fee schedule,193.34,2962.18,
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,302.27,,,,,,,fee schedule,193.34,2962.18,
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.15,,,,,,,fee schedule,193.34,2962.18,
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,262.84,,,,,,,fee schedule,193.34,2962.18,
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,193.34,2962.18,APC
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,193.34,2962.18,APC
Biopsy of floor of mouth,41108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,193.34,2962.18,APC
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3758.54,,,,,,,fee schedule,376.99,5946.37,
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.99,,,,,,,fee schedule,376.99,5946.37,
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,376.99,,,,,,,fee schedule,376.99,5946.37,
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2464.1,,,,,,,fee schedule,376.99,5946.37,
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3076.36,,,,,,,fee schedule,376.99,5946.37,
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,433.54,,,,,,,fee schedule,376.99,5946.37,
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4322.32,,,,,,,fee schedule,376.99,5946.37,
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,376.99,,,,,,,fee schedule,376.99,5946.37,
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,376.99,5946.37,APC
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,376.99,5946.37,APC
Excision of tongue lesion,41110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,376.99,5946.37,APC
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Excision of tongue lesion,41112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Excision of tongue lesion,41113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of tongue lesion,41114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,494.83,,,,,,,fee schedule,324.41,2782.81,
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,430.12,,,,,,,fee schedule,324.41,2782.81,
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,430.12,,,,,,,fee schedule,324.41,2782.81,
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,324.41,,,,,,,fee schedule,324.41,2782.81,
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,405.02,,,,,,,fee schedule,324.41,2782.81,
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,494.64,,,,,,,fee schedule,324.41,2782.81,
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,569.05,,,,,,,fee schedule,324.41,2782.81,
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,430.12,,,,,,,fee schedule,324.41,2782.81,
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,324.41,2782.81,APC
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,324.41,2782.81,APC
Excision of tongue fold,41115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,324.41,2782.81,APC
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of mouth lesion,41116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Partial removal of tongue,41120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,171.91,801.21,
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,171.91,801.21,
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,171.91,801.21,
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,171.91,801.21,
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,171.91,801.21,
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,171.91,801.21,
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,171.91,801.21,
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,171.91,801.21,
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,171.91,801.21,APC
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,171.91,801.21,APC
Repair tongue laceration,41250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,171.91,801.21,APC
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,553.62,
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,171.38,553.62,
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,553.62,
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,553.62,
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,171.38,553.62,
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,553.62,
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,553.62,APC
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,553.62,APC
Repair tongue laceration,41251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,553.62,APC
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,236,985.44,
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,236,985.44,
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,236,985.44,
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,236,985.44,
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,236,985.44,
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,236,985.44,
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,236,985.44,
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,236,985.44,
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,985.44,APC
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,985.44,APC
Repair tongue laceration,41252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,985.44,APC
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Tongue to lip surgery,41510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Tongue suspension,41512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,2606.48,5946.37,
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,2606.48,5946.37,
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,2606.48,5946.37,
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,2606.48,5946.37,
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,2606.48,5946.37,
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,2606.48,5946.37,
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,2606.48,5946.37,
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,2606.48,5946.37,
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2606.48,5946.37,APC
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2606.48,5946.37,APC
Reconstruction tongue fold,41520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2606.48,5946.37,APC
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2362.41,,,,,,,fee schedule,1548.8,5946.37,
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1548.8,5946.37,
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1548.8,5946.37,
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1548.8,,,,,,,fee schedule,1548.8,5946.37,
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1933.63,,,,,,,fee schedule,1548.8,5946.37,
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1548.8,5946.37,
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2716.77,,,,,,,fee schedule,1548.8,5946.37,
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1548.8,5946.37,
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1548.8,5946.37,APC
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1548.8,5946.37,APC
Tongue base vol reduction,41530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1548.8,5946.37,APC
Tongue and mouth surgery,41599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Tongue and mouth surgery,41599,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Tongue and mouth surgery,41599,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,246.81,
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,98.06,246.81,
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,98.06,246.81,
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,246.81,
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,246.81,
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,98.06,246.81,
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,246.81,
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,98.06,246.81,
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,246.81,APC
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,246.81,APC
Drainage of gum lesion,41800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,246.81,APC
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,546.75,,,,,,,fee schedule,358.45,2782.81,
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,491.14,,,,,,,fee schedule,358.45,2782.81,
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,491.14,,,,,,,fee schedule,358.45,2782.81,
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,358.45,,,,,,,fee schedule,358.45,2782.81,
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,447.51,,,,,,,fee schedule,358.45,2782.81,
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,564.81,,,,,,,fee schedule,358.45,2782.81,
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,628.76,,,,,,,fee schedule,358.45,2782.81,
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,491.14,,,,,,,fee schedule,358.45,2782.81,
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,358.45,2782.81,APC
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,358.45,2782.81,APC
Removal foreign body gum,41805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,358.45,2782.81,APC
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,686.87,,,,,,,fee schedule,450.31,2782.81,
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,616.51,,,,,,,fee schedule,450.31,2782.81,
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,616.51,,,,,,,fee schedule,450.31,2782.81,
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,450.31,,,,,,,fee schedule,450.31,2782.81,
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,562.2,,,,,,,fee schedule,450.31,2782.81,
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,708.99,,,,,,,fee schedule,450.31,2782.81,
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,789.9,,,,,,,fee schedule,450.31,2782.81,
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,616.51,,,,,,,fee schedule,450.31,2782.81,
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,450.31,2782.81,APC
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,450.31,2782.81,APC
Removal foreign body jawbone,41806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,450.31,2782.81,APC
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excision gum each quadrant,41820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Excision of gum flap,41821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,617.3,,,,,,,fee schedule,404.7,2782.81,
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,540.39,,,,,,,fee schedule,404.7,2782.81,
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,540.39,,,,,,,fee schedule,404.7,2782.81,
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,404.7,,,,,,,fee schedule,404.7,2782.81,
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,505.26,,,,,,,fee schedule,404.7,2782.81,
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,621.45,,,,,,,fee schedule,404.7,2782.81,
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,709.9,,,,,,,fee schedule,404.7,2782.81,
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,540.39,,,,,,,fee schedule,404.7,2782.81,
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,404.7,2782.81,APC
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,404.7,2782.81,APC
Excision of gum lesion,41822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,404.7,2782.81,APC
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,873.05,,,,,,,fee schedule,572.37,10617.38,
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,765.21,,,,,,,fee schedule,572.37,10617.38,
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,765.21,,,,,,,fee schedule,572.37,10617.38,
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,572.37,,,,,,,fee schedule,572.37,10617.38,
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,714.59,,,,,,,fee schedule,572.37,10617.38,
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,879.99,,,,,,,fee schedule,572.37,10617.38,
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1004.01,,,,,,,fee schedule,572.37,10617.38,
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,765.21,,,,,,,fee schedule,572.37,10617.38,
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,572.37,10617.38,APC
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,572.37,10617.38,APC
Excision of gum lesion,41823,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,572.37,10617.38,APC
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,441.92,,,,,,,fee schedule,289.72,5946.37,
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,391.71,,,,,,,fee schedule,289.72,5946.37,
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,391.71,,,,,,,fee schedule,289.72,5946.37,
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,289.72,,,,,,,fee schedule,289.72,5946.37,
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,361.71,,,,,,,fee schedule,289.72,5946.37,
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,450.47,,,,,,,fee schedule,289.72,5946.37,
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,508.21,,,,,,,fee schedule,289.72,5946.37,
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.71,,,,,,,fee schedule,289.72,5946.37,
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,289.72,5946.37,APC
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,289.72,5946.37,APC
Excision of gum lesion,41825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,289.72,5946.37,APC
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7613.76,,,,,,,fee schedule,527.57,8755.82,
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,527.57,,,,,,,fee schedule,527.57,8755.82,
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,527.57,,,,,,,fee schedule,527.57,8755.82,
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4991.58,,,,,,,fee schedule,527.57,8755.82,
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6231.86,,,,,,,fee schedule,527.57,8755.82,
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,606.71,,,,,,,fee schedule,527.57,8755.82,
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8755.82,,,,,,,fee schedule,527.57,8755.82,
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,527.57,,,,,,,fee schedule,527.57,8755.82,
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,527.57,8755.82,APC
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,527.57,8755.82,APC
Excision of gum lesion,41826,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,527.57,8755.82,APC
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Excision of gum lesion,41827,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,516.38,,,,,,,fee schedule,338.54,2782.81,
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,461.73,,,,,,,fee schedule,338.54,2782.81,
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,461.73,,,,,,,fee schedule,338.54,2782.81,
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,338.54,,,,,,,fee schedule,338.54,2782.81,
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,422.66,,,,,,,fee schedule,338.54,2782.81,
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,530.99,,,,,,,fee schedule,338.54,2782.81,
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,593.84,,,,,,,fee schedule,338.54,2782.81,
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,461.73,,,,,,,fee schedule,338.54,2782.81,
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,338.54,2782.81,APC
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,338.54,2782.81,APC
Excision of gum lesion,41828,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,338.54,2782.81,APC
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8548.96,,,,,,,fee schedule,649.36,9831.3,
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,649.36,,,,,,,fee schedule,649.36,9831.3,
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,649.36,,,,,,,fee schedule,649.36,9831.3,
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5604.7,,,,,,,fee schedule,649.36,9831.3,
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6997.32,,,,,,,fee schedule,649.36,9831.3,
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,746.76,,,,,,,fee schedule,649.36,9831.3,
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9831.3,,,,,,,fee schedule,649.36,9831.3,
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,649.36,,,,,,,fee schedule,649.36,9831.3,
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,649.36,9831.3,APC
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,649.36,9831.3,APC
Removal of gum tissue,41830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,649.36,9831.3,APC
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Treatment of gum lesion,41850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1546,5684.21,
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1546,5684.21,
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1546,5684.21,
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1546,5684.21,
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1546,5684.21,
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1546,5684.21,
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1546,5684.21,
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1546,5684.21,
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1546,5684.21,APC
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1546,5684.21,APC
Gum graft,41870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1546,5684.21,APC
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,729.97,,,,,,,fee schedule,478.57,5946.37,
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,640.67,,,,,,,fee schedule,478.57,5946.37,
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,640.67,,,,,,,fee schedule,478.57,5946.37,
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,478.57,,,,,,,fee schedule,478.57,5946.37,
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,597.48,,,,,,,fee schedule,478.57,5946.37,
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,736.77,,,,,,,fee schedule,478.57,5946.37,
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,839.47,,,,,,,fee schedule,478.57,5946.37,
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,640.67,,,,,,,fee schedule,478.57,5946.37,
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,478.57,5946.37,APC
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,478.57,5946.37,APC
Repair gum,41872,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,478.57,5946.37,APC
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,716.28,,,,,,,fee schedule,469.59,5946.37,
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,633.79,,,,,,,fee schedule,469.59,5946.37,
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,633.79,,,,,,,fee schedule,469.59,5946.37,
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,469.59,,,,,,,fee schedule,469.59,5946.37,
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,586.28,,,,,,,fee schedule,469.59,5946.37,
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,728.86,,,,,,,fee schedule,469.59,5946.37,
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,823.72,,,,,,,fee schedule,469.59,5946.37,
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,633.79,,,,,,,fee schedule,469.59,5946.37,
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,469.59,5946.37,APC
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,469.59,5946.37,APC
Repair tooth socket,41874,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,469.59,5946.37,APC
Dental surgery procedure,41899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Dental surgery procedure,41899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Dental surgery procedure,41899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,553.62,
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,553.62,
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,553.62,
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,171.38,553.62,
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,553.62,
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,553.62,APC
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,553.62,APC
Drainage mouth roof lesion,42000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,553.62,APC
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3758.54,,,,,,,fee schedule,242.96,4322.32,
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.96,,,,,,,fee schedule,242.96,4322.32,
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,242.96,,,,,,,fee schedule,242.96,4322.32,
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2464.1,,,,,,,fee schedule,242.96,4322.32,
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3076.36,,,,,,,fee schedule,242.96,4322.32,
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,279.4,,,,,,,fee schedule,242.96,4322.32,
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4322.32,,,,,,,fee schedule,242.96,4322.32,
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.96,,,,,,,fee schedule,242.96,4322.32,
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,242.96,4322.32,APC
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,242.96,4322.32,APC
Biopsy roof of mouth,42100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,242.96,4322.32,APC
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,419.37,,,,,,,fee schedule,274.94,5946.37,
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,357.03,,,,,,,fee schedule,274.94,5946.37,
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,357.03,,,,,,,fee schedule,274.94,5946.37,
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,274.94,,,,,,,fee schedule,274.94,5946.37,
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,343.25,,,,,,,fee schedule,274.94,5946.37,
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.58,,,,,,,fee schedule,274.94,5946.37,
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,482.28,,,,,,,fee schedule,274.94,5946.37,
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,357.03,,,,,,,fee schedule,274.94,5946.37,
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,274.94,5946.37,APC
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,274.94,5946.37,APC
Excision lesion mouth roof,42104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,274.94,5946.37,APC
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5739.42,,,,,,,fee schedule,474.71,6600.33,
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,474.71,,,,,,,fee schedule,474.71,6600.33,
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,474.71,,,,,,,fee schedule,474.71,6600.33,
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3762.76,,,,,,,fee schedule,474.71,6600.33,
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4697.72,,,,,,,fee schedule,474.71,6600.33,
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,545.92,,,,,,,fee schedule,474.71,6600.33,
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6600.33,,,,,,,fee schedule,474.71,6600.33,
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,474.71,,,,,,,fee schedule,474.71,6600.33,
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,474.71,6600.33,APC
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,474.71,6600.33,APC
Excision lesion mouth roof,42106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,474.71,6600.33,APC
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7613.76,,,,,,,fee schedule,4942.79,10617.38,
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4991.58,,,,,,,fee schedule,4942.79,10617.38,
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6231.86,,,,,,,fee schedule,4942.79,10617.38,
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8755.82,,,,,,,fee schedule,4942.79,10617.38,
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Excision lesion mouth roof,42107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Remove palate/lesion,42120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10033.43,,,,,,,fee schedule,1678.74,11538.44,
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,11538.44,
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,11538.44,
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6577.92,,,,,,,fee schedule,1678.74,11538.44,
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8212.36,,,,,,,fee schedule,1678.74,11538.44,
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,11538.44,
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11538.44,,,,,,,fee schedule,1678.74,11538.44,
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,11538.44,
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,11538.44,APC
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,11538.44,APC
Excision of uvula,42140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,11538.44,APC
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6074.82,,,,,,,fee schedule,3982.65,10617.38,
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3982.65,10617.38,
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3982.65,10617.38,
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3982.65,,,,,,,fee schedule,3982.65,10617.38,
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4972.24,,,,,,,fee schedule,3982.65,10617.38,
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3982.65,10617.38,
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6986.04,,,,,,,fee schedule,3982.65,10617.38,
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3982.65,10617.38,
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3982.65,10617.38,APC
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3982.65,10617.38,APC
Repair palate pharynx/uvula,42145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3982.65,10617.38,APC
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,447.78,,,,,,,fee schedule,293.56,5946.37,
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,399.5,,,,,,,fee schedule,293.56,5946.37,
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,399.5,,,,,,,fee schedule,293.56,5946.37,
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,293.56,,,,,,,fee schedule,293.56,5946.37,
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,366.51,,,,,,,fee schedule,293.56,5946.37,
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,459.43,,,,,,,fee schedule,293.56,5946.37,
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,514.95,,,,,,,fee schedule,293.56,5946.37,
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,399.5,,,,,,,fee schedule,293.56,5946.37,
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,293.56,5946.37,APC
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,293.56,5946.37,APC
Treatment mouth roof lesion,42160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,293.56,5946.37,APC
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,967.3,
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,428.37,967.3,
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,967.3,
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,967.3,
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,428.37,967.3,
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,967.3,
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,967.3,APC
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,967.3,APC
Repair palate,42180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,967.3,APC
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Repair palate,42182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cleft palate,42200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruct cleft palate,42205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14366.92,,,,,,,fee schedule,4942.79,16521.96,
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,16521.96,
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,16521.96,
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9418.95,,,,,,,fee schedule,4942.79,16521.96,
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11759.32,,,,,,,fee schedule,4942.79,16521.96,
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,16521.96,
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16521.96,,,,,,,fee schedule,4942.79,16521.96,
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,16521.96,
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,16521.96,APC
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,16521.96,APC
Reconstruct cleft palate,42210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,16521.96,APC
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,2821.05,10617.38,
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,2821.05,10617.38,
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,2821.05,10617.38,
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,2821.05,10617.38,
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,2821.05,10617.38,
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,2821.05,10617.38,
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,2821.05,10617.38,
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,2821.05,10617.38,
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2821.05,10617.38,APC
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2821.05,10617.38,APC
Reconstruct cleft palate,42215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2821.05,10617.38,APC
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cleft palate,42220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruct cleft palate,42225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Lengthening of palate,42226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Lengthening of palate,42227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair palate,42235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Repair nose to lip fistula,42260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,282.19,,,,,,,fee schedule,185,967.3,
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.2,,,,,,,fee schedule,185,967.3,
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,254.2,,,,,,,fee schedule,185,967.3,
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185,,,,,,,fee schedule,185,967.3,
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,230.97,,,,,,,fee schedule,185,967.3,
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.33,,,,,,,fee schedule,185,967.3,
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,324.52,,,,,,,fee schedule,185,967.3,
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.2,,,,,,,fee schedule,185,967.3,
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,185,967.3,APC
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,185,967.3,APC
Preparation palate mold,42280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,185,967.3,APC
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,1678.74,10617.38,
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,10617.38,
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,10617.38,
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,1678.74,10617.38,
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,1678.74,10617.38,
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,10617.38,
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,1678.74,10617.38,
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,10617.38,
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,1678.74,10617.38,APC
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,1678.74,10617.38,APC
Insertion palate prosthesis,42281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,1678.74,10617.38,APC
Palate/uvula surgery,42299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Palate/uvula surgery,42299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Palate/uvula surgery,42299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Drainage of salivary gland,42300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Drainage of salivary gland,42305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,967.3,APC
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,967.3,APC
Drainage of salivary gland,42310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,967.3,APC
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,653.4,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,428.37,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.81,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,751.41,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,428.37,967.3,
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,428.37,967.3,APC
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,428.37,967.3,APC
Drainage of salivary gland,42320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,428.37,967.3,APC
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,400.73,,,,,,,fee schedule,262.72,5946.37,
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,357.12,,,,,,,fee schedule,262.72,5946.37,
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,357.12,,,,,,,fee schedule,262.72,5946.37,
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.72,,,,,,,fee schedule,262.72,5946.37,
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,328,,,,,,,fee schedule,262.72,5946.37,
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.69,,,,,,,fee schedule,262.72,5946.37,
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,460.84,,,,,,,fee schedule,262.72,5946.37,
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,357.12,,,,,,,fee schedule,262.72,5946.37,
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,262.72,5946.37,APC
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,262.72,5946.37,APC
Removal of salivary stone,42330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,262.72,5946.37,APC
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,671.21,,,,,,,fee schedule,440.05,5946.37,
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,600.09,,,,,,,fee schedule,440.05,5946.37,
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,600.09,,,,,,,fee schedule,440.05,5946.37,
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,440.05,,,,,,,fee schedule,440.05,5946.37,
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,549.39,,,,,,,fee schedule,440.05,5946.37,
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,690.1,,,,,,,fee schedule,440.05,5946.37,
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,771.89,,,,,,,fee schedule,440.05,5946.37,
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,600.09,,,,,,,fee schedule,440.05,5946.37,
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,440.05,5946.37,APC
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,440.05,5946.37,APC
Removal of salivary stone,42335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,440.05,5946.37,APC
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Removal of salivary stone,42340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,891.78,,,,,,,fee schedule,190.23,1270.05,
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.23,,,,,,,fee schedule,190.23,1270.05,
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,190.23,,,,,,,fee schedule,190.23,1270.05,
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,584.65,,,,,,,fee schedule,190.23,1270.05,
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,729.92,,,,,,,fee schedule,190.23,1270.05,
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.76,,,,,,,fee schedule,190.23,1270.05,
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1025.55,,,,,,,fee schedule,190.23,1270.05,
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.23,,,,,,,fee schedule,190.23,1270.05,
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,190.23,1270.05,APC
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,190.23,1270.05,APC
Biopsy of salivary gland,42400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,190.23,1270.05,APC
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1546,2965.84,
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1546,2965.84,
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1546,2965.84,
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1546,2965.84,
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1546,2965.84,
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1546,2965.84,
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1546,2965.84,
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1546,2965.84,
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1546,2965.84,APC
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1546,2965.84,APC
Biopsy of salivary gland,42405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1546,2965.84,APC
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of salivary cyst,42408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Drainage of salivary cyst,42409,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Excise parotid gland/lesion,42410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8548.95,,,,,,,fee schedule,4942.79,10617.38,
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5604.69,,,,,,,fee schedule,4942.79,10617.38,
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6997.32,,,,,,,fee schedule,4942.79,10617.38,
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9831.29,,,,,,,fee schedule,4942.79,10617.38,
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Excise parotid gland/lesion,42415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15971.31,,,,,,,fee schedule,4942.79,18367.01,
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,18367.01,
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,18367.01,
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10470.79,,,,,,,fee schedule,4942.79,18367.01,
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13072.52,,,,,,,fee schedule,4942.79,18367.01,
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,18367.01,
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18367.01,,,,,,,fee schedule,4942.79,18367.01,
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,18367.01,
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,18367.01,APC
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,18367.01,APC
Excise parotid gland/lesion,42420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,18367.01,APC
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Excise parotid gland/lesion,42425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7720.34,,,,,,,fee schedule,4942.79,10617.38,
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5061.45,,,,,,,fee schedule,4942.79,10617.38,
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6319.1,,,,,,,fee schedule,4942.79,10617.38,
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8878.39,,,,,,,fee schedule,4942.79,10617.38,
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Excise submaxillary gland,42440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Excise sublingual gland,42450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Repair salivary duct,42500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair salivary duct,42505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Parotid duct diversion,42507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Parotid duct diversion,42509,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Parotid duct diversion,42510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Injection for salivary x-ray,42550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,245.94,,,,,,,fee schedule,161.24,282.83,
Injection for salivary x-ray,42550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.24,,,,,,,fee schedule,161.24,282.83,
Injection for salivary x-ray,42550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.3,,,,,,,fee schedule,161.24,282.83,
Injection for salivary x-ray,42550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,282.83,,,,,,,fee schedule,161.24,282.83,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Closure of salivary fistula,42600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.94,,,,,,,fee schedule,97.65,2782.81,
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.13,,,,,,,fee schedule,97.65,2782.81,
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.13,,,,,,,fee schedule,97.65,2782.81,
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.65,,,,,,,fee schedule,97.65,2782.81,
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.91,,,,,,,fee schedule,97.65,2782.81,
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.1,,,,,,,fee schedule,97.65,2782.81,
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.28,,,,,,,fee schedule,97.65,2782.81,
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.13,,,,,,,fee schedule,97.65,2782.81,
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,97.65,2782.81,APC
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,97.65,2782.81,APC
Dilation of salivary duct,42650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,97.65,2782.81,APC
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,218.5,,,,,,,fee schedule,143.25,967.3,
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.09,,,,,,,fee schedule,143.25,967.3,
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.09,,,,,,,fee schedule,143.25,967.3,
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.25,,,,,,,fee schedule,143.25,967.3,
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.84,,,,,,,fee schedule,143.25,967.3,
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,219.75,,,,,,,fee schedule,143.25,967.3,
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,251.28,,,,,,,fee schedule,143.25,967.3,
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.09,,,,,,,fee schedule,143.25,967.3,
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,143.25,967.3,APC
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,143.25,967.3,APC
Dilation of salivary duct,42660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,143.25,967.3,APC
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Ligation of salivary duct,42665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Salivary surgery procedure,42699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Salivary surgery procedure,42699,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Salivary surgery procedure,42699,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,553.62,
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,553.62,
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,553.62,
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.62,,,,,,,fee schedule,171.38,553.62,
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,553.62,
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.41,,,,,,,fee schedule,171.38,553.62,
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,553.62,APC
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,553.62,APC
Drainage of tonsil abscess,42700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,553.62,APC
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of throat abscess,42720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Drainage of throat abscess,42725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.17,,,,,,,fee schedule,186.3,2782.81,
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.2,,,,,,,fee schedule,186.3,2782.81,
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,254.2,,,,,,,fee schedule,186.3,2782.81,
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.3,,,,,,,fee schedule,186.3,2782.81,
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.59,,,,,,,fee schedule,186.3,2782.81,
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.33,,,,,,,fee schedule,186.3,2782.81,
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.8,,,,,,,fee schedule,186.3,2782.81,
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.2,,,,,,,fee schedule,186.3,2782.81,
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,186.3,2782.81,APC
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,186.3,2782.81,APC
Biopsy of throat,42800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,186.3,2782.81,APC
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Biopsy of upper nose/throat,42804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Biopsy of upper nose/throat,42806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,1684.24,5946.37,
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,1684.24,5946.37,
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excise pharynx lesion,42808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Remove pharynx foreign body,42809,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.85,,,,,,,fee schedule,2578.99,7300.03,
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,7300.03,
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,7300.03,
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.65,,,,,,,fee schedule,2578.99,7300.03,
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.72,,,,,,,fee schedule,2578.99,7300.03,
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,7300.03,
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.03,,,,,,,fee schedule,2578.99,7300.03,
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,7300.03,
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2578.99,7300.03,APC
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2578.99,7300.03,APC
Excision of neck cyst,42810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2578.99,7300.03,APC
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13504.79,,,,,,,fee schedule,4942.79,15530.51,
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,15530.51,
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,15530.51,
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8853.74,,,,,,,fee schedule,4942.79,15530.51,
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11053.67,,,,,,,fee schedule,4942.79,15530.51,
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,15530.51,
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15530.51,,,,,,,fee schedule,4942.79,15530.51,
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,15530.51,
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,15530.51,APC
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,15530.51,APC
Excision of neck cyst,42815,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,15530.51,APC
Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5730.25,,,,,,,fee schedule,5730.25,10617.38,
Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5730.25,,,,,,,fee schedule,5730.25,10617.38,
Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6589.79,,,,,,,fee schedule,5730.25,10617.38,
Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5730.25,,,,,,,fee schedule,5730.25,10617.38,
Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5730.25,10617.38,APC
Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5730.25,10617.38,APC
Remove tonsils and adenoids,42820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5730.25,10617.38,APC
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4732.93,,,,,,,fee schedule,2258.7,5946.37,
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3102.91,,,,,,,fee schedule,2258.7,5946.37,
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3873.9,,,,,,,fee schedule,2258.7,5946.37,
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,2258.7,5946.37,
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5442.87,,,,,,,fee schedule,2258.7,5946.37,
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2258.7,5946.37,APC
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2258.7,5946.37,APC
Remove tonsils and adenoids,42821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2258.7,5946.37,APC
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5197.63,,,,,,,fee schedule,3407.57,10617.38,
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3407.57,10617.38,
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3407.57,10617.38,
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3407.57,,,,,,,fee schedule,3407.57,10617.38,
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4254.26,,,,,,,fee schedule,3407.57,10617.38,
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3407.57,10617.38,
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5977.27,,,,,,,fee schedule,3407.57,10617.38,
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3407.57,10617.38,
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3407.57,10617.38,APC
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3407.57,10617.38,APC
Removal of tonsils,42825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3407.57,10617.38,APC
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4935.27,,,,,,,fee schedule,2258.7,5946.37,
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3235.56,,,,,,,fee schedule,2258.7,5946.37,
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4039.52,,,,,,,fee schedule,2258.7,5946.37,
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,2258.7,5946.37,
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5675.56,,,,,,,fee schedule,2258.7,5946.37,
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,5946.37,
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2258.7,5946.37,APC
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2258.7,5946.37,APC
Removal of tonsils,42826,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2258.7,5946.37,APC
Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5170.87,,,,,,,fee schedule,3303.54,5946.5,
Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5170.87,,,,,,,fee schedule,3303.54,5946.5,
Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5946.5,,,,,,,fee schedule,3303.54,5946.5,
Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5170.87,,,,,,,fee schedule,3303.54,5946.5,
Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,3303.54,5946.5,APC
Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,3303.54,5946.5,APC
Removal of adenoids,42830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,3303.54,5946.5,APC
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6773.5,,,,,,,fee schedule,2258.7,7789.53,
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,7789.53,
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,2258.7,7789.53,
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4440.71,,,,,,,fee schedule,2258.7,7789.53,
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5544.11,,,,,,,fee schedule,2258.7,7789.53,
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,2258.7,7789.53,
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7789.53,,,,,,,fee schedule,2258.7,7789.53,
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,7789.53,
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2258.7,7789.53,APC
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2258.7,7789.53,APC
Removal of adenoids,42831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2258.7,7789.53,APC
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4303.01,,,,,,,fee schedule,2578.99,5946.37,
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,5946.37,
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,5946.37,
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2821.05,,,,,,,fee schedule,2578.99,5946.37,
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3522.01,,,,,,,fee schedule,2578.99,5946.37,
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,5946.37,
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4948.46,,,,,,,fee schedule,2578.99,5946.37,
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,5946.37,
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2578.99,5946.37,APC
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2578.99,5946.37,APC
Removal of adenoids,42835,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2578.99,5946.37,APC
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Removal of adenoids,42836,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Extensive surgery of throat,42842,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Extensive surgery of throat,42844,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of tonsil tags,42860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Excision of lingual tonsil,42870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Partial removal of pharynx,42890,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revision of pharyngeal walls,42892,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Repair throat wound,42900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Reconstruction of throat,42950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Surgical opening of throat,42955,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5236.65,,,,,,,fee schedule,171.91,6022.15,
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,171.91,6022.15,
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,171.91,6022.15,
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3433.15,,,,,,,fee schedule,171.91,6022.15,
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4286.2,,,,,,,fee schedule,171.91,6022.15,
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,171.91,6022.15,
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6022.15,,,,,,,fee schedule,171.91,6022.15,
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,171.91,6022.15,
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,171.91,6022.15,APC
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,171.91,6022.15,APC
Control throat bleeding,42960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,171.91,6022.15,APC
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5186.39,,,,,,,fee schedule,2578.99,5964.35,
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,5964.35,
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,5964.35,
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3400.2,,,,,,,fee schedule,2578.99,5964.35,
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4245.06,,,,,,,fee schedule,2578.99,5964.35,
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,5964.35,
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5964.35,,,,,,,fee schedule,2578.99,5964.35,
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,5964.35,
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2578.99,5964.35,APC
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2578.99,5964.35,APC
Control throat bleeding,42962,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2578.99,5964.35,APC
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,424.8,
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.91,,,,,,,fee schedule,171.38,424.8,
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,424.8,
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,424.8,
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.7,,,,,,,fee schedule,171.38,424.8,
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,424.8,
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.91,,,,,,,fee schedule,171.38,424.8,
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,424.8,APC
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,424.8,APC
Control nose/throat bleeding,42970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,424.8,APC
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1678.74,5946.37,
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1678.74,5946.37,
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1678.74,5946.37,
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1678.74,5946.37,
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Control nose/throat bleeding,42972,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,326.61,,,,,,,fee schedule,136.68,3192.3,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.68,,,,,,,fee schedule,136.68,3192.3,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.68,,,,,,,fee schedule,136.68,3192.3,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.13,,,,,,,fee schedule,136.68,3192.3,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,267.33,,,,,,,fee schedule,136.68,3192.3,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.18,,,,,,,fee schedule,136.68,3192.3,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,375.6,,,,,,,fee schedule,136.68,3192.3,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.68,,,,,,,fee schedule,136.68,3192.3,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1862.17,,,,,,,fee schedule,136.68,3192.3,APC
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1773.5,,,,,,,fee schedule,136.68,3192.3,APC
Dise eval slp do brth flx dx,42975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3192.3,,,,,,,fee schedule,136.68,3192.3,APC
Throat surgery procedure,42999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Throat surgery procedure,42999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Throat surgery procedure,42999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1553.2,,,,,,,fee schedule,1018.28,2782.81,
Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1018.28,,,,,,,fee schedule,1018.28,2782.81,
Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1271.29,,,,,,,fee schedule,1018.28,2782.81,
Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1786.18,,,,,,,fee schedule,1018.28,2782.81,
Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1018.28,2782.81,APC
Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1018.28,2782.81,APC
Incision of esophagus,43020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1018.28,2782.81,APC
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Throat muscle surgery,43030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Removal of esophagus pouch,43130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Esophagoscopy rigid trnso,43180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,988.04,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.04,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1136.25,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,988.04,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,988.04,3441.61,APC
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,988.04,3441.61,APC
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,988.04,3441.61,APC
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscp rig trnso inject,43192,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,1411.09,6914.9,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,6914.9,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1411.09,6914.9,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,1411.09,6914.9,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,1411.09,6914.9,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1411.09,6914.9,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,1411.09,6914.9,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,6914.9,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,1411.09,6914.9,APC
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,1411.09,6914.9,APC
Esophagoscopy rigid balloon,43195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,1411.09,6914.9,APC
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,1411.09,3565.78,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,3565.78,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1411.09,3565.78,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,1411.09,3565.78,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,1411.09,3565.78,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1411.09,3565.78,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,1411.09,3565.78,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,3565.78,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1411.09,3565.78,APC
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1411.09,3565.78,APC
Esophagoscp guide wire dilat,43196,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1411.09,3565.78,APC
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,353.72,,,,,,,fee schedule,231.9,1626.7,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,988.04,,,,,,,fee schedule,231.9,1626.7,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.04,,,,,,,fee schedule,231.9,1626.7,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,231.9,,,,,,,fee schedule,231.9,1626.7,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,289.52,,,,,,,fee schedule,231.9,1626.7,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1136.25,,,,,,,fee schedule,231.9,1626.7,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,406.78,,,,,,,fee schedule,231.9,1626.7,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,988.04,,,,,,,fee schedule,231.9,1626.7,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,231.9,1626.7,APC
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,231.9,1626.7,APC
Esophagoscopy flex dx brush,43197,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,231.9,1626.7,APC
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,377.23,,,,,,,fee schedule,247.31,1626.7,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,988.04,,,,,,,fee schedule,247.31,1626.7,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.04,,,,,,,fee schedule,247.31,1626.7,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,247.31,,,,,,,fee schedule,247.31,1626.7,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,308.76,,,,,,,fee schedule,247.31,1626.7,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1136.25,,,,,,,fee schedule,247.31,1626.7,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,433.81,,,,,,,fee schedule,247.31,1626.7,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,988.04,,,,,,,fee schedule,247.31,1626.7,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,247.31,1626.7,APC
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,247.31,1626.7,APC
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,247.31,1626.7,APC
Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,994.36,,,,,,,fee schedule,903.72,1626.7,
Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1143.51,,,,,,,fee schedule,903.72,1626.7,
Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Esophagoscopy flexible brush,43200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esoph scope w/submucous inj,43201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2815.27,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,988.04,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.04,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1845.69,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2304.3,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1136.25,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3237.56,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,988.04,,,,,,,fee schedule,988.04,3441.61,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,988.04,3441.61,APC
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,988.04,3441.61,APC
Esophagoscopy flex biopsy,43202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,988.04,3441.61,APC
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,988.04,3441.61,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,988.04,,,,,,,fee schedule,988.04,3441.61,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.04,,,,,,,fee schedule,988.04,3441.61,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,988.04,3441.61,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,988.04,3441.61,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1136.25,,,,,,,fee schedule,988.04,3441.61,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,988.04,3441.61,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,988.04,,,,,,,fee schedule,988.04,3441.61,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,988.04,3441.61,APC
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,988.04,3441.61,APC
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,988.04,3441.61,APC
Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Esophagus endoscopy/ligation,43205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esoph optical endomicroscopy,43206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4786.67,,,,,,,fee schedule,3138.14,19064.9,
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3138.14,,,,,,,fee schedule,3138.14,19064.9,
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3917.89,,,,,,,fee schedule,3138.14,19064.9,
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5504.67,,,,,,,fee schedule,3138.14,19064.9,
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,3138.14,19064.9,APC
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,3138.14,19064.9,APC
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,3138.14,19064.9,APC
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscop mucosal resect,43211,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7028.01,,,,,,,fee schedule,3175.17,10888.32,
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4607.56,,,,,,,fee schedule,3175.17,10888.32,
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5752.43,,,,,,,fee schedule,3175.17,10888.32,
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3651.45,,,,,,,fee schedule,3175.17,10888.32,
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8082.21,,,,,,,fee schedule,3175.17,10888.32,
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,3175.17,10888.32,APC
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,3175.17,10888.32,APC
Esophagoscop stent placement,43212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,3175.17,10888.32,APC
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy retro balloon,43213,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagosc dilate balloon 30,43214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy flex remove fb,43215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.86,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2537.86,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2918.54,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2537.86,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy lesion removal,43216,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy snare les remv,43217,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esoph endoscopy dilation,43226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy control bleed,43227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,2032.81,6914.9,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.86,,,,,,,fee schedule,2032.81,6914.9,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2537.86,,,,,,,fee schedule,2032.81,6914.9,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,2032.81,6914.9,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,2032.81,6914.9,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2918.54,,,,,,,fee schedule,2032.81,6914.9,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,2032.81,6914.9,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2537.86,,,,,,,fee schedule,2032.81,6914.9,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2032.81,6914.9,APC
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2032.81,6914.9,APC
Esophagoscopy lesion ablate,43229,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2032.81,6914.9,APC
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscop ultrasound exam,43231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1764.83,,,,,,,fee schedule,903.72,2029.55,
Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1764.83,,,,,,,fee schedule,903.72,2029.55,
Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2029.55,,,,,,,fee schedule,903.72,2029.55,
Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1764.83,,,,,,,fee schedule,903.72,2029.55,
Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,2029.55,APC
Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,2029.55,APC
Egd diagnostic brush wash,43235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,2029.55,APC
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,994.36,,,,,,,fee schedule,903.72,1626.7,
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1143.51,,,,,,,fee schedule,903.72,1626.7,
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Endoscopic us exam esoph,43237,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5351.18,,,,,,,fee schedule,1912.01,6153.86,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2737.74,,,,,,,fee schedule,1912.01,6153.86,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2737.74,,,,,,,fee schedule,1912.01,6153.86,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3508.23,,,,,,,fee schedule,1912.01,6153.86,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4379.94,,,,,,,fee schedule,1912.01,6153.86,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3148.4,,,,,,,fee schedule,1912.01,6153.86,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6153.86,,,,,,,fee schedule,1912.01,6153.86,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2737.74,,,,,,,fee schedule,1912.01,6153.86,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1912.01,6153.86,APC
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1912.01,6153.86,APC
Egd us fine needle bx/aspir,43238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1912.01,6153.86,APC
Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1764.83,,,,,,,fee schedule,903.72,2029.55,
Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1764.83,,,,,,,fee schedule,903.72,2029.55,
Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2029.55,,,,,,,fee schedule,903.72,2029.55,
Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1764.83,,,,,,,fee schedule,903.72,2029.55,
Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,2029.55,APC
Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,2029.55,APC
Egd biopsy single/multiple,43239,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,2029.55,APC
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,2032.81,10888.32,
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2684.45,,,,,,,fee schedule,2032.81,10888.32,
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2684.45,,,,,,,fee schedule,2032.81,10888.32,
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,2032.81,10888.32,
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,2032.81,10888.32,
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3087.12,,,,,,,fee schedule,2032.81,10888.32,
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,2032.81,10888.32,
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2684.45,,,,,,,fee schedule,2032.81,10888.32,
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,2032.81,10888.32,APC
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,2032.81,10888.32,APC
Egd w/transmural drain cyst,43240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,2032.81,10888.32,APC
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,988.04,3441.61,
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,988.04,,,,,,,fee schedule,988.04,3441.61,
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.04,,,,,,,fee schedule,988.04,3441.61,
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,988.04,3441.61,
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,988.04,3441.61,
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1136.25,,,,,,,fee schedule,988.04,3441.61,
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,988.04,3441.61,
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,988.04,,,,,,,fee schedule,988.04,3441.61,
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,988.04,3441.61,APC
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,988.04,3441.61,APC
Egd tube/cath insertion,43241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,988.04,3441.61,APC
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4770.62,,,,,,,fee schedule,1411.09,5486.21,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,5486.21,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1411.09,5486.21,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3127.62,,,,,,,fee schedule,1411.09,5486.21,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3904.75,,,,,,,fee schedule,1411.09,5486.21,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1411.09,5486.21,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5486.21,,,,,,,fee schedule,1411.09,5486.21,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,5486.21,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1411.09,5486.21,APC
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1411.09,5486.21,APC
Egd us fine needle bx/aspir,43242,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1411.09,5486.21,APC
Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,994.36,,,,,,,fee schedule,994.36,3441.61,
Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,994.36,,,,,,,fee schedule,994.36,3441.61,
Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1143.51,,,,,,,fee schedule,994.36,3441.61,
Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,994.36,,,,,,,fee schedule,994.36,3441.61,
Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,994.36,3441.61,APC
Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,994.36,3441.61,APC
Egd injection varices,43243,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,994.36,3441.61,APC
Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Egd varices ligation,43244,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Egd dilate stricture,43245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Egd place gastrostomy tube,43246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,994.36,,,,,,,fee schedule,903.72,1626.7,
Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1143.51,,,,,,,fee schedule,903.72,1626.7,
Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Egd remove foreign body,43247,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,994.36,,,,,,,fee schedule,903.72,1626.7,
Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1143.51,,,,,,,fee schedule,903.72,1626.7,
Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Egd guide wire insertion,43248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Esoph egd dilation <30 mm,43249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Egd cautery tumor polyp,43250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Egd remove lesion snare,43251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,1411.09,3565.78,
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,3565.78,
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1411.09,3565.78,
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,1411.09,3565.78,
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,1411.09,3565.78,
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1411.09,3565.78,
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,1411.09,3565.78,
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,3565.78,
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1411.09,3565.78,APC
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1411.09,3565.78,APC
Egd optical endomicroscopy,43252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1411.09,3565.78,APC
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Egd us transmural injxn/mark,43253,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1089.23,3441.61,
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1089.23,3441.61,
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Egd endo mucosal resection,43254,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Egd control bleeding any,43255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6058.09,,,,,,,fee schedule,2537.86,6966.8,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.86,,,,,,,fee schedule,2537.86,6966.8,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2537.86,,,,,,,fee schedule,2537.86,6966.8,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3971.68,,,,,,,fee schedule,2537.86,6966.8,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4958.55,,,,,,,fee schedule,2537.86,6966.8,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2918.54,,,,,,,fee schedule,2537.86,6966.8,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6966.8,,,,,,,fee schedule,2537.86,6966.8,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2537.86,,,,,,,fee schedule,2537.86,6966.8,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2537.86,6966.8,APC
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2537.86,6966.8,APC
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2537.86,6966.8,APC
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2645.29,,,,,,,fee schedule,1411.09,3441.61,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,3441.61,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1411.09,3441.61,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1734.25,,,,,,,fee schedule,1411.09,3441.61,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2165.17,,,,,,,fee schedule,1411.09,3441.61,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1411.09,3441.61,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3042.08,,,,,,,fee schedule,1411.09,3441.61,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,3441.61,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1411.09,3441.61,APC
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1411.09,3441.61,APC
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1411.09,3441.61,APC
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,2032.81,6914.9,
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2737.74,,,,,,,fee schedule,2032.81,6914.9,
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2737.74,,,,,,,fee schedule,2032.81,6914.9,
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,2032.81,6914.9,
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,2032.81,6914.9,
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3148.4,,,,,,,fee schedule,2032.81,6914.9,
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,2032.81,6914.9,
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2737.74,,,,,,,fee schedule,2032.81,6914.9,
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2032.81,6914.9,APC
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2032.81,6914.9,APC
Ercp w/specimen collection,43260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2032.81,6914.9,APC
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11913.93,,,,,,,fee schedule,2588.05,13701.02,
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2588.05,,,,,,,fee schedule,2588.05,13701.02,
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2588.05,,,,,,,fee schedule,2588.05,13701.02,
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7810.77,,,,,,,fee schedule,2588.05,13701.02,
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9751.55,,,,,,,fee schedule,2588.05,13701.02,
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2976.26,,,,,,,fee schedule,2588.05,13701.02,
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13701.02,,,,,,,fee schedule,2588.05,13701.02,
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2588.05,,,,,,,fee schedule,2588.05,13701.02,
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2588.05,13701.02,APC
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2588.05,13701.02,APC
Endo cholangiopancreatograph,43261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2588.05,13701.02,APC
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5524.64,,,,,,,fee schedule,2588.05,6914.9,
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2588.05,,,,,,,fee schedule,2588.05,6914.9,
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2588.05,,,,,,,fee schedule,2588.05,6914.9,
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3621.95,,,,,,,fee schedule,2588.05,6914.9,
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4521.92,,,,,,,fee schedule,2588.05,6914.9,
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2976.26,,,,,,,fee schedule,2588.05,6914.9,
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6353.34,,,,,,,fee schedule,2588.05,6914.9,
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2588.05,,,,,,,fee schedule,2588.05,6914.9,
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2588.05,6914.9,APC
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2588.05,6914.9,APC
Endo cholangiopancreatograph,43262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2588.05,6914.9,APC
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,1912.01,3565.78,
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2588.05,,,,,,,fee schedule,1912.01,3565.78,
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2588.05,,,,,,,fee schedule,1912.01,3565.78,
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,1912.01,3565.78,
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,1912.01,3565.78,
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2976.26,,,,,,,fee schedule,1912.01,3565.78,
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,1912.01,3565.78,
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2588.05,,,,,,,fee schedule,1912.01,3565.78,
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1912.01,3565.78,APC
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1912.01,3565.78,APC
Ercp sphincter pressure meas,43263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1912.01,3565.78,APC
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6658.95,,,,,,,fee schedule,2588.05,7657.79,
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2588.05,,,,,,,fee schedule,2588.05,7657.79,
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2588.05,,,,,,,fee schedule,2588.05,7657.79,
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4365.61,,,,,,,fee schedule,2588.05,7657.79,
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.35,,,,,,,fee schedule,2588.05,7657.79,
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2976.26,,,,,,,fee schedule,2588.05,7657.79,
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7657.79,,,,,,,fee schedule,2588.05,7657.79,
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2588.05,,,,,,,fee schedule,2588.05,7657.79,
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2588.05,7657.79,APC
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2588.05,7657.79,APC
Ercp remove duct calculi,43264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2588.05,7657.79,APC
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14034.2,,,,,,,fee schedule,2588.05,16139.33,
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2588.05,,,,,,,fee schedule,2588.05,16139.33,
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2588.05,,,,,,,fee schedule,2588.05,16139.33,
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9200.82,,,,,,,fee schedule,2588.05,16139.33,
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11486.99,,,,,,,fee schedule,2588.05,16139.33,
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2976.26,,,,,,,fee schedule,2588.05,16139.33,
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16139.33,,,,,,,fee schedule,2588.05,16139.33,
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2588.05,,,,,,,fee schedule,2588.05,16139.33,
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,2588.05,16139.33,APC
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,2588.05,16139.33,APC
Ercp lithotripsy calculi,43265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,2588.05,16139.33,APC
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7176.84,,,,,,,fee schedule,3175.17,10888.32,
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4705.14,,,,,,,fee schedule,3175.17,10888.32,
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5874.24,,,,,,,fee schedule,3175.17,10888.32,
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3651.45,,,,,,,fee schedule,3175.17,10888.32,
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8253.37,,,,,,,fee schedule,3175.17,10888.32,
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,3175.17,10888.32,APC
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,3175.17,10888.32,APC
Egd endoscopic stent place,43266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,3175.17,10888.32,APC
Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Egd lesion ablation,43270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6865.84,,,,,,,fee schedule,3175.17,10888.32,
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4501.24,,,,,,,fee schedule,3175.17,10888.32,
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5619.69,,,,,,,fee schedule,3175.17,10888.32,
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3651.45,,,,,,,fee schedule,3175.17,10888.32,
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7895.72,,,,,,,fee schedule,3175.17,10888.32,
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,3175.17,10888.32,APC
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,3175.17,10888.32,APC
Ercp duct stent placement,43274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,3175.17,10888.32,APC
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4913.64,,,,,,,fee schedule,1912.01,5650.69,
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2588.05,,,,,,,fee schedule,1912.01,5650.69,
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2588.05,,,,,,,fee schedule,1912.01,5650.69,
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3221.38,,,,,,,fee schedule,1912.01,5650.69,
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4021.81,,,,,,,fee schedule,1912.01,5650.69,
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2976.26,,,,,,,fee schedule,1912.01,5650.69,
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5650.69,,,,,,,fee schedule,1912.01,5650.69,
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2588.05,,,,,,,fee schedule,1912.01,5650.69,
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1912.01,5650.69,APC
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1912.01,5650.69,APC
Ercp remove forgn body duct,43275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1912.01,5650.69,APC
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4786.67,,,,,,,fee schedule,3138.14,10888.32,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3175.17,,,,,,,fee schedule,3138.14,10888.32,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3175.17,,,,,,,fee schedule,3138.14,10888.32,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3138.14,,,,,,,fee schedule,3138.14,10888.32,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3917.89,,,,,,,fee schedule,3138.14,10888.32,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3651.45,,,,,,,fee schedule,3138.14,10888.32,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5504.67,,,,,,,fee schedule,3138.14,10888.32,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3175.17,,,,,,,fee schedule,3138.14,10888.32,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,3138.14,10888.32,APC
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,3138.14,10888.32,APC
Ercp stent exchange w/dilate,43276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,3138.14,10888.32,APC
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,2032.81,6914.9,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2588.05,,,,,,,fee schedule,2032.81,6914.9,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2588.05,,,,,,,fee schedule,2032.81,6914.9,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,2032.81,6914.9,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,2032.81,6914.9,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2976.26,,,,,,,fee schedule,2032.81,6914.9,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,2032.81,6914.9,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2588.05,,,,,,,fee schedule,2032.81,6914.9,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2032.81,6914.9,APC
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2032.81,6914.9,APC
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2032.81,6914.9,APC
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,2032.81,6914.9,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2588.05,,,,,,,fee schedule,2032.81,6914.9,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2588.05,,,,,,,fee schedule,2032.81,6914.9,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,2032.81,6914.9,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,2032.81,6914.9,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2976.26,,,,,,,fee schedule,2032.81,6914.9,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,2032.81,6914.9,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2588.05,,,,,,,fee schedule,2032.81,6914.9,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2032.81,6914.9,APC
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2032.81,6914.9,APC
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2032.81,6914.9,APC
Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7071.56,,,,,,,fee schedule,4636.11,19064.9,
Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4636.11,,,,,,,fee schedule,4636.11,19064.9,
Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5788.07,,,,,,,fee schedule,4636.11,19064.9,
Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8132.29,,,,,,,fee schedule,4636.11,19064.9,
Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,4636.11,19064.9,APC
Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,4636.11,19064.9,APC
Laparoscopy fundoplasty,43280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,4636.11,19064.9,APC
Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8993.22,,,,,,,fee schedule,5895.96,19064.9,
Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5895.96,,,,,,,fee schedule,5895.96,19064.9,
Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7360.95,,,,,,,fee schedule,5895.96,19064.9,
Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10342.2,,,,,,,fee schedule,5895.96,19064.9,
Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5895.96,19064.9,APC
Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5895.96,19064.9,APC
Lap paraesophag hern repair,43281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5895.96,19064.9,APC
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12657.97,,,,,,,fee schedule,8298.57,19064.9,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8298.57,,,,,,,fee schedule,8298.57,19064.9,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10360.55,,,,,,,fee schedule,8298.57,19064.9,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14556.67,,,,,,,fee schedule,8298.57,19064.9,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,8298.57,19064.9,APC
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,8298.57,19064.9,APC
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,8298.57,19064.9,APC
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7509.76,,,,,,,fee schedule,4923.4,10842.82,
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4923.4,,,,,,,fee schedule,4923.4,10842.82,
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6146.74,,,,,,,fee schedule,4923.4,10842.82,
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8636.22,,,,,,,fee schedule,4923.4,10842.82,
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4923.4,10842.82,APC
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4923.4,10842.82,APC
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4923.4,10842.82,APC
Esphg tot w/laps moblj,43286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7465.97,,,,,,,fee schedule,4894.69,8585.87,
Esphg tot w/laps moblj,43286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4894.69,,,,,,,fee schedule,4894.69,8585.87,
Esphg tot w/laps moblj,43286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6110.9,,,,,,,fee schedule,4894.69,8585.87,
Esphg tot w/laps moblj,43286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8585.87,,,,,,,fee schedule,4894.69,8585.87,
Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8300.44,,,,,,,fee schedule,5441.77,9545.51,
Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5441.77,,,,,,,fee schedule,5441.77,9545.51,
Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6793.91,,,,,,,fee schedule,5441.77,9545.51,
Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9545.51,,,,,,,fee schedule,5441.77,9545.51,
Esphg thrsc moblj,43288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8657.22,,,,,,,fee schedule,5675.67,9955.8,
Esphg thrsc moblj,43288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5675.67,,,,,,,fee schedule,5675.67,9955.8,
Esphg thrsc moblj,43288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7085.93,,,,,,,fee schedule,5675.67,9955.8,
Esphg thrsc moblj,43288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9955.8,,,,,,,fee schedule,5675.67,9955.8,
Laparoscope proc esoph,43289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc esoph,43289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc esoph,43289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3328.82,,,,,,,fee schedule,1181.42,3828.14,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1181.42,,,,,,,fee schedule,1181.42,3828.14,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1181.42,,,,,,,fee schedule,1181.42,3828.14,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.37,,,,,,,fee schedule,1181.42,3828.14,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2724.64,,,,,,,fee schedule,1181.42,3828.14,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1358.63,,,,,,,fee schedule,1181.42,3828.14,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3828.14,,,,,,,fee schedule,1181.42,3828.14,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1181.42,,,,,,,fee schedule,1181.42,3828.14,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1181.42,3828.14,APC
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1181.42,3828.14,APC
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1181.42,3828.14,APC
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1577.86,,,,,,,fee schedule,674.82,1814.54,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,674.82,,,,,,,fee schedule,674.82,1814.54,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,674.82,,,,,,,fee schedule,674.82,1814.54,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1034.45,,,,,,,fee schedule,674.82,1814.54,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1291.48,,,,,,,fee schedule,674.82,1814.54,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,776.04,,,,,,,fee schedule,674.82,1814.54,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1814.54,,,,,,,fee schedule,674.82,1814.54,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,674.82,,,,,,,fee schedule,674.82,1814.54,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,674.82,1814.54,APC
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,674.82,1814.54,APC
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,674.82,1814.54,APC
Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3250.82,,,,,,,fee schedule,2131.24,5946.37,
Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2131.24,,,,,,,fee schedule,2131.24,5946.37,
Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2660.8,,,,,,,fee schedule,2131.24,5946.37,
Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3738.44,,,,,,,fee schedule,2131.24,5946.37,
Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2131.24,5946.37,APC
Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2131.24,5946.37,APC
Repair esophagus opening,43420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2131.24,5946.37,APC
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,994.36,,,,,,,fee schedule,903.72,1626.7,
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1143.51,,,,,,,fee schedule,903.72,1626.7,
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,994.36,,,,,,,fee schedule,903.72,1626.7,
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1633.14,,,,,,,fee schedule,1420.12,3441.61,
Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1420.12,,,,,,,fee schedule,1420.12,3441.61,
Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1420.12,3441.61,APC
Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1420.12,3441.61,APC
Dilate esophagus,43453,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1420.12,3441.61,APC
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6092.13,,,,,,,fee schedule,3994,10888.32,
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3994,,,,,,,fee schedule,3994,10888.32,
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4986.41,,,,,,,fee schedule,3994,10888.32,
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7005.95,,,,,,,fee schedule,3994,10888.32,
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,3994,10888.32,APC
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,3994,10888.32,APC
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,3994,10888.32,APC
Esophagus surgery procedure,43499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Esophagus surgery procedure,43499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Esophagus surgery procedure,43499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.56,,,,,,,fee schedule,686.12,1626.7,
Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,686.12,,,,,,,fee schedule,686.12,1626.7,
Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.61,,,,,,,fee schedule,686.12,1626.7,
Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.54,,,,,,,fee schedule,686.12,1626.7,
Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,686.12,1626.7,APC
Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,686.12,1626.7,APC
Surgical opening of stomach,43510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,686.12,1626.7,APC
Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8592.08,,,,,,,fee schedule,5632.97,19984.73,
Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5632.97,,,,,,,fee schedule,5632.97,19984.73,
Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7032.62,,,,,,,fee schedule,5632.97,19984.73,
Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9880.89,,,,,,,fee schedule,5632.97,19984.73,
Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,5632.97,19984.73,APC
Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,5632.97,19984.73,APC
Lap impl electrode antrum,43647,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,5632.97,19984.73,APC
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,19064.9,
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,19064.9,
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,19064.9,
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,19064.9,
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,4117.16,19064.9,APC
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,4117.16,19064.9,APC
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,4117.16,19064.9,APC
Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscopy vagus nerve,43651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscopy vagus nerve,43652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9926.3,,,,,,,fee schedule,5008.21,11415.25,
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,11415.25,
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,5008.21,11415.25,
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6507.68,,,,,,,fee schedule,5008.21,11415.25,
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8124.68,,,,,,,fee schedule,5008.21,11415.25,
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,5008.21,11415.25,
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11415.25,,,,,,,fee schedule,5008.21,11415.25,
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,11415.25,
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5008.21,11415.25,APC
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5008.21,11415.25,APC
Laparoscopy gastrostomy,43653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5008.21,11415.25,APC
Laparoscope proc stom,43659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc stom,43659,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc stom,43659,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,565.12,,,,,,,fee schedule,200.06,801.21,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,200.06,,,,,,,fee schedule,200.06,801.21,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,200.06,,,,,,,fee schedule,200.06,801.21,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,370.49,,,,,,,fee schedule,200.06,801.21,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,462.55,,,,,,,fee schedule,200.06,801.21,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,230.07,,,,,,,fee schedule,200.06,801.21,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,649.89,,,,,,,fee schedule,200.06,801.21,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,200.06,,,,,,,fee schedule,200.06,801.21,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,200.06,801.21,APC
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,200.06,801.21,APC
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,200.06,801.21,APC
Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Tx gastro intub w/asp,43753,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Dx gastr intub w/asp spec,43754,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,187.62,,,,,,,fee schedule,123,502.52,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,436.97,,,,,,,fee schedule,123,502.52,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,436.97,,,,,,,fee schedule,123,502.52,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123,,,,,,,fee schedule,123,502.52,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.57,,,,,,,fee schedule,123,502.52,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,502.52,,,,,,,fee schedule,123,502.52,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,215.76,,,,,,,fee schedule,123,502.52,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,436.97,,,,,,,fee schedule,123,502.52,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,123,502.52,APC
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,123,502.52,APC
Dx gastr intub w/asp specs,43755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,123,502.52,APC
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.04,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.41,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.41,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.26,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.54,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.12,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.41,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,211.41,1626.7,APC
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,211.41,1626.7,APC
Dx duod intub w/asp spec,43756,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,211.41,1626.7,APC
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.04,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.41,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.41,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.26,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.54,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.12,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.41,,,,,,,fee schedule,211.41,1626.7,
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,211.41,1626.7,APC
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,211.41,1626.7,APC
Dx duod intub w/asp specs,43757,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,211.41,1626.7,APC
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,318.91,,,,,,,fee schedule,209.08,1136.25,
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,988.04,,,,,,,fee schedule,209.08,1136.25,
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.04,,,,,,,fee schedule,209.08,1136.25,
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,209.08,,,,,,,fee schedule,209.08,1136.25,
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.03,,,,,,,fee schedule,209.08,1136.25,
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1136.25,,,,,,,fee schedule,209.08,1136.25,
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,366.75,,,,,,,fee schedule,209.08,1136.25,
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,988.04,,,,,,,fee schedule,209.08,1136.25,
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,209.08,1136.25,APC
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,209.08,1136.25,APC
Reposition gastrostomy tube,43761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,209.08,1136.25,APC
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,607.52,,,,,,,fee schedule,191.04,698.65,
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.04,,,,,,,fee schedule,191.04,698.65,
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.04,,,,,,,fee schedule,191.04,698.65,
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,398.29,,,,,,,fee schedule,191.04,698.65,
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,497.26,,,,,,,fee schedule,191.04,698.65,
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,219.7,,,,,,,fee schedule,191.04,698.65,
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,698.65,,,,,,,fee schedule,191.04,698.65,
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.04,,,,,,,fee schedule,191.04,698.65,
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,191.04,698.65,APC
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,191.04,698.65,APC
Rplc gtube no revj trc,43762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,191.04,698.65,APC
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,607.52,,,,,,,fee schedule,191.04,698.65,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.04,,,,,,,fee schedule,191.04,698.65,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.04,,,,,,,fee schedule,191.04,698.65,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,398.29,,,,,,,fee schedule,191.04,698.65,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,497.26,,,,,,,fee schedule,191.04,698.65,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,219.7,,,,,,,fee schedule,191.04,698.65,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,698.65,,,,,,,fee schedule,191.04,698.65,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.04,,,,,,,fee schedule,191.04,698.65,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,191.04,698.65,APC
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,191.04,698.65,APC
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,191.04,698.65,APC
Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10423.72,,,,,,,fee schedule,6833.79,19064.9,
Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6833.79,,,,,,,fee schedule,6833.79,19064.9,
Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8531.81,,,,,,,fee schedule,6833.79,19064.9,
Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11987.28,,,,,,,fee schedule,6833.79,19064.9,
Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,6833.79,19064.9,APC
Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,6833.79,19064.9,APC
Lap place gastr adj device,43770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,6833.79,19064.9,APC
Lap rmvl gastr adj device,43772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,3841.61,6914.9,APC
Lap rmvl gastr adj device,43772,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,3841.61,6914.9,APC
Lap rmvl gastr adj device,43772,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,3841.61,6914.9,APC
Lap replace gastr adj device,43773,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Lap replace gastr adj device,43773,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Lap replace gastr adj device,43773,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,3841.61,6914.9,APC
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,3841.61,6914.9,APC
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,3841.61,6914.9,APC
Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1996.29,,,,,,,fee schedule,1308.77,3441.61,
Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1633.96,,,,,,,fee schedule,1308.77,3441.61,
Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1308.77,,,,,,,fee schedule,1308.77,3441.61,
Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2295.73,,,,,,,fee schedule,1308.77,3441.61,
Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1308.77,3441.61,APC
Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1308.77,3441.61,APC
Place gastrostomy tube,43830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1308.77,3441.61,APC
Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.56,,,,,,,fee schedule,686.12,1626.7,
Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.61,,,,,,,fee schedule,686.12,1626.7,
Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,686.12,,,,,,,fee schedule,686.12,1626.7,
Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.54,,,,,,,fee schedule,686.12,1626.7,
Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,686.12,1626.7,APC
Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,686.12,1626.7,APC
Place gastrostomy tube,43831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,686.12,1626.7,APC
Repair of stomach lesion,43840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,3841.61,6914.9,APC
Repair of stomach lesion,43840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,3841.61,6914.9,APC
Repair of stomach lesion,43840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,3841.61,6914.9,APC
V-band gastroplasty,43842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8194.54,,,,,,,fee schedule,5372.34,9423.72,
V-band gastroplasty,43842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6707.23,,,,,,,fee schedule,5372.34,9423.72,
V-band gastroplasty,43842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5372.34,,,,,,,fee schedule,5372.34,9423.72,
V-band gastroplasty,43842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9423.72,,,,,,,fee schedule,5372.34,9423.72,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.68,,,,,,,fee schedule,2537.86,9651.58,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.86,,,,,,,fee schedule,2537.86,9651.58,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2537.86,,,,,,,fee schedule,2537.86,9651.58,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.41,,,,,,,fee schedule,2537.86,9651.58,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.24,,,,,,,fee schedule,2537.86,9651.58,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2918.54,,,,,,,fee schedule,2537.86,9651.58,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.58,,,,,,,fee schedule,2537.86,9651.58,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2537.86,,,,,,,fee schedule,2537.86,9651.58,
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2537.86,9651.58,APC
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2537.86,9651.58,APC
Repair stomach opening,43870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2537.86,9651.58,APC
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Revise gastric port open,43886,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2144.76,,,,,,,fee schedule,1381.8,3700.55,
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1865.01,,,,,,,fee schedule,1381.8,3700.55,
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Remove gastric port open,43887,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Change gastric port open,43888,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Stomach surgery procedure,43999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Stomach surgery procedure,43999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Stomach surgery procedure,43999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.04,,,,,,,fee schedule,677.26,1626.7,
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,677.26,1626.7,
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,677.26,1626.7,
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.54,,,,,,,fee schedule,677.26,1626.7,
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.26,,,,,,,fee schedule,677.26,1626.7,
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,677.26,1626.7,
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188,,,,,,,fee schedule,677.26,1626.7,
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,677.26,1626.7,
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,677.26,1626.7,APC
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,677.26,1626.7,APC
Biopsy of bowel,44100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,677.26,1626.7,APC
Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5579.99,,,,,,,fee schedule,3658.24,10842.82,
Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.22,,,,,,,fee schedule,3658.24,10842.82,
Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.24,,,,,,,fee schedule,3658.24,10842.82,
Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6416.99,,,,,,,fee schedule,3658.24,10842.82,
Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3658.24,10842.82,APC
Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3658.24,10842.82,APC
Lap enterolysis,44180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3658.24,10842.82,APC
Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Lap jejunostomy,44186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscope proc intestine,44238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc intestine,44238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc intestine,44238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Open bowel to skin,44300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1912.01,3441.61,APC
Open bowel to skin,44300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1912.01,3441.61,APC
Open bowel to skin,44300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1912.01,3441.61,APC
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Revision of ileostomy,44312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Revision of ileostomy,44314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3530.98,6355.77,APC
Revision of ileostomy,44314,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3530.98,6355.77,APC
Revision of ileostomy,44314,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3530.98,6355.77,APC
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3697.47,,,,,,,fee schedule,2424.06,6355.77,
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2424.06,,,,,,,fee schedule,2424.06,6355.77,
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3026.38,,,,,,,fee schedule,2424.06,6355.77,
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3507.29,,,,,,,fee schedule,2424.06,6355.77,
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4252.09,,,,,,,fee schedule,2424.06,6355.77,
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3049.82,,,,,,,fee schedule,2424.06,6355.77,
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,2424.06,6355.77,APC
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,2424.06,6355.77,APC
Revision of colostomy,44340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,2424.06,6355.77,APC
Revision of colostomy,44345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3530.98,6355.77,APC
Revision of colostomy,44345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3530.98,6355.77,APC
Revision of colostomy,44345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3530.98,6355.77,APC
Revision of colostomy,44346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3707.53,,,,,,,fee schedule,3530.98,6355.77,APC
Revision of colostomy,44346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3530.98,,,,,,,fee schedule,3530.98,6355.77,APC
Revision of colostomy,44346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6355.77,,,,,,,fee schedule,3530.98,6355.77,APC
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1299.01,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1136.83,,,,,,,fee schedule,1136.83,3441.61,
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1136.83,,,,,,,fee schedule,1136.83,3441.61,
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1307.35,,,,,,,fee schedule,1136.83,3441.61,
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1136.83,,,,,,,fee schedule,1136.83,3441.61,
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1136.83,3441.61,APC
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1136.83,3441.61,APC
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1136.83,3441.61,APC
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1299.01,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44363,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1903.95,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44364,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1903.95,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1903.95,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1903.95,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44369,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6917.02,,,,,,,fee schedule,3175.17,10888.32,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4534.8,,,,,,,fee schedule,3175.17,10888.32,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5661.58,,,,,,,fee schedule,3175.17,10888.32,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3651.45,,,,,,,fee schedule,3175.17,10888.32,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7954.57,,,,,,,fee schedule,3175.17,10888.32,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3175.17,,,,,,,fee schedule,3175.17,10888.32,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,3175.17,10888.32,APC
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,3175.17,10888.32,APC
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,3175.17,10888.32,APC
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1903.95,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44372,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1903.95,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44373,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1136.83,,,,,,,fee schedule,1136.83,3441.61,
Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1136.83,,,,,,,fee schedule,1136.83,3441.61,
Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1307.35,,,,,,,fee schedule,1136.83,3441.61,
Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1136.83,,,,,,,fee schedule,1136.83,3441.61,
Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1136.83,3441.61,APC
Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1136.83,3441.61,APC
Small bowel endoscopy,44376,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1136.83,3441.61,APC
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1666.25,,,,,,,fee schedule,1666.25,3441.61,
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1666.25,,,,,,,fee schedule,1666.25,3441.61,
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1916.19,,,,,,,fee schedule,1666.25,3441.61,
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1666.25,,,,,,,fee schedule,1666.25,3441.61,
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1666.25,3441.61,APC
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1666.25,3441.61,APC
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1666.25,3441.61,APC
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1903.95,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1655.61,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44378,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4786.67,,,,,,,fee schedule,3138.14,10888.32,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3175.17,,,,,,,fee schedule,3138.14,10888.32,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3175.17,,,,,,,fee schedule,3138.14,10888.32,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3138.14,,,,,,,fee schedule,3138.14,10888.32,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3917.89,,,,,,,fee schedule,3138.14,10888.32,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3651.45,,,,,,,fee schedule,3138.14,10888.32,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5504.67,,,,,,,fee schedule,3138.14,10888.32,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3175.17,,,,,,,fee schedule,3138.14,10888.32,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,3138.14,10888.32,APC
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,3138.14,10888.32,APC
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,3138.14,10888.32,APC
Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1136.83,,,,,,,fee schedule,903.72,1626.7,
Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1136.83,,,,,,,fee schedule,903.72,1626.7,
Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1307.35,,,,,,,fee schedule,903.72,1626.7,
Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1136.83,,,,,,,fee schedule,903.72,1626.7,
Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Small bowel endoscopy br/wa,44380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1299.01,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1129.57,,,,,,,fee schedule,1089.23,3441.61,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy br/wa,44381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1136.83,,,,,,,fee schedule,903.72,1626.7,
Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1136.83,,,,,,,fee schedule,903.72,1626.7,
Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1307.35,,,,,,,fee schedule,903.72,1626.7,
Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1136.83,,,,,,,fee schedule,903.72,1626.7,
Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Small bowel endoscopy,44382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3100.68,,,,,,,fee schedule,1129.57,3565.78,
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1129.57,,,,,,,fee schedule,1129.57,3565.78,
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1129.57,,,,,,,fee schedule,1129.57,3565.78,
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2032.81,,,,,,,fee schedule,1129.57,3565.78,
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2537.91,,,,,,,fee schedule,1129.57,3565.78,
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1299.01,,,,,,,fee schedule,1129.57,3565.78,
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3565.78,,,,,,,fee schedule,1129.57,3565.78,
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1129.57,,,,,,,fee schedule,1129.57,3565.78,
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1129.57,3565.78,APC
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1129.57,3565.78,APC
Small bowel endoscopy,44384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1129.57,3565.78,APC
Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,926.61,1667.9,
Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,926.61,1667.9,
Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,926.61,1667.9,
Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,926.61,1667.9,
Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,926.61,1667.9,APC
Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,926.61,1667.9,APC
Endoscopy of bowel pouch,44385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,926.61,1667.9,APC
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,926.61,1667.9,
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,926.61,1667.9,
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,926.61,1667.9,
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,926.61,1667.9,
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,926.61,1667.9,APC
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,926.61,1667.9,APC
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,926.61,1667.9,APC
Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,926.61,1667.9,
Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,926.61,1667.9,
Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,926.61,1667.9,
Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,926.61,1667.9,
Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,926.61,1667.9,APC
Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,926.61,1667.9,APC
Colonoscopy thru stoma spx,44388,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,926.61,1667.9,APC
Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy with biopsy,44389,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,1667.9,
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,1667.9,
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,1667.9,
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,1667.9,
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,1667.9,
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,1667.9,
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,1667.9,
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,1667.9,
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,849.34,1667.9,APC
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,849.34,1667.9,APC
Colonoscopy for foreign body,44390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,849.34,1667.9,APC
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy for bleeding,44391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy & polypectomy,44392,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/snare,44394,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy with ablation,44401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8567.09,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5616.58,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7012.16,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9852.15,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,1046.68,10888.32,APC
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,1046.68,10888.32,APC
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,1046.68,10888.32,APC
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/resection,44403,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/injection,44404,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/dilation,44405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/ultrasound,44406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,985.63,,,,,,,fee schedule,646.18,1667.9,
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,646.18,1667.9,
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,646.18,1667.9,
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.18,,,,,,,fee schedule,646.18,1667.9,
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,806.74,,,,,,,fee schedule,646.18,1667.9,
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,646.18,1667.9,
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1133.47,,,,,,,fee schedule,646.18,1667.9,
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,646.18,1667.9,
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,646.18,1667.9,APC
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,646.18,1667.9,APC
Colonoscopy w/decompression,44408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,646.18,1667.9,APC
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,821.49,,,,,,,fee schedule,538.57,1626.7,
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,538.57,1626.7,
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,538.57,1626.7,
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,538.57,,,,,,,fee schedule,538.57,1626.7,
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,672.39,,,,,,,fee schedule,538.57,1626.7,
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,538.57,1626.7,
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,944.71,,,,,,,fee schedule,538.57,1626.7,
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,538.57,1626.7,
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,538.57,1626.7,APC
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,538.57,1626.7,APC
Intro gastrointestinal tube,44500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,538.57,1626.7,APC
Suture small intestine,44602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,3841.61,6914.9,APC
Suture small intestine,44602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,3841.61,6914.9,APC
Suture small intestine,44602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,3841.61,6914.9,APC
Unlisted px small intestine,44799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Unlisted px small intestine,44799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Unlisted px small intestine,44799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7370.27,,,,,,,fee schedule,4831.95,11610.97,
Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4831.95,,,,,,,fee schedule,4831.95,11610.97,
Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6032.57,,,,,,,fee schedule,4831.95,11610.97,
Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8475.81,,,,,,,fee schedule,4831.95,11610.97,
Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,4831.95,11610.97,APC
Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,4831.95,11610.97,APC
Appendectomy,44950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,4831.95,11610.97,APC
Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7418.64,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7418.64,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8531.44,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7418.64,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscopy appendectomy,44970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc app,44979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc app,44979,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc app,44979,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2958.54,
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,849.34,2958.54,
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,849.34,2958.54,
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2958.54,
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2958.54,
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,849.34,2958.54,
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2958.54,
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,849.34,2958.54,
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2958.54,APC
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2958.54,APC
Drainage of pelvic abscess,45000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2958.54,APC
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2217.52,
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,849.34,2217.52,
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,849.34,2217.52,
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2217.52,
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2217.52,
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,849.34,2217.52,
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2217.52,
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,849.34,2217.52,
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2217.52,APC
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2217.52,APC
Drainage of rectal abscess,45005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2217.52,APC
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3716.46,,,,,,,fee schedule,1928.28,4978.22,
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2436.51,,,,,,,fee schedule,1928.28,4978.22,
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3041.92,,,,,,,fee schedule,1928.28,4978.22,
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,1928.28,4978.22,
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4273.93,,,,,,,fee schedule,1928.28,4978.22,
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1928.28,4978.22,APC
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1928.28,4978.22,APC
Drainage of rectal abscess,45020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1928.28,4978.22,APC
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7029.45,,,,,,,fee schedule,1928.28,8083.87,
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,8083.87,
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,1928.28,8083.87,
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4608.51,,,,,,,fee schedule,1928.28,8083.87,
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5753.6,,,,,,,fee schedule,1928.28,8083.87,
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,1928.28,8083.87,
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8083.87,,,,,,,fee schedule,1928.28,8083.87,
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,8083.87,
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1928.28,8083.87,APC
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1928.28,8083.87,APC
Biopsy of rectum,45100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1928.28,8083.87,APC
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Removal of anorectal lesion,45108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2958.54,
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,849.34,2958.54,
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,849.34,2958.54,
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2958.54,
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2958.54,
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,849.34,2958.54,
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2958.54,
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,849.34,2958.54,
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2958.54,APC
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2958.54,APC
Excision of rectal stricture,45150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2958.54,APC
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Excision of rectal lesion,45160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3982.24,,,,,,,fee schedule,2572.64,4978.22,
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2610.76,,,,,,,fee schedule,2572.64,4978.22,
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3259.46,,,,,,,fee schedule,2572.64,4978.22,
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2572.64,4978.22,
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4579.58,,,,,,,fee schedule,2572.64,4978.22,
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2572.64,4978.22,APC
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2572.64,4978.22,APC
Exc rect tum transanal part,45171,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2572.64,4978.22,APC
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,1995.25,4978.22,
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Exc rect tum transanal full,45172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Destruction rectal tumor,45190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.11,,,,,,,fee schedule,227.11,1667.9,
Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.11,,,,,,,fee schedule,227.11,1667.9,
Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.18,,,,,,,fee schedule,227.11,1667.9,
Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.11,,,,,,,fee schedule,227.11,1667.9,
Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,227.11,1667.9,APC
Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,227.11,1667.9,APC
Proctosigmoidoscopy dx,45300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,227.11,1667.9,APC
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2526.14,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy fb,45307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1096.45,4978.22,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,1096.45,4978.22,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,1096.45,4978.22,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1096.45,4978.22,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1096.45,4978.22,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,1096.45,4978.22,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1096.45,4978.22,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,1096.45,4978.22,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1096.45,4978.22,APC
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1096.45,4978.22,APC
Proctosigmoidoscopy removal,45308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1096.45,4978.22,APC
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy removal,45309,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy removal,45315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2526.14,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2526.14,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4786.67,,,,,,,fee schedule,3138.14,10888.32,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3175.17,,,,,,,fee schedule,3138.14,10888.32,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3175.17,,,,,,,fee schedule,3138.14,10888.32,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3138.14,,,,,,,fee schedule,3138.14,10888.32,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3917.89,,,,,,,fee schedule,3138.14,10888.32,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3651.45,,,,,,,fee schedule,3138.14,10888.32,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5504.67,,,,,,,fee schedule,3138.14,10888.32,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3175.17,,,,,,,fee schedule,3138.14,10888.32,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,3138.14,10888.32,APC
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,3138.14,10888.32,APC
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,3138.14,10888.32,APC
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,243.64,,,,,,,fee schedule,243.64,1667.9,
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,243.64,,,,,,,fee schedule,243.64,1667.9,
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,280.19,,,,,,,fee schedule,243.64,1667.9,
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,243.64,,,,,,,fee schedule,243.64,1667.9,
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,243.64,1667.9,APC
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,243.64,1667.9,APC
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,243.64,1667.9,APC
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,757.16,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,757.16,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1268.99,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,757.16,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,658.4,,,,,,,fee schedule,658.4,1667.9,
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,658.4,1667.9,APC
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,849.34,1667.9,APC
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,849.34,1667.9,APC
Sigmoidoscopy & decompress,45337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,849.34,1667.9,APC
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1268.99,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1103.47,2146.21,APC
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1268.99,,,,,,,fee schedule,1103.47,2146.21,
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1103.47,2146.21,APC
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1103.47,2146.21,APC
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,1667.9,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,849.34,1667.9,APC
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,849.34,1667.9,APC
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,849.34,1667.9,APC
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1268.99,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1103.47,2146.21,APC
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7401.33,,,,,,,fee schedule,1096.45,10888.32,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,1096.45,10888.32,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,1096.45,10888.32,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4852.31,,,,,,,fee schedule,1096.45,10888.32,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6057.99,,,,,,,fee schedule,1096.45,10888.32,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,1096.45,10888.32,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8511.53,,,,,,,fee schedule,1096.45,10888.32,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,1096.45,10888.32,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,1096.45,10888.32,APC
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,1096.45,10888.32,APC
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,1096.45,10888.32,APC
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,4978.22,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,4978.22,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,4978.22,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,4978.22,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,4978.22,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,4978.22,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,4978.22,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,4978.22,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,849.34,4978.22,APC
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,849.34,4978.22,APC
Sigmoidoscopy w/resection,45349,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,849.34,4978.22,APC
Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1268.99,,,,,,,fee schedule,1103.47,2146.21,
Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1103.47,2146.21,APC
Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1103.47,2146.21,APC
Sgmdsc w/band ligation,45350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1103.47,2146.21,APC
Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1076.73,,,,,,,fee schedule,926.61,1667.9,
Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1076.73,,,,,,,fee schedule,926.61,1667.9,
Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1238.24,,,,,,,fee schedule,926.61,1667.9,
Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1076.73,,,,,,,fee schedule,926.61,1667.9,
Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,926.61,1667.9,APC
Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,926.61,1667.9,APC
Diagnostic colonoscopy,45378,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,926.61,1667.9,APC
Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1282.38,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/fb removal,45379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1282.38,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy and biopsy,45380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1282.38,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy submucous njx,45381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/control bleed,45382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1282.38,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/lesion removal,45384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1282.38,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1115.11,,,,,,,fee schedule,1115.11,2146.21,
Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/lesion removal,45385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1115.11,2146.21,APC
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/ablation,45388,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7215.05,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4730.19,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5905.52,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8297.31,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,1046.68,10888.32,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6351.52,,,,,,,fee schedule,1046.68,10888.32,APC
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6049.07,,,,,,,fee schedule,1046.68,10888.32,APC
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10888.32,,,,,,,fee schedule,1046.68,10888.32,APC
Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,4978.22,
Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,1053.4,4978.22,
Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,1053.4,4978.22,
Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,4978.22,
Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1053.4,4978.22,APC
Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1053.4,4978.22,APC
Colonoscopy w/resection,45390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1053.4,4978.22,APC
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1076.73,,,,,,,fee schedule,1076.73,2146.21,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1094.38,,,,,,,fee schedule,1076.73,2146.21,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1076.73,,,,,,,fee schedule,1076.73,2146.21,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1094.38,,,,,,,fee schedule,1076.73,2146.21,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1238.24,,,,,,,fee schedule,1076.73,2146.21,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1258.54,,,,,,,fee schedule,1076.73,2146.21,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1076.73,,,,,,,fee schedule,1076.73,2146.21,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1094.38,,,,,,,fee schedule,1076.73,2146.21,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1076.73,2146.21,APC
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1076.73,2146.21,APC
Colonoscopy w/endoscope us,45391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1076.73,2146.21,APC
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1203.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1046.68,,,,,,,fee schedule,849.34,2146.21,
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/decompression,45393,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.41,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.4,,,,,,,fee schedule,1053.4,2146.21,
Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1053.4,2146.21,APC
Colonoscopy w/band ligation,45398,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1053.4,2146.21,APC
Unlisted procedure colon,45399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,926.61,1667.9,APC
Unlisted procedure colon,45399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,926.61,1667.9,APC
Unlisted procedure colon,45399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,926.61,1667.9,APC
Laparoscope proc rectum,45499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc rectum,45499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc rectum,45499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of rectum,45500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6388.47,,,,,,,fee schedule,2765.68,7346.74,
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,2765.68,7346.74,
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,2765.68,7346.74,
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4188.28,,,,,,,fee schedule,2765.68,7346.74,
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5228.96,,,,,,,fee schedule,2765.68,7346.74,
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,2765.68,7346.74,
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7346.74,,,,,,,fee schedule,2765.68,7346.74,
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,2765.68,7346.74,
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2765.68,7346.74,APC
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2765.68,7346.74,APC
Repair of rectum,45505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2765.68,7346.74,APC
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,998.54,,,,,,,fee schedule,193.65,1667.9,
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,1667.9,
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,1667.9,
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,654.64,,,,,,,fee schedule,193.65,1667.9,
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,817.3,,,,,,,fee schedule,193.65,1667.9,
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,1667.9,
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1148.32,,,,,,,fee schedule,193.65,1667.9,
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,1667.9,
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,193.65,1667.9,APC
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,193.65,1667.9,APC
Treatment of rectal prolapse,45520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,193.65,1667.9,APC
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,1995.25,4978.22,
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Correct rectal prolapse,45541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of rectocele,45560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,985.63,,,,,,,fee schedule,586.38,1667.9,
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,586.38,,,,,,,fee schedule,586.38,1667.9,
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,586.38,,,,,,,fee schedule,586.38,1667.9,
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.18,,,,,,,fee schedule,586.38,1667.9,
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,806.74,,,,,,,fee schedule,586.38,1667.9,
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,674.34,,,,,,,fee schedule,586.38,1667.9,
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1133.47,,,,,,,fee schedule,586.38,1667.9,
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,586.38,,,,,,,fee schedule,586.38,1667.9,
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,586.38,1667.9,APC
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,586.38,1667.9,APC
Reduction of rectal prolapse,45900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,586.38,1667.9,APC
Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2231.75,,,,,,,fee schedule,1192.34,2231.75,
Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1192.34,2231.75,APC
Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1192.34,2231.75,APC
Dilation of anal sphincter,45905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1192.34,2231.75,APC
Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2231.75,,,,,,,fee schedule,1192.34,2231.75,
Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1192.34,2231.75,APC
Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1192.34,2231.75,APC
Dilation of rectal narrowing,45910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1192.34,2231.75,APC
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2217.52,
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,849.34,2217.52,
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,849.34,2217.52,
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2217.52,
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2217.52,
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,849.34,2217.52,
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2217.52,
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,849.34,2217.52,
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2217.52,APC
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2217.52,APC
Remove rectal obstruction,45915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2217.52,APC
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4384.46,,,,,,,fee schedule,1928.28,5042.13,
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,5042.13,
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,1928.28,5042.13,
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2874.45,,,,,,,fee schedule,1928.28,5042.13,
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3588.68,,,,,,,fee schedule,1928.28,5042.13,
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,1928.28,5042.13,
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5042.13,,,,,,,fee schedule,1928.28,5042.13,
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,5042.13,
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1928.28,5042.13,APC
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1928.28,5042.13,APC
Surg dx exam anorectal,45990,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1928.28,5042.13,APC
Rectum surgery procedure,45999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,926.61,1667.9,APC
Rectum surgery procedure,45999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,926.61,1667.9,APC
Rectum surgery procedure,45999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,926.61,1667.9,APC
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4161.79,,,,,,,fee schedule,2572.64,4978.22,
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2728.47,,,,,,,fee schedule,2572.64,4978.22,
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3406.43,,,,,,,fee schedule,2572.64,4978.22,
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2572.64,4978.22,
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4786.06,,,,,,,fee schedule,2572.64,4978.22,
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2572.64,4978.22,APC
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2572.64,4978.22,APC
Placement of seton,46020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2572.64,4978.22,APC
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,586.38,2146.21,
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,586.38,,,,,,,fee schedule,586.38,2146.21,
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,586.38,,,,,,,fee schedule,586.38,2146.21,
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,586.38,2146.21,
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,586.38,2146.21,
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,674.34,,,,,,,fee schedule,586.38,2146.21,
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,586.38,2146.21,
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,586.38,,,,,,,fee schedule,586.38,2146.21,
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,586.38,2146.21,APC
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,586.38,2146.21,APC
Removal of rectal marker,46030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,586.38,2146.21,APC
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3461.24,,,,,,,fee schedule,1176.66,3980.43,
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1176.66,,,,,,,fee schedule,1176.66,3980.43,
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1176.66,,,,,,,fee schedule,1176.66,3980.43,
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2269.19,,,,,,,fee schedule,1176.66,3980.43,
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2833.02,,,,,,,fee schedule,1176.66,3980.43,
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1353.16,,,,,,,fee schedule,1176.66,3980.43,
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3980.43,,,,,,,fee schedule,1176.66,3980.43,
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1176.66,,,,,,,fee schedule,1176.66,3980.43,
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1176.66,3980.43,APC
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1176.66,3980.43,APC
Incision of rectal abscess,46040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1176.66,3980.43,APC
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Incision of rectal abscess,46045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2816.05,,,,,,,fee schedule,586.38,3238.46,
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,586.38,,,,,,,fee schedule,586.38,3238.46,
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,586.38,,,,,,,fee schedule,586.38,3238.46,
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1846.2,,,,,,,fee schedule,586.38,3238.46,
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2304.94,,,,,,,fee schedule,586.38,3238.46,
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,674.34,,,,,,,fee schedule,586.38,3238.46,
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3238.46,,,,,,,fee schedule,586.38,3238.46,
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,586.38,,,,,,,fee schedule,586.38,3238.46,
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,586.38,3238.46,APC
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,586.38,3238.46,APC
Incision of anal abscess,46050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,586.38,3238.46,APC
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4004.33,,,,,,,fee schedule,1928.28,4978.22,
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2625.24,,,,,,,fee schedule,1928.28,4978.22,
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3277.54,,,,,,,fee schedule,1928.28,4978.22,
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,1928.28,4978.22,
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4604.98,,,,,,,fee schedule,1928.28,4978.22,
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1928.28,4978.22,APC
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1928.28,4978.22,APC
Incision of rectal abscess,46060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1928.28,4978.22,APC
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1928.28,4978.22,APC
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1928.28,4978.22,APC
Incision of anal septum,46070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1928.28,4978.22,APC
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1928.28,4978.22,APC
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1928.28,4978.22,APC
Incision of anal sphincter,46080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1928.28,4978.22,APC
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,318.91,,,,,,,fee schedule,209.08,448.11,
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.29,,,,,,,fee schedule,209.08,448.11,
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.29,,,,,,,fee schedule,209.08,448.11,
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,209.08,,,,,,,fee schedule,209.08,448.11,
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.03,,,,,,,fee schedule,209.08,448.11,
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.78,,,,,,,fee schedule,209.08,448.11,
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,366.75,,,,,,,fee schedule,209.08,448.11,
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.29,,,,,,,fee schedule,209.08,448.11,
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,209.08,448.11,APC
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,209.08,448.11,APC
Incise external hemorrhoid,46083,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,209.08,448.11,APC
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Removal of anal fissure,46200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2231.75,,,,,,,fee schedule,1192.34,2231.75,
Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1940.65,,,,,,,fee schedule,1192.34,2231.75,
Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1192.34,2231.75,APC
Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1192.34,2231.75,APC
Excise anal ext tag/papilla,46220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1192.34,2231.75,APC
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,435.1,,,,,,,fee schedule,424.23,1667.9,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,424.23,,,,,,,fee schedule,424.23,1667.9,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,435.1,,,,,,,fee schedule,424.23,1667.9,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,424.23,,,,,,,fee schedule,424.23,1667.9,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,500.37,,,,,,,fee schedule,424.23,1667.9,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,487.86,,,,,,,fee schedule,424.23,1667.9,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,435.1,,,,,,,fee schedule,424.23,1667.9,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,424.23,,,,,,,fee schedule,424.23,1667.9,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,424.23,1667.9,APC
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,424.23,1667.9,APC
Ligation of hemorrhoid(s),46221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,424.23,1667.9,APC
Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1940.65,,,,,,,fee schedule,1940.65,4978.22,
Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1940.65,,,,,,,fee schedule,1940.65,4978.22,
Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2231.75,,,,,,,fee schedule,1940.65,4978.22,
Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1940.65,,,,,,,fee schedule,1940.65,4978.22,
Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1940.65,4978.22,APC
Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1940.65,4978.22,APC
Removal of anal tags,46230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1940.65,4978.22,APC
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Remove ext hem groups 2+,46250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3410.2,,,,,,,fee schedule,2235.73,4978.22,
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2235.73,4978.22,
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2235.73,4978.22,
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2235.73,,,,,,,fee schedule,2235.73,4978.22,
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2791.25,,,,,,,fee schedule,2235.73,4978.22,
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2235.73,4978.22,
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3921.73,,,,,,,fee schedule,2235.73,4978.22,
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2235.73,4978.22,
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2235.73,4978.22,APC
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2235.73,4978.22,APC
Remove int/ext hem 1 group,46255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2235.73,4978.22,APC
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3806.28,,,,,,,fee schedule,2495.4,4978.22,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2495.4,4978.22,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2495.4,4978.22,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2495.4,,,,,,,fee schedule,2495.4,4978.22,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3115.44,,,,,,,fee schedule,2495.4,4978.22,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2495.4,4978.22,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4377.22,,,,,,,fee schedule,2495.4,4978.22,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2495.4,4978.22,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2495.4,4978.22,APC
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2495.4,4978.22,APC
Remove in/ex hem groups 2+,46260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2495.4,4978.22,APC
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4598.45,,,,,,,fee schedule,2572.64,5288.22,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5288.22,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2572.64,5288.22,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3014.74,,,,,,,fee schedule,2572.64,5288.22,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3763.83,,,,,,,fee schedule,2572.64,5288.22,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2572.64,5288.22,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5288.22,,,,,,,fee schedule,2572.64,5288.22,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5288.22,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2572.64,5288.22,APC
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2572.64,5288.22,APC
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2572.64,5288.22,APC
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4030.11,,,,,,,fee schedule,2572.64,4978.22,
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2642.14,,,,,,,fee schedule,2572.64,4978.22,
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3298.65,,,,,,,fee schedule,2572.64,4978.22,
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2572.64,4978.22,
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4634.63,,,,,,,fee schedule,2572.64,4978.22,
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,4978.22,
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2572.64,4978.22,APC
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2572.64,4978.22,APC
Remove anal fist subq,46270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2572.64,4978.22,APC
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4384.46,,,,,,,fee schedule,2572.64,5042.13,
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5042.13,
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2572.64,5042.13,
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2874.45,,,,,,,fee schedule,2572.64,5042.13,
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3588.68,,,,,,,fee schedule,2572.64,5042.13,
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2572.64,5042.13,
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5042.13,,,,,,,fee schedule,2572.64,5042.13,
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5042.13,
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2572.64,5042.13,APC
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2572.64,5042.13,APC
Remove anal fist inter,46275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2572.64,5042.13,APC
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4607.11,,,,,,,fee schedule,2572.64,5298.18,
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5298.18,
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2572.64,5298.18,
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3020.42,,,,,,,fee schedule,2572.64,5298.18,
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3770.92,,,,,,,fee schedule,2572.64,5298.18,
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2572.64,5298.18,
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5298.18,,,,,,,fee schedule,2572.64,5298.18,
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5298.18,
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2572.64,5298.18,APC
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2572.64,5298.18,APC
Remove anal fist complex,46280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2572.64,5298.18,APC
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Remove anal fist 2 stage,46285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7724.46,,,,,,,fee schedule,2765.68,8883.13,
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,2765.68,8883.13,
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,2765.68,8883.13,
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5064.16,,,,,,,fee schedule,2765.68,8883.13,
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6322.47,,,,,,,fee schedule,2765.68,8883.13,
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,2765.68,8883.13,
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8883.13,,,,,,,fee schedule,2765.68,8883.13,
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,2765.68,8883.13,
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2765.68,8883.13,APC
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2765.68,8883.13,APC
Repair anal fistula,46288,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2765.68,8883.13,APC
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.32,,,,,,,fee schedule,212.62,2146.21,
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,286.18,,,,,,,fee schedule,212.62,2146.21,
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.18,,,,,,,fee schedule,212.62,2146.21,
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.62,,,,,,,fee schedule,212.62,2146.21,
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.46,,,,,,,fee schedule,212.62,2146.21,
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,329.11,,,,,,,fee schedule,212.62,2146.21,
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,372.97,,,,,,,fee schedule,212.62,2146.21,
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,286.18,,,,,,,fee schedule,212.62,2146.21,
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,212.62,2146.21,APC
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,212.62,2146.21,APC
Removal of hemorrhoid clot,46320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,212.62,2146.21,APC
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,363.52,,,,,,,fee schedule,238.32,1667.9,
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,422.82,,,,,,,fee schedule,238.32,1667.9,
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,422.82,,,,,,,fee schedule,238.32,1667.9,
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,238.32,,,,,,,fee schedule,238.32,1667.9,
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,297.54,,,,,,,fee schedule,238.32,1667.9,
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.24,,,,,,,fee schedule,238.32,1667.9,
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,418.05,,,,,,,fee schedule,238.32,1667.9,
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,422.82,,,,,,,fee schedule,238.32,1667.9,
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,238.32,1667.9,APC
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,238.32,1667.9,APC
Injection into hemorrhoid(s),46500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,238.32,1667.9,APC
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,1192.34,4572.08,
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,1192.34,4572.08,
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,1192.34,4572.08,
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,1192.34,4572.08,
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,1192.34,4572.08,
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,1192.34,4572.08,
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,1192.34,4572.08,
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,1192.34,4572.08,
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1192.34,4572.08,APC
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1192.34,4572.08,APC
Chemodenervation anal musc,46505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1192.34,4572.08,APC
Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Diagnostic anoscopy spx,46600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,801.21,
Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,801.21,
Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,801.21,
Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,801.21,
Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,53.47,801.21,APC
Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,53.47,801.21,APC
Diagnostic anoscopy,46601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,53.47,801.21,APC
Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1268.99,,,,,,,fee schedule,1103.47,2146.21,
Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.47,,,,,,,fee schedule,1103.47,2146.21,
Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,1103.47,2146.21,APC
Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,1103.47,2146.21,APC
Anoscopy and dilation,46604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,1103.47,2146.21,APC
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.84,,,,,,,fee schedule,323.76,2146.21,
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,435.79,,,,,,,fee schedule,323.76,2146.21,
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,435.79,,,,,,,fee schedule,323.76,2146.21,
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,323.76,,,,,,,fee schedule,323.76,2146.21,
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,404.21,,,,,,,fee schedule,323.76,2146.21,
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.16,,,,,,,fee schedule,323.76,2146.21,
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,567.92,,,,,,,fee schedule,323.76,2146.21,
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,435.79,,,,,,,fee schedule,323.76,2146.21,
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,323.76,2146.21,APC
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,323.76,2146.21,APC
Anoscopy and biopsy,46606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,323.76,2146.21,APC
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2146.21,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,849.34,2146.21,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2146.21,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2146.21,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,849.34,2146.21,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2146.21,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,849.34,2146.21,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2146.21,APC
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2146.21,APC
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2146.21,APC
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,985.63,,,,,,,fee schedule,646.18,1667.9,
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,646.18,1667.9,
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,646.18,1667.9,
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.18,,,,,,,fee schedule,646.18,1667.9,
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,806.74,,,,,,,fee schedule,646.18,1667.9,
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,646.18,1667.9,
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1133.47,,,,,,,fee schedule,646.18,1667.9,
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,646.18,1667.9,
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,646.18,1667.9,APC
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,646.18,1667.9,APC
Anoscopy remove for body,46608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,646.18,1667.9,APC
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2526.14,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Anoscopy remove lesion,46610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,985.63,,,,,,,fee schedule,646.18,1667.9,
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.45,,,,,,,fee schedule,646.18,1667.9,
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1096.45,,,,,,,fee schedule,646.18,1667.9,
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.18,,,,,,,fee schedule,646.18,1667.9,
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,806.74,,,,,,,fee schedule,646.18,1667.9,
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1260.92,,,,,,,fee schedule,646.18,1667.9,
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1133.47,,,,,,,fee schedule,646.18,1667.9,
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1096.45,,,,,,,fee schedule,646.18,1667.9,
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,646.18,1667.9,APC
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,646.18,1667.9,APC
Anoscopy,46611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,646.18,1667.9,APC
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2526.14,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Anoscopy remove lesions,46612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,244.94,,,,,,,fee schedule,160.58,2146.21,
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.75,,,,,,,fee schedule,160.58,2146.21,
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.75,,,,,,,fee schedule,160.58,2146.21,
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,160.58,,,,,,,fee schedule,160.58,2146.21,
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,200.48,,,,,,,fee schedule,160.58,2146.21,
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,251.56,,,,,,,fee schedule,160.58,2146.21,
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,281.68,,,,,,,fee schedule,160.58,2146.21,
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,218.75,,,,,,,fee schedule,160.58,2146.21,
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,160.58,2146.21,APC
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,160.58,2146.21,APC
Anoscopy control bleeding,46614,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,160.58,2146.21,APC
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2526.14,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2196.64,,,,,,,fee schedule,1995.25,4978.22,
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Anoscopy,46615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5052.46,,,,,,,fee schedule,2572.64,5810.33,
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5810.33,
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2572.64,5810.33,
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3312.39,,,,,,,fee schedule,2572.64,5810.33,
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4135.44,,,,,,,fee schedule,2572.64,5810.33,
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2572.64,5810.33,
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5810.33,,,,,,,fee schedule,2572.64,5810.33,
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5810.33,
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2572.64,5810.33,APC
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2572.64,5810.33,APC
Repair of anal stricture,46700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2572.64,5810.33,APC
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Repr of anal fistula w/glue,46706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,1995.25,4978.22,
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Repair anorectal fist w/plug,46707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal sphincter,46750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Reconstruction of anus,46753,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1928.28,4978.22,
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1928.28,4978.22,
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1928.28,4978.22,
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,1928.28,4978.22,
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1928.28,4978.22,
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,1928.28,4978.22,
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1928.28,4978.22,APC
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1928.28,4978.22,APC
Removal of suture from anus,46754,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1928.28,4978.22,APC
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal sphincter,46760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Repair of anal sphincter,46761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.96,,,,,,,fee schedule,283.19,729.1,
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.19,,,,,,,fee schedule,283.19,729.1,
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.19,,,,,,,fee schedule,283.19,729.1,
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.19,,,,,,,fee schedule,283.19,729.1,
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.56,,,,,,,fee schedule,283.19,729.1,
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.47,,,,,,,fee schedule,283.19,729.1,
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.75,,,,,,,fee schedule,283.19,729.1,
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.19,,,,,,,fee schedule,283.19,729.1,
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,283.19,729.1,APC
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,283.19,729.1,APC
Destruction anal lesion(s),46900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,283.19,729.1,APC
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.73,,,,,,,fee schedule,326.97,3700.55,
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434.31,,,,,,,fee schedule,326.97,3700.55,
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,434.31,,,,,,,fee schedule,326.97,3700.55,
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.97,,,,,,,fee schedule,326.97,3700.55,
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408.21,,,,,,,fee schedule,326.97,3700.55,
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,499.46,,,,,,,fee schedule,326.97,3700.55,
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,573.54,,,,,,,fee schedule,326.97,3700.55,
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,434.31,,,,,,,fee schedule,326.97,3700.55,
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,326.97,3700.55,APC
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,326.97,3700.55,APC
Destruction anal lesion(s),46910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,326.97,3700.55,APC
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.03,,,,,,,fee schedule,148.19,359.84,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,148.19,359.84,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.19,,,,,,,fee schedule,148.19,359.84,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.01,,,,,,,fee schedule,148.19,359.84,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,148.19,359.84,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.93,,,,,,,fee schedule,148.19,359.84,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,148.19,359.84,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,148.19,359.84,APC
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,148.19,359.84,APC
Cryosurgery anal lesion(s),46916,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,148.19,359.84,APC
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Laser surgery anal lesions,46917,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4384.46,,,,,,,fee schedule,2572.64,5042.13,
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5042.13,
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,2572.64,5042.13,
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2874.45,,,,,,,fee schedule,2572.64,5042.13,
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3588.68,,,,,,,fee schedule,2572.64,5042.13,
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,2572.64,5042.13,
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5042.13,,,,,,,fee schedule,2572.64,5042.13,
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,2572.64,5042.13,
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2572.64,5042.13,APC
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2572.64,5042.13,APC
Excision of anal lesion(s),46922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2572.64,5042.13,APC
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.54,,,,,,,fee schedule,1995.25,4978.22,
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.64,,,,,,,fee schedule,1995.25,4978.22,
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Destruction anal lesion(s),46924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.86,,,,,,,fee schedule,259.53,2146.21,
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,351.91,,,,,,,fee schedule,259.53,2146.21,
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,351.91,,,,,,,fee schedule,259.53,2146.21,
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.53,,,,,,,fee schedule,259.53,2146.21,
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.01,,,,,,,fee schedule,259.53,2146.21,
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,404.7,,,,,,,fee schedule,259.53,2146.21,
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.24,,,,,,,fee schedule,259.53,2146.21,
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,351.91,,,,,,,fee schedule,259.53,2146.21,
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,259.53,2146.21,APC
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,259.53,2146.21,APC
Destroy internal hemorrhoids,46930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,259.53,2146.21,APC
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,373.33,,,,,,,fee schedule,244.76,4978.22,
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.77,,,,,,,fee schedule,244.76,4978.22,
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,333.77,,,,,,,fee schedule,244.76,4978.22,
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,244.76,,,,,,,fee schedule,244.76,4978.22,
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,305.57,,,,,,,fee schedule,244.76,4978.22,
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.84,,,,,,,fee schedule,244.76,4978.22,
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,429.33,,,,,,,fee schedule,244.76,4978.22,
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.77,,,,,,,fee schedule,244.76,4978.22,
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,244.76,4978.22,APC
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,244.76,4978.22,APC
Treatment of anal fissure,46940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,244.76,4978.22,APC
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,370.37,,,,,,,fee schedule,242.81,1667.9,
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.01,,,,,,,fee schedule,242.81,1667.9,
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.01,,,,,,,fee schedule,242.81,1667.9,
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,242.81,,,,,,,fee schedule,242.81,1667.9,
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,303.15,,,,,,,fee schedule,242.81,1667.9,
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,381.81,,,,,,,fee schedule,242.81,1667.9,
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,425.93,,,,,,,fee schedule,242.81,1667.9,
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.01,,,,,,,fee schedule,242.81,1667.9,
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,242.81,1667.9,APC
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,242.81,1667.9,APC
Treatment of anal fissure,46942,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,242.81,1667.9,APC
Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,541.26,,,,,,,fee schedule,541.26,4978.22,
Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,541.26,,,,,,,fee schedule,541.26,4978.22,
Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,622.45,,,,,,,fee schedule,541.26,4978.22,
Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,541.26,,,,,,,fee schedule,541.26,4978.22,
Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,541.26,4978.22,APC
Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,541.26,4978.22,APC
Remove by ligat int hem grp,46945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,541.26,4978.22,APC
Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2589.14,,,,,,,fee schedule,2589.14,4978.22,
Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2589.14,,,,,,,fee schedule,2589.14,4978.22,
Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2977.51,,,,,,,fee schedule,2589.14,4978.22,
Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2589.14,,,,,,,fee schedule,2589.14,4978.22,
Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2589.14,4978.22,APC
Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2589.14,4978.22,APC
Remove by ligat int hem grps,46946,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2589.14,4978.22,APC
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.4,,,,,,,fee schedule,1995.25,4978.22,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.25,,,,,,,fee schedule,1995.25,4978.22,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.02,,,,,,,fee schedule,1995.25,4978.22,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3963.76,,,,,,,fee schedule,1995.25,4978.22,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.91,,,,,,,fee schedule,1995.25,4978.22,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3446.75,,,,,,,fee schedule,1995.25,4978.22,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,1995.25,4978.22,APC
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,1995.25,4978.22,APC
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,1995.25,4978.22,APC
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4553.55,,,,,,,fee schedule,2765.68,5236.58,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4553.55,,,,,,,fee schedule,2765.68,5236.58,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4553.55,,,,,,,fee schedule,2765.68,5236.58,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2985.31,,,,,,,fee schedule,2765.68,5236.58,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3727.08,,,,,,,fee schedule,2765.68,5236.58,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5236.58,,,,,,,fee schedule,2765.68,5236.58,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2765.68,5236.58,APC
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2765.68,5236.58,APC
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2765.68,5236.58,APC
Anus surgery procedure,46999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,926.61,1667.9,APC
Anus surgery procedure,46999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,926.61,1667.9,APC
Anus surgery procedure,46999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,926.61,1667.9,APC
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1414.2,,,,,,,fee schedule,927.15,2962.18,
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,927.15,2962.18,
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,927.15,2962.18,
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,927.15,,,,,,,fee schedule,927.15,2962.18,
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1157.52,,,,,,,fee schedule,927.15,2962.18,
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,927.15,2962.18,
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1626.33,,,,,,,fee schedule,927.15,2962.18,
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,927.15,2962.18,
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,927.15,2962.18,APC
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,927.15,2962.18,APC
Needle biopsy of liver,47000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,927.15,2962.18,APC
Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10423.72,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6833.79,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8531.81,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11987.28,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,6833.79,19064.9,APC
Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,6833.79,19064.9,APC
Laparo ablate liver tumor rf,47370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,6833.79,19064.9,APC
Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10423.72,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6833.79,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8531.81,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11987.28,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,6833.79,19064.9,APC
Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,6833.79,19064.9,APC
Laparo ablate liver cryosurg,47371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,6833.79,19064.9,APC
Laparoscope procedure liver,47379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope procedure liver,47379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope procedure liver,47379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10271.97,,,,,,,fee schedule,5427.63,11812.77,
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5427.63,,,,,,,fee schedule,5427.63,11812.77,
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5427.63,,,,,,,fee schedule,5427.63,11812.77,
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6734.3,,,,,,,fee schedule,5427.63,11812.77,
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8407.61,,,,,,,fee schedule,5427.63,11812.77,
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6241.77,,,,,,,fee schedule,5427.63,11812.77,
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11812.77,,,,,,,fee schedule,5427.63,11812.77,
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5427.63,,,,,,,fee schedule,5427.63,11812.77,
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5427.63,11812.77,APC
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5427.63,11812.77,APC
Percut ablate liver rf,47382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5427.63,11812.77,APC
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,19064.9,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5427.63,,,,,,,fee schedule,3651.57,19064.9,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5427.63,,,,,,,fee schedule,3651.57,19064.9,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,19064.9,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,19064.9,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6241.77,,,,,,,fee schedule,3651.57,19064.9,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,19064.9,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5427.63,,,,,,,fee schedule,3651.57,19064.9,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,3651.57,19064.9,APC
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,3651.57,19064.9,APC
Perq abltj lvr cryoablation,47383,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,3651.57,19064.9,APC
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Liver surgery procedure,47399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,705.59,1270.05,APC
Liver surgery procedure,47399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,705.59,1270.05,APC
Liver surgery procedure,47399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,705.59,1270.05,APC
Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4281.37,,,,,,,fee schedule,2806.87,6421.55,
Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2806.87,,,,,,,fee schedule,2806.87,6421.55,
Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3504.3,,,,,,,fee schedule,2806.87,6421.55,
Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4923.58,,,,,,,fee schedule,2806.87,6421.55,
Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2806.87,6421.55,APC
Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2806.87,6421.55,APC
Incision of gallbladder,47490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2806.87,6421.55,APC
Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1086.89,,,,,,,fee schedule,712.57,6421.55,
Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,712.57,,,,,,,fee schedule,712.57,6421.55,
Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,889.62,,,,,,,fee schedule,712.57,6421.55,
Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1249.92,,,,,,,fee schedule,712.57,6421.55,
Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,712.57,6421.55,APC
Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,712.57,6421.55,APC
Injection for cholangiogram,47531,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,712.57,6421.55,APC
Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5046.1,,,,,,,fee schedule,3308.22,6421.55,
Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3308.22,,,,,,,fee schedule,3308.22,6421.55,
Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4130.23,,,,,,,fee schedule,3308.22,6421.55,
Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5803.02,,,,,,,fee schedule,3308.22,6421.55,
Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3308.22,6421.55,APC
Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3308.22,6421.55,APC
Injection for cholangiogram,47532,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3308.22,6421.55,APC
Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Plmt biliary drainage cath,47533,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1525.46,,,,,,,fee schedule,1000.09,6421.55,
Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1000.09,,,,,,,fee schedule,1000.09,6421.55,
Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1248.59,,,,,,,fee schedule,1000.09,6421.55,
Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1754.28,,,,,,,fee schedule,1000.09,6421.55,
Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,1000.09,6421.55,APC
Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,1000.09,6421.55,APC
Plmt biliary drainage cath,47534,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,1000.09,6421.55,APC
Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Conversion ext bil drg cath,47535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5046.1,,,,,,,fee schedule,3308.22,6421.55,
Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3308.22,,,,,,,fee schedule,3308.22,6421.55,
Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4130.23,,,,,,,fee schedule,3308.22,6421.55,
Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5803.02,,,,,,,fee schedule,3308.22,6421.55,
Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3308.22,6421.55,APC
Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3308.22,6421.55,APC
Exchange biliary drg cath,47536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3308.22,6421.55,APC
Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.04,,,,,,,fee schedule,677.26,1626.7,
Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.26,,,,,,,fee schedule,677.26,1626.7,
Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.54,,,,,,,fee schedule,677.26,1626.7,
Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188,,,,,,,fee schedule,677.26,1626.7,
Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,677.26,1626.7,APC
Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,677.26,1626.7,APC
Removal biliary drg cath,47537,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,677.26,1626.7,APC
Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Perq plmt bile duct stent,47538,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Perq plmt bile duct stent,47539,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Perq plmt bile duct stent,47540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,11610.97,
Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,11610.97,
Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,11610.97,
Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,11610.97,
Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2604.09,11610.97,APC
Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2604.09,11610.97,APC
Plmt access bil tree sm bwl,47541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2604.09,11610.97,APC
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2429.62,11610.97,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2429.62,,,,,,,fee schedule,2429.62,11610.97,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2429.62,,,,,,,fee schedule,2429.62,11610.97,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2429.62,11610.97,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2429.62,11610.97,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2794.06,,,,,,,fee schedule,2429.62,11610.97,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2429.62,11610.97,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2429.62,,,,,,,fee schedule,2429.62,11610.97,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2429.62,11610.97,APC
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2429.62,11610.97,APC
Biliary endo perq dx w/speci,47552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2429.62,11610.97,APC
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,11610.97,
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5427.63,,,,,,,fee schedule,2604.09,11610.97,
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5427.63,,,,,,,fee schedule,2604.09,11610.97,
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,11610.97,
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,11610.97,
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6241.77,,,,,,,fee schedule,2604.09,11610.97,
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,11610.97,
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5427.63,,,,,,,fee schedule,2604.09,11610.97,
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2604.09,11610.97,APC
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2604.09,11610.97,APC
Biliary endoscopy thru skin,47553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2604.09,11610.97,APC
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,2429.62,19064.9,
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2429.62,,,,,,,fee schedule,2429.62,19064.9,
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2429.62,,,,,,,fee schedule,2429.62,19064.9,
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,2429.62,19064.9,
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,2429.62,19064.9,
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2794.06,,,,,,,fee schedule,2429.62,19064.9,
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,2429.62,19064.9,
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2429.62,,,,,,,fee schedule,2429.62,19064.9,
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,2429.62,19064.9,APC
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,2429.62,19064.9,APC
Biliary endoscopy thru skin,47554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,2429.62,19064.9,APC
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2429.62,11610.97,
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2429.62,,,,,,,fee schedule,2429.62,11610.97,
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2429.62,,,,,,,fee schedule,2429.62,11610.97,
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2429.62,11610.97,
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2429.62,11610.97,
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2794.06,,,,,,,fee schedule,2429.62,11610.97,
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2429.62,11610.97,
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2429.62,,,,,,,fee schedule,2429.62,11610.97,
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2429.62,11610.97,APC
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2429.62,11610.97,APC
Biliary endoscopy thru skin,47555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2429.62,11610.97,APC
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8191.08,,,,,,,fee schedule,5370.07,19064.9,
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5427.63,,,,,,,fee schedule,5370.07,19064.9,
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5427.63,,,,,,,fee schedule,5370.07,19064.9,
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5370.07,,,,,,,fee schedule,5370.07,19064.9,
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6704.4,,,,,,,fee schedule,5370.07,19064.9,
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6241.77,,,,,,,fee schedule,5370.07,19064.9,
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9419.74,,,,,,,fee schedule,5370.07,19064.9,
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5427.63,,,,,,,fee schedule,5370.07,19064.9,
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5370.07,19064.9,APC
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5370.07,19064.9,APC
Biliary endoscopy thru skin,47556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5370.07,19064.9,APC
Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5823.28,,,,,,,fee schedule,5823.28,10842.82,
Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5823.28,,,,,,,fee schedule,5823.28,10842.82,
Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6696.77,,,,,,,fee schedule,5823.28,10842.82,
Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5823.28,,,,,,,fee schedule,5823.28,10842.82,
Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5823.28,10842.82,APC
Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5823.28,10842.82,APC
Laparoscopic cholecystectomy,47562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5823.28,10842.82,APC
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7068.21,,,,,,,fee schedule,4633.92,10842.82,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4964.52,,,,,,,fee schedule,4633.92,10842.82,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4964.52,,,,,,,fee schedule,4633.92,10842.82,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4633.92,,,,,,,fee schedule,4633.92,10842.82,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5785.33,,,,,,,fee schedule,4633.92,10842.82,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5709.2,,,,,,,fee schedule,4633.92,10842.82,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8128.44,,,,,,,fee schedule,4633.92,10842.82,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4964.52,,,,,,,fee schedule,4633.92,10842.82,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4633.92,10842.82,APC
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4633.92,10842.82,APC
Laparo cholecystectomy/graph,47563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4633.92,10842.82,APC
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,19064.9,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,19064.9,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,19064.9,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,19064.9,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,19064.9,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,3651.57,19064.9,APC
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,3651.57,19064.9,APC
Laparo cholecystectomy/explr,47564,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,3651.57,19064.9,APC
Laparoscope proc biliary,47579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc biliary,47579,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc biliary,47579,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Bile tract surgery procedure,47999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Bile tract surgery procedure,47999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Bile tract surgery procedure,47999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Needle biopsy pancreas,48102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Pancreas removal/transplant,48160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9408.69,,,,,,,fee schedule,6168.34,10819.99,
Pancreas removal/transplant,48160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6168.34,,,,,,,fee schedule,6168.34,10819.99,
Pancreas removal/transplant,48160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7701.01,,,,,,,fee schedule,6168.34,10819.99,
Pancreas removal/transplant,48160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10819.99,,,,,,,fee schedule,6168.34,10819.99,
Pancreas surgery procedure,48999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,705.59,1270.05,APC
Pancreas surgery procedure,48999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,705.59,1270.05,APC
Pancreas surgery procedure,48999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,705.59,1270.05,APC
Exploration behind abdomen,49010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,6450.54,11610.97,APC
Exploration behind abdomen,49010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,6450.54,11610.97,APC
Exploration behind abdomen,49010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,6450.54,11610.97,APC
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,616.25,,,,,,,fee schedule,404.01,708.69,
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,616.25,,,,,,,fee schedule,404.01,708.69,
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,616.25,,,,,,,fee schedule,404.01,708.69,
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,404.01,,,,,,,fee schedule,404.01,708.69,
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,504.4,,,,,,,fee schedule,404.01,708.69,
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,708.69,,,,,,,fee schedule,404.01,708.69,
Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,551.06,,,,,,,fee schedule,361.27,633.72,
Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,551.06,,,,,,,fee schedule,361.27,633.72,
Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,551.06,,,,,,,fee schedule,361.27,633.72,
Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,361.27,,,,,,,fee schedule,361.27,633.72,
Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,451.04,,,,,,,fee schedule,361.27,633.72,
Reexploration pelvic wound,49014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,633.72,,,,,,,fee schedule,361.27,633.72,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.04,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.26,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.54,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,648.43,1626.7,APC
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,648.43,1626.7,APC
Abd paracentesis,49082,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,648.43,1626.7,APC
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.04,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.26,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.54,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,1626.7,
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,648.43,1626.7,APC
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,648.43,1626.7,APC
Abd paracentesis w/imaging,49083,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,648.43,1626.7,APC
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.04,,,,,,,fee schedule,648.43,1626.7,
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,1626.7,
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,648.43,,,,,,,fee schedule,648.43,1626.7,
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.26,,,,,,,fee schedule,648.43,1626.7,
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.54,,,,,,,fee schedule,648.43,1626.7,
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,745.69,,,,,,,fee schedule,648.43,1626.7,
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188,,,,,,,fee schedule,648.43,1626.7,
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,648.43,,,,,,,fee schedule,648.43,1626.7,
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,648.43,1626.7,APC
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,648.43,1626.7,APC
Peritoneal lavage,49084,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,648.43,1626.7,APC
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1164.47,,,,,,,fee schedule,763.43,2962.18,
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,763.43,2962.18,
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,763.43,2962.18,
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,763.43,,,,,,,fee schedule,763.43,2962.18,
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,953.12,,,,,,,fee schedule,763.43,2962.18,
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,763.43,2962.18,
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1339.14,,,,,,,fee schedule,763.43,2962.18,
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,763.43,2962.18,
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,763.43,2962.18,APC
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,763.43,2962.18,APC
Biopsy abdominal mass,49180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,763.43,2962.18,APC
Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2911.07,,,,,,,fee schedule,1645.66,3347.73,
Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1908.5,,,,,,,fee schedule,1645.66,3347.73,
Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2382.71,,,,,,,fee schedule,1645.66,3347.73,
Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3347.73,,,,,,,fee schedule,1645.66,3347.73,
Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,3347.73,APC
Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,3347.73,APC
Sclerotx fluid collection,49185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,3347.73,APC
Opn exc/dstr ntra-abd 5 cm/<,49186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2078.44,,,,,,,fee schedule,1362.63,2390.21,
Opn exc/dstr ntra-abd 5 cm/<,49186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1362.63,,,,,,,fee schedule,1362.63,2390.21,
Opn exc/dstr ntra-abd 5 cm/<,49186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1701.2,,,,,,,fee schedule,1362.63,2390.21,
Opn exc/dstr ntra-abd 5 cm/<,49186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2390.21,,,,,,,fee schedule,1362.63,2390.21,
Opn exc/dstr ntra-abd 5.1-10,49187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2467.17,,,,,,,fee schedule,1617.48,2837.25,
Opn exc/dstr ntra-abd 5.1-10,49187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1617.48,,,,,,,fee schedule,1617.48,2837.25,
Opn exc/dstr ntra-abd 5.1-10,49187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2019.38,,,,,,,fee schedule,1617.48,2837.25,
Opn exc/dstr ntra-abd 5.1-10,49187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2837.25,,,,,,,fee schedule,1617.48,2837.25,
Opn exc/dst ntra-abd 10.1-20,49188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2992.3,,,,,,,fee schedule,1961.75,3441.15,
Opn exc/dst ntra-abd 10.1-20,49188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1961.75,,,,,,,fee schedule,1961.75,3441.15,
Opn exc/dst ntra-abd 10.1-20,49188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2449.2,,,,,,,fee schedule,1961.75,3441.15,
Opn exc/dst ntra-abd 10.1-20,49188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3441.15,,,,,,,fee schedule,1961.75,3441.15,
Opn exc/dst ntra-abd 20.1-30,49189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3390.53,,,,,,,fee schedule,2222.83,3899.11,
Opn exc/dst ntra-abd 20.1-30,49189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2222.83,,,,,,,fee schedule,2222.83,3899.11,
Opn exc/dst ntra-abd 20.1-30,49189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2775.15,,,,,,,fee schedule,2222.83,3899.11,
Opn exc/dst ntra-abd 20.1-30,49189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3899.11,,,,,,,fee schedule,2222.83,3899.11,
Opn exc/dstr ntra-abd >30 cm,49190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4083.9,,,,,,,fee schedule,2677.4,4696.49,
Opn exc/dstr ntra-abd >30 cm,49190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2677.4,,,,,,,fee schedule,2677.4,4696.49,
Opn exc/dstr ntra-abd >30 cm,49190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3342.67,,,,,,,fee schedule,2677.4,4696.49,
Opn exc/dstr ntra-abd >30 cm,49190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4696.49,,,,,,,fee schedule,2677.4,4696.49,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3483.52,,,,,,,fee schedule,2604.09,6421.55,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Excision of umbilicus,49250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Removal of omentum,49255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,6450.54,11610.97,APC
Removal of omentum,49255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,6450.54,11610.97,APC
Removal of omentum,49255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,6450.54,11610.97,APC
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,3171.64,10842.82,
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3997.81,,,,,,,fee schedule,3171.64,10842.82,
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3997.81,,,,,,,fee schedule,3171.64,10842.82,
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,3171.64,10842.82,
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,3171.64,10842.82,
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4597.48,,,,,,,fee schedule,3171.64,10842.82,
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,3171.64,10842.82,
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3997.81,,,,,,,fee schedule,3171.64,10842.82,
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3171.64,10842.82,APC
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3171.64,10842.82,APC
Diag laparo separate proc,49320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3171.64,10842.82,APC
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3997.81,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3997.81,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4597.48,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3997.81,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3171.64,10842.82,APC
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3171.64,10842.82,APC
Laparoscopy biopsy,49321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3171.64,10842.82,APC
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7497.55,,,,,,,fee schedule,3997.81,10842.82,
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3997.81,,,,,,,fee schedule,3997.81,10842.82,
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3997.81,,,,,,,fee schedule,3997.81,10842.82,
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4915.39,,,,,,,fee schedule,3997.81,10842.82,
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6136.74,,,,,,,fee schedule,3997.81,10842.82,
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4597.48,,,,,,,fee schedule,3997.81,10842.82,
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8622.18,,,,,,,fee schedule,3997.81,10842.82,
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3997.81,,,,,,,fee schedule,3997.81,10842.82,
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3997.81,10842.82,APC
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3997.81,10842.82,APC
Laparoscopy aspiration,49322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3997.81,10842.82,APC
Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Laparo drain lymphocele,49323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3997.81,,,,,,,fee schedule,3651.57,10842.82,
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3997.81,,,,,,,fee schedule,3651.57,10842.82,
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4597.48,,,,,,,fee schedule,3651.57,10842.82,
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3997.81,,,,,,,fee schedule,3651.57,10842.82,
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Lap insert tunnel ip cath,49324,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3997.81,,,,,,,fee schedule,3651.57,10842.82,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3997.81,,,,,,,fee schedule,3651.57,10842.82,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4597.48,,,,,,,fee schedule,3651.57,10842.82,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3997.81,,,,,,,fee schedule,3651.57,10842.82,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Lap Revision Perm IP Cath,49325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo proc abdm/per/oment,49329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc abdm/per/oment,49329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc abdm/per/oment,49329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Air injection into abdomen,49400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.47,,,,,,,fee schedule,112.42,197.19,
Air injection into abdomen,49400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.42,,,,,,,fee schedule,112.42,197.19,
Air injection into abdomen,49400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.35,,,,,,,fee schedule,112.42,197.19,
Air injection into abdomen,49400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.19,,,,,,,fee schedule,112.42,197.19,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3483.52,,,,,,,fee schedule,2604.09,6421.55,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Remove foreign body adbomen,49402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2075.37,,,,,,,fee schedule,1360.61,2962.18,
Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1360.61,,,,,,,fee schedule,1360.61,2962.18,
Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1698.69,,,,,,,fee schedule,1360.61,2962.18,
Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2386.68,,,,,,,fee schedule,1360.61,2962.18,
Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1360.61,2962.18,APC
Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1360.61,2962.18,APC
Image cath fluid colxn visc,49405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1360.61,2962.18,APC
Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2347.9,,,,,,,fee schedule,1539.28,2962.18,
Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1539.28,,,,,,,fee schedule,1539.28,2962.18,
Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1921.76,,,,,,,fee schedule,1539.28,2962.18,
Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2700.09,,,,,,,fee schedule,1539.28,2962.18,
Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1539.28,2962.18,APC
Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1539.28,2962.18,APC
Image cath fluid peri/retro,49406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1539.28,2962.18,APC
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,933.69,2962.18,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,933.69,2962.18,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,933.69,2962.18,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,933.69,2962.18,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Image cath fluid trns/vgnl,49407,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,962.21,,,,,,,fee schedule,630.82,2482.48,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,988.28,,,,,,,fee schedule,630.82,2482.48,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.28,,,,,,,fee schedule,630.82,2482.48,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,630.82,,,,,,,fee schedule,630.82,2482.48,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,787.57,,,,,,,fee schedule,630.82,2482.48,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1136.52,,,,,,,fee schedule,630.82,2482.48,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1106.54,,,,,,,fee schedule,630.82,2482.48,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,988.28,,,,,,,fee schedule,630.82,2482.48,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1448.11,,,,,,,fee schedule,630.82,2482.48,APC
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1379.15,,,,,,,fee schedule,630.82,2482.48,APC
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2482.48,,,,,,,fee schedule,630.82,2482.48,APC
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3487.06,,,,,,,fee schedule,2604.09,6421.55,
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Insert tun ip cath perc,49418,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5793.08,,,,,,,fee schedule,2963.35,9980.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3797.94,,,,,,,fee schedule,2963.35,9980.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4741.64,,,,,,,fee schedule,2963.35,9980.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.85,,,,,,,fee schedule,2963.35,9980.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6662.04,,,,,,,fee schedule,2963.35,9980.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.35,,,,,,,fee schedule,2963.35,9980.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2963.35,9980.06,APC
Insert tun ip cath w/port,49419,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2963.35,9980.06,APC
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3487.06,,,,,,,fee schedule,2604.09,6421.55,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3032.23,,,,,,,fee schedule,2604.09,6421.55,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Ins tun ip cath for dial opn,49421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.2,,,,,,,fee schedule,2088.47,5663.03,
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2088.47,,,,,,,fee schedule,2088.47,5663.03,
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2088.47,,,,,,,fee schedule,2088.47,5663.03,
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.85,,,,,,,fee schedule,2088.47,5663.03,
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.31,,,,,,,fee schedule,2088.47,5663.03,
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2401.74,,,,,,,fee schedule,2088.47,5663.03,
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.33,,,,,,,fee schedule,2088.47,5663.03,
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2088.47,,,,,,,fee schedule,2088.47,5663.03,
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2088.47,5663.03,APC
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2088.47,5663.03,APC
Remove tunneled ip cath,49422,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2088.47,5663.03,APC
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3933.09,,,,,,,fee schedule,1708.19,4523.05,
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1708.19,,,,,,,fee schedule,1708.19,4523.05,
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1708.19,,,,,,,fee schedule,1708.19,4523.05,
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.53,,,,,,,fee schedule,1708.19,4523.05,
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3219.23,,,,,,,fee schedule,1708.19,4523.05,
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1964.42,,,,,,,fee schedule,1708.19,4523.05,
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4523.05,,,,,,,fee schedule,1708.19,4523.05,
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1708.19,,,,,,,fee schedule,1708.19,4523.05,
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1708.19,4523.05,APC
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1708.19,4523.05,APC
Exchange drainage catheter,49423,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1708.19,4523.05,APC
Assess cyst contrast inject,49424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.32,,,,,,,fee schedule,212.62,372.97,
Assess cyst contrast inject,49424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.62,,,,,,,fee schedule,212.62,372.97,
Assess cyst contrast inject,49424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.46,,,,,,,fee schedule,212.62,372.97,
Assess cyst contrast inject,49424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,372.97,,,,,,,fee schedule,212.62,372.97,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3483.52,,,,,,,fee schedule,2604.09,6421.55,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3029.15,,,,,,,fee schedule,2604.09,6421.55,
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Revise abdomen-venous shunt,49426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Injection abdominal shunt,49427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.35,,,,,,,fee schedule,20.55,36.05,
Injection abdominal shunt,49427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.55,,,,,,,fee schedule,20.55,36.05,
Injection abdominal shunt,49427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.66,,,,,,,fee schedule,20.55,36.05,
Injection abdominal shunt,49427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.05,,,,,,,fee schedule,20.55,36.05,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3484.75,,,,,,,fee schedule,2088.47,5663.03,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2088.47,,,,,,,fee schedule,2088.47,5663.03,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2088.47,,,,,,,fee schedule,2088.47,5663.03,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.6,,,,,,,fee schedule,2088.47,5663.03,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.27,,,,,,,fee schedule,2088.47,5663.03,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2401.74,,,,,,,fee schedule,2088.47,5663.03,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.46,,,,,,,fee schedule,2088.47,5663.03,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2088.47,,,,,,,fee schedule,2088.47,5663.03,
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2088.47,5663.03,APC
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2088.47,5663.03,APC
Removal of shunt,49429,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2088.47,5663.03,APC
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1661.43,,,,,,,fee schedule,1089.23,3441.61,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1708.19,,,,,,,fee schedule,1089.23,3441.61,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1708.19,,,,,,,fee schedule,1089.23,3441.61,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1089.23,,,,,,,fee schedule,1089.23,3441.61,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1359.88,,,,,,,fee schedule,1089.23,3441.61,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1964.42,,,,,,,fee schedule,1089.23,3441.61,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1910.64,,,,,,,fee schedule,1089.23,3441.61,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1708.19,,,,,,,fee schedule,1089.23,3441.61,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1089.23,3441.61,APC
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1089.23,3441.61,APC
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1089.23,3441.61,APC
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1388.43,,,,,,,fee schedule,910.25,3441.61,
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,910.25,3441.61,
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,910.25,3441.61,
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,910.25,,,,,,,fee schedule,910.25,3441.61,
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1136.43,,,,,,,fee schedule,910.25,3441.61,
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,910.25,3441.61,
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1596.69,,,,,,,fee schedule,910.25,3441.61,
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,910.25,3441.61,
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,910.25,3441.61,APC
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,910.25,3441.61,APC
Place gastrostomy tube perc,49440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,910.25,3441.61,APC
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1878.48,,,,,,,fee schedule,1231.53,3441.61,
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1231.53,3441.61,
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1231.53,3441.61,
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1231.53,,,,,,,fee schedule,1231.53,3441.61,
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1537.54,,,,,,,fee schedule,1231.53,3441.61,
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1231.53,3441.61,
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2160.25,,,,,,,fee schedule,1231.53,3441.61,
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1231.53,3441.61,
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1231.53,3441.61,APC
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1231.53,3441.61,APC
Place duod/jej tube perc,49441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1231.53,3441.61,APC
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1295.52,,,,,,,fee schedule,849.34,2217.52,
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1928.28,,,,,,,fee schedule,849.34,2217.52,
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.28,,,,,,,fee schedule,849.34,2217.52,
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,849.34,,,,,,,fee schedule,849.34,2217.52,
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1060.38,,,,,,,fee schedule,849.34,2217.52,
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2217.52,,,,,,,fee schedule,849.34,2217.52,
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1489.85,,,,,,,fee schedule,849.34,2217.52,
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1928.28,,,,,,,fee schedule,849.34,2217.52,
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1251.96,,,,,,,fee schedule,849.34,2217.52,APC
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1192.34,,,,,,,fee schedule,849.34,2217.52,APC
Place cecostomy tube perc,49442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2146.21,,,,,,,fee schedule,849.34,2217.52,APC
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2180.26,,,,,,,fee schedule,1411.09,3441.61,
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,3441.61,
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1411.09,,,,,,,fee schedule,1411.09,3441.61,
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1429.38,,,,,,,fee schedule,1411.09,3441.61,
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1784.54,,,,,,,fee schedule,1411.09,3441.61,
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.75,,,,,,,fee schedule,1411.09,3441.61,
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2507.3,,,,,,,fee schedule,1411.09,3441.61,
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1411.09,,,,,,,fee schedule,1411.09,3441.61,
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.61,,,,,,,fee schedule,1411.09,3441.61,APC
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.01,,,,,,,fee schedule,1411.09,3441.61,APC
Change g-tube to g-j perc,49446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.61,,,,,,,fee schedule,1411.09,3441.61,APC
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,715.39,,,,,,,fee schedule,469.01,1626.7,
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,469.01,1626.7,
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,469.01,1626.7,
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,469.01,,,,,,,fee schedule,469.01,1626.7,
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,585.55,,,,,,,fee schedule,469.01,1626.7,
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,469.01,1626.7,
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,822.7,,,,,,,fee schedule,469.01,1626.7,
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,469.01,1626.7,
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,469.01,1626.7,APC
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,469.01,1626.7,APC
Replace g/c tube perc,49450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,469.01,1626.7,APC
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.63,,,,,,,fee schedule,445.57,1626.7,
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,445.57,1626.7,
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,445.57,1626.7,
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.57,,,,,,,fee schedule,445.57,1626.7,
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,556.28,,,,,,,fee schedule,445.57,1626.7,
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,445.57,1626.7,
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.57,,,,,,,fee schedule,445.57,1626.7,
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,445.57,1626.7,
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,445.57,1626.7,APC
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,445.57,1626.7,APC
Replace duod/jej tube perc,49451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,445.57,1626.7,APC
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.17,,,,,,,fee schedule,531.8,1626.7,
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,531.8,1626.7,
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,531.8,1626.7,
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.8,,,,,,,fee schedule,531.8,1626.7,
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.94,,,,,,,fee schedule,531.8,1626.7,
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,531.8,1626.7,
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.85,,,,,,,fee schedule,531.8,1626.7,
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,531.8,1626.7,
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,531.8,1626.7,APC
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,531.8,1626.7,APC
Replace g-j tube perc,49452,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,531.8,1626.7,APC
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.04,,,,,,,fee schedule,646.75,1626.7,
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,646.75,1626.7,
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,646.75,1626.7,
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.26,,,,,,,fee schedule,646.75,1626.7,
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.54,,,,,,,fee schedule,646.75,1626.7,
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,646.75,1626.7,
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1188,,,,,,,fee schedule,646.75,1626.7,
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,646.75,1626.7,
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,646.75,1626.7,APC
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,646.75,1626.7,APC
Fix g/colon tube w/device,49460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,646.75,1626.7,APC
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,354.71,,,,,,,fee schedule,200.06,427.94,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,200.06,,,,,,,fee schedule,200.06,427.94,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,200.06,,,,,,,fee schedule,200.06,427.94,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,232.55,,,,,,,fee schedule,200.06,427.94,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,290.33,,,,,,,fee schedule,200.06,427.94,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,230.07,,,,,,,fee schedule,200.06,427.94,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,407.92,,,,,,,fee schedule,200.06,427.94,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,200.06,,,,,,,fee schedule,200.06,427.94,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,200.06,427.94,APC
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,200.06,427.94,APC
Fluoro exam of g/colon tube,49465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,200.06,427.94,APC
Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.66,,,,,,,fee schedule,5502.23,10842.82,
Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.23,,,,,,,fee schedule,5502.23,10842.82,
Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.39,,,,,,,fee schedule,5502.23,10842.82,
Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.56,,,,,,,fee schedule,5502.23,10842.82,
Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5502.23,10842.82,APC
Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5502.23,10842.82,APC
Rpr hern preemie reduc,49491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5502.23,10842.82,APC
Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4281.37,,,,,,,fee schedule,2806.87,6421.55,
Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2806.87,,,,,,,fee schedule,2806.87,6421.55,
Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3504.3,,,,,,,fee schedule,2806.87,6421.55,
Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4923.58,,,,,,,fee schedule,2806.87,6421.55,
Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2806.87,6421.55,APC
Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2806.87,6421.55,APC
Rpr ing hern premie blocked,49492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2806.87,6421.55,APC
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.85,,,,,,,fee schedule,3545.32,7300.03,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,7300.03,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,7300.03,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.65,,,,,,,fee schedule,3545.32,7300.03,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.72,,,,,,,fee schedule,3545.32,7300.03,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,7300.03,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.03,,,,,,,fee schedule,3545.32,7300.03,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,7300.03,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3545.32,7300.03,APC
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3545.32,7300.03,APC
Rpr ing hernia baby reduc,49495,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3545.32,7300.03,APC
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,6421.55,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr ing hernia baby blocked,49496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.1,,,,,,,fee schedule,3545.32,11610.97,
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,11610.97,
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,11610.97,
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.54,,,,,,,fee schedule,3545.32,11610.97,
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.26,,,,,,,fee schedule,3545.32,11610.97,
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,11610.97,
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.37,,,,,,,fee schedule,3545.32,11610.97,
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,11610.97,
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,3545.32,11610.97,APC
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,3545.32,11610.97,APC
Rpr ing hernia init reduce,49500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,3545.32,11610.97,APC
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.84,,,,,,,fee schedule,3545.32,7300.02,
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,7300.02,
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,7300.02,
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.64,,,,,,,fee schedule,3545.32,7300.02,
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.71,,,,,,,fee schedule,3545.32,7300.02,
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,7300.02,
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.02,,,,,,,fee schedule,3545.32,7300.02,
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,7300.02,
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3545.32,7300.02,APC
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3545.32,7300.02,APC
Rpr ing hernia init blocked,49501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3545.32,7300.02,APC
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7039.23,,,,,,,fee schedule,3131.79,8095.11,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3131.79,,,,,,,fee schedule,3131.79,8095.11,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3131.79,,,,,,,fee schedule,3131.79,8095.11,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4614.92,,,,,,,fee schedule,3131.79,8095.11,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5761.61,,,,,,,fee schedule,3131.79,8095.11,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3601.56,,,,,,,fee schedule,3131.79,8095.11,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8095.11,,,,,,,fee schedule,3131.79,8095.11,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3131.79,,,,,,,fee schedule,3131.79,8095.11,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3131.79,8095.11,APC
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3131.79,8095.11,APC
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3131.79,8095.11,APC
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9398.47,,,,,,,fee schedule,3545.32,10808.24,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,10808.24,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,10808.24,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6161.64,,,,,,,fee schedule,3545.32,10808.24,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7692.65,,,,,,,fee schedule,3545.32,10808.24,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,10808.24,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10808.24,,,,,,,fee schedule,3545.32,10808.24,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,10808.24,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3545.32,10808.24,APC
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3545.32,10808.24,APC
Prp i/hern init block >5 yr,49507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3545.32,10808.24,APC
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7724.46,,,,,,,fee schedule,3131.79,8883.13,
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3131.79,,,,,,,fee schedule,3131.79,8883.13,
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3131.79,,,,,,,fee schedule,3131.79,8883.13,
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5064.16,,,,,,,fee schedule,3131.79,8883.13,
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6322.47,,,,,,,fee schedule,3131.79,8883.13,
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3601.56,,,,,,,fee schedule,3131.79,8883.13,
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8883.13,,,,,,,fee schedule,3131.79,8883.13,
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3131.79,,,,,,,fee schedule,3131.79,8883.13,
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3131.79,8883.13,APC
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3131.79,8883.13,APC
Rerepair ing hernia reduce,49520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3131.79,8883.13,APC
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,11610.97,
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,11610.97,
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,11610.97,
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,11610.97,
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,11610.97,
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,11610.97,
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,11610.97,
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,11610.97,
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2604.09,11610.97,APC
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2604.09,11610.97,APC
Rerepair ing hernia blocked,49521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2604.09,11610.97,APC
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,6421.55,
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Repair ing hernia sliding,49525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3545.32,10842.82,
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,10842.82,
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,10842.82,
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3545.32,10842.82,
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3545.32,10842.82,
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,10842.82,
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3545.32,10842.82,
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,10842.82,
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3545.32,10842.82,APC
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3545.32,10842.82,APC
Repair lumbar hernia,49540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3545.32,10842.82,APC
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,6421.55,
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr rem hernia init reduce,49550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,6421.55,
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr fem hernia init blocked,49553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4384.46,,,,,,,fee schedule,2874.45,6421.55,
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2874.45,6421.55,
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2874.45,6421.55,
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2874.45,,,,,,,fee schedule,2874.45,6421.55,
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3588.68,,,,,,,fee schedule,2874.45,6421.55,
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2874.45,6421.55,
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5042.13,,,,,,,fee schedule,2874.45,6421.55,
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2874.45,6421.55,
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2874.45,6421.55,APC
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2874.45,6421.55,APC
Rerepair fem hernia reduce,49555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2874.45,6421.55,APC
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,6421.55,
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Rerepair fem hernia blocked,49557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6769.91,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2615.52,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4438.35,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5541.17,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3007.85,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7785.4,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2615.52,7785.4,APC
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2615.52,7785.4,APC
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2615.52,7785.4,APC
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9962.31,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6531.29,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8154.15,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4511.3,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11456.66,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6769.91,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4438.35,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5541.17,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3007.85,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7785.4,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9962.31,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6531.29,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8154.15,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4511.3,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11456.66,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6769.91,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4438.35,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5541.17,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3007.85,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7785.4,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn 1st > 10 ncr/strn,49596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1406.63,,,,,,,fee schedule,922.19,1617.62,
Rpr aa hrn 1st > 10 ncr/strn,49596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,922.19,,,,,,,fee schedule,922.19,1617.62,
Rpr aa hrn 1st > 10 ncr/strn,49596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1151.33,,,,,,,fee schedule,922.19,1617.62,
Rpr aa hrn 1st > 10 ncr/strn,49596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1617.62,,,,,,,fee schedule,922.19,1617.62,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,6421.55,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Repair umbilical lesion,49600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6769.91,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2615.52,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4438.35,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5541.17,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3007.85,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7785.4,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,7785.4,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2615.52,7785.4,APC
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2615.52,7785.4,APC
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2615.52,7785.4,APC
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9962.31,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6531.29,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8154.15,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4511.3,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11456.66,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3922.87,,,,,,,fee schedule,3922.87,11456.66,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3922.87,11456.66,APC
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6769.91,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4438.35,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5541.17,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3007.85,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7785.4,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2615.52,,,,,,,fee schedule,2615.52,11610.97,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2615.52,11610.97,APC
Rpr aa hrn rcr 3-10 ncr/strn,49616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1190.5,,,,,,,fee schedule,780.49,1369.08,
Rpr aa hrn rcr 3-10 ncr/strn,49616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,780.49,,,,,,,fee schedule,780.49,1369.08,
Rpr aa hrn rcr 3-10 ncr/strn,49616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,974.42,,,,,,,fee schedule,780.49,1369.08,
Rpr aa hrn rcr 3-10 ncr/strn,49616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1369.08,,,,,,,fee schedule,780.49,1369.08,
Rpr aa hrn rcr > 10 rdc,49617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1245.5,,,,,,,fee schedule,816.55,1432.33,
Rpr aa hrn rcr > 10 rdc,49617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,816.55,,,,,,,fee schedule,816.55,1432.33,
Rpr aa hrn rcr > 10 rdc,49617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1019.44,,,,,,,fee schedule,816.55,1432.33,
Rpr aa hrn rcr > 10 rdc,49617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1432.33,,,,,,,fee schedule,816.55,1432.33,
Rpr aa hrn rcr > 10 ncr/strn,49618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1687.2,,,,,,,fee schedule,1106.13,1940.28,
Rpr aa hrn rcr > 10 ncr/strn,49618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1106.13,,,,,,,fee schedule,1106.13,1940.28,
Rpr aa hrn rcr > 10 ncr/strn,49618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1380.97,,,,,,,fee schedule,1106.13,1940.28,
Rpr aa hrn rcr > 10 ncr/strn,49618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1940.28,,,,,,,fee schedule,1106.13,1940.28,
Rpr parastomal hernia rdc,49621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1038.85,,,,,,,fee schedule,681.07,1194.68,
Rpr parastomal hernia rdc,49621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,681.07,,,,,,,fee schedule,681.07,1194.68,
Rpr parastomal hernia rdc,49621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,850.3,,,,,,,fee schedule,681.07,1194.68,
Rpr parastomal hernia rdc,49621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1194.68,,,,,,,fee schedule,681.07,1194.68,
Rpr parastomal hrna ncr/strn,49622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1253.07,,,,,,,fee schedule,821.51,1441.03,
Rpr parastomal hrna ncr/strn,49622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,821.51,,,,,,,fee schedule,821.51,1441.03,
Rpr parastomal hrna ncr/strn,49622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1025.64,,,,,,,fee schedule,821.51,1441.03,
Rpr parastomal hrna ncr/strn,49622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1441.03,,,,,,,fee schedule,821.51,1441.03,
Rmvl ninfct mesh hernia rpr,49623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.01,,,,,,,fee schedule,166.53,292.11,
Rmvl ninfct mesh hernia rpr,49623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.53,,,,,,,fee schedule,166.53,292.11,
Rmvl ninfct mesh hernia rpr,49623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.91,,,,,,,fee schedule,166.53,292.11,
Rmvl ninfct mesh hernia rpr,49623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.11,,,,,,,fee schedule,166.53,292.11,
Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8418.61,,,,,,,fee schedule,6023.79,10842.82,
Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Lap ing hernia repair init,49650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.44,,,,,,,fee schedule,4964.52,10842.82,
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4964.52,,,,,,,fee schedule,4964.52,10842.82,
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4964.52,,,,,,,fee schedule,4964.52,10842.82,
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.08,,,,,,,fee schedule,4964.52,10842.82,
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.21,,,,,,,fee schedule,4964.52,10842.82,
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5709.2,,,,,,,fee schedule,4964.52,10842.82,
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.31,,,,,,,fee schedule,4964.52,10842.82,
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4964.52,,,,,,,fee schedule,4964.52,10842.82,
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4964.52,10842.82,APC
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4964.52,10842.82,APC
Lap ing hernia repair recur,49651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4964.52,10842.82,APC
Laparo proc hernia repair,49659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc hernia repair,49659,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc hernia repair,49659,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Abdomen surgery procedure,49999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Abdomen surgery procedure,49999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Abdomen surgery procedure,49999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3802.52,,,,,,,fee schedule,2082.87,4372.9,
Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2492.93,,,,,,,fee schedule,2082.87,4372.9,
Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3112.36,,,,,,,fee schedule,2082.87,4372.9,
Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4372.9,,,,,,,fee schedule,2082.87,4372.9,
Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,4372.9,APC
Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,4372.9,APC
Renal abscess open drain,50020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,4372.9,APC
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11056.57,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7248.69,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9049.8,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12715.06,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,4126.14,16978.36,APC
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,4126.14,16978.36,APC
Removal of kidney stone,50080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,4126.14,16978.36,APC
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11056.57,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7248.69,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9049.8,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12715.06,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,4126.14,16978.36,
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,4126.14,16978.36,APC
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,4126.14,16978.36,APC
Removal of kidney stone,50081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,4126.14,16978.36,APC
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1803.25,,,,,,,fee schedule,1182.21,2962.18,
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,1182.21,2962.18,
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,1182.21,2962.18,
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1182.21,,,,,,,fee schedule,1182.21,2962.18,
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1475.96,,,,,,,fee schedule,1182.21,2962.18,
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,1182.21,2962.18,
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2073.74,,,,,,,fee schedule,1182.21,2962.18,
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,1182.21,2962.18,
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1182.21,2962.18,APC
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1182.21,2962.18,APC
Renal biopsy perq,50200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1182.21,2962.18,APC
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,3749.16,
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Change ureter stent percut,50382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1419.05,3749.16,
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1419.05,3749.16,
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1419.05,3749.16,
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1419.05,3749.16,
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Remove ureter stent percut,50384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,3749.16,
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Change stent via transureth,50385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1584.41,,,,,,,fee schedule,727.4,3749.16,
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,3749.16,
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,3749.16,
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1038.74,,,,,,,fee schedule,727.4,3749.16,
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1296.84,,,,,,,fee schedule,727.4,3749.16,
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,3749.16,
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1822.07,,,,,,,fee schedule,727.4,3749.16,
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,3749.16,
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,727.4,3749.16,APC
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,727.4,3749.16,APC
Remove stent via transureth,50386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,727.4,3749.16,APC
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1708.19,,,,,,,fee schedule,1419.05,3749.16,
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1708.19,,,,,,,fee schedule,1419.05,3749.16,
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1964.42,,,,,,,fee schedule,1419.05,3749.16,
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1708.19,,,,,,,fee schedule,1419.05,3749.16,
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Change nephroureteral cath,50387,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,531.76,1250.62,
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,1250.62,
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,531.76,1250.62,
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,531.76,1250.62,
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,531.76,1250.62,
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,531.76,1250.62,
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,531.76,1250.62,
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,1250.62,
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,531.76,1250.62,APC
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,531.76,1250.62,APC
Remove renal tube w/fluoro,50389,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,531.76,1250.62,APC
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1007.88,,,,,,,fee schedule,660.77,1604.12,
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,660.77,1604.12,
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,660.77,1604.12,
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,660.77,,,,,,,fee schedule,660.77,1604.12,
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,824.95,,,,,,,fee schedule,660.77,1604.12,
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,660.77,1604.12,
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1159.06,,,,,,,fee schedule,660.77,1604.12,
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,660.77,1604.12,
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,660.77,1604.12,APC
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,660.77,1604.12,APC
Drainage of kidney lesion,50390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,660.77,1604.12,APC
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.3,,,,,,,fee schedule,86.08,448.11,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.98,,,,,,,fee schedule,86.08,448.11,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.98,,,,,,,fee schedule,86.08,448.11,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.08,,,,,,,fee schedule,86.08,448.11,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.47,,,,,,,fee schedule,86.08,448.11,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.23,,,,,,,fee schedule,86.08,448.11,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151,,,,,,,fee schedule,86.08,448.11,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.98,,,,,,,fee schedule,86.08,448.11,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,86.08,448.11,APC
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,86.08,448.11,APC
Instll rx agnt into rnal tub,50391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,86.08,448.11,APC
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,283.29,1250.62,
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.29,,,,,,,fee schedule,283.29,1250.62,
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.29,,,,,,,fee schedule,283.29,1250.62,
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,283.29,1250.62,
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,283.29,1250.62,
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.78,,,,,,,fee schedule,283.29,1250.62,
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,283.29,1250.62,
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.29,,,,,,,fee schedule,283.29,1250.62,
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,283.29,1250.62,APC
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,283.29,1250.62,APC
Measure kidney pressure,50396,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,283.29,1250.62,APC
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,821.74,,,,,,,fee schedule,538.73,1250.62,
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,538.73,,,,,,,fee schedule,538.73,1250.62,
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,672.59,,,,,,,fee schedule,538.73,1250.62,
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,945,,,,,,,fee schedule,538.73,1250.62,
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,538.73,1250.62,APC
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,538.73,1250.62,APC
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,538.73,1250.62,APC
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1377.72,,,,,,,fee schedule,694.79,1584.38,
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,903.23,,,,,,,fee schedule,694.79,1584.38,
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1127.66,,,,,,,fee schedule,694.79,1584.38,
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1584.38,,,,,,,fee schedule,694.79,1584.38,
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,694.79,1584.38,APC
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,694.79,1584.38,APC
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,694.79,1584.38,APC
Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1215.64,,,,,,,fee schedule,796.97,3749.16,
Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,796.97,,,,,,,fee schedule,796.97,3749.16,
Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,995,,,,,,,fee schedule,796.97,3749.16,
Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1397.99,,,,,,,fee schedule,796.97,3749.16,
Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,796.97,3749.16,APC
Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,796.97,3749.16,APC
Plmt nephrostomy catheter,50432,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,796.97,3749.16,APC
Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Plmt nephroureteral catheter,50433,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,531.76,3749.16,
Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,531.76,3749.16,
Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,531.76,3749.16,
Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,531.76,3749.16,
Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,531.76,3749.16,APC
Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,531.76,3749.16,APC
Convert nephrostomy catheter,50434,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,531.76,3749.16,APC
Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1094.09,,,,,,,fee schedule,717.29,3749.16,
Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,717.29,,,,,,,fee schedule,717.29,3749.16,
Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,895.51,,,,,,,fee schedule,717.29,3749.16,
Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1258.2,,,,,,,fee schedule,717.29,3749.16,
Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,717.29,3749.16,APC
Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,717.29,3749.16,APC
Exchange nephrostomy cath,50435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,717.29,3749.16,APC
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4567.25,,,,,,,fee schedule,1259.22,6322.15,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1259.22,,,,,,,fee schedule,1259.22,6322.15,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1259.22,,,,,,,fee schedule,1259.22,6322.15,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2994.29,,,,,,,fee schedule,1259.22,6322.15,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3738.29,,,,,,,fee schedule,1259.22,6322.15,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1448.1,,,,,,,fee schedule,1259.22,6322.15,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5252.34,,,,,,,fee schedule,1259.22,6322.15,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1259.22,,,,,,,fee schedule,1259.22,6322.15,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1259.22,6322.15,APC
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1259.22,6322.15,APC
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1259.22,6322.15,APC
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7683.72,,,,,,,fee schedule,2193.73,8836.28,
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2193.73,,,,,,,fee schedule,2193.73,8836.28,
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2193.73,,,,,,,fee schedule,2193.73,8836.28,
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5037.45,,,,,,,fee schedule,2193.73,8836.28,
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6289.12,,,,,,,fee schedule,2193.73,8836.28,
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2522.79,,,,,,,fee schedule,2193.73,8836.28,
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8836.28,,,,,,,fee schedule,2193.73,8836.28,
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2193.73,,,,,,,fee schedule,2193.73,8836.28,
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2193.73,8836.28,APC
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2193.73,8836.28,APC
Dilat xst trc new access rcs,50437,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2193.73,8836.28,APC
Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,19064.9,
Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,19064.9,
Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,19064.9,
Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,19064.9,
Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,4117.16,19064.9,APC
Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,4117.16,19064.9,APC
Laparo ablate renal cyst,50541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,4117.16,19064.9,APC
Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10423.72,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6833.79,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8531.81,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11987.28,,,,,,,fee schedule,6833.79,19064.9,
Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,6833.79,19064.9,APC
Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,6833.79,19064.9,APC
Laparo ablate renal mass,50542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,6833.79,19064.9,APC
Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21481.49,,,,,,,fee schedule,10591.61,24703.71,
Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14083.26,,,,,,,fee schedule,10591.61,24703.71,
Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17582.6,,,,,,,fee schedule,10591.61,24703.71,
Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24703.71,,,,,,,fee schedule,10591.61,24703.71,
Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,24703.71,APC
Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,24703.71,APC
Laparo partial nephrectomy,50543,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,24703.71,APC
Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12962.51,,,,,,,fee schedule,8498.22,19064.9,
Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8498.22,,,,,,,fee schedule,8498.22,19064.9,
Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10609.81,,,,,,,fee schedule,8498.22,19064.9,
Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14906.89,,,,,,,fee schedule,8498.22,19064.9,
Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,8498.22,19064.9,APC
Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,8498.22,19064.9,APC
Laparoscopy pyeloplasty,50544,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,8498.22,19064.9,APC
Laparoscope proc renal,50549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc renal,50549,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc renal,50549,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,727.4,9616.53,
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,9616.53,
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,9616.53,
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,727.4,9616.53,
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,727.4,9616.53,
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,9616.53,
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,727.4,9616.53,
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,9616.53,
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,727.4,9616.53,APC
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,727.4,9616.53,APC
Kidney endoscopy,50551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,727.4,9616.53,APC
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Kidney endoscopy,50553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,727.4,16978.36,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,16978.36,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,16978.36,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,727.4,16978.36,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,727.4,16978.36,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,16978.36,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,727.4,16978.36,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,16978.36,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,727.4,16978.36,APC
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,727.4,16978.36,APC
Kidney endoscopy & biopsy,50555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,727.4,16978.36,APC
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11056.57,,,,,,,fee schedule,2762.68,16978.36,
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,16978.36,
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,16978.36,
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7248.69,,,,,,,fee schedule,2762.68,16978.36,
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9049.8,,,,,,,fee schedule,2762.68,16978.36,
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,16978.36,
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12715.06,,,,,,,fee schedule,2762.68,16978.36,
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,16978.36,
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,2762.68,16978.36,APC
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,2762.68,16978.36,APC
Kidney endoscopy & treatment,50557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,2762.68,16978.36,APC
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Kidney endoscopy & treatment,50561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11056.57,,,,,,,fee schedule,727.4,16978.36,
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,16978.36,
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,16978.36,
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7248.69,,,,,,,fee schedule,727.4,16978.36,
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9049.8,,,,,,,fee schedule,727.4,16978.36,
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,16978.36,
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12715.06,,,,,,,fee schedule,727.4,16978.36,
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,16978.36,
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,727.4,16978.36,APC
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,727.4,16978.36,APC
Renal scope w/tumor resect,50562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,727.4,16978.36,APC
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,727.4,6322.15,
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,6322.15,
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,6322.15,
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,727.4,6322.15,
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,727.4,6322.15,
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,6322.15,
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,727.4,6322.15,
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,6322.15,
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,727.4,6322.15,APC
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,727.4,6322.15,APC
Kidney endoscopy,50570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,727.4,6322.15,APC
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,531.76,1250.62,
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,1250.62,
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,531.76,1250.62,
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,531.76,1250.62,
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,531.76,1250.62,
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,531.76,1250.62,
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,531.76,1250.62,
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,1250.62,
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,531.76,1250.62,APC
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,531.76,1250.62,APC
Kidney endoscopy,50572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,531.76,1250.62,APC
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,531.76,6322.15,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,6322.15,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,531.76,6322.15,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,531.76,6322.15,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,531.76,6322.15,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,531.76,6322.15,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,531.76,6322.15,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,6322.15,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,531.76,6322.15,APC
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,531.76,6322.15,APC
Kidney endoscopy & biopsy,50574,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,531.76,6322.15,APC
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,3116.77,9616.53,
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,3116.77,9616.53,
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,3116.77,9616.53,
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,3116.77,9616.53,
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Kidney endoscopy,50575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,1625.89,16978.36,
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,16978.36,
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,16978.36,
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,1625.89,16978.36,
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,1625.89,16978.36,
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,16978.36,
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,1625.89,16978.36,
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,16978.36,
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,1625.89,16978.36,APC
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,1625.89,16978.36,APC
Kidney endoscopy & treatment,50576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,1625.89,16978.36,APC
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,1625.89,9616.53,
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,1625.89,9616.53,
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,1625.89,9616.53,
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,9616.53,
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,1625.89,9616.53,
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,1625.89,9616.53,APC
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,1625.89,9616.53,APC
Kidney endoscopy & treatment,50580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,1625.89,9616.53,APC
Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4662.44,,,,,,,fee schedule,3512.31,6322.15,
Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4662.44,,,,,,,fee schedule,3512.31,6322.15,
Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5361.81,,,,,,,fee schedule,3512.31,6322.15,
Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4662.44,,,,,,,fee schedule,3512.31,6322.15,
Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6322.15,APC
Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6322.15,APC
Fragmenting of kidney stone,50590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6322.15,APC
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16357.5,,,,,,,fee schedule,5427.63,18811.13,
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5427.63,,,,,,,fee schedule,5427.63,18811.13,
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5427.63,,,,,,,fee schedule,5427.63,18811.13,
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10723.98,,,,,,,fee schedule,5427.63,18811.13,
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13388.61,,,,,,,fee schedule,5427.63,18811.13,
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6241.77,,,,,,,fee schedule,5427.63,18811.13,
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18811.13,,,,,,,fee schedule,5427.63,18811.13,
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5427.63,,,,,,,fee schedule,5427.63,18811.13,
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5427.63,18811.13,APC
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5427.63,18811.13,APC
Perc rf ablate renal tumor,50592,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5427.63,18811.13,APC
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8948.41,,,,,,,fee schedule,5427.63,19064.9,
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5427.63,,,,,,,fee schedule,5427.63,19064.9,
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5427.63,,,,,,,fee schedule,5427.63,19064.9,
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5866.58,,,,,,,fee schedule,5427.63,19064.9,
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7324.27,,,,,,,fee schedule,5427.63,19064.9,
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6241.77,,,,,,,fee schedule,5427.63,19064.9,
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10290.67,,,,,,,fee schedule,5427.63,19064.9,
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5427.63,,,,,,,fee schedule,5427.63,19064.9,
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5427.63,19064.9,APC
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5427.63,19064.9,APC
Perc cryo ablate renal tum,50593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5427.63,19064.9,APC
Injection for ureter x-ray,50684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.6,,,,,,,fee schedule,140.69,246.79,
Injection for ureter x-ray,50684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.69,,,,,,,fee schedule,140.69,246.79,
Injection for ureter x-ray,50684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.65,,,,,,,fee schedule,140.69,246.79,
Injection for ureter x-ray,50684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.79,,,,,,,fee schedule,140.69,246.79,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,187.62,,,,,,,fee schedule,123,230.78,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.05,,,,,,,fee schedule,123,230.78,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.05,,,,,,,fee schedule,123,230.78,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123,,,,,,,fee schedule,123,230.78,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.57,,,,,,,fee schedule,123,230.78,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.56,,,,,,,fee schedule,123,230.78,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,215.76,,,,,,,fee schedule,123,230.78,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.05,,,,,,,fee schedule,123,230.78,
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,123,230.78,APC
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,123,230.78,APC
Measure ureter pressure,50686,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,123,230.78,APC
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1708.19,,,,,,,fee schedule,1419.05,3749.16,
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1708.19,,,,,,,fee schedule,1419.05,3749.16,
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1964.42,,,,,,,fee schedule,1419.05,3749.16,
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1708.19,,,,,,,fee schedule,1419.05,3749.16,
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Change of ureter tube/stent,50688,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Injection for ureter x-ray,50690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9408.69,,,,,,,fee schedule,6168.34,10819.99,
Injection for ureter x-ray,50690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6168.34,,,,,,,fee schedule,6168.34,10819.99,
Injection for ureter x-ray,50690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7701.01,,,,,,,fee schedule,6168.34,10819.99,
Injection for ureter x-ray,50690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10819.99,,,,,,,fee schedule,6168.34,10819.99,
Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5199.96,,,,,,,fee schedule,3409.09,6322.15,
Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3409.09,,,,,,,fee schedule,3409.09,6322.15,
Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4256.17,,,,,,,fee schedule,3409.09,6322.15,
Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5979.95,,,,,,,fee schedule,3409.09,6322.15,
Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3409.09,6322.15,APC
Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3409.09,6322.15,APC
Plmt ureteral stent prq,50693,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3409.09,6322.15,APC
Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Plmt ureteral stent prq,50694,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5199.96,,,,,,,fee schedule,3409.09,6322.15,
Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3409.09,,,,,,,fee schedule,3409.09,6322.15,
Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4256.17,,,,,,,fee schedule,3409.09,6322.15,
Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5979.95,,,,,,,fee schedule,3409.09,6322.15,
Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3409.09,6322.15,APC
Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3409.09,6322.15,APC
Plmt ureteral stent prq,50695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3409.09,6322.15,APC
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,1823.05,6322.15,
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1823.05,,,,,,,fee schedule,1823.05,6322.15,
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1823.05,,,,,,,fee schedule,1823.05,6322.15,
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,1823.05,6322.15,
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,1823.05,6322.15,
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2096.51,,,,,,,fee schedule,1823.05,6322.15,
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,1823.05,6322.15,
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1823.05,,,,,,,fee schedule,1823.05,6322.15,
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1823.05,6322.15,APC
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1823.05,6322.15,APC
Revise ureter,50727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1823.05,6322.15,APC
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,19064.9,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,19064.9,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,19064.9,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,19064.9,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,19064.9,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,3651.57,19064.9,APC
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,3651.57,19064.9,APC
Laparo New Ureter/Bladder,50947,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,3651.57,19064.9,APC
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8948.41,,,,,,,fee schedule,5008.21,19064.9,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5866.58,,,,,,,fee schedule,5008.21,19064.9,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7324.27,,,,,,,fee schedule,5008.21,19064.9,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,5008.21,19064.9,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10290.67,,,,,,,fee schedule,5008.21,19064.9,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5008.21,19064.9,APC
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5008.21,19064.9,APC
Laparo New Ureter/Bladder,50948,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5008.21,19064.9,APC
Laparoscope proc ureter,50949,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc ureter,50949,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc ureter,50949,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,727.4,6322.15,APC
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,727.4,6322.15,APC
Endoscopy of ureter,50951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,727.4,6322.15,APC
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,6322.15,
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,727.4,6322.15,APC
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,727.4,6322.15,APC
Endoscopy of ureter,50953,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,727.4,6322.15,APC
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & biopsy,50955,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6322.24,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4144.86,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5174.75,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7270.58,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & treatment,50957,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & treatment,50961,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,531.76,6322.15,APC
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,531.76,6322.15,APC
Ureter endoscopy,50970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,531.76,6322.15,APC
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,6322.15,
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,531.76,6322.15,APC
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,531.76,6322.15,APC
Ureter endoscopy & catheter,50972,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,531.76,6322.15,APC
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,1625.89,9616.53,APC
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,1625.89,9616.53,APC
Ureter endoscopy & biopsy,50974,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,1625.89,9616.53,APC
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,9616.53,
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,1625.89,9616.53,APC
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,1625.89,9616.53,APC
Ureter endoscopy & treatment,50976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,1625.89,9616.53,APC
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Ureter endoscopy & treatment,50980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Incise & treat bladder,51020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,3749.16,
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Incise & drain bladder,51040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,727.4,3749.16,
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,3749.16,
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,3749.16,
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,727.4,3749.16,
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,727.4,3749.16,
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,3749.16,
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,727.4,3749.16,
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,3749.16,
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,727.4,3749.16,APC
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,727.4,3749.16,APC
Incise bladder/drain ureter,51045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,727.4,3749.16,APC
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Removal of bladder stone,51050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2459.66,,,,,,,fee schedule,1612.55,3749.16,
Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1612.55,,,,,,,fee schedule,1612.55,3749.16,
Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2013.23,,,,,,,fee schedule,1612.55,3749.16,
Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2828.61,,,,,,,fee schedule,1612.55,3749.16,
Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1612.55,3749.16,APC
Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1612.55,3749.16,APC
Removal of ureter stone,51060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1612.55,3749.16,APC
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,6322.15,
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,6322.15,
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,6322.15,
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,6322.15,
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Remove ureter calculus,51065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,1847.27,5209.69,
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Drainage of bladder abscess,51080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.2,,,,,,,fee schedule,57.17,448.11,
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.82,,,,,,,fee schedule,57.17,448.11,
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.82,,,,,,,fee schedule,57.17,448.11,
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.17,,,,,,,fee schedule,57.17,448.11,
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.17,448.11,
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.49,,,,,,,fee schedule,57.17,448.11,
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.28,,,,,,,fee schedule,57.17,448.11,
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.82,,,,,,,fee schedule,57.17,448.11,
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,57.17,448.11,APC
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,57.17,448.11,APC
Drain bladder by needle,51100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,57.17,448.11,APC
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,234.16,,,,,,,fee schedule,150.05,1540.17,
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.05,,,,,,,fee schedule,150.05,1540.17,
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.05,,,,,,,fee schedule,150.05,1540.17,
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,153.52,,,,,,,fee schedule,150.05,1540.17,
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.66,,,,,,,fee schedule,150.05,1540.17,
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.56,,,,,,,fee schedule,150.05,1540.17,
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,269.28,,,,,,,fee schedule,150.05,1540.17,
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.05,,,,,,,fee schedule,150.05,1540.17,
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,150.05,1540.17,APC
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,150.05,1540.17,APC
Drain bladder by trocar/cath,51101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,150.05,1540.17,APC
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3410.17,,,,,,,fee schedule,1823.05,3921.7,
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1823.05,,,,,,,fee schedule,1823.05,3921.7,
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1823.05,,,,,,,fee schedule,1823.05,3921.7,
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2235.71,,,,,,,fee schedule,1823.05,3921.7,
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2791.22,,,,,,,fee schedule,1823.05,3921.7,
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2096.51,,,,,,,fee schedule,1823.05,3921.7,
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3921.7,,,,,,,fee schedule,1823.05,3921.7,
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1823.05,,,,,,,fee schedule,1823.05,3921.7,
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1823.05,3921.7,APC
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1823.05,3921.7,APC
Drain bl w/cath insertion,51102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1823.05,3921.7,APC
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3545.32,10842.82,
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,10842.82,
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,10842.82,
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3545.32,10842.82,
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3545.32,10842.82,
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,10842.82,
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3545.32,10842.82,
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,10842.82,
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3545.32,10842.82,APC
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3545.32,10842.82,APC
Removal of bladder cyst,51500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3545.32,10842.82,APC
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,6322.15,
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of bladder lesion,51520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,6322.15,
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Repair of ureter lesion,51535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Injection for bladder x-ray,51600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,685.89,,,,,,,fee schedule,449.67,788.77,
Injection for bladder x-ray,51600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,449.67,,,,,,,fee schedule,449.67,788.77,
Injection for bladder x-ray,51600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,561.4,,,,,,,fee schedule,449.67,788.77,
Injection for bladder x-ray,51600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,788.77,,,,,,,fee schedule,449.67,788.77,
Preparation for bladder xray,51605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.21,,,,,,,fee schedule,25.71,45.09,
Preparation for bladder xray,51605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.71,,,,,,,fee schedule,25.71,45.09,
Preparation for bladder xray,51605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.09,,,,,,,fee schedule,25.71,45.09,
Preparation for bladder xray,51605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.09,,,,,,,fee schedule,25.71,45.09,
Injection for bladder x-ray,51610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,439.89,,,,,,,fee schedule,288.39,505.87,
Injection for bladder x-ray,51610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,288.39,,,,,,,fee schedule,288.39,505.87,
Injection for bladder x-ray,51610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,360.05,,,,,,,fee schedule,288.39,505.87,
Injection for bladder x-ray,51610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,505.87,,,,,,,fee schedule,288.39,505.87,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,138.16,,,,,,,fee schedule,90.58,448.11,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.3,,,,,,,fee schedule,90.58,448.11,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.3,,,,,,,fee schedule,90.58,448.11,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.58,,,,,,,fee schedule,90.58,448.11,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.08,,,,,,,fee schedule,90.58,448.11,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.2,,,,,,,fee schedule,90.58,448.11,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,158.88,,,,,,,fee schedule,90.58,448.11,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.3,,,,,,,fee schedule,90.58,448.11,
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,90.58,448.11,APC
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,90.58,448.11,APC
Irrigation of bladder,51700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,90.58,448.11,APC
Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Insert bladder catheter,51701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Insert temp bladder cath,51702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,187.62,,,,,,,fee schedule,123,230.78,
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.05,,,,,,,fee schedule,123,230.78,
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.05,,,,,,,fee schedule,123,230.78,
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123,,,,,,,fee schedule,123,230.78,
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.57,,,,,,,fee schedule,123,230.78,
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.56,,,,,,,fee schedule,123,230.78,
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,215.76,,,,,,,fee schedule,123,230.78,
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.05,,,,,,,fee schedule,123,230.78,
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,123,230.78,APC
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,123,230.78,APC
Insert bladder cath complex,51703,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,123,230.78,APC
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.77,,,,,,,fee schedule,102.12,448.11,
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.59,,,,,,,fee schedule,102.12,448.11,
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.59,,,,,,,fee schedule,102.12,448.11,
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.12,,,,,,,fee schedule,102.12,448.11,
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.5,,,,,,,fee schedule,102.12,448.11,
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.08,,,,,,,fee schedule,102.12,448.11,
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.14,,,,,,,fee schedule,102.12,448.11,
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.59,,,,,,,fee schedule,102.12,448.11,
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,102.12,448.11,APC
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,102.12,448.11,APC
Change of bladder tube,51705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,102.12,448.11,APC
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,531.76,1250.62,
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,531.76,1250.62,
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,531.76,1250.62,
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,531.76,1250.62,
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,531.76,1250.62,
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,531.76,1250.62,
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,531.76,1250.62,
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,531.76,1250.62,
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,531.76,1250.62,APC
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,531.76,1250.62,APC
Change of bladder tube,51710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,531.76,1250.62,APC
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,2114.87,6322.15,
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,2114.87,6322.15,
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,2114.87,6322.15,
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,2114.87,6322.15,
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Endoscopic injection/implant,51715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.87,,,,,,,fee schedule,99.57,1250.62,
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.54,,,,,,,fee schedule,99.57,1250.62,
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.54,,,,,,,fee schedule,99.57,1250.62,
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.57,,,,,,,fee schedule,99.57,1250.62,
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.31,,,,,,,fee schedule,99.57,1250.62,
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.22,,,,,,,fee schedule,99.57,1250.62,
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.65,,,,,,,fee schedule,99.57,1250.62,
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.54,,,,,,,fee schedule,99.57,1250.62,
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,99.57,1250.62,APC
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,99.57,1250.62,APC
Treatment of bladder lesion,51720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,99.57,1250.62,APC
Ins trurl ablt trnsdc thr us,51721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1856.3,,,,,,,fee schedule,1216.99,2134.75,
Ins trurl ablt trnsdc thr us,51721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1216.99,,,,,,,fee schedule,1216.99,2134.75,
Ins trurl ablt trnsdc thr us,51721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1519.38,,,,,,,fee schedule,1216.99,2134.75,
Ins trurl ablt trnsdc thr us,51721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2134.75,,,,,,,fee schedule,1216.99,2134.75,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,305.69,,,,,,,fee schedule,200.41,448.11,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.03,,,,,,,fee schedule,200.41,448.11,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,268.03,,,,,,,fee schedule,200.41,448.11,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,200.41,,,,,,,fee schedule,200.41,448.11,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,250.21,,,,,,,fee schedule,200.41,448.11,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.23,,,,,,,fee schedule,200.41,448.11,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,351.54,,,,,,,fee schedule,200.41,448.11,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.03,,,,,,,fee schedule,200.41,448.11,
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,200.41,448.11,APC
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,200.41,448.11,APC
Simple cystometrogram,51725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,200.41,448.11,APC
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,492.85,,,,,,,fee schedule,248.95,569.62,
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,495.32,,,,,,,fee schedule,248.95,569.62,
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,495.32,,,,,,,fee schedule,248.95,569.62,
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,323.11,,,,,,,fee schedule,248.95,569.62,
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,403.4,,,,,,,fee schedule,248.95,569.62,
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,569.62,,,,,,,fee schedule,248.95,569.62,
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,566.78,,,,,,,fee schedule,248.95,569.62,
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,495.32,,,,,,,fee schedule,248.95,569.62,
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,248.95,569.62,APC
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,248.95,569.62,APC
Complex cystometrogram,51726,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,248.95,569.62,APC
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,564.4,,,,,,,fee schedule,370.02,1250.62,
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,493.73,,,,,,,fee schedule,370.02,1250.62,
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,493.73,,,,,,,fee schedule,370.02,1250.62,
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,370.02,,,,,,,fee schedule,370.02,1250.62,
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,461.96,,,,,,,fee schedule,370.02,1250.62,
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,567.79,,,,,,,fee schedule,370.02,1250.62,
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,649.06,,,,,,,fee schedule,370.02,1250.62,
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.73,,,,,,,fee schedule,370.02,1250.62,
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,370.02,1250.62,APC
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,370.02,1250.62,APC
Cystometrogram w/up,51727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,370.02,1250.62,APC
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,618.55,,,,,,,fee schedule,405.52,1250.62,
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,495.32,,,,,,,fee schedule,405.52,1250.62,
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,495.32,,,,,,,fee schedule,405.52,1250.62,
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,405.52,,,,,,,fee schedule,405.52,1250.62,
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,506.28,,,,,,,fee schedule,405.52,1250.62,
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,569.62,,,,,,,fee schedule,405.52,1250.62,
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,711.33,,,,,,,fee schedule,405.52,1250.62,
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,495.32,,,,,,,fee schedule,405.52,1250.62,
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,405.52,1250.62,APC
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,405.52,1250.62,APC
Cystometrogram w/vp,51728,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,405.52,1250.62,APC
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,589.85,,,,,,,fee schedule,386.71,1250.62,
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,495.32,,,,,,,fee schedule,386.71,1250.62,
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,495.32,,,,,,,fee schedule,386.71,1250.62,
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,386.71,,,,,,,fee schedule,386.71,1250.62,
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,482.79,,,,,,,fee schedule,386.71,1250.62,
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,569.62,,,,,,,fee schedule,386.71,1250.62,
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,678.33,,,,,,,fee schedule,386.71,1250.62,
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,495.32,,,,,,,fee schedule,386.71,1250.62,
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,386.71,1250.62,APC
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,386.71,1250.62,APC
Cystometrogram w/vp&up,51729,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,386.71,1250.62,APC
Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,12.85,238.63,
Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,12.85,238.63,
Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,12.85,238.63,
Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,12.85,238.63,
Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,12.85,238.63,APC
Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,12.85,238.63,APC
Urine flow measurement,51736,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,12.85,238.63,APC
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,13.49,387.26,
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.29,,,,,,,fee schedule,13.49,387.26,
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.29,,,,,,,fee schedule,13.49,387.26,
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,13.49,387.26,
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,13.49,387.26,
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.88,,,,,,,fee schedule,13.49,387.26,
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,13.49,387.26,
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.29,,,,,,,fee schedule,13.49,387.26,
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,13.49,387.26,APC
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,13.49,387.26,APC
Electro-uroflowmetry first,51741,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,13.49,387.26,APC
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.75,,,,,,,fee schedule,128.21,455.11,
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.05,,,,,,,fee schedule,128.21,455.11,
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.05,,,,,,,fee schedule,128.21,455.11,
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.45,,,,,,,fee schedule,128.21,455.11,
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,323.92,,,,,,,fee schedule,128.21,455.11,
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.56,,,,,,,fee schedule,128.21,455.11,
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.11,,,,,,,fee schedule,128.21,455.11,
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.05,,,,,,,fee schedule,128.21,455.11,
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,455.11,APC
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,455.11,APC
Anal/urinary muscle study,51784,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,455.11,APC
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,485.02,,,,,,,fee schedule,248.95,557.77,
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.29,,,,,,,fee schedule,248.95,557.77,
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.29,,,,,,,fee schedule,248.95,557.77,
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,317.98,,,,,,,fee schedule,248.95,557.77,
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,396.99,,,,,,,fee schedule,248.95,557.77,
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.78,,,,,,,fee schedule,248.95,557.77,
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,557.77,,,,,,,fee schedule,248.95,557.77,
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.29,,,,,,,fee schedule,248.95,557.77,
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,248.95,557.77,APC
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,248.95,557.77,APC
Anal/urinary muscle study,51785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,248.95,557.77,APC
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,433.08,,,,,,,fee schedule,58.78,498.04,
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.05,,,,,,,fee schedule,58.78,498.04,
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.05,,,,,,,fee schedule,58.78,498.04,
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.93,,,,,,,fee schedule,58.78,498.04,
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,354.48,,,,,,,fee schedule,58.78,498.04,
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.56,,,,,,,fee schedule,58.78,498.04,
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,498.04,,,,,,,fee schedule,58.78,498.04,
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.05,,,,,,,fee schedule,58.78,498.04,
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,498.04,APC
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,498.04,APC
Urinary reflex study,51792,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,498.04,APC
Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.24,,,,,,,fee schedule,58.78,170.48,
Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.19,,,,,,,fee schedule,58.78,170.48,
Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.33,,,,,,,fee schedule,58.78,170.48,
Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.48,,,,,,,fee schedule,58.78,170.48,
Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,170.48,APC
Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,170.48,APC
Us urine capacity measure,51798,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,170.48,APC
Attach bladder/urethra,51840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,8972.03,APC
Attach bladder/urethra,51840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,8972.03,APC
Attach bladder/urethra,51840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,8972.03,APC
Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5699.29,,,,,,,fee schedule,3736.45,8972.03,
Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3736.45,,,,,,,fee schedule,3736.45,8972.03,
Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4664.87,,,,,,,fee schedule,3736.45,8972.03,
Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6554.18,,,,,,,fee schedule,3736.45,8972.03,
Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3736.45,8972.03,APC
Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3736.45,8972.03,APC
Repair bladder neck,51845,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3736.45,8972.03,APC
Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5210.48,,,,,,,fee schedule,3415.99,16978.36,
Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3415.99,,,,,,,fee schedule,3415.99,16978.36,
Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4264.78,,,,,,,fee schedule,3415.99,16978.36,
Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5992.05,,,,,,,fee schedule,3415.99,16978.36,
Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,3415.99,16978.36,APC
Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,3415.99,16978.36,APC
Repair of bladder wound,51860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,3415.99,16978.36,APC
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Repair of bladder opening,51880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6279.99,,,,,,,fee schedule,4117.16,10842.82,
Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4117.16,,,,,,,fee schedule,4117.16,10842.82,
Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5140.17,,,,,,,fee schedule,4117.16,10842.82,
Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7221.99,,,,,,,fee schedule,4117.16,10842.82,
Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4117.16,10842.82,APC
Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4117.16,10842.82,APC
Laparo urethral suspension,51990,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4117.16,10842.82,APC
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,10842.82,
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo sling operation,51992,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscope proc bla,51999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc bla,51999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc bla,51999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,747.97,,,,,,,fee schedule,694.79,1250.62,
Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,747.97,,,,,,,fee schedule,694.79,1250.62,
Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,860.17,,,,,,,fee schedule,694.79,1250.62,
Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,747.97,,,,,,,fee schedule,694.79,1250.62,
Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,694.79,1250.62,APC
Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,694.79,1250.62,APC
Cystoscopy,52000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,694.79,1250.62,APC
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.52,,,,,,,fee schedule,1625.89,6322.15,
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,6322.15,
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,6322.15,
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,1625.89,6322.15,
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.18,,,,,,,fee schedule,1625.89,6322.15,
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,6322.15,
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.85,,,,,,,fee schedule,1625.89,6322.15,
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,6322.15,
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1625.89,6322.15,APC
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1625.89,6322.15,APC
Cystoscopy removal of clots,52001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1625.89,6322.15,APC
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3677.59,,,,,,,fee schedule,2082.87,4229.23,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2082.87,4229.23,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2082.87,4229.23,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2411.03,,,,,,,fee schedule,2082.87,4229.23,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3010.11,,,,,,,fee schedule,2082.87,4229.23,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2082.87,4229.23,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4229.23,,,,,,,fee schedule,2082.87,4229.23,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2082.87,4229.23,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,4229.23,APC
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,4229.23,APC
Cystoscopy & ureter catheter,52005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,4229.23,APC
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and biopsy,52007,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.11,,,,,,,fee schedule,531.76,1250.62,
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,1250.62,
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,531.76,1250.62,
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.76,,,,,,,fee schedule,531.76,1250.62,
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,663.89,,,,,,,fee schedule,531.76,1250.62,
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,531.76,1250.62,
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,932.78,,,,,,,fee schedule,531.76,1250.62,
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,531.76,1250.62,
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,531.76,1250.62,APC
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,531.76,1250.62,APC
Cystoscopy & duct catheter,52010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,531.76,1250.62,APC
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3620.37,,,,,,,fee schedule,2082.87,4163.43,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2082.87,4163.43,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2082.87,4163.43,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2373.51,,,,,,,fee schedule,2082.87,4163.43,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2963.27,,,,,,,fee schedule,2082.87,4163.43,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2082.87,4163.43,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4163.43,,,,,,,fee schedule,2082.87,4163.43,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2082.87,4163.43,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,4163.43,APC
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,4163.43,APC
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,4163.43,APC
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4611.1,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3023.04,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3774.19,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5302.77,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy and treatment,52214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3897.33,,,,,,,fee schedule,2555.09,6322.15,
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2555.09,6322.15,
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2555.09,6322.15,
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2555.09,,,,,,,fee schedule,2555.09,6322.15,
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3189.96,,,,,,,fee schedule,2555.09,6322.15,
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2555.09,6322.15,
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4481.93,,,,,,,fee schedule,2555.09,6322.15,
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2555.09,6322.15,
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2555.09,6322.15,APC
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2555.09,6322.15,APC
Cystoscopy and treatment,52224,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2555.09,6322.15,APC
Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2780.42,,,,,,,fee schedule,2780.42,6322.15,
Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2780.42,,,,,,,fee schedule,2780.42,6322.15,
Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3197.48,,,,,,,fee schedule,2780.42,6322.15,
Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2780.42,,,,,,,fee schedule,2780.42,6322.15,
Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2780.42,6322.15,APC
Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2780.42,6322.15,APC
Cystoscopy and treatment,52234,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2780.42,6322.15,APC
Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5516.2,,,,,,,fee schedule,3512.31,6343.63,
Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5516.2,,,,,,,fee schedule,3512.31,6343.63,
Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6343.63,,,,,,,fee schedule,3512.31,6343.63,
Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5516.2,,,,,,,fee schedule,3512.31,6343.63,
Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6343.63,APC
Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6343.63,APC
Cystoscopy and treatment,52235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6343.63,APC
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5181.48,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3396.98,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4241.04,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5958.7,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy and treatment,52240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy and radiotracer,52250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4535.56,,,,,,,fee schedule,1625.89,5215.89,
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,5215.89,
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,5215.89,
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2973.51,,,,,,,fee schedule,1625.89,5215.89,
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3712.36,,,,,,,fee schedule,1625.89,5215.89,
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,5215.89,
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5215.89,,,,,,,fee schedule,1625.89,5215.89,
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,5215.89,
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1625.89,5215.89,APC
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1625.89,5215.89,APC
Cystoscopy and treatment,52260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1625.89,5215.89,APC
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,698.65,,,,,,,fee schedule,458.03,3749.16,
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,611.32,,,,,,,fee schedule,458.03,3749.16,
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,611.32,,,,,,,fee schedule,458.03,3749.16,
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,458.03,,,,,,,fee schedule,458.03,3749.16,
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,571.85,,,,,,,fee schedule,458.03,3749.16,
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,703.02,,,,,,,fee schedule,458.03,3749.16,
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,803.45,,,,,,,fee schedule,458.03,3749.16,
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,611.32,,,,,,,fee schedule,458.03,3749.16,
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,458.03,3749.16,APC
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,458.03,3749.16,APC
Cystoscopy and treatment,52265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,458.03,3749.16,APC
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy & revise urethra,52270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy & revise urethra,52275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3842.82,,,,,,,fee schedule,2082.87,4419.24,
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2082.87,4419.24,
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2082.87,4419.24,
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2519.35,,,,,,,fee schedule,2082.87,4419.24,
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3145.35,,,,,,,fee schedule,2082.87,4419.24,
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2082.87,4419.24,
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4419.24,,,,,,,fee schedule,2082.87,4419.24,
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2082.87,4419.24,
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,4419.24,APC
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,4419.24,APC
Cystoscopy and treatment,52276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,4419.24,APC
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.99,,,,,,,fee schedule,1625.89,4491.89,
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,4491.89,
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,4491.89,
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2560.77,,,,,,,fee schedule,1625.89,4491.89,
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3197.05,,,,,,,fee schedule,1625.89,4491.89,
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,4491.89,
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.89,,,,,,,fee schedule,1625.89,4491.89,
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,4491.89,
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1625.89,4491.89,APC
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1625.89,4491.89,APC
Cystoscopy and treatment,52281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1625.89,4491.89,APC
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy implant stent,52282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy and treatment,52283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8907.44,,,,,,,fee schedule,3407.17,10243.56,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3407.17,,,,,,,fee schedule,3407.17,10243.56,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3407.17,,,,,,,fee schedule,3407.17,10243.56,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5839.72,,,,,,,fee schedule,3407.17,10243.56,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7290.74,,,,,,,fee schedule,3407.17,10243.56,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3918.25,,,,,,,fee schedule,3407.17,10243.56,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10243.56,,,,,,,fee schedule,3407.17,10243.56,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3407.17,,,,,,,fee schedule,3407.17,10243.56,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3407.17,10243.56,APC
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3407.17,10243.56,APC
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3407.17,10243.56,APC
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,694.79,2489.19,
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,694.79,2489.19,
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,694.79,2489.19,
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,694.79,2489.19,
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,694.79,2489.19,
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,694.79,2489.19,
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,694.79,2489.19,
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,694.79,2489.19,
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,694.79,2489.19,APC
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,694.79,2489.19,APC
Cystoscopy and treatment,52285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,694.79,2489.19,APC
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4695.83,,,,,,,fee schedule,1625.89,5400.2,
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,5400.2,
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,5400.2,
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3078.59,,,,,,,fee schedule,1625.89,5400.2,
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3843.54,,,,,,,fee schedule,1625.89,5400.2,
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,5400.2,
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5400.2,,,,,,,fee schedule,1625.89,5400.2,
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,5400.2,
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1625.89,5400.2,APC
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1625.89,5400.2,APC
Cystoscopy chemodenervation,52287,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1625.89,5400.2,APC
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy and treatment,52290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy and treatment,52305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5666.23,,,,,,,fee schedule,1625.89,6516.16,
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,6516.16,
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,6516.16,
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3714.78,,,,,,,fee schedule,1625.89,6516.16,
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4637.81,,,,,,,fee schedule,1625.89,6516.16,
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,6516.16,
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6516.16,,,,,,,fee schedule,1625.89,6516.16,
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,6516.16,
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1625.89,6516.16,APC
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1625.89,6516.16,APC
Cystoscopy and treatment,52310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1625.89,6516.16,APC
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,3749.16,
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Cystoscopy and treatment,52315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4211.23,,,,,,,fee schedule,2760.88,6322.15,
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2760.88,6322.15,
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2760.88,6322.15,
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2760.88,,,,,,,fee schedule,2760.88,6322.15,
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3446.89,,,,,,,fee schedule,2760.88,6322.15,
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2760.88,6322.15,
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4842.91,,,,,,,fee schedule,2760.88,6322.15,
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2760.88,6322.15,
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2760.88,6322.15,APC
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2760.88,6322.15,APC
Remove bladder stone,52317,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2760.88,6322.15,APC
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12720.87,,,,,,,fee schedule,2762.68,14629,
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,14629,
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,14629,
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8339.8,,,,,,,fee schedule,2762.68,14629,
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10412.03,,,,,,,fee schedule,2762.68,14629,
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,14629,
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14629,,,,,,,fee schedule,2762.68,14629,
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,14629,
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,14629,APC
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,14629,APC
Remove bladder stone,52318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,14629,APC
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4230.61,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2773.59,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3462.75,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4865.2,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy and treatment,52320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4598.45,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3014.74,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3763.83,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5288.22,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy stone removal,52325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4885.25,,,,,,,fee schedule,3202.77,9616.53,
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,3202.77,9616.53,
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,3202.77,9616.53,
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3202.77,,,,,,,fee schedule,3202.77,9616.53,
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3998.58,,,,,,,fee schedule,3202.77,9616.53,
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,3202.77,9616.53,
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5618.04,,,,,,,fee schedule,3202.77,9616.53,
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,3202.77,9616.53,
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3202.77,9616.53,APC
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3202.77,9616.53,APC
Cystoscopy inject material,52327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3202.77,9616.53,APC
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3758.54,,,,,,,fee schedule,2464.1,6322.15,
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2464.1,6322.15,
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2464.1,6322.15,
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2464.1,,,,,,,fee schedule,2464.1,6322.15,
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3076.36,,,,,,,fee schedule,2464.1,6322.15,
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2464.1,6322.15,
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4322.32,,,,,,,fee schedule,2464.1,6322.15,
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2464.1,6322.15,
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2464.1,6322.15,APC
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2464.1,6322.15,APC
Cystoscopy and treatment,52330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2464.1,6322.15,APC
Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5678.02,,,,,,,fee schedule,3512.31,6529.72,
Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5678.02,,,,,,,fee schedule,3512.31,6529.72,
Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6529.72,,,,,,,fee schedule,3512.31,6529.72,
Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5678.02,,,,,,,fee schedule,3512.31,6529.72,
Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6529.72,APC
Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6529.72,APC
Cystoscopy and treatment,52332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6529.72,APC
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Create passage to kidney,52334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,6322.15,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4418.84,,,,,,,fee schedule,2762.68,6322.15,
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2896.99,,,,,,,fee schedule,2762.68,6322.15,
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3616.82,,,,,,,fee schedule,2762.68,6322.15,
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5081.67,,,,,,,fee schedule,2762.68,6322.15,
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto/uretero stricture tx,52344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,6322.15,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,6322.15,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,6322.15,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,6322.15,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Cystouretero W/Renal Strict,52346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3678.8,,,,,,,fee schedule,2411.82,6322.15,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2411.82,6322.15,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2411.82,6322.15,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2411.82,,,,,,,fee schedule,2411.82,6322.15,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3011.1,,,,,,,fee schedule,2411.82,6322.15,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2411.82,6322.15,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4230.62,,,,,,,fee schedule,2411.82,6322.15,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2411.82,6322.15,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2411.82,6322.15,APC
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2411.82,6322.15,APC
Cystouretero & or pyeloscope,52351,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2411.82,6322.15,APC
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3750.73,,,,,,,fee schedule,2458.98,6322.15,
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2458.98,6322.15,
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2458.98,6322.15,
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2458.98,,,,,,,fee schedule,2458.98,6322.15,
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3069.97,,,,,,,fee schedule,2458.98,6322.15,
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2458.98,6322.15,
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4313.34,,,,,,,fee schedule,2458.98,6322.15,
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2458.98,6322.15,
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2458.98,6322.15,APC
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2458.98,6322.15,APC
Cystouretero w/stone remove,52352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2458.98,6322.15,APC
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.51,,,,,,,fee schedule,2685.02,9616.53,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,2685.02,9616.53,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,2685.02,9616.53,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,2685.02,9616.53,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.17,,,,,,,fee schedule,2685.02,9616.53,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,2685.02,9616.53,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.84,,,,,,,fee schedule,2685.02,9616.53,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,2685.02,9616.53,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2685.02,9616.53,APC
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2685.02,9616.53,APC
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2685.02,9616.53,APC
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4418.82,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2896.98,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3616.8,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5081.64,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Cystouretero W/Biopsy,52354,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4987.94,,,,,,,fee schedule,3270.09,9616.53,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,3270.09,9616.53,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,3270.09,9616.53,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3270.09,,,,,,,fee schedule,3270.09,9616.53,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4082.63,,,,,,,fee schedule,3270.09,9616.53,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,3270.09,9616.53,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5736.13,,,,,,,fee schedule,3270.09,9616.53,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,3270.09,9616.53,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3270.09,9616.53,APC
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3270.09,9616.53,APC
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3270.09,9616.53,APC
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,6322.15,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Cystouretero W/Congen Repr,52400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Cystourethro cut ejacul duct,52402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Cystourethro w/implant,52441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.06,,,,,,,fee schedule,2044.2,3585.77,
Cystourethro w/implant,52441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.2,,,,,,,fee schedule,2044.2,3585.77,
Cystourethro w/implant,52441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.13,,,,,,,fee schedule,2044.2,3585.77,
Cystourethro w/implant,52441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3585.77,,,,,,,fee schedule,2044.2,3585.77,
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,16978.36,APC
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,16978.36,APC
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2114.87,6322.15,
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2114.87,6322.15,
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Incision of prostate,52450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3353.28,,,,,,,fee schedule,2198.41,6322.15,
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2198.41,6322.15,
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2198.41,6322.15,
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2198.41,,,,,,,fee schedule,2198.41,6322.15,
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2744.66,,,,,,,fee schedule,2198.41,6322.15,
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2198.41,6322.15,
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3856.27,,,,,,,fee schedule,2198.41,6322.15,
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2198.41,6322.15,
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2198.41,6322.15,APC
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2198.41,6322.15,APC
Revision of bladder neck,52500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2198.41,6322.15,APC
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,16978.36,APC
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,16978.36,APC
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,16978.36,APC
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5404.15,,,,,,,fee schedule,3542.96,9616.53,
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,3542.96,9616.53,
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,3542.96,9616.53,
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3542.96,,,,,,,fee schedule,3542.96,9616.53,
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4423.3,,,,,,,fee schedule,3542.96,9616.53,
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,3542.96,9616.53,
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6214.77,,,,,,,fee schedule,3542.96,9616.53,
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,3542.96,9616.53,
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3542.96,9616.53,APC
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3542.96,9616.53,APC
Prostatectomy (TURP),52601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3542.96,9616.53,APC
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,3171.64,9616.53,
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,3171.64,9616.53,
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,3171.64,9616.53,
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,3171.64,9616.53,
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,3171.64,9616.53,
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,3171.64,9616.53,
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,3171.64,9616.53,
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,3171.64,9616.53,
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3171.64,9616.53,APC
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3171.64,9616.53,APC
Remove prostate regrowth,52630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3171.64,9616.53,APC
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3716.46,,,,,,,fee schedule,2436.51,6322.15,
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2436.51,6322.15,
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2436.51,6322.15,
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2436.51,,,,,,,fee schedule,2436.51,6322.15,
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3041.92,,,,,,,fee schedule,2436.51,6322.15,
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2436.51,6322.15,
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4273.93,,,,,,,fee schedule,2436.51,6322.15,
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2436.51,6322.15,
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2436.51,6322.15,APC
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2436.51,6322.15,APC
Relieve bladder contracture,52640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2436.51,6322.15,APC
Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,5467.19,
Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,3116.77,5467.19,
Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,3116.77,5467.19,
Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,5467.19,
Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,5467.19,
Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,3116.77,5467.19,
Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,5467.19,
Laser surgery of prostate,52647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,3116.77,5467.19,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5052.46,,,,,,,fee schedule,3312.39,9616.53,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,3312.39,9616.53,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,3312.39,9616.53,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3312.39,,,,,,,fee schedule,3312.39,9616.53,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4135.44,,,,,,,fee schedule,3312.39,9616.53,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,3312.39,9616.53,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5810.33,,,,,,,fee schedule,3312.39,9616.53,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,3312.39,9616.53,
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3312.39,9616.53,APC
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3312.39,9616.53,APC
Laser surgery of prostate,52648,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3312.39,9616.53,APC
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7724.46,,,,,,,fee schedule,4126.14,9616.53,
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4126.14,,,,,,,fee schedule,4126.14,9616.53,
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4126.14,,,,,,,fee schedule,4126.14,9616.53,
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5064.16,,,,,,,fee schedule,4126.14,9616.53,
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6322.47,,,,,,,fee schedule,4126.14,9616.53,
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4745.06,,,,,,,fee schedule,4126.14,9616.53,
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8883.13,,,,,,,fee schedule,4126.14,9616.53,
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4126.14,,,,,,,fee schedule,4126.14,9616.53,
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,4126.14,9616.53,APC
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,4126.14,9616.53,APC
Prostate laser enucleation,52649,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,4126.14,9616.53,APC
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2762.68,6322.15,
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2762.68,6322.15,
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2762.68,6322.15,
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,6322.15,
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2762.68,6322.15,
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,6322.15,
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2762.68,6322.15,APC
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2762.68,6322.15,APC
Drainage of prostate abscess,52700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2762.68,6322.15,APC
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Incision of urethra,53000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2158.32,9616.53,
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2158.32,9616.53,
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2158.32,9616.53,
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2158.32,9616.53,
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2158.32,9616.53,
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2158.32,9616.53,APC
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2158.32,9616.53,APC
Incision of urethra,53010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2158.32,9616.53,APC
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.85,,,,,,,fee schedule,2082.87,7300.03,
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2082.87,7300.03,
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2082.87,7300.03,
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.65,,,,,,,fee schedule,2082.87,7300.03,
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.72,,,,,,,fee schedule,2082.87,7300.03,
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2082.87,7300.03,
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.03,,,,,,,fee schedule,2082.87,7300.03,
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2082.87,7300.03,
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,7300.03,APC
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,7300.03,APC
Incision of urethra,53020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,7300.03,APC
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Incision of urethra,53025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2158.32,6322.15,
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,6322.15,
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2158.32,6322.15,
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2158.32,6322.15,
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2158.32,6322.15,
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2158.32,6322.15,
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2158.32,6322.15,
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,6322.15,
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2158.32,6322.15,APC
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2158.32,6322.15,APC
Drainage of urethra abscess,53040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2158.32,6322.15,APC
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,222.44,,,,,,,fee schedule,145.83,3749.16,
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.54,,,,,,,fee schedule,145.83,3749.16,
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,194.54,,,,,,,fee schedule,145.83,3749.16,
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.83,,,,,,,fee schedule,145.83,3749.16,
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.07,,,,,,,fee schedule,145.83,3749.16,
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,223.72,,,,,,,fee schedule,145.83,3749.16,
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.81,,,,,,,fee schedule,145.83,3749.16,
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194.54,,,,,,,fee schedule,145.83,3749.16,
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,145.83,3749.16,APC
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,145.83,3749.16,APC
Drainage of urethra abscess,53060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,145.83,3749.16,APC
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,694.79,2489.19,
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,694.79,2489.19,
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,694.79,2489.19,
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,694.79,2489.19,
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,694.79,2489.19,
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,694.79,2489.19,
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,694.79,2489.19,
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,694.79,2489.19,
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,694.79,2489.19,APC
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,694.79,2489.19,APC
Drainage of urinary leakage,53080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,694.79,2489.19,APC
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,3749.16,
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Drainage of urinary leakage,53085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2082.87,3749.16,
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2082.87,3749.16,
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2082.87,3749.16,
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2082.87,3749.16,
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2082.87,3749.16,
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2082.87,3749.16,
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2082.87,3749.16,
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2082.87,3749.16,
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,3749.16,APC
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,3749.16,APC
Biopsy of urethra,53200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,3749.16,APC
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,6322.15,
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,6322.15,
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,6322.15,
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,6322.15,
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,6322.15,
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3116.77,6322.15,APC
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3116.77,6322.15,APC
Removal of urethra,53210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3116.77,6322.15,APC
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2158.32,9616.53,APC
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2158.32,9616.53,APC
Removal of urethra,53215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2158.32,9616.53,APC
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,6322.15,
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,6322.15,
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,6322.15,
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,6322.15,
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,6322.15,
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3116.77,6322.15,APC
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3116.77,6322.15,APC
Treatment of urethra lesion,53220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3116.77,6322.15,APC
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Removal of urethra lesion,53230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2158.32,9616.53,APC
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2158.32,9616.53,APC
Removal of urethra lesion,53235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2158.32,9616.53,APC
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,6322.15,
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,6322.15,
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,6322.15,
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,6322.15,
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,6322.15,
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,6322.15,
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3116.77,6322.15,APC
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3116.77,6322.15,APC
Surgery for urethra pouch,53240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3116.77,6322.15,APC
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,6322.15,
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of urethra gland,53250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,6322.15,
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Treatment of urethra lesion,53260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,3749.16,
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Treatment of urethra lesion,53265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2114.87,6322.15,
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2114.87,6322.15,
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2114.87,6322.15,
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2114.87,6322.15,
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Removal of urethra gland,53270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,6322.15,
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Repair of urethra defect,53275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Revise urethra stage 1,53400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Revise urethra stage 2,53405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruction of urethra,53410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruct urethra stage 1,53420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruct urethra stage 2,53425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10775.67,,,,,,,fee schedule,3325.5,12392.02,
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3325.5,12392.02,
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3325.5,12392.02,
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7064.53,,,,,,,fee schedule,3325.5,12392.02,
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8819.89,,,,,,,fee schedule,3325.5,12392.02,
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3325.5,12392.02,
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12392.02,,,,,,,fee schedule,3325.5,12392.02,
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3325.5,12392.02,
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3325.5,12392.02,APC
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3325.5,12392.02,APC
Reconstruction of urethra,53430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3325.5,12392.02,APC
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruct urethra/bladder,53431,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16930.63,,,,,,,fee schedule,11099.72,23662.82,
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16029.77,,,,,,,fee schedule,11099.72,23662.82,
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16029.77,,,,,,,fee schedule,11099.72,23662.82,
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11099.72,,,,,,,fee schedule,11099.72,23662.82,
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13857.72,,,,,,,fee schedule,11099.72,23662.82,
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18434.24,,,,,,,fee schedule,11099.72,23662.82,
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19470.22,,,,,,,fee schedule,11099.72,23662.82,
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16029.77,,,,,,,fee schedule,11099.72,23662.82,
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13803.31,,,,,,,fee schedule,11099.72,23662.82,APC
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13146.01,,,,,,,fee schedule,11099.72,23662.82,APC
Male sling procedure,53440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23662.82,,,,,,,fee schedule,11099.72,23662.82,APC
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Remove/revise male sling,53442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32223.16,,,,,,,fee schedule,16029.77,37172.87,
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16029.77,,,,,,,fee schedule,16029.77,37172.87,
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16029.77,,,,,,,fee schedule,16029.77,37172.87,
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21125.5,,,,,,,fee schedule,16029.77,37172.87,
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26374.66,,,,,,,fee schedule,16029.77,37172.87,
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18434.24,,,,,,,fee schedule,16029.77,37172.87,
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37056.63,,,,,,,fee schedule,16029.77,37172.87,
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16029.77,,,,,,,fee schedule,16029.77,37172.87,
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,16029.77,37172.87,APC
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,16029.77,37172.87,APC
Insert tandem cuff,53444,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,16029.77,37172.87,APC
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34165.01,,,,,,,fee schedule,20651.59,39289.76,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,39289.76,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28459.78,,,,,,,fee schedule,20651.59,39289.76,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22398.58,,,,,,,fee schedule,20651.59,39289.76,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27964.06,,,,,,,fee schedule,20651.59,39289.76,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32728.75,,,,,,,fee schedule,20651.59,39289.76,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39289.76,,,,,,,fee schedule,20651.59,39289.76,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,39289.76,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,20651.59,39289.76,APC
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,20651.59,39289.76,APC
Insert uro/ves nck sphincter,53445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,20651.59,39289.76,APC
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Remove uro sphincter,53446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33238.74,,,,,,,fee schedule,20651.59,38224.55,
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,38224.55,
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28459.78,,,,,,,fee schedule,20651.59,38224.55,
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21791.32,,,,,,,fee schedule,20651.59,38224.55,
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27205.91,,,,,,,fee schedule,20651.59,38224.55,
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32728.75,,,,,,,fee schedule,20651.59,38224.55,
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38224.55,,,,,,,fee schedule,20651.59,38224.55,
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,38224.55,
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,20651.59,38224.55,APC
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,20651.59,38224.55,APC
Remove/replace ur sphincter,53447,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,20651.59,38224.55,APC
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,16978.36,
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,16978.36,
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,16978.36,
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,16978.36,
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,16978.36,
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,16978.36,
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,16978.36,
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,16978.36,
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,3116.77,16978.36,APC
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,3116.77,16978.36,APC
Repair uro sphincter,53449,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,3116.77,16978.36,APC
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,1419.05,6322.15,
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,1419.05,6322.15,
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,1419.05,6322.15,
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,1419.05,6322.15,
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Revision of urethra,53450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22787.89,,,,,,,fee schedule,13146.01,26206.07,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16322.54,,,,,,,fee schedule,13146.01,26206.07,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16322.54,,,,,,,fee schedule,13146.01,26206.07,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14939.74,,,,,,,fee schedule,13146.01,26206.07,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18651.89,,,,,,,fee schedule,13146.01,26206.07,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18770.92,,,,,,,fee schedule,13146.01,26206.07,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26206.07,,,,,,,fee schedule,13146.01,26206.07,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16322.54,,,,,,,fee schedule,13146.01,26206.07,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13803.31,,,,,,,fee schedule,13146.01,26206.07,APC
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13146.01,,,,,,,fee schedule,13146.01,26206.07,APC
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23662.82,,,,,,,fee schedule,13146.01,26206.07,APC
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8753.63,,,,,,,fee schedule,5667.35,16978.36,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5667.35,,,,,,,fee schedule,5667.35,16978.36,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5667.35,,,,,,,fee schedule,5667.35,16978.36,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5738.88,,,,,,,fee schedule,5667.35,16978.36,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7164.85,,,,,,,fee schedule,5667.35,16978.36,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6517.45,,,,,,,fee schedule,5667.35,16978.36,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10066.67,,,,,,,fee schedule,5667.35,16978.36,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5667.35,,,,,,,fee schedule,5667.35,16978.36,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,5667.35,16978.36,APC
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,5667.35,16978.36,APC
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,5667.35,16978.36,APC
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6100.17,,,,,,,fee schedule,2292.26,7015.2,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2292.26,,,,,,,fee schedule,2292.26,7015.2,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2292.26,,,,,,,fee schedule,2292.26,7015.2,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3999.27,,,,,,,fee schedule,2292.26,7015.2,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4992.99,,,,,,,fee schedule,2292.26,7015.2,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2636.1,,,,,,,fee schedule,2292.26,7015.2,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7015.2,,,,,,,fee schedule,2292.26,7015.2,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2292.26,,,,,,,fee schedule,2292.26,7015.2,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2292.26,7015.2,APC
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2292.26,7015.2,APC
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2292.26,7015.2,APC
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,527.99,,,,,,,fee schedule,220.92,607.19,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.92,,,,,,,fee schedule,220.92,607.19,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,220.92,,,,,,,fee schedule,220.92,607.19,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,346.15,,,,,,,fee schedule,220.92,607.19,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,432.16,,,,,,,fee schedule,220.92,607.19,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,254.06,,,,,,,fee schedule,220.92,607.19,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,607.19,,,,,,,fee schedule,220.92,607.19,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.92,,,,,,,fee schedule,220.92,607.19,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,220.92,607.19,APC
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,220.92,607.19,APC
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,220.92,607.19,APC
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2158.32,6322.15,
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,6322.15,
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2158.32,6322.15,
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2158.32,6322.15,
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2158.32,6322.15,
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2158.32,6322.15,
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2158.32,6322.15,
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,6322.15,
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2158.32,6322.15,APC
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2158.32,6322.15,APC
Revision of urethra,53460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2158.32,6322.15,APC
Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3802.52,,,,,,,fee schedule,2492.93,6322.15,
Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2492.93,,,,,,,fee schedule,2492.93,6322.15,
Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3112.36,,,,,,,fee schedule,2492.93,6322.15,
Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4372.9,,,,,,,fee schedule,2492.93,6322.15,
Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2492.93,6322.15,APC
Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2492.93,6322.15,APC
Urethrlys transvag w/ scope,53500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2492.93,6322.15,APC
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2114.87,6322.15,
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2114.87,6322.15,
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2114.87,6322.15,
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2114.87,6322.15,
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Repair of urethra injury,53502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Repair of urethra injury,53505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2158.32,9616.53,
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2158.32,9616.53,
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2158.32,9616.53,
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,2158.32,9616.53,
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2158.32,9616.53,
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,2158.32,9616.53,
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2158.32,9616.53,APC
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2158.32,9616.53,APC
Repair of urethra injury,53510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2158.32,9616.53,APC
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3116.77,9616.53,
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Repair of urethra injury,53515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10437.49,,,,,,,fee schedule,3325.5,12003.11,
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3325.5,,,,,,,fee schedule,3325.5,12003.11,
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3325.5,,,,,,,fee schedule,3325.5,12003.11,
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6842.82,,,,,,,fee schedule,3325.5,12003.11,
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8543.09,,,,,,,fee schedule,3325.5,12003.11,
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3824.33,,,,,,,fee schedule,3325.5,12003.11,
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12003.11,,,,,,,fee schedule,3325.5,12003.11,
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3325.5,,,,,,,fee schedule,3325.5,12003.11,
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3325.5,12003.11,APC
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3325.5,12003.11,APC
Repair of urethra defect,53520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3325.5,12003.11,APC
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.88,,,,,,,fee schedule,66.79,448.11,
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.17,,,,,,,fee schedule,66.79,448.11,
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.17,,,,,,,fee schedule,66.79,448.11,
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.79,,,,,,,fee schedule,66.79,448.11,
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.39,,,,,,,fee schedule,66.79,448.11,
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.4,,,,,,,fee schedule,66.79,448.11,
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.16,,,,,,,fee schedule,66.79,448.11,
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.17,,,,,,,fee schedule,66.79,448.11,
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,66.79,448.11,APC
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,66.79,448.11,APC
Dilate urethra stricture,53600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,66.79,448.11,APC
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.61,,,,,,,fee schedule,98.06,238.63,
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.61,,,,,,,fee schedule,98.06,238.63,
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.3,,,,,,,fee schedule,98.06,238.63,
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.61,,,,,,,fee schedule,98.06,238.63,
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Dilate urethra stricture,53601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1419.05,6322.15,
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1419.05,6322.15,
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1419.05,6322.15,
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1419.05,6322.15,
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Dilate urethra stricture,53605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.91,,,,,,,fee schedule,98.28,1250.62,
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.66,,,,,,,fee schedule,98.28,1250.62,
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.66,,,,,,,fee schedule,98.28,1250.62,
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.28,,,,,,,fee schedule,98.28,1250.62,
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.7,,,,,,,fee schedule,98.28,1250.62,
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.11,,,,,,,fee schedule,98.28,1250.62,
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.4,,,,,,,fee schedule,98.28,1250.62,
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.66,,,,,,,fee schedule,98.28,1250.62,
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,98.28,1250.62,APC
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,98.28,1250.62,APC
Dilate urethra stricture,53620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,98.28,1250.62,APC
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.74,,,,,,,fee schedule,104.07,448.11,
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.21,,,,,,,fee schedule,104.07,448.11,
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.21,,,,,,,fee schedule,104.07,448.11,
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.07,,,,,,,fee schedule,104.07,448.11,
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.93,,,,,,,fee schedule,104.07,448.11,
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.09,,,,,,,fee schedule,104.07,448.11,
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.55,,,,,,,fee schedule,104.07,448.11,
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.21,,,,,,,fee schedule,104.07,448.11,
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,104.07,448.11,APC
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,104.07,448.11,APC
Dilate urethra stricture,53621,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,104.07,448.11,APC
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.51,,,,,,,fee schedule,78.35,230.78,
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.61,,,,,,,fee schedule,78.35,230.78,
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.61,,,,,,,fee schedule,78.35,230.78,
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.35,,,,,,,fee schedule,78.35,230.78,
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.82,,,,,,,fee schedule,78.35,230.78,
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.3,,,,,,,fee schedule,78.35,230.78,
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.44,,,,,,,fee schedule,78.35,230.78,
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.61,,,,,,,fee schedule,78.35,230.78,
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,78.35,230.78,APC
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,78.35,230.78,APC
Dilation of urethra,53660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,78.35,230.78,APC
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.31,,,,,,,fee schedule,98.06,238.63,
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.31,,,,,,,fee schedule,98.06,238.63,
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.36,,,,,,,fee schedule,98.06,238.63,
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.31,,,,,,,fee schedule,98.06,238.63,
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Dilation of urethra,53661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,3749.16,
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Dilation of urethra,53665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,1625.89,6322.15,
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,6322.15,
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1625.89,,,,,,,fee schedule,1625.89,6322.15,
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,1625.89,6322.15,
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,1625.89,6322.15,
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1869.77,,,,,,,fee schedule,1625.89,6322.15,
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,1625.89,6322.15,
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1625.89,,,,,,,fee schedule,1625.89,6322.15,
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1625.89,6322.15,APC
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1625.89,6322.15,APC
Prostatic microwave thermotx,53850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1625.89,6322.15,APC
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4150.65,,,,,,,fee schedule,2721.17,6322.15,
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3618.61,,,,,,,fee schedule,2721.17,6322.15,
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3618.61,,,,,,,fee schedule,2721.17,6322.15,
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2721.17,,,,,,,fee schedule,2721.17,6322.15,
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3397.31,,,,,,,fee schedule,2721.17,6322.15,
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4161.4,,,,,,,fee schedule,2721.17,6322.15,
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4773.25,,,,,,,fee schedule,2721.17,6322.15,
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3618.61,,,,,,,fee schedule,2721.17,6322.15,
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2721.17,6322.15,APC
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2721.17,6322.15,APC
Prostatic rf thermotx,53852,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2721.17,6322.15,APC
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4567.25,,,,,,,fee schedule,1259.22,6322.15,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1259.22,,,,,,,fee schedule,1259.22,6322.15,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1259.22,,,,,,,fee schedule,1259.22,6322.15,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2994.29,,,,,,,fee schedule,1259.22,6322.15,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3738.29,,,,,,,fee schedule,1259.22,6322.15,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1448.1,,,,,,,fee schedule,1259.22,6322.15,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5252.34,,,,,,,fee schedule,1259.22,6322.15,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1259.22,,,,,,,fee schedule,1259.22,6322.15,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1259.22,6322.15,APC
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1259.22,6322.15,APC
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1259.22,6322.15,APC
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1986.14,,,,,,,fee schedule,727.4,3749.16,
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,3749.16,
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,727.4,,,,,,,fee schedule,727.4,3749.16,
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1302.11,,,,,,,fee schedule,727.4,3749.16,
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.66,,,,,,,fee schedule,727.4,3749.16,
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,836.51,,,,,,,fee schedule,727.4,3749.16,
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2284.06,,,,,,,fee schedule,727.4,3749.16,
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.4,,,,,,,fee schedule,727.4,3749.16,
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,727.4,3749.16,APC
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,727.4,3749.16,APC
Insert prost urethral stent,53855,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,727.4,3749.16,APC
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1823.05,,,,,,,fee schedule,1419.05,3749.16,
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1823.05,,,,,,,fee schedule,1419.05,3749.16,
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2096.51,,,,,,,fee schedule,1419.05,3749.16,
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1823.05,,,,,,,fee schedule,1419.05,3749.16,
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Transurethral rf treatment,53860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15119.1,,,,,,,fee schedule,9432.42,17386.97,
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9912.08,,,,,,,fee schedule,9432.42,17386.97,
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12374.98,,,,,,,fee schedule,9432.42,17386.97,
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17386.97,,,,,,,fee schedule,9432.42,17386.97,
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,17386.97,APC
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,17386.97,APC
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,17386.97,APC
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,397.65,,,,,,,fee schedule,248.95,457.3,
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.7,,,,,,,fee schedule,248.95,457.3,
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,325.48,,,,,,,fee schedule,248.95,457.3,
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,457.3,,,,,,,fee schedule,248.95,457.3,
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,248.95,457.3,APC
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,248.95,457.3,APC
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,248.95,457.3,APC
Urology surgery procedure,53899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,248.95,448.11,APC
Urology surgery procedure,53899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,248.95,448.11,APC
Urology surgery procedure,53899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,248.95,448.11,APC
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,6322.15,
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,6322.15,
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Slitting of prepuce,54000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2482.07,,,,,,,fee schedule,1419.05,3749.16,
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2158.32,,,,,,,fee schedule,1419.05,3749.16,
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Slitting of prepuce,54001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,933.69,2962.18,
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,933.69,2962.18,
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,933.69,2962.18,
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,933.69,2962.18,
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Drain penis lesion,54015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,193.65,729.1,
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.65,,,,,,,fee schedule,193.65,729.1,
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,193.65,729.1,
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,193.65,729.1,
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.7,,,,,,,fee schedule,193.65,729.1,
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,193.65,729.1,
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.65,,,,,,,fee schedule,193.65,729.1,
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,193.65,729.1,APC
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,193.65,729.1,APC
Destruction penis lesion(s),54050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,193.65,729.1,APC
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194,,,,,,,fee schedule,127.19,3700.55,
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.2,,,,,,,fee schedule,127.19,3700.55,
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.2,,,,,,,fee schedule,127.19,3700.55,
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.19,,,,,,,fee schedule,127.19,3700.55,
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.79,,,,,,,fee schedule,127.19,3700.55,
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.88,,,,,,,fee schedule,127.19,3700.55,
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,223.1,,,,,,,fee schedule,127.19,3700.55,
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.2,,,,,,,fee schedule,127.19,3700.55,
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,127.19,3700.55,APC
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,127.19,3700.55,APC
Destruction penis lesion(s),54055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,127.19,3700.55,APC
Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Cryosurgery penis lesion(s),54056,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1962.38,,,,,,,fee schedule,1381.8,3700.55,
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Laser surg penis lesion(s),54057,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1962.38,,,,,,,fee schedule,1381.8,3700.55,
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Excision of penis lesion(s),54060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,3700.55,
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,3700.55,
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,3700.55,
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1962.38,,,,,,,fee schedule,1381.8,3700.55,
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,3700.55,
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1706.42,,,,,,,fee schedule,1381.8,3700.55,
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1381.8,3700.55,APC
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1381.8,3700.55,APC
Destruction penis lesion(s),54065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1381.8,3700.55,APC
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,933.69,2962.18,
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,933.69,2962.18,
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,933.69,2962.18,
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy of penis,54100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2780.04,,,,,,,fee schedule,1847.27,5209.69,
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.43,,,,,,,fee schedule,1847.27,5209.69,
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Biopsy of penis,54105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,6322.15,
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3116.77,6322.15,
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3116.77,6322.15,
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,6322.15,
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,6322.15,
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3116.77,6322.15,
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,6322.15,
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3116.77,6322.15,
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3116.77,6322.15,APC
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3116.77,6322.15,APC
Treatment of penis lesion,54110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3116.77,6322.15,APC
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3116.77,9616.53,
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Treat penis lesion graft,54111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11056.57,,,,,,,fee schedule,4527.14,16978.36,
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,4527.14,16978.36,
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,4527.14,16978.36,
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7248.69,,,,,,,fee schedule,4527.14,16978.36,
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9049.8,,,,,,,fee schedule,4527.14,16978.36,
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,4527.14,16978.36,
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12715.06,,,,,,,fee schedule,4527.14,16978.36,
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,4527.14,16978.36,
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,4527.14,16978.36,APC
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,4527.14,16978.36,APC
Treat penis lesion graft,54112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,4527.14,16978.36,APC
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,1847.27,5209.69,
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
Treatment of penis lesion,54115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2961.94,6322.15,
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,6322.15,
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,6322.15,
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2961.94,6322.15,
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2961.94,6322.15,
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,6322.15,
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2961.94,6322.15,
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,6322.15,
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2961.94,6322.15,APC
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2961.94,6322.15,APC
Partial removal of penis,54120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2961.94,6322.15,APC
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,3749.16,
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Circumcision w/regionl block,54150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,694.79,2761.56,
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,694.79,2761.56,
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,694.79,2761.56,
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,694.79,2761.56,
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,694.79,2761.56,
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,694.79,2761.56,
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,694.79,2761.56,
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,694.79,2761.56,
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.53,,,,,,,fee schedule,694.79,2761.56,APC
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,694.79,,,,,,,fee schedule,694.79,2761.56,APC
Circumcision neonate,54160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1250.62,,,,,,,fee schedule,694.79,2761.56,APC
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6249.54,,,,,,,fee schedule,2082.87,7186.97,
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,7186.97,
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2082.87,7186.97,
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4097.2,,,,,,,fee schedule,2082.87,7186.97,
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5115.25,,,,,,,fee schedule,2082.87,7186.97,
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2082.87,7186.97,
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7186.97,,,,,,,fee schedule,2082.87,7186.97,
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,7186.97,
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,7186.97,APC
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,7186.97,APC
Circum 28 days or older,54161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,7186.97,APC
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4929.68,,,,,,,fee schedule,2082.87,5669.13,
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,5669.13,
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2082.87,5669.13,
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3231.9,,,,,,,fee schedule,2082.87,5669.13,
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4034.94,,,,,,,fee schedule,2082.87,5669.13,
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2082.87,5669.13,
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5669.13,,,,,,,fee schedule,2082.87,5669.13,
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,5669.13,
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,5669.13,APC
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,5669.13,APC
Lysis penil circumic lesion,54162,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,5669.13,APC
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6623.1,,,,,,,fee schedule,2082.87,7616.57,
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,7616.57,
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2082.87,7616.57,
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4342.1,,,,,,,fee schedule,2082.87,7616.57,
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5421.01,,,,,,,fee schedule,2082.87,7616.57,
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2082.87,7616.57,
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7616.57,,,,,,,fee schedule,2082.87,7616.57,
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,7616.57,
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,7616.57,APC
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,7616.57,APC
Repair of circumcision,54163,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,7616.57,APC
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,3749.16,
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Frenulotomy of penis,54164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,179.31,,,,,,,fee schedule,117.56,448.11,
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.5,,,,,,,fee schedule,117.56,448.11,
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.5,,,,,,,fee schedule,117.56,448.11,
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.56,,,,,,,fee schedule,117.56,448.11,
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.77,,,,,,,fee schedule,117.56,448.11,
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.98,,,,,,,fee schedule,117.56,448.11,
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,206.21,,,,,,,fee schedule,117.56,448.11,
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.5,,,,,,,fee schedule,117.56,448.11,
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,117.56,448.11,APC
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,117.56,448.11,APC
Treatment of penis lesion,54200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,117.56,448.11,APC
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2961.94,9616.53,
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,9616.53,
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,9616.53,
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2961.94,9616.53,
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2961.94,9616.53,
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,9616.53,
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2961.94,9616.53,
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,9616.53,
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2961.94,9616.53,APC
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2961.94,9616.53,APC
Treatment of penis lesion,54205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2961.94,9616.53,APC
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,318.91,,,,,,,fee schedule,209.08,448.11,
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.29,,,,,,,fee schedule,209.08,448.11,
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.29,,,,,,,fee schedule,209.08,448.11,
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,209.08,,,,,,,fee schedule,209.08,448.11,
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.03,,,,,,,fee schedule,209.08,448.11,
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.78,,,,,,,fee schedule,209.08,448.11,
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,366.75,,,,,,,fee schedule,209.08,448.11,
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.29,,,,,,,fee schedule,209.08,448.11,
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,209.08,448.11,APC
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,209.08,448.11,APC
Treatment of penis lesion,54220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,209.08,448.11,APC
Prepare penis study,54230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.44,,,,,,,fee schedule,82.24,144.26,
Prepare penis study,54230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.24,,,,,,,fee schedule,82.24,144.26,
Prepare penis study,54230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.67,,,,,,,fee schedule,82.24,144.26,
Prepare penis study,54230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,144.26,,,,,,,fee schedule,82.24,144.26,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.47,,,,,,,fee schedule,112.42,448.11,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.57,,,,,,,fee schedule,112.42,448.11,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.57,,,,,,,fee schedule,112.42,448.11,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.42,,,,,,,fee schedule,112.42,448.11,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.35,,,,,,,fee schedule,112.42,448.11,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,112.42,448.11,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.19,,,,,,,fee schedule,112.42,448.11,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,112.42,448.11,
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,112.42,448.11,APC
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,112.42,448.11,APC
Dynamic cavernosometry,54231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,112.42,448.11,APC
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.43,,,,,,,fee schedule,81.58,448.11,
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.06,,,,,,,fee schedule,81.58,448.11,
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.06,,,,,,,fee schedule,81.58,448.11,
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.58,,,,,,,fee schedule,81.58,448.11,
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.85,,,,,,,fee schedule,81.58,448.11,
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.27,,,,,,,fee schedule,81.58,448.11,
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.09,,,,,,,fee schedule,81.58,448.11,
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.06,,,,,,,fee schedule,81.58,448.11,
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,81.58,448.11,APC
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,81.58,448.11,APC
Penile injection,54235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,81.58,448.11,APC
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97,,,,,,,fee schedule,63.59,387.26,
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.73,,,,,,,fee schedule,63.59,387.26,
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.73,,,,,,,fee schedule,63.59,387.26,
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.59,,,,,,,fee schedule,63.59,387.26,
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.39,,,,,,,fee schedule,63.59,387.26,
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.44,,,,,,,fee schedule,63.59,387.26,
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.55,,,,,,,fee schedule,63.59,387.26,
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.73,,,,,,,fee schedule,63.59,387.26,
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,63.59,387.26,APC
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,63.59,387.26,APC
Penis study,54240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,63.59,387.26,APC
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.39,,,,,,,fee schedule,19.92,448.11,
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.93,,,,,,,fee schedule,19.92,448.11,
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,19.92,448.11,
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.92,,,,,,,fee schedule,19.92,448.11,
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.87,,,,,,,fee schedule,19.92,448.11,
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.82,,,,,,,fee schedule,19.92,448.11,
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.95,,,,,,,fee schedule,19.92,448.11,
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.93,,,,,,,fee schedule,19.92,448.11,
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,19.92,448.11,APC
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,19.92,448.11,APC
Penis study,54250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,19.92,448.11,APC
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10342.31,,,,,,,fee schedule,3512.31,11893.66,
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,11893.66,
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3512.31,11893.66,
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6780.42,,,,,,,fee schedule,3512.31,11893.66,
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8465.18,,,,,,,fee schedule,3512.31,11893.66,
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3512.31,11893.66,
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11893.66,,,,,,,fee schedule,3512.31,11893.66,
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,11893.66,
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,11893.66,APC
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,11893.66,APC
Revision of penis,54300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,11893.66,APC
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12737.91,,,,,,,fee schedule,3512.31,14648.6,
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,14648.6,
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3512.31,14648.6,
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8350.97,,,,,,,fee schedule,3512.31,14648.6,
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10425.98,,,,,,,fee schedule,3512.31,14648.6,
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3512.31,14648.6,
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14648.6,,,,,,,fee schedule,3512.31,14648.6,
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,14648.6,
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,14648.6,APC
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,14648.6,APC
Revision of penis,54304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,14648.6,APC
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruction of urethra,54308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Reconstruction of urethra,54312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2961.94,16978.36,
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,16978.36,
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,16978.36,
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2961.94,16978.36,
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2961.94,16978.36,
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,16978.36,
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2961.94,16978.36,
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,16978.36,
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,2961.94,16978.36,APC
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,2961.94,16978.36,APC
Reconstruction of urethra,54316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,2961.94,16978.36,APC
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Reconstruction of urethra,54318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,1419.05,6322.15,
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Reconstruction of urethra,54322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11961.62,,,,,,,fee schedule,3512.31,13755.86,
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,13755.86,
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3512.31,13755.86,
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7842.04,,,,,,,fee schedule,3512.31,13755.86,
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9790.59,,,,,,,fee schedule,3512.31,13755.86,
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3512.31,13755.86,
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13755.86,,,,,,,fee schedule,3512.31,13755.86,
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,13755.86,
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,13755.86,APC
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,13755.86,APC
Reconstruction of urethra,54324,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,13755.86,APC
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14527.14,,,,,,,fee schedule,2961.94,16706.21,
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,16706.21,
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,16706.21,
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9523.99,,,,,,,fee schedule,2961.94,16706.21,
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11890.46,,,,,,,fee schedule,2961.94,16706.21,
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,16706.21,
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16706.21,,,,,,,fee schedule,2961.94,16706.21,
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,16706.21,
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2961.94,16706.21,APC
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2961.94,16706.21,APC
Reconstruction of urethra,54326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2961.94,16706.21,APC
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11459.91,,,,,,,fee schedule,3512.31,13178.9,
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,13178.9,
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3512.31,13178.9,
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7513.12,,,,,,,fee schedule,3512.31,13178.9,
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9379.94,,,,,,,fee schedule,3512.31,13178.9,
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3512.31,13178.9,
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13178.9,,,,,,,fee schedule,3512.31,13178.9,
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,13178.9,
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,13178.9,APC
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,13178.9,APC
Revise penis/urethra,54328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,13178.9,APC
Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17594.39,,,,,,,fee schedule,3512.31,20233.55,
Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11534.88,,,,,,,fee schedule,3512.31,20233.55,
Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14401.01,,,,,,,fee schedule,3512.31,20233.55,
Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20233.55,,,,,,,fee schedule,3512.31,20233.55,
Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,20233.55,APC
Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,20233.55,APC
Revise penis/urethra,54332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,20233.55,APC
Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3802.52,,,,,,,fee schedule,2492.93,6322.15,
Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2492.93,,,,,,,fee schedule,2492.93,6322.15,
Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3112.36,,,,,,,fee schedule,2492.93,6322.15,
Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4372.9,,,,,,,fee schedule,2492.93,6322.15,
Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2492.93,6322.15,APC
Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2492.93,6322.15,APC
Revise penis/urethra,54336,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2492.93,6322.15,APC
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10437.49,,,,,,,fee schedule,2961.94,12003.11,
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,12003.11,
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,12003.11,
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6842.82,,,,,,,fee schedule,2961.94,12003.11,
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8543.09,,,,,,,fee schedule,2961.94,12003.11,
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,12003.11,
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12003.11,,,,,,,fee schedule,2961.94,12003.11,
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,12003.11,
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2961.94,12003.11,APC
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2961.94,12003.11,APC
Secondary urethral surgery,54340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2961.94,12003.11,APC
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11459.91,,,,,,,fee schedule,2961.94,16978.36,
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,16978.36,
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,16978.36,
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7513.12,,,,,,,fee schedule,2961.94,16978.36,
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9379.94,,,,,,,fee schedule,2961.94,16978.36,
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,16978.36,
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13178.9,,,,,,,fee schedule,2961.94,16978.36,
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,16978.36,
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,2961.94,16978.36,APC
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,2961.94,16978.36,APC
Secondary urethral surgery,54344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,2961.94,16978.36,APC
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2961.94,9616.53,
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,9616.53,
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,9616.53,
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2961.94,9616.53,
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2961.94,9616.53,
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,9616.53,
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2961.94,9616.53,
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,9616.53,
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2961.94,9616.53,APC
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2961.94,9616.53,APC
Secondary urethral surgery,54348,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2961.94,9616.53,APC
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11056.57,,,,,,,fee schedule,4527.14,12715.06,
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,4527.14,12715.06,
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,4527.14,12715.06,
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7248.69,,,,,,,fee schedule,4527.14,12715.06,
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9049.8,,,,,,,fee schedule,4527.14,12715.06,
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,4527.14,12715.06,
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12715.06,,,,,,,fee schedule,4527.14,12715.06,
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,4527.14,12715.06,
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,4527.14,12715.06,APC
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,4527.14,12715.06,APC
Reconstruct urethra/penis,54352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,4527.14,12715.06,APC
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8214.24,,,,,,,fee schedule,3512.31,9446.38,
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,9446.38,
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3512.31,9446.38,
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5385.26,,,,,,,fee schedule,3512.31,9446.38,
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6723.36,,,,,,,fee schedule,3512.31,9446.38,
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3512.31,9446.38,
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9446.38,,,,,,,fee schedule,3512.31,9446.38,
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3512.31,9446.38,
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,9446.38,APC
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,9446.38,APC
Penis plastic surgery,54360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,9446.38,APC
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2082.87,3749.16,
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2082.87,3749.16,
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2082.87,3749.16,
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2082.87,3749.16,
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2082.87,3749.16,
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2082.87,3749.16,
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2082.87,3749.16,
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2082.87,3749.16,
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,3749.16,APC
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,3749.16,APC
Repair penis,54380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,3749.16,APC
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,1419.05,3749.16,
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,1419.05,3749.16,
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,1419.05,3749.16,
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,1419.05,3749.16,
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Repair penis,54385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33298.93,,,,,,,fee schedule,13146.01,38293.77,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16029.77,,,,,,,fee schedule,13146.01,38293.77,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16029.77,,,,,,,fee schedule,13146.01,38293.77,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21830.78,,,,,,,fee schedule,13146.01,38293.77,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27255.17,,,,,,,fee schedule,13146.01,38293.77,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18434.24,,,,,,,fee schedule,13146.01,38293.77,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38293.77,,,,,,,fee schedule,13146.01,38293.77,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16029.77,,,,,,,fee schedule,13146.01,38293.77,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13803.31,,,,,,,fee schedule,13146.01,38293.77,APC
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13146.01,,,,,,,fee schedule,13146.01,38293.77,APC
Insert semi-rigid prosthesis,54400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23662.82,,,,,,,fee schedule,13146.01,38293.77,APC
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34330.92,,,,,,,fee schedule,20651.59,39480.56,
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,39480.56,
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28459.78,,,,,,,fee schedule,20651.59,39480.56,
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22507.35,,,,,,,fee schedule,20651.59,39480.56,
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28099.86,,,,,,,fee schedule,20651.59,39480.56,
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32728.75,,,,,,,fee schedule,20651.59,39480.56,
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39480.56,,,,,,,fee schedule,20651.59,39480.56,
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,39480.56,
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,20651.59,39480.56,APC
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,20651.59,39480.56,APC
Insert self-contd prosthesis,54401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,20651.59,39480.56,APC
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7064.48,,,,,,,fee schedule,4631.47,37172.87,
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28459.78,,,,,,,fee schedule,4631.47,37172.87,
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28459.78,,,,,,,fee schedule,4631.47,37172.87,
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4631.47,,,,,,,fee schedule,4631.47,37172.87,
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5782.28,,,,,,,fee schedule,4631.47,37172.87,
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32728.75,,,,,,,fee schedule,4631.47,37172.87,
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8124.15,,,,,,,fee schedule,4631.47,37172.87,
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28459.78,,,,,,,fee schedule,4631.47,37172.87,
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,4631.47,37172.87,APC
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,4631.47,37172.87,APC
Insert multi-comp penis pros,54405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,4631.47,37172.87,APC
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2114.87,6322.15,
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Remove muti-comp penis pros,54406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,3116.77,9616.53,
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,3116.77,9616.53,
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,3116.77,9616.53,
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,3116.77,9616.53,
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,3116.77,9616.53,
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,3116.77,9616.53,
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,3116.77,9616.53,APC
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,3116.77,9616.53,APC
Repair multi-comp penis pros,54408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,3116.77,9616.53,APC
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33887.84,,,,,,,fee schedule,20651.59,38971.02,
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,38971.02,
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28459.78,,,,,,,fee schedule,20651.59,38971.02,
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22216.87,,,,,,,fee schedule,20651.59,38971.02,
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27737.2,,,,,,,fee schedule,20651.59,38971.02,
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32728.75,,,,,,,fee schedule,20651.59,38971.02,
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38971.02,,,,,,,fee schedule,20651.59,38971.02,
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,38971.02,
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,20651.59,38971.02,APC
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,20651.59,38971.02,APC
Remove/replace penis prosth,54410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,20651.59,38971.02,APC
Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21481.49,,,,,,,fee schedule,14083.26,37172.87,
Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14083.26,,,,,,,fee schedule,14083.26,37172.87,
Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17582.6,,,,,,,fee schedule,14083.26,37172.87,
Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24703.71,,,,,,,fee schedule,14083.26,37172.87,
Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,14083.26,37172.87,APC
Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,14083.26,37172.87,APC
Remov/replc penis pros comp,54411,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,14083.26,37172.87,APC
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2114.87,6322.15,
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2114.87,6322.15,
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Remove self-contd penis pros,54415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33503.17,,,,,,,fee schedule,20651.59,38528.65,
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,38528.65,
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28459.78,,,,,,,fee schedule,20651.59,38528.65,
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21964.68,,,,,,,fee schedule,20651.59,38528.65,
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27422.34,,,,,,,fee schedule,20651.59,38528.65,
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32728.75,,,,,,,fee schedule,20651.59,38528.65,
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38528.65,,,,,,,fee schedule,20651.59,38528.65,
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28459.78,,,,,,,fee schedule,20651.59,38528.65,
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,20651.59,38528.65,APC
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,20651.59,38528.65,APC
Remv/repl penis contain pros,54416,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,20651.59,38528.65,APC
Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21481.49,,,,,,,fee schedule,14083.26,37172.87,
Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14083.26,,,,,,,fee schedule,14083.26,37172.87,
Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17582.6,,,,,,,fee schedule,14083.26,37172.87,
Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24703.71,,,,,,,fee schedule,14083.26,37172.87,
Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21684.17,,,,,,,fee schedule,14083.26,37172.87,APC
Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20651.59,,,,,,,fee schedule,14083.26,37172.87,APC
Remv/replc penis pros compl,54417,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37172.87,,,,,,,fee schedule,14083.26,37172.87,APC
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Revision of penis,54420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,1419.05,6322.15,
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Revision of penis,54435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Repair corporeal tear,54437,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2961.94,6322.15,
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,6322.15,
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,6322.15,
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2961.94,6322.15,
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2961.94,6322.15,
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,6322.15,
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2961.94,6322.15,
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,6322.15,
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2961.94,6322.15,APC
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2961.94,6322.15,APC
Repair of penis,54440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2961.94,6322.15,APC
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,318.91,,,,,,,fee schedule,209.08,448.11,
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.29,,,,,,,fee schedule,209.08,448.11,
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.29,,,,,,,fee schedule,209.08,448.11,
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,209.08,,,,,,,fee schedule,209.08,448.11,
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.03,,,,,,,fee schedule,209.08,448.11,
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.78,,,,,,,fee schedule,209.08,448.11,
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,366.75,,,,,,,fee schedule,209.08,448.11,
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.29,,,,,,,fee schedule,209.08,448.11,
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,209.08,448.11,APC
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,209.08,448.11,APC
Preputial stretching,54450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,209.08,448.11,APC
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1394.89,5209.69,
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,1394.89,5209.69,
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,1394.89,5209.69,
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1394.89,5209.69,
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1394.89,5209.69,
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,1394.89,5209.69,
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1394.89,5209.69,
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,1394.89,5209.69,
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1394.89,5209.69,APC
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1394.89,5209.69,APC
Biopsy of testis,54500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1394.89,5209.69,APC
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2114.87,6322.15,
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Biopsy of testis,54505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,6322.15,
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Excise Lesion Testis,54512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.68,,,,,,,fee schedule,2961.94,9651.58,
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,9651.58,
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,9651.58,
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.24,,,,,,,fee schedule,2961.94,9651.58,
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.41,,,,,,,fee schedule,2961.94,9651.58,
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,9651.58,
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.58,,,,,,,fee schedule,2961.94,9651.58,
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,9651.58,
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2961.94,9651.58,APC
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2961.94,9651.58,APC
Removal of testis,54520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2961.94,9651.58,APC
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2114.87,6322.15,
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Orchiectomy partial,54522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6284.44,,,,,,,fee schedule,3545.32,7227.11,
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,7227.11,
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,7227.11,
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4120.08,,,,,,,fee schedule,3545.32,7227.11,
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5143.81,,,,,,,fee schedule,3545.32,7227.11,
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,7227.11,
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7227.11,,,,,,,fee schedule,3545.32,7227.11,
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,7227.11,
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3545.32,7227.11,APC
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3545.32,7227.11,APC
Removal of testis,54530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3545.32,7227.11,APC
Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5210.48,,,,,,,fee schedule,3415.99,6322.15,
Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3415.99,,,,,,,fee schedule,3415.99,6322.15,
Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4264.78,,,,,,,fee schedule,3415.99,6322.15,
Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5992.05,,,,,,,fee schedule,3415.99,6322.15,
Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3415.99,6322.15,APC
Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3415.99,6322.15,APC
Extensive testis surgery,54535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3415.99,6322.15,APC
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,6421.55,
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Exploration for testis,54550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,3749.16,
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Exploration for testis,54560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6986.34,,,,,,,fee schedule,2401.36,8034.29,
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,8034.29,
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2401.36,8034.29,
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4580.24,,,,,,,fee schedule,2401.36,8034.29,
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5718.32,,,,,,,fee schedule,2401.36,8034.29,
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2401.36,8034.29,
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8034.29,,,,,,,fee schedule,2401.36,8034.29,
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,8034.29,
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2401.36,8034.29,APC
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2401.36,8034.29,APC
Reduce testis torsion,54600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2401.36,8034.29,APC
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2114.87,6322.15,
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Suspension of testis,54620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8801.65,,,,,,,fee schedule,3545.32,10121.9,
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,10121.9,
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,10121.9,
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5770.36,,,,,,,fee schedule,3545.32,10121.9,
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7204.15,,,,,,,fee schedule,3545.32,10121.9,
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,10121.9,
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10121.9,,,,,,,fee schedule,3545.32,10121.9,
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,10121.9,
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3545.32,10121.9,APC
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3545.32,10121.9,APC
Suspension of testis,54640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3545.32,10121.9,APC
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4281.37,,,,,,,fee schedule,2806.87,6421.55,
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2806.87,,,,,,,fee schedule,2806.87,6421.55,
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3504.3,,,,,,,fee schedule,2806.87,6421.55,
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4923.58,,,,,,,fee schedule,2806.87,6421.55,
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2806.87,6421.55,APC
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2806.87,6421.55,APC
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2806.87,6421.55,APC
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6388.47,,,,,,,fee schedule,2401.36,9616.53,
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,9616.53,
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2401.36,9616.53,
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4188.28,,,,,,,fee schedule,2401.36,9616.53,
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5228.96,,,,,,,fee schedule,2401.36,9616.53,
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2401.36,9616.53,
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7346.74,,,,,,,fee schedule,2401.36,9616.53,
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,9616.53,
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2401.36,9616.53,APC
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2401.36,9616.53,APC
Revision of testis,54660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2401.36,9616.53,APC
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,6322.15,
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Repair testis injury,54670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,6322.15,
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Relocation of testis(es),54680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy orchiectomy,54690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7370.27,,,,,,,fee schedule,4831.95,10842.82,
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7260.58,,,,,,,fee schedule,4831.95,10842.82,
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7260.58,,,,,,,fee schedule,4831.95,10842.82,
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4831.95,,,,,,,fee schedule,4831.95,10842.82,
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6032.57,,,,,,,fee schedule,4831.95,10842.82,
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8349.67,,,,,,,fee schedule,4831.95,10842.82,
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8475.81,,,,,,,fee schedule,4831.95,10842.82,
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7260.58,,,,,,,fee schedule,4831.95,10842.82,
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4831.95,10842.82,APC
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4831.95,10842.82,APC
Laparoscopy orchiopexy,54692,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4831.95,10842.82,APC
Laparoscope proc testis,54699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc testis,54699,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscope proc testis,54699,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2082.87,5563.42,
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,5563.42,
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2082.87,5563.42,
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2082.87,5563.42,
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2082.87,5563.42,
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2082.87,5563.42,
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2082.87,5563.42,
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,5563.42,
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,5563.42,APC
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,5563.42,APC
Drainage of scrotum,54700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,5563.42,APC
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,645.78,2962.18,
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,645.78,,,,,,,fee schedule,645.78,2962.18,
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.78,,,,,,,fee schedule,645.78,2962.18,
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,645.78,2962.18,
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,645.78,2962.18,
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.65,,,,,,,fee schedule,645.78,2962.18,
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,645.78,2962.18,
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,645.78,,,,,,,fee schedule,645.78,2962.18,
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,645.78,2962.18,APC
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,645.78,2962.18,APC
Biopsy of epididymis,54800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,645.78,2962.18,APC
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,6322.15,
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Remove epididymis lesion,54830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4909.33,,,,,,,fee schedule,2082.87,5645.73,
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,5645.73,
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2082.87,5645.73,
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3218.56,,,,,,,fee schedule,2082.87,5645.73,
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4018.29,,,,,,,fee schedule,2082.87,5645.73,
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2082.87,5645.73,
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5645.73,,,,,,,fee schedule,2082.87,5645.73,
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2082.87,5645.73,
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,2082.87,5645.73,APC
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,2082.87,5645.73,APC
Remove epididymis lesion,54840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,2082.87,5645.73,APC
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,6322.15,
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of epididymis,54860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2114.87,6322.15,
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Removal of epididymis,54861,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2114.87,6322.15,
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Explore Epididymis,54865,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,3749.16,
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Fusion of spermatic ducts,54900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2114.87,6322.15,
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Fusion of spermatic ducts,54901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.47,,,,,,,fee schedule,112.42,1270.05,
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.42,,,,,,,fee schedule,112.42,1270.05,
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.42,,,,,,,fee schedule,112.42,1270.05,
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.42,,,,,,,fee schedule,112.42,1270.05,
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.35,,,,,,,fee schedule,112.42,1270.05,
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.98,,,,,,,fee schedule,112.42,1270.05,
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.19,,,,,,,fee schedule,112.42,1270.05,
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.42,,,,,,,fee schedule,112.42,1270.05,
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,112.42,1270.05,APC
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,112.42,1270.05,APC
Drainage of hydrocele,55000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,112.42,1270.05,APC
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5579.99,,,,,,,fee schedule,3545.32,6421.55,
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,6421.55,
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,6421.55,
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.24,,,,,,,fee schedule,3545.32,6421.55,
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.22,,,,,,,fee schedule,3545.32,6421.55,
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,6421.55,
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6416.99,,,,,,,fee schedule,3545.32,6421.55,
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,6421.55,
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3545.32,6421.55,APC
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3545.32,6421.55,APC
Removal of hydrocele,55040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3545.32,6421.55,APC
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,6421.55,
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,6421.55,
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,6421.55,
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,6421.55,
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,6421.55,
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,6421.55,
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,2604.09,6421.55,APC
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,2604.09,6421.55,APC
Removal of hydroceles,55041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,2604.09,6421.55,APC
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6347.85,,,,,,,fee schedule,2401.36,7300.03,
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,7300.03,
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2401.36,7300.03,
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4161.65,,,,,,,fee schedule,2401.36,7300.03,
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5195.72,,,,,,,fee schedule,2401.36,7300.03,
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2401.36,7300.03,
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7300.03,,,,,,,fee schedule,2401.36,7300.03,
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,7300.03,
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2401.36,7300.03,APC
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2401.36,7300.03,APC
Repair of hydrocele,55060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2401.36,7300.03,APC
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1319.63,,,,,,,fee schedule,933.69,2962.18,
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1147.5,,,,,,,fee schedule,933.69,2962.18,
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Drainage of scrotum abscess,55100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,6322.15,
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Explore scrotum,55110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,3749.16,
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Removal of scrotum lesion,55120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2114.87,6322.15,
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2114.87,6322.15,
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Removal of scrotum,55150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,2114.87,6322.15,
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4527.14,,,,,,,fee schedule,2114.87,6322.15,
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4527.14,,,,,,,fee schedule,2114.87,6322.15,
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,2114.87,6322.15,
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,2114.87,6322.15,
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5206.21,,,,,,,fee schedule,2114.87,6322.15,
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,2114.87,6322.15,
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4527.14,,,,,,,fee schedule,2114.87,6322.15,
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2114.87,6322.15,APC
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2114.87,6322.15,APC
Revision of scrotum,55175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2114.87,6322.15,APC
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,2401.36,9616.53,
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,9616.53,
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2401.36,9616.53,
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,2401.36,9616.53,
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,2401.36,9616.53,
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2401.36,9616.53,
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,2401.36,9616.53,
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,9616.53,
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2401.36,9616.53,APC
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2401.36,9616.53,APC
Revision of scrotum,55180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2401.36,9616.53,APC
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,6322.15,
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Incision of sperm duct,55200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,717.39,,,,,,,fee schedule,470.32,3749.16,
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,729.16,,,,,,,fee schedule,470.32,3749.16,
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,729.16,,,,,,,fee schedule,470.32,3749.16,
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,470.32,,,,,,,fee schedule,470.32,3749.16,
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.18,,,,,,,fee schedule,470.32,3749.16,
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,838.53,,,,,,,fee schedule,470.32,3749.16,
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,825,,,,,,,fee schedule,470.32,3749.16,
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,729.16,,,,,,,fee schedule,470.32,3749.16,
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,470.32,3749.16,APC
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,470.32,3749.16,APC
Removal of sperm duct(s),55250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,470.32,3749.16,APC
Prepare sperm duct x-ray,55300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.9,,,,,,,fee schedule,98.93,173.54,
Prepare sperm duct x-ray,55300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.93,,,,,,,fee schedule,98.93,173.54,
Prepare sperm duct x-ray,55300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.51,,,,,,,fee schedule,98.93,173.54,
Prepare sperm duct x-ray,55300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.54,,,,,,,fee schedule,98.93,173.54,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10033.43,,,,,,,fee schedule,2401.36,11538.44,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,11538.44,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2401.36,11538.44,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6577.92,,,,,,,fee schedule,2401.36,11538.44,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8212.36,,,,,,,fee schedule,2401.36,11538.44,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2401.36,11538.44,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11538.44,,,,,,,fee schedule,2401.36,11538.44,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,11538.44,
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2401.36,11538.44,APC
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2401.36,11538.44,APC
Repair of sperm duct,55400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2401.36,11538.44,APC
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.68,,,,,,,fee schedule,2961.94,9651.58,
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,9651.58,
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.94,,,,,,,fee schedule,2961.94,9651.58,
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.24,,,,,,,fee schedule,2961.94,9651.58,
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.41,,,,,,,fee schedule,2961.94,9651.58,
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3406.23,,,,,,,fee schedule,2961.94,9651.58,
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.58,,,,,,,fee schedule,2961.94,9651.58,
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2961.94,,,,,,,fee schedule,2961.94,9651.58,
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2961.94,9651.58,APC
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2961.94,9651.58,APC
Removal of hydrocele,55500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2961.94,9651.58,APC
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5720.47,,,,,,,fee schedule,1831.6,6578.54,
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1831.6,,,,,,,fee schedule,1831.6,6578.54,
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1831.6,,,,,,,fee schedule,1831.6,6578.54,
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3750.34,,,,,,,fee schedule,1831.6,6578.54,
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4682.2,,,,,,,fee schedule,1831.6,6578.54,
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2106.34,,,,,,,fee schedule,1831.6,6578.54,
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6578.54,,,,,,,fee schedule,1831.6,6578.54,
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1831.6,,,,,,,fee schedule,1831.6,6578.54,
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1831.6,6578.54,APC
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1831.6,6578.54,APC
Removal of sperm cord lesion,55520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1831.6,6578.54,APC
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5579.99,,,,,,,fee schedule,2401.36,6416.99,
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,6416.99,
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,2401.36,6416.99,
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.24,,,,,,,fee schedule,2401.36,6416.99,
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.22,,,,,,,fee schedule,2401.36,6416.99,
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,2401.36,6416.99,
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6416.99,,,,,,,fee schedule,2401.36,6416.99,
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,2401.36,6416.99,
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2401.36,6416.99,APC
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2401.36,6416.99,APC
Revise spermatic cord veins,55530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2401.36,6416.99,APC
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,11610.97,
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,11610.97,
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,2604.09,11610.97,
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,11610.97,
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,11610.97,
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,2604.09,11610.97,
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,11610.97,
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,2604.09,11610.97,
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,2604.09,11610.97,APC
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,2604.09,11610.97,APC
Revise spermatic cord veins,55535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,2604.09,11610.97,APC
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11459.91,,,,,,,fee schedule,3545.32,13178.9,
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,13178.9,
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3545.32,,,,,,,fee schedule,3545.32,13178.9,
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7513.12,,,,,,,fee schedule,3545.32,13178.9,
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9379.94,,,,,,,fee schedule,3545.32,13178.9,
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4077.12,,,,,,,fee schedule,3545.32,13178.9,
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13178.9,,,,,,,fee schedule,3545.32,13178.9,
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3545.32,,,,,,,fee schedule,3545.32,13178.9,
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3745.9,,,,,,,fee schedule,3545.32,13178.9,APC
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3567.53,,,,,,,fee schedule,3545.32,13178.9,APC
Revise hernia & sperm veins,55540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6421.55,,,,,,,fee schedule,3545.32,13178.9,APC
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,10842.82,
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo ligate spermatic vein,55550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo proc spermatic cord,55559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc spermatic cord,55559,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc spermatic cord,55559,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,3749.16,
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,3749.16,
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,3749.16,
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,3749.16,
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,3749.16,
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,3749.16,
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,1419.05,3749.16,APC
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,1419.05,3749.16,APC
Incise sperm duct pouch,55600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,1419.05,3749.16,APC
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.56,,,,,,,fee schedule,1419.05,6322.15,
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.36,,,,,,,fee schedule,1419.05,6322.15,
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Remove sperm pouch lesion,55680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,2489.19,
Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1831.6,,,,,,,fee schedule,1419.05,2489.19,
Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1831.6,,,,,,,fee schedule,1419.05,2489.19,
Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,2489.19,
Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,2489.19,
Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2106.34,,,,,,,fee schedule,1419.05,2489.19,
Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,2489.19,
Biopsy of prostate,55700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1831.6,,,,,,,fee schedule,1419.05,2489.19,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1937.73,,,,,,,fee schedule,1419.05,6322.15,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1937.73,,,,,,,fee schedule,1419.05,6322.15,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2228.39,,,,,,,fee schedule,1419.05,6322.15,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1937.73,,,,,,,fee schedule,1419.05,6322.15,
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Biopsy of prostate,55705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3225.86,,,,,,,fee schedule,1937.73,6322.15,
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1937.73,,,,,,,fee schedule,1937.73,6322.15,
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1937.73,,,,,,,fee schedule,1937.73,6322.15,
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2114.87,,,,,,,fee schedule,1937.73,6322.15,
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2640.37,,,,,,,fee schedule,1937.73,6322.15,
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2228.39,,,,,,,fee schedule,1937.73,6322.15,
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3709.74,,,,,,,fee schedule,1937.73,6322.15,
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1937.73,,,,,,,fee schedule,1937.73,6322.15,
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1937.73,6322.15,APC
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1937.73,6322.15,APC
Prostate saturation sampling,55706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1937.73,6322.15,APC
Bx prst8 trct us guided,55707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 trct us guided,55707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 trct us guided,55707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprnl us guided,55709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprnl us guided,55709,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprnl us guided,55709,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,3512.31,6322.15,APC
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,5342.52,9616.53,APC
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,5342.52,9616.53,APC
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,5342.52,9616.53,APC
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,5342.52,9616.53,APC
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,5342.52,9616.53,APC
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,5342.52,9616.53,APC
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Drainage of prostate abscess,55720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2164.51,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1419.05,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1771.65,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2489.19,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,1419.05,6322.15,
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,1419.05,6322.15,APC
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,1419.05,6322.15,APC
Drainage of prostate abscess,55725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,1419.05,6322.15,APC
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4754.08,,,,,,,fee schedule,1823.05,9616.53,
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1823.05,,,,,,,fee schedule,1823.05,9616.53,
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1823.05,,,,,,,fee schedule,1823.05,9616.53,
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3116.77,,,,,,,fee schedule,1823.05,9616.53,
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3891.21,,,,,,,fee schedule,1823.05,9616.53,
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2096.51,,,,,,,fee schedule,1823.05,9616.53,
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5467.19,,,,,,,fee schedule,1823.05,9616.53,
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1823.05,,,,,,,fee schedule,1823.05,9616.53,
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,1823.05,9616.53,APC
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,1823.05,9616.53,APC
Surgical exposure prostate,55860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,1823.05,9616.53,APC
Laparo radical prostatectomy,55866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Laparo radical prostatectomy,55866,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Laparo radical prostatectomy,55866,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17369.12,,,,,,,fee schedule,10591.61,19974.49,
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11387.2,,,,,,,fee schedule,10591.61,19974.49,
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14216.62,,,,,,,fee schedule,10591.61,19974.49,
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19974.49,,,,,,,fee schedule,10591.61,19974.49,
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19974.49,APC
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19974.49,APC
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19974.49,APC
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.6,,,,,,,fee schedule,139.38,1651.93,
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.04,,,,,,,fee schedule,139.38,1651.93,
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.04,,,,,,,fee schedule,139.38,1651.93,
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.38,,,,,,,fee schedule,139.38,1651.93,
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.01,,,,,,,fee schedule,139.38,1651.93,
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,212.8,,,,,,,fee schedule,139.38,1651.93,
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.49,,,,,,,fee schedule,139.38,1651.93,
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,185.04,,,,,,,fee schedule,139.38,1651.93,
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,139.38,1651.93,APC
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,139.38,1651.93,APC
Electroejaculation,55870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,139.38,1651.93,APC
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16423.46,,,,,,,fee schedule,9432.42,18886.98,
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16029.77,,,,,,,fee schedule,9432.42,18886.98,
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16029.77,,,,,,,fee schedule,9432.42,18886.98,
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10767.22,,,,,,,fee schedule,9432.42,18886.98,
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13442.6,,,,,,,fee schedule,9432.42,18886.98,
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18434.24,,,,,,,fee schedule,9432.42,18886.98,
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18886.98,,,,,,,fee schedule,9432.42,18886.98,
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16029.77,,,,,,,fee schedule,9432.42,18886.98,
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,18886.98,APC
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,18886.98,APC
Cryoablate Prostate,55873,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,18886.98,APC
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10117.69,,,,,,,fee schedule,2934.67,11635.34,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2934.67,,,,,,,fee schedule,2934.67,11635.34,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2934.67,,,,,,,fee schedule,2934.67,11635.34,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6633.16,,,,,,,fee schedule,2934.67,11635.34,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8281.33,,,,,,,fee schedule,2934.67,11635.34,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3374.87,,,,,,,fee schedule,2934.67,11635.34,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11635.34,,,,,,,fee schedule,2934.67,11635.34,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2934.67,,,,,,,fee schedule,2934.67,11635.34,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2934.67,11635.34,APC
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2934.67,11635.34,APC
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2934.67,11635.34,APC
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5079.13,,,,,,,fee schedule,2762.68,9616.53,
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3329.88,,,,,,,fee schedule,2762.68,9616.53,
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4157.27,,,,,,,fee schedule,2762.68,9616.53,
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3177.08,,,,,,,fee schedule,2762.68,9616.53,
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5841,,,,,,,fee schedule,2762.68,9616.53,
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2762.68,,,,,,,fee schedule,2762.68,9616.53,
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,2762.68,9616.53,APC
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,2762.68,9616.53,APC
Transperi needle place pros,55875,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,2762.68,9616.53,APC
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.02,,,,,,,fee schedule,126.54,2482.48,
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.72,,,,,,,fee schedule,126.54,2482.48,
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.72,,,,,,,fee schedule,126.54,2482.48,
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.54,,,,,,,fee schedule,126.54,2482.48,
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.99,,,,,,,fee schedule,126.54,2482.48,
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,192.88,,,,,,,fee schedule,126.54,2482.48,
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.97,,,,,,,fee schedule,126.54,2482.48,
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,167.72,,,,,,,fee schedule,126.54,2482.48,
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1448.11,,,,,,,fee schedule,126.54,2482.48,APC
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1379.15,,,,,,,fee schedule,126.54,2482.48,APC
Place rt device/marker pros,55876,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2482.48,,,,,,,fee schedule,126.54,2482.48,APC
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8574.92,,,,,,,fee schedule,68.93,16978.36,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.93,,,,,,,fee schedule,68.93,16978.36,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.93,,,,,,,fee schedule,68.93,16978.36,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5621.72,,,,,,,fee schedule,68.93,16978.36,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7018.57,,,,,,,fee schedule,68.93,16978.36,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.27,,,,,,,fee schedule,68.93,16978.36,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9861.16,,,,,,,fee schedule,68.93,16978.36,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.93,,,,,,,fee schedule,68.93,16978.36,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,68.93,16978.36,APC
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,68.93,16978.36,APC
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,68.93,16978.36,APC
Ablt trurl prst8 tis thrm us,55881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39994.93,,,,,,,fee schedule,26220.68,45994.17,
Ablt trurl prst8 tis thrm us,55881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26220.68,,,,,,,fee schedule,26220.68,45994.17,
Ablt trurl prst8 tis thrm us,55881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32735.85,,,,,,,fee schedule,26220.68,45994.17,
Ablt trurl prst8 tis thrm us,55881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45994.17,,,,,,,fee schedule,26220.68,45994.17,
Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21242.61,,,,,,,fee schedule,13146.01,24429,
Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13926.66,,,,,,,fee schedule,13146.01,24429,
Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17387.08,,,,,,,fee schedule,13146.01,24429,
Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24429,,,,,,,fee schedule,13146.01,24429,
Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13803.31,,,,,,,fee schedule,13146.01,24429,APC
Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13146.01,,,,,,,fee schedule,13146.01,24429,APC
Ablt trurl prst8 tis trnsdcr,55882,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23662.82,,,,,,,fee schedule,13146.01,24429,APC
Genital surgery procedure,55899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.4,,,,,,,fee schedule,248.95,448.11,APC
Genital surgery procedure,55899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.95,,,,,,,fee schedule,248.95,448.11,APC
Genital surgery procedure,55899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.11,,,,,,,fee schedule,248.95,448.11,APC
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3972.07,,,,,,,fee schedule,2604.09,8972.03,
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3029.15,,,,,,,fee schedule,2604.09,8972.03,
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3029.15,,,,,,,fee schedule,2604.09,8972.03,
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2604.09,,,,,,,fee schedule,2604.09,8972.03,
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3251.14,,,,,,,fee schedule,2604.09,8972.03,
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3483.52,,,,,,,fee schedule,2604.09,8972.03,
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.88,,,,,,,fee schedule,2604.09,8972.03,
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3029.15,,,,,,,fee schedule,2604.09,8972.03,
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,2604.09,8972.03,APC
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,2604.09,8972.03,APC
Place needles pelvic for rt,55920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,2604.09,8972.03,APC
Sex transformation m to f,55970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,8972.03,
Sex transformation m to f,55970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,8972.03,
Sex transformation m to f,55970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,8972.03,
Sex transformation m to f,55970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,8972.03,
Sex transformation m to f,55970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,2044.76,8972.03,APC
Sex transformation m to f,55970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,2044.76,8972.03,APC
Sex transformation m to f,55970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,2044.76,8972.03,APC
Sex transformation f to m,55980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3802.52,,,,,,,fee schedule,2492.93,6322.15,
Sex transformation f to m,55980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2492.93,,,,,,,fee schedule,2492.93,6322.15,
Sex transformation f to m,55980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3112.36,,,,,,,fee schedule,2492.93,6322.15,
Sex transformation f to m,55980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4372.9,,,,,,,fee schedule,2492.93,6322.15,
Sex transformation f to m,55980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3687.92,,,,,,,fee schedule,2492.93,6322.15,APC
Sex transformation f to m,55980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3512.31,,,,,,,fee schedule,2492.93,6322.15,APC
Sex transformation f to m,55980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6322.15,,,,,,,fee schedule,2492.93,6322.15,APC
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2816.05,,,,,,,fee schedule,122.76,3238.46,
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.76,,,,,,,fee schedule,122.76,3238.46,
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.76,,,,,,,fee schedule,122.76,3238.46,
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1846.2,,,,,,,fee schedule,122.76,3238.46,
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2304.94,,,,,,,fee schedule,122.76,3238.46,
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.17,,,,,,,fee schedule,122.76,3238.46,
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3238.46,,,,,,,fee schedule,122.76,3238.46,
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.76,,,,,,,fee schedule,122.76,3238.46,
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,122.76,3238.46,APC
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,122.76,3238.46,APC
I & D of vulva/perineum,56405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,122.76,3238.46,APC
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.35,,,,,,,fee schedule,116.93,362.6,
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.21,,,,,,,fee schedule,116.93,362.6,
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.21,,,,,,,fee schedule,116.93,362.6,
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.93,,,,,,,fee schedule,116.93,362.6,
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.98,,,,,,,fee schedule,116.93,362.6,
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,181.94,,,,,,,fee schedule,116.93,362.6,
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.1,,,,,,,fee schedule,116.93,362.6,
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.21,,,,,,,fee schedule,116.93,362.6,
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,116.93,362.6,APC
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,116.93,362.6,APC
Drainage of gland abscess,56420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,116.93,362.6,APC
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3758.54,,,,,,,fee schedule,2446.44,5805.87,
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2464.1,,,,,,,fee schedule,2446.44,5805.87,
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3076.36,,,,,,,fee schedule,2446.44,5805.87,
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4322.32,,,,,,,fee schedule,2446.44,5805.87,
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Surgery for vulva lesion,56440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Lysis of labial lesion(s),56441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Hymenotomy,56442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,3700.55,
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.86,,,,,,,fee schedule,124.61,3700.55,
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.86,,,,,,,fee schedule,124.61,3700.55,
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,3700.55,
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,3700.55,
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,191.89,,,,,,,fee schedule,124.61,3700.55,
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,3700.55,
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.86,,,,,,,fee schedule,124.61,3700.55,
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,124.61,3700.55,APC
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,124.61,3700.55,APC
Destroy vulva lesions sim,56501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,124.61,3700.55,APC
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4257.18,,,,,,,fee schedule,1706.42,4895.76,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1706.42,,,,,,,fee schedule,1706.42,4895.76,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1706.42,,,,,,,fee schedule,1706.42,4895.76,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2791.01,,,,,,,fee schedule,1706.42,4895.76,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3484.5,,,,,,,fee schedule,1706.42,4895.76,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1962.38,,,,,,,fee schedule,1706.42,4895.76,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4895.76,,,,,,,fee schedule,1706.42,4895.76,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1706.42,,,,,,,fee schedule,1706.42,4895.76,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1706.42,4895.76,APC
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1706.42,4895.76,APC
Destroy vulva lesion/s compl,56515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1706.42,4895.76,APC
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.77,,,,,,,fee schedule,70.65,1651.93,
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.21,,,,,,,fee schedule,70.65,1651.93,
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.21,,,,,,,fee schedule,70.65,1651.93,
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.65,,,,,,,fee schedule,70.65,1651.93,
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.21,,,,,,,fee schedule,70.65,1651.93,
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.34,,,,,,,fee schedule,70.65,1651.93,
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.94,,,,,,,fee schedule,70.65,1651.93,
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.21,,,,,,,fee schedule,70.65,1651.93,
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,70.65,1651.93,APC
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,70.65,1651.93,APC
Biopsy of vulva/perineum,56605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,70.65,1651.93,APC
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.52,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.18,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.85,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Partial removal of vulva,56620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Complete removal of vulva,56625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Extensive vulva surgery,56630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,8972.03,APC
Extensive vulva surgery,56630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,8972.03,APC
Extensive vulva surgery,56630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,8972.03,APC
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4134.1,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2710.32,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3383.76,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4754.22,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Partial removal of hymen,56700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vagina gland lesion,56740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Repair of vagina,56800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Repair clitoris,56805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Repair of perineum,56810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.06,,,,,,,fee schedule,93.79,362.6,
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.34,,,,,,,fee schedule,93.79,362.6,
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.34,,,,,,,fee schedule,93.79,362.6,
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.79,,,,,,,fee schedule,93.79,362.6,
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.09,,,,,,,fee schedule,93.79,362.6,
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,144.14,,,,,,,fee schedule,93.79,362.6,
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.52,,,,,,,fee schedule,93.79,362.6,
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.34,,,,,,,fee schedule,93.79,362.6,
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,93.79,362.6,APC
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,93.79,362.6,APC
Exam of vulva w/scope,56820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,93.79,362.6,APC
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4418.82,,,,,,,fee schedule,159.98,5081.64,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,159.98,,,,,,,fee schedule,159.98,5081.64,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.98,,,,,,,fee schedule,159.98,5081.64,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2896.98,,,,,,,fee schedule,159.98,5081.64,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3616.8,,,,,,,fee schedule,159.98,5081.64,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.98,,,,,,,fee schedule,159.98,5081.64,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5081.64,,,,,,,fee schedule,159.98,5081.64,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.98,,,,,,,fee schedule,159.98,5081.64,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,159.98,5081.64,APC
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,159.98,5081.64,APC
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,159.98,5081.64,APC
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4418.82,,,,,,,fee schedule,2446.44,5805.87,
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2896.98,,,,,,,fee schedule,2446.44,5805.87,
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3616.8,,,,,,,fee schedule,2446.44,5805.87,
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5081.64,,,,,,,fee schedule,2446.44,5805.87,
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Exploration of vagina,57000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Drainage of pelvic abscess,57010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,8972.03,
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,8972.03,
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,8972.03,
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,8972.03,
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,8972.03,
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,1909.64,8972.03,APC
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,1909.64,8972.03,APC
Drainage of pelvic fluid,57020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,1909.64,8972.03,APC
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3758.54,,,,,,,fee schedule,1147.5,5209.69,
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1147.5,,,,,,,fee schedule,1147.5,5209.69,
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1147.5,,,,,,,fee schedule,1147.5,5209.69,
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2464.1,,,,,,,fee schedule,1147.5,5209.69,
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3076.36,,,,,,,fee schedule,1147.5,5209.69,
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1319.63,,,,,,,fee schedule,1147.5,5209.69,
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4322.32,,,,,,,fee schedule,1147.5,5209.69,
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1147.5,,,,,,,fee schedule,1147.5,5209.69,
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1147.5,5209.69,APC
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1147.5,5209.69,APC
I & d vaginal hematoma pp,57022,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1147.5,5209.69,APC
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1847.27,5209.69,
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.63,,,,,,,fee schedule,1847.27,5209.69,
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1847.27,5209.69,
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1847.27,5209.69,
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2492.77,,,,,,,fee schedule,1847.27,5209.69,
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1847.27,5209.69,
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2167.63,,,,,,,fee schedule,1847.27,5209.69,
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1847.27,5209.69,APC
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1847.27,5209.69,APC
I & d vag hematoma non-ob,57023,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1847.27,5209.69,APC
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4253.75,,,,,,,fee schedule,152.19,5805.87,
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,152.19,,,,,,,fee schedule,152.19,5805.87,
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.19,,,,,,,fee schedule,152.19,5805.87,
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2788.76,,,,,,,fee schedule,152.19,5805.87,
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3481.69,,,,,,,fee schedule,152.19,5805.87,
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.02,,,,,,,fee schedule,152.19,5805.87,
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4891.81,,,,,,,fee schedule,152.19,5805.87,
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.19,,,,,,,fee schedule,152.19,5805.87,
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,152.19,5805.87,APC
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,152.19,5805.87,APC
Destroy vag lesions simple,57061,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,152.19,5805.87,APC
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Destroy vag lesions complex,57065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.64,,,,,,,fee schedule,74.5,1651.93,
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.44,,,,,,,fee schedule,74.5,1651.93,
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.44,,,,,,,fee schedule,74.5,1651.93,
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.5,,,,,,,fee schedule,74.5,1651.93,
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.01,,,,,,,fee schedule,74.5,1651.93,
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.36,,,,,,,fee schedule,74.5,1651.93,
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.69,,,,,,,fee schedule,74.5,1651.93,
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.44,,,,,,,fee schedule,74.5,1651.93,
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,74.5,1651.93,APC
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,74.5,1651.93,APC
Biopsy of vagina,57100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,74.5,1651.93,APC
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Biopsy of vagina,57105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,5805.87,
Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,5805.87,
Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,5805.87,
Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,5805.87,
Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2044.76,5805.87,APC
Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2044.76,5805.87,APC
Remove vagina wall partial,57106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2044.76,5805.87,APC
Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,5805.87,
Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,5805.87,
Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,5805.87,
Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,5805.87,
Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2044.76,5805.87,APC
Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2044.76,5805.87,APC
Remove vagina tissue part,57107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2044.76,5805.87,APC
Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,5805.87,
Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,5805.87,
Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,5805.87,
Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,5805.87,
Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2044.76,5805.87,APC
Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2044.76,5805.87,APC
Vaginectomy partial w/nodes,57109,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2044.76,5805.87,APC
Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4907.91,,,,,,,fee schedule,3217.63,8972.03,
Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3217.63,,,,,,,fee schedule,3217.63,8972.03,
Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4017.12,,,,,,,fee schedule,3217.63,8972.03,
Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5644.1,,,,,,,fee schedule,3217.63,8972.03,
Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3217.63,8972.03,APC
Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3217.63,8972.03,APC
Closure of vagina,57120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3217.63,8972.03,APC
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vagina lesion,57130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2446.44,5805.87,
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2446.44,5805.87,
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2446.44,5805.87,
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2446.44,5805.87,
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Remove vagina lesion,57135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,57.93,172.01,
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.93,,,,,,,fee schedule,57.93,172.01,
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.93,,,,,,,fee schedule,57.93,172.01,
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,57.93,172.01,
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,57.93,172.01,
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.62,,,,,,,fee schedule,57.93,172.01,
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,57.93,172.01,
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.93,,,,,,,fee schedule,57.93,172.01,
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,57.93,172.01,APC
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,57.93,172.01,APC
Treat vagina infection,57150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,57.93,172.01,APC
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,645.71,8972.03,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,645.71,,,,,,,fee schedule,645.71,8972.03,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.71,,,,,,,fee schedule,645.71,8972.03,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,645.71,8972.03,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,645.71,8972.03,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.57,,,,,,,fee schedule,645.71,8972.03,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,645.71,8972.03,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,645.71,,,,,,,fee schedule,645.71,8972.03,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,645.71,8972.03,APC
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,645.71,8972.03,APC
Insert uteri tandem/ovoids,57155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,645.71,8972.03,APC
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,546.54,
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.7,,,,,,,fee schedule,266.88,546.54,
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,546.54,
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,546.54,
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.66,,,,,,,fee schedule,266.88,546.54,
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,546.54,
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,266.88,546.54,APC
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,266.88,546.54,APC
Ins vag brachytx device,57156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,266.88,546.54,APC
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.62,,,,,,,fee schedule,75.8,362.6,
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.13,,,,,,,fee schedule,75.8,362.6,
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.13,,,,,,,fee schedule,75.8,362.6,
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.8,,,,,,,fee schedule,75.8,362.6,
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.63,,,,,,,fee schedule,75.8,362.6,
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.3,,,,,,,fee schedule,75.8,362.6,
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.96,,,,,,,fee schedule,75.8,362.6,
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.13,,,,,,,fee schedule,75.8,362.6,
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,75.8,362.6,APC
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,75.8,362.6,APC
Insert pessary/other device,57160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,75.8,362.6,APC
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,45.6,362.6,
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.52,,,,,,,fee schedule,45.6,362.6,
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.52,,,,,,,fee schedule,45.6,362.6,
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,45.6,362.6,
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,45.6,362.6,
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.6,,,,,,,fee schedule,45.6,362.6,
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,45.6,362.6,
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.52,,,,,,,fee schedule,45.6,362.6,
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,45.6,362.6,APC
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,45.6,362.6,APC
Fitting of diaphragm/cap,57170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,45.6,362.6,APC
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.69,,,,,,,fee schedule,147.31,362.6,
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.58,,,,,,,fee schedule,147.31,362.6,
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.58,,,,,,,fee schedule,147.31,362.6,
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.31,,,,,,,fee schedule,147.31,362.6,
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,183.91,,,,,,,fee schedule,147.31,362.6,
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.62,,,,,,,fee schedule,147.31,362.6,
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.39,,,,,,,fee schedule,147.31,362.6,
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.58,,,,,,,fee schedule,147.31,362.6,
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,147.31,362.6,APC
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,147.31,362.6,APC
Treat vaginal bleeding,57180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,147.31,362.6,APC
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2446.44,5805.87,
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2446.44,5805.87,
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2446.44,5805.87,
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2446.44,5805.87,
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Repair of vagina,57200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Repair vagina/perineum,57210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4907.91,,,,,,,fee schedule,3217.63,8972.03,
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3217.63,,,,,,,fee schedule,3217.63,8972.03,
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4017.12,,,,,,,fee schedule,3217.63,8972.03,
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,3217.63,8972.03,
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5644.1,,,,,,,fee schedule,3217.63,8972.03,
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3217.63,8972.03,APC
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3217.63,8972.03,APC
Revision of urethra,57220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3217.63,8972.03,APC
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Repair of urethral lesion,57230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6322.23,,,,,,,fee schedule,4144.85,8972.03,
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4304.72,,,,,,,fee schedule,4144.85,8972.03,
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4304.72,,,,,,,fee schedule,4144.85,8972.03,
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4144.85,,,,,,,fee schedule,4144.85,8972.03,
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5174.75,,,,,,,fee schedule,4144.85,8972.03,
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4950.43,,,,,,,fee schedule,4144.85,8972.03,
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7270.56,,,,,,,fee schedule,4144.85,8972.03,
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4304.72,,,,,,,fee schedule,4144.85,8972.03,
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4144.85,8972.03,APC
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4144.85,8972.03,APC
Repair bladder & vagina,57240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4144.85,8972.03,APC
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8177.81,,,,,,,fee schedule,4383.51,9404.48,
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,4383.51,9404.48,
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,4383.51,9404.48,
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5361.37,,,,,,,fee schedule,4383.51,9404.48,
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6693.54,,,,,,,fee schedule,4383.51,9404.48,
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,4383.51,9404.48,
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9404.48,,,,,,,fee schedule,4383.51,9404.48,
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,4383.51,9404.48,
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4383.51,9404.48,APC
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4383.51,9404.48,APC
Repair rectum & vagina,57250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4383.51,9404.48,APC
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10775.66,,,,,,,fee schedule,4304.72,12392.01,
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4304.72,,,,,,,fee schedule,4304.72,12392.01,
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4304.72,,,,,,,fee schedule,4304.72,12392.01,
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7064.52,,,,,,,fee schedule,4304.72,12392.01,
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8819.88,,,,,,,fee schedule,4304.72,12392.01,
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4950.43,,,,,,,fee schedule,4304.72,12392.01,
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12392.01,,,,,,,fee schedule,4304.72,12392.01,
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4304.72,,,,,,,fee schedule,4304.72,12392.01,
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4304.72,12392.01,APC
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4304.72,12392.01,APC
Repair of vagina,57260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4304.72,12392.01,APC
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9291.18,,,,,,,fee schedule,4383.51,10684.86,
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,4383.51,10684.86,
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,4383.51,10684.86,
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6091.3,,,,,,,fee schedule,4383.51,10684.86,
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7604.83,,,,,,,fee schedule,4383.51,10684.86,
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,4383.51,10684.86,
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10684.86,,,,,,,fee schedule,4383.51,10684.86,
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,4383.51,10684.86,
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4383.51,10684.86,APC
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4383.51,10684.86,APC
Extensive repair of vagina,57265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4383.51,10684.86,APC
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,8972.03,
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,8972.03,
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,8972.03,
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,8972.03,
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,8972.03,
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,1909.64,8972.03,APC
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,1909.64,8972.03,APC
Repair of bowel bulge,57268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,1909.64,8972.03,APC
Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7621.14,,,,,,,fee schedule,4996.42,13299.79,
Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4996.42,,,,,,,fee schedule,4996.42,13299.79,
Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6237.9,,,,,,,fee schedule,4996.42,13299.79,
Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8764.31,,,,,,,fee schedule,4996.42,13299.79,
Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,4996.42,13299.79,APC
Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,4996.42,13299.79,APC
Colpopexy extraperitoneal,57282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,4996.42,13299.79,APC
Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11669.07,,,,,,,fee schedule,7388.77,13419.43,
Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7650.24,,,,,,,fee schedule,7388.77,13419.43,
Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9551.13,,,,,,,fee schedule,7388.77,13419.43,
Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13419.43,,,,,,,fee schedule,7388.77,13419.43,
Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,7388.77,13419.43,APC
Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,7388.77,13419.43,APC
Colpopexy intraperitoneal,57283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,7388.77,13419.43,APC
Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5699.29,,,,,,,fee schedule,3736.45,8972.03,
Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3736.45,,,,,,,fee schedule,3736.45,8972.03,
Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4664.87,,,,,,,fee schedule,3736.45,8972.03,
Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6554.18,,,,,,,fee schedule,3736.45,8972.03,
Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3736.45,8972.03,APC
Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3736.45,8972.03,APC
Repair paravag defect open,57284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3736.45,8972.03,APC
Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14486.84,,,,,,,fee schedule,7388.77,16659.87,
Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9497.57,,,,,,,fee schedule,7388.77,16659.87,
Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11857.48,,,,,,,fee schedule,7388.77,16659.87,
Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16659.87,,,,,,,fee schedule,7388.77,16659.87,
Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,7388.77,16659.87,APC
Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,7388.77,16659.87,APC
Repair paravag defect vag,57285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,7388.77,16659.87,APC
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5332.6,,,,,,,fee schedule,2446.44,6132.49,
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,6132.49,
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,6132.49,
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3496.05,,,,,,,fee schedule,2446.44,6132.49,
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4364.73,,,,,,,fee schedule,2446.44,6132.49,
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,6132.49,
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6132.49,,,,,,,fee schedule,2446.44,6132.49,
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,6132.49,
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,6132.49,APC
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,6132.49,APC
Revise/Remove Sling Repair,57287,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,6132.49,APC
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4686.66,,,,,,,fee schedule,3072.57,8972.03,
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,3072.57,8972.03,
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,3072.57,8972.03,
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3072.57,,,,,,,fee schedule,3072.57,8972.03,
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3836.03,,,,,,,fee schedule,3072.57,8972.03,
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,3072.57,8972.03,
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5389.66,,,,,,,fee schedule,3072.57,8972.03,
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,3072.57,8972.03,
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3072.57,8972.03,APC
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3072.57,8972.03,APC
Repair bladder defect,57288,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3072.57,8972.03,APC
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7108.22,,,,,,,fee schedule,4383.51,13299.79,
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,4383.51,13299.79,
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,4383.51,13299.79,
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4660.15,,,,,,,fee schedule,4383.51,13299.79,
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5818.08,,,,,,,fee schedule,4383.51,13299.79,
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,4383.51,13299.79,
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8174.45,,,,,,,fee schedule,4383.51,13299.79,
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,4383.51,13299.79,
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,4383.51,13299.79,APC
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,4383.51,13299.79,APC
Repair bladder & vagina,57289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,4383.51,13299.79,APC
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,8972.03,
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,8972.03,
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,8972.03,
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,8972.03,
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,8972.03,
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,1909.64,8972.03,APC
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,1909.64,8972.03,APC
Construction of vagina,57291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,1909.64,8972.03,APC
Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5699.29,,,,,,,fee schedule,3736.45,8972.03,
Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3736.45,,,,,,,fee schedule,3736.45,8972.03,
Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4664.87,,,,,,,fee schedule,3736.45,8972.03,
Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6554.18,,,,,,,fee schedule,3736.45,8972.03,
Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3736.45,8972.03,APC
Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3736.45,8972.03,APC
Construct vagina with graft,57292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3736.45,8972.03,APC
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Revise vag graft via vagina,57295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Repair rectum-vagina fistula,57300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7108.22,,,,,,,fee schedule,4660.15,13299.79,
Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4660.15,,,,,,,fee schedule,4660.15,13299.79,
Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5818.08,,,,,,,fee schedule,4660.15,13299.79,
Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8174.45,,,,,,,fee schedule,4660.15,13299.79,
Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,4660.15,13299.79,APC
Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,4660.15,13299.79,APC
Repair urethrovaginal lesion,57310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,4660.15,13299.79,APC
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4907.91,,,,,,,fee schedule,3217.63,8972.03,
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3217.63,,,,,,,fee schedule,3217.63,8972.03,
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4017.12,,,,,,,fee schedule,3217.63,8972.03,
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,3217.63,8972.03,
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5644.1,,,,,,,fee schedule,3217.63,8972.03,
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3217.63,8972.03,APC
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3217.63,8972.03,APC
Repair bladder-vagina lesion,57320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3217.63,8972.03,APC
Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8772.98,,,,,,,fee schedule,5751.57,13299.79,
Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5751.57,,,,,,,fee schedule,5751.57,13299.79,
Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7180.68,,,,,,,fee schedule,5751.57,13299.79,
Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10088.93,,,,,,,fee schedule,5751.57,13299.79,
Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,5751.57,13299.79,APC
Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,5751.57,13299.79,APC
Repair bladder-vagina lesion,57330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,5751.57,13299.79,APC
Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,8972.03,
Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,8972.03,
Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,8972.03,
Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,8972.03,
Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,2044.76,8972.03,APC
Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,2044.76,8972.03,APC
Repair vagina,57335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,2044.76,8972.03,APC
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Dilation of vagina,57400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Pelvic examination,57410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Remove vaginal foreign body,57415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.49,,,,,,,fee schedule,130.49,546.54,
Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,130.49,,,,,,,fee schedule,130.49,546.54,
Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.06,,,,,,,fee schedule,130.49,546.54,
Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.49,,,,,,,fee schedule,130.49,546.54,
Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,130.49,546.54,APC
Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,130.49,546.54,APC
Exam of vagina w/scope,57420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,130.49,546.54,APC
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.68,,,,,,,fee schedule,169.68,1651.93,
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.68,,,,,,,fee schedule,169.68,1651.93,
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.13,,,,,,,fee schedule,169.68,1651.93,
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.68,,,,,,,fee schedule,169.68,1651.93,
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,169.68,1651.93,APC
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,169.68,1651.93,APC
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,169.68,1651.93,APC
Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10423.72,,,,,,,fee schedule,6833.79,19064.9,
Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6833.79,,,,,,,fee schedule,6833.79,19064.9,
Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8531.81,,,,,,,fee schedule,6833.79,19064.9,
Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11987.28,,,,,,,fee schedule,6833.79,19064.9,
Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,6833.79,19064.9,APC
Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,6833.79,19064.9,APC
Repair paravag defect lap,57423,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,6833.79,19064.9,APC
Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18047.32,,,,,,,fee schedule,10591.61,20754.42,
Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11831.82,,,,,,,fee schedule,10591.61,20754.42,
Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14771.73,,,,,,,fee schedule,10591.61,20754.42,
Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20754.42,,,,,,,fee schedule,10591.61,20754.42,
Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,20754.42,APC
Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,20754.42,APC
Laparoscopy surg colpopexy,57425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,20754.42,APC
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7108.22,,,,,,,fee schedule,4383.51,13299.79,
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,4383.51,13299.79,
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,4383.51,13299.79,
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4660.15,,,,,,,fee schedule,4383.51,13299.79,
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5818.08,,,,,,,fee schedule,4383.51,13299.79,
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,4383.51,13299.79,
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8174.45,,,,,,,fee schedule,4383.51,13299.79,
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,4383.51,13299.79,
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,4383.51,13299.79,APC
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,4383.51,13299.79,APC
Revise prosth vag graft lap,57426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,4383.51,13299.79,APC
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.18,,,,,,,fee schedule,89.94,362.6,
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.17,,,,,,,fee schedule,89.94,362.6,
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,120.17,,,,,,,fee schedule,89.94,362.6,
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.94,,,,,,,fee schedule,89.94,362.6,
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112.28,,,,,,,fee schedule,89.94,362.6,
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.2,,,,,,,fee schedule,89.94,362.6,
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.76,,,,,,,fee schedule,89.94,362.6,
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.17,,,,,,,fee schedule,89.94,362.6,
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,89.94,362.6,APC
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,89.94,362.6,APC
Exam of cervix w/scope,57452,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,89.94,362.6,APC
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.52,,,,,,,fee schedule,111.14,546.54,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.71,,,,,,,fee schedule,111.14,546.54,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.71,,,,,,,fee schedule,111.14,546.54,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.14,,,,,,,fee schedule,111.14,546.54,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.75,,,,,,,fee schedule,111.14,546.54,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.02,,,,,,,fee schedule,111.14,546.54,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.95,,,,,,,fee schedule,111.14,546.54,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.71,,,,,,,fee schedule,111.14,546.54,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,111.14,546.54,APC
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,111.14,546.54,APC
Bx/curett of cervix w/scope,57454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,111.14,546.54,APC
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.35,,,,,,,fee schedule,116.27,546.54,
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.5,,,,,,,fee schedule,116.27,546.54,
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.5,,,,,,,fee schedule,116.27,546.54,
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.27,,,,,,,fee schedule,116.27,546.54,
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.16,,,,,,,fee schedule,116.27,546.54,
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.98,,,,,,,fee schedule,116.27,546.54,
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,203.95,,,,,,,fee schedule,116.27,546.54,
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.5,,,,,,,fee schedule,116.27,546.54,
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,116.27,546.54,APC
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,116.27,546.54,APC
Biopsy of cervix w/scope,57455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,116.27,546.54,APC
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,170.5,,,,,,,fee schedule,111.78,546.54,
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.42,,,,,,,fee schedule,111.78,546.54,
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.42,,,,,,,fee schedule,111.78,546.54,
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.78,,,,,,,fee schedule,111.78,546.54,
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.55,,,,,,,fee schedule,111.78,546.54,
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.98,,,,,,,fee schedule,111.78,546.54,
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.08,,,,,,,fee schedule,111.78,546.54,
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.42,,,,,,,fee schedule,111.78,546.54,
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,111.78,546.54,APC
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,111.78,546.54,APC
Endocerv curettage w/scope,57456,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,111.78,546.54,APC
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,473.26,,,,,,,fee schedule,310.27,5805.87,
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,415.93,,,,,,,fee schedule,310.27,5805.87,
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,415.93,,,,,,,fee schedule,310.27,5805.87,
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.27,,,,,,,fee schedule,310.27,5805.87,
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,387.36,,,,,,,fee schedule,310.27,5805.87,
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,478.32,,,,,,,fee schedule,310.27,5805.87,
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,544.25,,,,,,,fee schedule,310.27,5805.87,
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,415.93,,,,,,,fee schedule,310.27,5805.87,
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,310.27,5805.87,APC
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,310.27,5805.87,APC
Bx of cervix w/scope leep,57460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,310.27,5805.87,APC
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,509.52,,,,,,,fee schedule,334.04,5805.87,
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,447.05,,,,,,,fee schedule,334.04,5805.87,
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,447.05,,,,,,,fee schedule,334.04,5805.87,
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.04,,,,,,,fee schedule,334.04,5805.87,
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,417.04,,,,,,,fee schedule,334.04,5805.87,
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,514.11,,,,,,,fee schedule,334.04,5805.87,
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,585.95,,,,,,,fee schedule,334.04,5805.87,
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,447.05,,,,,,,fee schedule,334.04,5805.87,
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,334.04,5805.87,APC
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,334.04,5805.87,APC
Conz of cervix w/scope leep,57461,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,334.04,5805.87,APC
Cam cervix uteri drg colp,57465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.4,,,,,,,fee schedule,95.98,168.36,
Cam cervix uteri drg colp,57465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.98,,,,,,,fee schedule,95.98,168.36,
Cam cervix uteri drg colp,57465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.83,,,,,,,fee schedule,95.98,168.36,
Cam cervix uteri drg colp,57465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,168.36,,,,,,,fee schedule,95.98,168.36,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3098.23,,,,,,,fee schedule,196.28,3562.96,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,196.28,,,,,,,fee schedule,196.28,3562.96,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,196.28,,,,,,,fee schedule,196.28,3562.96,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2031.2,,,,,,,fee schedule,196.28,3562.96,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2535.9,,,,,,,fee schedule,196.28,3562.96,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.72,,,,,,,fee schedule,196.28,3562.96,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3562.96,,,,,,,fee schedule,196.28,3562.96,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.28,,,,,,,fee schedule,196.28,3562.96,
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,196.28,3562.96,APC
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,196.28,3562.96,APC
Biopsy of cervix,57500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,196.28,3562.96,APC
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.87,,,,,,,fee schedule,99.57,1651.93,
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.13,,,,,,,fee schedule,99.57,1651.93,
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.13,,,,,,,fee schedule,99.57,1651.93,
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.57,,,,,,,fee schedule,99.57,1651.93,
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.31,,,,,,,fee schedule,99.57,1651.93,
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.1,,,,,,,fee schedule,99.57,1651.93,
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.65,,,,,,,fee schedule,99.57,1651.93,
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.13,,,,,,,fee schedule,99.57,1651.93,
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,99.57,1651.93,APC
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,99.57,1651.93,APC
Endocervical curettage,57505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,99.57,1651.93,APC
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.77,,,,,,,fee schedule,102.12,5805.87,
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.59,,,,,,,fee schedule,102.12,5805.87,
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.59,,,,,,,fee schedule,102.12,5805.87,
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.12,,,,,,,fee schedule,102.12,5805.87,
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.5,,,,,,,fee schedule,102.12,5805.87,
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.08,,,,,,,fee schedule,102.12,5805.87,
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.14,,,,,,,fee schedule,102.12,5805.87,
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.59,,,,,,,fee schedule,102.12,5805.87,
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,102.12,5805.87,APC
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,102.12,5805.87,APC
Cauterization of cervix,57510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,102.12,5805.87,APC
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.1,,,,,,,fee schedule,123.97,546.54,
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.01,,,,,,,fee schedule,123.97,546.54,
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.01,,,,,,,fee schedule,123.97,546.54,
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.97,,,,,,,fee schedule,123.97,546.54,
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.78,,,,,,,fee schedule,123.97,546.54,
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.91,,,,,,,fee schedule,123.97,546.54,
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.47,,,,,,,fee schedule,123.97,546.54,
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.01,,,,,,,fee schedule,123.97,546.54,
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,123.97,546.54,APC
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,123.97,546.54,APC
Cryocautery of cervix,57511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,123.97,546.54,APC
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3758.54,,,,,,,fee schedule,2446.44,5805.87,
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2464.1,,,,,,,fee schedule,2446.44,5805.87,
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3076.36,,,,,,,fee schedule,2446.44,5805.87,
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4322.32,,,,,,,fee schedule,2446.44,5805.87,
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Laser surgery of cervix,57513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Conization of cervix,57520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Conization of cervix,57522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,8972.03,
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,8972.03,
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,8972.03,
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,8972.03,
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,8972.03,
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,1909.64,8972.03,APC
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,1909.64,8972.03,APC
Removal of cervix,57530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,1909.64,8972.03,APC
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,8972.03,
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,8972.03,
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,8972.03,
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,8972.03,
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,8972.03,
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,1909.64,8972.03,APC
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,1909.64,8972.03,APC
Removal of residual cervix,57550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,1909.64,8972.03,APC
Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5699.29,,,,,,,fee schedule,3736.45,8972.03,
Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3736.45,,,,,,,fee schedule,3736.45,8972.03,
Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4664.87,,,,,,,fee schedule,3736.45,8972.03,
Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6554.18,,,,,,,fee schedule,3736.45,8972.03,
Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3736.45,8972.03,APC
Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3736.45,8972.03,APC
Remove cervix/repair vagina,57555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3736.45,8972.03,APC
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4907.91,,,,,,,fee schedule,3217.63,8972.03,
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3217.63,,,,,,,fee schedule,3217.63,8972.03,
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4017.12,,,,,,,fee schedule,3217.63,8972.03,
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,3217.63,8972.03,
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5644.1,,,,,,,fee schedule,3217.63,8972.03,
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3217.63,8972.03,APC
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3217.63,8972.03,APC
Remove cervix repair bowel,57556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3217.63,8972.03,APC
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
D&C oF Cervical Stump,57558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Revision of cervix,57700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Revision of cervix,57720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.29,,,,,,,fee schedule,54.6,5805.87,
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.48,,,,,,,fee schedule,54.6,5805.87,
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.48,,,,,,,fee schedule,54.6,5805.87,
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.6,,,,,,,fee schedule,54.6,5805.87,
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.17,,,,,,,fee schedule,54.6,5805.87,
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.5,,,,,,,fee schedule,54.6,5805.87,
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.78,,,,,,,fee schedule,54.6,5805.87,
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.48,,,,,,,fee schedule,54.6,5805.87,
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,54.6,5805.87,APC
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,54.6,5805.87,APC
Dilation of cervical canal,57800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,54.6,5805.87,APC
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,135.23,,,,,,,fee schedule,88.66,362.6,
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.42,,,,,,,fee schedule,88.66,362.6,
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.42,,,,,,,fee schedule,88.66,362.6,
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.66,,,,,,,fee schedule,88.66,362.6,
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.69,,,,,,,fee schedule,88.66,362.6,
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.18,,,,,,,fee schedule,88.66,362.6,
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.51,,,,,,,fee schedule,88.66,362.6,
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,118.42,,,,,,,fee schedule,88.66,362.6,
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,88.66,362.6,APC
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,88.66,362.6,APC
Biopsy of uterus lining,58100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,88.66,362.6,APC
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7638.2,,,,,,,fee schedule,2446.44,8783.93,
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,8783.93,
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,8783.93,
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5007.6,,,,,,,fee schedule,2446.44,8783.93,
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6251.87,,,,,,,fee schedule,2446.44,8783.93,
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,8783.93,
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8783.93,,,,,,,fee schedule,2446.44,8783.93,
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,8783.93,
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,8783.93,APC
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,8783.93,APC
Dilation and curettage,58120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,8783.93,APC
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4466.62,,,,,,,fee schedule,2446.44,5805.87,
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.32,,,,,,,fee schedule,2446.44,5805.87,
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3655.93,,,,,,,fee schedule,2446.44,5805.87,
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5136.61,,,,,,,fee schedule,2446.44,5805.87,
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Myomectomy vag method,58145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8073.59,,,,,,,fee schedule,4984.46,9284.63,
Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8073.59,,,,,,,fee schedule,4984.46,9284.63,
Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9284.63,,,,,,,fee schedule,4984.46,9284.63,
Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8073.59,,,,,,,fee schedule,4984.46,9284.63,
Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,9284.63,APC
Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,9284.63,APC
Vaginal hysterectomy,58260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,9284.63,APC
Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17829.18,,,,,,,fee schedule,4984.46,20503.56,
Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11688.81,,,,,,,fee schedule,4984.46,20503.56,
Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14593.18,,,,,,,fee schedule,4984.46,20503.56,
Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20503.56,,,,,,,fee schedule,4984.46,20503.56,
Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,20503.56,APC
Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,20503.56,APC
Vag hyst including t/o,58262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,20503.56,APC
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13744.62,,,,,,,fee schedule,4984.46,15806.31,
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11249.97,,,,,,,fee schedule,4984.46,15806.31,
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9010.97,,,,,,,fee schedule,4984.46,15806.31,
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15806.31,,,,,,,fee schedule,4984.46,15806.31,
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,15806.31,APC
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,15806.31,APC
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,15806.31,APC
Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7806.72,,,,,,,fee schedule,4984.46,8977.73,
Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6389.8,,,,,,,fee schedule,4984.46,8977.73,
Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5118.09,,,,,,,fee schedule,4984.46,8977.73,
Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8977.73,,,,,,,fee schedule,4984.46,8977.73,
Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,8977.73,APC
Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,8977.73,APC
Vag hyst w/enterocele repair,58270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,8977.73,APC
Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8772.98,,,,,,,fee schedule,5751.57,13299.79,
Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7180.68,,,,,,,fee schedule,5751.57,13299.79,
Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5751.57,,,,,,,fee schedule,5751.57,13299.79,
Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10088.93,,,,,,,fee schedule,5751.57,13299.79,
Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,5751.57,13299.79,APC
Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,5751.57,13299.79,APC
Vag hyst complex,58290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,5751.57,13299.79,APC
Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9291.18,,,,,,,fee schedule,4984.46,10684.86,
Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7604.83,,,,,,,fee schedule,4984.46,10684.86,
Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6091.3,,,,,,,fee schedule,4984.46,10684.86,
Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10684.86,,,,,,,fee schedule,4984.46,10684.86,
Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,10684.86,APC
Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,10684.86,APC
Vag hyst incl t/o complex,58291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,10684.86,APC
Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8772.98,,,,,,,fee schedule,5751.57,13299.79,
Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7180.68,,,,,,,fee schedule,5751.57,13299.79,
Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5751.57,,,,,,,fee schedule,5751.57,13299.79,
Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10088.93,,,,,,,fee schedule,5751.57,13299.79,
Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,5751.57,13299.79,APC
Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,5751.57,13299.79,APC
Vag hyst t/o & repair compl,58292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,5751.57,13299.79,APC
Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5699.29,,,,,,,fee schedule,3736.45,8972.03,
Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4664.87,,,,,,,fee schedule,3736.45,8972.03,
Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3736.45,,,,,,,fee schedule,3736.45,8972.03,
Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6554.18,,,,,,,fee schedule,3736.45,8972.03,
Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3736.45,8972.03,APC
Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3736.45,8972.03,APC
Vag hyst w/enterocele compl,58294,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3736.45,8972.03,APC
Insert intrauterine device,58300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.16,,,,,,,fee schedule,58.45,102.53,
Insert intrauterine device,58300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.98,,,,,,,fee schedule,58.45,102.53,
Insert intrauterine device,58300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.45,,,,,,,fee schedule,58.45,102.53,
Insert intrauterine device,58300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.53,,,,,,,fee schedule,58.45,102.53,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4466.62,,,,,,,fee schedule,107.53,5136.61,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.53,,,,,,,fee schedule,107.53,5136.61,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.53,,,,,,,fee schedule,107.53,5136.61,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3655.93,,,,,,,fee schedule,107.53,5136.61,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.32,,,,,,,fee schedule,107.53,5136.61,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.66,,,,,,,fee schedule,107.53,5136.61,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5136.61,,,,,,,fee schedule,107.53,5136.61,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.53,,,,,,,fee schedule,107.53,5136.61,
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,107.53,5136.61,APC
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,107.53,5136.61,APC
Remove intrauterine device,58301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,107.53,5136.61,APC
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.67,,,,,,,fee schedule,73.87,546.54,
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.69,,,,,,,fee schedule,73.87,546.54,
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.69,,,,,,,fee schedule,73.87,546.54,
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.22,,,,,,,fee schedule,73.87,546.54,
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.87,,,,,,,fee schedule,73.87,546.54,
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.34,,,,,,,fee schedule,73.87,546.54,
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.57,,,,,,,fee schedule,73.87,546.54,
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.69,,,,,,,fee schedule,73.87,546.54,
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,73.87,546.54,APC
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,73.87,546.54,APC
Artificial insemination,58321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,73.87,546.54,APC
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.59,,,,,,,fee schedule,77.09,362.6,
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.89,,,,,,,fee schedule,77.09,362.6,
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.89,,,,,,,fee schedule,77.09,362.6,
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.25,,,,,,,fee schedule,77.09,362.6,
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.09,,,,,,,fee schedule,77.09,362.6,
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.32,,,,,,,fee schedule,77.09,362.6,
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.23,,,,,,,fee schedule,77.09,362.6,
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.89,,,,,,,fee schedule,77.09,362.6,
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,77.09,362.6,APC
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,77.09,362.6,APC
Artificial insemination,58322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,77.09,362.6,APC
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.64,,,,,,,fee schedule,11.56,362.6,
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.57,,,,,,,fee schedule,11.56,362.6,
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.57,,,,,,,fee schedule,11.56,362.6,
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.44,,,,,,,fee schedule,11.56,362.6,
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.56,,,,,,,fee schedule,11.56,362.6,
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.91,,,,,,,fee schedule,11.56,362.6,
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.29,,,,,,,fee schedule,11.56,362.6,
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.57,,,,,,,fee schedule,11.56,362.6,
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,11.56,362.6,APC
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,11.56,362.6,APC
Sperm washing,58323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,11.56,362.6,APC
Catheter for hysterography,58340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.59,,,,,,,fee schedule,347.85,610.18,
Catheter for hysterography,58340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,434.29,,,,,,,fee schedule,347.85,610.18,
Catheter for hysterography,58340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.85,,,,,,,fee schedule,347.85,610.18,
Catheter for hysterography,58340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,610.18,,,,,,,fee schedule,347.85,610.18,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Reopen fallopian tube,58345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,8972.03,
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,8972.03,
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,8972.03,
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,8972.03,
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,8972.03,
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,1909.64,8972.03,APC
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,1909.64,8972.03,APC
Insert heyman uteri capsule,58346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,1909.64,8972.03,APC
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4907.91,,,,,,,fee schedule,3217.63,8972.03,
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3217.63,,,,,,,fee schedule,3217.63,8972.03,
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4017.12,,,,,,,fee schedule,3217.63,8972.03,
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4950.43,,,,,,,fee schedule,3217.63,8972.03,
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5644.1,,,,,,,fee schedule,3217.63,8972.03,
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3217.63,8972.03,APC
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3217.63,8972.03,APC
Reopen fallopian tube,58350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3217.63,8972.03,APC
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4907.91,,,,,,,fee schedule,3217.63,8972.03,
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3217.63,,,,,,,fee schedule,3217.63,8972.03,
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4017.12,,,,,,,fee schedule,3217.63,8972.03,
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4950.43,,,,,,,fee schedule,3217.63,8972.03,
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5644.1,,,,,,,fee schedule,3217.63,8972.03,
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3217.63,8972.03,APC
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3217.63,8972.03,APC
Endometr ablate thermal,58353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3217.63,8972.03,APC
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4510.26,,,,,,,fee schedule,2956.93,8972.03,
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3954.11,,,,,,,fee schedule,2956.93,8972.03,
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3954.11,,,,,,,fee schedule,2956.93,8972.03,
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2956.93,,,,,,,fee schedule,2956.93,8972.03,
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3691.65,,,,,,,fee schedule,2956.93,8972.03,
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4547.23,,,,,,,fee schedule,2956.93,8972.03,
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5186.8,,,,,,,fee schedule,2956.93,8972.03,
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3954.11,,,,,,,fee schedule,2956.93,8972.03,
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,2956.93,8972.03,APC
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,2956.93,8972.03,APC
Endometrial cryoablation,58356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,2956.93,8972.03,APC
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8548.96,,,,,,,fee schedule,5604.7,19064.9,
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7260.58,,,,,,,fee schedule,5604.7,19064.9,
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7260.58,,,,,,,fee schedule,5604.7,19064.9,
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5604.7,,,,,,,fee schedule,5604.7,19064.9,
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6997.32,,,,,,,fee schedule,5604.7,19064.9,
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8349.67,,,,,,,fee schedule,5604.7,19064.9,
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9831.3,,,,,,,fee schedule,5604.7,19064.9,
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7260.58,,,,,,,fee schedule,5604.7,19064.9,
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5604.7,19064.9,APC
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5604.7,19064.9,APC
Lsh uterus 250 g or less,58541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5604.7,19064.9,APC
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12631.48,,,,,,,fee schedule,7260.58,19064.9,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7260.58,,,,,,,fee schedule,7260.58,19064.9,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7260.58,,,,,,,fee schedule,7260.58,19064.9,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8281.2,,,,,,,fee schedule,7260.58,19064.9,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10338.87,,,,,,,fee schedule,7260.58,19064.9,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8349.67,,,,,,,fee schedule,7260.58,19064.9,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14526.2,,,,,,,fee schedule,7260.58,19064.9,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7260.58,,,,,,,fee schedule,7260.58,19064.9,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,7260.58,19064.9,APC
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,7260.58,19064.9,APC
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,7260.58,19064.9,APC
LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8948.41,,,,,,,fee schedule,5866.58,19064.9,
LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5866.58,,,,,,,fee schedule,5866.58,19064.9,
LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7324.27,,,,,,,fee schedule,5866.58,19064.9,
LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10290.67,,,,,,,fee schedule,5866.58,19064.9,
LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5866.58,19064.9,APC
LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5866.58,19064.9,APC
LSH Uterus Above 250 g,58543,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5866.58,19064.9,APC
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17496.02,,,,,,,fee schedule,10591.61,20120.42,
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11470.39,,,,,,,fee schedule,10591.61,20120.42,
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14320.49,,,,,,,fee schedule,10591.61,20120.42,
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20120.42,,,,,,,fee schedule,10591.61,20120.42,
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,20120.42,APC
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,20120.42,APC
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,20120.42,APC
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24958.62,,,,,,,fee schedule,3997.81,28702.41,
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3997.81,,,,,,,fee schedule,3997.81,28702.41,
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3997.81,,,,,,,fee schedule,3997.81,28702.41,
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16362.87,,,,,,,fee schedule,3997.81,28702.41,
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20428.63,,,,,,,fee schedule,3997.81,28702.41,
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4597.48,,,,,,,fee schedule,3997.81,28702.41,
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28702.41,,,,,,,fee schedule,3997.81,28702.41,
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3997.81,,,,,,,fee schedule,3997.81,28702.41,
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3997.81,28702.41,APC
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3997.81,28702.41,APC
Laparoscopic myomectomy,58545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3997.81,28702.41,APC
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8948.41,,,,,,,fee schedule,5008.21,19064.9,
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5866.58,,,,,,,fee schedule,5008.21,19064.9,
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7324.27,,,,,,,fee schedule,5008.21,19064.9,
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,5008.21,19064.9,
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10290.67,,,,,,,fee schedule,5008.21,19064.9,
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5008.21,19064.9,APC
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5008.21,19064.9,APC
Laparo-myomectomy complex,58546,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5008.21,19064.9,APC
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7260.58,,,,,,,fee schedule,3651.57,10842.82,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7260.58,,,,,,,fee schedule,3651.57,10842.82,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8349.67,,,,,,,fee schedule,3651.57,10842.82,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7260.58,,,,,,,fee schedule,3651.57,10842.82,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11846.17,,,,,,,fee schedule,5008.21,19064.9,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7766.35,,,,,,,fee schedule,5008.21,19064.9,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9696.09,,,,,,,fee schedule,5008.21,19064.9,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,5008.21,19064.9,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13623.1,,,,,,,fee schedule,5008.21,19064.9,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5008.21,19064.9,APC
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5008.21,19064.9,APC
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5008.21,19064.9,APC
Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8948.41,,,,,,,fee schedule,5866.58,19064.9,
Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5866.58,,,,,,,fee schedule,5866.58,19064.9,
Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7324.27,,,,,,,fee schedule,5866.58,19064.9,
Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10290.67,,,,,,,fee schedule,5866.58,19064.9,
Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5866.58,19064.9,APC
Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5866.58,19064.9,APC
Laparo-vag hyst complex,58553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5866.58,19064.9,APC
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14645.14,,,,,,,fee schedule,9601.35,19064.9,
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9601.35,,,,,,,fee schedule,9601.35,19064.9,
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11987.05,,,,,,,fee schedule,9601.35,19064.9,
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16841.91,,,,,,,fee schedule,9601.35,19064.9,
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,9601.35,19064.9,APC
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,9601.35,19064.9,APC
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,9601.35,19064.9,APC
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5579.99,,,,,,,fee schedule,2446.44,6416.99,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,6416.99,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,6416.99,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.24,,,,,,,fee schedule,2446.44,6416.99,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.22,,,,,,,fee schedule,2446.44,6416.99,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,6416.99,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6416.99,,,,,,,fee schedule,2446.44,6416.99,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,6416.99,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,6416.99,APC
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,6416.99,APC
Hysteroscopy dx sep proc,58555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,6416.99,APC
Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3982.01,,,,,,,fee schedule,3225.49,5805.87,
Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3982.01,,,,,,,fee schedule,3225.49,5805.87,
Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4579.31,,,,,,,fee schedule,3225.49,5805.87,
Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3982.01,,,,,,,fee schedule,3225.49,5805.87,
Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,3225.49,5805.87,APC
Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,3225.49,5805.87,APC
Hysteroscopy biopsy,58558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,3225.49,5805.87,APC
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4907.91,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3217.63,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4017.12,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4950.43,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5644.1,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4304.72,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3217.63,8972.03,APC
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3217.63,8972.03,APC
Hysteroscopy lysis,58559,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3217.63,8972.03,APC
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.52,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4304.72,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4304.72,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.18,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4950.43,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.85,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4304.72,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,2685.02,8972.03,APC
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,2685.02,8972.03,APC
Hysteroscopy resect septum,58560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,2685.02,8972.03,APC
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4095.51,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4304.72,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4304.72,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2685.02,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3352.17,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4950.43,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4709.84,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4304.72,,,,,,,fee schedule,2685.02,8972.03,
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,2685.02,8972.03,APC
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,2685.02,8972.03,APC
Hysteroscopy remove myoma,58561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,2685.02,8972.03,APC
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3353.28,,,,,,,fee schedule,2198.41,5805.87,
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2198.41,5805.87,
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2198.41,5805.87,
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2198.41,,,,,,,fee schedule,2198.41,5805.87,
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2744.66,,,,,,,fee schedule,2198.41,5805.87,
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2198.41,5805.87,
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3856.27,,,,,,,fee schedule,2198.41,5805.87,
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2198.41,5805.87,
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2198.41,5805.87,APC
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2198.41,5805.87,APC
Hysteroscopy remove fb,58562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2198.41,5805.87,APC
Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9024.18,,,,,,,fee schedule,4984.46,10377.81,
Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9024.18,,,,,,,fee schedule,4984.46,10377.81,
Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10377.81,,,,,,,fee schedule,4984.46,10377.81,
Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9024.18,,,,,,,fee schedule,4984.46,10377.81,
Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,10377.81,APC
Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,10377.81,APC
Hysteroscopy ablation,58563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,10377.81,APC
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4907.91,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3217.63,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4017.12,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5041.04,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5644.1,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4383.51,,,,,,,fee schedule,3217.63,8972.03,
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3217.63,8972.03,APC
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3217.63,8972.03,APC
Hysteroscopy sterilization,58565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3217.63,8972.03,APC
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9291.17,,,,,,,fee schedule,5008.21,19064.9,
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6091.29,,,,,,,fee schedule,5008.21,19064.9,
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7604.82,,,,,,,fee schedule,5008.21,19064.9,
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,5008.21,19064.9,
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10684.85,,,,,,,fee schedule,5008.21,19064.9,
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,19064.9,
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,5008.21,19064.9,APC
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,5008.21,19064.9,APC
Tlh uterus 250 g or less,58570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,5008.21,19064.9,APC
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12115.48,,,,,,,fee schedule,10591.61,19064.9,
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12115.48,,,,,,,fee schedule,10591.61,19064.9,
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13932.8,,,,,,,fee schedule,10591.61,19064.9,
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12115.48,,,,,,,fee schedule,10591.61,19064.9,
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10423.72,,,,,,,fee schedule,6833.79,19064.9,
Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6833.79,,,,,,,fee schedule,6833.79,19064.9,
Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8531.81,,,,,,,fee schedule,6833.79,19064.9,
Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11987.28,,,,,,,fee schedule,6833.79,19064.9,
Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,6833.79,19064.9,APC
Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,6833.79,19064.9,APC
Tlh uterus over 250 g,58572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,6833.79,19064.9,APC
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11554.33,,,,,,,fee schedule,7575.02,19064.9,
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7575.02,,,,,,,fee schedule,7575.02,19064.9,
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9457.22,,,,,,,fee schedule,7575.02,19064.9,
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13287.48,,,,,,,fee schedule,7575.02,19064.9,
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,7575.02,19064.9,APC
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,7575.02,19064.9,APC
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,7575.02,19064.9,APC
Laps tot hyst resj mal,58575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4717.79,,,,,,,fee schedule,3092.98,5425.46,
Laps tot hyst resj mal,58575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3092.98,,,,,,,fee schedule,3092.98,5425.46,
Laps tot hyst resj mal,58575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3861.51,,,,,,,fee schedule,3092.98,5425.46,
Laps tot hyst resj mal,58575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5425.46,,,,,,,fee schedule,3092.98,5425.46,
Laparo proc uterus,58578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc uterus,58578,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc uterus,58578,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Hysteroscope procedure,58579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,201.44,362.6,APC
Hysteroscope procedure,58579,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,201.44,362.6,APC
Hysteroscope procedure,58579,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,201.44,362.6,APC
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13008.23,,,,,,,fee schedule,5484.61,14959.46,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5484.61,,,,,,,fee schedule,5484.61,14959.46,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5484.61,,,,,,,fee schedule,5484.61,14959.46,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8528.2,,,,,,,fee schedule,5484.61,14959.46,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10647.24,,,,,,,fee schedule,5484.61,14959.46,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6307.3,,,,,,,fee schedule,5484.61,14959.46,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14959.46,,,,,,,fee schedule,5484.61,14959.46,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5484.61,,,,,,,fee schedule,5484.61,14959.46,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,5484.61,14959.46,APC
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,5484.61,14959.46,APC
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,5484.61,14959.46,APC
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2446.44,5805.87,
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2446.44,5805.87,
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2446.44,5805.87,
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2446.44,5805.87,
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Division of fallopian tube,58600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Occlude fallopian tube(s),58615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7806.72,,,,,,,fee schedule,5008.21,10842.82,
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,10842.82,
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,5008.21,10842.82,
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5118.09,,,,,,,fee schedule,5008.21,10842.82,
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6389.8,,,,,,,fee schedule,5008.21,10842.82,
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,5008.21,10842.82,
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8977.73,,,,,,,fee schedule,5008.21,10842.82,
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,5008.21,10842.82,
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5008.21,10842.82,APC
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5008.21,10842.82,APC
Laparoscopy lysis,58660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5008.21,10842.82,APC
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7098.94,,,,,,,fee schedule,4654.07,10842.82,
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4964.52,,,,,,,fee schedule,4654.07,10842.82,
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4964.52,,,,,,,fee schedule,4654.07,10842.82,
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4654.07,,,,,,,fee schedule,4654.07,10842.82,
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5810.48,,,,,,,fee schedule,4654.07,10842.82,
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5709.2,,,,,,,fee schedule,4654.07,10842.82,
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8163.78,,,,,,,fee schedule,4654.07,10842.82,
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4964.52,,,,,,,fee schedule,4654.07,10842.82,
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4654.07,10842.82,APC
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4654.07,10842.82,APC
Laparoscopy remove adnexa,58661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4654.07,10842.82,APC
Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8418.61,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscopy excise lesions,58662,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8418.61,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7320.53,,,,,,,fee schedule,6023.79,10842.82,
Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscopy tubal cautery,58670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3171.64,10842.82,
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3171.64,10842.82,APC
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3171.64,10842.82,APC
Laparoscopy tubal block,58671,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3171.64,10842.82,APC
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,19064.9,
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,19064.9,
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,19064.9,
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,19064.9,
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,19064.9,
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,19064.9,
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,3651.57,19064.9,APC
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,3651.57,19064.9,APC
Laparoscopy salpingostomy,58673,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,3651.57,19064.9,APC
Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12065.06,,,,,,,fee schedule,7909.85,19064.9,
Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7909.85,,,,,,,fee schedule,7909.85,19064.9,
Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9875.25,,,,,,,fee schedule,7909.85,19064.9,
Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13874.82,,,,,,,fee schedule,7909.85,19064.9,
Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,7909.85,19064.9,APC
Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,7909.85,19064.9,APC
Laps abltj uterine fibroids,58674,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,7909.85,19064.9,APC
Laparo proc oviduct-ovary,58679,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc oviduct-ovary,58679,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc oviduct-ovary,58679,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,5805.87,
Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,5805.87,
Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,5805.87,
Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,5805.87,
Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2044.76,5805.87,APC
Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2044.76,5805.87,APC
Create new tubal opening,58770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2044.76,5805.87,APC
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Drainage of ovarian cyst(s),58800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Drainage of ovarian cyst(s),58805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Drain ovary abscess open,58820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Biopsy of ovary(s),58900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8772.98,,,,,,,fee schedule,5751.57,13299.79,
Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5751.57,,,,,,,fee schedule,5751.57,13299.79,
Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7180.68,,,,,,,fee schedule,5751.57,13299.79,
Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10088.93,,,,,,,fee schedule,5751.57,13299.79,
Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7758.21,,,,,,,fee schedule,5751.57,13299.79,APC
Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7388.77,,,,,,,fee schedule,5751.57,13299.79,APC
Partial removal of ovary(s),58920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13299.79,,,,,,,fee schedule,5751.57,13299.79,APC
Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7806.72,,,,,,,fee schedule,4984.46,8977.73,
Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5118.09,,,,,,,fee schedule,4984.46,8977.73,
Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6389.8,,,,,,,fee schedule,4984.46,8977.73,
Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8977.73,,,,,,,fee schedule,4984.46,8977.73,
Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,4984.46,8977.73,APC
Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,4984.46,8977.73,APC
Removal of ovarian cyst(s),58925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,4984.46,8977.73,APC
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.95,,,,,,,fee schedule,644.42,1651.93,
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,645.71,,,,,,,fee schedule,644.42,1651.93,
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.71,,,,,,,fee schedule,644.42,1651.93,
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.42,,,,,,,fee schedule,644.42,1651.93,
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.54,,,,,,,fee schedule,644.42,1651.93,
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.57,,,,,,,fee schedule,644.42,1651.93,
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1130.39,,,,,,,fee schedule,644.42,1651.93,
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,645.71,,,,,,,fee schedule,644.42,1651.93,
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,644.42,1651.93,APC
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,644.42,1651.93,APC
Retrieval of oocyte,58970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,644.42,1651.93,APC
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,1651.93,
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,645.71,,,,,,,fee schedule,266.88,1651.93,
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.71,,,,,,,fee schedule,266.88,1651.93,
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,1651.93,
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,1651.93,
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.57,,,,,,,fee schedule,266.88,1651.93,
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,1651.93,
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,645.71,,,,,,,fee schedule,266.88,1651.93,
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,266.88,1651.93,APC
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,266.88,1651.93,APC
Transfer of embryo,58974,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,266.88,1651.93,APC
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,546.54,
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.7,,,,,,,fee schedule,266.88,546.54,
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,546.54,
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,546.54,
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.66,,,,,,,fee schedule,266.88,546.54,
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,546.54,
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,266.88,546.54,APC
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,266.88,546.54,APC
Transfer of embryo,58976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,266.88,546.54,APC
Genital surgery procedure,58999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,201.44,362.6,APC
Genital surgery procedure,58999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,201.44,362.6,APC
Genital surgery procedure,58999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,201.44,362.6,APC
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.02,,,,,,,fee schedule,126.54,1651.93,
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,170.35,,,,,,,fee schedule,126.54,1651.93,
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.35,,,,,,,fee schedule,126.54,1651.93,
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.54,,,,,,,fee schedule,126.54,1651.93,
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.99,,,,,,,fee schedule,126.54,1651.93,
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.9,,,,,,,fee schedule,126.54,1651.93,
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.97,,,,,,,fee schedule,126.54,1651.93,
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,170.35,,,,,,,fee schedule,126.54,1651.93,
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,126.54,1651.93,APC
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,126.54,1651.93,APC
Amniocentesis diagnostic,59000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,126.54,1651.93,APC
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,287.2,,,,,,,fee schedule,188.29,546.54,
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.7,,,,,,,fee schedule,188.29,546.54,
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.7,,,,,,,fee schedule,188.29,546.54,
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,188.29,,,,,,,fee schedule,188.29,546.54,
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,235.07,,,,,,,fee schedule,188.29,546.54,
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.66,,,,,,,fee schedule,188.29,546.54,
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,330.28,,,,,,,fee schedule,188.29,546.54,
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.7,,,,,,,fee schedule,188.29,546.54,
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,188.29,546.54,APC
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,188.29,546.54,APC
Amniocentesis therapeutic,59001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,188.29,546.54,APC
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,546.54,
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,546.54,
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,546.54,
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.66,,,,,,,fee schedule,266.88,546.54,
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,546.54,
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,266.88,546.54,APC
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,266.88,546.54,APC
Fetal cord puncture prenatal,59012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,266.88,546.54,APC
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,168.52,,,,,,,fee schedule,110.48,1651.93,
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.71,,,,,,,fee schedule,110.48,1651.93,
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.71,,,,,,,fee schedule,110.48,1651.93,
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.48,,,,,,,fee schedule,110.48,1651.93,
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.93,,,,,,,fee schedule,110.48,1651.93,
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.02,,,,,,,fee schedule,110.48,1651.93,
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,193.8,,,,,,,fee schedule,110.48,1651.93,
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.71,,,,,,,fee schedule,110.48,1651.93,
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.63,,,,,,,fee schedule,110.48,1651.93,APC
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.74,,,,,,,fee schedule,110.48,1651.93,APC
Chorion biopsy,59015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1651.93,,,,,,,fee schedule,110.48,1651.93,APC
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.05,,,,,,,fee schedule,61.66,362.6,
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.15,,,,,,,fee schedule,61.66,362.6,
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.15,,,,,,,fee schedule,61.66,362.6,
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.66,,,,,,,fee schedule,61.66,362.6,
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.98,,,,,,,fee schedule,61.66,362.6,
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.47,,,,,,,fee schedule,61.66,362.6,
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.16,,,,,,,fee schedule,61.66,362.6,
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.15,,,,,,,fee schedule,61.66,362.6,
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,61.66,362.6,APC
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,61.66,362.6,APC
Fetal contract stress test,59020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,61.66,362.6,APC
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.51,,,,,,,fee schedule,138.67,362.6,
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.51,,,,,,,fee schedule,138.67,362.6,
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.51,,,,,,,fee schedule,138.67,362.6,
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.67,,,,,,,fee schedule,138.67,362.6,
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.12,,,,,,,fee schedule,138.67,362.6,
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.24,,,,,,,fee schedule,138.67,362.6,
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,138.67,362.6,APC
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,138.67,362.6,APC
Fetal non-stress test,59025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,138.67,362.6,APC
Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,412.39,,,,,,,fee schedule,270.36,546.54,
Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,270.36,,,,,,,fee schedule,270.36,546.54,
Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,337.54,,,,,,,fee schedule,270.36,546.54,
Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,474.25,,,,,,,fee schedule,270.36,546.54,
Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,270.36,546.54,APC
Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,270.36,546.54,APC
Fetal scalp blood sample,59030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,270.36,546.54,APC
Fetal monitor w/report,59050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,22.47,39.42,
Fetal monitor w/report,59050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,22.47,39.42,
Fetal monitor w/report,59050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,22.47,39.42,
Fetal monitor w/report,59050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,22.47,39.42,
Fetal monitor/interpret only,59051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.4,,,,,,,fee schedule,19.27,33.81,
Fetal monitor/interpret only,59051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.27,,,,,,,fee schedule,19.27,33.81,
Fetal monitor/interpret only,59051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.06,,,,,,,fee schedule,19.27,33.81,
Fetal monitor/interpret only,59051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.81,,,,,,,fee schedule,19.27,33.81,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,742.57,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,645.71,,,,,,,fee schedule,266.88,742.57,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.71,,,,,,,fee schedule,266.88,742.57,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,742.57,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,742.57,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.57,,,,,,,fee schedule,266.88,742.57,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,742.57,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,645.71,,,,,,,fee schedule,266.88,742.57,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,266.88,742.57,APC
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,266.88,742.57,APC
Transabdom amnioinfus w/us,59070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,266.88,742.57,APC
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,546.54,
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.7,,,,,,,fee schedule,266.88,546.54,
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,546.54,
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,546.54,
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.66,,,,,,,fee schedule,266.88,546.54,
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,546.54,
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,266.88,546.54,APC
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,266.88,546.54,APC
Umbilical cord occlud w/us,59072,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,266.88,546.54,APC
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,546.54,
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,546.54,
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,546.54,
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.66,,,,,,,fee schedule,266.88,546.54,
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,546.54,
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,266.88,546.54,APC
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,266.88,546.54,APC
Fetal fluid drainage w/us,59074,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,266.88,546.54,APC
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,546.54,
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,546.54,
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,546.54,
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.66,,,,,,,fee schedule,266.88,546.54,
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,546.54,
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,266.88,546.54,APC
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,266.88,546.54,APC
Fetal shunt placement w/us,59076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,266.88,546.54,APC
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,8972.03,
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,8972.03,
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,8972.03,
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,8972.03,
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,8972.03,
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,8972.03,
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,1909.64,8972.03,APC
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,1909.64,8972.03,APC
Remove uterus lesion,59100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,1909.64,8972.03,APC
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,3651.57,10842.82,
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,3651.57,10842.82,
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Treat ectopic pregnancy,59150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6569.65,,,,,,,fee schedule,4307.06,10842.82,
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5008.21,,,,,,,fee schedule,4307.06,10842.82,
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5008.21,,,,,,,fee schedule,4307.06,10842.82,
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4307.06,,,,,,,fee schedule,4307.06,10842.82,
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5377.26,,,,,,,fee schedule,4307.06,10842.82,
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5759.44,,,,,,,fee schedule,4307.06,10842.82,
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7555.1,,,,,,,fee schedule,4307.06,10842.82,
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5008.21,,,,,,,fee schedule,4307.06,10842.82,
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,4307.06,10842.82,APC
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,4307.06,10842.82,APC
Treat ectopic pregnancy,59151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,4307.06,10842.82,APC
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3898.18,,,,,,,fee schedule,2446.44,5805.87,
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2555.65,,,,,,,fee schedule,2446.44,5805.87,
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3190.66,,,,,,,fee schedule,2446.44,5805.87,
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4482.91,,,,,,,fee schedule,2446.44,5805.87,
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
D & c after delivery,59160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.81,,,,,,,fee schedule,69.37,546.54,
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.52,,,,,,,fee schedule,69.37,546.54,
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.52,,,,,,,fee schedule,69.37,546.54,
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.37,,,,,,,fee schedule,69.37,546.54,
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.61,,,,,,,fee schedule,69.37,546.54,
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.4,,,,,,,fee schedule,69.37,546.54,
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.68,,,,,,,fee schedule,69.37,546.54,
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.52,,,,,,,fee schedule,69.37,546.54,
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,69.37,546.54,APC
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,69.37,546.54,APC
Insert cervical dilator,59200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,69.37,546.54,APC
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,248.87,,,,,,,fee schedule,163.16,5805.87,
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.75,,,,,,,fee schedule,163.16,5805.87,
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.75,,,,,,,fee schedule,163.16,5805.87,
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.16,,,,,,,fee schedule,163.16,5805.87,
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,203.7,,,,,,,fee schedule,163.16,5805.87,
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,251.56,,,,,,,fee schedule,163.16,5805.87,
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,286.2,,,,,,,fee schedule,163.16,5805.87,
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,218.75,,,,,,,fee schedule,163.16,5805.87,
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,163.16,5805.87,APC
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,163.16,5805.87,APC
Episiotomy or vaginal repair,59300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,163.16,5805.87,APC
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4466.62,,,,,,,fee schedule,2446.44,5805.87,
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.32,,,,,,,fee schedule,2446.44,5805.87,
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3655.93,,,,,,,fee schedule,2446.44,5805.87,
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5136.61,,,,,,,fee schedule,2446.44,5805.87,
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Revision of cervix,59320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Obstetrical care,59400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2001.85,,,,,,,fee schedule,1312.41,2302.13,
Obstetrical care,59400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1312.41,,,,,,,fee schedule,1312.41,2302.13,
Obstetrical care,59400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1638.51,,,,,,,fee schedule,1312.41,2302.13,
Obstetrical care,59400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2302.13,,,,,,,fee schedule,1312.41,2302.13,
Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,5805.87,
Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,5805.87,
Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,5805.87,
Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,5805.87,
Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2044.76,5805.87,APC
Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2044.76,5805.87,APC
Obstetrical care,59409,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2044.76,5805.87,APC
Obstetrical care,59410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,762.32,,,,,,,fee schedule,499.78,876.67,
Obstetrical care,59410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,499.78,,,,,,,fee schedule,499.78,876.67,
Obstetrical care,59410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,623.96,,,,,,,fee schedule,499.78,876.67,
Obstetrical care,59410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,876.67,,,,,,,fee schedule,499.78,876.67,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4404.78,,,,,,,fee schedule,2446.44,5805.87,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2887.77,,,,,,,fee schedule,2446.44,5805.87,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3605.31,,,,,,,fee schedule,2446.44,5805.87,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5065.5,,,,,,,fee schedule,2446.44,5805.87,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Antepartum manipulation,59412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Deliver placenta,59414,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Antepartum care only,59425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,518.34,,,,,,,fee schedule,339.82,596.09,
Antepartum care only,59425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,339.82,,,,,,,fee schedule,339.82,596.09,
Antepartum care only,59425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,424.26,,,,,,,fee schedule,339.82,596.09,
Antepartum care only,59425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,596.09,,,,,,,fee schedule,339.82,596.09,
Antepartum care only,59426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,952.42,,,,,,,fee schedule,624.41,1095.28,
Antepartum care only,59426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,624.41,,,,,,,fee schedule,624.41,1095.28,
Antepartum care only,59426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,779.56,,,,,,,fee schedule,624.41,1095.28,
Antepartum care only,59426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1095.28,,,,,,,fee schedule,624.41,1095.28,
Care after delivery,59430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,222.44,,,,,,,fee schedule,145.83,255.81,
Care after delivery,59430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.83,,,,,,,fee schedule,145.83,255.81,
Care after delivery,59430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.07,,,,,,,fee schedule,145.83,255.81,
Care after delivery,59430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.81,,,,,,,fee schedule,145.83,255.81,
Cesarean delivery,59510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2178.21,,,,,,,fee schedule,1428.03,2504.94,
Cesarean delivery,59510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1428.03,,,,,,,fee schedule,1428.03,2504.94,
Cesarean delivery,59510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1782.86,,,,,,,fee schedule,1428.03,2504.94,
Cesarean delivery,59510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2504.94,,,,,,,fee schedule,1428.03,2504.94,
Cesarean delivery,59515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,950.46,,,,,,,fee schedule,623.12,1093.03,
Cesarean delivery,59515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,623.12,,,,,,,fee schedule,623.12,1093.03,
Cesarean delivery,59515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,777.95,,,,,,,fee schedule,623.12,1093.03,
Cesarean delivery,59515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1093.03,,,,,,,fee schedule,623.12,1093.03,
Vbac delivery,59610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2046.91,,,,,,,fee schedule,1341.95,2353.95,
Vbac delivery,59610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1341.95,,,,,,,fee schedule,1341.95,2353.95,
Vbac delivery,59610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1675.4,,,,,,,fee schedule,1341.95,2353.95,
Vbac delivery,59610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2353.95,,,,,,,fee schedule,1341.95,2353.95,
Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3118.92,,,,,,,fee schedule,2044.76,5805.87,
Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2044.76,,,,,,,fee schedule,2044.76,5805.87,
Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2552.84,,,,,,,fee schedule,2044.76,5805.87,
Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3586.76,,,,,,,fee schedule,2044.76,5805.87,
Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2044.76,5805.87,APC
Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2044.76,5805.87,APC
Vbac delivery only,59612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2044.76,5805.87,APC
Vbac care after delivery,59614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,813.28,,,,,,,fee schedule,533.19,935.27,
Vbac care after delivery,59614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,533.19,,,,,,,fee schedule,533.19,935.27,
Vbac care after delivery,59614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,665.67,,,,,,,fee schedule,533.19,935.27,
Vbac care after delivery,59614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,935.27,,,,,,,fee schedule,533.19,935.27,
Attempted vbac delivery,59618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2192.92,,,,,,,fee schedule,1437.68,2521.86,
Attempted vbac delivery,59618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1437.68,,,,,,,fee schedule,1437.68,2521.86,
Attempted vbac delivery,59618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1794.91,,,,,,,fee schedule,1437.68,2521.86,
Attempted vbac delivery,59618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2521.86,,,,,,,fee schedule,1437.68,2521.86,
Attempted vbac after care,59622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,973.96,,,,,,,fee schedule,638.53,1120.05,
Attempted vbac after care,59622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,638.53,,,,,,,fee schedule,638.53,1120.05,
Attempted vbac after care,59622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,797.19,,,,,,,fee schedule,638.53,1120.05,
Attempted vbac after care,59622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1120.05,,,,,,,fee schedule,638.53,1120.05,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3728.37,,,,,,,fee schedule,2444.32,5805.87,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2444.32,5805.87,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2444.32,5805.87,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2444.32,,,,,,,fee schedule,2444.32,5805.87,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3051.67,,,,,,,fee schedule,2444.32,5805.87,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2444.32,5805.87,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4287.63,,,,,,,fee schedule,2444.32,5805.87,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2444.32,5805.87,
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2444.32,5805.87,APC
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2444.32,5805.87,APC
Treatment of miscarriage,59812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2444.32,5805.87,APC
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3664.22,,,,,,,fee schedule,2402.26,5805.87,
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2402.26,5805.87,
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2402.26,5805.87,
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2402.26,,,,,,,fee schedule,2402.26,5805.87,
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2999.16,,,,,,,fee schedule,2402.26,5805.87,
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2402.26,5805.87,
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4213.85,,,,,,,fee schedule,2402.26,5805.87,
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2402.26,5805.87,
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2402.26,5805.87,APC
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2402.26,5805.87,APC
Care of miscarriage,59820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2402.26,5805.87,APC
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4748.99,,,,,,,fee schedule,2446.44,5805.87,
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3113.44,,,,,,,fee schedule,2446.44,5805.87,
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3887.05,,,,,,,fee schedule,2446.44,5805.87,
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2446.44,5805.87,
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5461.34,,,,,,,fee schedule,2446.44,5805.87,
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2446.44,5805.87,
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2446.44,5805.87,APC
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2446.44,5805.87,APC
Treatment of miscarriage,59821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2446.44,5805.87,APC
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Abortion,59840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Abortion,59841,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.07,,,,,,,fee schedule,266.88,546.54,
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.7,,,,,,,fee schedule,266.88,546.54,
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.88,,,,,,,fee schedule,266.88,546.54,
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.19,,,,,,,fee schedule,266.88,546.54,
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.66,,,,,,,fee schedule,266.88,546.54,
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.13,,,,,,,fee schedule,266.88,546.54,
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.7,,,,,,,fee schedule,266.88,546.54,
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.82,,,,,,,fee schedule,266.88,546.54,APC
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.63,,,,,,,fee schedule,266.88,546.54,APC
Abortion (mpr),59866,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,546.54,,,,,,,fee schedule,266.88,546.54,APC
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3098.23,,,,,,,fee schedule,2031.2,5805.87,
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,2031.2,5805.87,
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,2031.2,5805.87,
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2031.2,,,,,,,fee schedule,2031.2,5805.87,
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2535.9,,,,,,,fee schedule,2031.2,5805.87,
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,2031.2,5805.87,
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3562.96,,,,,,,fee schedule,2031.2,5805.87,
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,2031.2,5805.87,
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,2031.2,5805.87,APC
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,2031.2,5805.87,APC
Evacuate mole of uterus,59870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,2031.2,5805.87,APC
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2912.82,,,,,,,fee schedule,1909.64,5805.87,
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1909.64,,,,,,,fee schedule,1909.64,5805.87,
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2384.14,,,,,,,fee schedule,1909.64,5805.87,
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2813.41,,,,,,,fee schedule,1909.64,5805.87,
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3349.74,,,,,,,fee schedule,1909.64,5805.87,
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2446.44,,,,,,,fee schedule,1909.64,5805.87,
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3386.76,,,,,,,fee schedule,1909.64,5805.87,APC
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3225.49,,,,,,,fee schedule,1909.64,5805.87,APC
Remove cerclage suture,59871,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5805.87,,,,,,,fee schedule,1909.64,5805.87,APC
Fetal invas px w/us,59897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,201.44,362.6,APC
Fetal invas px w/us,59897,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,201.44,362.6,APC
Fetal invas px w/us,59897,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,201.44,362.6,APC
Laparo proc ob care/deliver,59898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc ob care/deliver,59898,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc ob care/deliver,59898,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Maternity care procedure,59899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,201.44,362.6,APC
Maternity care procedure,59899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,201.44,362.6,APC
Maternity care procedure,59899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,201.44,362.6,APC
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,856.9,2782.81,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,856.9,,,,,,,fee schedule,856.9,2782.81,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,856.9,2782.81,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,856.9,2782.81,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,985.44,,,,,,,fee schedule,856.9,2782.81,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,856.9,2782.81,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,856.9,,,,,,,fee schedule,856.9,2782.81,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,856.9,2782.81,APC
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,856.9,2782.81,APC
Drain thyroid/tongue cyst,60000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,856.9,2782.81,APC
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1397.22,,,,,,,fee schedule,130.58,1606.8,
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.58,,,,,,,fee schedule,130.58,1606.8,
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,130.58,,,,,,,fee schedule,130.58,1606.8,
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,916.02,,,,,,,fee schedule,130.58,1606.8,
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1143.62,,,,,,,fee schedule,130.58,1606.8,
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.17,,,,,,,fee schedule,130.58,1606.8,
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1606.8,,,,,,,fee schedule,130.58,1606.8,
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.58,,,,,,,fee schedule,130.58,1606.8,
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,130.58,1606.8,APC
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,130.58,1606.8,APC
Biopsy of thyroid,60100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,130.58,1606.8,APC
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,3651.57,10842.82,
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Remove thyroid lesion,60200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9291.17,,,,,,,fee schedule,5618.09,10842.82,
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6091.29,,,,,,,fee schedule,5618.09,10842.82,
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7604.82,,,,,,,fee schedule,5618.09,10842.82,
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,5618.09,10842.82,
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10684.85,,,,,,,fee schedule,5618.09,10842.82,
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5618.09,10842.82,APC
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5618.09,10842.82,APC
Partial thyroid excision,60210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5618.09,10842.82,APC
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5569.81,,,,,,,fee schedule,3651.57,10842.82,
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3651.57,,,,,,,fee schedule,3651.57,10842.82,
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4558.89,,,,,,,fee schedule,3651.57,10842.82,
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,3651.57,10842.82,
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6405.28,,,,,,,fee schedule,3651.57,10842.82,
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,3651.57,10842.82,
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,3651.57,10842.82,APC
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,3651.57,10842.82,APC
Partial thyroid excision,60212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,3651.57,10842.82,APC
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.44,,,,,,,fee schedule,5502.08,10842.82,
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,5502.08,10842.82,
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,5502.08,10842.82,
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.08,,,,,,,fee schedule,5502.08,10842.82,
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.21,,,,,,,fee schedule,5502.08,10842.82,
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,5502.08,10842.82,
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.31,,,,,,,fee schedule,5502.08,10842.82,
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,5502.08,10842.82,
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5502.08,10842.82,APC
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5502.08,10842.82,APC
Partial removal of thyroid,60220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5502.08,10842.82,APC
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9394.45,,,,,,,fee schedule,5618.09,10842.82,
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6159,,,,,,,fee schedule,5618.09,10842.82,
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7689.36,,,,,,,fee schedule,5618.09,10842.82,
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,5618.09,10842.82,
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10803.62,,,,,,,fee schedule,5618.09,10842.82,
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5618.09,10842.82,APC
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5618.09,10842.82,APC
Partial removal of thyroid,60225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5618.09,10842.82,APC
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10935.72,,,,,,,fee schedule,5618.09,12576.08,
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,12576.08,
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,5618.09,12576.08,
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7169.46,,,,,,,fee schedule,5618.09,12576.08,
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8950.89,,,,,,,fee schedule,5618.09,12576.08,
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,5618.09,12576.08,
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12576.08,,,,,,,fee schedule,5618.09,12576.08,
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,12576.08,
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5618.09,12576.08,APC
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5618.09,12576.08,APC
Removal of thyroid,60240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5618.09,12576.08,APC
Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17076.44,,,,,,,fee schedule,5898.54,19637.91,
Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11195.31,,,,,,,fee schedule,5898.54,19637.91,
Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13977.07,,,,,,,fee schedule,5898.54,19637.91,
Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19637.91,,,,,,,fee schedule,5898.54,19637.91,
Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,19637.91,APC
Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,19637.91,APC
Removal of thyroid,60252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,19637.91,APC
Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7949.81,,,,,,,fee schedule,5211.9,10617.38,
Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5211.9,,,,,,,fee schedule,5211.9,10617.38,
Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6506.92,,,,,,,fee schedule,5211.9,10617.38,
Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9142.28,,,,,,,fee schedule,5211.9,10617.38,
Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5211.9,10617.38,APC
Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5211.9,10617.38,APC
Repeat thyroid surgery,60260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5211.9,10617.38,APC
Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18198.06,,,,,,,fee schedule,5898.54,20927.77,
Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11930.65,,,,,,,fee schedule,5898.54,20927.77,
Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14895.11,,,,,,,fee schedule,5898.54,20927.77,
Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20927.77,,,,,,,fee schedule,5898.54,20927.77,
Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,20927.77,APC
Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,20927.77,APC
Removal of thyroid,60271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,20927.77,APC
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.07,,,,,,,fee schedule,5618.09,10842.82,
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.52,,,,,,,fee schedule,5618.09,10842.82,
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.23,,,,,,,fee schedule,5618.09,10842.82,
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,5618.09,10842.82,
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.33,,,,,,,fee schedule,5618.09,10842.82,
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,10842.82,
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5618.09,10842.82,APC
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5618.09,10842.82,APC
Remove thyroid duct lesion,60280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5618.09,10842.82,APC
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10437.49,,,,,,,fee schedule,5618.09,12003.11,
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,12003.11,
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5618.09,,,,,,,fee schedule,5618.09,12003.11,
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6842.82,,,,,,,fee schedule,5618.09,12003.11,
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8543.09,,,,,,,fee schedule,5618.09,12003.11,
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6460.8,,,,,,,fee schedule,5618.09,12003.11,
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12003.11,,,,,,,fee schedule,5618.09,12003.11,
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.09,,,,,,,fee schedule,5618.09,12003.11,
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,5618.09,12003.11,APC
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,5618.09,12003.11,APC
Remove thyroid duct lesion,60281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,5618.09,12003.11,APC
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,223.41,,,,,,,fee schedule,146.47,1270.05,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.87,,,,,,,fee schedule,146.47,1270.05,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,198.87,,,,,,,fee schedule,146.47,1270.05,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.47,,,,,,,fee schedule,146.47,1270.05,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.86,,,,,,,fee schedule,146.47,1270.05,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.7,,,,,,,fee schedule,146.47,1270.05,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,256.92,,,,,,,fee schedule,146.47,1270.05,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.87,,,,,,,fee schedule,146.47,1270.05,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,146.47,1270.05,APC
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,146.47,1270.05,APC
Aspir/inj thyroid cyst,60300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,146.47,1270.05,APC
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8615.11,,,,,,,fee schedule,4942.79,10617.38,
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5648.07,,,,,,,fee schedule,4942.79,10617.38,
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7051.47,,,,,,,fee schedule,4942.79,10617.38,
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9907.38,,,,,,,fee schedule,4942.79,10617.38,
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Explore parathyroid glands,60500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Re-explore parathyroids,60502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Removal of thymus gland,60520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Laparo proc endocrine,60659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc endocrine,60659,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Laparo proc endocrine,60659,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2649.09,,,,,,,fee schedule,1645.66,3046.45,
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1736.74,,,,,,,fee schedule,1645.66,3046.45,
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2168.28,,,,,,,fee schedule,1645.66,3046.45,
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3046.45,,,,,,,fee schedule,1645.66,3046.45,
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1645.66,3046.45,APC
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1645.66,3046.45,APC
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1645.66,3046.45,APC
Abltj 1/+thyr ndul addl prq,60661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1112.21,,,,,,,fee schedule,729.16,1279.04,
Abltj 1/+thyr ndul addl prq,60661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,729.16,,,,,,,fee schedule,729.16,1279.04,
Abltj 1/+thyr ndul addl prq,60661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,910.34,,,,,,,fee schedule,729.16,1279.04,
Abltj 1/+thyr ndul addl prq,60661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1279.04,,,,,,,fee schedule,729.16,1279.04,
Endocrine surgery procedure,60699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.98,,,,,,,fee schedule,6023.79,10842.82,APC
Endocrine surgery procedure,60699,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6023.79,,,,,,,fee schedule,6023.79,10842.82,APC
Endocrine surgery procedure,60699,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10842.82,,,,,,,fee schedule,6023.79,10842.82,APC
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,748.72,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.86,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,612.83,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,861.03,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,490.86,1266.02,APC
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,490.86,1266.02,APC
Remove cranial cavity fluid,61000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,490.86,1266.02,APC
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,748.72,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.86,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,612.83,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,861.03,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,490.86,1266.02,
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,490.86,1266.02,APC
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,490.86,1266.02,APC
Remove cranial cavity fluid,61001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,490.86,1266.02,APC
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Remove brain cavity fluid,61020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,748.72,,,,,,,fee schedule,490.86,1266.02,
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,490.86,1266.02,
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,490.86,1266.02,
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.86,,,,,,,fee schedule,490.86,1266.02,
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,612.83,,,,,,,fee schedule,490.86,1266.02,
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,490.86,1266.02,
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,861.03,,,,,,,fee schedule,490.86,1266.02,
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,490.86,1266.02,
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,490.86,1266.02,APC
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,490.86,1266.02,APC
Injection into brain canal,61026,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,490.86,1266.02,APC
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,341.01,,,,,,,fee schedule,223.57,2240.18,
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,223.57,2240.18,
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,223.57,2240.18,
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.57,,,,,,,fee schedule,223.57,2240.18,
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.12,,,,,,,fee schedule,223.57,2240.18,
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,223.57,2240.18,
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.16,,,,,,,fee schedule,223.57,2240.18,
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,223.57,2240.18,
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,223.57,2240.18,APC
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,223.57,2240.18,APC
Remove brain canal fluid,61050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,223.57,2240.18,APC
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,341.01,,,,,,,fee schedule,223.57,1024.13,
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,223.57,1024.13,
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,223.57,1024.13,
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.57,,,,,,,fee schedule,223.57,1024.13,
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.12,,,,,,,fee schedule,223.57,1024.13,
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,223.57,1024.13,
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.16,,,,,,,fee schedule,223.57,1024.13,
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,223.57,1024.13,
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,223.57,1024.13,APC
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,223.57,1024.13,APC
Injection into brain canal,61055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,223.57,1024.13,APC
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.04,,,,,,,fee schedule,266.86,1266.02,
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,266.86,1266.02,
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.75,,,,,,,fee schedule,266.86,1266.02,
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.86,,,,,,,fee schedule,266.86,1266.02,
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.16,,,,,,,fee schedule,266.86,1266.02,
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.76,,,,,,,fee schedule,266.86,1266.02,
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.1,,,,,,,fee schedule,266.86,1266.02,
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.75,,,,,,,fee schedule,266.86,1266.02,
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,266.86,1266.02,APC
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,266.86,1266.02,APC
Brain canal shunt procedure,61070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,266.86,1266.02,APC
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Insert brain-fluid device,61215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Decompress eye socket,61330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Endovasc tempory vessel occl,61623,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Transcath occlusion cns,61624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Transcath occlusion cns,61624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Transcath occlusion cns,61624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Transcath occlusion non-cns,61626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Dilate ic vasospasm init,61640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9408.69,,,,,,,fee schedule,6168.34,10819.99,
Dilate ic vasospasm init,61640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6168.34,,,,,,,fee schedule,6168.34,10819.99,
Dilate ic vasospasm init,61640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7701.01,,,,,,,fee schedule,6168.34,10819.99,
Dilate ic vasospasm init,61640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10819.99,,,,,,,fee schedule,6168.34,10819.99,
Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20388.96,,,,,,,fee schedule,11102.63,23447.3,
Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13367,,,,,,,fee schedule,11102.63,23447.3,
Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16688.36,,,,,,,fee schedule,11102.63,23447.3,
Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23447.3,,,,,,,fee schedule,11102.63,23447.3,
Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,23447.3,APC
Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,23447.3,APC
Mrgfus strtctc ablt trgt icr,61715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,23447.3,APC
Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6209.32,,,,,,,fee schedule,4070.83,15739.73,
Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4070.83,,,,,,,fee schedule,4070.83,15739.73,
Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5082.33,,,,,,,fee schedule,4070.83,15739.73,
Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7140.72,,,,,,,fee schedule,4070.83,15739.73,
Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,4070.83,15739.73,APC
Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,4070.83,15739.73,APC
Incise skull/brain surgery,61720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,4070.83,15739.73,APC
Litt icr 1 traj 1 smpl les,61736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1107.29,,,,,,,fee schedule,725.94,1273.38,
Litt icr 1 traj 1 smpl les,61736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,725.94,,,,,,,fee schedule,725.94,1273.38,
Litt icr 1 traj 1 smpl les,61736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,906.32,,,,,,,fee schedule,725.94,1273.38,
Litt icr 1 traj 1 smpl les,61736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1273.38,,,,,,,fee schedule,725.94,1273.38,
Litt icr mlt trj mlt/cplx ls,61737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1300.89,,,,,,,fee schedule,852.86,1496.02,
Litt icr mlt trj mlt/cplx ls,61737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,852.86,,,,,,,fee schedule,852.86,1496.02,
Litt icr mlt trj mlt/cplx ls,61737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1064.78,,,,,,,fee schedule,852.86,1496.02,
Litt icr mlt trj mlt/cplx ls,61737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1496.02,,,,,,,fee schedule,852.86,1496.02,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Incise skull for treatment,61770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Treat trigeminal nerve,61790,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Treat trigeminal tract,61791,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Srs cranial lesion simple,61796,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4408.31,,,,,,,fee schedule,2890.09,5069.56,
Srs cranial lesion simple,61796,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2890.09,,,,,,,fee schedule,2890.09,5069.56,
Srs cranial lesion simple,61796,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3608.2,,,,,,,fee schedule,2890.09,5069.56,
Srs cranial lesion simple,61796,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5069.56,,,,,,,fee schedule,2890.09,5069.56,
Srs cranial lesion complex,61798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4408.31,,,,,,,fee schedule,2890.09,5069.56,
Srs cranial lesion complex,61798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2890.09,,,,,,,fee schedule,2890.09,5069.56,
Srs cranial lesion complex,61798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3608.2,,,,,,,fee schedule,2890.09,5069.56,
Srs cranial lesion complex,61798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5069.56,,,,,,,fee schedule,2890.09,5069.56,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3971.69,,,,,,,fee schedule,2603.84,6270.36,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2820.94,,,,,,,fee schedule,2603.84,6270.36,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2820.94,,,,,,,fee schedule,2603.84,6270.36,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2603.84,,,,,,,fee schedule,2603.84,6270.36,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3250.83,,,,,,,fee schedule,2603.84,6270.36,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3244.08,,,,,,,fee schedule,2603.84,6270.36,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.44,,,,,,,fee schedule,2603.84,6270.36,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2820.94,,,,,,,fee schedule,2603.84,6270.36,
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2603.84,6270.36,APC
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2603.84,6270.36,APC
Revise/remove neuroelectrode,61880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2603.84,6270.36,APC
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5081.6,,,,,,,fee schedule,3331.5,55344.12,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38353.52,,,,,,,fee schedule,3331.5,55344.12,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38353.52,,,,,,,fee schedule,3331.5,55344.12,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3331.5,,,,,,,fee schedule,3331.5,55344.12,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4159.29,,,,,,,fee schedule,3331.5,55344.12,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44106.55,,,,,,,fee schedule,3331.5,55344.12,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5843.84,,,,,,,fee schedule,3331.5,55344.12,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38353.52,,,,,,,fee schedule,3331.5,55344.12,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,3331.5,55344.12,APC
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,3331.5,55344.12,APC
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,3331.5,55344.12,APC
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,3171.64,57884.36,
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50334.23,,,,,,,fee schedule,3171.64,57884.36,
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50334.23,,,,,,,fee schedule,3171.64,57884.36,
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,3171.64,57884.36,
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,3171.64,57884.36,
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57884.36,,,,,,,fee schedule,3171.64,57884.36,
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,3171.64,57884.36,
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50334.23,,,,,,,fee schedule,3171.64,57884.36,
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,3171.64,57884.36,APC
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,3171.64,57884.36,APC
Implant neurostim arrays,61886,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,3171.64,57884.36,APC
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12920.67,,,,,,,fee schedule,8470.79,19984.73,
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,8470.79,19984.73,
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,8470.79,19984.73,
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8470.79,,,,,,,fee schedule,8470.79,19984.73,
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10575.57,,,,,,,fee schedule,8470.79,19984.73,
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,8470.79,19984.73,
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14858.77,,,,,,,fee schedule,8470.79,19984.73,
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,8470.79,19984.73,
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,8470.79,19984.73,APC
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,8470.79,19984.73,APC
Revise/remove neuroreceiver,61888,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,8470.79,19984.73,APC
Ins sk-mnt crnl nstm pg/rcvr,61889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1631.16,,,,,,,fee schedule,1069.39,1875.83,
Ins sk-mnt crnl nstm pg/rcvr,61889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1069.39,,,,,,,fee schedule,1069.39,1875.83,
Ins sk-mnt crnl nstm pg/rcvr,61889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1335.1,,,,,,,fee schedule,1069.39,1875.83,
Ins sk-mnt crnl nstm pg/rcvr,61889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1875.83,,,,,,,fee schedule,1069.39,1875.83,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37657.82,,,,,,,fee schedule,24688.47,55344.12,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24688.47,,,,,,,fee schedule,24688.47,55344.12,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30822.93,,,,,,,fee schedule,24688.47,55344.12,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43306.49,,,,,,,fee schedule,24688.47,55344.12,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,24688.47,55344.12,APC
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,24688.47,55344.12,APC
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,24688.47,55344.12,APC
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5572.08,,,,,,,fee schedule,3260.23,6407.89,
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.06,,,,,,,fee schedule,3260.23,6407.89,
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4560.75,,,,,,,fee schedule,3260.23,6407.89,
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6407.89,,,,,,,fee schedule,3260.23,6407.89,
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,6407.89,APC
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,6407.89,APC
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,6407.89,APC
Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3250.82,,,,,,,fee schedule,2131.24,5946.37,
Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2131.24,,,,,,,fee schedule,2131.24,5946.37,
Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2660.8,,,,,,,fee schedule,2131.24,5946.37,
Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3738.44,,,,,,,fee schedule,2131.24,5946.37,
Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2131.24,5946.37,APC
Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2131.24,5946.37,APC
Treat skull fracture,62000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2131.24,5946.37,APC
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,1412.88,3502.27,
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Replace/irrigate catheter,62194,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,1708.19,6126.95,
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1708.19,,,,,,,fee schedule,1708.19,6126.95,
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1708.19,,,,,,,fee schedule,1708.19,6126.95,
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,1708.19,6126.95,
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,1708.19,6126.95,
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1964.42,,,,,,,fee schedule,1708.19,6126.95,
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,1708.19,6126.95,
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1708.19,,,,,,,fee schedule,1708.19,6126.95,
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,1708.19,6126.95,APC
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,1708.19,6126.95,APC
Replace/irrigate catheter,62225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,1708.19,6126.95,APC
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13033.69,,,,,,,fee schedule,3905.88,15739.73,
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8544.89,,,,,,,fee schedule,3905.88,15739.73,
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10668.08,,,,,,,fee schedule,3905.88,15739.73,
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3905.88,15739.73,
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14988.74,,,,,,,fee schedule,3905.88,15739.73,
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3905.88,15739.73,APC
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3905.88,15739.73,APC
Replace/revise brain shunt,62230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3905.88,15739.73,APC
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.79,,,,,,,fee schedule,70.01,550.86,
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95.08,,,,,,,fee schedule,70.01,550.86,
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.08,,,,,,,fee schedule,70.01,550.86,
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.01,,,,,,,fee schedule,70.01,550.86,
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.41,,,,,,,fee schedule,70.01,550.86,
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.34,,,,,,,fee schedule,70.01,550.86,
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.81,,,,,,,fee schedule,70.01,550.86,
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.08,,,,,,,fee schedule,70.01,550.86,
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,70.01,550.86,APC
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,70.01,550.86,APC
Csf Shunt Reprogram,62252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,70.01,550.86,APC
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,2240.18,
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,618.36,2240.18,
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,2240.18,
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,2240.18,
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,618.36,2240.18,
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,2240.18,
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,2240.18,APC
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,2240.18,APC
Epidural lysis mult sessions,62263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,2240.18,APC
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Epidural lysis on single day,62264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.84,,,,,,,fee schedule,521.75,1270.05,
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,645.78,,,,,,,fee schedule,521.75,1270.05,
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.78,,,,,,,fee schedule,521.75,1270.05,
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.75,,,,,,,fee schedule,521.75,1270.05,
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.4,,,,,,,fee schedule,521.75,1270.05,
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.65,,,,,,,fee schedule,521.75,1270.05,
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,915.22,,,,,,,fee schedule,521.75,1270.05,
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,645.78,,,,,,,fee schedule,521.75,1270.05,
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,521.75,1270.05,APC
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,521.75,1270.05,APC
Interdiscal perq aspir dx,62267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,521.75,1270.05,APC
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Drain spinal cord cyst,62268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1424.18,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1394.89,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1394.89,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,933.69,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1165.69,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1604.12,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.81,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.89,,,,,,,fee schedule,933.69,2962.18,
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,933.69,2962.18,APC
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,933.69,2962.18,APC
Needle biopsy spinal cord,62269,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,933.69,2962.18,APC
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,939.11,,,,,,,fee schedule,493.94,1266.02,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,493.94,,,,,,,fee schedule,493.94,1266.02,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,493.94,,,,,,,fee schedule,493.94,1266.02,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,615.68,,,,,,,fee schedule,493.94,1266.02,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,768.66,,,,,,,fee schedule,493.94,1266.02,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,568.03,,,,,,,fee schedule,493.94,1266.02,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1079.98,,,,,,,fee schedule,493.94,1266.02,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.94,,,,,,,fee schedule,493.94,1266.02,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,493.94,1266.02,APC
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,493.94,1266.02,APC
Spinal fluid tap diagnostic,62270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,493.94,1266.02,APC
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.26,,,,,,,fee schedule,124.08,1266.02,
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,493.94,,,,,,,fee schedule,124.08,1266.02,
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,493.94,,,,,,,fee schedule,124.08,1266.02,
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.08,,,,,,,fee schedule,124.08,1266.02,
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.91,,,,,,,fee schedule,124.08,1266.02,
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,568.03,,,,,,,fee schedule,124.08,1266.02,
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.65,,,,,,,fee schedule,124.08,1266.02,
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.94,,,,,,,fee schedule,124.08,1266.02,
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,124.08,1266.02,APC
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,124.08,1266.02,APC
Drain cerebro spinal fluid,62272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,124.08,1266.02,APC
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,360.94,,,,,,,fee schedule,236.63,1266.02,
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,236.63,1266.02,
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,236.63,1266.02,
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,236.63,,,,,,,fee schedule,236.63,1266.02,
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,295.43,,,,,,,fee schedule,236.63,1266.02,
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,236.63,1266.02,
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,415.08,,,,,,,fee schedule,236.63,1266.02,
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,236.63,1266.02,
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,236.63,1266.02,APC
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,236.63,1266.02,APC
Inject epidural patch,62273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,236.63,1266.02,APC
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Treat spinal cord lesion,62280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,2240.18,
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,618.36,2240.18,
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,2240.18,
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,2240.18,
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,618.36,2240.18,
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,2240.18,
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,2240.18,APC
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,2240.18,APC
Treat spinal cord lesion,62281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,2240.18,APC
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,2240.18,
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,618.36,2240.18,
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,2240.18,
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,2240.18,
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,618.36,2240.18,
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,2240.18,
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,2240.18,APC
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,2240.18,APC
Treat spinal canal lesion,62282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,2240.18,APC
Injection for myelogram,62284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,351.75,,,,,,,fee schedule,230.61,404.51,
Injection for myelogram,62284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,230.61,,,,,,,fee schedule,230.61,404.51,
Injection for myelogram,62284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,287.91,,,,,,,fee schedule,230.61,404.51,
Injection for myelogram,62284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,404.51,,,,,,,fee schedule,230.61,404.51,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,1945.7,5927.15,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,1945.7,5927.15,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,1945.7,5927.15,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,1945.7,5927.15,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,1945.7,5927.15,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,5927.15,APC
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,5927.15,APC
Percutaneous diskectomy,62287,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,5927.15,APC
Inject for spine disk x-ray,62290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,596.71,,,,,,,fee schedule,391.2,686.22,
Inject for spine disk x-ray,62290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,391.2,,,,,,,fee schedule,391.2,686.22,
Inject for spine disk x-ray,62290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,488.41,,,,,,,fee schedule,391.2,686.22,
Inject for spine disk x-ray,62290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,686.22,,,,,,,fee schedule,391.2,686.22,
Inject for spine disk x-ray,62291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,614.36,,,,,,,fee schedule,402.77,706.51,
Inject for spine disk x-ray,62291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,402.77,,,,,,,fee schedule,402.77,706.51,
Inject for spine disk x-ray,62291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,502.85,,,,,,,fee schedule,402.77,706.51,
Inject for spine disk x-ray,62291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,706.51,,,,,,,fee schedule,402.77,706.51,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,1412.88,3502.27,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Injection into disk lesion,62292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Injection into spinal artery,62294,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2039.4,,,,,,,fee schedule,781.1,2345.31,
Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1337.03,,,,,,,fee schedule,781.1,2345.31,
Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.25,,,,,,,fee schedule,781.1,2345.31,
Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2345.31,,,,,,,fee schedule,781.1,2345.31,
Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,781.1,2345.31,APC
Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,781.1,2345.31,APC
Myelography lumbar injection,62302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,781.1,2345.31,APC
Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,672.54,,,,,,,fee schedule,440.92,1405.98,
Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,440.92,,,,,,,fee schedule,440.92,1405.98,
Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,550.47,,,,,,,fee schedule,440.92,1405.98,
Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,773.42,,,,,,,fee schedule,440.92,1405.98,
Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,440.92,1405.98,APC
Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,440.92,1405.98,APC
Myelography lumbar injection,62303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,440.92,1405.98,APC
Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2265.99,,,,,,,fee schedule,781.1,2605.89,
Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1485.58,,,,,,,fee schedule,781.1,2605.89,
Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1854.71,,,,,,,fee schedule,781.1,2605.89,
Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2605.89,,,,,,,fee schedule,781.1,2605.89,
Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,781.1,2605.89,APC
Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,781.1,2605.89,APC
Myelography lumbar injection,62304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,781.1,2605.89,APC
Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2039.4,,,,,,,fee schedule,781.1,2345.31,
Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1337.03,,,,,,,fee schedule,781.1,2345.31,
Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.25,,,,,,,fee schedule,781.1,2345.31,
Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2345.31,,,,,,,fee schedule,781.1,2345.31,
Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,781.1,2345.31,APC
Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,781.1,2345.31,APC
Myelography lumbar injection,62305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,781.1,2345.31,APC
Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,748.72,,,,,,,fee schedule,490.86,1266.02,
Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.86,,,,,,,fee schedule,490.86,1266.02,
Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,612.83,,,,,,,fee schedule,490.86,1266.02,
Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,861.03,,,,,,,fee schedule,490.86,1266.02,
Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,490.86,1266.02,APC
Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,490.86,1266.02,APC
Njx interlaminar crv/thrc,62320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,490.86,1266.02,APC
Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,748.72,,,,,,,fee schedule,490.86,1266.02,
Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.86,,,,,,,fee schedule,490.86,1266.02,
Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,612.83,,,,,,,fee schedule,490.86,1266.02,
Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,861.03,,,,,,,fee schedule,490.86,1266.02,
Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,490.86,1266.02,APC
Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,490.86,1266.02,APC
Njx interlaminar crv/thrc,62321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,490.86,1266.02,APC
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,748.72,,,,,,,fee schedule,490.86,1586.33,
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.86,,,,,,,fee schedule,490.86,1586.33,
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,612.83,,,,,,,fee schedule,490.86,1586.33,
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,861.03,,,,,,,fee schedule,490.86,1586.33,
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,490.86,1586.33,APC
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,490.86,1586.33,APC
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,490.86,1586.33,APC
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,709.84,,,,,,,fee schedule,465.37,1266.02,
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,465.37,,,,,,,fee schedule,465.37,1266.02,
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,581,,,,,,,fee schedule,465.37,1266.02,
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,816.32,,,,,,,fee schedule,465.37,1266.02,
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,465.37,1266.02,APC
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,465.37,1266.02,APC
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,465.37,1266.02,APC
Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar crv/thrc,62324,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar crv/thrc,62325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1214.15,,,,,,,fee schedule,703.34,1396.27,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1214.15,,,,,,,fee schedule,703.34,1396.27,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1214.15,,,,,,,fee schedule,703.34,1396.27,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,796,,,,,,,fee schedule,703.34,1396.27,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,993.78,,,,,,,fee schedule,703.34,1396.27,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1396.27,,,,,,,fee schedule,703.34,1396.27,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,703.34,1396.27,APC
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,703.34,1396.27,APC
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,703.34,1396.27,APC
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1214.15,,,,,,,fee schedule,703.34,1396.27,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1214.15,,,,,,,fee schedule,703.34,1396.27,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1214.15,,,,,,,fee schedule,703.34,1396.27,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,796,,,,,,,fee schedule,703.34,1396.27,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,993.78,,,,,,,fee schedule,703.34,1396.27,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1396.27,,,,,,,fee schedule,703.34,1396.27,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,703.34,1396.27,APC
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,703.34,1396.27,APC
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,703.34,1396.27,APC
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4853.36,,,,,,,fee schedule,3378.99,15739.73,
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4853.36,,,,,,,fee schedule,3378.99,15739.73,
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5581.36,,,,,,,fee schedule,3378.99,15739.73,
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4853.36,,,,,,,fee schedule,3378.99,15739.73,
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Implant spinal canal cath,62350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Implant spinal canal cath,62351,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Remove spinal canal catheter,62355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33012.17,,,,,,,fee schedule,4853.36,37964,
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4853.36,,,,,,,fee schedule,4853.36,37964,
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4853.36,,,,,,,fee schedule,4853.36,37964,
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21642.78,,,,,,,fee schedule,4853.36,37964,
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27020.46,,,,,,,fee schedule,4853.36,37964,
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5581.36,,,,,,,fee schedule,4853.36,37964,
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37964,,,,,,,fee schedule,4853.36,37964,
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4853.36,,,,,,,fee schedule,4853.36,37964,
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18856.99,,,,,,,fee schedule,4853.36,37964,APC
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17959.04,,,,,,,fee schedule,4853.36,37964,APC
Insert spine infusion device,62360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32326.27,,,,,,,fee schedule,4853.36,37964,APC
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33464.38,,,,,,,fee schedule,17959.04,38484.04,
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32021.89,,,,,,,fee schedule,17959.04,38484.04,
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32021.89,,,,,,,fee schedule,17959.04,38484.04,
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21939.25,,,,,,,fee schedule,17959.04,38484.04,
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27390.6,,,,,,,fee schedule,17959.04,38484.04,
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36825.17,,,,,,,fee schedule,17959.04,38484.04,
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38484.04,,,,,,,fee schedule,17959.04,38484.04,
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32021.89,,,,,,,fee schedule,17959.04,38484.04,
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18856.99,,,,,,,fee schedule,17959.04,38484.04,APC
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17959.04,,,,,,,fee schedule,17959.04,38484.04,APC
Implant spine infusion pump,62361,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32326.27,,,,,,,fee schedule,17959.04,38484.04,APC
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7255.8,,,,,,,fee schedule,4756.9,36293.85,
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31559.87,,,,,,,fee schedule,4756.9,36293.85,
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31559.87,,,,,,,fee schedule,4756.9,36293.85,
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4756.9,,,,,,,fee schedule,4756.9,36293.85,
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5938.87,,,,,,,fee schedule,4756.9,36293.85,
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36293.85,,,,,,,fee schedule,4756.9,36293.85,
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8344.17,,,,,,,fee schedule,4756.9,36293.85,
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31559.87,,,,,,,fee schedule,4756.9,36293.85,
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18856.99,,,,,,,fee schedule,4756.9,36293.85,APC
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17959.04,,,,,,,fee schedule,4756.9,36293.85,APC
Implant spine infusion pump,62362,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32326.27,,,,,,,fee schedule,4756.9,36293.85,APC
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6322.24,,,,,,,fee schedule,3403.86,7270.58,
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3403.86,7270.58,
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3403.86,7270.58,
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4144.86,,,,,,,fee schedule,3403.86,7270.58,
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5174.75,,,,,,,fee schedule,3403.86,7270.58,
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3403.86,7270.58,
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7270.58,,,,,,,fee schedule,3403.86,7270.58,
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3403.86,7270.58,
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3403.86,7270.58,APC
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3403.86,7270.58,APC
Remove spine infusion device,62365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3403.86,7270.58,APC
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.7,,,,,,,fee schedule,41.11,550.86,
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.32,,,,,,,fee schedule,41.11,550.86,
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.32,,,,,,,fee schedule,41.11,550.86,
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.11,,,,,,,fee schedule,41.11,550.86,
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.32,,,,,,,fee schedule,41.11,550.86,
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.62,,,,,,,fee schedule,41.11,550.86,
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.11,,,,,,,fee schedule,41.11,550.86,
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.32,,,,,,,fee schedule,41.11,550.86,
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,41.11,550.86,APC
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,41.11,550.86,APC
Analyze spine infus pump,62367,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,41.11,550.86,APC
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.25,,,,,,,fee schedule,55.23,550.86,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.06,,,,,,,fee schedule,55.23,550.86,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.06,,,,,,,fee schedule,55.23,550.86,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.23,,,,,,,fee schedule,55.23,550.86,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.96,,,,,,,fee schedule,55.23,550.86,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.47,,,,,,,fee schedule,55.23,550.86,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.89,,,,,,,fee schedule,55.23,550.86,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.06,,,,,,,fee schedule,55.23,550.86,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,55.23,550.86,APC
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,55.23,550.86,APC
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,55.23,550.86,APC
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.72,,,,,,,fee schedule,168.31,550.86,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,233.47,,,,,,,fee schedule,168.31,550.86,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.47,,,,,,,fee schedule,168.31,550.86,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.31,,,,,,,fee schedule,168.31,550.86,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.13,,,,,,,fee schedule,168.31,550.86,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,268.49,,,,,,,fee schedule,168.31,550.86,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,295.23,,,,,,,fee schedule,168.31,550.86,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,233.47,,,,,,,fee schedule,168.31,550.86,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,168.31,550.86,APC
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,168.31,550.86,APC
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,168.31,550.86,APC
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,251.81,,,,,,,fee schedule,165.09,550.86,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.4,,,,,,,fee schedule,165.09,550.86,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.4,,,,,,,fee schedule,165.09,550.86,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.09,,,,,,,fee schedule,165.09,550.86,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.11,,,,,,,fee schedule,165.09,550.86,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.51,,,,,,,fee schedule,165.09,550.86,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,289.58,,,,,,,fee schedule,165.09,550.86,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.4,,,,,,,fee schedule,165.09,550.86,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,165.09,550.86,APC
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,165.09,550.86,APC
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,165.09,550.86,APC
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9759.14,,,,,,,fee schedule,6398.09,13014.22,
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6398.09,,,,,,,fee schedule,6398.09,13014.22,
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7987.86,,,,,,,fee schedule,6398.09,13014.22,
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11223.01,,,,,,,fee schedule,6398.09,13014.22,
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,6398.09,13014.22,APC
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,6398.09,13014.22,APC
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,6398.09,13014.22,APC
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Remove lamina/facets lumbar,63012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 thrc,63016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10251.49,,,,,,,fee schedule,5450.5,13014.22,
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,5450.5,13014.22,
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,5450.5,13014.22,
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6720.88,,,,,,,fee schedule,5450.5,13014.22,
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8390.84,,,,,,,fee schedule,5450.5,13014.22,
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,5450.5,13014.22,
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11789.21,,,,,,,fee schedule,5450.5,13014.22,
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,5450.5,13014.22,
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5450.5,13014.22,APC
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5450.5,13014.22,APC
Neck spine disk surgery,63020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5450.5,13014.22,APC
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6826.52,,,,,,,fee schedule,4475.47,13014.22,
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4475.47,13014.22,
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4475.47,13014.22,
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4475.47,,,,,,,fee schedule,4475.47,13014.22,
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5587.51,,,,,,,fee schedule,4475.47,13014.22,
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4475.47,13014.22,
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7850.5,,,,,,,fee schedule,4475.47,13014.22,
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4475.47,13014.22,
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4475.47,13014.22,APC
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4475.47,13014.22,APC
Low back disk surgery,63030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4475.47,13014.22,APC
Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Laminotomy single cervical,63040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7056.44,,,,,,,fee schedule,4626.2,13014.22,
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4626.2,13014.22,
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4626.2,13014.22,
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4626.2,,,,,,,fee schedule,4626.2,13014.22,
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5775.7,,,,,,,fee schedule,4626.2,13014.22,
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4626.2,13014.22,
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8114.91,,,,,,,fee schedule,4626.2,13014.22,
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4626.2,13014.22,
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4626.2,13014.22,APC
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4626.2,13014.22,APC
Laminotomy single lumbar,63042,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4626.2,13014.22,APC
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10768.58,,,,,,,fee schedule,5450.5,13014.22,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,5450.5,13014.22,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,5450.5,13014.22,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7059.88,,,,,,,fee schedule,5450.5,13014.22,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8814.08,,,,,,,fee schedule,5450.5,13014.22,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,5450.5,13014.22,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12383.87,,,,,,,fee schedule,5450.5,13014.22,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,5450.5,13014.22,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5450.5,13014.22,APC
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5450.5,13014.22,APC
Remove spine lamina 1 crvl,63045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5450.5,13014.22,APC
Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1 thrc,63046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6611.11,,,,,,,fee schedule,4334.24,13014.22,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4334.24,13014.22,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4334.24,13014.22,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4334.24,,,,,,,fee schedule,4334.24,13014.22,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5411.19,,,,,,,fee schedule,4334.24,13014.22,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4334.24,13014.22,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7602.78,,,,,,,fee schedule,4334.24,13014.22,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4334.24,13014.22,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4334.24,13014.22,APC
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4334.24,13014.22,APC
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4334.24,13014.22,APC
Lam facetc/frmt arthrd lum 1,63052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,419.51,,,,,,,fee schedule,275.03,482.44,
Lam facetc/frmt arthrd lum 1,63052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,275.03,,,,,,,fee schedule,275.03,482.44,
Lam facetc/frmt arthrd lum 1,63052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,343.37,,,,,,,fee schedule,275.03,482.44,
Lam facetc/frmt arthrd lum 1,63052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,482.44,,,,,,,fee schedule,275.03,482.44,
Lam factc/frmt arthrd lum ea,63053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,314.66,,,,,,,fee schedule,206.29,361.86,
Lam factc/frmt arthrd lum ea,63053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.29,,,,,,,fee schedule,206.29,361.86,
Lam factc/frmt arthrd lum ea,63053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,257.55,,,,,,,fee schedule,206.29,361.86,
Lam factc/frmt arthrd lum ea,63053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,361.86,,,,,,,fee schedule,206.29,361.86,
Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Decompress spinal cord thrc,63055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7056.45,,,,,,,fee schedule,4626.21,13014.22,
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4626.21,13014.22,
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4626.21,13014.22,
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4626.21,,,,,,,fee schedule,4626.21,13014.22,
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5775.7,,,,,,,fee schedule,4626.21,13014.22,
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4626.21,13014.22,
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8114.92,,,,,,,fee schedule,4626.21,13014.22,
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4626.21,13014.22,
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4626.21,13014.22,APC
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4626.21,13014.22,APC
Decompress spinal cord lmbr,63056,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4626.21,13014.22,APC
Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Decompress spinal cord thrc,63064,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7809.1,,,,,,,fee schedule,5119.65,13014.22,
Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5119.65,,,,,,,fee schedule,5119.65,13014.22,
Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6391.75,,,,,,,fee schedule,5119.65,13014.22,
Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8980.47,,,,,,,fee schedule,5119.65,13014.22,
Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,5119.65,13014.22,APC
Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,5119.65,13014.22,APC
Neck spine disk surgery,63075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,5119.65,13014.22,APC
Excise intraspinl lesion crv,63265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intraspinl lesion crv,63265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intraspinl lesion crv,63265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion thrc,63266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion thrc,63266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion thrc,63266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion scrl,63268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion scrl,63268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Excise intrspinl lesion scrl,63268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Remove spinal cord lesion,63600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Stimulation of spinal cord,63610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Srs spinal lesion,63620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1077.85,,,,,,,fee schedule,706.64,1239.53,
Srs spinal lesion,63620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,706.64,,,,,,,fee schedule,706.64,1239.53,
Srs spinal lesion,63620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,882.22,,,,,,,fee schedule,706.64,1239.53,
Srs spinal lesion,63620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1239.53,,,,,,,fee schedule,706.64,1239.53,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11995.31,,,,,,,fee schedule,6350.08,13794.61,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,6350.08,13794.61,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,6350.08,13794.61,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7864.13,,,,,,,fee schedule,6350.08,13794.61,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9818.16,,,,,,,fee schedule,6350.08,13794.61,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,6350.08,13794.61,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13794.61,,,,,,,fee schedule,6350.08,13794.61,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,6350.08,13794.61,
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6667.58,,,,,,,fee schedule,6350.08,13794.61,APC
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6350.08,,,,,,,fee schedule,6350.08,13794.61,APC
Implant neuroelectrodes,63650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11430.14,,,,,,,fee schedule,6350.08,13794.61,APC
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7828.77,,,,,,,fee schedule,5132.54,44106.55,
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38353.52,,,,,,,fee schedule,5132.54,44106.55,
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38353.52,,,,,,,fee schedule,5132.54,44106.55,
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5132.54,,,,,,,fee schedule,5132.54,44106.55,
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6407.85,,,,,,,fee schedule,5132.54,44106.55,
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44106.55,,,,,,,fee schedule,5132.54,44106.55,
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9003.09,,,,,,,fee schedule,5132.54,44106.55,
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38353.52,,,,,,,fee schedule,5132.54,44106.55,
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20296.87,,,,,,,fee schedule,5132.54,44106.55,APC
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19330.35,,,,,,,fee schedule,5132.54,44106.55,APC
Implant neuroelectrodes,63655,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34794.63,,,,,,,fee schedule,5132.54,44106.55,APC
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2095.73,,,,,,,fee schedule,1412.88,3502.27,
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Remove spine eltrd perq aray,63661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5052.46,,,,,,,fee schedule,2820.94,6270.36,
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2820.94,,,,,,,fee schedule,2820.94,6270.36,
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2820.94,,,,,,,fee schedule,2820.94,6270.36,
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3312.39,,,,,,,fee schedule,2820.94,6270.36,
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4135.44,,,,,,,fee schedule,2820.94,6270.36,
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3244.08,,,,,,,fee schedule,2820.94,6270.36,
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5810.33,,,,,,,fee schedule,2820.94,6270.36,
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2820.94,,,,,,,fee schedule,2820.94,6270.36,
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2820.94,6270.36,APC
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2820.94,6270.36,APC
Remove spine eltrd plate,63662,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2820.94,6270.36,APC
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11502.26,,,,,,,fee schedule,6350.08,13227.6,
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,6350.08,13227.6,
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,6350.08,13227.6,
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7540.88,,,,,,,fee schedule,6350.08,13227.6,
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9414.6,,,,,,,fee schedule,6350.08,13227.6,
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,6350.08,13227.6,
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13227.6,,,,,,,fee schedule,6350.08,13227.6,
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,6350.08,13227.6,
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6667.58,,,,,,,fee schedule,6350.08,13227.6,APC
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6350.08,,,,,,,fee schedule,6350.08,13227.6,APC
Revise spine eltrd perq aray,63663,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11430.14,,,,,,,fee schedule,6350.08,13227.6,APC
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4685.34,,,,,,,fee schedule,3071.71,19984.73,
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,3071.71,19984.73,
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,3071.71,19984.73,
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3071.71,,,,,,,fee schedule,3071.71,19984.73,
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3834.95,,,,,,,fee schedule,3071.71,19984.73,
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,3071.71,19984.73,
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5388.14,,,,,,,fee schedule,3071.71,19984.73,
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,3071.71,19984.73,
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,3071.71,19984.73,APC
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,3071.71,19984.73,APC
Revise spine eltrd plate,63664,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,3071.71,19984.73,APC
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8271.42,,,,,,,fee schedule,5422.74,57884.36,
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50334.23,,,,,,,fee schedule,5422.74,57884.36,
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50334.23,,,,,,,fee schedule,5422.74,57884.36,
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5422.74,,,,,,,fee schedule,5422.74,57884.36,
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6770.16,,,,,,,fee schedule,5422.74,57884.36,
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57884.36,,,,,,,fee schedule,5422.74,57884.36,
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9512.13,,,,,,,fee schedule,5422.74,57884.36,
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50334.23,,,,,,,fee schedule,5422.74,57884.36,
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,5422.74,57884.36,APC
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,5422.74,57884.36,APC
Insrt/redo spine n generator,63685,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,5422.74,57884.36,APC
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5650.24,,,,,,,fee schedule,2820.94,6497.78,
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2820.94,,,,,,,fee schedule,2820.94,6497.78,
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2820.94,,,,,,,fee schedule,2820.94,6497.78,
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3704.3,,,,,,,fee schedule,2820.94,6497.78,
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4624.72,,,,,,,fee schedule,2820.94,6497.78,
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3244.08,,,,,,,fee schedule,2820.94,6497.78,
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6497.78,,,,,,,fee schedule,2820.94,6497.78,
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2820.94,,,,,,,fee schedule,2820.94,6497.78,
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2820.94,6497.78,APC
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2820.94,6497.78,APC
Revise/remove neuroreceiver,63688,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2820.94,6497.78,APC
Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6209.32,,,,,,,fee schedule,4070.83,15739.73,
Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4070.83,,,,,,,fee schedule,4070.83,15739.73,
Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5082.33,,,,,,,fee schedule,4070.83,15739.73,
Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7140.72,,,,,,,fee schedule,4070.83,15739.73,
Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,4070.83,15739.73,APC
Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,4070.83,15739.73,APC
Install spinal shunt,63741,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,4070.83,15739.73,APC
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Revision of spinal shunt,63744,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,1412.88,3502.27,
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Removal of spinal shunt,63746,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.4,,,,,,,fee schedule,147.12,550.53,
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.87,,,,,,,fee schedule,147.12,550.53,
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,198.87,,,,,,,fee schedule,147.12,550.53,
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.12,,,,,,,fee schedule,147.12,550.53,
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,183.67,,,,,,,fee schedule,147.12,550.53,
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.7,,,,,,,fee schedule,147.12,550.53,
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.06,,,,,,,fee schedule,147.12,550.53,
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.87,,,,,,,fee schedule,147.12,550.53,
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,147.12,550.53,APC
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,147.12,550.53,APC
N block inj trigeminal,64400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,147.12,550.53,APC
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.52,,,,,,,fee schedule,111.14,550.53,
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.3,,,,,,,fee schedule,111.14,550.53,
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.3,,,,,,,fee schedule,111.14,550.53,
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.14,,,,,,,fee schedule,111.14,550.53,
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.75,,,,,,,fee schedule,111.14,550.53,
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174,,,,,,,fee schedule,111.14,550.53,
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.95,,,,,,,fee schedule,111.14,550.53,
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.3,,,,,,,fee schedule,111.14,550.53,
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,111.14,550.53,APC
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,111.14,550.53,APC
N block inj occipital,64405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,111.14,550.53,APC
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,174.41,,,,,,,fee schedule,114.34,550.53,
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.06,,,,,,,fee schedule,114.34,550.53,
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,153.06,,,,,,,fee schedule,114.34,550.53,
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.34,,,,,,,fee schedule,114.34,550.53,
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.75,,,,,,,fee schedule,114.34,550.53,
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.02,,,,,,,fee schedule,114.34,550.53,
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,200.57,,,,,,,fee schedule,114.34,550.53,
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.06,,,,,,,fee schedule,114.34,550.53,
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,114.34,550.53,APC
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,114.34,550.53,APC
N block inj vagus,64408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,114.34,550.53,APC
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,493.94,1586.33,
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,493.94,,,,,,,fee schedule,493.94,1586.33,
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,493.94,,,,,,,fee schedule,493.94,1586.33,
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,493.94,1586.33,
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,493.94,1586.33,
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,568.03,,,,,,,fee schedule,493.94,1586.33,
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,493.94,1586.33,
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.94,,,,,,,fee schedule,493.94,1586.33,
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,493.94,1586.33,APC
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,493.94,1586.33,APC
N block inj brachial plexus,64415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,493.94,1586.33,APC
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N block cont infuse b plex,64416,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,493.94,1586.33,
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,493.94,,,,,,,fee schedule,493.94,1586.33,
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,493.94,,,,,,,fee schedule,493.94,1586.33,
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,493.94,1586.33,
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,493.94,1586.33,
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,568.03,,,,,,,fee schedule,493.94,1586.33,
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,493.94,1586.33,
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.94,,,,,,,fee schedule,493.94,1586.33,
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,493.94,1586.33,APC
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,493.94,1586.33,APC
N block inj axillary,64417,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,493.94,1586.33,APC
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,260.63,,,,,,,fee schedule,170.87,1266.02,
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,233.47,,,,,,,fee schedule,170.87,1266.02,
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.47,,,,,,,fee schedule,170.87,1266.02,
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.87,,,,,,,fee schedule,170.87,1266.02,
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.33,,,,,,,fee schedule,170.87,1266.02,
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,268.49,,,,,,,fee schedule,170.87,1266.02,
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,299.72,,,,,,,fee schedule,170.87,1266.02,
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,233.47,,,,,,,fee schedule,170.87,1266.02,
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,170.87,1266.02,APC
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,170.87,1266.02,APC
N block inj suprascapular,64418,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,170.87,1266.02,APC
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,748.72,,,,,,,fee schedule,490.86,1266.02,
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,493.94,,,,,,,fee schedule,490.86,1266.02,
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,493.94,,,,,,,fee schedule,490.86,1266.02,
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.86,,,,,,,fee schedule,490.86,1266.02,
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,612.83,,,,,,,fee schedule,490.86,1266.02,
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,568.03,,,,,,,fee schedule,490.86,1266.02,
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,861.03,,,,,,,fee schedule,490.86,1266.02,
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.94,,,,,,,fee schedule,490.86,1266.02,
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,490.86,1266.02,APC
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,490.86,1266.02,APC
N block inj intercost sng,64420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,490.86,1266.02,APC
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N block inj intercost mlt,64421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.35,,,,,,,fee schedule,116.93,1266.02,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.33,,,,,,,fee schedule,116.93,1266.02,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,157.33,,,,,,,fee schedule,116.93,1266.02,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.93,,,,,,,fee schedule,116.93,1266.02,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.98,,,,,,,fee schedule,116.93,1266.02,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.93,,,,,,,fee schedule,116.93,1266.02,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.1,,,,,,,fee schedule,116.93,1266.02,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,157.33,,,,,,,fee schedule,116.93,1266.02,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,116.93,1266.02,APC
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,116.93,1266.02,APC
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,116.93,1266.02,APC
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N block inj pudendal,64430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.5,,,,,,,fee schedule,142.59,1266.02,
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.94,,,,,,,fee schedule,142.59,1266.02,
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.94,,,,,,,fee schedule,142.59,1266.02,
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.59,,,,,,,fee schedule,142.59,1266.02,
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.02,,,,,,,fee schedule,142.59,1266.02,
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.73,,,,,,,fee schedule,142.59,1266.02,
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.13,,,,,,,fee schedule,142.59,1266.02,
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.94,,,,,,,fee schedule,142.59,1266.02,
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,142.59,1266.02,APC
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,142.59,1266.02,APC
N block inj paracervical,64435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,142.59,1266.02,APC
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,216.52,,,,,,,fee schedule,141.95,1266.02,
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.86,,,,,,,fee schedule,141.95,1266.02,
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,189.86,,,,,,,fee schedule,141.95,1266.02,
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.95,,,,,,,fee schedule,141.95,1266.02,
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.22,,,,,,,fee schedule,141.95,1266.02,
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.34,,,,,,,fee schedule,141.95,1266.02,
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,249,,,,,,,fee schedule,141.95,1266.02,
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.86,,,,,,,fee schedule,141.95,1266.02,
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,141.95,1266.02,APC
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,141.95,1266.02,APC
N block inj sciatic sng,64445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,141.95,1266.02,APC
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N blk inj sciatic cont inf,64446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.43,,,,,,,fee schedule,113.05,1266.02,
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.06,,,,,,,fee schedule,113.05,1266.02,
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,153.06,,,,,,,fee schedule,113.05,1266.02,
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.05,,,,,,,fee schedule,113.05,1266.02,
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.13,,,,,,,fee schedule,113.05,1266.02,
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.02,,,,,,,fee schedule,113.05,1266.02,
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.29,,,,,,,fee schedule,113.05,1266.02,
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.06,,,,,,,fee schedule,113.05,1266.02,
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,113.05,1266.02,APC
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,113.05,1266.02,APC
N block inj fem single,64447,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,113.05,1266.02,APC
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,2240.18,
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,618.36,2240.18,
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,2240.18,
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,2240.18,
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,618.36,2240.18,
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,2240.18,
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,2240.18,APC
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,2240.18,APC
N block inj fem cont inf,64448,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,2240.18,APC
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N block inj lumbar plexus,64449,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.08,,,,,,,fee schedule,93.15,1266.02,
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.1,,,,,,,fee schedule,93.15,1266.02,
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,115.1,,,,,,,fee schedule,93.15,1266.02,
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.15,,,,,,,fee schedule,93.15,1266.02,
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,116.29,,,,,,,fee schedule,93.15,1266.02,
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.37,,,,,,,fee schedule,93.15,1266.02,
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,163.39,,,,,,,fee schedule,93.15,1266.02,
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.1,,,,,,,fee schedule,93.15,1266.02,
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,93.15,1266.02,APC
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,93.15,1266.02,APC
N block other peripheral,64450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,93.15,1266.02,APC
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1214.15,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1214.15,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1214.15,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,796,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,993.78,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1396.27,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,703.34,1396.27,APC
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,703.34,1396.27,APC
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,703.34,1396.27,APC
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1214.15,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1214.15,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1214.15,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,796,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,993.78,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1396.27,,,,,,,fee schedule,703.34,1396.27,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,703.34,1396.27,APC
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,703.34,1396.27,APC
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,703.34,1396.27,APC
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.9,,,,,,,fee schedule,35.34,550.53,
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.55,,,,,,,fee schedule,35.34,550.53,
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.55,,,,,,,fee schedule,35.34,550.53,
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.34,,,,,,,fee schedule,35.34,550.53,
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.12,,,,,,,fee schedule,35.34,550.53,
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.68,,,,,,,fee schedule,35.34,550.53,
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.99,,,,,,,fee schedule,35.34,550.53,
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.55,,,,,,,fee schedule,35.34,550.53,
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,35.34,550.53,APC
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,35.34,550.53,APC
N block inj plantar digit,64455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,35.34,550.53,APC
Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.4,,,,,,,fee schedule,147.12,1266.02,
Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.12,,,,,,,fee schedule,147.12,1266.02,
Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,183.67,,,,,,,fee schedule,147.12,1266.02,
Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.06,,,,,,,fee schedule,147.12,1266.02,
Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,147.12,1266.02,APC
Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,147.12,1266.02,APC
Pvb thoracic single inj site,64461,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,147.12,1266.02,APC
Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,257.7,,,,,,,fee schedule,168.95,1266.02,
Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.95,,,,,,,fee schedule,168.95,1266.02,
Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.93,,,,,,,fee schedule,168.95,1266.02,
Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,296.36,,,,,,,fee schedule,168.95,1266.02,
Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,168.95,1266.02,APC
Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,168.95,1266.02,APC
Pvb thoracic cont infusion,64463,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,168.95,1266.02,APC
Thrc fascial pln blk uni njx,64466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,326.83,,,,,,,fee schedule,214.27,375.85,
Thrc fascial pln blk uni njx,64466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.27,,,,,,,fee schedule,214.27,375.85,
Thrc fascial pln blk uni njx,64466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,267.51,,,,,,,fee schedule,214.27,375.85,
Thrc fascial pln blk uni njx,64466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,375.85,,,,,,,fee schedule,214.27,375.85,
Thrc fascial pln blk uni nfs,64467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,786.96,,,,,,,fee schedule,515.93,905,
Thrc fascial pln blk uni nfs,64467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,515.93,,,,,,,fee schedule,515.93,905,
Thrc fascial pln blk uni nfs,64467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,644.13,,,,,,,fee schedule,515.93,905,
Thrc fascial pln blk uni nfs,64467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,905,,,,,,,fee schedule,515.93,905,
Thrc fascial pln blk bi njx,64468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,388.73,,,,,,,fee schedule,254.85,447.04,
Thrc fascial pln blk bi njx,64468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,254.85,,,,,,,fee schedule,254.85,447.04,
Thrc fascial pln blk bi njx,64468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,318.18,,,,,,,fee schedule,254.85,447.04,
Thrc fascial pln blk bi njx,64468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,447.04,,,,,,,fee schedule,254.85,447.04,
Thrc fascial pln blk bi nfs,64469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1345.44,,,,,,,fee schedule,882.07,1547.26,
Thrc fascial pln blk bi nfs,64469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,882.07,,,,,,,fee schedule,882.07,1547.26,
Thrc fascial pln blk bi nfs,64469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1101.24,,,,,,,fee schedule,882.07,1547.26,
Thrc fascial pln blk bi nfs,64469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1547.26,,,,,,,fee schedule,882.07,1547.26,
Lwr xtr fscl pln blk uni njx,64473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,322.06,,,,,,,fee schedule,211.14,370.37,
Lwr xtr fscl pln blk uni njx,64473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.14,,,,,,,fee schedule,211.14,370.37,
Lwr xtr fscl pln blk uni njx,64473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,263.61,,,,,,,fee schedule,211.14,370.37,
Lwr xtr fscl pln blk uni njx,64473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,370.37,,,,,,,fee schedule,211.14,370.37,
Lwr xtr fscl pln blk uni nfs,64474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,785.39,,,,,,,fee schedule,514.9,903.2,
Lwr xtr fscl pln blk uni nfs,64474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,514.9,,,,,,,fee schedule,514.9,903.2,
Lwr xtr fscl pln blk uni nfs,64474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,642.84,,,,,,,fee schedule,514.9,903.2,
Lwr xtr fscl pln blk uni nfs,64474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,903.2,,,,,,,fee schedule,514.9,903.2,
Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1248.76,,,,,,,fee schedule,881.29,1586.33,
Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1248.76,,,,,,,fee schedule,881.29,1586.33,
Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1436.07,,,,,,,fee schedule,881.29,1586.33,
Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1248.76,,,,,,,fee schedule,881.29,1586.33,
Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,881.29,1586.33,APC
Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,881.29,1586.33,APC
Inj foramen epidural c/t,64479,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,881.29,1586.33,APC
Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1669.26,,,,,,,fee schedule,881.29,1919.65,
Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1669.26,,,,,,,fee schedule,881.29,1919.65,
Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1919.65,,,,,,,fee schedule,881.29,1919.65,
Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1669.26,,,,,,,fee schedule,881.29,1919.65,
Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,881.29,1919.65,APC
Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,881.29,1919.65,APC
Inj foramen epidural l/s,64483,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,881.29,1919.65,APC
Tap block unil by injection,64486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.87,,,,,,,fee schedule,131.03,229.85,
Tap block unil by injection,64486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.03,,,,,,,fee schedule,131.03,229.85,
Tap block unil by injection,64486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.59,,,,,,,fee schedule,131.03,229.85,
Tap block unil by injection,64486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.85,,,,,,,fee schedule,131.03,229.85,
Tap block uni by infusion,64487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.5,,,,,,,fee schedule,142.59,250.13,
Tap block uni by infusion,64487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.59,,,,,,,fee schedule,142.59,250.13,
Tap block uni by infusion,64487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.02,,,,,,,fee schedule,142.59,250.13,
Tap block uni by infusion,64487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.13,,,,,,,fee schedule,142.59,250.13,
Tap block bi injection,64488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2075.76,,,,,,,fee schedule,1360.87,2387.12,
Tap block bi injection,64488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1360.87,,,,,,,fee schedule,1360.87,2387.12,
Tap block bi injection,64488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1699.01,,,,,,,fee schedule,1360.87,2387.12,
Tap block bi injection,64488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2387.12,,,,,,,fee schedule,1360.87,2387.12,
Tap block bi by infusion,64489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,305.69,,,,,,,fee schedule,200.41,351.54,
Tap block bi by infusion,64489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,200.41,,,,,,,fee schedule,200.41,351.54,
Tap block bi by infusion,64489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,250.21,,,,,,,fee schedule,200.41,351.54,
Tap block bi by infusion,64489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,351.54,,,,,,,fee schedule,200.41,351.54,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1182.11,,,,,,,fee schedule,774.99,1586.33,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,774.99,1586.33,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,774.99,1586.33,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,774.99,,,,,,,fee schedule,774.99,1586.33,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,967.56,,,,,,,fee schedule,774.99,1586.33,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,774.99,1586.33,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1359.43,,,,,,,fee schedule,774.99,1586.33,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,774.99,1586.33,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,774.99,1586.33,APC
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,774.99,1586.33,APC
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,774.99,1586.33,APC
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.05,,,,,,,fee schedule,95.09,550.53,
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.1,,,,,,,fee schedule,95.09,550.53,
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.1,,,,,,,fee schedule,95.09,550.53,
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.09,,,,,,,fee schedule,95.09,550.53,
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.72,,,,,,,fee schedule,95.09,550.53,
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.17,,,,,,,fee schedule,95.09,550.53,
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,166.81,,,,,,,fee schedule,95.09,550.53,
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.1,,,,,,,fee schedule,95.09,550.53,
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,95.09,550.53,APC
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,95.09,550.53,APC
N block spenopalatine gangl,64505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,95.09,550.53,APC
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N block stellate ganglion,64510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N block inj hypogas plxs,64517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N block lumbar/thoracic,64520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
N block inj celiac pelus,64530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12402.49,,,,,,,fee schedule,8131.07,19984.73,
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,8131.07,19984.73,
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,8131.07,19984.73,
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8131.07,,,,,,,fee schedule,8131.07,19984.73,
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10151.44,,,,,,,fee schedule,8131.07,19984.73,
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,8131.07,19984.73,
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14262.86,,,,,,,fee schedule,8131.07,19984.73,
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,8131.07,19984.73,
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,8131.07,19984.73,APC
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,8131.07,19984.73,APC
Implant neuroelectrodes,64553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,8131.07,19984.73,APC
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6322.24,,,,,,,fee schedule,4144.86,11430.14,
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,4144.86,11430.14,
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,4144.86,11430.14,
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4144.86,,,,,,,fee schedule,4144.86,11430.14,
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5174.75,,,,,,,fee schedule,4144.86,11430.14,
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,4144.86,11430.14,
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7270.58,,,,,,,fee schedule,4144.86,11430.14,
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,4144.86,11430.14,
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6667.58,,,,,,,fee schedule,4144.86,11430.14,APC
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6350.08,,,,,,,fee schedule,4144.86,11430.14,APC
Implant neuroelectrodes,64555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11430.14,,,,,,,fee schedule,4144.86,11430.14,APC
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12152.45,,,,,,,fee schedule,6350.08,13975.32,
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,6350.08,13975.32,
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,6350.08,13975.32,
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7967.15,,,,,,,fee schedule,6350.08,13975.32,
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9946.78,,,,,,,fee schedule,6350.08,13975.32,
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,6350.08,13975.32,
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13975.32,,,,,,,fee schedule,6350.08,13975.32,
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,6350.08,13975.32,
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6667.58,,,,,,,fee schedule,6350.08,13975.32,APC
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6350.08,,,,,,,fee schedule,6350.08,13975.32,APC
Implant neuroelectrodes,64561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11430.14,,,,,,,fee schedule,6350.08,13975.32,APC
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,289.05,,,,,,,fee schedule,189.5,550.53,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,240.36,,,,,,,fee schedule,189.5,550.53,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,240.36,,,,,,,fee schedule,189.5,550.53,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,189.5,,,,,,,fee schedule,189.5,550.53,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,236.59,,,,,,,fee schedule,189.5,550.53,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,276.41,,,,,,,fee schedule,189.5,550.53,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,332.41,,,,,,,fee schedule,189.5,550.53,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,240.36,,,,,,,fee schedule,189.5,550.53,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,189.5,550.53,APC
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,189.5,550.53,APC
Neuroeltrd stim post tibial,64566,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,189.5,550.53,APC
Perq elec nrv field stimj cn,64567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,1626.7,APC
Perq elec nrv field stimj cn,64567,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,1626.7,APC
Perq elec nrv field stimj cn,64567,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,1626.7,APC
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61489.84,,,,,,,fee schedule,40312.74,78998.56,
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50334.23,,,,,,,fee schedule,40312.74,78998.56,
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50334.23,,,,,,,fee schedule,40312.74,78998.56,
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40312.74,,,,,,,fee schedule,40312.74,78998.56,
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50329.43,,,,,,,fee schedule,40312.74,78998.56,
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57884.36,,,,,,,fee schedule,40312.74,78998.56,
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70713.32,,,,,,,fee schedule,40312.74,78998.56,
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50334.23,,,,,,,fee schedule,40312.74,78998.56,
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46082.49,,,,,,,fee schedule,40312.74,78998.56,APC
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43888.09,,,,,,,fee schedule,40312.74,78998.56,APC
Inc for vagus n elect impl,64568,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78998.56,,,,,,,fee schedule,40312.74,78998.56,APC
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10775.67,,,,,,,fee schedule,7064.53,19984.73,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,7064.53,19984.73,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,7064.53,19984.73,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7064.53,,,,,,,fee schedule,7064.53,19984.73,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8819.89,,,,,,,fee schedule,7064.53,19984.73,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,7064.53,19984.73,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12392.02,,,,,,,fee schedule,7064.53,19984.73,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,7064.53,19984.73,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,7064.53,19984.73,APC
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,7064.53,19984.73,APC
Revise/repl vagus n eltrd,64569,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,7064.53,19984.73,APC
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8548.96,,,,,,,fee schedule,3403.86,9831.3,
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3403.86,9831.3,
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3403.86,9831.3,
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5604.7,,,,,,,fee schedule,3403.86,9831.3,
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6997.32,,,,,,,fee schedule,3403.86,9831.3,
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3403.86,9831.3,
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9831.3,,,,,,,fee schedule,3403.86,9831.3,
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3403.86,9831.3,
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3403.86,9831.3,APC
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3403.86,9831.3,APC
Remove vagus n eltrd,64570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3403.86,9831.3,APC
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39099.63,,,,,,,fee schedule,9280.7,44964.57,
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,9280.7,44964.57,
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,9280.7,44964.57,
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25633.72,,,,,,,fee schedule,9280.7,44964.57,
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32003.05,,,,,,,fee schedule,9280.7,44964.57,
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,9280.7,44964.57,
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44964.57,,,,,,,fee schedule,9280.7,44964.57,
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,9280.7,44964.57,
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,9280.7,44964.57,APC
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,9280.7,44964.57,APC
Implant neuroelectrodes,64575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,9280.7,44964.57,APC
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40305.08,,,,,,,fee schedule,19330.35,46350.84,
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38353.52,,,,,,,fee schedule,19330.35,46350.84,
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38353.52,,,,,,,fee schedule,19330.35,46350.84,
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26424.01,,,,,,,fee schedule,19330.35,46350.84,
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32989.71,,,,,,,fee schedule,19330.35,46350.84,
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44106.55,,,,,,,fee schedule,19330.35,46350.84,
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46350.84,,,,,,,fee schedule,19330.35,46350.84,
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38353.52,,,,,,,fee schedule,19330.35,46350.84,
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20296.87,,,,,,,fee schedule,19330.35,46350.84,APC
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19330.35,,,,,,,fee schedule,19330.35,46350.84,APC
Implant neuroelectrodes,64580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34794.63,,,,,,,fee schedule,19330.35,46350.84,APC
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12779.6,,,,,,,fee schedule,6350.08,14696.54,
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9280.7,,,,,,,fee schedule,6350.08,14696.54,
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9280.7,,,,,,,fee schedule,6350.08,14696.54,
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8378.31,,,,,,,fee schedule,6350.08,14696.54,
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10460.1,,,,,,,fee schedule,6350.08,14696.54,
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10672.81,,,,,,,fee schedule,6350.08,14696.54,
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14696.54,,,,,,,fee schedule,6350.08,14696.54,
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9280.7,,,,,,,fee schedule,6350.08,14696.54,
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6667.58,,,,,,,fee schedule,6350.08,14696.54,APC
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6350.08,,,,,,,fee schedule,6350.08,14696.54,APC
Implant neuroelectrodes,64581,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11430.14,,,,,,,fee schedule,6350.08,14696.54,APC
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58404.55,,,,,,,fee schedule,30746.74,67165.23,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39801.09,,,,,,,fee schedule,30746.74,67165.23,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39801.09,,,,,,,fee schedule,30746.74,67165.23,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38290.02,,,,,,,fee schedule,30746.74,67165.23,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47804.12,,,,,,,fee schedule,30746.74,67165.23,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45771.25,,,,,,,fee schedule,30746.74,67165.23,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67165.23,,,,,,,fee schedule,30746.74,67165.23,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39801.09,,,,,,,fee schedule,30746.74,67165.23,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,30746.74,67165.23,APC
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,30746.74,67165.23,APC
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,30746.74,67165.23,APC
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22308.86,,,,,,,fee schedule,11102.63,25655.19,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12976.18,,,,,,,fee schedule,11102.63,25655.19,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12976.18,,,,,,,fee schedule,11102.63,25655.19,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14625.69,,,,,,,fee schedule,11102.63,25655.19,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18259.8,,,,,,,fee schedule,11102.63,25655.19,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14922.61,,,,,,,fee schedule,11102.63,25655.19,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25655.19,,,,,,,fee schedule,11102.63,25655.19,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12976.18,,,,,,,fee schedule,11102.63,25655.19,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,25655.19,APC
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,25655.19,APC
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,25655.19,APC
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11314.24,,,,,,,fee schedule,3403.86,13011.38,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4004.5,,,,,,,fee schedule,3403.86,13011.38,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4004.5,,,,,,,fee schedule,3403.86,13011.38,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7417.62,,,,,,,fee schedule,3403.86,13011.38,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9260.71,,,,,,,fee schedule,3403.86,13011.38,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4605.18,,,,,,,fee schedule,3403.86,13011.38,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13011.38,,,,,,,fee schedule,3403.86,13011.38,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4004.5,,,,,,,fee schedule,3403.86,13011.38,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3403.86,13011.38,APC
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3403.86,13011.38,APC
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3403.86,13011.38,APC
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7435.58,,,,,,,fee schedule,2820.94,8550.92,
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2820.94,,,,,,,fee schedule,2820.94,8550.92,
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2820.94,,,,,,,fee schedule,2820.94,8550.92,
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4874.77,,,,,,,fee schedule,2820.94,8550.92,
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6086.02,,,,,,,fee schedule,2820.94,8550.92,
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3244.08,,,,,,,fee schedule,2820.94,8550.92,
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8550.92,,,,,,,fee schedule,2820.94,8550.92,
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2820.94,,,,,,,fee schedule,2820.94,8550.92,
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2820.94,8550.92,APC
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2820.94,8550.92,APC
Revise/remove neuroelectrode,64585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2820.94,8550.92,APC
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5827.41,,,,,,,fee schedule,3820.45,44106.55,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38353.52,,,,,,,fee schedule,3820.45,44106.55,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38353.52,,,,,,,fee schedule,3820.45,44106.55,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3820.45,,,,,,,fee schedule,3820.45,44106.55,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4769.74,,,,,,,fee schedule,3820.45,44106.55,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44106.55,,,,,,,fee schedule,3820.45,44106.55,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6701.52,,,,,,,fee schedule,3820.45,44106.55,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38353.52,,,,,,,fee schedule,3820.45,44106.55,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20296.87,,,,,,,fee schedule,3820.45,44106.55,APC
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19330.35,,,,,,,fee schedule,3820.45,44106.55,APC
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34794.63,,,,,,,fee schedule,3820.45,44106.55,APC
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3971.69,,,,,,,fee schedule,2603.84,6270.36,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2820.94,,,,,,,fee schedule,2603.84,6270.36,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2820.94,,,,,,,fee schedule,2603.84,6270.36,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2603.84,,,,,,,fee schedule,2603.84,6270.36,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3250.83,,,,,,,fee schedule,2603.84,6270.36,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3244.08,,,,,,,fee schedule,2603.84,6270.36,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4567.44,,,,,,,fee schedule,2603.84,6270.36,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2820.94,,,,,,,fee schedule,2603.84,6270.36,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2603.84,6270.36,APC
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2603.84,6270.36,APC
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2603.84,6270.36,APC
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23449.76,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15373.66,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19193.63,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14632.85,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26967.22,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12724.22,,,,,,,fee schedule,11102.63,26967.22,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,26967.22,APC
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,26967.22,APC
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,26967.22,APC
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5857.31,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3840.05,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4794.21,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3009.69,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6735.91,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2617.12,,,,,,,fee schedule,2617.12,6735.91,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,2617.12,6735.91,APC
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,2617.12,6735.91,APC
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,2240.18,APC
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,2240.18,APC
Injection treatment of nerve,64600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,2240.18,APC
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Injection treatment of nerve,64605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Injection treatment of nerve,64610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,550.53,
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.01,,,,,,,fee schedule,124.61,550.53,
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.01,,,,,,,fee schedule,124.61,550.53,
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,550.53,
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,550.53,
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.91,,,,,,,fee schedule,124.61,550.53,
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,550.53,
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.01,,,,,,,fee schedule,124.61,550.53,
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,124.61,550.53,APC
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,124.61,550.53,APC
Chemodenerv saliv glands,64611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,124.61,550.53,APC
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.89,,,,,,,fee schedule,130.39,550.53,
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.5,,,,,,,fee schedule,130.39,550.53,
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.5,,,,,,,fee schedule,130.39,550.53,
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,130.39,,,,,,,fee schedule,130.39,550.53,
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.79,,,,,,,fee schedule,130.39,550.53,
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,201.83,,,,,,,fee schedule,130.39,550.53,
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.72,,,,,,,fee schedule,130.39,550.53,
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,175.5,,,,,,,fee schedule,130.39,550.53,
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,130.39,550.53,APC
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,130.39,550.53,APC
Destroy nerve face muscle,64612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,130.39,550.53,APC
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.62,,,,,,,fee schedule,107.27,550.53,
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.26,,,,,,,fee schedule,107.27,550.53,
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.26,,,,,,,fee schedule,107.27,550.53,
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.27,,,,,,,fee schedule,107.27,550.53,
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.92,,,,,,,fee schedule,107.27,550.53,
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.05,,,,,,,fee schedule,107.27,550.53,
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.16,,,,,,,fee schedule,107.27,550.53,
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.26,,,,,,,fee schedule,107.27,550.53,
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,107.27,550.53,APC
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,107.27,550.53,APC
Chemodenerv musc migraine,64615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,107.27,550.53,APC
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.77,,,,,,,fee schedule,102.78,550.53,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.13,,,,,,,fee schedule,102.78,550.53,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.13,,,,,,,fee schedule,102.78,550.53,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.78,,,,,,,fee schedule,102.78,550.53,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.32,,,,,,,fee schedule,102.78,550.53,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.1,,,,,,,fee schedule,102.78,550.53,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.29,,,,,,,fee schedule,102.78,550.53,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.13,,,,,,,fee schedule,102.78,550.53,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,102.78,550.53,APC
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,102.78,550.53,APC
Chemodenerv musc neck dyston,64616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,102.78,550.53,APC
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,270.42,,,,,,,fee schedule,177.29,1266.02,
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.27,,,,,,,fee schedule,177.29,1266.02,
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,279.27,,,,,,,fee schedule,177.29,1266.02,
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.29,,,,,,,fee schedule,177.29,1266.02,
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,221.34,,,,,,,fee schedule,177.29,1266.02,
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,321.16,,,,,,,fee schedule,177.29,1266.02,
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,310.98,,,,,,,fee schedule,177.29,1266.02,
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,279.27,,,,,,,fee schedule,177.29,1266.02,
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,177.29,1266.02,APC
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,177.29,1266.02,APC
Chemodener muscle larynx emg,64617,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,177.29,1266.02,APC
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,618.36,2240.18,
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,2240.18,APC
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,2240.18,APC
Injection treatment of nerve,64620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,2240.18,APC
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3339.83,,,,,,,fee schedule,1945.7,3840.8,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3339.83,,,,,,,fee schedule,1945.7,3840.8,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3339.83,,,,,,,fee schedule,1945.7,3840.8,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2189.59,,,,,,,fee schedule,1945.7,3840.8,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2733.65,,,,,,,fee schedule,1945.7,3840.8,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3840.8,,,,,,,fee schedule,1945.7,3840.8,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,3840.8,APC
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,3840.8,APC
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,3840.8,APC
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3339.83,,,,,,,fee schedule,1945.7,3840.8,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3339.83,,,,,,,fee schedule,1945.7,3840.8,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3339.83,,,,,,,fee schedule,1945.7,3840.8,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2189.59,,,,,,,fee schedule,1945.7,3840.8,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2733.65,,,,,,,fee schedule,1945.7,3840.8,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3840.8,,,,,,,fee schedule,1945.7,3840.8,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,3840.8,APC
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,3840.8,APC
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,3840.8,APC
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24465.09,,,,,,,fee schedule,12792.51,28134.85,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15100.86,,,,,,,fee schedule,12792.51,28134.85,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15100.86,,,,,,,fee schedule,12792.51,28134.85,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16039.31,,,,,,,fee schedule,12792.51,28134.85,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20024.68,,,,,,,fee schedule,12792.51,28134.85,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17365.99,,,,,,,fee schedule,12792.51,28134.85,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28134.85,,,,,,,fee schedule,12792.51,28134.85,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15100.86,,,,,,,fee schedule,12792.51,28134.85,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,28134.85,APC
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,28134.85,APC
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,28134.85,APC
Trml dstrj ios bvn ea addl,64629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,342.87,,,,,,,fee schedule,224.79,394.3,
Trml dstrj ios bvn ea addl,64629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.79,,,,,,,fee schedule,224.79,394.3,
Trml dstrj ios bvn ea addl,64629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,280.64,,,,,,,fee schedule,224.79,394.3,
Trml dstrj ios bvn ea addl,64629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,394.3,,,,,,,fee schedule,224.79,394.3,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Injection treatment of nerve,64630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.75,,,,,,,fee schedule,71.95,550.53,
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.85,,,,,,,fee schedule,71.95,550.53,
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.85,,,,,,,fee schedule,71.95,550.53,
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.95,,,,,,,fee schedule,71.95,550.53,
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.83,,,,,,,fee schedule,71.95,550.53,
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.38,,,,,,,fee schedule,71.95,550.53,
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.21,,,,,,,fee schedule,71.95,550.53,
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.85,,,,,,,fee schedule,71.95,550.53,
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,71.95,550.53,APC
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,71.95,550.53,APC
N block inj common digit,64632,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,71.95,550.53,APC
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,1412.88,3502.27,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,1412.88,3502.27,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,1412.88,3502.27,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,237.11,,,,,,,fee schedule,155.45,1586.33,
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.69,,,,,,,fee schedule,155.45,1586.33,
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.69,,,,,,,fee schedule,155.45,1586.33,
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,155.45,,,,,,,fee schedule,155.45,1586.33,
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.07,,,,,,,fee schedule,155.45,1586.33,
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.59,,,,,,,fee schedule,155.45,1586.33,
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,272.68,,,,,,,fee schedule,155.45,1586.33,
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.69,,,,,,,fee schedule,155.45,1586.33,
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,155.45,1586.33,APC
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,155.45,1586.33,APC
Injection treatment of nerve,64640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,155.45,1586.33,APC
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,322.92,,,,,,,fee schedule,173.78,1266.02,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.78,,,,,,,fee schedule,173.78,1266.02,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.78,,,,,,,fee schedule,173.78,1266.02,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.71,,,,,,,fee schedule,173.78,1266.02,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,264.31,,,,,,,fee schedule,173.78,1266.02,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.85,,,,,,,fee schedule,173.78,1266.02,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,371.36,,,,,,,fee schedule,173.78,1266.02,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.78,,,,,,,fee schedule,173.78,1266.02,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,173.78,1266.02,APC
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,173.78,1266.02,APC
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,173.78,1266.02,APC
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,238.09,,,,,,,fee schedule,156.09,1266.02,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.63,,,,,,,fee schedule,156.09,1266.02,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.63,,,,,,,fee schedule,156.09,1266.02,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.09,,,,,,,fee schedule,156.09,1266.02,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.88,,,,,,,fee schedule,156.09,1266.02,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,237.62,,,,,,,fee schedule,156.09,1266.02,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,273.8,,,,,,,fee schedule,156.09,1266.02,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,206.63,,,,,,,fee schedule,156.09,1266.02,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,156.09,1266.02,APC
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,156.09,1266.02,APC
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,156.09,1266.02,APC
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3098.23,,,,,,,fee schedule,185.89,3562.96,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.89,,,,,,,fee schedule,185.89,3562.96,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.89,,,,,,,fee schedule,185.89,3562.96,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2031.2,,,,,,,fee schedule,185.89,3562.96,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2535.9,,,,,,,fee schedule,185.89,3562.96,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,213.77,,,,,,,fee schedule,185.89,3562.96,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3562.96,,,,,,,fee schedule,185.89,3562.96,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,185.89,,,,,,,fee schedule,185.89,3562.96,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,185.89,3562.96,APC
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,185.89,3562.96,APC
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,185.89,3562.96,APC
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,234.16,,,,,,,fee schedule,153.52,1266.02,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.69,,,,,,,fee schedule,153.52,1266.02,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.69,,,,,,,fee schedule,153.52,1266.02,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,153.52,,,,,,,fee schedule,153.52,1266.02,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.66,,,,,,,fee schedule,153.52,1266.02,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.59,,,,,,,fee schedule,153.52,1266.02,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,269.28,,,,,,,fee schedule,153.52,1266.02,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.69,,,,,,,fee schedule,153.52,1266.02,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,153.52,1266.02,APC
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,153.52,1266.02,APC
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,153.52,1266.02,APC
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,135.23,,,,,,,fee schedule,88.66,550.53,
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.06,,,,,,,fee schedule,88.66,550.53,
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.06,,,,,,,fee schedule,88.66,550.53,
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.66,,,,,,,fee schedule,88.66,550.53,
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.69,,,,,,,fee schedule,88.66,550.53,
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.22,,,,,,,fee schedule,88.66,550.53,
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.51,,,,,,,fee schedule,88.66,550.53,
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.06,,,,,,,fee schedule,88.66,550.53,
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,88.66,550.53,APC
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,88.66,550.53,APC
Chemodenerv eccrine glands,64650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,88.66,550.53,APC
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.81,,,,,,,fee schedule,101.49,550.53,
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.48,,,,,,,fee schedule,101.49,550.53,
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.48,,,,,,,fee schedule,101.49,550.53,
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.49,,,,,,,fee schedule,101.49,550.53,
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.71,,,,,,,fee schedule,101.49,550.53,
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,158.1,,,,,,,fee schedule,101.49,550.53,
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.03,,,,,,,fee schedule,101.49,550.53,
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.48,,,,,,,fee schedule,101.49,550.53,
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,101.49,550.53,APC
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,101.49,550.53,APC
Chemodenerv eccrine glands,64653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,101.49,550.53,APC
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,3483.53,6270.36,APC
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,3483.53,6270.36,APC
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,3483.53,6270.36,APC
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,30746.74,55344.12,APC
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,30746.74,55344.12,APC
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,30746.74,55344.12,APC
Rmvl bat modulj sys tot sys,64657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3403.86,6126.95,APC
Rmvl bat modulj sys tot sys,64657,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3403.86,6126.95,APC
Rmvl bat modulj sys tot sys,64657,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3403.86,6126.95,APC
Rmvl bat modul sys lead only,64658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,3483.53,6270.36,APC
Rmvl bat modul sys lead only,64658,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,3483.53,6270.36,APC
Rmvl bat modul sys lead only,64658,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,3483.53,6270.36,APC
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3657.71,,,,,,,fee schedule,3483.53,6270.36,APC
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3483.53,,,,,,,fee schedule,3483.53,6270.36,APC
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6270.36,,,,,,,fee schedule,3483.53,6270.36,APC
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1385.97,,,,,,,fee schedule,881.29,2240.18,
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1947.98,,,,,,,fee schedule,881.29,2240.18,
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1947.98,,,,,,,fee schedule,881.29,2240.18,
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,908.64,,,,,,,fee schedule,881.29,2240.18,
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1134.42,,,,,,,fee schedule,881.29,2240.18,
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2240.18,,,,,,,fee schedule,881.29,2240.18,
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1593.87,,,,,,,fee schedule,881.29,2240.18,
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1947.98,,,,,,,fee schedule,881.29,2240.18,
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,881.29,2240.18,APC
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,881.29,2240.18,APC
Injection treatment of nerve,64680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,881.29,2240.18,APC
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.19,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.36,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.67,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,618.36,1586.33,
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,925.36,,,,,,,fee schedule,618.36,1586.33,APC
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,881.29,,,,,,,fee schedule,618.36,1586.33,APC
Injection treatment of nerve,64681,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1586.33,,,,,,,fee schedule,618.36,1586.33,APC
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Revise finger/toe nerve,64702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2095.73,,,,,,,fee schedule,1412.88,3502.27,
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Revise hand/foot nerve,64704,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2095.73,,,,,,,fee schedule,1412.88,3502.27,
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Revise arm/leg nerve,64708,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of sciatic nerve,64712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of arm nerve(s),64713,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Revise low back nerve(s),64714,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Revision of cranial nerve,64716,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5720.47,,,,,,,fee schedule,1822.37,6578.54,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.37,,,,,,,fee schedule,1822.37,6578.54,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1822.37,,,,,,,fee schedule,1822.37,6578.54,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3750.34,,,,,,,fee schedule,1822.37,6578.54,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4682.2,,,,,,,fee schedule,1822.37,6578.54,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2095.73,,,,,,,fee schedule,1822.37,6578.54,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6578.54,,,,,,,fee schedule,1822.37,6578.54,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1822.37,,,,,,,fee schedule,1822.37,6578.54,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1822.37,6578.54,APC
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1822.37,6578.54,APC
Revise ulnar nerve at elbow,64718,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1822.37,6578.54,APC
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2095.73,,,,,,,fee schedule,1412.88,3502.27,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Revise ulnar nerve at wrist,64719,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2170.04,,,,,,,fee schedule,1945.7,3502.27,
Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2170.04,,,,,,,fee schedule,1945.7,3502.27,
Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2495.55,,,,,,,fee schedule,1945.7,3502.27,
Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2170.04,,,,,,,fee schedule,1945.7,3502.27,
Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,3502.27,APC
Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,3502.27,APC
Carpal tunnel surgery,64721,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,3502.27,APC
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2095.73,,,,,,,fee schedule,1412.88,3502.27,
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Relieve pressure on nerve(s),64722,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Release foot/toe nerve,64726,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,3502.27,APC
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,3502.27,APC
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,3502.27,APC
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of brow nerve,64732,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of cheek nerve,64734,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of chin nerve,64736,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of jaw nerve,64738,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of tongue nerve,64740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of facial nerve,64742,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incise nerve back of head,64744,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incise diaphragm nerve,64746,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incise hip/thigh nerve,64763,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6946.56,,,,,,,fee schedule,1945.7,7988.54,
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,7988.54,
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,1945.7,7988.54,
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4554.16,,,,,,,fee schedule,1945.7,7988.54,
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5685.76,,,,,,,fee schedule,1945.7,7988.54,
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,1945.7,7988.54,
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7988.54,,,,,,,fee schedule,1945.7,7988.54,
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,7988.54,
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,7988.54,APC
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,7988.54,APC
Incise hip/thigh nerve,64766,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,7988.54,APC
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Sever cranial nerve,64771,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2095.73,,,,,,,fee schedule,1412.88,3502.27,
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Incision of spinal nerve,64772,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Remove skin nerve lesion,64774,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Remove digit nerve lesion,64776,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2095.73,,,,,,,fee schedule,1412.88,3502.27,
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1822.37,,,,,,,fee schedule,1412.88,3502.27,
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Remove limb nerve lesion,64782,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Remove nerve lesion,64784,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Remove sciatic nerve lesion,64786,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5951.13,,,,,,,fee schedule,1834.07,6843.8,
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1834.07,6843.8,
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1834.07,6843.8,
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3901.56,,,,,,,fee schedule,1834.07,6843.8,
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4871,,,,,,,fee schedule,1834.07,6843.8,
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1834.07,6843.8,
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6843.8,,,,,,,fee schedule,1834.07,6843.8,
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1834.07,6843.8,
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1834.07,6843.8,APC
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1834.07,6843.8,APC
Remove skin nerve lesion,64788,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1834.07,6843.8,APC
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Removal of nerve lesion,64790,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Removal of nerve lesion,64792,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Biopsy of nerve,64795,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Sympathectomy cervical,64802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2338.16,,,,,,,fee schedule,1532.9,3502.27,
Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1532.9,,,,,,,fee schedule,1532.9,3502.27,
Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1913.78,,,,,,,fee schedule,1532.9,3502.27,
Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2688.88,,,,,,,fee schedule,1532.9,3502.27,
Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1532.9,3502.27,APC
Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1532.9,3502.27,APC
Remove sympathetic nerves,64804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1532.9,3502.27,APC
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2155.1,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1412.88,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1763.95,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2109.18,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2478.37,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1834.07,,,,,,,fee schedule,1412.88,3502.27,
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1412.88,3502.27,APC
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1412.88,3502.27,APC
Sympathectomy digital artery,64820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1412.88,3502.27,APC
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove sympathetic nerves,64821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3329.64,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.91,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2725.31,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3829.09,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,2182.91,5868.42,
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.91,5868.42,APC
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.91,5868.42,APC
Remove sympathetic nerves,64822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.91,5868.42,APC
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1899.94,,,,,,,fee schedule,1245.6,5868.42,
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.69,,,,,,,fee schedule,1245.6,5868.42,
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2928.69,,,,,,,fee schedule,1245.6,5868.42,
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1245.6,,,,,,,fee schedule,1245.6,5868.42,
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1555.1,,,,,,,fee schedule,1245.6,5868.42,
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3367.99,,,,,,,fee schedule,1245.6,5868.42,
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2184.93,,,,,,,fee schedule,1245.6,5868.42,
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2928.69,,,,,,,fee schedule,1245.6,5868.42,
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1245.6,5868.42,APC
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1245.6,5868.42,APC
Sympathectomy supfc palmar,64823,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1245.6,5868.42,APC
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15229.09,,,,,,,fee schedule,1945.7,17513.45,
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,17513.45,
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,1945.7,17513.45,
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9984.19,,,,,,,fee schedule,1945.7,17513.45,
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12465.01,,,,,,,fee schedule,1945.7,17513.45,
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,1945.7,17513.45,
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17513.45,,,,,,,fee schedule,1945.7,17513.45,
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,17513.45,
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,17513.45,APC
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,17513.45,APC
Repair of digit nerve,64831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,17513.45,APC
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of hand or foot nerve,64834,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of hand or foot nerve,64835,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of hand or foot nerve,64836,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Repair of leg nerve,64840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Repair/transpose nerve,64856,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Repair arm/leg nerve,64857,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,1945.7,5927.15,
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,1945.7,5927.15,
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,1945.7,5927.15,
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,1945.7,5927.15,
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,1945.7,5927.15,
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,5927.15,APC
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,5927.15,APC
Repair sciatic nerve,64858,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,5927.15,APC
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,1945.7,5927.15,
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,1945.7,5927.15,
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,1945.7,5927.15,
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,1945.7,5927.15,
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,1945.7,5927.15,
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,1945.7,5927.15,
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,1945.7,5927.15,APC
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,1945.7,5927.15,APC
Repair of arm nerves,64861,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,1945.7,5927.15,APC
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of low back nerves,64862,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Repair of facial nerve,64864,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,6126.95,
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,6126.95,
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,6126.95,
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,6126.95,
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,6126.95,
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,6126.95,
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3378.99,6126.95,APC
Repair of facial nerve,64865,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3378.99,6126.95,APC
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7356.8,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4823.12,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6021.54,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8460.32,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7517.89,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4928.73,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6153.39,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8645.57,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6925.98,,,,,,,fee schedule,3403.86,7964.88,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3403.86,7964.88,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3403.86,7964.88,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4540.67,,,,,,,fee schedule,3403.86,7964.88,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5668.91,,,,,,,fee schedule,3403.86,7964.88,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3403.86,7964.88,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7964.88,,,,,,,fee schedule,3403.86,7964.88,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3403.86,7964.88,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3403.86,7964.88,APC
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3403.86,7964.88,APC
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3403.86,7964.88,APC
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8447.42,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5538.13,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6914.21,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9714.53,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3905.88,15739.73,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3905.88,15739.73,APC
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve pedicle transfer,64905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve pedicle transfer,64907,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5154.04,,,,,,,fee schedule,3378.99,15739.73,
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3378.99,,,,,,,fee schedule,3378.99,15739.73,
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4218.58,,,,,,,fee schedule,3378.99,15739.73,
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4491.76,,,,,,,fee schedule,3378.99,15739.73,
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5927.15,,,,,,,fee schedule,3378.99,15739.73,
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3905.88,,,,,,,fee schedule,3378.99,15739.73,
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3378.99,15739.73,APC
Nerve repair w/allograft,64910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3378.99,15739.73,APC
Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6209.32,,,,,,,fee schedule,4070.83,15739.73,
Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4070.83,,,,,,,fee schedule,4070.83,15739.73,
Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5082.33,,,,,,,fee schedule,4070.83,15739.73,
Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7140.72,,,,,,,fee schedule,4070.83,15739.73,
Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,4070.83,15739.73,APC
Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,4070.83,15739.73,APC
Neurorraphy w/vein autograft,64911,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,4070.83,15739.73,APC
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12633.62,,,,,,,fee schedule,3395.8,15739.73,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3395.8,,,,,,,fee schedule,3395.8,15739.73,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3395.8,,,,,,,fee schedule,3395.8,15739.73,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8282.6,,,,,,,fee schedule,3395.8,15739.73,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10340.62,,,,,,,fee schedule,3395.8,15739.73,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3905.17,,,,,,,fee schedule,3395.8,15739.73,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14528.66,,,,,,,fee schedule,3395.8,15739.73,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3395.8,,,,,,,fee schedule,3395.8,15739.73,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.51,,,,,,,fee schedule,3395.8,15739.73,APC
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8744.29,,,,,,,fee schedule,3395.8,15739.73,APC
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15739.73,,,,,,,fee schedule,3395.8,15739.73,APC
Nervous system surgery,64999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,305.85,550.53,APC
Nervous system surgery,64999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,305.85,550.53,APC
Nervous system surgery,64999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,305.85,550.53,APC
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Revise eye,65091,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Revise eye with implant,65093,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of eye,65101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/insert implant,65103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/attach implant,65105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of eye,65110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/revise socket,65112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Remove eye/revise socket,65114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revise ocular implant,65125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Insert ocular implant,65130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Insert ocular implant,65135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Attach ocular implant,65140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Revise ocular implant,65150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Reinsert ocular implant,65155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Removal of ocular implant,65175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Remove foreign body from eye,65205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Remove foreign body from eye,65210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Remove foreign body from eye,65220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Remove foreign body from eye,65222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Remove foreign body from eye,65235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,416.64,4139.14,
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.64,,,,,,,fee schedule,416.64,4139.14,
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.64,,,,,,,fee schedule,416.64,4139.14,
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,416.64,4139.14,
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,416.64,4139.14,
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,479.14,,,,,,,fee schedule,416.64,4139.14,
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,416.64,4139.14,
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,416.64,,,,,,,fee schedule,416.64,4139.14,
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,416.64,4139.14,APC
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,416.64,4139.14,APC
Remove foreign body from eye,65260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,416.64,4139.14,APC
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Remove foreign body from eye,65265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair of eye wound,65270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair of eye wound,65272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Repair of eye wound,65275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,2322.45,9543.9,APC
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,2322.45,9543.9,APC
Repair of eye wound,65280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,2322.45,9543.9,APC
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,2322.45,9543.9,APC
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,2322.45,9543.9,APC
Repair of eye wound,65285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,2322.45,9543.9,APC
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1253.24,,,,,,,fee schedule,821.62,4139.14,
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,996.75,,,,,,,fee schedule,821.62,4139.14,
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,996.75,,,,,,,fee schedule,821.62,4139.14,
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,821.62,,,,,,,fee schedule,821.62,4139.14,
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1025.78,,,,,,,fee schedule,821.62,4139.14,
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1146.26,,,,,,,fee schedule,821.62,4139.14,
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1441.23,,,,,,,fee schedule,821.62,4139.14,
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,996.75,,,,,,,fee schedule,821.62,4139.14,
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,821.62,4139.14,APC
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,821.62,4139.14,APC
Repair of eye wound,65286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,821.62,4139.14,APC
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Repair of eye socket wound,65290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1143.41,,,,,,,fee schedule,749.62,1787.93,
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,929.79,,,,,,,fee schedule,749.62,1787.93,
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,929.79,,,,,,,fee schedule,749.62,1787.93,
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,749.62,,,,,,,fee schedule,749.62,1787.93,
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,935.88,,,,,,,fee schedule,749.62,1787.93,
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1069.26,,,,,,,fee schedule,749.62,1787.93,
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1314.92,,,,,,,fee schedule,749.62,1787.93,
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,929.79,,,,,,,fee schedule,749.62,1787.93,
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,749.62,1787.93,APC
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,749.62,1787.93,APC
Removal of eye lesion,65400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,749.62,1787.93,APC
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,929.79,4264.08,
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,929.79,,,,,,,fee schedule,929.79,4264.08,
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,929.79,,,,,,,fee schedule,929.79,4264.08,
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,929.79,4264.08,
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,929.79,4264.08,
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1069.26,,,,,,,fee schedule,929.79,4264.08,
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,929.79,4264.08,
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,929.79,,,,,,,fee schedule,929.79,4264.08,
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,929.79,4264.08,APC
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,929.79,4264.08,APC
Biopsy of cornea,65410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,929.79,4264.08,APC
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Removal of eye lesion,65420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Removal of eye lesion,65426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Corneal smear,65430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.44,,,,,,,fee schedule,82.24,1787.93,
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.8,,,,,,,fee schedule,82.24,1787.93,
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.8,,,,,,,fee schedule,82.24,1787.93,
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.24,,,,,,,fee schedule,82.24,1787.93,
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.67,,,,,,,fee schedule,82.24,1787.93,
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.27,,,,,,,fee schedule,82.24,1787.93,
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,144.26,,,,,,,fee schedule,82.24,1787.93,
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.8,,,,,,,fee schedule,82.24,1787.93,
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,82.24,1787.93,APC
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,82.24,1787.93,APC
Curette/treat cornea,65435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,82.24,1787.93,APC
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,568.29,,,,,,,fee schedule,372.57,4264.08,
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,499.79,,,,,,,fee schedule,372.57,4264.08,
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,499.79,,,,,,,fee schedule,372.57,4264.08,
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,372.57,,,,,,,fee schedule,372.57,4264.08,
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,465.15,,,,,,,fee schedule,372.57,4264.08,
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,574.76,,,,,,,fee schedule,372.57,4264.08,
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,653.53,,,,,,,fee schedule,372.57,4264.08,
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,499.79,,,,,,,fee schedule,372.57,4264.08,
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,372.57,4264.08,APC
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,372.57,4264.08,APC
Curette/treat cornea,65436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,372.57,4264.08,APC
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.66,,,,,,,fee schedule,259.85,569.27,
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Treatment of corneal lesion,65450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,652.58,,,,,,,fee schedule,427.83,4264.08,
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,574.11,,,,,,,fee schedule,427.83,4264.08,
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,574.11,,,,,,,fee schedule,427.83,4264.08,
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,427.83,,,,,,,fee schedule,427.83,4264.08,
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.14,,,,,,,fee schedule,427.83,4264.08,
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,660.23,,,,,,,fee schedule,427.83,4264.08,
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,750.47,,,,,,,fee schedule,427.83,4264.08,
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,574.11,,,,,,,fee schedule,427.83,4264.08,
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,427.83,4264.08,APC
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,427.83,4264.08,APC
Revision of cornea,65600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,427.83,4264.08,APC
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,3132.44,9543.9,APC
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,3132.44,9543.9,APC
Corneal transplant,65710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,3132.44,9543.9,APC
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Corneal transplant,65730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,3132.44,9543.9,APC
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,3132.44,9543.9,APC
Corneal transplant,65750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,3132.44,9543.9,APC
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Corneal transplant,65755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,7413.41,
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Corneal trnspl endothelial,65756,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Revision of cornea,65760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1354.15,,,,,,,fee schedule,887.78,1557.27,
Revision of cornea,65760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,887.78,,,,,,,fee schedule,887.78,1557.27,
Revision of cornea,65760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1108.37,,,,,,,fee schedule,887.78,1557.27,
Revision of cornea,65760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1557.27,,,,,,,fee schedule,887.78,1557.27,
Revision of cornea,65765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1962.63,,,,,,,fee schedule,1286.7,2257.02,
Revision of cornea,65765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1286.7,,,,,,,fee schedule,1286.7,2257.02,
Revision of cornea,65765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1606.41,,,,,,,fee schedule,1286.7,2257.02,
Revision of cornea,65765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2257.02,,,,,,,fee schedule,1286.7,2257.02,
Corneal tissue transplant,65767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1827.42,,,,,,,fee schedule,1198.06,2101.53,
Corneal tissue transplant,65767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1198.06,,,,,,,fee schedule,1198.06,2101.53,
Corneal tissue transplant,65767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1495.74,,,,,,,fee schedule,1198.06,2101.53,
Corneal tissue transplant,65767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2101.53,,,,,,,fee schedule,1198.06,2101.53,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17886.25,,,,,,,fee schedule,11726.23,26017.1,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16166.28,,,,,,,fee schedule,11726.23,26017.1,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16166.28,,,,,,,fee schedule,11726.23,26017.1,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11726.23,,,,,,,fee schedule,11726.23,26017.1,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14639.9,,,,,,,fee schedule,11726.23,26017.1,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18591.22,,,,,,,fee schedule,11726.23,26017.1,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20569.19,,,,,,,fee schedule,11726.23,26017.1,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16166.28,,,,,,,fee schedule,11726.23,26017.1,
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15176.64,,,,,,,fee schedule,11726.23,26017.1,APC
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14453.94,,,,,,,fee schedule,11726.23,26017.1,APC
Revise cornea with implant,65770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26017.1,,,,,,,fee schedule,11726.23,26017.1,APC
Radial keratotomy,65771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,744.67,,,,,,,fee schedule,488.21,856.37,
Radial keratotomy,65771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,488.21,,,,,,,fee schedule,488.21,856.37,
Radial keratotomy,65771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,609.51,,,,,,,fee schedule,488.21,856.37,
Radial keratotomy,65771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,856.37,,,,,,,fee schedule,488.21,856.37,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1143.41,,,,,,,fee schedule,749.62,1787.93,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,929.79,,,,,,,fee schedule,749.62,1787.93,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,929.79,,,,,,,fee schedule,749.62,1787.93,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,749.62,,,,,,,fee schedule,749.62,1787.93,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,935.88,,,,,,,fee schedule,749.62,1787.93,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1069.26,,,,,,,fee schedule,749.62,1787.93,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1314.92,,,,,,,fee schedule,749.62,1787.93,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,929.79,,,,,,,fee schedule,749.62,1787.93,
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,749.62,1787.93,APC
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,749.62,1787.93,APC
Correction of astigmatism,65772,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,749.62,1787.93,APC
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Correction of astigmatism,65775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1158.4,,,,,,,fee schedule,759.45,1787.93,
Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,759.45,,,,,,,fee schedule,759.45,1787.93,
Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,948.15,,,,,,,fee schedule,759.45,1787.93,
Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1332.16,,,,,,,fee schedule,759.45,1787.93,
Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,759.45,1787.93,APC
Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,759.45,1787.93,APC
Cover eye w/membrane,65778,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,759.45,1787.93,APC
Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4149.91,,,,,,,fee schedule,2720.68,7051.07,
Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2720.68,,,,,,,fee schedule,2720.68,7051.07,
Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3396.7,,,,,,,fee schedule,2720.68,7051.07,
Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4772.4,,,,,,,fee schedule,2720.68,7051.07,
Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2720.68,7051.07,APC
Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2720.68,7051.07,APC
Cover eye w/membrane suture,65779,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2720.68,7051.07,APC
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Ocular reconst transplant,65780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,9543.9,
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,9543.9,
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,9543.9,
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,9543.9,
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,9543.9,
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,3132.44,9543.9,APC
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,3132.44,9543.9,APC
Ocular reconst transplant,65781,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,3132.44,9543.9,APC
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Ocular reconst transplant,65782,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,416.64,4139.14,
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.64,,,,,,,fee schedule,416.64,4139.14,
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.64,,,,,,,fee schedule,416.64,4139.14,
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,416.64,4139.14,
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,416.64,4139.14,
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,479.14,,,,,,,fee schedule,416.64,4139.14,
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,416.64,4139.14,
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,416.64,,,,,,,fee schedule,416.64,4139.14,
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,416.64,4139.14,APC
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,416.64,4139.14,APC
Drainage of eye,65800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,416.64,4139.14,APC
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Drainage of eye,65810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Drainage of eye,65815,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,7413.41,
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,7413.41,
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,7413.41,
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,7413.41,
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,7413.41,
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,2322.45,7413.41,APC
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,2322.45,7413.41,APC
Relieve inner eye pressure,65820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,2322.45,7413.41,APC
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2620.14,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Incision of eye,65850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,362.54,,,,,,,fee schedule,237.68,986.44,
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,455.69,,,,,,,fee schedule,237.68,986.44,
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,455.69,,,,,,,fee schedule,237.68,986.44,
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,237.68,,,,,,,fee schedule,237.68,986.44,
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,296.74,,,,,,,fee schedule,237.68,986.44,
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,524.04,,,,,,,fee schedule,237.68,986.44,
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,416.92,,,,,,,fee schedule,237.68,986.44,
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,455.69,,,,,,,fee schedule,237.68,986.44,
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,237.68,986.44,APC
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,237.68,986.44,APC
Trabeculoplasty laser surg,65855,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,237.68,986.44,APC
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,478.15,,,,,,,fee schedule,313.48,986.44,
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,421.1,,,,,,,fee schedule,313.48,986.44,
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,421.1,,,,,,,fee schedule,313.48,986.44,
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,313.48,,,,,,,fee schedule,313.48,986.44,
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,391.37,,,,,,,fee schedule,313.48,986.44,
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,484.27,,,,,,,fee schedule,313.48,986.44,
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,549.87,,,,,,,fee schedule,313.48,986.44,
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,421.1,,,,,,,fee schedule,313.48,986.44,
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,313.48,986.44,APC
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,313.48,986.44,APC
Incise inner eye adhesions,65860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,313.48,986.44,APC
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65865,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65875,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,7413.41,
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,7413.41,
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,7413.41,
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,7413.41,
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,7413.41,
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,2322.45,7413.41,APC
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,2322.45,7413.41,APC
Incise inner eye adhesions,65880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,2322.45,7413.41,APC
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Remove eye lesion,65900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Remove implant of eye,65920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Remove blood clot from eye,65930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,996.75,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1146.26,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,996.75,4139.14,APC
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,996.75,4139.14,APC
Injection treatment of eye,66020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,996.75,4139.14,APC
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,996.75,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1146.26,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,996.75,4139.14,APC
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,996.75,4139.14,APC
Injection treatment of eye,66030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,996.75,4139.14,APC
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eye lesion,66130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,2322.45,7413.41,APC
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,2322.45,7413.41,APC
Glaucoma surgery,66150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,2322.45,7413.41,APC
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,2322.45,7413.41,APC
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,2322.45,7413.41,APC
Glaucoma surgery,66155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,2322.45,7413.41,APC
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Glaucoma surgery,66160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2620.14,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Glaucoma surgery,66170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Incision of eye,66172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,7413.41,
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Translum dil eye canal,66174,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,9543.9,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,9543.9,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,9543.9,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,9543.9,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,9543.9,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,3132.44,9543.9,APC
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,3132.44,9543.9,APC
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,3132.44,9543.9,APC
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,3132.44,9543.9,APC
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,3132.44,9543.9,APC
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,3132.44,9543.9,APC
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,9543.9,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,3132.44,9543.9,APC
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,3132.44,9543.9,APC
Aqueous shunt eye w/graft,66180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,3132.44,9543.9,APC
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,7413.41,
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Insert ant drainage device,66183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Revision of aqueous shunt,66184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Revise aqueous shunt eye,66185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,9543.9,
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,9543.9,
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,9543.9,
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,9543.9,
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,9543.9,
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,9543.9,
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,2322.45,9543.9,APC
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,2322.45,9543.9,APC
Repair/graft eye lesion,66225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,2322.45,9543.9,APC
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1418.23,4264.08,
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1418.23,4264.08,
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1418.23,4264.08,
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1418.23,4264.08,
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Follow-up surgery of eye,66250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,416.64,4139.14,
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.64,,,,,,,fee schedule,416.64,4139.14,
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.64,,,,,,,fee schedule,416.64,4139.14,
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,416.64,4139.14,
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,416.64,4139.14,
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,479.14,,,,,,,fee schedule,416.64,4139.14,
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,416.64,4139.14,
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,416.64,,,,,,,fee schedule,416.64,4139.14,
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,416.64,4139.14,APC
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,416.64,4139.14,APC
Incision of iris,66500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,416.64,4139.14,APC
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,996.75,4139.14,
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,996.75,,,,,,,fee schedule,996.75,4139.14,
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,996.75,4139.14,
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,996.75,4139.14,
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1146.26,,,,,,,fee schedule,996.75,4139.14,
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,996.75,4139.14,
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,996.75,4139.14,APC
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,996.75,4139.14,APC
Incision of iris,66505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,996.75,4139.14,APC
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,7413.41,
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,7413.41,
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,7413.41,
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,7413.41,
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,7413.41,
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,2322.45,7413.41,APC
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,2322.45,7413.41,APC
Remove iris and lesion,66600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,2322.45,7413.41,APC
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4758.46,
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,1750.95,4758.46,
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,1750.95,4758.46,
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4758.46,
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4758.46,
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,1750.95,4758.46,
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4758.46,
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,1750.95,4758.46,
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4758.46,APC
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4758.46,APC
Removal of iris,66605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4758.46,APC
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,996.75,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1146.26,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,996.75,4139.14,APC
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,996.75,4139.14,APC
Removal of iris,66625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,996.75,4139.14,APC
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,996.75,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1146.26,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,996.75,4139.14,APC
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,996.75,4139.14,APC
Removal of iris,66630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,996.75,4139.14,APC
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of iris,66635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Repair iris & ciliary body,66680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Repair iris & ciliary body,66682,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26840.88,,,,,,,fee schedule,16401.63,30867.01,
Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17596.88,,,,,,,fee schedule,16401.63,30867.01,
Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21969.26,,,,,,,fee schedule,16401.63,30867.01,
Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30867.01,,,,,,,fee schedule,16401.63,30867.01,
Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17221.72,,,,,,,fee schedule,16401.63,30867.01,APC
Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16401.63,,,,,,,fee schedule,16401.63,30867.01,APC
Implantation iris prosthesis,66683,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29522.94,,,,,,,fee schedule,16401.63,30867.01,APC
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,996.75,4139.14,
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,996.75,,,,,,,fee schedule,996.75,4139.14,
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,996.75,4139.14,
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,996.75,4139.14,
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1146.26,,,,,,,fee schedule,996.75,4139.14,
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,996.75,4139.14,
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,996.75,,,,,,,fee schedule,996.75,4139.14,
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,996.75,4139.14,APC
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,996.75,4139.14,APC
Destruction ciliary body,66700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,996.75,4139.14,APC
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Ciliary transsleral therapy,66710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Ciliary endoscopic ablation,66711,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Destruction ciliary body,66720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Destruction ciliary body,66740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,504.64,,,,,,,fee schedule,330.84,986.44,
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,444.46,,,,,,,fee schedule,330.84,986.44,
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,444.46,,,,,,,fee schedule,330.84,986.44,
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,330.84,,,,,,,fee schedule,330.84,986.44,
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,413.05,,,,,,,fee schedule,330.84,986.44,
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,511.13,,,,,,,fee schedule,330.84,986.44,
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,580.34,,,,,,,fee schedule,330.84,986.44,
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,444.46,,,,,,,fee schedule,330.84,986.44,
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,330.84,986.44,APC
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,330.84,986.44,APC
Revision of iris,66761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,330.84,986.44,APC
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
Revision of iris,66762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
Removal of inner eye lesion,66770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,416.64,4139.14,
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.64,,,,,,,fee schedule,416.64,4139.14,
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.64,,,,,,,fee schedule,416.64,4139.14,
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,416.64,4139.14,
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,416.64,4139.14,
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,479.14,,,,,,,fee schedule,416.64,4139.14,
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,416.64,4139.14,
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,416.64,,,,,,,fee schedule,416.64,4139.14,
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,416.64,4139.14,APC
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,416.64,4139.14,APC
Incision secondary cataract,66820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,416.64,4139.14,APC
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
After cataract laser surgery,66821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Reposition intraocular lens,66825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2825.84,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens lesion,66830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2825.84,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens material,66840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2620.14,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens material,66850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2457.25,7413.41,
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2457.25,,,,,,,fee schedule,2457.25,7413.41,
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2457.25,,,,,,,fee schedule,2457.25,7413.41,
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2457.25,7413.41,
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2457.25,7413.41,
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2825.84,,,,,,,fee schedule,2457.25,7413.41,
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2457.25,7413.41,
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2457.25,,,,,,,fee schedule,2457.25,7413.41,
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,2457.25,7413.41,APC
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,2457.25,7413.41,APC
Removal of lens material,66852,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,2457.25,7413.41,APC
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2825.84,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Extraction of lens,66920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2457.25,7413.41,
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2457.25,,,,,,,fee schedule,2457.25,7413.41,
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2457.25,,,,,,,fee schedule,2457.25,7413.41,
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2457.25,7413.41,
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2457.25,7413.41,
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2825.84,,,,,,,fee schedule,2457.25,7413.41,
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2457.25,7413.41,
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2457.25,,,,,,,fee schedule,2457.25,7413.41,
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,2457.25,7413.41,APC
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,2457.25,7413.41,APC
Extraction of lens,66930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,2457.25,7413.41,APC
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2825.84,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Extraction of lens,66940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2620.14,,,,,,,fee schedule,1750.95,4139.14,
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Cataract surgery complex,66982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2620.14,,,,,,,fee schedule,1750.95,4139.14,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2444,,,,,,,fee schedule,2299.52,4139.14,
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2444,,,,,,,fee schedule,2299.52,4139.14,
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2810.6,,,,,,,fee schedule,2299.52,4139.14,
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2444,,,,,,,fee schedule,2299.52,4139.14,
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,2299.52,4139.14,APC
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,2299.52,4139.14,APC
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,2299.52,4139.14,APC
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2825.84,,,,,,,fee schedule,1750.95,4139.14,
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2457.25,,,,,,,fee schedule,1750.95,4139.14,
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Insert lens prosthesis,66985,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Exchange lens prosthesis,66986,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7417.07,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7417.07,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7417.07,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4862.63,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6070.87,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8529.63,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,4118.56,8529.63,APC
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,4118.56,8529.63,APC
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,4118.56,8529.63,APC
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7417.07,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7417.07,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7417.07,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4862.63,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6070.87,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8529.63,,,,,,,fee schedule,4118.56,8529.63,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,4118.56,8529.63,APC
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,4118.56,8529.63,APC
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,4118.56,8529.63,APC
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8257.48,,,,,,,fee schedule,5202.71,9543.9,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5202.71,,,,,,,fee schedule,5202.71,9543.9,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5202.71,,,,,,,fee schedule,5202.71,9543.9,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5413.6,,,,,,,fee schedule,5202.71,9543.9,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6758.75,,,,,,,fee schedule,5202.71,9543.9,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5983.12,,,,,,,fee schedule,5202.71,9543.9,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9496.1,,,,,,,fee schedule,5202.71,9543.9,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5202.71,,,,,,,fee schedule,5202.71,9543.9,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,5202.71,9543.9,APC
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,5202.71,9543.9,APC
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,5202.71,9543.9,APC
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8257.48,,,,,,,fee schedule,5202.71,9543.9,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5202.71,,,,,,,fee schedule,5202.71,9543.9,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5202.71,,,,,,,fee schedule,5202.71,9543.9,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5413.6,,,,,,,fee schedule,5202.71,9543.9,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6758.75,,,,,,,fee schedule,5202.71,9543.9,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5983.12,,,,,,,fee schedule,5202.71,9543.9,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9496.1,,,,,,,fee schedule,5202.71,9543.9,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5202.71,,,,,,,fee schedule,5202.71,9543.9,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,5202.71,9543.9,APC
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,5202.71,9543.9,APC
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,5202.71,9543.9,APC
Eye surgery procedure,66999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,2299.52,4139.14,APC
Eye surgery procedure,66999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,2299.52,4139.14,APC
Eye surgery procedure,66999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,2299.52,4139.14,APC
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2620.14,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Partial removal of eye fluid,67005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Partial removal of eye fluid,67010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Release of eye fluid,67015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2620.14,,,,,,,fee schedule,1750.95,4139.14,
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,4139.14,
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Replace eye fluid,67025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4273.62,,,,,,,fee schedule,2801.79,25025.01,
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,2801.79,25025.01,
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,2801.79,25025.01,
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2801.79,,,,,,,fee schedule,2801.79,25025.01,
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3497.96,,,,,,,fee schedule,2801.79,25025.01,
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,2801.79,25025.01,
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4914.66,,,,,,,fee schedule,2801.79,25025.01,
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,2801.79,25025.01,
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14597.92,,,,,,,fee schedule,2801.79,25025.01,APC
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13902.78,,,,,,,fee schedule,2801.79,25025.01,APC
Implant eye drug system,67027,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25025.01,,,,,,,fee schedule,2801.79,25025.01,APC
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.3,,,,,,,fee schedule,86.08,592.41,
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.85,,,,,,,fee schedule,86.08,592.41,
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,115.85,,,,,,,fee schedule,86.08,592.41,
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.08,,,,,,,fee schedule,86.08,592.41,
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.47,,,,,,,fee schedule,86.08,592.41,
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,133.23,,,,,,,fee schedule,86.08,592.41,
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151,,,,,,,fee schedule,86.08,592.41,
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.85,,,,,,,fee schedule,86.08,592.41,
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,86.08,592.41,APC
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,86.08,592.41,APC
Injection eye drug,67028,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,86.08,592.41,APC
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Incise inner eye strands,67030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
Laser surgery eye strands,67031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4749.97,,,,,,,fee schedule,3132.44,7413.41,
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Removal of inner eye fluid,67036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Laser treatment of retina,67039,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Laser treatment of retina,67040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4749.97,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for macular pucker,67041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4749.97,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for macular hole,67042,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,3132.44,7413.41,
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,3132.44,7413.41,
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Vit for membrane dissect,67043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,541.85,,,,,,,fee schedule,355.24,4139.14,
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1098.13,,,,,,,fee schedule,355.24,4139.14,
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1098.13,,,,,,,fee schedule,355.24,4139.14,
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,355.24,,,,,,,fee schedule,355.24,4139.14,
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,443.5,,,,,,,fee schedule,355.24,4139.14,
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1262.85,,,,,,,fee schedule,355.24,4139.14,
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,623.13,,,,,,,fee schedule,355.24,4139.14,
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1098.13,,,,,,,fee schedule,355.24,4139.14,
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,355.24,4139.14,APC
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,355.24,4139.14,APC
Repair detached retina crtx,67101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,355.24,4139.14,APC
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,466.41,,,,,,,fee schedule,305.78,986.44,
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,305.78,986.44,
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,305.78,986.44,
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,305.78,,,,,,,fee schedule,305.78,986.44,
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,381.76,,,,,,,fee schedule,305.78,986.44,
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,305.78,986.44,
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,536.37,,,,,,,fee schedule,305.78,986.44,
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,305.78,986.44,
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,305.78,986.44,APC
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,305.78,986.44,APC
Repair detached retina pc,67105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,305.78,986.44,APC
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4749.97,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Repair detached retina,67107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4749.97,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,7413.41,
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,3132.44,7413.41,APC
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,3132.44,7413.41,APC
Repair detached retina,67108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,3132.44,7413.41,APC
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1355.13,,,,,,,fee schedule,888.42,4139.14,
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1172.48,,,,,,,fee schedule,888.42,4139.14,
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1172.48,,,,,,,fee schedule,888.42,4139.14,
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,888.42,,,,,,,fee schedule,888.42,4139.14,
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1109.17,,,,,,,fee schedule,888.42,4139.14,
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1348.35,,,,,,,fee schedule,888.42,4139.14,
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1558.4,,,,,,,fee schedule,888.42,4139.14,
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1172.48,,,,,,,fee schedule,888.42,4139.14,
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,888.42,4139.14,APC
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,888.42,4139.14,APC
Repair detached retina,67110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,888.42,4139.14,APC
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,3132.44,9543.9,
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,9543.9,
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4130.41,,,,,,,fee schedule,3132.44,9543.9,
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,3132.44,9543.9,
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,3132.44,9543.9,
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4749.97,,,,,,,fee schedule,3132.44,9543.9,
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,3132.44,9543.9,
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4130.41,,,,,,,fee schedule,3132.44,9543.9,
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5567.28,,,,,,,fee schedule,3132.44,9543.9,APC
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5302.17,,,,,,,fee schedule,3132.44,9543.9,APC
Repair retinal detach cplx,67113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9543.9,,,,,,,fee schedule,3132.44,9543.9,APC
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4777.97,,,,,,,fee schedule,2322.45,7413.41,
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3132.44,,,,,,,fee schedule,2322.45,7413.41,
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3910.77,,,,,,,fee schedule,2322.45,7413.41,
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,2322.45,7413.41,
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5494.67,,,,,,,fee schedule,2322.45,7413.41,
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,2322.45,7413.41,
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,2322.45,7413.41,APC
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,2322.45,7413.41,APC
Release encircling material,67115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,2322.45,7413.41,APC
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Remove eye implant material,67120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4758.46,
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4137.79,,,,,,,fee schedule,1750.95,4758.46,
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4137.79,,,,,,,fee schedule,1750.95,4758.46,
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4758.46,
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4758.46,
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4758.46,,,,,,,fee schedule,1750.95,4758.46,
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4758.46,
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4137.79,,,,,,,fee schedule,1750.95,4758.46,
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4758.46,APC
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4758.46,APC
Remove eye implant material,67121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4758.46,APC
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.66,,,,,,,fee schedule,259.85,569.27,
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Treatment of retina,67141,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
Treatment of retina,67145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.66,,,,,,,fee schedule,259.85,569.27,
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Treatment of retinal lesion,67208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
Treatment of retinal lesion,67210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Treatment of retinal lesion,67218,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
Treatment of choroid lesion,67220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,433.08,,,,,,,fee schedule,283.93,986.44,
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,380.45,,,,,,,fee schedule,283.93,986.44,
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,380.45,,,,,,,fee schedule,283.93,986.44,
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.93,,,,,,,fee schedule,283.93,986.44,
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,354.48,,,,,,,fee schedule,283.93,986.44,
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,437.52,,,,,,,fee schedule,283.93,986.44,
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,498.04,,,,,,,fee schedule,283.93,986.44,
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,380.45,,,,,,,fee schedule,283.93,986.44,
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,283.93,986.44,APC
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,283.93,986.44,APC
Ocular Photodynamic Ther,67221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,283.93,986.44,APC
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,384.75,7051.07,
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,384.75,,,,,,,fee schedule,384.75,7051.07,
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,384.75,,,,,,,fee schedule,384.75,7051.07,
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,384.75,7051.07,
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,384.75,7051.07,
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,442.46,,,,,,,fee schedule,384.75,7051.07,
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,384.75,7051.07,
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.75,,,,,,,fee schedule,384.75,7051.07,
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,384.75,7051.07,APC
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,384.75,7051.07,APC
Dstrj extensive retinopathy,67227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,384.75,7051.07,APC
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,484.03,,,,,,,fee schedule,317.33,986.44,
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,421.72,,,,,,,fee schedule,317.33,986.44,
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,421.72,,,,,,,fee schedule,317.33,986.44,
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,317.33,,,,,,,fee schedule,317.33,986.44,
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,396.18,,,,,,,fee schedule,317.33,986.44,
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,484.98,,,,,,,fee schedule,317.33,986.44,
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,556.63,,,,,,,fee schedule,317.33,986.44,
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,421.72,,,,,,,fee schedule,317.33,986.44,
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,317.33,986.44,APC
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,317.33,986.44,APC
Treatment x10sv retinopathy,67228,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,317.33,986.44,APC
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
Tr retinal les preterm inf,67229,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Reinforce eye wall,67250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,7413.41,
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,7413.41,
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.38,,,,,,,fee schedule,1750.95,7413.41,
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,7413.41,
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,7413.41,
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2620.14,,,,,,,fee schedule,1750.95,7413.41,
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,7413.41,
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2278.38,,,,,,,fee schedule,1750.95,7413.41,
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.49,,,,,,,fee schedule,1750.95,7413.41,APC
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4118.56,,,,,,,fee schedule,1750.95,7413.41,APC
Reinforce/graft eye wall,67255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7413.41,,,,,,,fee schedule,1750.95,7413.41,APC
Eye surgery procedure,67299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,2299.52,4139.14,APC
Eye surgery procedure,67299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,2299.52,4139.14,APC
Eye surgery procedure,67299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,2299.52,4139.14,APC
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7370.27,,,,,,,fee schedule,1876.98,8475.81,
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,8475.81,
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1876.98,8475.81,
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4831.95,,,,,,,fee schedule,1876.98,8475.81,
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6032.57,,,,,,,fee schedule,1876.98,8475.81,
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1876.98,8475.81,
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8475.81,,,,,,,fee schedule,1876.98,8475.81,
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,8475.81,
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1876.98,8475.81,APC
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1876.98,8475.81,APC
Revise eye muscle,67311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1876.98,8475.81,APC
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11459.93,,,,,,,fee schedule,2033.63,13178.92,
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,13178.92,
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,13178.92,
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7513.13,,,,,,,fee schedule,2033.63,13178.92,
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9379.95,,,,,,,fee schedule,2033.63,13178.92,
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,13178.92,
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13178.92,,,,,,,fee schedule,2033.63,13178.92,
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,13178.92,
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,13178.92,APC
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,13178.92,APC
Revise two eye muscles,67312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,13178.92,APC
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11459.91,,,,,,,fee schedule,1876.98,13178.9,
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,13178.9,
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1876.98,13178.9,
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7513.12,,,,,,,fee schedule,1876.98,13178.9,
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9379.94,,,,,,,fee schedule,1876.98,13178.9,
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1876.98,13178.9,
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13178.9,,,,,,,fee schedule,1876.98,13178.9,
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,13178.9,
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1876.98,13178.9,APC
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1876.98,13178.9,APC
Revise eye muscle,67314,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1876.98,13178.9,APC
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revise two eye muscles,67316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10144.52,,,,,,,fee schedule,1876.98,11666.2,
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,11666.2,
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1876.98,11666.2,
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6650.75,,,,,,,fee schedule,1876.98,11666.2,
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8303.29,,,,,,,fee schedule,1876.98,11666.2,
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1876.98,11666.2,
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11666.2,,,,,,,fee schedule,1876.98,11666.2,
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,11666.2,
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1876.98,11666.2,APC
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1876.98,11666.2,APC
Revise eye muscle(s),67318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1876.98,11666.2,APC
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Release eye tissue,67343,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,339.99,,,,,,,fee schedule,222.9,569.27,
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.15,,,,,,,fee schedule,222.9,569.27,
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.15,,,,,,,fee schedule,222.9,569.27,
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.9,,,,,,,fee schedule,222.9,569.27,
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,278.28,,,,,,,fee schedule,222.9,569.27,
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.02,,,,,,,fee schedule,222.9,569.27,
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,390.99,,,,,,,fee schedule,222.9,569.27,
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.15,,,,,,,fee schedule,222.9,569.27,
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,222.9,569.27,APC
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,222.9,569.27,APC
Destroy nerve of eye muscle,67345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,222.9,569.27,APC
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Biopsy eye muscle,67346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Unlisted px extraocular musc,67399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,316.26,569.27,APC
Unlisted px extraocular musc,67399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,316.26,569.27,APC
Unlisted px extraocular musc,67399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,316.26,569.27,APC
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/biopsy eye socket,67400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Explore/drain eye socket,67405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9432.83,,,,,,,fee schedule,2033.63,10847.75,
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,10847.75,
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,10847.75,
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6184.16,,,,,,,fee schedule,2033.63,10847.75,
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7720.77,,,,,,,fee schedule,2033.63,10847.75,
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,10847.75,
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10847.75,,,,,,,fee schedule,2033.63,10847.75,
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,10847.75,
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,2033.63,10847.75,APC
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,2033.63,10847.75,APC
Explore/treat eye socket,67412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,2033.63,10847.75,APC
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Explore/treat eye socket,67413,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9786,,,,,,,fee schedule,3535.46,11253.9,
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,3535.46,11253.9,
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,3535.46,11253.9,
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6415.7,,,,,,,fee schedule,3535.46,11253.9,
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8009.84,,,,,,,fee schedule,3535.46,11253.9,
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,3535.46,11253.9,
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11253.9,,,,,,,fee schedule,3535.46,11253.9,
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,3535.46,11253.9,
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,3535.46,11253.9,APC
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,3535.46,11253.9,APC
Explr/decompress eye socket,67414,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,3535.46,11253.9,APC
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4837.76,,,,,,,fee schedule,2033.63,5563.42,
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,5563.42,
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,5563.42,
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3171.64,,,,,,,fee schedule,2033.63,5563.42,
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3959.71,,,,,,,fee schedule,2033.63,5563.42,
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,5563.42,
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5563.42,,,,,,,fee schedule,2033.63,5563.42,
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,5563.42,
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,2033.63,5563.42,APC
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,2033.63,5563.42,APC
Aspiration orbital contents,67415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,2033.63,5563.42,APC
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/treat eye socket,67420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/treat eye socket,67430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/drain eye socket,67440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10033.43,,,,,,,fee schedule,3535.46,11538.44,
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,3535.46,11538.44,
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,3535.46,11538.44,
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6577.92,,,,,,,fee schedule,3535.46,11538.44,
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8212.36,,,,,,,fee schedule,3535.46,11538.44,
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,3535.46,11538.44,
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11538.44,,,,,,,fee schedule,3535.46,11538.44,
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,3535.46,11538.44,
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,3535.46,11538.44,APC
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,3535.46,11538.44,APC
Explr/decompress eye socket,67445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,3535.46,11538.44,APC
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Explore/biopsy eye socket,67450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.36,,,,,,,fee schedule,259.85,569.27,
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.66,,,,,,,fee schedule,259.85,569.27,
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Inject/treat eye socket,67500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.67,,,,,,,fee schedule,73.87,569.27,
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.31,,,,,,,fee schedule,73.87,569.27,
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.31,,,,,,,fee schedule,73.87,569.27,
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.87,,,,,,,fee schedule,73.87,569.27,
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.22,,,,,,,fee schedule,73.87,569.27,
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.36,,,,,,,fee schedule,73.87,569.27,
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.57,,,,,,,fee schedule,73.87,569.27,
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.31,,,,,,,fee schedule,73.87,569.27,
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,73.87,569.27,APC
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,73.87,569.27,APC
Inject/treat eye socket,67505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,73.87,569.27,APC
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.46,,,,,,,fee schedule,80.28,569.27,
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.21,,,,,,,fee schedule,80.28,569.27,
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.21,,,,,,,fee schedule,80.28,569.27,
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.28,,,,,,,fee schedule,80.28,569.27,
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.23,,,,,,,fee schedule,80.28,569.27,
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.29,,,,,,,fee schedule,80.28,569.27,
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,140.83,,,,,,,fee schedule,80.28,569.27,
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.21,,,,,,,fee schedule,80.28,569.27,
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,80.28,569.27,APC
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,80.28,569.27,APC
Inject/treat eye socket,67515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,80.28,569.27,APC
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,583.01,,,,,,,fee schedule,87.13,670.46,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.13,,,,,,,fee schedule,87.13,670.46,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.13,,,,,,,fee schedule,87.13,670.46,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,382.22,,,,,,,fee schedule,87.13,670.46,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,477.19,,,,,,,fee schedule,87.13,670.46,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.2,,,,,,,fee schedule,87.13,670.46,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,670.46,,,,,,,fee schedule,87.13,670.46,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.13,,,,,,,fee schedule,87.13,670.46,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,87.13,670.46,APC
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,87.13,670.46,APC
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,87.13,670.46,APC
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Insert eye socket implant,67550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Revise eye socket implant,67560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Decompress optic nerve,67570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Orbit surgery procedure,67599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,316.26,569.27,APC
Orbit surgery procedure,67599,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,316.26,569.27,APC
Orbit surgery procedure,67599,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,316.26,569.27,APC
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.36,,,,,,,fee schedule,259.85,569.27,
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.66,,,,,,,fee schedule,259.85,569.27,
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Drainage of eyelid abscess,67700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,503.65,,,,,,,fee schedule,330.19,1787.93,
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,444.46,,,,,,,fee schedule,330.19,1787.93,
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,444.46,,,,,,,fee schedule,330.19,1787.93,
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,330.19,,,,,,,fee schedule,330.19,1787.93,
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,412.24,,,,,,,fee schedule,330.19,1787.93,
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,511.13,,,,,,,fee schedule,330.19,1787.93,
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,579.2,,,,,,,fee schedule,330.19,1787.93,
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,444.46,,,,,,,fee schedule,330.19,1787.93,
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,330.19,1787.93,APC
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,330.19,1787.93,APC
Incision of eyelid,67710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,330.19,1787.93,APC
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Incision of eyelid fold,67715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,202.82,,,,,,,fee schedule,132.97,569.27,
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,179.84,,,,,,,fee schedule,132.97,569.27,
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.84,,,,,,,fee schedule,132.97,569.27,
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.97,,,,,,,fee schedule,132.97,569.27,
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.01,,,,,,,fee schedule,132.97,569.27,
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,206.82,,,,,,,fee schedule,132.97,569.27,
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.24,,,,,,,fee schedule,132.97,569.27,
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,179.84,,,,,,,fee schedule,132.97,569.27,
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,132.97,569.27,APC
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,132.97,569.27,APC
Remove eyelid lesion,67800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,132.97,569.27,APC
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5794.76,,,,,,,fee schedule,218.75,6663.97,
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.75,,,,,,,fee schedule,218.75,6663.97,
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.75,,,,,,,fee schedule,218.75,6663.97,
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3799.04,,,,,,,fee schedule,218.75,6663.97,
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4743.01,,,,,,,fee schedule,218.75,6663.97,
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,251.56,,,,,,,fee schedule,218.75,6663.97,
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6663.97,,,,,,,fee schedule,218.75,6663.97,
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,218.75,,,,,,,fee schedule,218.75,6663.97,
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,218.75,6663.97,APC
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,218.75,6663.97,APC
Remove eyelid lesions,67801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,218.75,6663.97,APC
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5794.76,,,,,,,fee schedule,280.99,6663.97,
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,280.99,,,,,,,fee schedule,280.99,6663.97,
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,280.99,,,,,,,fee schedule,280.99,6663.97,
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3799.04,,,,,,,fee schedule,280.99,6663.97,
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4743.01,,,,,,,fee schedule,280.99,6663.97,
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,323.14,,,,,,,fee schedule,280.99,6663.97,
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6663.97,,,,,,,fee schedule,280.99,6663.97,
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,280.99,,,,,,,fee schedule,280.99,6663.97,
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,280.99,6663.97,APC
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,280.99,6663.97,APC
Remove eyelid lesions,67805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,280.99,6663.97,APC
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6249.54,,,,,,,fee schedule,2033.63,7186.97,
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7186.97,
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7186.97,
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4097.2,,,,,,,fee schedule,2033.63,7186.97,
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5115.25,,,,,,,fee schedule,2033.63,7186.97,
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7186.97,
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7186.97,,,,,,,fee schedule,2033.63,7186.97,
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7186.97,
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,2033.63,7186.97,APC
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,2033.63,7186.97,APC
Remove eyelid lesion(s),67808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,2033.63,7186.97,APC
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,346.86,,,,,,,fee schedule,227.4,569.27,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,304.36,,,,,,,fee schedule,227.4,569.27,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,304.36,,,,,,,fee schedule,227.4,569.27,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.4,,,,,,,fee schedule,227.4,569.27,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.9,,,,,,,fee schedule,227.4,569.27,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,350.01,,,,,,,fee schedule,227.4,569.27,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,398.89,,,,,,,fee schedule,227.4,569.27,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,304.36,,,,,,,fee schedule,227.4,569.27,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,227.4,569.27,APC
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,227.4,569.27,APC
Biopsy eyelid & lid margin,67810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,227.4,569.27,APC
Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Revise eyelashes,67820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,205.78,,,,,,,fee schedule,134.91,569.27,
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.43,,,,,,,fee schedule,134.91,569.27,
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.43,,,,,,,fee schedule,134.91,569.27,
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.91,,,,,,,fee schedule,134.91,569.27,
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,168.43,,,,,,,fee schedule,134.91,569.27,
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.79,,,,,,,fee schedule,134.91,569.27,
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,236.65,,,,,,,fee schedule,134.91,569.27,
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.43,,,,,,,fee schedule,134.91,569.27,
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,134.91,569.27,APC
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,134.91,569.27,APC
Revise eyelashes,67825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,134.91,569.27,APC
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1143.41,,,,,,,fee schedule,749.62,1787.93,
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,929.79,,,,,,,fee schedule,749.62,1787.93,
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,929.79,,,,,,,fee schedule,749.62,1787.93,
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,749.62,,,,,,,fee schedule,749.62,1787.93,
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,935.88,,,,,,,fee schedule,749.62,1787.93,
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1069.26,,,,,,,fee schedule,749.62,1787.93,
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1314.92,,,,,,,fee schedule,749.62,1787.93,
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,929.79,,,,,,,fee schedule,749.62,1787.93,
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,749.62,1787.93,APC
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,749.62,1787.93,APC
Revise eyelashes,67830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,749.62,1787.93,APC
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelashes,67835,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,539.91,,,,,,,fee schedule,353.96,1787.93,
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,475.59,,,,,,,fee schedule,353.96,1787.93,
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,475.59,,,,,,,fee schedule,353.96,1787.93,
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,353.96,,,,,,,fee schedule,353.96,1787.93,
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,441.92,,,,,,,fee schedule,353.96,1787.93,
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,546.93,,,,,,,fee schedule,353.96,1787.93,
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,620.9,,,,,,,fee schedule,353.96,1787.93,
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,475.59,,,,,,,fee schedule,353.96,1787.93,
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,353.96,1787.93,APC
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,353.96,1787.93,APC
Remove eyelid lesion,67840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,353.96,1787.93,APC
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,406.66,,,,,,,fee schedule,266.61,1787.93,
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.27,,,,,,,fee schedule,266.61,1787.93,
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,356.27,,,,,,,fee schedule,266.61,1787.93,
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.61,,,,,,,fee schedule,266.61,1787.93,
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.85,,,,,,,fee schedule,266.61,1787.93,
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,409.71,,,,,,,fee schedule,266.61,1787.93,
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,467.66,,,,,,,fee schedule,266.61,1787.93,
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,356.27,,,,,,,fee schedule,266.61,1787.93,
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,266.61,1787.93,APC
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,266.61,1787.93,APC
Treat eyelid lesion,67850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,266.61,1787.93,APC
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1143.41,,,,,,,fee schedule,749.62,1787.93,
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,929.79,,,,,,,fee schedule,749.62,1787.93,
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,929.79,,,,,,,fee schedule,749.62,1787.93,
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,749.62,,,,,,,fee schedule,749.62,1787.93,
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,935.88,,,,,,,fee schedule,749.62,1787.93,
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1069.26,,,,,,,fee schedule,749.62,1787.93,
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1314.92,,,,,,,fee schedule,749.62,1787.93,
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,929.79,,,,,,,fee schedule,749.62,1787.93,
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,749.62,1787.93,APC
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,749.62,1787.93,APC
Closure of eyelid by suture,67875,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,749.62,1787.93,APC
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67882,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.66,,,,,,,fee schedule,2033.63,9651.56,
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,9651.56,
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,9651.56,
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.23,,,,,,,fee schedule,2033.63,9651.56,
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.39,,,,,,,fee schedule,2033.63,9651.56,
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,9651.56,
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.56,,,,,,,fee schedule,2033.63,9651.56,
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,9651.56,
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,2033.63,9651.56,APC
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,2033.63,9651.56,APC
Repair brow defect,67900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,2033.63,9651.56,APC
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3038.72,,,,,,,fee schedule,2336.4,7051.07,
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3038.72,,,,,,,fee schedule,2336.4,7051.07,
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3494.53,,,,,,,fee schedule,2336.4,7051.07,
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3038.72,,,,,,,fee schedule,2336.4,7051.07,
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Repair eyelid defect,67902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67904,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Repair eyelid defect,67906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67908,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid defect,67909,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid defect,67911,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Correction eyelid w/implant,67912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67914,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,593.79,,,,,,,fee schedule,389.29,4264.08,
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,523.12,,,,,,,fee schedule,389.29,4264.08,
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,523.12,,,,,,,fee schedule,389.29,4264.08,
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,389.29,,,,,,,fee schedule,389.29,4264.08,
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,486.02,,,,,,,fee schedule,389.29,4264.08,
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,601.59,,,,,,,fee schedule,389.29,4264.08,
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,682.86,,,,,,,fee schedule,389.29,4264.08,
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.12,,,,,,,fee schedule,389.29,4264.08,
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,389.29,4264.08,APC
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,389.29,4264.08,APC
Repair eyelid defect,67915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,389.29,4264.08,APC
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67916,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67917,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,586.92,,,,,,,fee schedule,384.78,4264.08,
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,516.21,,,,,,,fee schedule,384.78,4264.08,
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,516.21,,,,,,,fee schedule,384.78,4264.08,
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,384.78,,,,,,,fee schedule,384.78,4264.08,
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,480.39,,,,,,,fee schedule,384.78,4264.08,
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,593.64,,,,,,,fee schedule,384.78,4264.08,
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,674.96,,,,,,,fee schedule,384.78,4264.08,
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,516.21,,,,,,,fee schedule,384.78,4264.08,
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,384.78,4264.08,APC
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,384.78,4264.08,APC
Repair eyelid defect,67922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,384.78,4264.08,APC
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67923,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid defect,67924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,623.16,,,,,,,fee schedule,408.54,4264.08,
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,548.18,,,,,,,fee schedule,408.54,4264.08,
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,548.18,,,,,,,fee schedule,408.54,4264.08,
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,408.54,,,,,,,fee schedule,408.54,4264.08,
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,510.06,,,,,,,fee schedule,408.54,4264.08,
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,630.41,,,,,,,fee schedule,408.54,4264.08,
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,716.63,,,,,,,fee schedule,408.54,4264.08,
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,548.18,,,,,,,fee schedule,408.54,4264.08,
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,408.54,4264.08,APC
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,408.54,4264.08,APC
Repair eyelid wound,67930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,408.54,4264.08,APC
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair eyelid wound,67935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.36,,,,,,,fee schedule,259.85,569.27,
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.66,,,,,,,fee schedule,259.85,569.27,
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Remove eyelid foreign body,67938,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67961,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67966,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67973,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Reconstruction of eyelid,67974,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Reconstruction of eyelid,67975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revision of eyelid,67999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,316.26,569.27,APC
Revision of eyelid,67999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,316.26,569.27,APC
Revision of eyelid,67999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,316.26,569.27,APC
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.25,,,,,,,fee schedule,119.48,1787.93,
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.8,,,,,,,fee schedule,119.48,1787.93,
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,160.8,,,,,,,fee schedule,119.48,1787.93,
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.48,,,,,,,fee schedule,119.48,1787.93,
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.17,,,,,,,fee schedule,119.48,1787.93,
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.92,,,,,,,fee schedule,119.48,1787.93,
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.59,,,,,,,fee schedule,119.48,1787.93,
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.8,,,,,,,fee schedule,119.48,1787.93,
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,119.48,1787.93,APC
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,119.48,1787.93,APC
Incise/drain eyelid lining,68020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,119.48,1787.93,APC
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.29,,,,,,,fee schedule,54.6,569.27,
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.35,,,,,,,fee schedule,54.6,569.27,
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.35,,,,,,,fee schedule,54.6,569.27,
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.6,,,,,,,fee schedule,54.6,569.27,
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.17,,,,,,,fee schedule,54.6,569.27,
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.5,,,,,,,fee schedule,54.6,569.27,
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.78,,,,,,,fee schedule,54.6,569.27,
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.35,,,,,,,fee schedule,54.6,569.27,
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,54.6,569.27,APC
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,54.6,569.27,APC
Treatment of eyelid lesions,68040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,54.6,569.27,APC
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,327.26,,,,,,,fee schedule,214.55,4264.08,
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,287.93,,,,,,,fee schedule,214.55,4264.08,
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,287.93,,,,,,,fee schedule,214.55,4264.08,
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.55,,,,,,,fee schedule,214.55,4264.08,
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,267.86,,,,,,,fee schedule,214.55,4264.08,
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,331.12,,,,,,,fee schedule,214.55,4264.08,
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,376.35,,,,,,,fee schedule,214.55,4264.08,
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,287.93,,,,,,,fee schedule,214.55,4264.08,
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,214.55,4264.08,APC
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,214.55,4264.08,APC
Biopsy of eyelid lining,68100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,214.55,4264.08,APC
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,432.12,,,,,,,fee schedule,283.3,4264.08,
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,379.59,,,,,,,fee schedule,283.3,4264.08,
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,379.59,,,,,,,fee schedule,283.3,4264.08,
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.3,,,,,,,fee schedule,283.3,4264.08,
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.69,,,,,,,fee schedule,283.3,4264.08,
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,436.53,,,,,,,fee schedule,283.3,4264.08,
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.94,,,,,,,fee schedule,283.3,4264.08,
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,379.59,,,,,,,fee schedule,283.3,4264.08,
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,283.3,4264.08,APC
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,283.3,4264.08,APC
Remove eyelid lining lesion,68110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,283.3,4264.08,APC
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid lining lesion,68115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid lining lesion,68130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,235.15,,,,,,,fee schedule,154.16,4264.08,
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.51,,,,,,,fee schedule,154.16,4264.08,
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,207.51,,,,,,,fee schedule,154.16,4264.08,
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.16,,,,,,,fee schedule,154.16,4264.08,
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,192.47,,,,,,,fee schedule,154.16,4264.08,
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,238.64,,,,,,,fee schedule,154.16,4264.08,
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,270.42,,,,,,,fee schedule,154.16,4264.08,
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,207.51,,,,,,,fee schedule,154.16,4264.08,
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,154.16,4264.08,APC
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,154.16,4264.08,APC
Remove eyelid lining lesion,68135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,154.16,4264.08,APC
Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Treat eyelid by injection,68200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revise/graft eyelid lining,68320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Revise/graft eyelid lining,68325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Revise/graft eyelid lining,68326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revise/graft eyelid lining,68328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2670.76,,,,,,,fee schedule,1750.95,4139.14,
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1750.95,,,,,,,fee schedule,1750.95,4139.14,
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.02,,,,,,,fee schedule,1750.95,4139.14,
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2670.82,,,,,,,fee schedule,1750.95,4139.14,
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.37,,,,,,,fee schedule,1750.95,4139.14,
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2322.45,,,,,,,fee schedule,1750.95,4139.14,
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2414.5,,,,,,,fee schedule,1750.95,4139.14,APC
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2299.52,,,,,,,fee schedule,1750.95,4139.14,APC
Revise eyelid lining,68330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4139.14,,,,,,,fee schedule,1750.95,4139.14,APC
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Revise/graft eyelid lining,68335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Separate eyelid adhesions,68340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Revise eyelid lining,68360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Revise eyelid lining,68362,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Harvest eye tissue alograft,68371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Eyelid lining surgery,68399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,316.26,569.27,APC
Eyelid lining surgery,68399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,316.26,569.27,APC
Eyelid lining surgery,68399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,316.26,569.27,APC
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,600.66,,,,,,,fee schedule,393.79,1787.93,
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,531.75,,,,,,,fee schedule,393.79,1787.93,
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.75,,,,,,,fee schedule,393.79,1787.93,
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,393.79,,,,,,,fee schedule,393.79,1787.93,
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,491.64,,,,,,,fee schedule,393.79,1787.93,
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,611.51,,,,,,,fee schedule,393.79,1787.93,
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,690.76,,,,,,,fee schedule,393.79,1787.93,
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,531.75,,,,,,,fee schedule,393.79,1787.93,
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1042.96,,,,,,,fee schedule,393.79,1787.93,APC
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,993.29,,,,,,,fee schedule,393.79,1787.93,APC
Incise/drain tear gland,68400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1787.93,,,,,,,fee schedule,393.79,1787.93,APC
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,637.9,,,,,,,fee schedule,418.21,4264.08,
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,562.06,,,,,,,fee schedule,418.21,4264.08,
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,562.06,,,,,,,fee schedule,418.21,4264.08,
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,418.21,,,,,,,fee schedule,418.21,4264.08,
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,522.12,,,,,,,fee schedule,418.21,4264.08,
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,646.37,,,,,,,fee schedule,418.21,4264.08,
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,733.59,,,,,,,fee schedule,418.21,4264.08,
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,562.06,,,,,,,fee schedule,418.21,4264.08,
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,418.21,4264.08,APC
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,418.21,4264.08,APC
Incise/drain tear sac,68420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,418.21,4264.08,APC
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.35,,,,,,,fee schedule,116.93,569.27,
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.21,,,,,,,fee schedule,116.93,569.27,
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.21,,,,,,,fee schedule,116.93,569.27,
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.93,,,,,,,fee schedule,116.93,569.27,
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.98,,,,,,,fee schedule,116.93,569.27,
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,181.94,,,,,,,fee schedule,116.93,569.27,
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.1,,,,,,,fee schedule,116.93,569.27,
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.21,,,,,,,fee schedule,116.93,569.27,
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,116.93,569.27,APC
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,116.93,569.27,APC
Incise tear duct opening,68440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,116.93,569.27,APC
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of tear gland,68500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Partial removal tear gland,68505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Biopsy of tear gland,68510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Removal of tear sac,68520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Biopsy of tear sac,68525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.36,,,,,,,fee schedule,259.85,569.27,
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.66,,,,,,,fee schedule,259.85,569.27,
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Clearance of tear duct,68530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,1418.23,4264.08,
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,1418.23,4264.08,
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Remove tear gland lesion,68540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Remove tear gland lesion,68550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,1418.23,4264.08,
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,1418.23,4264.08,
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,1418.23,4264.08,
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1418.23,4264.08,
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,1418.23,4264.08,
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1418.23,4264.08,
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1418.23,4264.08,APC
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1418.23,4264.08,APC
Repair tear ducts,68700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1418.23,4264.08,APC
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,379.59,,,,,,,fee schedule,259.85,569.27,
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,379.59,,,,,,,fee schedule,259.85,569.27,
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,436.53,,,,,,,fee schedule,259.85,569.27,
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,379.59,,,,,,,fee schedule,259.85,569.27,
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Revise tear duct opening,68705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3038.72,,,,,,,fee schedule,2336.4,7051.07,
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3038.72,,,,,,,fee schedule,2336.4,7051.07,
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3494.53,,,,,,,fee schedule,2336.4,7051.07,
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3038.72,,,,,,,fee schedule,2336.4,7051.07,
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Create tear sac drain,68720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2336.4,7051.07,
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2336.4,7051.07,
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2336.4,7051.07,
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4065.78,,,,,,,fee schedule,2336.4,7051.07,
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2336.4,7051.07,
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3535.46,,,,,,,fee schedule,2336.4,7051.07,
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2336.4,7051.07,APC
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2336.4,7051.07,APC
Create tear duct drain,68745,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2336.4,7051.07,APC
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3563.76,,,,,,,fee schedule,2033.63,7051.07,
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2336.4,,,,,,,fee schedule,2033.63,7051.07,
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.94,,,,,,,fee schedule,2033.63,7051.07,
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7051.07,
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4098.32,,,,,,,fee schedule,2033.63,7051.07,
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7051.07,
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4113.12,,,,,,,fee schedule,2033.63,7051.07,APC
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3917.26,,,,,,,fee schedule,2033.63,7051.07,APC
Create tear duct drain,68750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7051.07,,,,,,,fee schedule,2033.63,7051.07,APC
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,369.38,,,,,,,fee schedule,242.17,569.27,
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,325.13,,,,,,,fee schedule,242.17,569.27,
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.13,,,,,,,fee schedule,242.17,569.27,
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,242.17,,,,,,,fee schedule,242.17,569.27,
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,302.34,,,,,,,fee schedule,242.17,569.27,
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,373.9,,,,,,,fee schedule,242.17,569.27,
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,424.79,,,,,,,fee schedule,242.17,569.27,
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.13,,,,,,,fee schedule,242.17,569.27,
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,242.17,569.27,APC
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,242.17,569.27,APC
Close tear duct opening,68760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,242.17,569.27,APC
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.61,,,,,,,fee schedule,171.51,569.27,
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,230.85,,,,,,,fee schedule,171.51,569.27,
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,230.85,,,,,,,fee schedule,171.51,569.27,
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.51,,,,,,,fee schedule,171.51,569.27,
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.13,,,,,,,fee schedule,171.51,569.27,
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.48,,,,,,,fee schedule,171.51,569.27,
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.85,,,,,,,fee schedule,171.51,569.27,
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,230.85,,,,,,,fee schedule,171.51,569.27,
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,171.51,569.27,APC
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,171.51,569.27,APC
Close tear duct opening,68761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,171.51,569.27,APC
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2163.25,,,,,,,fee schedule,929.79,4264.08,
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,929.79,,,,,,,fee schedule,929.79,4264.08,
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,929.79,,,,,,,fee schedule,929.79,4264.08,
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1418.23,,,,,,,fee schedule,929.79,4264.08,
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1770.62,,,,,,,fee schedule,929.79,4264.08,
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1069.26,,,,,,,fee schedule,929.79,4264.08,
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2487.74,,,,,,,fee schedule,929.79,4264.08,
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,929.79,,,,,,,fee schedule,929.79,4264.08,
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,929.79,4264.08,APC
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,929.79,4264.08,APC
Close tear system fistula,68770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,929.79,4264.08,APC
Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Dilate tear duct opening,68801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.35,,,,,,,fee schedule,259.85,569.27,
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.36,,,,,,,fee schedule,259.85,569.27,
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.85,,,,,,,fee schedule,259.85,569.27,
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.41,,,,,,,fee schedule,259.85,569.27,
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.66,,,,,,,fee schedule,259.85,569.27,
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.8,,,,,,,fee schedule,259.85,569.27,
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.36,,,,,,,fee schedule,259.85,569.27,
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,259.85,569.27,APC
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,259.85,569.27,APC
Probe nasolacrimal duct,68810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,259.85,569.27,APC
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6485.47,,,,,,,fee schedule,1876.98,7458.29,
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,7458.29,
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1876.98,7458.29,
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4251.87,,,,,,,fee schedule,1876.98,7458.29,
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5308.36,,,,,,,fee schedule,1876.98,7458.29,
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1876.98,7458.29,
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7458.29,,,,,,,fee schedule,1876.98,7458.29,
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,7458.29,
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1876.98,7458.29,APC
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1876.98,7458.29,APC
Probe nasolacrimal duct,68811,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1876.98,7458.29,APC
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9415.1,,,,,,,fee schedule,1876.98,10827.37,
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,10827.37,
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1876.98,,,,,,,fee schedule,1876.98,10827.37,
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6172.54,,,,,,,fee schedule,1876.98,10827.37,
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7706.26,,,,,,,fee schedule,1876.98,10827.37,
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2158.53,,,,,,,fee schedule,1876.98,10827.37,
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10827.37,,,,,,,fee schedule,1876.98,10827.37,
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1876.98,,,,,,,fee schedule,1876.98,10827.37,
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,1876.98,10827.37,APC
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,1876.98,10827.37,APC
Probe nasolacrimal duct,68815,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,1876.98,10827.37,APC
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6603.45,,,,,,,fee schedule,2033.63,7593.97,
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7593.97,
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2033.63,,,,,,,fee schedule,2033.63,7593.97,
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4329.22,,,,,,,fee schedule,2033.63,7593.97,
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5404.92,,,,,,,fee schedule,2033.63,7593.97,
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2338.67,,,,,,,fee schedule,2033.63,7593.97,
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7593.97,,,,,,,fee schedule,2033.63,7593.97,
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2033.63,,,,,,,fee schedule,2033.63,7593.97,
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,2033.63,7593.97,APC
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,2033.63,7593.97,APC
Probe nl duct w/balloon,68816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,2033.63,7593.97,APC
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.5,,,,,,,fee schedule,142.59,569.27,
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.94,,,,,,,fee schedule,142.59,569.27,
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.94,,,,,,,fee schedule,142.59,569.27,
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.59,,,,,,,fee schedule,142.59,569.27,
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.02,,,,,,,fee schedule,142.59,569.27,
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.73,,,,,,,fee schedule,142.59,569.27,
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.13,,,,,,,fee schedule,142.59,569.27,
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.94,,,,,,,fee schedule,142.59,569.27,
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,142.59,569.27,APC
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,142.59,569.27,APC
Explore/irrigate tear ducts,68840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,142.59,569.27,APC
Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,632.61,,,,,,,fee schedule,414.74,4264.08,
Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,414.74,,,,,,,fee schedule,414.74,4264.08,
Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,517.79,,,,,,,fee schedule,414.74,4264.08,
Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,727.5,,,,,,,fee schedule,414.74,4264.08,
Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,414.74,4264.08,APC
Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,414.74,4264.08,APC
Insj rx elut implt lac canal,68841,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,414.74,4264.08,APC
Injection for tear sac x-ray,68850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.21,,,,,,,fee schedule,56.52,99.14,
Injection for tear sac x-ray,68850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.52,,,,,,,fee schedule,56.52,99.14,
Injection for tear sac x-ray,68850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.56,,,,,,,fee schedule,56.52,99.14,
Injection for tear sac x-ray,68850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.14,,,,,,,fee schedule,56.52,99.14,
Tear duct system surgery,68899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.08,,,,,,,fee schedule,316.26,569.27,APC
Tear duct system surgery,68899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.26,,,,,,,fee schedule,316.26,569.27,APC
Tear duct system surgery,68899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,569.27,,,,,,,fee schedule,316.26,569.27,APC
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,355.68,,,,,,,fee schedule,214.62,1270.05,
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,214.62,1270.05,
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.18,,,,,,,fee schedule,214.62,1270.05,
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.12,,,,,,,fee schedule,214.62,1270.05,
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,214.62,1270.05,
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,409.03,,,,,,,fee schedule,214.62,1270.05,
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,214.62,1270.05,APC
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,214.62,1270.05,APC
Drain external ear lesion,69000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,214.62,1270.05,APC
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,355.68,,,,,,,fee schedule,233.18,2962.18,
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,315.61,,,,,,,fee schedule,233.18,2962.18,
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.61,,,,,,,fee schedule,233.18,2962.18,
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.18,,,,,,,fee schedule,233.18,2962.18,
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.12,,,,,,,fee schedule,233.18,2962.18,
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,362.95,,,,,,,fee schedule,233.18,2962.18,
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,409.03,,,,,,,fee schedule,233.18,2962.18,
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.61,,,,,,,fee schedule,233.18,2962.18,
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,233.18,2962.18,APC
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,233.18,2962.18,APC
Drain external ear lesion,69005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,233.18,2962.18,APC
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,473.26,,,,,,,fee schedule,214.62,1270.05,
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.62,,,,,,,fee schedule,214.62,1270.05,
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.27,,,,,,,fee schedule,214.62,1270.05,
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,387.36,,,,,,,fee schedule,214.62,1270.05,
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.81,,,,,,,fee schedule,214.62,1270.05,
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,544.25,,,,,,,fee schedule,214.62,1270.05,
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.62,,,,,,,fee schedule,214.62,1270.05,
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,214.62,1270.05,APC
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,214.62,1270.05,APC
Drain outer ear canal lesion,69020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,214.62,1270.05,APC
Pierce earlobes,69090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.26,,,,,,,fee schedule,23.12,40.55,
Pierce earlobes,69090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.12,,,,,,,fee schedule,23.12,40.55,
Pierce earlobes,69090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.86,,,,,,,fee schedule,23.12,40.55,
Pierce earlobes,69090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.55,,,,,,,fee schedule,23.12,40.55,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,424.8,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.72,,,,,,,fee schedule,124.61,424.8,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.72,,,,,,,fee schedule,124.61,424.8,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,424.8,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,424.8,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,192.88,,,,,,,fee schedule,124.61,424.8,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,424.8,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,167.72,,,,,,,fee schedule,124.61,424.8,
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,124.61,424.8,APC
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,124.61,424.8,APC
Biopsy of external ear,69100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,124.61,424.8,APC
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,293.95,,,,,,,fee schedule,192.71,2782.81,
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.84,,,,,,,fee schedule,192.71,2782.81,
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.84,,,,,,,fee schedule,192.71,2782.81,
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.71,,,,,,,fee schedule,192.71,2782.81,
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,240.6,,,,,,,fee schedule,192.71,2782.81,
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,302.27,,,,,,,fee schedule,192.71,2782.81,
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,338.04,,,,,,,fee schedule,192.71,2782.81,
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,262.84,,,,,,,fee schedule,192.71,2782.81,
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,192.71,2782.81,APC
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,192.71,2782.81,APC
Biopsy of external ear canal,69105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,192.71,2782.81,APC
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Remove external ear partial,69110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Removal of external ear,69120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear canal lesion(s),69140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2817.68,,,,,,,fee schedule,1777.52,5209.69,
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1847.27,,,,,,,fee schedule,1777.52,5209.69,
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2306.27,,,,,,,fee schedule,1777.52,5209.69,
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.15,,,,,,,fee schedule,1777.52,5209.69,
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3240.33,,,,,,,fee schedule,1777.52,5209.69,
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.52,,,,,,,fee schedule,1777.52,5209.69,
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3038.98,,,,,,,fee schedule,1777.52,5209.69,APC
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2894.27,,,,,,,fee schedule,1777.52,5209.69,APC
Remove ear canal lesion(s),69145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5209.69,,,,,,,fee schedule,1777.52,5209.69,APC
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,2578.99,10617.38,
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,2578.99,10617.38,
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,2578.99,10617.38,
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,10617.38,
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,2578.99,10617.38,
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,10617.38,
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,2578.99,10617.38,APC
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,2578.99,10617.38,APC
Extensive ear canal surgery,69150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,2578.99,10617.38,APC
Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Clear outer ear canal,69200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,1275.58,4572.08,
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,4572.08,
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1275.58,,,,,,,fee schedule,1275.58,4572.08,
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,1275.58,4572.08,
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,1275.58,4572.08,
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1466.92,,,,,,,fee schedule,1275.58,4572.08,
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,1275.58,4572.08,
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1275.58,,,,,,,fee schedule,1275.58,4572.08,
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1727.94,,,,,,,fee schedule,1275.58,4572.08,APC
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1645.66,,,,,,,fee schedule,1275.58,4572.08,APC
Clear outer ear canal,69205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2962.18,,,,,,,fee schedule,1275.58,4572.08,APC
Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.9,,,,,,,fee schedule,58.78,198.84,
Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.35,,,,,,,fee schedule,58.78,198.84,
Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.52,,,,,,,fee schedule,58.78,198.84,
Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.84,,,,,,,fee schedule,58.78,198.84,
Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,198.84,APC
Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,198.84,APC
Remove impacted ear wax uni,69209,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,198.84,APC
Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Remove impacted ear wax uni,69210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Clean out mastoid cavity,69220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,446.8,,,,,,,fee schedule,292.92,967.3,
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.75,,,,,,,fee schedule,292.92,967.3,
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,397.75,,,,,,,fee schedule,292.92,967.3,
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,292.92,,,,,,,fee schedule,292.92,967.3,
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,365.71,,,,,,,fee schedule,292.92,967.3,
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,457.41,,,,,,,fee schedule,292.92,967.3,
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,513.82,,,,,,,fee schedule,292.92,967.3,
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,397.75,,,,,,,fee schedule,292.92,967.3,
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,292.92,967.3,APC
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,292.92,967.3,APC
Clean out mastoid cavity,69222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,292.92,967.3,APC
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10437.51,,,,,,,fee schedule,2578.99,12003.14,
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,12003.14,
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,2578.99,12003.14,
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6842.83,,,,,,,fee schedule,2578.99,12003.14,
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8543.1,,,,,,,fee schedule,2578.99,12003.14,
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,2578.99,12003.14,
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12003.14,,,,,,,fee schedule,2578.99,12003.14,
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,2578.99,12003.14,
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2578.99,12003.14,APC
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2578.99,12003.14,APC
Revise external ear,69300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2578.99,12003.14,APC
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14527.14,,,,,,,fee schedule,4942.79,16706.21,
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,16706.21,
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,16706.21,
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9523.99,,,,,,,fee schedule,4942.79,16706.21,
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11890.46,,,,,,,fee schedule,4942.79,16706.21,
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,16706.21,
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16706.21,,,,,,,fee schedule,4942.79,16706.21,
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,16706.21,
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,16706.21,APC
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,16706.21,APC
Rebuild outer ear canal,69310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,16706.21,APC
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Rebuild outer ear canal,69320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Outer ear surgery procedure,69399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Outer ear surgery procedure,69399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Outer ear surgery procedure,69399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.41,,,,,,,fee schedule,171.38,424.8,
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,335.48,,,,,,,fee schedule,171.38,424.8,
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,335.48,,,,,,,fee schedule,171.38,424.8,
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.38,,,,,,,fee schedule,171.38,424.8,
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.96,,,,,,,fee schedule,171.38,424.8,
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,385.8,,,,,,,fee schedule,171.38,424.8,
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.62,,,,,,,fee schedule,171.38,424.8,
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,335.48,,,,,,,fee schedule,171.38,424.8,
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,171.38,424.8,APC
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,171.38,424.8,APC
Incision of eardrum,69420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,171.38,424.8,APC
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3867.15,,,,,,,fee schedule,1678.74,5946.37,
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2535.3,,,,,,,fee schedule,1678.74,5946.37,
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3165.26,,,,,,,fee schedule,1678.74,5946.37,
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.55,,,,,,,fee schedule,1678.74,5946.37,
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4447.22,,,,,,,fee schedule,1678.74,5946.37,
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.74,,,,,,,fee schedule,1678.74,5946.37,
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1678.74,5946.37,APC
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1678.74,5946.37,APC
Incision of eardrum,69421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1678.74,5946.37,APC
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,223.45,5946.37,
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,223.45,,,,,,,fee schedule,223.45,5946.37,
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.45,,,,,,,fee schedule,223.45,5946.37,
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,223.45,5946.37,
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,223.45,5946.37,
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,256.97,,,,,,,fee schedule,223.45,5946.37,
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,223.45,5946.37,
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,223.45,,,,,,,fee schedule,223.45,5946.37,
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,223.45,5946.37,APC
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,223.45,5946.37,APC
Remove ventilating tube,69424,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,223.45,5946.37,APC
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,386.07,,,,,,,fee schedule,253.11,967.3,
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,344.12,,,,,,,fee schedule,253.11,967.3,
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,344.12,,,,,,,fee schedule,253.11,967.3,
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,253.11,,,,,,,fee schedule,253.11,967.3,
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,316,,,,,,,fee schedule,253.11,967.3,
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,395.74,,,,,,,fee schedule,253.11,967.3,
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,443.98,,,,,,,fee schedule,253.11,967.3,
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,344.12,,,,,,,fee schedule,253.11,967.3,
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,253.11,967.3,APC
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,253.11,967.3,APC
Create eardrum opening,69433,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,253.11,967.3,APC
Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1959.21,,,,,,,fee schedule,1546,2782.81,
Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1959.21,,,,,,,fee schedule,1546,2782.81,
Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2253.09,,,,,,,fee schedule,1546,2782.81,
Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1959.21,,,,,,,fee schedule,1546,2782.81,
Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1546,2782.81,APC
Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1546,2782.81,APC
Create eardrum opening,69436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1546,2782.81,APC
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Exploration of middle ear,69440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Eardrum revision,69450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoidectomy,69501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoidectomy,69502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove mastoid structures,69505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Extensive mastoid surgery,69511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Extensive mastoid surgery,69530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,439.95,,,,,,,fee schedule,288.43,2782.81,
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,390.83,,,,,,,fee schedule,288.43,2782.81,
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,390.83,,,,,,,fee schedule,288.43,2782.81,
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,288.43,,,,,,,fee schedule,288.43,2782.81,
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,360.1,,,,,,,fee schedule,288.43,2782.81,
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.45,,,,,,,fee schedule,288.43,2782.81,
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,505.94,,,,,,,fee schedule,288.43,2782.81,
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,390.83,,,,,,,fee schedule,288.43,2782.81,
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,288.43,2782.81,APC
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,288.43,2782.81,APC
Remove ear lesion,69540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,288.43,2782.81,APC
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear lesion,69550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove ear lesion,69552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Mastoid surgery revision,69604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4425.65,,,,,,,fee schedule,480.53,5089.5,
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,480.53,,,,,,,fee schedule,480.53,5089.5,
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,480.53,,,,,,,fee schedule,480.53,5089.5,
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2901.46,,,,,,,fee schedule,480.53,5089.5,
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3622.39,,,,,,,fee schedule,480.53,5089.5,
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.61,,,,,,,fee schedule,480.53,5089.5,
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5089.5,,,,,,,fee schedule,480.53,5089.5,
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.53,,,,,,,fee schedule,480.53,5089.5,
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,480.53,5089.5,APC
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,480.53,5089.5,APC
Repair of eardrum,69610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,480.53,5089.5,APC
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7436.45,,,,,,,fee schedule,2258.7,8551.92,
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,8551.92,
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2258.7,,,,,,,fee schedule,2258.7,8551.92,
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4875.34,,,,,,,fee schedule,2258.7,8551.92,
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6086.73,,,,,,,fee schedule,2258.7,8551.92,
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2597.51,,,,,,,fee schedule,2258.7,8551.92,
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8551.92,,,,,,,fee schedule,2258.7,8551.92,
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2258.7,,,,,,,fee schedule,2258.7,8551.92,
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2258.7,8551.92,APC
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2258.7,8551.92,APC
Repair of eardrum,69620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2258.7,8551.92,APC
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11127.88,,,,,,,fee schedule,4942.79,12797.06,
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,12797.06,
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,12797.06,
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7295.44,,,,,,,fee schedule,4942.79,12797.06,
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9108.17,,,,,,,fee schedule,4942.79,12797.06,
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,12797.06,
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12797.06,,,,,,,fee schedule,4942.79,12797.06,
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,12797.06,
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,12797.06,APC
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,12797.06,APC
Repair eardrum structures,69631,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,12797.06,APC
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10587.88,,,,,,,fee schedule,4942.79,12176.06,
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,12176.06,
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,12176.06,
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6941.41,,,,,,,fee schedule,4942.79,12176.06,
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8666.18,,,,,,,fee schedule,4942.79,12176.06,
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,12176.06,
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12176.06,,,,,,,fee schedule,4942.79,12176.06,
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,12176.06,
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,12176.06,APC
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,12176.06,APC
Rebuild eardrum structures,69632,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,12176.06,APC
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8239.79,,,,,,,fee schedule,4942.79,10617.38,
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5402.01,,,,,,,fee schedule,4942.79,10617.38,
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6744.27,,,,,,,fee schedule,4942.79,10617.38,
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9475.76,,,,,,,fee schedule,4942.79,10617.38,
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Rebuild eardrum structures,69633,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair eardrum structures,69635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Rebuild eardrum structures,69636,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21032.98,,,,,,,fee schedule,4942.79,24187.93,
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,24187.93,
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,24187.93,
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13789.22,,,,,,,fee schedule,4942.79,24187.93,
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17215.49,,,,,,,fee schedule,4942.79,24187.93,
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,24187.93,
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24187.93,,,,,,,fee schedule,4942.79,24187.93,
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,24187.93,
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,24187.93,APC
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,24187.93,APC
Rebuild eardrum structures,69637,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,24187.93,APC
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16579.68,,,,,,,fee schedule,4942.79,19066.63,
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,19066.63,
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,19066.63,
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10869.64,,,,,,,fee schedule,4942.79,19066.63,
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13570.47,,,,,,,fee schedule,4942.79,19066.63,
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,19066.63,
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19066.63,,,,,,,fee schedule,4942.79,19066.63,
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,19066.63,
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,19066.63,APC
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,19066.63,APC
Revise middle ear & mastoid,69641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,19066.63,APC
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear & mastoid,69642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear & mastoid,69643,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14503.05,,,,,,,fee schedule,4942.79,16678.51,
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,16678.51,
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,16678.51,
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9508.2,,,,,,,fee schedule,4942.79,16678.51,
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11870.75,,,,,,,fee schedule,4942.79,16678.51,
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,16678.51,
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16678.51,,,,,,,fee schedule,4942.79,16678.51,
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,16678.51,
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,16678.51,APC
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,16678.51,APC
Revise middle ear & mastoid,69644,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,16678.51,APC
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18366.55,,,,,,,fee schedule,4942.79,21121.53,
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,21121.53,
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,21121.53,
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12041.11,,,,,,,fee schedule,4942.79,21121.53,
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15033.02,,,,,,,fee schedule,4942.79,21121.53,
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,21121.53,
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21121.53,,,,,,,fee schedule,4942.79,21121.53,
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,21121.53,
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,21121.53,APC
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,21121.53,APC
Revise middle ear & mastoid,69645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,21121.53,APC
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear & mastoid,69646,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Release middle ear bone,69650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7064.46,,,,,,,fee schedule,4631.46,10617.38,
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4631.46,10617.38,
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4631.46,10617.38,
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4631.46,,,,,,,fee schedule,4631.46,10617.38,
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5782.26,,,,,,,fee schedule,4631.46,10617.38,
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4631.46,10617.38,
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8124.13,,,,,,,fee schedule,4631.46,10617.38,
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4631.46,10617.38,
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4631.46,10617.38,APC
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4631.46,10617.38,APC
Revise middle ear bone,69660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4631.46,10617.38,APC
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10033.43,,,,,,,fee schedule,4942.79,11538.44,
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,11538.44,
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,11538.44,
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6577.92,,,,,,,fee schedule,4942.79,11538.44,
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8212.36,,,,,,,fee schedule,4942.79,11538.44,
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,11538.44,
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11538.44,,,,,,,fee schedule,4942.79,11538.44,
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,11538.44,
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,11538.44,APC
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,11538.44,APC
Revise middle ear bone,69661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,11538.44,APC
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Revise middle ear bone,69662,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Repair middle ear structures,69666,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Repair middle ear structures,69667,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove mastoid air cells,69670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1684.24,5946.37,
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1684.24,5946.37,
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Remove middle ear nerve,69676,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2965.84,
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2965.84,
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2965.84,
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2965.84,,,,,,,fee schedule,1005.11,2965.84,
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2965.84,
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2578.99,,,,,,,fee schedule,1005.11,2965.84,
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2965.84,APC
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2965.84,APC
Close mastoid fistula,69700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2965.84,APC
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9880.72,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.82,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.82,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6477.8,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8087.37,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.64,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11362.83,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,118.82,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,118.82,11362.83,APC
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,118.82,11362.83,APC
Nps surg dilat eust tube uni,69705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,118.82,11362.83,APC
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9880.72,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.82,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.82,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6477.8,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8087.37,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.64,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11362.83,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,118.82,,,,,,,fee schedule,118.82,11362.83,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,118.82,11362.83,APC
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,118.82,11362.83,APC
Nps surg dilat eust tube bi,69706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,118.82,11362.83,APC
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Remove/repair hearing aid,69711,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13744.62,,,,,,,fee schedule,9010.97,23026.52,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18968.56,,,,,,,fee schedule,9010.97,23026.52,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18968.56,,,,,,,fee schedule,9010.97,23026.52,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9010.97,,,,,,,fee schedule,9010.97,23026.52,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11249.97,,,,,,,fee schedule,9010.97,23026.52,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21813.84,,,,,,,fee schedule,9010.97,23026.52,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15806.31,,,,,,,fee schedule,9010.97,23026.52,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18968.56,,,,,,,fee schedule,9010.97,23026.52,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,9010.97,23026.52,APC
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,9010.97,23026.52,APC
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,9010.97,23026.52,APC
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24465.09,,,,,,,fee schedule,12556.54,28134.85,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12556.54,,,,,,,fee schedule,12556.54,28134.85,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12556.54,,,,,,,fee schedule,12556.54,28134.85,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16039.31,,,,,,,fee schedule,12556.54,28134.85,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20024.68,,,,,,,fee schedule,12556.54,28134.85,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14440.02,,,,,,,fee schedule,12556.54,28134.85,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28134.85,,,,,,,fee schedule,12556.54,28134.85,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12556.54,,,,,,,fee schedule,12556.54,28134.85,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12556.54,28134.85,APC
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12556.54,28134.85,APC
Impltj oi implt skl tc esp,69716,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12556.54,28134.85,APC
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10709.71,,,,,,,fee schedule,4458.15,13014.22,
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7021.29,,,,,,,fee schedule,4458.15,13014.22,
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8765.9,,,,,,,fee schedule,4458.15,13014.22,
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5126.87,,,,,,,fee schedule,4458.15,13014.22,
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12316.17,,,,,,,fee schedule,4458.15,13014.22,
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4458.15,,,,,,,fee schedule,4458.15,13014.22,
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4458.15,13014.22,APC
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4458.15,13014.22,APC
Temple Bone Implant Revision,69717,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4458.15,13014.22,APC
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24465.09,,,,,,,fee schedule,12556.54,28134.85,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12556.54,,,,,,,fee schedule,12556.54,28134.85,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12556.54,,,,,,,fee schedule,12556.54,28134.85,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16039.31,,,,,,,fee schedule,12556.54,28134.85,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20024.68,,,,,,,fee schedule,12556.54,28134.85,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14440.02,,,,,,,fee schedule,12556.54,28134.85,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28134.85,,,,,,,fee schedule,12556.54,28134.85,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12556.54,,,,,,,fee schedule,12556.54,28134.85,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12556.54,28134.85,APC
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12556.54,28134.85,APC
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12556.54,28134.85,APC
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Release facial nerve,69720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Release facial nerve,69725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.84,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2182.71,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.71,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3683.71,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4599.02,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2510.12,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6461.67,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2182.71,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.71,6461.67,APC
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.71,6461.67,APC
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.71,6461.67,APC
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5618.84,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2182.71,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2182.71,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3683.71,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4599.02,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2510.12,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6461.67,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2182.71,,,,,,,fee schedule,2182.71,6461.67,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2182.71,6461.67,APC
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2182.71,6461.67,APC
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2182.71,6461.67,APC
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5689.46,,,,,,,fee schedule,2221.32,6542.88,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2221.32,,,,,,,fee schedule,2221.32,6542.88,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2221.32,,,,,,,fee schedule,2221.32,6542.88,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3730.01,,,,,,,fee schedule,2221.32,6542.88,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4656.82,,,,,,,fee schedule,2221.32,6542.88,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2554.52,,,,,,,fee schedule,2221.32,6542.88,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6542.88,,,,,,,fee schedule,2221.32,6542.88,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2221.32,,,,,,,fee schedule,2221.32,6542.88,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,2221.32,6542.88,APC
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,2221.32,6542.88,APC
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,2221.32,6542.88,APC
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24939.6,,,,,,,fee schedule,12792.51,28680.54,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12984.64,,,,,,,fee schedule,12792.51,28680.54,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12984.64,,,,,,,fee schedule,12792.51,28680.54,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16350.4,,,,,,,fee schedule,12792.51,28680.54,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20413.06,,,,,,,fee schedule,12792.51,28680.54,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14932.34,,,,,,,fee schedule,12792.51,28680.54,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28680.54,,,,,,,fee schedule,12792.51,28680.54,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12984.64,,,,,,,fee schedule,12792.51,28680.54,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,28680.54,APC
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,28680.54,APC
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,28680.54,APC
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24939.6,,,,,,,fee schedule,12792.51,28680.54,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12984.64,,,,,,,fee schedule,12792.51,28680.54,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12984.64,,,,,,,fee schedule,12792.51,28680.54,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16350.4,,,,,,,fee schedule,12792.51,28680.54,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20413.06,,,,,,,fee schedule,12792.51,28680.54,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14932.34,,,,,,,fee schedule,12792.51,28680.54,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28680.54,,,,,,,fee schedule,12792.51,28680.54,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12984.64,,,,,,,fee schedule,12792.51,28680.54,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,28680.54,APC
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,28680.54,APC
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,28680.54,APC
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair facial nerve,69740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Repair facial nerve,69745,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Middle ear surgery procedure,69799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Middle ear surgery procedure,69799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Middle ear surgery procedure,69799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,313.55,,,,,,,fee schedule,205.56,2782.81,
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,280.15,,,,,,,fee schedule,205.56,2782.81,
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,280.15,,,,,,,fee schedule,205.56,2782.81,
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,205.56,,,,,,,fee schedule,205.56,2782.81,
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,256.64,,,,,,,fee schedule,205.56,2782.81,
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,322.17,,,,,,,fee schedule,205.56,2782.81,
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,360.58,,,,,,,fee schedule,205.56,2782.81,
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,280.15,,,,,,,fee schedule,205.56,2782.81,
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,205.56,2782.81,APC
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,205.56,2782.81,APC
Incise inner ear,69801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,205.56,2782.81,APC
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.47,,,,,,,fee schedule,4942.79,10617.38,
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.1,,,,,,,fee schedule,4942.79,10617.38,
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.24,,,,,,,fee schedule,4942.79,10617.38,
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,4942.79,10617.38,
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.34,,,,,,,fee schedule,4942.79,10617.38,
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,4942.79,10617.38,
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4942.79,10617.38,APC
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4942.79,10617.38,APC
Explore inner ear,69805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4942.79,10617.38,APC
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Explore inner ear,69806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove inner ear,69905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5568.37,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3650.62,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4557.71,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6403.63,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,3650.62,10617.38,
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,3650.62,10617.38,APC
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,3650.62,10617.38,APC
Remove inner ear & mastoid,69910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,3650.62,10617.38,APC
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2569.01,,,,,,,fee schedule,1684.24,5946.37,
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1684.24,,,,,,,fee schedule,1684.24,5946.37,
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2102.73,,,,,,,fee schedule,1684.24,5946.37,
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5684.21,,,,,,,fee schedule,1684.24,5946.37,
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2954.36,,,,,,,fee schedule,1684.24,5946.37,
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4942.79,,,,,,,fee schedule,1684.24,5946.37,
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,1684.24,5946.37,APC
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,1684.24,5946.37,APC
Incise inner ear nerve,69915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,1684.24,5946.37,APC
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18266.94,,,,,,,fee schedule,11975.81,77553.16,
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67437.53,,,,,,,fee schedule,11975.81,77553.16,
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67437.53,,,,,,,fee schedule,11975.81,77553.16,
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11975.81,,,,,,,fee schedule,11975.81,77553.16,
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14951.49,,,,,,,fee schedule,11975.81,77553.16,
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77553.16,,,,,,,fee schedule,11975.81,77553.16,
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21006.98,,,,,,,fee schedule,11975.81,77553.16,
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67437.53,,,,,,,fee schedule,11975.81,77553.16,
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34496.23,,,,,,,fee schedule,11975.81,77553.16,APC
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32853.56,,,,,,,fee schedule,11975.81,77553.16,APC
Implant cochlear device,69930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59136.4,,,,,,,fee schedule,11975.81,77553.16,APC
Inner ear surgery procedure,69949,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Inner ear surgery procedure,69949,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Inner ear surgery procedure,69949,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Release facial nerve,69955,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Release inner ear canal,69960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6178,,,,,,,fee schedule,4050.3,10617.38,
Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4050.3,,,,,,,fee schedule,4050.3,10617.38,
Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5056.69,,,,,,,fee schedule,4050.3,10617.38,
Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7104.7,,,,,,,fee schedule,4050.3,10617.38,
Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,4050.3,10617.38,APC
Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,4050.3,10617.38,APC
Remove inner ear lesion,69970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,4050.3,10617.38,APC
Temporal bone surgery,69979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Temporal bone surgery,69979,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Temporal bone surgery,69979,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,138.16,,,,,,,fee schedule,90.58,625.71,
Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.58,,,,,,,fee schedule,90.58,625.71,
Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.08,,,,,,,fee schedule,90.58,625.71,
Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,158.88,,,,,,,fee schedule,90.58,625.71,
Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,90.58,625.71,APC
Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,90.58,625.71,APC
Contrast x-ray of brain,70010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,90.58,625.71,APC
Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.74,,,,,,,fee schedule,167.66,1405.98,
Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.66,,,,,,,fee schedule,167.66,1405.98,
Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.32,,,,,,,fee schedule,167.66,1405.98,
Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.1,,,,,,,fee schedule,167.66,1405.98,
Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,167.66,1405.98,APC
Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,167.66,1405.98,APC
Contrast x-ray of brain,70015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,167.66,1405.98,APC
X-ray eye for foreign body,70030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray eye for foreign body,70030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray eye for foreign body,70030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.73,,,,,,,fee schedule,54.24,156.08,
X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.24,,,,,,,fee schedule,54.24,156.08,
X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.71,,,,,,,fee schedule,54.24,156.08,
X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.14,,,,,,,fee schedule,54.24,156.08,
X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,54.24,156.08,APC
X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,54.24,156.08,APC
X-ray exam of jaw <4views,70100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,54.24,156.08,APC
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,44.32,187.51,
X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,44.32,187.51,
X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,44.32,187.51,
X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,44.32,187.51,
X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,44.32,187.51,APC
X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,44.32,187.51,APC
X-ray exam of mastoids,70120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,44.32,187.51,APC
X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.85,,,,,,,fee schedule,67.43,187.51,
X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.43,,,,,,,fee schedule,67.43,187.51,
X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.18,,,,,,,fee schedule,67.43,187.51,
X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.28,,,,,,,fee schedule,67.43,187.51,
X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,67.43,187.51,APC
X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,67.43,187.51,APC
X-ray exam of mastoids,70130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,67.43,187.51,APC
X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.05,,,,,,,fee schedule,61.66,980.01,
X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.66,,,,,,,fee schedule,61.66,980.01,
X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.98,,,,,,,fee schedule,61.66,980.01,
X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.16,,,,,,,fee schedule,61.66,980.01,
X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,61.66,980.01,APC
X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,61.66,980.01,APC
X-ray exam of middle ear,70134,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,61.66,980.01,APC
X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of facial bones,70140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of facial bones,70150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of nasal bones,70160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.85,,,,,,,fee schedule,67.43,427.94,
X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.43,,,,,,,fee schedule,67.43,427.94,
X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.18,,,,,,,fee schedule,67.43,427.94,
X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.28,,,,,,,fee schedule,67.43,427.94,
X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,67.43,427.94,APC
X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,67.43,427.94,APC
X-ray exam of tear duct,70170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,67.43,427.94,APC
X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.6,,,,,,,fee schedule,43.66,156.08,
X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.66,,,,,,,fee schedule,43.66,156.08,
X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.51,,,,,,,fee schedule,43.66,156.08,
X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.59,,,,,,,fee schedule,43.66,156.08,
X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,43.66,156.08,APC
X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,43.66,156.08,APC
X-ray exam of eye sockets,70190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,43.66,156.08,APC
X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of eye sockets,70200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of sinuses,70210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of sinuses,70220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of sinuses,70220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of sinuses,70220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.87,,,,,,,fee schedule,36.63,156.08,
X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.63,,,,,,,fee schedule,36.63,156.08,
X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.73,,,,,,,fee schedule,36.63,156.08,
X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.25,,,,,,,fee schedule,36.63,156.08,
X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,36.63,156.08,APC
X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,36.63,156.08,APC
X-ray exam pituitary saddle,70240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,36.63,156.08,APC
X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam of skull,70250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam of skull,70260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of skull,70260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of skull,70260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.49,,,,,,,fee schedule,16.06,156.08,
X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.06,,,,,,,fee schedule,16.06,156.08,
X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.05,,,,,,,fee schedule,16.06,156.08,
X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.16,,,,,,,fee schedule,16.06,156.08,
X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,16.06,156.08,APC
X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,16.06,156.08,APC
X-ray exam of teeth,70300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,16.06,156.08,APC
X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.39,,,,,,,fee schedule,50.74,427.94,
X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.74,,,,,,,fee schedule,50.74,427.94,
X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.34,,,,,,,fee schedule,50.74,427.94,
X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89,,,,,,,fee schedule,50.74,427.94,
X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,50.74,427.94,APC
X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,50.74,427.94,APC
X-ray exam of teeth,70310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,50.74,427.94,APC
Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.67,,,,,,,fee schedule,73.87,427.94,
Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.87,,,,,,,fee schedule,73.87,427.94,
Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.22,,,,,,,fee schedule,73.87,427.94,
Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.57,,,,,,,fee schedule,73.87,427.94,
Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,73.87,427.94,APC
Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,73.87,427.94,APC
Full mouth x-ray of teeth,70320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,73.87,427.94,APC
X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of jaw joint,70328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of jaw joints,70330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.85,,,,,,,fee schedule,167.08,427.94,
X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.08,,,,,,,fee schedule,167.08,427.94,
X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.59,,,,,,,fee schedule,167.08,427.94,
X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,293.08,,,,,,,fee schedule,167.08,427.94,
X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,167.08,427.94,APC
X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,167.08,427.94,APC
X-ray exam of jaw joint,70332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,167.08,427.94,APC
Magnetic image jaw joint,70336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Magnetic image jaw joint,70336,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Magnetic image jaw joint,70336,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,156.08,
X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,156.08,
X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,156.08,
X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,156.08,
X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,17.36,156.08,APC
X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,17.36,156.08,APC
X-ray head for orthodontia,70350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,17.36,156.08,APC
Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.41,,,,,,,fee schedule,46.16,156.08,
Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.16,,,,,,,fee schedule,46.16,156.08,
Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.63,,,,,,,fee schedule,46.16,156.08,
Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.97,,,,,,,fee schedule,46.16,156.08,
Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,46.16,156.08,APC
Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,46.16,156.08,APC
Panoramic x-ray of jaws,70355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,46.16,156.08,APC
X-ray exam of neck,70360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of neck,70360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of neck,70360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.24,,,,,,,fee schedule,86.71,292.38,
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.68,,,,,,,fee schedule,86.71,292.38,
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.1,,,,,,,fee schedule,86.71,292.38,
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.38,,,,,,,fee schedule,86.71,292.38,
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,292.38,APC
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,292.38,APC
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,292.38,APC
Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,132.29,,,,,,,fee schedule,86.73,427.94,
Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.73,,,,,,,fee schedule,86.73,427.94,
Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.28,,,,,,,fee schedule,86.73,427.94,
Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,152.13,,,,,,,fee schedule,86.73,427.94,
Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,86.73,427.94,APC
Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,86.73,427.94,APC
Speech evaluation complex,70371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,86.73,427.94,APC
X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.49,,,,,,,fee schedule,48.18,156.08,
X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.18,,,,,,,fee schedule,48.18,156.08,
X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.15,,,,,,,fee schedule,48.18,156.08,
X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.51,,,,,,,fee schedule,48.18,156.08,
X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,48.18,156.08,APC
X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,48.18,156.08,APC
X-ray exam of salivary gland,70380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,48.18,156.08,APC
X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,205.78,,,,,,,fee schedule,134.91,427.94,
X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.91,,,,,,,fee schedule,134.91,427.94,
X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,168.43,,,,,,,fee schedule,134.91,427.94,
X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,236.65,,,,,,,fee schedule,134.91,427.94,
X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,134.91,427.94,APC
X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,134.91,427.94,APC
X-ray exam of salivary duct,70390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,134.91,427.94,APC
Ct head/brain w/o dye,70450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct head/brain w/o dye,70450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct head/brain w/o dye,70450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct head/brain w/dye,70460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct head/brain w/dye,70460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct head/brain w/dye,70460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,338.67,,,,,,,fee schedule,104.17,389.47,
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.03,,,,,,,fee schedule,104.17,389.47,
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.2,,,,,,,fee schedule,104.17,389.47,
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,389.47,,,,,,,fee schedule,104.17,389.47,
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,389.47,APC
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,389.47,APC
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,389.47,APC
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.88,,,,,,,fee schedule,174.77,781.86,
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.73,,,,,,,fee schedule,174.77,781.86,
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,556.48,,,,,,,fee schedule,174.77,781.86,
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.86,,,,,,,fee schedule,174.77,781.86,
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,781.86,APC
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,781.86,APC
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,781.86,APC
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct maxillofacial w/o dye,70486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct maxillofacial w/o dye,70486,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct maxillofacial w/o dye,70486,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct maxillofacial w/dye,70487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct maxillofacial w/dye,70487,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct maxillofacial w/dye,70487,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,760.81,,,,,,,fee schedule,174.77,874.93,
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,498.79,,,,,,,fee schedule,174.77,874.93,
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,622.72,,,,,,,fee schedule,174.77,874.93,
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,874.93,,,,,,,fee schedule,174.77,874.93,
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,874.93,APC
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,874.93,APC
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,874.93,APC
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct soft tissue neck w/dye,70491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct soft tissue neck w/dye,70491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct soft tissue neck w/dye,70491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct angiography head,70496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct angiography head,70496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct angiography head,70496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.62,,,,,,,fee schedule,174.77,914.96,
Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.61,,,,,,,fee schedule,174.77,914.96,
Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,651.21,,,,,,,fee schedule,174.77,914.96,
Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,914.96,,,,,,,fee schedule,174.77,914.96,
Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,914.96,APC
Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,914.96,APC
Ct angiography neck,70498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,914.96,APC
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1205.1,,,,,,,fee schedule,347.62,1385.87,
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.06,,,,,,,fee schedule,347.62,1385.87,
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,986.37,,,,,,,fee schedule,347.62,1385.87,
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1385.87,,,,,,,fee schedule,347.62,1385.87,
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1385.87,APC
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1385.87,APC
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1385.87,APC
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,906.37,,,,,,,fee schedule,347.62,1042.33,
Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,594.22,,,,,,,fee schedule,347.62,1042.33,
Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,741.86,,,,,,,fee schedule,347.62,1042.33,
Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1042.33,,,,,,,fee schedule,347.62,1042.33,
Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1042.33,APC
Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1042.33,APC
Mr Angiography Head W/Dye,70545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1042.33,APC
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2637.76,,,,,,,fee schedule,347.62,3033.42,
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1729.32,,,,,,,fee schedule,347.62,3033.42,
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2159.01,,,,,,,fee schedule,347.62,3033.42,
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3033.42,,,,,,,fee schedule,347.62,3033.42,
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,3033.42,APC
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,3033.42,APC
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,3033.42,APC
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,921.06,,,,,,,fee schedule,237.74,1059.22,
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,603.85,,,,,,,fee schedule,237.74,1059.22,
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,753.89,,,,,,,fee schedule,237.74,1059.22,
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1059.22,,,,,,,fee schedule,237.74,1059.22,
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,1059.22,APC
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,1059.22,APC
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,1059.22,APC
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2370.47,,,,,,,fee schedule,347.62,2726.04,
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1554.08,,,,,,,fee schedule,347.62,2726.04,
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1940.23,,,,,,,fee schedule,347.62,2726.04,
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2726.04,,,,,,,fee schedule,347.62,2726.04,
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,2726.04,APC
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,2726.04,APC
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,2726.04,APC
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2515.43,,,,,,,fee schedule,347.62,2892.74,
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1649.12,,,,,,,fee schedule,347.62,2892.74,
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2058.88,,,,,,,fee schedule,347.62,2892.74,
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2892.74,,,,,,,fee schedule,347.62,2892.74,
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,2892.74,APC
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,2892.74,APC
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,2892.74,APC
Mri brain stem w/o dye,70551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri brain stem w/o dye,70551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri brain stem w/o dye,70551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri brain stem w/dye,70552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri brain stem w/dye,70552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri brain stem w/dye,70552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1453.81,,,,,,,fee schedule,237.74,1671.88,
Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,953.12,,,,,,,fee schedule,237.74,1671.88,
Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1189.94,,,,,,,fee schedule,237.74,1671.88,
Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1671.88,,,,,,,fee schedule,237.74,1671.88,
Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,1671.88,APC
Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,1671.88,APC
Fmri brain by tech,70554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,1671.88,APC
Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1707.88,,,,,,,fee schedule,237.74,1964.06,
Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1119.69,,,,,,,fee schedule,237.74,1964.06,
Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1397.9,,,,,,,fee schedule,237.74,1964.06,
Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1964.06,,,,,,,fee schedule,237.74,1964.06,
Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,1964.06,APC
Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,1964.06,APC
Fmri brain by phys/psych,70555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,1964.06,APC
Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3322.69,,,,,,,fee schedule,544.45,3821.09,
Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2178.36,,,,,,,fee schedule,544.45,3821.09,
Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2719.62,,,,,,,fee schedule,544.45,3821.09,
Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3821.09,,,,,,,fee schedule,544.45,3821.09,
Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,3821.09,APC
Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,3821.09,APC
Mri brain w/o dye,70557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,3821.09,APC
Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3623.47,,,,,,,fee schedule,174.77,4166.99,
Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2375.55,,,,,,,fee schedule,174.77,4166.99,
Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2965.81,,,,,,,fee schedule,174.77,4166.99,
Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4166.99,,,,,,,fee schedule,174.77,4166.99,
Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,4166.99,APC
Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,4166.99,APC
Mri brain w/dye,70558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,4166.99,APC
Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3670.52,,,,,,,fee schedule,174.77,4221.1,
Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2406.39,,,,,,,fee schedule,174.77,4221.1,
Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3004.32,,,,,,,fee schedule,174.77,4221.1,
Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4221.1,,,,,,,fee schedule,174.77,4221.1,
Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,4221.1,APC
Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,4221.1,APC
Mri brain w/o & w/dye,70559,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,4221.1,APC
X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.58,,,,,,,fee schedule,86.71,195.02,
X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.18,,,,,,,fee schedule,86.71,195.02,
X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.8,,,,,,,fee schedule,86.71,195.02,
X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.02,,,,,,,fee schedule,86.71,195.02,
X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,195.02,APC
X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,195.02,APC
X-ray exam chest 1 view,71045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,195.02,APC
X-ray exam chest 2 views,71046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam chest 2 views,71046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam chest 2 views,71046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.58,,,,,,,fee schedule,86.71,195.02,
X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.18,,,,,,,fee schedule,86.71,195.02,
X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.8,,,,,,,fee schedule,86.71,195.02,
X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.02,,,,,,,fee schedule,86.71,195.02,
X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,195.02,APC
X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,195.02,APC
X-ray exam chest 3 views,71047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,195.02,APC
X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.19,,,,,,,fee schedule,104.17,372.82,
X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.54,,,,,,,fee schedule,104.17,372.82,
X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.35,,,,,,,fee schedule,104.17,372.82,
X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,372.82,,,,,,,fee schedule,104.17,372.82,
X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam chest 4+ views,71048,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Ct thorax w/o dye,71250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct thorax w/o dye,71250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct thorax w/o dye,71250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct thorax w/dye,71260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct thorax w/dye,71260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct thorax w/dye,71260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct thorax w/o & w/dye,71270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct thorax w/o & w/dye,71270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct thorax w/o & w/dye,71270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,157.17,,,,,,,fee schedule,103.04,187.51,
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.04,,,,,,,fee schedule,103.04,187.51,
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.64,,,,,,,fee schedule,103.04,187.51,
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.75,,,,,,,fee schedule,103.04,187.51,
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.04,187.51,APC
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.04,187.51,APC
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.04,187.51,APC
Ct angiography chest,71275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct angiography chest,71275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct angiography chest,71275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Mri chest w/o dye,71550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri chest w/o dye,71550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri chest w/o dye,71550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1205.1,,,,,,,fee schedule,781.1,1405.98,
Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.06,,,,,,,fee schedule,781.1,1405.98,
Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,986.37,,,,,,,fee schedule,781.1,1405.98,
Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1385.87,,,,,,,fee schedule,781.1,1405.98,
Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,781.1,1405.98,APC
Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,781.1,1405.98,APC
Mri Chest W/Dye,71551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,781.1,1405.98,APC
Mri chest w/o & w/dye,71552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri chest w/o & w/dye,71552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri chest w/o & w/dye,71552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mri angio chest w or w/o dye,71555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2301.16,,,,,,,fee schedule,1508.64,2646.33,
Mri angio chest w or w/o dye,71555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1508.64,,,,,,,fee schedule,1508.64,2646.33,
Mri angio chest w or w/o dye,71555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1883.5,,,,,,,fee schedule,1508.64,2646.33,
Mri angio chest w or w/o dye,71555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2646.33,,,,,,,fee schedule,1508.64,2646.33,
X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.31,,,,,,,fee schedule,86.71,160.21,
X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.33,,,,,,,fee schedule,86.71,160.21,
X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.03,,,,,,,fee schedule,86.71,160.21,
X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.21,,,,,,,fee schedule,86.71,160.21,
X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,160.21,APC
X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,160.21,APC
X-ray exam of spine 1 view,72020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,160.21,APC
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.16,,,,,,,fee schedule,59.11,187.51,
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.11,,,,,,,fee schedule,59.11,187.51,
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.8,,,,,,,fee schedule,59.11,187.51,
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.68,,,,,,,fee schedule,59.11,187.51,
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,59.11,187.51,APC
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,59.11,187.51,APC
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,59.11,187.51,APC
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam l-s spine bending,72114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.33,,,,,,,fee schedule,52.66,187.51,
X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.66,,,,,,,fee schedule,52.66,187.51,
X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.75,,,,,,,fee schedule,52.66,187.51,
X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.38,,,,,,,fee schedule,52.66,187.51,
X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,52.66,187.51,APC
X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,52.66,187.51,APC
X-ray bend only l-s spine,72120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,52.66,187.51,APC
Ct neck spine w/o dye,72125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct neck spine w/o dye,72125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct neck spine w/o dye,72125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.88,,,,,,,fee schedule,347.62,781.86,
Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.73,,,,,,,fee schedule,347.62,781.86,
Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,556.48,,,,,,,fee schedule,347.62,781.86,
Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.86,,,,,,,fee schedule,347.62,781.86,
Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,781.86,APC
Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,781.86,APC
Ct neck spine w/dye,72126,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,781.86,APC
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,760.81,,,,,,,fee schedule,174.77,874.93,
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,498.79,,,,,,,fee schedule,174.77,874.93,
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,622.72,,,,,,,fee schedule,174.77,874.93,
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,874.93,,,,,,,fee schedule,174.77,874.93,
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,874.93,APC
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,874.93,APC
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,874.93,APC
Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,338.67,,,,,,,fee schedule,104.17,389.47,
Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.03,,,,,,,fee schedule,104.17,389.47,
Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.2,,,,,,,fee schedule,104.17,389.47,
Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,389.47,,,,,,,fee schedule,104.17,389.47,
Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,389.47,APC
Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,389.47,APC
Ct chest spine w/o dye,72128,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,389.47,APC
Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.88,,,,,,,fee schedule,174.77,781.86,
Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.73,,,,,,,fee schedule,174.77,781.86,
Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,556.48,,,,,,,fee schedule,174.77,781.86,
Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.86,,,,,,,fee schedule,174.77,781.86,
Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,781.86,APC
Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,781.86,APC
Ct chest spine w/dye,72129,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,781.86,APC
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,760.81,,,,,,,fee schedule,174.77,874.93,
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,498.79,,,,,,,fee schedule,174.77,874.93,
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,622.72,,,,,,,fee schedule,174.77,874.93,
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,874.93,,,,,,,fee schedule,174.77,874.93,
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,874.93,APC
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,874.93,APC
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,874.93,APC
Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,338.67,,,,,,,fee schedule,104.17,389.47,
Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.03,,,,,,,fee schedule,104.17,389.47,
Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.2,,,,,,,fee schedule,104.17,389.47,
Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,389.47,,,,,,,fee schedule,104.17,389.47,
Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,389.47,APC
Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,389.47,APC
Ct lumbar spine w/o dye,72131,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,389.47,APC
Ct lumbar spine w/dye,72132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Ct lumbar spine w/dye,72132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Ct lumbar spine w/dye,72132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,747.28,,,,,,,fee schedule,174.77,859.37,
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,489.92,,,,,,,fee schedule,174.77,859.37,
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,611.65,,,,,,,fee schedule,174.77,859.37,
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,859.37,,,,,,,fee schedule,174.77,859.37,
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,859.37,APC
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,859.37,APC
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,859.37,APC
Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,808.22,,,,,,,fee schedule,237.74,929.45,
Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,529.87,,,,,,,fee schedule,237.74,929.45,
Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,661.53,,,,,,,fee schedule,237.74,929.45,
Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,929.45,,,,,,,fee schedule,237.74,929.45,
Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,929.45,APC
Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,929.45,APC
Mri neck spine w/o dye,72141,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,929.45,APC
Mri neck spine w/dye,72142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri neck spine w/dye,72142,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri neck spine w/dye,72142,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,808.22,,,,,,,fee schedule,237.74,929.45,
Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,529.87,,,,,,,fee schedule,237.74,929.45,
Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,661.53,,,,,,,fee schedule,237.74,929.45,
Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,929.45,,,,,,,fee schedule,237.74,929.45,
Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,929.45,APC
Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,929.45,APC
Mri chest spine w/o dye,72146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,929.45,APC
Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1205.1,,,,,,,fee schedule,347.62,1385.87,
Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.06,,,,,,,fee schedule,347.62,1385.87,
Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,986.37,,,,,,,fee schedule,347.62,1385.87,
Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1385.87,,,,,,,fee schedule,347.62,1385.87,
Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1385.87,APC
Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1385.87,APC
Mri chest spine w/dye,72147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1385.87,APC
Mri lumbar spine w/o dye,72148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri lumbar spine w/o dye,72148,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri lumbar spine w/o dye,72148,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1205.1,,,,,,,fee schedule,347.62,1385.87,
Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.06,,,,,,,fee schedule,347.62,1385.87,
Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,986.37,,,,,,,fee schedule,347.62,1385.87,
Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1385.87,,,,,,,fee schedule,347.62,1385.87,
Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1385.87,APC
Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1385.87,APC
Mri lumbar spine w/dye,72149,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1385.87,APC
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1363.22,,,,,,,fee schedule,347.62,1567.7,
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,893.73,,,,,,,fee schedule,347.62,1567.7,
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1115.8,,,,,,,fee schedule,347.62,1567.7,
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1567.7,,,,,,,fee schedule,347.62,1567.7,
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1567.7,APC
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1567.7,APC
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1567.7,APC
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1363.22,,,,,,,fee schedule,347.62,1567.7,
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,893.73,,,,,,,fee schedule,347.62,1567.7,
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1115.8,,,,,,,fee schedule,347.62,1567.7,
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1567.7,,,,,,,fee schedule,347.62,1567.7,
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1567.7,APC
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1567.7,APC
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1567.7,APC
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mr angio spine w/o&w/dye,72159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,898.53,,,,,,,fee schedule,589.08,1033.31,
Mr angio spine w/o&w/dye,72159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,589.08,,,,,,,fee schedule,589.08,1033.31,
Mr angio spine w/o&w/dye,72159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,735.45,,,,,,,fee schedule,589.08,1033.31,
Mr angio spine w/o&w/dye,72159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1033.31,,,,,,,fee schedule,589.08,1033.31,
X-ray exam of pelvis,72170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of pelvis,72170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of pelvis,72170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam of pelvis,72190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,593.79,,,,,,,fee schedule,174.77,682.86,
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,389.29,,,,,,,fee schedule,174.77,682.86,
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,486.02,,,,,,,fee schedule,174.77,682.86,
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,682.86,,,,,,,fee schedule,174.77,682.86,
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,682.86,APC
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,682.86,APC
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,682.86,APC
Ct pelvis w/o dye,72192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct pelvis w/o dye,72192,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct pelvis w/o dye,72192,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct pelvis w/dye,72193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct pelvis w/dye,72193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct pelvis w/dye,72193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Mri Pelvis W/O Dye,72195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri Pelvis W/O Dye,72195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri Pelvis W/O Dye,72195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1205.1,,,,,,,fee schedule,347.62,1385.87,
Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.06,,,,,,,fee schedule,347.62,1385.87,
Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,986.37,,,,,,,fee schedule,347.62,1385.87,
Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1385.87,,,,,,,fee schedule,347.62,1385.87,
Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1385.87,APC
Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1385.87,APC
Mri pelvis w/dye,72196,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1385.87,APC
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2221.09,,,,,,,fee schedule,1456.15,2554.25,
Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1456.15,,,,,,,fee schedule,1456.15,2554.25,
Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1817.96,,,,,,,fee schedule,1456.15,2554.25,
Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2554.25,,,,,,,fee schedule,1456.15,2554.25,
X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam si joints,72200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,103.93,187.51,
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,103.93,187.51,
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,103.93,187.51,
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,103.93,187.51,
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,103.93,187.51,APC
X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam sacrum tailbone,72220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.98,,,,,,,fee schedule,95.7,1405.98,
Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.7,,,,,,,fee schedule,95.7,1405.98,
Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.48,,,,,,,fee schedule,95.7,1405.98,
Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.88,,,,,,,fee schedule,95.7,1405.98,
Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,95.7,1405.98,APC
Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,95.7,1405.98,APC
Myelography neck spine,72240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,95.7,1405.98,APC
Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.06,,,,,,,fee schedule,93.79,1405.98,
Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.79,,,,,,,fee schedule,93.79,1405.98,
Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.09,,,,,,,fee schedule,93.79,1405.98,
Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.52,,,,,,,fee schedule,93.79,1405.98,
Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,93.79,1405.98,APC
Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,93.79,1405.98,APC
Myelography thoracic spine,72255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,93.79,1405.98,APC
Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.12,,,,,,,fee schedule,91.86,1405.98,
Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.86,,,,,,,fee schedule,91.86,1405.98,
Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.69,,,,,,,fee schedule,91.86,1405.98,
Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.14,,,,,,,fee schedule,91.86,1405.98,
Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,91.86,1405.98,APC
Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,91.86,1405.98,APC
Myelography l-s spine,72265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,91.86,1405.98,APC
Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.59,,,,,,,fee schedule,108.56,1405.98,
Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.56,,,,,,,fee schedule,108.56,1405.98,
Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.54,,,,,,,fee schedule,108.56,1405.98,
Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.43,,,,,,,fee schedule,108.56,1405.98,
Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,108.56,1405.98,APC
Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,108.56,1405.98,APC
Myelogphy 2/> spine regions,72270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,108.56,1405.98,APC
Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,3502.27,
Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,3502.27,
Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,3502.27,
Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,3502.27,
Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,94.43,3502.27,APC
Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,94.43,3502.27,APC
Discography cerv/thor spine,72285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,94.43,3502.27,APC
X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.91,,,,,,,fee schedule,98.28,3502.27,
X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.28,,,,,,,fee schedule,98.28,3502.27,
X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.7,,,,,,,fee schedule,98.28,3502.27,
X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.4,,,,,,,fee schedule,98.28,3502.27,
X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2042.99,,,,,,,fee schedule,98.28,3502.27,APC
X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1945.7,,,,,,,fee schedule,98.28,3502.27,APC
X-ray of lower spine disk,72295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3502.27,,,,,,,fee schedule,98.28,3502.27,APC
X-ray exam of collar bone,73000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of collar bone,73000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of collar bone,73000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of shoulder blade,73010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of shoulder,73020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of shoulder,73030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of shoulder,73030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of shoulder,73030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.87,,,,,,,fee schedule,131.03,625.71,
Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.03,,,,,,,fee schedule,131.03,625.71,
Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.59,,,,,,,fee schedule,131.03,625.71,
Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.85,,,,,,,fee schedule,131.03,625.71,
Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,131.03,625.71,APC
Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,131.03,625.71,APC
Contrast x-ray of shoulder,73040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,131.03,625.71,APC
X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of shoulders,73050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.19,,,,,,,fee schedule,57.16,156.08,
X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.16,,,,,,,fee schedule,57.16,156.08,
X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.16,156.08,
X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.27,,,,,,,fee schedule,57.16,156.08,
X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of humerus,73060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.19,,,,,,,fee schedule,57.16,156.08,
X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.16,,,,,,,fee schedule,57.16,156.08,
X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.16,156.08,
X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.27,,,,,,,fee schedule,57.16,156.08,
X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of elbow,73070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of elbow,73080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of elbow,73080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of elbow,73080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.18,,,,,,,fee schedule,245.97,625.71,
Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,245.97,,,,,,,fee schedule,245.97,625.71,
Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.08,,,,,,,fee schedule,245.97,625.71,
Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.46,,,,,,,fee schedule,245.97,625.71,
Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,245.97,625.71,APC
Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,245.97,625.71,APC
Contrast x-ray of elbow,73085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,245.97,625.71,APC
X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.19,,,,,,,fee schedule,57.16,156.08,
X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.16,,,,,,,fee schedule,57.16,156.08,
X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.16,156.08,
X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.27,,,,,,,fee schedule,57.16,156.08,
X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of forearm,73090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.75,,,,,,,fee schedule,64.08,187.51,
X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.08,,,,,,,fee schedule,64.08,187.51,
X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.01,,,,,,,fee schedule,64.08,187.51,
X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.41,,,,,,,fee schedule,64.08,187.51,
X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,64.08,187.51,APC
X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,64.08,187.51,APC
X-ray exam of arm infant,73092,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,64.08,187.51,APC
X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.23,,,,,,,fee schedule,42.76,156.08,
X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.76,,,,,,,fee schedule,42.76,156.08,
X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.39,,,,,,,fee schedule,42.76,156.08,
X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.01,,,,,,,fee schedule,42.76,156.08,
X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,42.76,156.08,APC
X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,42.76,156.08,APC
X-ray exam of wrist,73100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,42.76,156.08,APC
X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of wrist,73110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.6,,,,,,,fee schedule,140.69,625.71,
Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.69,,,,,,,fee schedule,140.69,625.71,
Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.65,,,,,,,fee schedule,140.69,625.71,
Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.79,,,,,,,fee schedule,140.69,625.71,
Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,140.69,625.71,APC
Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,140.69,625.71,APC
Contrast x-ray of wrist,73115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,140.69,625.71,APC
X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of hand,73120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam of hand,73130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of hand,73130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of hand,73130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of finger(s),73140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Ct upper extremity w/o dye,73200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct upper extremity w/o dye,73200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct upper extremity w/o dye,73200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct upper extremity w/dye,73201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Ct upper extremity w/dye,73201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Ct upper extremity w/dye,73201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,760.81,,,,,,,fee schedule,174.77,874.93,
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,498.79,,,,,,,fee schedule,174.77,874.93,
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,622.72,,,,,,,fee schedule,174.77,874.93,
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,874.93,,,,,,,fee schedule,174.77,874.93,
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,874.93,APC
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,874.93,APC
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,874.93,APC
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1531.95,,,,,,,fee schedule,174.77,1761.74,
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1004.35,,,,,,,fee schedule,174.77,1761.74,
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1253.9,,,,,,,fee schedule,174.77,1761.74,
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1761.74,,,,,,,fee schedule,174.77,1761.74,
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,1761.74,APC
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,1761.74,APC
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,1761.74,APC
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1205.1,,,,,,,fee schedule,347.62,1385.87,
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.06,,,,,,,fee schedule,347.62,1385.87,
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,986.37,,,,,,,fee schedule,347.62,1385.87,
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1385.87,,,,,,,fee schedule,347.62,1385.87,
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1385.87,APC
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1385.87,APC
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1385.87,APC
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri joint upr extrem w/dye,73222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,781.1,1405.98,APC
Mri joint upr extrem w/dye,73222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,781.1,1405.98,APC
Mri joint upr extrem w/dye,73222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,781.1,1405.98,APC
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mr angio upr extr w/o&w/dye,73225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3273.13,,,,,,,fee schedule,2145.86,3764.1,
Mr angio upr extr w/o&w/dye,73225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2145.86,,,,,,,fee schedule,2145.86,3764.1,
Mr angio upr extr w/o&w/dye,73225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2679.06,,,,,,,fee schedule,2145.86,3764.1,
Mr angio upr extr w/o&w/dye,73225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3764.1,,,,,,,fee schedule,2145.86,3764.1,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam hip uni 1 view,73501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 2 views,73521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,386.47,,,,,,,fee schedule,253.37,625.71,
Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,253.37,,,,,,,fee schedule,253.37,625.71,
Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,316.33,,,,,,,fee schedule,253.37,625.71,
Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,444.44,,,,,,,fee schedule,253.37,625.71,
Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,253.37,625.71,APC
Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,253.37,625.71,APC
Contrast x-ray of hip,73525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,253.37,625.71,APC
X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.19,,,,,,,fee schedule,57.16,156.08,
X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.16,,,,,,,fee schedule,57.16,156.08,
X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.16,156.08,
X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.27,,,,,,,fee schedule,57.16,156.08,
X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of femur 1,73551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.19,,,,,,,fee schedule,57.16,156.08,
X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.16,,,,,,,fee schedule,57.16,156.08,
X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.16,156.08,
X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.27,,,,,,,fee schedule,57.16,156.08,
X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of femur 2/>,73552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of knee 3,73562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam knee 4 or more,73564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam knee 4 or more,73564,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam knee 4 or more,73564,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
X-ray exam of knees,73565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.13,,,,,,,fee schedule,154.81,625.71,
Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.81,,,,,,,fee schedule,154.81,625.71,
Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.27,,,,,,,fee schedule,154.81,625.71,
Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,271.55,,,,,,,fee schedule,154.81,625.71,
Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,154.81,625.71,APC
Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,154.81,625.71,APC
Contrast x-ray of knee joint,73580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,154.81,625.71,APC
X-ray exam of lower leg,73590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of lower leg,73590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of lower leg,73590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.75,,,,,,,fee schedule,64.08,156.08,
X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.08,,,,,,,fee schedule,64.08,156.08,
X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.01,,,,,,,fee schedule,64.08,156.08,
X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.41,,,,,,,fee schedule,64.08,156.08,
X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,64.08,156.08,APC
X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,64.08,156.08,APC
X-ray exam of leg infant,73592,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,64.08,156.08,APC
X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,86.71,156.08,
X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,86.71,156.08,
X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,86.71,156.08,
X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,86.71,156.08,
X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of ankle,73600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of ankle,73610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of ankle,73610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of ankle,73610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.63,,,,,,,fee schedule,138.74,625.71,
Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.74,,,,,,,fee schedule,138.74,625.71,
Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.22,,,,,,,fee schedule,138.74,625.71,
Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.37,,,,,,,fee schedule,138.74,625.71,
Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,138.74,625.71,APC
Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,138.74,625.71,APC
Contrast x-ray of ankle,73615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,138.74,625.71,APC
X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.19,,,,,,,fee schedule,57.16,156.08,
X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.16,,,,,,,fee schedule,57.16,156.08,
X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.16,156.08,
X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.27,,,,,,,fee schedule,57.16,156.08,
X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of foot,73620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of foot,73630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of foot,73630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of foot,73630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.19,,,,,,,fee schedule,57.16,156.08,
X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.16,,,,,,,fee schedule,57.16,156.08,
X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.16,156.08,
X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.27,,,,,,,fee schedule,57.16,156.08,
X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of heel,73650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.19,,,,,,,fee schedule,57.16,156.08,
X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.16,,,,,,,fee schedule,57.16,156.08,
X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.16,156.08,
X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.27,,,,,,,fee schedule,57.16,156.08,
X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,57.16,156.08,APC
X-ray exam of toe(s),73660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,57.16,156.08,APC
Ct lower extremity w/o dye,73700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct lower extremity w/o dye,73700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct lower extremity w/o dye,73700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct lower extremity w/dye,73701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct lower extremity w/dye,73701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct lower extremity w/dye,73701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,760.81,,,,,,,fee schedule,174.77,874.93,
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,498.79,,,,,,,fee schedule,174.77,874.93,
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,622.72,,,,,,,fee schedule,174.77,874.93,
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,874.93,,,,,,,fee schedule,174.77,874.93,
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,874.93,APC
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,874.93,APC
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,874.93,APC
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2612.61,,,,,,,fee schedule,174.77,3004.5,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1712.83,,,,,,,fee schedule,174.77,3004.5,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2138.42,,,,,,,fee schedule,174.77,3004.5,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3004.5,,,,,,,fee schedule,174.77,3004.5,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,3004.5,APC
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,3004.5,APC
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,3004.5,APC
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1205.1,,,,,,,fee schedule,347.62,1385.87,
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.06,,,,,,,fee schedule,347.62,1385.87,
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,986.37,,,,,,,fee schedule,347.62,1385.87,
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1385.87,,,,,,,fee schedule,347.62,1385.87,
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1385.87,APC
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1385.87,APC
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1385.87,APC
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,781.1,1405.98,APC
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,781.1,1405.98,APC
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,781.1,1405.98,APC
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3548.83,,,,,,,fee schedule,2326.61,4081.15,
Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2326.61,,,,,,,fee schedule,2326.61,4081.15,
Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2904.72,,,,,,,fee schedule,2326.61,4081.15,
Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4081.15,,,,,,,fee schedule,2326.61,4081.15,
X-ray exam abdomen 1 view,74018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam abdomen 1 view,74018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam abdomen 1 view,74018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.19,,,,,,,fee schedule,104.17,372.82,
X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.54,,,,,,,fee schedule,104.17,372.82,
X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.35,,,,,,,fee schedule,104.17,372.82,
X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,372.82,,,,,,,fee schedule,104.17,372.82,
X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam abdomen 2 views,74019,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.19,,,,,,,fee schedule,104.17,372.82,
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.54,,,,,,,fee schedule,104.17,372.82,
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.35,,,,,,,fee schedule,104.17,372.82,
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,372.82,,,,,,,fee schedule,104.17,372.82,
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,372.82,APC
X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.76,,,,,,,fee schedule,88.35,187.51,
X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.35,,,,,,,fee schedule,88.35,187.51,
X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.3,,,,,,,fee schedule,88.35,187.51,
X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.97,,,,,,,fee schedule,88.35,187.51,
X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.35,187.51,APC
X-ray exam series abdomen,74022,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.35,187.51,APC
Ct abdomen w/o dye,74150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct abdomen w/o dye,74150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct abdomen w/o dye,74150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct abdomen w/dye,74160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct abdomen w/dye,74160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct abdomen w/dye,74160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,314.59,APC
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,314.59,APC
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,314.59,APC
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1950.72,,,,,,,fee schedule,347.62,2243.33,
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1278.89,,,,,,,fee schedule,347.62,2243.33,
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1596.66,,,,,,,fee schedule,347.62,2243.33,
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2243.33,,,,,,,fee schedule,347.62,2243.33,
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,2243.33,APC
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,2243.33,APC
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,2243.33,APC
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1517.19,,,,,,,fee schedule,174.77,1744.77,
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,994.67,,,,,,,fee schedule,174.77,1744.77,
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1241.82,,,,,,,fee schedule,174.77,1744.77,
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1744.77,,,,,,,fee schedule,174.77,1744.77,
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,1744.77,APC
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,1744.77,APC
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,1744.77,APC
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Ct abd & pelv w/contrast,74177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Ct abd & pelv w/contrast,74177,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Ct abd & pelv w/contrast,74177,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mri abdomen w/o dye,74181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Mri abdomen w/o dye,74181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Mri abdomen w/o dye,74181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1205.1,,,,,,,fee schedule,347.62,1385.87,
Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.06,,,,,,,fee schedule,347.62,1385.87,
Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,986.37,,,,,,,fee schedule,347.62,1385.87,
Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1385.87,,,,,,,fee schedule,347.62,1385.87,
Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1385.87,APC
Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1385.87,APC
Mri Abdomen W/Dye,74182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1385.87,APC
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Mri angio abdom w orw/o dye,74185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2384.51,,,,,,,fee schedule,1563.28,2742.19,
Mri angio abdom w orw/o dye,74185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1563.28,,,,,,,fee schedule,1563.28,2742.19,
Mri angio abdom w orw/o dye,74185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1951.72,,,,,,,fee schedule,1563.28,2742.19,
Mri angio abdom w orw/o dye,74185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2742.19,,,,,,,fee schedule,1563.28,2742.19,
X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.96,,,,,,,fee schedule,64.88,980.01,
X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.88,,,,,,,fee schedule,64.88,980.01,
X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81,,,,,,,fee schedule,64.88,980.01,
X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.8,,,,,,,fee schedule,64.88,980.01,
X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,64.88,980.01,APC
X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,64.88,980.01,APC
X-ray exam of peritoneum,74190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,64.88,980.01,APC
Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.62,,,,,,,fee schedule,107.27,314.59,
Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.27,,,,,,,fee schedule,107.27,314.59,
Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.92,,,,,,,fee schedule,107.27,314.59,
Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.16,,,,,,,fee schedule,107.27,314.59,
Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,107.27,314.59,APC
Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,107.27,314.59,APC
Contrst x-ray exam of throat,74210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,107.27,314.59,APC
Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.3,,,,,,,fee schedule,119.52,314.59,
Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.52,,,,,,,fee schedule,119.52,314.59,
Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.21,,,,,,,fee schedule,119.52,314.59,
Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.65,,,,,,,fee schedule,119.52,314.59,
Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,119.52,314.59,APC
Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,119.52,314.59,APC
Contrast x-ray esophagus,74220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,119.52,314.59,APC
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,353.97,,,,,,,fee schedule,174.77,407.07,
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,232.06,,,,,,,fee schedule,174.77,407.07,
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,289.72,,,,,,,fee schedule,174.77,407.07,
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,407.07,,,,,,,fee schedule,174.77,407.07,
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,407.07,APC
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,407.07,APC
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,407.07,APC
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.08,,,,,,,fee schedule,174.77,412.94,
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.41,,,,,,,fee schedule,174.77,412.94,
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,293.91,,,,,,,fee schedule,174.77,412.94,
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,412.94,,,,,,,fee schedule,174.77,412.94,
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,412.94,APC
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,412.94,APC
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,412.94,APC
Remove esophagus obstruction,74235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,320.43,,,,,,,fee schedule,210.07,368.49,
Remove esophagus obstruction,74235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,210.07,,,,,,,fee schedule,210.07,368.49,
Remove esophagus obstruction,74235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.27,,,,,,,fee schedule,210.07,368.49,
Remove esophagus obstruction,74235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,368.49,,,,,,,fee schedule,210.07,368.49,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.47,,,,,,,fee schedule,174.77,399.59,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.8,,,,,,,fee schedule,174.77,399.59,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.4,,,,,,,fee schedule,174.77,399.59,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.59,,,,,,,fee schedule,174.77,399.59,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,399.59,APC
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,399.59,APC
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,399.59,APC
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.28,,,,,,,fee schedule,102.46,314.59,
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.46,,,,,,,fee schedule,102.46,314.59,
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.92,,,,,,,fee schedule,102.46,314.59,
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.72,,,,,,,fee schedule,102.46,314.59,
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,102.46,314.59,APC
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,102.46,314.59,APC
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,102.46,314.59,APC
X-ray sm int f-thru std,74248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,162.66,,,,,,,fee schedule,106.64,187.06,
X-ray sm int f-thru std,74248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.64,,,,,,,fee schedule,106.64,187.06,
X-ray sm int f-thru std,74248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.14,,,,,,,fee schedule,106.64,187.06,
X-ray sm int f-thru std,74248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.06,,,,,,,fee schedule,106.64,187.06,
X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,200.78,,,,,,,fee schedule,131.63,314.59,
X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.63,,,,,,,fee schedule,131.63,314.59,
X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.34,,,,,,,fee schedule,131.63,314.59,
X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,230.9,,,,,,,fee schedule,131.63,314.59,
X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,131.63,314.59,APC
X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,131.63,314.59,APC
X-ray exam of small bowel,74250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,131.63,314.59,APC
X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1062.14,,,,,,,fee schedule,174.77,1221.46,
X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,696.34,,,,,,,fee schedule,174.77,1221.46,
X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,869.36,,,,,,,fee schedule,174.77,1221.46,
X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1221.46,,,,,,,fee schedule,174.77,1221.46,
X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,1221.46,APC
X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,1221.46,APC
X-ray exam of small bowel,74251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,1221.46,APC
Ct colonography dx,74261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ct colonography dx,74261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ct colonography dx,74261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,733.18,,,,,,,fee schedule,174.77,843.16,
Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,480.67,,,,,,,fee schedule,174.77,843.16,
Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,600.11,,,,,,,fee schedule,174.77,843.16,
Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,843.16,,,,,,,fee schedule,174.77,843.16,
Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,843.16,APC
Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,843.16,APC
Ct colonography dx w/dye,74262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,843.16,APC
Ct colonography screening,74263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Ct colonography screening,74263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Ct colonography screening,74263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,280.58,,,,,,,fee schedule,174.77,322.67,
Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,183.95,,,,,,,fee schedule,174.77,322.67,
Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,229.65,,,,,,,fee schedule,174.77,322.67,
Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,322.67,,,,,,,fee schedule,174.77,322.67,
Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,322.67,APC
Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,322.67,APC
Contrast x-ray exam of colon,74270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,322.67,APC
Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,379.09,,,,,,,fee schedule,174.77,435.95,
Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,248.53,,,,,,,fee schedule,174.77,435.95,
Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,310.29,,,,,,,fee schedule,174.77,435.95,
Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,435.95,,,,,,,fee schedule,174.77,435.95,
Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,435.95,APC
Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,435.95,APC
Contrast x-ray exam of colon,74280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,435.95,APC
Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,325.78,,,,,,,fee schedule,174.77,374.65,
Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.58,,,,,,,fee schedule,174.77,374.65,
Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,266.65,,,,,,,fee schedule,174.77,374.65,
Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,374.65,,,,,,,fee schedule,174.77,374.65,
Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,374.65,APC
Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,374.65,APC
Contrast x-ray exam of colon,74283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,374.65,APC
Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.94,,,,,,,fee schedule,97.65,314.59,
Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.65,,,,,,,fee schedule,97.65,314.59,
Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.91,,,,,,,fee schedule,97.65,314.59,
Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.28,,,,,,,fee schedule,97.65,314.59,
Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,97.65,314.59,APC
Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,97.65,314.59,APC
Contrast x-ray gallbladder,74290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,97.65,314.59,APC
X-ray bile ducts/pancreas,74300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.06,,,,,,,fee schedule,81.33,142.67,
X-ray bile ducts/pancreas,74300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.33,,,,,,,fee schedule,81.33,142.67,
X-ray bile ducts/pancreas,74300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.54,,,,,,,fee schedule,81.33,142.67,
X-ray bile ducts/pancreas,74300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.67,,,,,,,fee schedule,81.33,142.67,
X-rays at surgery add-on,74301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.87,,,,,,,fee schedule,35.97,63.1,
X-rays at surgery add-on,74301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.97,,,,,,,fee schedule,35.97,63.1,
X-rays at surgery add-on,74301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.91,,,,,,,fee schedule,35.97,63.1,
X-rays at surgery add-on,74301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.1,,,,,,,fee schedule,35.97,63.1,
X-ray bile duct endoscopy,74328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,233.19,,,,,,,fee schedule,152.88,268.17,
X-ray bile duct endoscopy,74328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.88,,,,,,,fee schedule,152.88,268.17,
X-ray bile duct endoscopy,74328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.87,,,,,,,fee schedule,152.88,268.17,
X-ray bile duct endoscopy,74328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,268.17,,,,,,,fee schedule,152.88,268.17,
X-ray for pancreas endoscopy,74329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,185.2,,,,,,,fee schedule,121.42,212.98,
X-ray for pancreas endoscopy,74329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.42,,,,,,,fee schedule,121.42,212.98,
X-ray for pancreas endoscopy,74329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.59,,,,,,,fee schedule,121.42,212.98,
X-ray for pancreas endoscopy,74329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,212.98,,,,,,,fee schedule,121.42,212.98,
X-ray bile/panc endoscopy,74330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,342.14,,,,,,,fee schedule,224.31,393.46,
X-ray bile/panc endoscopy,74330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.31,,,,,,,fee schedule,224.31,393.46,
X-ray bile/panc endoscopy,74330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,280.04,,,,,,,fee schedule,224.31,393.46,
X-ray bile/panc endoscopy,74330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,393.46,,,,,,,fee schedule,224.31,393.46,
X-ray guide for GI tube,74340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,371.35,,,,,,,fee schedule,243.46,427.05,
X-ray guide for GI tube,74340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,243.46,,,,,,,fee schedule,243.46,427.05,
X-ray guide for GI tube,74340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,303.95,,,,,,,fee schedule,243.46,427.05,
X-ray guide for GI tube,74340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,427.05,,,,,,,fee schedule,243.46,427.05,
X-ray guide intestinal tube,74355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,289.05,,,,,,,fee schedule,189.5,332.41,
X-ray guide intestinal tube,74355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,189.5,,,,,,,fee schedule,189.5,332.41,
X-ray guide intestinal tube,74355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,236.59,,,,,,,fee schedule,189.5,332.41,
X-ray guide intestinal tube,74355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,332.41,,,,,,,fee schedule,189.5,332.41,
X-ray guide gi dilation,74360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,247.9,,,,,,,fee schedule,162.52,285.09,
X-ray guide gi dilation,74360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,162.52,,,,,,,fee schedule,162.52,285.09,
X-ray guide gi dilation,74360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.91,,,,,,,fee schedule,162.52,285.09,
X-ray guide gi dilation,74360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,285.09,,,,,,,fee schedule,162.52,285.09,
X-ray bile duct dilation,74363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,222.44,,,,,,,fee schedule,145.83,255.81,
X-ray bile duct dilation,74363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.83,,,,,,,fee schedule,145.83,255.81,
X-ray bile duct dilation,74363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.07,,,,,,,fee schedule,145.83,255.81,
X-ray bile duct dilation,74363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.81,,,,,,,fee schedule,145.83,255.81,
Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,274.23,,,,,,,fee schedule,174.77,315.36,
Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.79,,,,,,,fee schedule,174.77,315.36,
Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.46,,,,,,,fee schedule,174.77,315.36,
Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,315.36,,,,,,,fee schedule,174.77,315.36,
Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,315.36,APC
Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,315.36,APC
Contrst x-ray urinary tract,74400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,315.36,APC
Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,232.22,,,,,,,fee schedule,152.24,314.59,
Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.24,,,,,,,fee schedule,152.24,314.59,
Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.07,,,,,,,fee schedule,152.24,314.59,
Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,267.05,,,,,,,fee schedule,152.24,314.59,
Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,152.24,314.59,APC
Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,152.24,314.59,APC
Contrst x-ray urinary tract,74410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,152.24,314.59,APC
Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,308.64,,,,,,,fee schedule,174.77,354.94,
Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.34,,,,,,,fee schedule,174.77,354.94,
Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,252.62,,,,,,,fee schedule,174.77,354.94,
Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,354.94,,,,,,,fee schedule,174.77,354.94,
Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,354.94,APC
Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,354.94,APC
Contrst x-ray urinary tract,74415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,354.94,APC
Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,277.32,,,,,,,fee schedule,181.81,625.71,
Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,181.81,,,,,,,fee schedule,181.81,625.71,
Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,226.99,,,,,,,fee schedule,181.81,625.71,
Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,318.92,,,,,,,fee schedule,181.81,625.71,
Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,181.81,625.71,APC
Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,181.81,625.71,APC
Contrst x-ray urinary tract,74420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,181.81,625.71,APC
Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,132.29,,,,,,,fee schedule,86.73,625.71,
Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.73,,,,,,,fee schedule,86.73,625.71,
Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.28,,,,,,,fee schedule,86.73,625.71,
Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,152.13,,,,,,,fee schedule,86.73,625.71,
Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,86.73,625.71,APC
Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,86.73,625.71,APC
Contrst x-ray urinary tract,74425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,86.73,625.71,APC
Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.77,,,,,,,fee schedule,161.78,625.71,
Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.78,,,,,,,fee schedule,161.78,625.71,
Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.98,,,,,,,fee schedule,161.78,625.71,
Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.79,,,,,,,fee schedule,161.78,625.71,
Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,161.78,625.71,APC
Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,161.78,625.71,APC
Contrast x-ray bladder,74430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,161.78,625.71,APC
X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.43,,,,,,,fee schedule,113.05,427.94,
X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.05,,,,,,,fee schedule,113.05,427.94,
X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.13,,,,,,,fee schedule,113.05,427.94,
X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.29,,,,,,,fee schedule,113.05,427.94,
X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,113.05,427.94,APC
X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,113.05,427.94,APC
X-ray male genital tract,74440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,113.05,427.94,APC
X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.64,,,,,,,fee schedule,74.5,187.51,
X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.5,,,,,,,fee schedule,74.5,187.51,
X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.01,,,,,,,fee schedule,74.5,187.51,
X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.69,,,,,,,fee schedule,74.5,187.51,
X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,74.5,187.51,APC
X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,74.5,187.51,APC
X-ray exam of penis,74445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,74.5,187.51,APC
X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.77,,,,,,,fee schedule,161.78,427.94,
X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.78,,,,,,,fee schedule,161.78,427.94,
X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.98,,,,,,,fee schedule,161.78,427.94,
X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.79,,,,,,,fee schedule,161.78,427.94,
X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,161.78,427.94,APC
X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,161.78,427.94,APC
X-ray urethra/bladder,74450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,161.78,427.94,APC
X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,708.11,,,,,,,fee schedule,237.74,814.33,
X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,464.24,,,,,,,fee schedule,237.74,814.33,
X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,579.59,,,,,,,fee schedule,237.74,814.33,
X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,814.33,,,,,,,fee schedule,237.74,814.33,
X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,814.33,APC
X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,814.33,APC
X-ray urethra/bladder,74455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,814.33,APC
X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.31,,,,,,,fee schedule,85.43,980.01,
X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.43,,,,,,,fee schedule,85.43,980.01,
X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.66,,,,,,,fee schedule,85.43,980.01,
X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.86,,,,,,,fee schedule,85.43,980.01,
X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,85.43,980.01,APC
X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,85.43,980.01,APC
X-ray exam of kidney lesion,74470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,85.43,980.01,APC
X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,3749.16,
X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,3749.16,
X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,3749.16,
X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,3749.16,
X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2187.01,,,,,,,fee schedule,118.83,3749.16,APC
X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2082.87,,,,,,,fee schedule,118.83,3749.16,APC
X-ray guide gu dilation,74485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3749.16,,,,,,,fee schedule,118.83,3749.16,APC
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1532.14,,,,,,,fee schedule,237.74,1761.96,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1004.47,,,,,,,fee schedule,237.74,1761.96,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.06,,,,,,,fee schedule,237.74,1761.96,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1761.96,,,,,,,fee schedule,237.74,1761.96,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,1761.96,APC
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,1761.96,APC
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,1761.96,APC
Mri fetal ea addl gestation,74713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,385.08,,,,,,,fee schedule,252.46,442.84,
Mri fetal ea addl gestation,74713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,252.46,,,,,,,fee schedule,252.46,442.84,
Mri fetal ea addl gestation,74713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,315.19,,,,,,,fee schedule,252.46,442.84,
Mri fetal ea addl gestation,74713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,442.84,,,,,,,fee schedule,252.46,442.84,
X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,414.03,,,,,,,fee schedule,237.74,476.13,
X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,271.44,,,,,,,fee schedule,237.74,476.13,
X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,338.88,,,,,,,fee schedule,237.74,476.13,
X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,476.13,,,,,,,fee schedule,237.74,476.13,
X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,476.13,APC
X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,476.13,APC
X-ray female genital tract,74740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,476.13,APC
X-ray fallopian tube,74742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.74,,,,,,,fee schedule,104.07,182.55,
X-ray fallopian tube,74742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.07,,,,,,,fee schedule,104.07,182.55,
X-ray fallopian tube,74742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.93,,,,,,,fee schedule,104.07,182.55,
X-ray fallopian tube,74742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.55,,,,,,,fee schedule,104.07,182.55,
X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.81,,,,,,,fee schedule,101.49,427.94,
X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.49,,,,,,,fee schedule,101.49,427.94,
X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.71,,,,,,,fee schedule,101.49,427.94,
X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.03,,,,,,,fee schedule,101.49,427.94,
X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,101.49,427.94,APC
X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,101.49,427.94,APC
X-ray exam of perineum,74775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,101.49,427.94,APC
Cardiac mri for morph,75557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Cardiac mri for morph,75557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Cardiac mri for morph,75557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.31,,,,,,,fee schedule,531.89,980.01,
Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.89,,,,,,,fee schedule,531.89,980.01,
Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,664.06,,,,,,,fee schedule,531.89,980.01,
Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,933.01,,,,,,,fee schedule,531.89,980.01,
Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,531.89,980.01,APC
Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,531.89,980.01,APC
Cardiac mri w/stress img,75559,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,531.89,980.01,APC
Cardiac mri for morph w/dye,75561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Cardiac mri for morph w/dye,75561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Cardiac mri for morph w/dye,75561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3231.14,,,,,,,fee schedule,781.1,3715.81,
Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2118.34,,,,,,,fee schedule,781.1,3715.81,
Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2644.69,,,,,,,fee schedule,781.1,3715.81,
Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3715.81,,,,,,,fee schedule,781.1,3715.81,
Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,781.1,3715.81,APC
Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,781.1,3715.81,APC
Card mri w/stress img & dye,75563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,781.1,3715.81,APC
Card mri veloc flow mapping,75565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.45,,,,,,,fee schedule,116.34,204.07,
Card mri veloc flow mapping,75565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.34,,,,,,,fee schedule,116.34,204.07,
Card mri veloc flow mapping,75565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.24,,,,,,,fee schedule,116.34,204.07,
Card mri veloc flow mapping,75565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,204.07,,,,,,,fee schedule,116.34,204.07,
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Ct hrt w/3d image,75572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Ct hrt w/3d image,75572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Ct hrt w/3d image,75572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,733.18,,,,,,,fee schedule,347.62,843.16,
Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,480.67,,,,,,,fee schedule,347.62,843.16,
Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,600.11,,,,,,,fee schedule,347.62,843.16,
Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,843.16,,,,,,,fee schedule,347.62,843.16,
Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,843.16,APC
Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,843.16,APC
Ct hrt w/3d image congen,75573,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,843.16,APC
Ct angio hrt w/3d image,75574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,625.71,APC
Ct angio hrt w/3d image,75574,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,625.71,APC
Ct angio hrt w/3d image,75574,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,625.71,APC
Quan&char c athrosclrtc plaq,75577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,973.35,,,,,,,fee schedule,927,1668.61,APC
Quan&char c athrosclrtc plaq,75577,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,927,,,,,,,fee schedule,927,1668.61,APC
Quan&char c athrosclrtc plaq,75577,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1668.61,,,,,,,fee schedule,927,1668.61,APC
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1799.86,,,,,,,fee schedule,855.65,2069.84,
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1179.99,,,,,,,fee schedule,855.65,2069.84,
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1473.19,,,,,,,fee schedule,855.65,2069.84,
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2069.84,,,,,,,fee schedule,855.65,2069.84,
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,2069.84,APC
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,2069.84,APC
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,2069.84,APC
Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,479.15,,,,,,,fee schedule,314.13,5663.03,
Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,314.13,,,,,,,fee schedule,314.13,5663.03,
Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,392.18,,,,,,,fee schedule,314.13,5663.03,
Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,551.02,,,,,,,fee schedule,314.13,5663.03,
Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,314.13,5663.03,APC
Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,314.13,5663.03,APC
Contrast exam thoracic aorta,75600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,314.13,5663.03,APC
Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3080.06,,,,,,,fee schedule,2019.29,9980.06,
Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2019.29,,,,,,,fee schedule,2019.29,9980.06,
Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2521.03,,,,,,,fee schedule,2019.29,9980.06,
Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3542.07,,,,,,,fee schedule,2019.29,9980.06,
Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2019.29,9980.06,APC
Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2019.29,9980.06,APC
Contrast exam thoracic aorta,75605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2019.29,9980.06,APC
Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2638.68,,,,,,,fee schedule,1729.92,5663.03,
Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1729.92,,,,,,,fee schedule,1729.92,5663.03,
Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2159.76,,,,,,,fee schedule,1729.92,5663.03,
Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3034.48,,,,,,,fee schedule,1729.92,5663.03,
Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,1729.92,5663.03,APC
Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,1729.92,5663.03,APC
Contrast exam abdominl aorta,75625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,1729.92,5663.03,APC
X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2860.06,,,,,,,fee schedule,1875.06,5663.03,
X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1875.06,,,,,,,fee schedule,1875.06,5663.03,
X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2340.96,,,,,,,fee schedule,1875.06,5663.03,
X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3289.07,,,,,,,fee schedule,1875.06,5663.03,
X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,1875.06,5663.03,APC
X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,1875.06,5663.03,APC
X-ray aorta leg arteries,75630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,1875.06,5663.03,APC
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1614.41,,,,,,,fee schedule,174.77,1856.57,
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1058.41,,,,,,,fee schedule,174.77,1856.57,
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1321.39,,,,,,,fee schedule,174.77,1856.57,
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1856.57,,,,,,,fee schedule,174.77,1856.57,
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,1856.57,APC
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,1856.57,APC
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,1856.57,APC
Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,364.52,,,,,,,fee schedule,238.98,9980.06,
Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,238.98,,,,,,,fee schedule,238.98,9980.06,
Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,298.36,,,,,,,fee schedule,238.98,9980.06,
Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,419.2,,,,,,,fee schedule,238.98,9980.06,
Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,238.98,9980.06,APC
Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,238.98,9980.06,APC
Artery x-rays spine,75705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,238.98,9980.06,APC
Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,942.56,,,,,,,fee schedule,617.94,5663.03,
Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,617.94,,,,,,,fee schedule,617.94,5663.03,
Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,771.49,,,,,,,fee schedule,617.94,5663.03,
Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1083.94,,,,,,,fee schedule,617.94,5663.03,
Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,617.94,5663.03,APC
Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,617.94,5663.03,APC
Artery x-rays arm/leg,75710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,617.94,5663.03,APC
Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2397.14,,,,,,,fee schedule,1571.56,5663.03,
Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1571.56,,,,,,,fee schedule,1571.56,5663.03,
Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1962.06,,,,,,,fee schedule,1571.56,5663.03,
Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2756.71,,,,,,,fee schedule,1571.56,5663.03,
Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,1571.56,5663.03,APC
Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,1571.56,5663.03,APC
Artery x-rays arms/legs,75716,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,1571.56,5663.03,APC
Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3695.59,,,,,,,fee schedule,2422.83,9980.06,
Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2422.83,,,,,,,fee schedule,2422.83,9980.06,
Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3024.84,,,,,,,fee schedule,2422.83,9980.06,
Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4249.93,,,,,,,fee schedule,2422.83,9980.06,
Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,2422.83,9980.06,APC
Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,2422.83,9980.06,APC
Artery x-rays abdomen,75726,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,2422.83,9980.06,APC
Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.51,,,,,,,fee schedule,206.85,5663.03,
Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.85,,,,,,,fee schedule,206.85,5663.03,
Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.24,,,,,,,fee schedule,206.85,5663.03,
Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,362.84,,,,,,,fee schedule,206.85,5663.03,
Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,206.85,5663.03,APC
Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,206.85,5663.03,APC
Artery x-rays adrenal gland,75731,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,206.85,5663.03,APC
Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,337.08,,,,,,,fee schedule,220.99,5663.03,
Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,220.99,,,,,,,fee schedule,220.99,5663.03,
Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,275.9,,,,,,,fee schedule,220.99,5663.03,
Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,387.64,,,,,,,fee schedule,220.99,5663.03,
Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,220.99,5663.03,APC
Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,220.99,5663.03,APC
Artery x-rays adrenals,75733,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,220.99,5663.03,APC
Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,289.05,,,,,,,fee schedule,189.5,9980.06,
Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,189.5,,,,,,,fee schedule,189.5,9980.06,
Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,236.59,,,,,,,fee schedule,189.5,9980.06,
Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,332.41,,,,,,,fee schedule,189.5,9980.06,
Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,189.5,9980.06,APC
Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,189.5,9980.06,APC
Artery x-rays pelvis,75736,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,189.5,9980.06,APC
Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,240.06,,,,,,,fee schedule,157.38,5663.03,
Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,157.38,,,,,,,fee schedule,157.38,5663.03,
Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,196.49,,,,,,,fee schedule,157.38,5663.03,
Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,276.07,,,,,,,fee schedule,157.38,5663.03,
Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,157.38,5663.03,APC
Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,157.38,5663.03,APC
Artery x-rays lung,75741,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,157.38,5663.03,APC
Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3080.06,,,,,,,fee schedule,2019.29,5663.03,
Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2019.29,,,,,,,fee schedule,2019.29,5663.03,
Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2521.03,,,,,,,fee schedule,2019.29,5663.03,
Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3542.07,,,,,,,fee schedule,2019.29,5663.03,
Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2019.29,5663.03,APC
Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2019.29,5663.03,APC
Artery x-rays lungs,75743,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2019.29,5663.03,APC
Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,267.52,,,,,,,fee schedule,175.39,5663.03,
Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.39,,,,,,,fee schedule,175.39,5663.03,
Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.97,,,,,,,fee schedule,175.39,5663.03,
Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,307.65,,,,,,,fee schedule,175.39,5663.03,
Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,175.39,5663.03,APC
Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,175.39,5663.03,APC
Artery x-rays lung,75746,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,175.39,5663.03,APC
Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,311.61,,,,,,,fee schedule,204.29,5663.03,
Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,204.29,,,,,,,fee schedule,204.29,5663.03,
Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,255.05,,,,,,,fee schedule,204.29,5663.03,
Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,358.35,,,,,,,fee schedule,204.29,5663.03,
Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,204.29,5663.03,APC
Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,204.29,5663.03,APC
Artery x-rays chest,75756,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,204.29,5663.03,APC
Artery x-ray each vessel,75774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1318.9,,,,,,,fee schedule,864.67,1516.74,
Artery x-ray each vessel,75774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,864.67,,,,,,,fee schedule,864.67,1516.74,
Artery x-ray each vessel,75774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1079.52,,,,,,,fee schedule,864.67,1516.74,
Artery x-ray each vessel,75774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1516.74,,,,,,,fee schedule,864.67,1516.74,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,607.5,,,,,,,fee schedule,398.28,1125.08,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,398.28,,,,,,,fee schedule,398.28,1125.08,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,497.24,,,,,,,fee schedule,398.28,1125.08,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,698.63,,,,,,,fee schedule,398.28,1125.08,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,398.28,1125.08,APC
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,398.28,1125.08,APC
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,398.28,1125.08,APC
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,600.66,,,,,,,fee schedule,393.79,2823.29,
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,393.79,,,,,,,fee schedule,393.79,2823.29,
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,491.64,,,,,,,fee schedule,393.79,2823.29,
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,690.76,,,,,,,fee schedule,393.79,2823.29,
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,393.79,2823.29,APC
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,393.79,2823.29,APC
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,393.79,2823.29,APC
Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,643.76,,,,,,,fee schedule,422.05,5663.03,
Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,422.05,,,,,,,fee schedule,422.05,5663.03,
Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,526.92,,,,,,,fee schedule,422.05,5663.03,
Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,740.32,,,,,,,fee schedule,422.05,5663.03,
Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,422.05,5663.03,APC
Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,422.05,5663.03,APC
Lymph vessel x-ray trunk,75805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,422.05,5663.03,APC
Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,658.45,,,,,,,fee schedule,431.68,5663.03,
Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,431.68,,,,,,,fee schedule,431.68,5663.03,
Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,538.94,,,,,,,fee schedule,431.68,5663.03,
Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,757.22,,,,,,,fee schedule,431.68,5663.03,
Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,431.68,5663.03,APC
Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,431.68,5663.03,APC
Lymph vessel x-ray trunk,75807,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,431.68,5663.03,APC
Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,206.76,,,,,,,fee schedule,104.17,237.77,
Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.55,,,,,,,fee schedule,104.17,237.77,
Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.23,,,,,,,fee schedule,104.17,237.77,
Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,237.77,,,,,,,fee schedule,104.17,237.77,
Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,237.77,APC
Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,237.77,APC
Nonvascular shunt x-ray,75809,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,237.77,APC
Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1300.24,,,,,,,fee schedule,852.44,5663.03,
Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,852.44,,,,,,,fee schedule,852.44,5663.03,
Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1064.25,,,,,,,fee schedule,852.44,5663.03,
Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1495.28,,,,,,,fee schedule,852.44,5663.03,
Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,852.44,5663.03,APC
Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,852.44,5663.03,APC
Vein x-ray spleen/liver,75810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,852.44,5663.03,APC
Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,692.4,,,,,,,fee schedule,453.94,2823.29,
Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,453.94,,,,,,,fee schedule,453.94,2823.29,
Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,566.73,,,,,,,fee schedule,453.94,2823.29,
Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,796.26,,,,,,,fee schedule,453.94,2823.29,
Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,453.94,2823.29,APC
Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,453.94,2823.29,APC
Vein x-ray arm/leg,75820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,453.94,2823.29,APC
Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1022.18,,,,,,,fee schedule,670.14,2823.29,
Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.14,,,,,,,fee schedule,670.14,2823.29,
Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,836.65,,,,,,,fee schedule,670.14,2823.29,
Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1175.51,,,,,,,fee schedule,670.14,2823.29,
Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,670.14,2823.29,APC
Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,670.14,2823.29,APC
Vein x-ray arms/legs,75822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,670.14,2823.29,APC
Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3514.52,,,,,,,fee schedule,2304.12,5663.03,
Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2304.12,,,,,,,fee schedule,2304.12,5663.03,
Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2876.63,,,,,,,fee schedule,2304.12,5663.03,
Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4041.7,,,,,,,fee schedule,2304.12,5663.03,
Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2304.12,5663.03,APC
Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2304.12,5663.03,APC
Vein x-ray trunk,75825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2304.12,5663.03,APC
Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1606.4,,,,,,,fee schedule,1053.16,2823.29,
Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.16,,,,,,,fee schedule,1053.16,2823.29,
Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1314.84,,,,,,,fee schedule,1053.16,2823.29,
Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1847.36,,,,,,,fee schedule,1053.16,2823.29,
Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,1053.16,2823.29,APC
Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,1053.16,2823.29,APC
Vein x-ray chest,75827,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,1053.16,2823.29,APC
Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3704.54,,,,,,,fee schedule,2428.7,5663.03,
Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2428.7,,,,,,,fee schedule,2428.7,5663.03,
Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3032.17,,,,,,,fee schedule,2428.7,5663.03,
Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4260.22,,,,,,,fee schedule,2428.7,5663.03,
Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2428.7,5663.03,APC
Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2428.7,5663.03,APC
Vein x-ray kidney,75831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2428.7,5663.03,APC
Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3080.06,,,,,,,fee schedule,2019.29,5663.03,
Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2019.29,,,,,,,fee schedule,2019.29,5663.03,
Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2521.03,,,,,,,fee schedule,2019.29,5663.03,
Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3542.07,,,,,,,fee schedule,2019.29,5663.03,
Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2019.29,5663.03,APC
Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2019.29,5663.03,APC
Vein x-ray kidneys,75833,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2019.29,5663.03,APC
Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.78,,,,,,,fee schedule,165.72,5663.03,
Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.72,,,,,,,fee schedule,165.72,5663.03,
Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.9,,,,,,,fee schedule,165.72,5663.03,
Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.7,,,,,,,fee schedule,165.72,5663.03,
Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,165.72,5663.03,APC
Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,165.72,5663.03,APC
Vein x-ray adrenal gland,75840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,165.72,5663.03,APC
Vein x-ray adrenal glands,75842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.98,,,,,,,fee schedule,192.08,336.93,
Vein x-ray adrenal glands,75842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.08,,,,,,,fee schedule,192.08,336.93,
Vein x-ray adrenal glands,75842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.8,,,,,,,fee schedule,192.08,336.93,
Vein x-ray adrenal glands,75842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,336.93,,,,,,,fee schedule,192.08,336.93,
Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.02,,,,,,,fee schedule,158.67,5663.03,
Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.67,,,,,,,fee schedule,158.67,5663.03,
Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.09,,,,,,,fee schedule,158.67,5663.03,
Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.32,,,,,,,fee schedule,158.67,5663.03,
Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,158.67,5663.03,APC
Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,158.67,5663.03,APC
Vein x-ray neck,75860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,158.67,5663.03,APC
Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.78,,,,,,,fee schedule,165.72,5663.03,
Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.72,,,,,,,fee schedule,165.72,5663.03,
Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.9,,,,,,,fee schedule,165.72,5663.03,
Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.7,,,,,,,fee schedule,165.72,5663.03,
Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,165.72,5663.03,APC
Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,165.72,5663.03,APC
Vein x-ray skull,75870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,165.72,5663.03,APC
Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.42,,,,,,,fee schedule,177.94,1125.08,
Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.94,,,,,,,fee schedule,177.94,1125.08,
Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.16,,,,,,,fee schedule,177.94,1125.08,
Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.13,,,,,,,fee schedule,177.94,1125.08,
Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,177.94,1125.08,APC
Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,177.94,1125.08,APC
Vein x-ray skull epidural,75872,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,177.94,1125.08,APC
Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,306.68,,,,,,,fee schedule,201.06,1125.08,
Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.06,,,,,,,fee schedule,201.06,1125.08,
Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.02,,,,,,,fee schedule,201.06,1125.08,
Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,352.68,,,,,,,fee schedule,201.06,1125.08,
Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.3,,,,,,,fee schedule,201.06,1125.08,APC
Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,625.05,,,,,,,fee schedule,201.06,1125.08,APC
Vein x-ray eye socket,75880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1125.08,,,,,,,fee schedule,201.06,1125.08,APC
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3080.06,,,,,,,fee schedule,2019.29,5663.03,
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2019.29,,,,,,,fee schedule,2019.29,5663.03,
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2521.03,,,,,,,fee schedule,2019.29,5663.03,
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3542.07,,,,,,,fee schedule,2019.29,5663.03,
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,2019.29,5663.03,APC
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,2019.29,5663.03,APC
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,2019.29,5663.03,APC
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,245.94,,,,,,,fee schedule,161.24,5663.03,
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.24,,,,,,,fee schedule,161.24,5663.03,
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.3,,,,,,,fee schedule,161.24,5663.03,
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,282.83,,,,,,,fee schedule,161.24,5663.03,
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,161.24,5663.03,APC
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,161.24,5663.03,APC
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,161.24,5663.03,APC
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,244.94,,,,,,,fee schedule,160.58,5663.03,
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,160.58,,,,,,,fee schedule,160.58,5663.03,
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,200.48,,,,,,,fee schedule,160.58,5663.03,
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,281.68,,,,,,,fee schedule,160.58,5663.03,
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,160.58,5663.03,APC
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,160.58,5663.03,APC
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,160.58,5663.03,APC
Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.92,,,,,,,fee schedule,161.88,5663.03,
Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.88,,,,,,,fee schedule,161.88,5663.03,
Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.1,,,,,,,fee schedule,161.88,5663.03,
Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.96,,,,,,,fee schedule,161.88,5663.03,
Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,161.88,5663.03,APC
Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,161.88,5663.03,APC
Vein x-ray liver,75891,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,161.88,5663.03,APC
Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,253.78,,,,,,,fee schedule,166.38,9980.06,
Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.38,,,,,,,fee schedule,166.38,9980.06,
Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.72,,,,,,,fee schedule,166.38,9980.06,
Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,291.85,,,,,,,fee schedule,166.38,9980.06,
Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5821.7,,,,,,,fee schedule,166.38,9980.06,APC
Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5544.48,,,,,,,fee schedule,166.38,9980.06,APC
Venous sampling by catheter,75893,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9980.06,,,,,,,fee schedule,166.38,9980.06,APC
X-rays transcath therapy,75894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2525.06,,,,,,,fee schedule,1655.43,2903.82,
X-rays transcath therapy,75894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1655.43,,,,,,,fee schedule,1655.43,2903.82,
X-rays transcath therapy,75894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2066.76,,,,,,,fee schedule,1655.43,2903.82,
X-rays transcath therapy,75894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2903.82,,,,,,,fee schedule,1655.43,2903.82,
Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,118.56,,,,,,,fee schedule,77.73,5663.03,
Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.73,,,,,,,fee schedule,77.73,5663.03,
Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.04,,,,,,,fee schedule,77.73,5663.03,
Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.34,,,,,,,fee schedule,77.73,5663.03,
Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,77.73,5663.03,APC
Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,77.73,5663.03,APC
Follow-up angiography,75898,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,77.73,5663.03,APC
Remove cva device obstruct,75901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.22,,,,,,,fee schedule,129.95,227.95,
Remove cva device obstruct,75901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.95,,,,,,,fee schedule,129.95,227.95,
Remove cva device obstruct,75901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.24,,,,,,,fee schedule,129.95,227.95,
Remove cva device obstruct,75901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227.95,,,,,,,fee schedule,129.95,227.95,
Remove cva lumen obstruct,75902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.98,,,,,,,fee schedule,96.36,169.03,
Remove cva lumen obstruct,75902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.36,,,,,,,fee schedule,96.36,169.03,
Remove cva lumen obstruct,75902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.3,,,,,,,fee schedule,96.36,169.03,
Remove cva lumen obstruct,75902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.03,,,,,,,fee schedule,96.36,169.03,
Vascular biopsy,75970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1129.76,,,,,,,fee schedule,740.67,1299.22,
Vascular biopsy,75970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,740.67,,,,,,,fee schedule,740.67,1299.22,
Vascular biopsy,75970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,924.71,,,,,,,fee schedule,740.67,1299.22,
Vascular biopsy,75970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1299.22,,,,,,,fee schedule,740.67,1299.22,
Xray control catheter change,75984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.54,,,,,,,fee schedule,130.16,228.32,
Xray control catheter change,75984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,130.16,,,,,,,fee schedule,130.16,228.32,
Xray control catheter change,75984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.5,,,,,,,fee schedule,130.16,228.32,
Xray control catheter change,75984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.32,,,,,,,fee schedule,130.16,228.32,
Abscess drainage under x-ray,75989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,432.36,,,,,,,fee schedule,283.46,497.21,
Abscess drainage under x-ray,75989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.46,,,,,,,fee schedule,283.46,497.21,
Abscess drainage under x-ray,75989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.89,,,,,,,fee schedule,283.46,497.21,
Abscess drainage under x-ray,75989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,497.21,,,,,,,fee schedule,283.46,497.21,
Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,265.46,,,,,,,fee schedule,174.04,427.94,
Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.04,,,,,,,fee schedule,174.04,427.94,
Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,217.28,,,,,,,fee schedule,174.04,427.94,
Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,305.28,,,,,,,fee schedule,174.04,427.94,
Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,174.04,427.94,APC
Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,174.04,427.94,APC
Fluoroscope examination,76000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,174.04,427.94,APC
X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.57,,,,,,,fee schedule,81.01,156.08,
X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.01,,,,,,,fee schedule,81.01,156.08,
X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.14,,,,,,,fee schedule,81.01,156.08,
X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.11,,,,,,,fee schedule,81.01,156.08,
X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,81.01,156.08,APC
X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,81.01,156.08,APC
X-ray nose to rectum,76010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,81.01,156.08,APC
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.05,,,,,,,fee schedule,26.26,51.88,
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.26,,,,,,,fee schedule,26.26,51.88,
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.78,,,,,,,fee schedule,26.26,51.88,
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.06,,,,,,,fee schedule,26.26,51.88,
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,26.26,51.88,APC
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,26.26,51.88,APC
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,26.26,51.88,APC
Mr sfty mplt&/fb asmt stf ea,76015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.44,,,,,,,fee schedule,53.39,93.66,
Mr sfty mplt&/fb asmt stf ea,76015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.39,,,,,,,fee schedule,53.39,93.66,
Mr sfty mplt&/fb asmt stf ea,76015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.66,,,,,,,fee schedule,53.39,93.66,
Mr sfty mplt&/fb asmt stf ea,76015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.66,,,,,,,fee schedule,53.39,93.66,
Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.97,,,,,,,fee schedule,86.71,165.57,
Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.39,,,,,,,fee schedule,86.71,165.57,
Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.84,,,,,,,fee schedule,86.71,165.57,
Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.57,,,,,,,fee schedule,86.71,165.57,
Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,165.57,APC
Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,165.57,APC
Mr safety deter phys/qhp,76016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,165.57,APC
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.21,,,,,,,fee schedule,237.74,454.49,
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.1,,,,,,,fee schedule,237.74,454.49,
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,323.48,,,,,,,fee schedule,237.74,454.49,
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.49,,,,,,,fee schedule,237.74,454.49,
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,454.49,APC
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,454.49,APC
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,454.49,APC
Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.08,,,,,,,fee schedule,94.73,172.59,
Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.39,,,,,,,fee schedule,94.73,172.59,
Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.84,,,,,,,fee schedule,94.73,172.59,
Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.59,,,,,,,fee schedule,94.73,172.59,
Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,172.59,APC
Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,172.59,APC
Mr safety implant elec prepj,76018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,172.59,APC
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.12,,,,,,,fee schedule,58.78,111.69,
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.49,,,,,,,fee schedule,58.78,111.69,
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.67,,,,,,,fee schedule,58.78,111.69,
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.69,,,,,,,fee schedule,58.78,111.69,
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,111.69,APC
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,111.69,APC
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,111.69,APC
X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,298.86,,,,,,,fee schedule,195.93,980.01,
X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,244.62,,,,,,,fee schedule,195.93,980.01,
X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.93,,,,,,,fee schedule,195.93,980.01,
X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,343.69,,,,,,,fee schedule,195.93,980.01,
X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,195.93,980.01,APC
X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,195.93,980.01,APC
X-ray exam of fistula,76080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,195.93,980.01,APC
X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.63,,,,,,,fee schedule,27.29,980.01,
X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.07,,,,,,,fee schedule,27.29,980.01,
X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.29,,,,,,,fee schedule,27.29,980.01,
X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.87,,,,,,,fee schedule,27.29,980.01,
X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,27.29,980.01,APC
X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,27.29,980.01,APC
X-ray exam breast specimen,76098,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,27.29,980.01,APC
X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.59,,,,,,,fee schedule,104.17,190.43,
X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.56,,,,,,,fee schedule,104.17,190.43,
X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.54,,,,,,,fee schedule,104.17,190.43,
X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.43,,,,,,,fee schedule,104.17,190.43,
X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,190.43,APC
X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,190.43,APC
X-ray exam of body section,76100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,190.43,APC
Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,180.3,,,,,,,fee schedule,104.17,207.35,
Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.2,,,,,,,fee schedule,104.17,207.35,
Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.58,,,,,,,fee schedule,104.17,207.35,
Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,207.35,,,,,,,fee schedule,104.17,207.35,
Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,207.35,APC
Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,207.35,APC
Cine/video x-rays,76120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,207.35,APC
Cine/video x-rays add-on,76125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.16,,,,,,,fee schedule,58.45,102.53,
Cine/video x-rays add-on,76125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.45,,,,,,,fee schedule,58.45,102.53,
Cine/video x-rays add-on,76125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.98,,,,,,,fee schedule,58.45,102.53,
Cine/video x-rays add-on,76125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.53,,,,,,,fee schedule,58.45,102.53,
Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.48,,,,,,,fee schedule,161.59,669.27,
Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.59,,,,,,,fee schedule,161.59,669.27,
Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.74,,,,,,,fee schedule,161.59,669.27,
Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.45,,,,,,,fee schedule,161.59,669.27,
Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,161.59,669.27,APC
Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,161.59,669.27,APC
Med physic dos eval rad exps,76145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,161.59,669.27,APC
3d render w/intrp postproces,76376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,511.87,,,,,,,fee schedule,335.58,588.65,
3d render w/intrp postproces,76376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,335.58,,,,,,,fee schedule,335.58,588.65,
3d render w/intrp postproces,76376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,418.97,,,,,,,fee schedule,335.58,588.65,
3d render w/intrp postproces,76376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.65,,,,,,,fee schedule,335.58,588.65,
3d render w/intrp postproces,76377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,579.62,,,,,,,fee schedule,380,666.56,
3d render w/intrp postproces,76377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,380,,,,,,,fee schedule,380,666.56,
3d render w/intrp postproces,76377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,474.42,,,,,,,fee schedule,380,666.56,
3d render w/intrp postproces,76377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,666.56,,,,,,,fee schedule,380,666.56,
CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,399.67,,,,,,,fee schedule,86.71,459.62,
CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.02,,,,,,,fee schedule,86.71,459.62,
CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,327.13,,,,,,,fee schedule,86.71,459.62,
CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,459.62,,,,,,,fee schedule,86.71,459.62,
CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,459.62,APC
CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,459.62,APC
CAT scan follow-up study,76380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,459.62,APC
Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3727.15,,,,,,,fee schedule,86.71,4286.22,
Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2443.52,,,,,,,fee schedule,86.71,4286.22,
Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3050.67,,,,,,,fee schedule,86.71,4286.22,
Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4286.22,,,,,,,fee schedule,86.71,4286.22,
Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,4286.22,APC
Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,4286.22,APC
Mr spectroscopy,76390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,4286.22,APC
Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,605.27,,,,,,,fee schedule,237.74,696.06,
Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,396.82,,,,,,,fee schedule,237.74,696.06,
Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,495.41,,,,,,,fee schedule,237.74,696.06,
Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,696.06,,,,,,,fee schedule,237.74,696.06,
Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,696.06,APC
Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,696.06,APC
Mr elastography,76391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,696.06,APC
Fluoroscopic procedure,76496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Fluoroscopic procedure,76496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Fluoroscopic procedure,76496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Ct procedure,76497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Ct procedure,76497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Ct procedure,76497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Mri procedure,76498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Mri procedure,76498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Mri procedure,76498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Radiographic procedure,76499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Radiographic procedure,76499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Radiographic procedure,76499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,434.31,,,,,,,fee schedule,104.17,499.46,
Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,284.73,,,,,,,fee schedule,104.17,499.46,
Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,355.48,,,,,,,fee schedule,104.17,499.46,
Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,499.46,,,,,,,fee schedule,104.17,499.46,
Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,499.46,APC
Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,499.46,APC
Echo exam of head,76506,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,499.46,APC
Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,223.41,,,,,,,fee schedule,132.57,256.92,
Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.47,,,,,,,fee schedule,132.57,256.92,
Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.86,,,,,,,fee schedule,132.57,256.92,
Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,256.92,,,,,,,fee schedule,132.57,256.92,
Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,256.92,APC
Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,256.92,APC
Ophth us b & quant a,76510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,256.92,APC
Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.24,,,,,,,fee schedule,88.01,187.51,
Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.01,,,,,,,fee schedule,88.01,187.51,
Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.88,,,,,,,fee schedule,88.01,187.51,
Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.38,,,,,,,fee schedule,88.01,187.51,
Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,88.01,187.51,APC
Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,88.01,187.51,APC
Ophth us quant a only,76511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,88.01,187.51,APC
Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,244.69,,,,,,,fee schedule,104.17,281.39,
Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,160.42,,,,,,,fee schedule,104.17,281.39,
Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,200.28,,,,,,,fee schedule,104.17,281.39,
Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,281.39,,,,,,,fee schedule,104.17,281.39,
Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,281.39,APC
Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,281.39,APC
Ophth us b w/non-quant a,76512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,281.39,APC
Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.6,,,,,,,fee schedule,104.17,189.29,
Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.91,,,,,,,fee schedule,104.17,189.29,
Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.73,,,,,,,fee schedule,104.17,189.29,
Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.29,,,,,,,fee schedule,104.17,189.29,
Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,189.29,APC
Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,189.29,APC
Echo exam of eye water bath,76513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,189.29,APC
Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.69,,,,,,,fee schedule,9.63,51.88,
Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.63,,,,,,,fee schedule,9.63,51.88,
Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.02,,,,,,,fee schedule,9.63,51.88,
Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.89,,,,,,,fee schedule,9.63,51.88,
Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,9.63,51.88,APC
Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,9.63,51.88,APC
Echo exam of eye thickness,76514,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,9.63,51.88,APC
Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.3,,,,,,,fee schedule,86.08,187.51,
Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.08,,,,,,,fee schedule,86.08,187.51,
Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.47,,,,,,,fee schedule,86.08,187.51,
Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151,,,,,,,fee schedule,86.08,187.51,
Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,86.08,187.51,APC
Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,86.08,187.51,APC
Echo exam of eye,76516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,86.08,187.51,APC
Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.98,,,,,,,fee schedule,96.36,187.51,
Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.36,,,,,,,fee schedule,96.36,187.51,
Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.3,,,,,,,fee schedule,96.36,187.51,
Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.03,,,,,,,fee schedule,96.36,187.51,
Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,96.36,187.51,APC
Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,96.36,187.51,APC
Echo exam of eye,76519,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,96.36,187.51,APC
Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.34,,,,,,,fee schedule,84.8,156.08,
Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.8,,,,,,,fee schedule,84.8,156.08,
Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.86,,,,,,,fee schedule,84.8,156.08,
Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.74,,,,,,,fee schedule,84.8,156.08,
Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,84.8,156.08,APC
Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,84.8,156.08,APC
Echo exam of eye,76529,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,84.8,156.08,APC
Us exam of head and neck,76536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Us exam of head and neck,76536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Us exam of head and neck,76536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.69,,,,,,,fee schedule,104.17,220.44,
Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.67,,,,,,,fee schedule,104.17,220.44,
Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.9,,,,,,,fee schedule,104.17,220.44,
Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.44,,,,,,,fee schedule,104.17,220.44,
Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,220.44,APC
Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,220.44,APC
Us exam chest,76604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,220.44,APC
Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.99,,,,,,,fee schedule,94.4,187.51,
Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.4,,,,,,,fee schedule,94.4,187.51,
Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.86,,,,,,,fee schedule,94.4,187.51,
Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.59,,,,,,,fee schedule,94.4,187.51,
Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,94.4,187.51,APC
Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,94.4,187.51,APC
Ultrasound breast complete,76641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,94.4,187.51,APC
Ultrasound breast limited,76642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Ultrasound breast limited,76642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Ultrasound breast limited,76642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.57,,,,,,,fee schedule,104.17,258.26,
Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.23,,,,,,,fee schedule,104.17,258.26,
Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,183.81,,,,,,,fee schedule,104.17,258.26,
Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.26,,,,,,,fee schedule,104.17,258.26,
Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,258.26,APC
Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,258.26,APC
Us exam abdom complete,76700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,258.26,APC
Echo exam of abdomen,76705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Echo exam of abdomen,76705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Echo exam of abdomen,76705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,183.22,,,,,,,fee schedule,104.17,210.7,
Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,120.12,,,,,,,fee schedule,104.17,210.7,
Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.97,,,,,,,fee schedule,104.17,210.7,
Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,210.7,,,,,,,fee schedule,104.17,210.7,
Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,210.7,APC
Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,210.7,APC
Us abdl aorta screen aaa,76706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,210.7,APC
Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.57,,,,,,,fee schedule,104.17,258.26,
Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.23,,,,,,,fee schedule,104.17,258.26,
Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,183.81,,,,,,,fee schedule,104.17,258.26,
Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.26,,,,,,,fee schedule,104.17,258.26,
Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,258.26,APC
Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,258.26,APC
Us exam abdo back wall comp,76770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,258.26,APC
Us exam abdo back wall lim,76775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Us exam abdo back wall lim,76775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Us exam abdo back wall lim,76775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,331.15,,,,,,,fee schedule,104.17,380.82,
Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.1,,,,,,,fee schedule,104.17,380.82,
Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,271.05,,,,,,,fee schedule,104.17,380.82,
Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.82,,,,,,,fee schedule,104.17,380.82,
Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,380.82,APC
Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,380.82,APC
Us exam k transpl w/doppler,76776,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,380.82,APC
Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.53,,,,,,,fee schedule,104.17,413.46,
Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.71,,,,,,,fee schedule,104.17,413.46,
Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.28,,,,,,,fee schedule,104.17,413.46,
Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.46,,,,,,,fee schedule,104.17,413.46,
Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,413.46,APC
Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,413.46,APC
Us exam spinal canal,76800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,413.46,APC
Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.98,,,,,,,fee schedule,104.17,250.68,
Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.91,,,,,,,fee schedule,104.17,250.68,
Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.42,,,,,,,fee schedule,104.17,250.68,
Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.68,,,,,,,fee schedule,104.17,250.68,
Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,250.68,APC
Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,250.68,APC
Ob us < 14 wks single fetus,76801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,250.68,APC
Ob us < 14 wks addl fetus,76802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.58,,,,,,,fee schedule,42.34,74.27,
Ob us < 14 wks addl fetus,76802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.34,,,,,,,fee schedule,42.34,74.27,
Ob us < 14 wks addl fetus,76802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.86,,,,,,,fee schedule,42.34,74.27,
Ob us < 14 wks addl fetus,76802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.27,,,,,,,fee schedule,42.34,74.27,
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.15,,,,,,,fee schedule,82.05,143.92,
Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.05,,,,,,,fee schedule,82.05,143.92,
Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.44,,,,,,,fee schedule,82.05,143.92,
Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.92,,,,,,,fee schedule,82.05,143.92,
Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,749.22,,,,,,,fee schedule,237.74,861.6,
Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,491.19,,,,,,,fee schedule,237.74,861.6,
Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,613.24,,,,,,,fee schedule,237.74,861.6,
Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,861.6,,,,,,,fee schedule,237.74,861.6,
Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,861.6,APC
Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,861.6,APC
Ob us detailed sngl fetus,76811,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,861.6,APC
Ob us detailed addl fetus,76812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.51,,,,,,,fee schedule,206.85,362.84,
Ob us detailed addl fetus,76812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.85,,,,,,,fee schedule,206.85,362.84,
Ob us detailed addl fetus,76812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.24,,,,,,,fee schedule,206.85,362.84,
Ob us detailed addl fetus,76812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,362.84,,,,,,,fee schedule,206.85,362.84,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,170.5,,,,,,,fee schedule,104.17,196.08,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.78,,,,,,,fee schedule,104.17,196.08,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.55,,,,,,,fee schedule,104.17,196.08,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.08,,,,,,,fee schedule,104.17,196.08,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,196.08,APC
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,196.08,APC
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,196.08,APC
Ob us nuchal meas add-on,76814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.29,,,,,,,fee schedule,54.6,95.78,
Ob us nuchal meas add-on,76814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.6,,,,,,,fee schedule,54.6,95.78,
Ob us nuchal meas add-on,76814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.17,,,,,,,fee schedule,54.6,95.78,
Ob us nuchal meas add-on,76814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.78,,,,,,,fee schedule,54.6,95.78,
Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.98,,,,,,,fee schedule,104.17,250.68,
Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.91,,,,,,,fee schedule,104.17,250.68,
Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.42,,,,,,,fee schedule,104.17,250.68,
Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.68,,,,,,,fee schedule,104.17,250.68,
Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,250.68,APC
Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,250.68,APC
Ob us limited fetus(s),76815,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,250.68,APC
Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.98,,,,,,,fee schedule,104.17,250.68,
Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.91,,,,,,,fee schedule,104.17,250.68,
Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.42,,,,,,,fee schedule,104.17,250.68,
Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.68,,,,,,,fee schedule,104.17,250.68,
Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,250.68,APC
Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,250.68,APC
Ob us follow-up per fetus,76816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,250.68,APC
Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.98,,,,,,,fee schedule,104.17,250.68,
Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.91,,,,,,,fee schedule,104.17,250.68,
Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.42,,,,,,,fee schedule,104.17,250.68,
Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.68,,,,,,,fee schedule,104.17,250.68,
Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,250.68,APC
Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,250.68,APC
Transvaginal us obstetric,76817,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,250.68,APC
Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.02,,,,,,,fee schedule,104.17,221.97,
Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.54,,,,,,,fee schedule,104.17,221.97,
Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.99,,,,,,,fee schedule,104.17,221.97,
Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.97,,,,,,,fee schedule,104.17,221.97,
Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,221.97,APC
Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,221.97,APC
Fetal biophys profile w/nst,76818,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,221.97,APC
Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.61,,,,,,,fee schedule,104.17,373.3,
Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.81,,,,,,,fee schedule,104.17,373.3,
Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.69,,,,,,,fee schedule,104.17,373.3,
Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,373.3,,,,,,,fee schedule,104.17,373.3,
Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,373.3,APC
Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,373.3,APC
Fetal biophys profil w/o nst,76819,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,373.3,APC
Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,421.62,,,,,,,fee schedule,104.17,484.86,
Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,276.41,,,,,,,fee schedule,104.17,484.86,
Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,345.1,,,,,,,fee schedule,104.17,484.86,
Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,484.86,,,,,,,fee schedule,104.17,484.86,
Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,484.86,APC
Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,484.86,APC
Umbilical artery echo,76820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,484.86,APC
Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.74,,,,,,,fee schedule,104.07,187.51,
Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.07,,,,,,,fee schedule,104.07,187.51,
Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.93,,,,,,,fee schedule,104.07,187.51,
Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.55,,,,,,,fee schedule,104.07,187.51,
Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.07,187.51,APC
Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.07,187.51,APC
Middle cerebral artery echo,76821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.07,187.51,APC
Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,541.85,,,,,,,fee schedule,355.24,980.01,
Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,355.24,,,,,,,fee schedule,355.24,980.01,
Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,443.5,,,,,,,fee schedule,355.24,980.01,
Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,623.13,,,,,,,fee schedule,355.24,980.01,
Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,355.24,980.01,APC
Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,355.24,980.01,APC
Echo exam of fetal heart,76825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,355.24,980.01,APC
Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,340.98,,,,,,,fee schedule,223.55,427.94,
Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.55,,,,,,,fee schedule,223.55,427.94,
Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.09,,,,,,,fee schedule,223.55,427.94,
Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.13,,,,,,,fee schedule,223.55,427.94,
Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,223.55,427.94,APC
Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,223.55,427.94,APC
Echo exam of fetal heart,76826,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,223.55,427.94,APC
Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.31,,,,,,,fee schedule,85.43,187.51,
Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.43,,,,,,,fee schedule,85.43,187.51,
Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.66,,,,,,,fee schedule,85.43,187.51,
Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.86,,,,,,,fee schedule,85.43,187.51,
Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,85.43,187.51,APC
Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,85.43,187.51,APC
Echo exam of fetal heart,76827,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,85.43,187.51,APC
Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.54,,,,,,,fee schedule,46.25,187.51,
Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.25,,,,,,,fee schedule,46.25,187.51,
Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.74,,,,,,,fee schedule,46.25,187.51,
Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.12,,,,,,,fee schedule,46.25,187.51,
Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,46.25,187.51,APC
Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,46.25,187.51,APC
Echo exam of fetal heart,76828,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,46.25,187.51,APC
Transvaginal us non-ob,76830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Transvaginal us non-ob,76830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Transvaginal us non-ob,76830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,231.25,,,,,,,fee schedule,151.61,427.94,
Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.61,,,,,,,fee schedule,151.61,427.94,
Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.28,,,,,,,fee schedule,151.61,427.94,
Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.94,,,,,,,fee schedule,151.61,427.94,
Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,151.61,427.94,APC
Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,151.61,427.94,APC
Echo exam uterus,76831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,151.61,427.94,APC
Us exam pelvic complete,76856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Us exam pelvic complete,76856,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Us exam pelvic complete,76856,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.98,,,,,,,fee schedule,104.17,250.68,
Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.91,,,,,,,fee schedule,104.17,250.68,
Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.42,,,,,,,fee schedule,104.17,250.68,
Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.68,,,,,,,fee schedule,104.17,250.68,
Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,250.68,APC
Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,250.68,APC
Us exam pelvic limited,76857,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,250.68,APC
Us exam scrotum,76870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Us exam scrotum,76870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Us exam scrotum,76870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.47,,,,,,,fee schedule,104.17,197.19,
Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.42,,,,,,,fee schedule,104.17,197.19,
Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.35,,,,,,,fee schedule,104.17,197.19,
Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.19,,,,,,,fee schedule,104.17,197.19,
Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,197.19,APC
Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,197.19,APC
Us transrectal,76872,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,197.19,APC
Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.87,,,,,,,fee schedule,104.17,554.15,
Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.91,,,,,,,fee schedule,104.17,554.15,
Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,394.41,,,,,,,fee schedule,104.17,554.15,
Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,554.15,,,,,,,fee schedule,104.17,554.15,
Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,554.15,APC
Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,554.15,APC
Echograp trans r pros study,76873,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,554.15,APC
Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.99,,,,,,,fee schedule,104.17,327.74,
Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.84,,,,,,,fee schedule,104.17,327.74,
Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,233.26,,,,,,,fee schedule,104.17,327.74,
Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,327.74,,,,,,,fee schedule,104.17,327.74,
Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,327.74,APC
Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,327.74,APC
Us xtr non-vasc complete,76881,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,327.74,APC
Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.46,,,,,,,fee schedule,104.17,204.08,
Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.34,,,,,,,fee schedule,104.17,204.08,
Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.25,,,,,,,fee schedule,104.17,204.08,
Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,204.08,,,,,,,fee schedule,104.17,204.08,
Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,204.08,APC
Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,204.08,APC
Us xtr non-vasc lmtd,76882,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,204.08,APC
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.29,,,,,,,fee schedule,104.17,234.93,
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.93,,,,,,,fee schedule,104.17,234.93,
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.21,,,,,,,fee schedule,104.17,234.93,
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,234.93,,,,,,,fee schedule,104.17,234.93,
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,234.93,APC
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,234.93,APC
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,234.93,APC
Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,304.72,,,,,,,fee schedule,86.71,350.43,
Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.77,,,,,,,fee schedule,86.71,350.43,
Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,249.41,,,,,,,fee schedule,86.71,350.43,
Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,350.43,,,,,,,fee schedule,86.71,350.43,
Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,350.43,APC
Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,350.43,APC
Us exam infant hips dynamic,76885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,350.43,APC
Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,528.07,,,,,,,fee schedule,86.71,607.28,
Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,346.2,,,,,,,fee schedule,86.71,607.28,
Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,432.23,,,,,,,fee schedule,86.71,607.28,
Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,607.28,,,,,,,fee schedule,86.71,607.28,
Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,607.28,APC
Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,607.28,APC
Us exam infant hips static,76886,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,607.28,APC
Echo guide for heart biopsy,76932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.81,,,,,,,fee schedule,101.49,178.03,
Echo guide for heart biopsy,76932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.49,,,,,,,fee schedule,101.49,178.03,
Echo guide for heart biopsy,76932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.71,,,,,,,fee schedule,101.49,178.03,
Echo guide for heart biopsy,76932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.03,,,,,,,fee schedule,101.49,178.03,
Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,485.02,,,,,,,fee schedule,215.15,557.77,
Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,317.98,,,,,,,fee schedule,215.15,557.77,
Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,396.99,,,,,,,fee schedule,215.15,557.77,
Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,557.77,,,,,,,fee schedule,215.15,557.77,
Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,557.77,APC
Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,557.77,APC
Echo guide for artery repair,76936,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,557.77,APC
Us guide vascular access,76937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.14,,,,,,,fee schedule,57.78,101.36,
Us guide vascular access,76937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.78,,,,,,,fee schedule,57.78,101.36,
Us guide vascular access,76937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.14,,,,,,,fee schedule,57.78,101.36,
Us guide vascular access,76937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.36,,,,,,,fee schedule,57.78,101.36,
Us guide tissue ablation,76940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.35,,,,,,,fee schedule,116.27,203.95,
Us guide tissue ablation,76940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.27,,,,,,,fee schedule,116.27,203.95,
Us guide tissue ablation,76940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.16,,,,,,,fee schedule,116.27,203.95,
Us guide tissue ablation,76940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,203.95,,,,,,,fee schedule,116.27,203.95,
Echo guide for transfusion,76941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.84,,,,,,,fee schedule,100.86,176.92,
Echo guide for transfusion,76941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.86,,,,,,,fee schedule,100.86,176.92,
Echo guide for transfusion,76941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.92,,,,,,,fee schedule,100.86,176.92,
Echo guide for transfusion,76941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.92,,,,,,,fee schedule,100.86,176.92,
Echo guide for biopsy,76942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,488.95,,,,,,,fee schedule,320.56,562.29,
Echo guide for biopsy,76942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,320.56,,,,,,,fee schedule,320.56,562.29,
Echo guide for biopsy,76942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,400.21,,,,,,,fee schedule,320.56,562.29,
Echo guide for biopsy,76942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,562.29,,,,,,,fee schedule,320.56,562.29,
Echo guide villus sampling,76945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,174.41,,,,,,,fee schedule,114.34,200.57,
Echo guide villus sampling,76945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.34,,,,,,,fee schedule,114.34,200.57,
Echo guide villus sampling,76945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.75,,,,,,,fee schedule,114.34,200.57,
Echo guide villus sampling,76945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,200.57,,,,,,,fee schedule,114.34,200.57,
Echo guide for amniocentesis,76946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Echo guide for amniocentesis,76946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Echo guide for amniocentesis,76946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Echo guide for amniocentesis,76946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Echo guide ova aspiration,76948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.83,,,,,,,fee schedule,68.73,120.55,
Echo guide ova aspiration,76948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.73,,,,,,,fee schedule,68.73,120.55,
Echo guide ova aspiration,76948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.8,,,,,,,fee schedule,68.73,120.55,
Echo guide ova aspiration,76948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.55,,,,,,,fee schedule,68.73,120.55,
Echo guidance radiotherapy,76965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.6,,,,,,,fee schedule,43.66,76.59,
Echo guidance radiotherapy,76965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.66,,,,,,,fee schedule,43.66,76.59,
Echo guidance radiotherapy,76965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.51,,,,,,,fee schedule,43.66,76.59,
Echo guidance radiotherapy,76965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.59,,,,,,,fee schedule,43.66,76.59,
GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.52,,,,,,,fee schedule,111.14,427.94,
GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.14,,,,,,,fee schedule,111.14,427.94,
GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.75,,,,,,,fee schedule,111.14,427.94,
GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.95,,,,,,,fee schedule,111.14,427.94,
GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,111.14,427.94,APC
GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,111.14,427.94,APC
GI endoscopic ultrasound,76975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,111.14,427.94,APC
Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.74,,,,,,,fee schedule,8.35,187.51,
Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.35,,,,,,,fee schedule,8.35,187.51,
Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.43,,,,,,,fee schedule,8.35,187.51,
Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.65,,,,,,,fee schedule,8.35,187.51,
Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,8.35,187.51,APC
Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,8.35,187.51,APC
Us bone density measure,76977,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,8.35,187.51,APC
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,529.61,,,,,,,fee schedule,347.21,625.71,
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.21,,,,,,,fee schedule,347.21,625.71,
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,433.49,,,,,,,fee schedule,347.21,625.71,
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.05,,,,,,,fee schedule,347.21,625.71,
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.21,625.71,APC
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.21,625.71,APC
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.21,625.71,APC
Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,474.93,,,,,,,fee schedule,311.36,546.17,
Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,311.36,,,,,,,fee schedule,311.36,546.17,
Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,388.73,,,,,,,fee schedule,311.36,546.17,
Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,546.17,,,,,,,fee schedule,311.36,546.17,
Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.36,,,,,,,fee schedule,104.17,339.66,
Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.64,,,,,,,fee schedule,104.17,339.66,
Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.75,,,,,,,fee schedule,104.17,339.66,
Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.66,,,,,,,fee schedule,104.17,339.66,
Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,339.66,APC
Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,339.66,APC
Use parenchyma,76981,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,339.66,APC
Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.36,,,,,,,fee schedule,104.17,339.66,
Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.64,,,,,,,fee schedule,104.17,339.66,
Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.75,,,,,,,fee schedule,104.17,339.66,
Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,339.66,,,,,,,fee schedule,104.17,339.66,
Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,339.66,APC
Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,339.66,APC
Use 1st target lesion,76982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,339.66,APC
Use ea addl target lesion,76983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.87,,,,,,,fee schedule,58.92,103.35,
Use ea addl target lesion,76983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.92,,,,,,,fee schedule,58.92,103.35,
Use ea addl target lesion,76983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.56,,,,,,,fee schedule,58.92,103.35,
Use ea addl target lesion,76983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.35,,,,,,,fee schedule,58.92,103.35,
Us guide intraop,76998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,520.87,,,,,,,fee schedule,341.48,599,
Us guide intraop,76998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,341.48,,,,,,,fee schedule,341.48,599,
Us guide intraop,76998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,426.33,,,,,,,fee schedule,341.48,599,
Us guide intraop,76998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,599,,,,,,,fee schedule,341.48,599,
Echo examination procedure,76999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Echo examination procedure,76999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Echo examination procedure,76999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Fluoroguide for Vein Device,77001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.12,,,,,,,fee schedule,128.58,225.54,
Fluoroguide for Vein Device,77001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.58,,,,,,,fee schedule,128.58,225.54,
Fluoroguide for Vein Device,77001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.52,,,,,,,fee schedule,128.58,225.54,
Fluoroguide for Vein Device,77001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.54,,,,,,,fee schedule,128.58,225.54,
Needle localization by xray,77002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.8,,,,,,,fee schedule,83.79,146.97,
Needle localization by xray,77002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.79,,,,,,,fee schedule,83.79,146.97,
Needle localization by xray,77002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.6,,,,,,,fee schedule,83.79,146.97,
Needle localization by xray,77002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.97,,,,,,,fee schedule,83.79,146.97,
Fluoroguide for Spine Inject,77003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,138.34,,,,,,,fee schedule,90.7,159.09,
Fluoroguide for Spine Inject,77003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.7,,,,,,,fee schedule,90.7,159.09,
Fluoroguide for Spine Inject,77003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.23,,,,,,,fee schedule,90.7,159.09,
Fluoroguide for Spine Inject,77003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,159.09,,,,,,,fee schedule,90.7,159.09,
CT Scan for Localization,77011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,444.83,,,,,,,fee schedule,291.63,511.55,
CT Scan for Localization,77011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.63,,,,,,,fee schedule,291.63,511.55,
CT Scan for Localization,77011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,364.09,,,,,,,fee schedule,291.63,511.55,
CT Scan for Localization,77011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,511.55,,,,,,,fee schedule,291.63,511.55,
Ct scan for needle biopsy,77012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,459.74,,,,,,,fee schedule,301.41,528.7,
Ct scan for needle biopsy,77012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.41,,,,,,,fee schedule,301.41,528.7,
Ct scan for needle biopsy,77012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.3,,,,,,,fee schedule,301.41,528.7,
Ct scan for needle biopsy,77012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,528.7,,,,,,,fee schedule,301.41,528.7,
CT Guide for Tissue Ablation,77013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2055.11,,,,,,,fee schedule,1347.33,2363.38,
CT Guide for Tissue Ablation,77013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1347.33,,,,,,,fee schedule,1347.33,2363.38,
CT Guide for Tissue Ablation,77013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1682.11,,,,,,,fee schedule,1347.33,2363.38,
CT Guide for Tissue Ablation,77013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2363.38,,,,,,,fee schedule,1347.33,2363.38,
CT Scan for Therapy Guide,77014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,205.78,,,,,,,fee schedule,134.91,236.65,
CT Scan for Therapy Guide,77014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.91,,,,,,,fee schedule,134.91,236.65,
CT Scan for Therapy Guide,77014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,168.43,,,,,,,fee schedule,134.91,236.65,
CT Scan for Therapy Guide,77014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,236.65,,,,,,,fee schedule,134.91,236.65,
MR Guidance for Needle Place,77021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2234.31,,,,,,,fee schedule,1464.81,2569.46,
MR Guidance for Needle Place,77021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1464.81,,,,,,,fee schedule,1464.81,2569.46,
MR Guidance for Needle Place,77021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1828.78,,,,,,,fee schedule,1464.81,2569.46,
MR Guidance for Needle Place,77021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2569.46,,,,,,,fee schedule,1464.81,2569.46,
MRI for Tissue Ablation,77022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1323.77,,,,,,,fee schedule,867.86,1522.34,
MRI for Tissue Ablation,77022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,867.86,,,,,,,fee schedule,867.86,1522.34,
MRI for Tissue Ablation,77022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1083.51,,,,,,,fee schedule,867.86,1522.34,
MRI for Tissue Ablation,77022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1522.34,,,,,,,fee schedule,867.86,1522.34,
Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,605.27,,,,,,,fee schedule,237.74,696.06,
Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,396.82,,,,,,,fee schedule,237.74,696.06,
Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,495.41,,,,,,,fee schedule,237.74,696.06,
Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,696.06,,,,,,,fee schedule,237.74,696.06,
Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,696.06,APC
Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,696.06,APC
Mri breast c- unilateral,77046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,696.06,APC
Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,605.27,,,,,,,fee schedule,237.74,696.06,
Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,396.82,,,,,,,fee schedule,237.74,696.06,
Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,495.41,,,,,,,fee schedule,237.74,696.06,
Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,696.06,,,,,,,fee schedule,237.74,696.06,
Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,696.06,APC
Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,696.06,APC
Mri breast c- bilateral,77047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,696.06,APC
Mri breast c-+ w/cad uni,77048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,772.97,,,,,,,fee schedule,506.76,888.92,
Mri breast c-+ w/cad uni,77048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,506.76,,,,,,,fee schedule,506.76,888.92,
Mri breast c-+ w/cad uni,77048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,632.68,,,,,,,fee schedule,506.76,888.92,
Mri breast c-+ w/cad uni,77048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,888.92,,,,,,,fee schedule,506.76,888.92,
X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,273.9,,,,,,,fee schedule,179.57,427.94,
X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.57,,,,,,,fee schedule,179.57,427.94,
X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.19,,,,,,,fee schedule,179.57,427.94,
X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,314.99,,,,,,,fee schedule,179.57,427.94,
X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,179.57,427.94,APC
X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,179.57,427.94,APC
X-Ray of Mammary Duct,77053,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,179.57,427.94,APC
X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.9,,,,,,,fee schedule,98.93,427.94,
X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.93,,,,,,,fee schedule,98.93,427.94,
X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.51,,,,,,,fee schedule,98.93,427.94,
X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.54,,,,,,,fee schedule,98.93,427.94,
X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,98.93,427.94,APC
X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,98.93,427.94,APC
X-ray of mammary ducts,77054,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,98.93,427.94,APC
Breast tomosynthesis uni,77061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.67,,,,,,,fee schedule,170.24,298.62,
Breast tomosynthesis uni,77061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.24,,,,,,,fee schedule,170.24,298.62,
Breast tomosynthesis uni,77061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.54,,,,,,,fee schedule,170.24,298.62,
Breast tomosynthesis uni,77061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.62,,,,,,,fee schedule,170.24,298.62,
Breast tomosynthesis bi,77062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.16,,,,,,,fee schedule,217.76,381.98,
Breast tomosynthesis bi,77062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.76,,,,,,,fee schedule,217.76,381.98,
Breast tomosynthesis bi,77062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,271.87,,,,,,,fee schedule,217.76,381.98,
Breast tomosynthesis bi,77062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,381.98,,,,,,,fee schedule,217.76,381.98,
Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.08,,,,,,,fee schedule,103.64,181.79,
Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.64,,,,,,,fee schedule,103.64,181.79,
Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.39,,,,,,,fee schedule,103.64,181.79,
Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,181.79,,,,,,,fee schedule,103.64,181.79,
Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,22.42,,,,,,,fee schedule,21.35,38.43,APC
Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,TC,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.35,,,,,,,fee schedule,21.35,38.43,APC
Breast tomosynthesis bi,77063,HCPCS,,,,,facility,outpatient,,,TC,,,Meridian Health Plan,Ambetter Exchange,38.43,,,,,,,fee schedule,21.35,38.43,APC
Dx mammo incl cad uni,77065,HCPCS,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,82.69,,,,,,,fee schedule,78.75,141.75,APC
Dx mammo incl cad uni,77065,HCPCS,,,,,facility,outpatient,,,TC,,,BCBS,Blue Care Network Medicare Managed Care Plan,78.75,,,,,,,fee schedule,78.75,141.75,APC
Dx mammo incl cad uni,77065,HCPCS,,,,,facility,outpatient,,,TC,,,Meridian Health Plan,Ambetter Exchange,141.75,,,,,,,fee schedule,78.75,141.75,APC
Dx mammo incl cad bi,77066,HCPCS,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,106.13,,,,,,,fee schedule,101.08,181.94,APC
Dx mammo incl cad bi,77066,HCPCS,,,,,facility,outpatient,,,TC,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.08,,,,,,,fee schedule,101.08,181.94,APC
Dx mammo incl cad bi,77066,HCPCS,,,,,facility,outpatient,,,TC,,,Meridian Health Plan,Ambetter Exchange,181.94,,,,,,,fee schedule,101.08,181.94,APC
Scr mammo bi incl cad,77067,HCPCS,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,87.49,,,,,,,fee schedule,83.32,149.98,APC
Scr mammo bi incl cad,77067,HCPCS,,,,,facility,outpatient,,,TC,,,BCBS,Blue Care Network Medicare Managed Care Plan,83.32,,,,,,,fee schedule,83.32,149.98,APC
Scr mammo bi incl cad,77067,HCPCS,,,,,facility,outpatient,,,TC,,,Meridian Health Plan,Ambetter Exchange,149.98,,,,,,,fee schedule,83.32,149.98,APC
X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.09,,,,,,,fee schedule,78.73,156.08,
X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.73,,,,,,,fee schedule,78.73,156.08,
X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.29,,,,,,,fee schedule,78.73,156.08,
X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.1,,,,,,,fee schedule,78.73,156.08,
X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,78.73,156.08,APC
X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,78.73,156.08,APC
X-Ray Stress View,77071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,78.73,156.08,APC
X-Rays for Bone Age,77072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
X-Rays for Bone Age,77072,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
X-Rays for Bone Age,77072,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
X-rays bone length studies,77073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
X-rays bone length studies,77073,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
X-rays bone length studies,77073,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.64,,,,,,,fee schedule,75.16,187.51,
X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.16,,,,,,,fee schedule,75.16,187.51,
X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.83,,,,,,,fee schedule,75.16,187.51,
X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.84,,,,,,,fee schedule,75.16,187.51,
X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,75.16,187.51,APC
X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,75.16,187.51,APC
X-rays bone survey limited,77074,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,75.16,187.51,APC
X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.11,,,,,,,fee schedule,104.17,292.23,
X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.59,,,,,,,fee schedule,104.17,292.23,
X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.99,,,,,,,fee schedule,104.17,292.23,
X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.23,,,,,,,fee schedule,104.17,292.23,
X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,292.23,APC
X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,292.23,APC
X-rays bone survey complete,77075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,292.23,APC
X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,205.09,,,,,,,fee schedule,104.17,235.85,
X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.46,,,,,,,fee schedule,104.17,235.85,
X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.87,,,,,,,fee schedule,104.17,235.85,
X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.85,,,,,,,fee schedule,104.17,235.85,
X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,235.85,APC
X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,235.85,APC
X-rays bone survey infant,77076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,235.85,APC
Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.79,,,,,,,fee schedule,37.89,187.51,
Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.89,,,,,,,fee schedule,37.89,187.51,
Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.3,,,,,,,fee schedule,37.89,187.51,
Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.46,,,,,,,fee schedule,37.89,187.51,
Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,37.89,187.51,APC
Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,37.89,187.51,APC
Joint survey single view,77077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,37.89,187.51,APC
Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.79,,,,,,,fee schedule,86.71,188.36,
Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.38,,,,,,,fee schedule,86.71,188.36,
Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.06,,,,,,,fee schedule,86.71,188.36,
Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.36,,,,,,,fee schedule,86.71,188.36,
Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,188.36,APC
Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,188.36,APC
Ct bone density axial,77078,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,188.36,APC
Dxa bone density axial,77080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Dxa bone density axial,77080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Dxa bone density axial,77080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
Dxa bone density/peripheral,77081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,854.43,,,,,,,fee schedule,237.74,982.59,
Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,560.16,,,,,,,fee schedule,237.74,982.59,
Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,699.35,,,,,,,fee schedule,237.74,982.59,
Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,982.59,,,,,,,fee schedule,237.74,982.59,
Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,982.59,APC
Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,982.59,APC
Magnetic image bone marrow,77084,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,982.59,APC
Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,400.18,,,,,,,fee schedule,104.17,460.21,
Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.36,,,,,,,fee schedule,104.17,460.21,
Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,327.55,,,,,,,fee schedule,104.17,460.21,
Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,460.21,,,,,,,fee schedule,104.17,460.21,
Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,460.21,APC
Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,460.21,APC
Dxa bone density study,77085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,460.21,APC
Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.53,,,,,,,fee schedule,86.71,182.31,
Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.93,,,,,,,fee schedule,86.71,182.31,
Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.76,,,,,,,fee schedule,86.71,182.31,
Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.31,,,,,,,fee schedule,86.71,182.31,
Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,182.31,APC
Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,182.31,APC
Fracture assessment via dxa,77086,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,182.31,APC
Tbs dxa cal w/i&r fx risk,77089,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.23,,,,,,,fee schedule,42.76,75.01,
Tbs dxa cal w/i&r fx risk,77089,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.76,,,,,,,fee schedule,42.76,75.01,
Tbs dxa cal w/i&r fx risk,77089,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.39,,,,,,,fee schedule,42.76,75.01,
Tbs dxa cal w/i&r fx risk,77089,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.01,,,,,,,fee schedule,42.76,75.01,
Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.49,,,,,,,fee schedule,86.71,184.56,
Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.22,,,,,,,fee schedule,86.71,184.56,
Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.36,,,,,,,fee schedule,86.71,184.56,
Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.56,,,,,,,fee schedule,86.71,184.56,
Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,184.56,APC
Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,184.56,APC
Tbs techl prep&transmis data,77090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,184.56,APC
Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.49,,,,,,,fee schedule,86.71,184.56,
Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.22,,,,,,,fee schedule,86.71,184.56,
Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.36,,,,,,,fee schedule,86.71,184.56,
Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.56,,,,,,,fee schedule,86.71,184.56,
Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,184.56,APC
Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,184.56,APC
Tbs techl calculation only,77091,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,184.56,APC
Tbs i&r fx rsk qhp,77092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.05,,,,,,,fee schedule,3.97,6.96,
Tbs i&r fx rsk qhp,77092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.97,,,,,,,fee schedule,3.97,6.96,
Tbs i&r fx rsk qhp,77092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.95,,,,,,,fee schedule,3.97,6.96,
Tbs i&r fx rsk qhp,77092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.96,,,,,,,fee schedule,3.97,6.96,
Radiation therapy planning,77261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.6,,,,,,,fee schedule,43.66,76.59,
Radiation therapy planning,77261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.66,,,,,,,fee schedule,43.66,76.59,
Radiation therapy planning,77261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.51,,,,,,,fee schedule,43.66,76.59,
Radiation therapy planning,77261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.59,,,,,,,fee schedule,43.66,76.59,
Radiation therapy planning,77262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.05,,,,,,,fee schedule,61.66,108.16,
Radiation therapy planning,77262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.66,,,,,,,fee schedule,61.66,108.16,
Radiation therapy planning,77262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.98,,,,,,,fee schedule,61.66,108.16,
Radiation therapy planning,77262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.16,,,,,,,fee schedule,61.66,108.16,
Radiation therapy planning,77263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.3,,,,,,,fee schedule,86.08,151,
Radiation therapy planning,77263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.08,,,,,,,fee schedule,86.08,151,
Radiation therapy planning,77263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.47,,,,,,,fee schedule,86.08,151,
Radiation therapy planning,77263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151,,,,,,,fee schedule,86.08,151,
Set radiation therapy field,77280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,435.69,,,,,,,fee schedule,133.93,501.04,
Set radiation therapy field,77280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,285.64,,,,,,,fee schedule,133.93,501.04,
Set radiation therapy field,77280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.61,,,,,,,fee schedule,133.93,501.04,
Set radiation therapy field,77280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.04,,,,,,,fee schedule,133.93,501.04,
Set radiation therapy field,77280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,501.04,APC
Set radiation therapy field,77280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,501.04,APC
Set radiation therapy field,77280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,501.04,APC
Set radiation therapy field,77285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1061.16,,,,,,,fee schedule,373.08,1220.33,
Set radiation therapy field,77285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,695.7,,,,,,,fee schedule,373.08,1220.33,
Set radiation therapy field,77285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,868.56,,,,,,,fee schedule,373.08,1220.33,
Set radiation therapy field,77285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1220.33,,,,,,,fee schedule,373.08,1220.33,
Set radiation therapy field,77285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,373.08,1220.33,APC
Set radiation therapy field,77285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,373.08,1220.33,APC
Set radiation therapy field,77285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,373.08,1220.33,APC
Set radiation therapy field,77290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1154.45,,,,,,,fee schedule,373.08,1327.62,
Set radiation therapy field,77290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,756.86,,,,,,,fee schedule,373.08,1327.62,
Set radiation therapy field,77290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,944.92,,,,,,,fee schedule,373.08,1327.62,
Set radiation therapy field,77290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1327.62,,,,,,,fee schedule,373.08,1327.62,
Set radiation therapy field,77290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,373.08,1327.62,APC
Set radiation therapy field,77290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,373.08,1327.62,APC
Set radiation therapy field,77290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,373.08,1327.62,APC
Respirator motion mgmt simul,77293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1007.3,,,,,,,fee schedule,660.39,1158.4,
Respirator motion mgmt simul,77293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,660.39,,,,,,,fee schedule,660.39,1158.4,
Respirator motion mgmt simul,77293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,824.48,,,,,,,fee schedule,660.39,1158.4,
Respirator motion mgmt simul,77293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1158.4,,,,,,,fee schedule,660.39,1158.4,
3-d radiotherapy plan,77295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5674.49,,,,,,,fee schedule,1379.15,6525.66,
3-d radiotherapy plan,77295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3720.2,,,,,,,fee schedule,1379.15,6525.66,
3-d radiotherapy plan,77295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4644.57,,,,,,,fee schedule,1379.15,6525.66,
3-d radiotherapy plan,77295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6525.66,,,,,,,fee schedule,1379.15,6525.66,
3-d radiotherapy plan,77295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1448.11,,,,,,,fee schedule,1379.15,6525.66,APC
3-d radiotherapy plan,77295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1379.15,,,,,,,fee schedule,1379.15,6525.66,APC
3-d radiotherapy plan,77295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2482.48,,,,,,,fee schedule,1379.15,6525.66,APC
Radiation therapy planning,77299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,241.07,APC
Radiation therapy planning,77299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,241.07,APC
Radiation therapy planning,77299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,241.07,APC
Radiation therapy dose plan,77300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,435.69,,,,,,,fee schedule,133.93,501.04,
Radiation therapy dose plan,77300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,285.64,,,,,,,fee schedule,133.93,501.04,
Radiation therapy dose plan,77300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.61,,,,,,,fee schedule,133.93,501.04,
Radiation therapy dose plan,77300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.04,,,,,,,fee schedule,133.93,501.04,
Radiation therapy dose plan,77300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,501.04,APC
Radiation therapy dose plan,77300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,501.04,APC
Radiation therapy dose plan,77300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,501.04,APC
Radiotherapy dose plan imrt,77301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5467.48,,,,,,,fee schedule,1379.15,6287.6,
Radiotherapy dose plan imrt,77301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3584.48,,,,,,,fee schedule,1379.15,6287.6,
Radiotherapy dose plan imrt,77301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4475.13,,,,,,,fee schedule,1379.15,6287.6,
Radiotherapy dose plan imrt,77301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6287.6,,,,,,,fee schedule,1379.15,6287.6,
Radiotherapy dose plan imrt,77301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1448.11,,,,,,,fee schedule,1379.15,6287.6,APC
Radiotherapy dose plan imrt,77301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1379.15,,,,,,,fee schedule,1379.15,6287.6,APC
Radiotherapy dose plan imrt,77301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2482.48,,,,,,,fee schedule,1379.15,6287.6,APC
Telethx isodose plan simple,77306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,213.6,,,,,,,fee schedule,140.04,671.55,
Telethx isodose plan simple,77306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.04,,,,,,,fee schedule,140.04,671.55,
Telethx isodose plan simple,77306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.83,,,,,,,fee schedule,140.04,671.55,
Telethx isodose plan simple,77306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,245.64,,,,,,,fee schedule,140.04,671.55,
Telethx isodose plan simple,77306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,140.04,671.55,APC
Telethx isodose plan simple,77306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,140.04,671.55,APC
Telethx isodose plan simple,77306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,140.04,671.55,APC
Telethx isodose plan cplx,77307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1154.45,,,,,,,fee schedule,373.08,1327.62,
Telethx isodose plan cplx,77307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,756.86,,,,,,,fee schedule,373.08,1327.62,
Telethx isodose plan cplx,77307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,944.92,,,,,,,fee schedule,373.08,1327.62,
Telethx isodose plan cplx,77307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1327.62,,,,,,,fee schedule,373.08,1327.62,
Telethx isodose plan cplx,77307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,373.08,1327.62,APC
Telethx isodose plan cplx,77307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,373.08,1327.62,APC
Telethx isodose plan cplx,77307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,373.08,1327.62,APC
Brachytx isodose plan simple,77316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1775.88,,,,,,,fee schedule,373.08,2042.26,
Brachytx isodose plan simple,77316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1164.27,,,,,,,fee schedule,373.08,2042.26,
Brachytx isodose plan simple,77316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1453.56,,,,,,,fee schedule,373.08,2042.26,
Brachytx isodose plan simple,77316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2042.26,,,,,,,fee schedule,373.08,2042.26,
Brachytx isodose plan simple,77316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,373.08,2042.26,APC
Brachytx isodose plan simple,77316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,373.08,2042.26,APC
Brachytx isodose plan simple,77316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,373.08,2042.26,APC
Brachytx isodose intermed,77317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,419.37,,,,,,,fee schedule,274.94,671.55,
Brachytx isodose intermed,77317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,274.94,,,,,,,fee schedule,274.94,671.55,
Brachytx isodose intermed,77317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,343.25,,,,,,,fee schedule,274.94,671.55,
Brachytx isodose intermed,77317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,482.28,,,,,,,fee schedule,274.94,671.55,
Brachytx isodose intermed,77317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,274.94,671.55,APC
Brachytx isodose intermed,77317,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,274.94,671.55,APC
Brachytx isodose intermed,77317,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,274.94,671.55,APC
Brachytx isodose complex,77318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2203.34,,,,,,,fee schedule,373.08,2533.84,
Brachytx isodose complex,77318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1444.51,,,,,,,fee schedule,373.08,2533.84,
Brachytx isodose complex,77318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1803.43,,,,,,,fee schedule,373.08,2533.84,
Brachytx isodose complex,77318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2533.84,,,,,,,fee schedule,373.08,2533.84,
Brachytx isodose complex,77318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,373.08,2533.84,APC
Brachytx isodose complex,77318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,373.08,2533.84,APC
Brachytx isodose complex,77318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,373.08,2533.84,APC
Special teletx port plan,77321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1154.45,,,,,,,fee schedule,373.08,1327.62,
Special teletx port plan,77321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,756.86,,,,,,,fee schedule,373.08,1327.62,
Special teletx port plan,77321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,944.92,,,,,,,fee schedule,373.08,1327.62,
Special teletx port plan,77321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1327.62,,,,,,,fee schedule,373.08,1327.62,
Special teletx port plan,77321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,373.08,1327.62,APC
Special teletx port plan,77321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,373.08,1327.62,APC
Special teletx port plan,77321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,373.08,1327.62,APC
Special radiation dosimetry,77331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,552.86,,,,,,,fee schedule,133.93,635.79,
Special radiation dosimetry,77331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,362.46,,,,,,,fee schedule,133.93,635.79,
Special radiation dosimetry,77331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,452.52,,,,,,,fee schedule,133.93,635.79,
Special radiation dosimetry,77331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,635.79,,,,,,,fee schedule,133.93,635.79,
Special radiation dosimetry,77331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,635.79,APC
Special radiation dosimetry,77331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,635.79,APC
Special radiation dosimetry,77331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,635.79,APC
Radiation treatment aid(s),77332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,435.69,,,,,,,fee schedule,133.93,501.04,
Radiation treatment aid(s),77332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.61,,,,,,,fee schedule,133.93,501.04,
Radiation treatment aid(s),77332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,285.64,,,,,,,fee schedule,133.93,501.04,
Radiation treatment aid(s),77332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.04,,,,,,,fee schedule,133.93,501.04,
Radiation treatment aid(s),77332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,501.04,APC
Radiation treatment aid(s),77332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,501.04,APC
Radiation treatment aid(s),77332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,501.04,APC
Radiation treatment aid(s),77333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,435.69,,,,,,,fee schedule,133.93,501.04,
Radiation treatment aid(s),77333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.61,,,,,,,fee schedule,133.93,501.04,
Radiation treatment aid(s),77333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,285.64,,,,,,,fee schedule,133.93,501.04,
Radiation treatment aid(s),77333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.04,,,,,,,fee schedule,133.93,501.04,
Radiation treatment aid(s),77333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,501.04,APC
Radiation treatment aid(s),77333,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,501.04,APC
Radiation treatment aid(s),77333,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,501.04,APC
Radiation treatment aid(s),77334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1154.45,,,,,,,fee schedule,373.08,1327.62,
Radiation treatment aid(s),77334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,944.92,,,,,,,fee schedule,373.08,1327.62,
Radiation treatment aid(s),77334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,756.86,,,,,,,fee schedule,373.08,1327.62,
Radiation treatment aid(s),77334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1327.62,,,,,,,fee schedule,373.08,1327.62,
Radiation treatment aid(s),77334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,373.08,1327.62,APC
Radiation treatment aid(s),77334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,373.08,1327.62,APC
Radiation treatment aid(s),77334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,373.08,1327.62,APC
Radiation physics consult,77336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,435.69,,,,,,,fee schedule,133.93,501.04,
Radiation physics consult,77336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.61,,,,,,,fee schedule,133.93,501.04,
Radiation physics consult,77336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,285.64,,,,,,,fee schedule,133.93,501.04,
Radiation physics consult,77336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.04,,,,,,,fee schedule,133.93,501.04,
Radiation physics consult,77336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,501.04,APC
Radiation physics consult,77336,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,501.04,APC
Radiation physics consult,77336,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,501.04,APC
Design mlc device for imrt,77338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1154.45,,,,,,,fee schedule,373.08,1327.62,
Design mlc device for imrt,77338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,944.92,,,,,,,fee schedule,373.08,1327.62,
Design mlc device for imrt,77338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,756.86,,,,,,,fee schedule,373.08,1327.62,
Design mlc device for imrt,77338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1327.62,,,,,,,fee schedule,373.08,1327.62,
Design mlc device for imrt,77338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.74,,,,,,,fee schedule,373.08,1327.62,APC
Design mlc device for imrt,77338,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,373.08,,,,,,,fee schedule,373.08,1327.62,APC
Design mlc device for imrt,77338,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,671.55,,,,,,,fee schedule,373.08,1327.62,APC
Radiation physics consult,77370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,435.69,,,,,,,fee schedule,133.93,501.04,
Radiation physics consult,77370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.61,,,,,,,fee schedule,133.93,501.04,
Radiation physics consult,77370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,285.64,,,,,,,fee schedule,133.93,501.04,
Radiation physics consult,77370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.04,,,,,,,fee schedule,133.93,501.04,
Radiation physics consult,77370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,501.04,APC
Radiation physics consult,77370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,501.04,APC
Radiation physics consult,77370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,501.04,APC
Srs multisource,77371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3390.28,,,,,,,fee schedule,2222.67,13209.85,
Srs multisource,77371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2774.94,,,,,,,fee schedule,2222.67,13209.85,
Srs multisource,77371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2222.67,,,,,,,fee schedule,2222.67,13209.85,
Srs multisource,77371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3898.82,,,,,,,fee schedule,2222.67,13209.85,
Srs multisource,77371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7705.75,,,,,,,fee schedule,2222.67,13209.85,APC
Srs multisource,77371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7338.81,,,,,,,fee schedule,2222.67,13209.85,APC
Srs multisource,77371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13209.85,,,,,,,fee schedule,2222.67,13209.85,APC
Srs linear based,77372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20719.8,,,,,,,fee schedule,7338.81,23827.77,
Srs linear based,77372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16959.16,,,,,,,fee schedule,7338.81,23827.77,
Srs linear based,77372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13583.9,,,,,,,fee schedule,7338.81,23827.77,
Srs linear based,77372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23827.77,,,,,,,fee schedule,7338.81,23827.77,
Srs linear based,77372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7705.75,,,,,,,fee schedule,7338.81,23827.77,APC
Srs linear based,77372,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7338.81,,,,,,,fee schedule,7338.81,23827.77,APC
Srs linear based,77372,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13209.85,,,,,,,fee schedule,7338.81,23827.77,APC
SBRT Delivery,77373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6118.48,,,,,,,fee schedule,1781.62,7036.25,
SBRT Delivery,77373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5007.98,,,,,,,fee schedule,1781.62,7036.25,
SBRT Delivery,77373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4011.28,,,,,,,fee schedule,1781.62,7036.25,
SBRT Delivery,77373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7036.25,,,,,,,fee schedule,1781.62,7036.25,
SBRT Delivery,77373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1870.7,,,,,,,fee schedule,1781.62,7036.25,APC
SBRT Delivery,77373,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1781.62,,,,,,,fee schedule,1781.62,7036.25,APC
SBRT Delivery,77373,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3206.92,,,,,,,fee schedule,1781.62,7036.25,APC
Ntsty modul rad tx dlvr smpl,77385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1832.73,,,,,,,fee schedule,1201.54,2107.64,
Ntsty modul rad tx dlvr smpl,77385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1500.09,,,,,,,fee schedule,1201.54,2107.64,
Ntsty modul rad tx dlvr smpl,77385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1201.54,,,,,,,fee schedule,1201.54,2107.64,
Ntsty modul rad tx dlvr smpl,77385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2107.64,,,,,,,fee schedule,1201.54,2107.64,
Ntsty modul rad tx dlvr cplx,77386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1832.73,,,,,,,fee schedule,1201.54,2107.64,
Ntsty modul rad tx dlvr cplx,77386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1500.09,,,,,,,fee schedule,1201.54,2107.64,
Ntsty modul rad tx dlvr cplx,77386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1201.54,,,,,,,fee schedule,1201.54,2107.64,
Ntsty modul rad tx dlvr cplx,77386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2107.64,,,,,,,fee schedule,1201.54,2107.64,
Guidance for radiaj tx dlvr,77387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,571.14,,,,,,,fee schedule,374.44,656.81,
Guidance for radiaj tx dlvr,77387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,467.48,,,,,,,fee schedule,374.44,656.81,
Guidance for radiaj tx dlvr,77387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,374.44,,,,,,,fee schedule,374.44,656.81,
Guidance for radiaj tx dlvr,77387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,656.81,,,,,,,fee schedule,374.44,656.81,
External radiation dosimetry,77399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.62,,,,,,,fee schedule,133.93,241.07,APC
External radiation dosimetry,77399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.93,,,,,,,fee schedule,133.93,241.07,APC
External radiation dosimetry,77399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,241.07,,,,,,,fee schedule,133.93,241.07,APC
Radiation treatment delivery,77401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.58,,,,,,,fee schedule,44.96,78.87,
Radiation treatment delivery,77401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.13,,,,,,,fee schedule,44.96,78.87,
Radiation treatment delivery,77401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.96,,,,,,,fee schedule,44.96,78.87,
Radiation treatment delivery,77401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.87,,,,,,,fee schedule,44.96,78.87,
Radiation treatment delivery,77402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,418.31,,,,,,,fee schedule,101.66,481.06,
Radiation treatment delivery,77402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.39,,,,,,,fee schedule,101.66,481.06,
Radiation treatment delivery,77402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,274.24,,,,,,,fee schedule,101.66,481.06,
Radiation treatment delivery,77402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,481.06,,,,,,,fee schedule,101.66,481.06,
Radiation treatment delivery,77402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.75,,,,,,,fee schedule,101.66,481.06,APC
Radiation treatment delivery,77402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.66,,,,,,,fee schedule,101.66,481.06,APC
Radiation treatment delivery,77402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.99,,,,,,,fee schedule,101.66,481.06,APC
Radiation treatment delivery,77407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,549.7,,,,,,,fee schedule,360.38,691.76,
Radiation treatment delivery,77407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,449.93,,,,,,,fee schedule,360.38,691.76,
Radiation treatment delivery,77407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,360.38,,,,,,,fee schedule,360.38,691.76,
Radiation treatment delivery,77407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,632.16,,,,,,,fee schedule,360.38,691.76,
Radiation treatment delivery,77407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.52,,,,,,,fee schedule,360.38,691.76,APC
Radiation treatment delivery,77407,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,384.31,,,,,,,fee schedule,360.38,691.76,APC
Radiation treatment delivery,77407,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,691.76,,,,,,,fee schedule,360.38,691.76,APC
Radiation treatment delivery,77412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,757.77,,,,,,,fee schedule,496.79,991,
Radiation treatment delivery,77412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,620.23,,,,,,,fee schedule,496.79,991,
Radiation treatment delivery,77412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,496.79,,,,,,,fee schedule,496.79,991,
Radiation treatment delivery,77412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,871.44,,,,,,,fee schedule,496.79,991,
Radiation treatment delivery,77412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,496.79,991,APC
Radiation treatment delivery,77412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,496.79,991,APC
Radiation treatment delivery,77412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,496.79,991,APC
Radiology port images(s),77417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,250.2,,,,,,,fee schedule,164.03,287.73,
Radiology port images(s),77417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,204.79,,,,,,,fee schedule,164.03,287.73,
Radiology port images(s),77417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.03,,,,,,,fee schedule,164.03,287.73,
Radiology port images(s),77417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,287.73,,,,,,,fee schedule,164.03,287.73,
Neutron beam tx complex,77423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,267.52,,,,,,,fee schedule,175.39,991,
Neutron beam tx complex,77423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.97,,,,,,,fee schedule,175.39,991,
Neutron beam tx complex,77423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.39,,,,,,,fee schedule,175.39,991,
Neutron beam tx complex,77423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,307.65,,,,,,,fee schedule,175.39,991,
Neutron beam tx complex,77423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,175.39,991,APC
Neutron beam tx complex,77423,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,175.39,991,APC
Neutron beam tx complex,77423,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,175.39,991,APC
Io rad tx delivery by x-ray,77424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4702.15,,,,,,,fee schedule,3082.73,13209.85,
Io rad tx delivery by x-ray,77424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3848.71,,,,,,,fee schedule,3082.73,13209.85,
Io rad tx delivery by x-ray,77424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3082.73,,,,,,,fee schedule,3082.73,13209.85,
Io rad tx delivery by x-ray,77424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5407.47,,,,,,,fee schedule,3082.73,13209.85,
Io rad tx delivery by x-ray,77424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7705.75,,,,,,,fee schedule,3082.73,13209.85,APC
Io rad tx delivery by x-ray,77424,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7338.81,,,,,,,fee schedule,3082.73,13209.85,APC
Io rad tx delivery by x-ray,77424,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13209.85,,,,,,,fee schedule,3082.73,13209.85,APC
Io rad tx deliver by elctrns,77425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4702.15,,,,,,,fee schedule,3082.73,13209.85,
Io rad tx deliver by elctrns,77425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3848.71,,,,,,,fee schedule,3082.73,13209.85,
Io rad tx deliver by elctrns,77425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3082.73,,,,,,,fee schedule,3082.73,13209.85,
Io rad tx deliver by elctrns,77425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5407.47,,,,,,,fee schedule,3082.73,13209.85,
Io rad tx deliver by elctrns,77425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7705.75,,,,,,,fee schedule,3082.73,13209.85,APC
Io rad tx deliver by elctrns,77425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7338.81,,,,,,,fee schedule,3082.73,13209.85,APC
Io rad tx deliver by elctrns,77425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13209.85,,,,,,,fee schedule,3082.73,13209.85,APC
Radiation tx management x5,77427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,162.67,,,,,,,fee schedule,106.65,187.07,
Radiation tx management x5,77427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.15,,,,,,,fee schedule,106.65,187.07,
Radiation tx management x5,77427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.65,,,,,,,fee schedule,106.65,187.07,
Radiation tx management x5,77427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.07,,,,,,,fee schedule,106.65,187.07,
Radiation therapy management,77431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.05,,,,,,,fee schedule,61.66,108.16,
Radiation therapy management,77431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.98,,,,,,,fee schedule,61.66,108.16,
Radiation therapy management,77431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.66,,,,,,,fee schedule,61.66,108.16,
Radiation therapy management,77431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.16,,,,,,,fee schedule,61.66,108.16,
Stereotactic radiation trmt,77432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.19,,,,,,,fee schedule,216.47,379.72,
Stereotactic radiation trmt,77432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.26,,,,,,,fee schedule,216.47,379.72,
Stereotactic radiation trmt,77432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,216.47,,,,,,,fee schedule,216.47,379.72,
Stereotactic radiation trmt,77432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,379.72,,,,,,,fee schedule,216.47,379.72,
SBRT Management,77435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,506.54,,,,,,,fee schedule,332.09,582.52,
SBRT Management,77435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,414.6,,,,,,,fee schedule,332.09,582.52,
SBRT Management,77435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.09,,,,,,,fee schedule,332.09,582.52,
SBRT Management,77435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,582.52,,,,,,,fee schedule,332.09,582.52,
Surf radj ther tx planning,77436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,66.99,APC
Surf radj ther tx planning,77436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,66.99,APC
Surf radj ther tx planning,77436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,66.99,APC
Io radiation tx management,77469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.01,,,,,,,fee schedule,191.44,335.81,
Io radiation tx management,77469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.01,,,,,,,fee schedule,191.44,335.81,
Io radiation tx management,77469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.44,,,,,,,fee schedule,191.44,335.81,
Io radiation tx management,77469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.81,,,,,,,fee schedule,191.44,335.81,
Special radiation treatment,77470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2061.83,,,,,,,fee schedule,550.56,2371.1,
Special radiation treatment,77470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1687.61,,,,,,,fee schedule,550.56,2371.1,
Special radiation treatment,77470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1351.74,,,,,,,fee schedule,550.56,2371.1,
Special radiation treatment,77470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2371.1,,,,,,,fee schedule,550.56,2371.1,
Special radiation treatment,77470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,550.56,2371.1,APC
Special radiation treatment,77470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,550.56,2371.1,APC
Special radiation treatment,77470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,550.56,2371.1,APC
Proton trmt simple w/o comp,77520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,730.18,,,,,,,fee schedule,478.71,991,
Proton trmt simple w/o comp,77520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,478.71,,,,,,,fee schedule,478.71,991,
Proton trmt simple w/o comp,77520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,597.65,,,,,,,fee schedule,478.71,991,
Proton trmt simple w/o comp,77520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,839.71,,,,,,,fee schedule,478.71,991,
Proton trmt simple w/o comp,77520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,478.71,991,APC
Proton trmt simple w/o comp,77520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,478.71,991,APC
Proton trmt simple w/o comp,77520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,478.71,991,APC
Proton trmt simple w/comp,77522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1467.53,,,,,,,fee schedule,962.11,2241.45,
Proton trmt simple w/comp,77522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,962.11,,,,,,,fee schedule,962.11,2241.45,
Proton trmt simple w/comp,77522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1201.17,,,,,,,fee schedule,962.11,2241.45,
Proton trmt simple w/comp,77522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1687.66,,,,,,,fee schedule,962.11,2241.45,
Proton trmt simple w/comp,77522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1307.51,,,,,,,fee schedule,962.11,2241.45,APC
Proton trmt simple w/comp,77522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1245.25,,,,,,,fee schedule,962.11,2241.45,APC
Proton trmt simple w/comp,77522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2241.45,,,,,,,fee schedule,962.11,2241.45,APC
Proton trmt intermediate,77523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1467.53,,,,,,,fee schedule,962.11,2241.45,
Proton trmt intermediate,77523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,962.11,,,,,,,fee schedule,962.11,2241.45,
Proton trmt intermediate,77523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1201.17,,,,,,,fee schedule,962.11,2241.45,
Proton trmt intermediate,77523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1687.66,,,,,,,fee schedule,962.11,2241.45,
Proton trmt intermediate,77523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1307.51,,,,,,,fee schedule,962.11,2241.45,APC
Proton trmt intermediate,77523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1245.25,,,,,,,fee schedule,962.11,2241.45,APC
Proton trmt intermediate,77523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2241.45,,,,,,,fee schedule,962.11,2241.45,APC
Proton treatment complex,77525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1467.53,,,,,,,fee schedule,962.11,2241.45,
Proton treatment complex,77525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,962.11,,,,,,,fee schedule,962.11,2241.45,
Proton treatment complex,77525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1201.17,,,,,,,fee schedule,962.11,2241.45,
Proton treatment complex,77525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1687.66,,,,,,,fee schedule,962.11,2241.45,
Proton treatment complex,77525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1307.51,,,,,,,fee schedule,962.11,2241.45,APC
Proton treatment complex,77525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1245.25,,,,,,,fee schedule,962.11,2241.45,APC
Proton treatment complex,77525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2241.45,,,,,,,fee schedule,962.11,2241.45,APC
Hyperthermia treatment,77600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,957.29,,,,,,,fee schedule,384.31,1100.88,
Hyperthermia treatment,77600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,627.6,,,,,,,fee schedule,384.31,1100.88,
Hyperthermia treatment,77600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,783.54,,,,,,,fee schedule,384.31,1100.88,
Hyperthermia treatment,77600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1100.88,,,,,,,fee schedule,384.31,1100.88,
Hyperthermia treatment,77600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.52,,,,,,,fee schedule,384.31,1100.88,APC
Hyperthermia treatment,77600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,384.31,,,,,,,fee schedule,384.31,1100.88,APC
Hyperthermia treatment,77600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,691.76,,,,,,,fee schedule,384.31,1100.88,APC
Hyperthermia treatment,77605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1881.29,,,,,,,fee schedule,693.97,2163.48,
Hyperthermia treatment,77605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1233.37,,,,,,,fee schedule,693.97,2163.48,
Hyperthermia treatment,77605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1539.84,,,,,,,fee schedule,693.97,2163.48,
Hyperthermia treatment,77605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2163.48,,,,,,,fee schedule,693.97,2163.48,
Hyperthermia treatment,77605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.67,,,,,,,fee schedule,693.97,2163.48,APC
Hyperthermia treatment,77605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.97,,,,,,,fee schedule,693.97,2163.48,APC
Hyperthermia treatment,77605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1249.15,,,,,,,fee schedule,693.97,2163.48,APC
Hyperthermia treatment,77610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2196.82,,,,,,,fee schedule,550.56,2526.34,
Hyperthermia treatment,77610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1440.24,,,,,,,fee schedule,550.56,2526.34,
Hyperthermia treatment,77610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1798.1,,,,,,,fee schedule,550.56,2526.34,
Hyperthermia treatment,77610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2526.34,,,,,,,fee schedule,550.56,2526.34,
Hyperthermia treatment,77610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,550.56,2526.34,APC
Hyperthermia treatment,77610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,550.56,2526.34,APC
Hyperthermia treatment,77610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,550.56,2526.34,APC
Hyperthermia treatment,77615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2581.9,,,,,,,fee schedule,550.56,2969.19,
Hyperthermia treatment,77615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1692.69,,,,,,,fee schedule,550.56,2969.19,
Hyperthermia treatment,77615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2113.29,,,,,,,fee schedule,550.56,2969.19,
Hyperthermia treatment,77615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2969.19,,,,,,,fee schedule,550.56,2969.19,
Hyperthermia treatment,77615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,550.56,2969.19,APC
Hyperthermia treatment,77615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,550.56,2969.19,APC
Hyperthermia treatment,77615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,550.56,2969.19,APC
Hyperthermia treatment,77620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1043.53,,,,,,,fee schedule,550.56,1200.06,
Hyperthermia treatment,77620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,684.14,,,,,,,fee schedule,550.56,1200.06,
Hyperthermia treatment,77620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,854.13,,,,,,,fee schedule,550.56,1200.06,
Hyperthermia treatment,77620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1200.06,,,,,,,fee schedule,550.56,1200.06,
Hyperthermia treatment,77620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,550.56,1200.06,APC
Hyperthermia treatment,77620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,550.56,1200.06,APC
Hyperthermia treatment,77620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,550.56,1200.06,APC
Infuse radioactive materials,77750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.51,,,,,,,fee schedule,206.85,691.76,
Infuse radioactive materials,77750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.85,,,,,,,fee schedule,206.85,691.76,
Infuse radioactive materials,77750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.24,,,,,,,fee schedule,206.85,691.76,
Infuse radioactive materials,77750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,362.84,,,,,,,fee schedule,206.85,691.76,
Infuse radioactive materials,77750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.52,,,,,,,fee schedule,206.85,691.76,APC
Infuse radioactive materials,77750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,384.31,,,,,,,fee schedule,206.85,691.76,APC
Infuse radioactive materials,77750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,691.76,,,,,,,fee schedule,206.85,691.76,APC
Apply intrcav radiat simple,77761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,537.94,,,,,,,fee schedule,352.67,991,
Apply intrcav radiat simple,77761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,352.67,,,,,,,fee schedule,352.67,991,
Apply intrcav radiat simple,77761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,440.3,,,,,,,fee schedule,352.67,991,
Apply intrcav radiat simple,77761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,618.63,,,,,,,fee schedule,352.67,991,
Apply intrcav radiat simple,77761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,352.67,991,APC
Apply intrcav radiat simple,77761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,352.67,991,APC
Apply intrcav radiat simple,77761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,352.67,991,APC
Apply intrcav radiat interm,77762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,622.19,,,,,,,fee schedule,407.91,991,
Apply intrcav radiat interm,77762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,407.91,,,,,,,fee schedule,407.91,991,
Apply intrcav radiat interm,77762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,509.26,,,,,,,fee schedule,407.91,991,
Apply intrcav radiat interm,77762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,715.52,,,,,,,fee schedule,407.91,991,
Apply intrcav radiat interm,77762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,578.08,,,,,,,fee schedule,407.91,991,APC
Apply intrcav radiat interm,77762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,550.56,,,,,,,fee schedule,407.91,991,APC
Apply intrcav radiat interm,77762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,991,,,,,,,fee schedule,407.91,991,APC
Apply intrcav radiat compl,77763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,798.57,,,,,,,fee schedule,523.54,1249.15,
Apply intrcav radiat compl,77763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,523.54,,,,,,,fee schedule,523.54,1249.15,
Apply intrcav radiat compl,77763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,653.63,,,,,,,fee schedule,523.54,1249.15,
Apply intrcav radiat compl,77763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,918.36,,,,,,,fee schedule,523.54,1249.15,
Apply intrcav radiat compl,77763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.67,,,,,,,fee schedule,523.54,1249.15,APC
Apply intrcav radiat compl,77763,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.97,,,,,,,fee schedule,523.54,1249.15,APC
Apply intrcav radiat compl,77763,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1249.15,,,,,,,fee schedule,523.54,1249.15,APC
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,473.26,,,,,,,fee schedule,310.27,691.76,
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.27,,,,,,,fee schedule,310.27,691.76,
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,387.36,,,,,,,fee schedule,310.27,691.76,
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,544.25,,,,,,,fee schedule,310.27,691.76,
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.52,,,,,,,fee schedule,310.27,691.76,APC
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,384.31,,,,,,,fee schedule,310.27,691.76,APC
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,691.76,,,,,,,fee schedule,310.27,691.76,APC
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,778.99,,,,,,,fee schedule,384.31,895.84,
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,510.71,,,,,,,fee schedule,384.31,895.84,
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,637.6,,,,,,,fee schedule,384.31,895.84,
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,895.84,,,,,,,fee schedule,384.31,895.84,
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.52,,,,,,,fee schedule,384.31,895.84,APC
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,384.31,,,,,,,fee schedule,384.31,895.84,APC
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,691.76,,,,,,,fee schedule,384.31,895.84,APC
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3989.92,,,,,,,fee schedule,693.97,4588.41,
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2615.79,,,,,,,fee schedule,693.97,4588.41,
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3265.75,,,,,,,fee schedule,693.97,4588.41,
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4588.41,,,,,,,fee schedule,693.97,4588.41,
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.67,,,,,,,fee schedule,693.97,4588.41,APC
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.97,,,,,,,fee schedule,693.97,4588.41,APC
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1249.15,,,,,,,fee schedule,693.97,4588.41,APC
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1114.07,,,,,,,fee schedule,693.97,1281.18,
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,730.38,,,,,,,fee schedule,693.97,1281.18,
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,911.87,,,,,,,fee schedule,693.97,1281.18,
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1281.18,,,,,,,fee schedule,693.97,1281.18,
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.67,,,,,,,fee schedule,693.97,1281.18,APC
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.97,,,,,,,fee schedule,693.97,1281.18,APC
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1249.15,,,,,,,fee schedule,693.97,1281.18,APC
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1762.75,,,,,,,fee schedule,693.97,2027.16,
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1155.66,,,,,,,fee schedule,693.97,2027.16,
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1442.81,,,,,,,fee schedule,693.97,2027.16,
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2027.16,,,,,,,fee schedule,693.97,2027.16,
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.67,,,,,,,fee schedule,693.97,2027.16,APC
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.97,,,,,,,fee schedule,693.97,2027.16,APC
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1249.15,,,,,,,fee schedule,693.97,2027.16,APC
Apply interstit radiat compl,77778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6248.46,,,,,,,fee schedule,693.97,7185.73,
Apply interstit radiat compl,77778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4096.49,,,,,,,fee schedule,693.97,7185.73,
Apply interstit radiat compl,77778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5114.36,,,,,,,fee schedule,693.97,7185.73,
Apply interstit radiat compl,77778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7185.73,,,,,,,fee schedule,693.97,7185.73,
Apply interstit radiat compl,77778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.67,,,,,,,fee schedule,693.97,7185.73,APC
Apply interstit radiat compl,77778,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.97,,,,,,,fee schedule,693.97,7185.73,APC
Apply interstit radiat compl,77778,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1249.15,,,,,,,fee schedule,693.97,7185.73,APC
Apply surf ldr radionuclide,77789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.59,,,,,,,fee schedule,101.66,190.43,
Apply surf ldr radionuclide,77789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.56,,,,,,,fee schedule,101.66,190.43,
Apply surf ldr radionuclide,77789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.54,,,,,,,fee schedule,101.66,190.43,
Apply surf ldr radionuclide,77789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.43,,,,,,,fee schedule,101.66,190.43,
Apply surf ldr radionuclide,77789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.75,,,,,,,fee schedule,101.66,190.43,APC
Apply surf ldr radionuclide,77789,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.66,,,,,,,fee schedule,101.66,190.43,APC
Apply surf ldr radionuclide,77789,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.99,,,,,,,fee schedule,101.66,190.43,APC
Radiation handling,77790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.66,,,,,,,fee schedule,10.92,19.16,
Radiation handling,77790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.92,,,,,,,fee schedule,10.92,19.16,
Radiation handling,77790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.64,,,,,,,fee schedule,10.92,19.16,
Radiation handling,77790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.16,,,,,,,fee schedule,10.92,19.16,
Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.03,,,,,,,fee schedule,129.83,717,
Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.83,,,,,,,fee schedule,129.83,717,
Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.09,,,,,,,fee schedule,129.83,717,
Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227.73,,,,,,,fee schedule,129.83,717,
Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,129.83,717,APC
Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,129.83,717,APC
Thyroid uptake measurement,78012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,129.83,717,APC
Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.43,,,,,,,fee schedule,252.03,717,
Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,252.03,,,,,,,fee schedule,252.03,717,
Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.66,,,,,,,fee schedule,252.03,717,
Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,442.09,,,,,,,fee schedule,252.03,717,
Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,252.03,717,APC
Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,252.03,717,APC
Thyroid imaging w/blood flow,78013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,252.03,717,APC
Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,821.9,,,,,,,fee schedule,398.33,945.19,
Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,538.84,,,,,,,fee schedule,398.33,945.19,
Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,672.73,,,,,,,fee schedule,398.33,945.19,
Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,945.19,,,,,,,fee schedule,398.33,945.19,
Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,945.19,APC
Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,945.19,APC
Thyroid imaging w/blood flow,78014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,945.19,APC
Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,543.81,,,,,,,fee schedule,356.52,717,
Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,356.52,,,,,,,fee schedule,356.52,717,
Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,445.11,,,,,,,fee schedule,356.52,717,
Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,625.38,,,,,,,fee schedule,356.52,717,
Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,356.52,717,APC
Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,356.52,717,APC
Thyroid met imaging,78015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,356.52,717,APC
Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,718.2,,,,,,,fee schedule,398.33,825.93,
Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,470.85,,,,,,,fee schedule,398.33,825.93,
Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.85,,,,,,,fee schedule,398.33,825.93,
Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,825.93,,,,,,,fee schedule,398.33,825.93,
Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,825.93,APC
Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,825.93,APC
Thyroid met imaging/studies,78016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,825.93,APC
Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,763.35,,,,,,,fee schedule,500.45,973.83,
Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,624.8,,,,,,,fee schedule,500.45,973.83,
Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,500.45,,,,,,,fee schedule,500.45,973.83,
Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,877.85,,,,,,,fee schedule,500.45,973.83,
Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,500.45,973.83,APC
Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,500.45,973.83,APC
Thyroid met imaging body,78018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,500.45,973.83,APC
Thyroid met uptake,78020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.7,,,,,,,fee schedule,105.35,184.81,
Thyroid met uptake,78020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.53,,,,,,,fee schedule,105.35,184.81,
Thyroid met uptake,78020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.35,,,,,,,fee schedule,105.35,184.81,
Thyroid met uptake,78020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.81,,,,,,,fee schedule,105.35,184.81,
Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,750.55,,,,,,,fee schedule,398.33,863.13,
Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,614.33,,,,,,,fee schedule,398.33,863.13,
Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,492.06,,,,,,,fee schedule,398.33,863.13,
Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,863.13,,,,,,,fee schedule,398.33,863.13,
Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,863.13,APC
Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,863.13,APC
Parathyroid planar imaging,78070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,863.13,APC
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,860.28,,,,,,,fee schedule,398.33,989.32,
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,704.14,,,,,,,fee schedule,398.33,989.32,
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,564,,,,,,,fee schedule,398.33,989.32,
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,989.32,,,,,,,fee schedule,398.33,989.32,
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,989.32,APC
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,989.32,APC
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,989.32,APC
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1018.99,,,,,,,fee schedule,541.02,1171.84,
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,834.04,,,,,,,fee schedule,541.02,1171.84,
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,668.05,,,,,,,fee schedule,541.02,1171.84,
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1171.84,,,,,,,fee schedule,541.02,1171.84,
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1171.84,APC
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1171.84,APC
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1171.84,APC
Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1169.93,,,,,,,fee schedule,767.01,2321.99,
Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,957.59,,,,,,,fee schedule,767.01,2321.99,
Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,767.01,,,,,,,fee schedule,767.01,2321.99,
Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1345.42,,,,,,,fee schedule,767.01,2321.99,
Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,767.01,2321.99,APC
Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,767.01,2321.99,APC
Adrenal cortex & medulla img,78075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,767.01,2321.99,APC
Endocrine nuclear procedure,78099,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Endocrine nuclear procedure,78099,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Endocrine nuclear procedure,78099,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,413.5,,,,,,,fee schedule,271.09,717,
Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,338.45,,,,,,,fee schedule,271.09,717,
Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,271.09,,,,,,,fee schedule,271.09,717,
Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,475.53,,,,,,,fee schedule,271.09,717,
Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,271.09,717,APC
Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,271.09,717,APC
Bone marrow imaging ltd,78102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,271.09,717,APC
Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,582.63,,,,,,,fee schedule,381.97,717,
Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,476.88,,,,,,,fee schedule,381.97,717,
Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,381.97,,,,,,,fee schedule,381.97,717,
Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,670.02,,,,,,,fee schedule,381.97,717,
Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,381.97,717,APC
Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,381.97,717,APC
Bone marrow imaging mult,78103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,381.97,717,APC
Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,595.73,,,,,,,fee schedule,390.56,717,
Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,487.61,,,,,,,fee schedule,390.56,717,
Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,390.56,,,,,,,fee schedule,390.56,717,
Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,685.09,,,,,,,fee schedule,390.56,717,
Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,390.56,717,APC
Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,390.56,717,APC
Bone marrow imaging body,78104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,390.56,717,APC
Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,258.69,,,,,,,fee schedule,169.6,2321.99,
Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.74,,,,,,,fee schedule,169.6,2321.99,
Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.6,,,,,,,fee schedule,169.6,2321.99,
Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,297.49,,,,,,,fee schedule,169.6,2321.99,
Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,169.6,2321.99,APC
Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,169.6,2321.99,APC
Plasma volume single,78110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,169.6,2321.99,APC
Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.02,,,,,,,fee schedule,158.67,2321.99,
Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.09,,,,,,,fee schedule,158.67,2321.99,
Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.67,,,,,,,fee schedule,158.67,2321.99,
Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.32,,,,,,,fee schedule,158.67,2321.99,
Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,158.67,2321.99,APC
Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,158.67,2321.99,APC
Plasma volume multiple,78111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,158.67,2321.99,APC
Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.13,,,,,,,fee schedule,154.81,717,
Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.27,,,,,,,fee schedule,154.81,717,
Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.81,,,,,,,fee schedule,154.81,717,
Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,271.55,,,,,,,fee schedule,154.81,717,
Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,154.81,717,APC
Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,154.81,717,APC
Red cell mass single,78120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,154.81,717,APC
Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,253.78,,,,,,,fee schedule,166.38,973.83,
Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.72,,,,,,,fee schedule,166.38,973.83,
Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.38,,,,,,,fee schedule,166.38,973.83,
Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,291.85,,,,,,,fee schedule,166.38,973.83,
Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,166.38,973.83,APC
Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,166.38,973.83,APC
Red cell mass multiple,78121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,166.38,973.83,APC
Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,216.52,,,,,,,fee schedule,141.95,973.83,
Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.22,,,,,,,fee schedule,141.95,973.83,
Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.95,,,,,,,fee schedule,141.95,973.83,
Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,249,,,,,,,fee schedule,141.95,973.83,
Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,141.95,973.83,APC
Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,141.95,973.83,APC
Blood volume,78122,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,141.95,973.83,APC
Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.86,,,,,,,fee schedule,258.87,717,
Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,323.19,,,,,,,fee schedule,258.87,717,
Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.87,,,,,,,fee schedule,258.87,717,
Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.09,,,,,,,fee schedule,258.87,717,
Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,258.87,717,APC
Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,258.87,717,APC
Red cell survival study,78130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,258.87,717,APC
Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,310.61,,,,,,,fee schedule,203.64,717,
Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.23,,,,,,,fee schedule,203.64,717,
Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.64,,,,,,,fee schedule,203.64,717,
Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.2,,,,,,,fee schedule,203.64,717,
Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,203.64,717,APC
Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,203.64,717,APC
Red cell sequestration,78140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,203.64,717,APC
Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,549.7,,,,,,,fee schedule,360.38,717,
Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,449.93,,,,,,,fee schedule,360.38,717,
Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,360.38,,,,,,,fee schedule,360.38,717,
Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,632.16,,,,,,,fee schedule,360.38,717,
Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,360.38,717,APC
Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,360.38,717,APC
Spleen imaging,78185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,360.38,717,APC
Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.86,,,,,,,fee schedule,258.87,717,
Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,323.19,,,,,,,fee schedule,258.87,717,
Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.87,,,,,,,fee schedule,258.87,717,
Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.09,,,,,,,fee schedule,258.87,717,
Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,258.87,717,APC
Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,258.87,717,APC
Platelet survival,78191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,258.87,717,APC
Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,656.46,,,,,,,fee schedule,430.38,973.83,
Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,537.31,,,,,,,fee schedule,430.38,973.83,
Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,430.38,,,,,,,fee schedule,430.38,973.83,
Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,754.93,,,,,,,fee schedule,430.38,973.83,
Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,430.38,973.83,APC
Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,430.38,973.83,APC
Lymph system imaging,78195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,430.38,973.83,APC
Blood/lymph nuclear exam,78199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Blood/lymph nuclear exam,78199,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Blood/lymph nuclear exam,78199,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,482.06,,,,,,,fee schedule,316.04,973.83,
Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,394.57,,,,,,,fee schedule,316.04,973.83,
Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.04,,,,,,,fee schedule,316.04,973.83,
Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,554.37,,,,,,,fee schedule,316.04,973.83,
Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,316.04,973.83,APC
Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,316.04,973.83,APC
Liver imaging,78201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,316.04,973.83,APC
Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,507.56,,,,,,,fee schedule,332.76,973.83,
Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,415.44,,,,,,,fee schedule,332.76,973.83,
Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.76,,,,,,,fee schedule,332.76,973.83,
Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,583.69,,,,,,,fee schedule,332.76,973.83,
Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,332.76,973.83,APC
Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,332.76,973.83,APC
Liver imaging with flow,78202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,332.76,973.83,APC
Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,488.93,,,,,,,fee schedule,320.54,717,
Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,400.19,,,,,,,fee schedule,320.54,717,
Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,320.54,,,,,,,fee schedule,320.54,717,
Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,562.27,,,,,,,fee schedule,320.54,717,
Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,320.54,717,APC
Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,320.54,717,APC
Liver and spleen imaging,78215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,320.54,717,APC
Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,286.11,,,,,,,fee schedule,187.57,717,
Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.18,,,,,,,fee schedule,187.57,717,
Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,187.57,,,,,,,fee schedule,187.57,717,
Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,329.03,,,,,,,fee schedule,187.57,717,
Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,187.57,717,APC
Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,187.57,717,APC
Liver & spleen image/flow,78216,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,187.57,717,APC
Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,598.6,,,,,,,fee schedule,392.44,717,
Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,489.95,,,,,,,fee schedule,392.44,717,
Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,392.44,,,,,,,fee schedule,392.44,717,
Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,688.39,,,,,,,fee schedule,392.44,717,
Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,392.44,717,APC
Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,392.44,717,APC
Hepatobiliary system imaging,78226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,392.44,717,APC
Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1312.5,,,,,,,fee schedule,541.02,1509.38,
Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1074.28,,,,,,,fee schedule,541.02,1509.38,
Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,860.48,,,,,,,fee schedule,541.02,1509.38,
Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1509.38,,,,,,,fee schedule,541.02,1509.38,
Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1509.38,APC
Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1509.38,APC
Hepatobil syst image w/drug,78227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1509.38,APC
Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,436.98,,,,,,,fee schedule,286.48,717,
Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,357.67,,,,,,,fee schedule,286.48,717,
Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.48,,,,,,,fee schedule,286.48,717,
Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,502.53,,,,,,,fee schedule,286.48,717,
Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,286.48,717,APC
Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,286.48,717,APC
Salivary gland imaging,78230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,286.48,717,APC
Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.9,,,,,,,fee schedule,193.99,717,
Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.19,,,,,,,fee schedule,193.99,717,
Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.99,,,,,,,fee schedule,193.99,717,
Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.29,,,,,,,fee schedule,193.99,717,
Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,193.99,717,APC
Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,193.99,717,APC
Serial salivary imaging,78231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,193.99,717,APC
Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,231.25,,,,,,,fee schedule,151.61,717,
Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.28,,,,,,,fee schedule,151.61,717,
Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.61,,,,,,,fee schedule,151.61,717,
Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.94,,,,,,,fee schedule,151.61,717,
Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,151.61,717,APC
Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,151.61,717,APC
Salivary gland function exam,78232,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,151.61,717,APC
Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,541.85,,,,,,,fee schedule,355.24,717,
Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,443.5,,,,,,,fee schedule,355.24,717,
Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,355.24,,,,,,,fee schedule,355.24,717,
Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,623.13,,,,,,,fee schedule,355.24,717,
Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,355.24,717,APC
Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,355.24,717,APC
Esophageal motility study,78258,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,355.24,717,APC
Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,609.47,,,,,,,fee schedule,398.33,717,
Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,498.85,,,,,,,fee schedule,398.33,717,
Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,399.57,,,,,,,fee schedule,398.33,717,
Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,700.89,,,,,,,fee schedule,398.33,717,
Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Gastric mucosa imaging,78261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,602.62,,,,,,,fee schedule,395.08,717,
Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,493.24,,,,,,,fee schedule,395.08,717,
Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.08,,,,,,,fee schedule,395.08,717,
Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,693.01,,,,,,,fee schedule,395.08,717,
Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,395.08,717,APC
Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,395.08,717,APC
Gastroesophageal reflux exam,78262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,395.08,717,APC
Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,795.13,,,,,,,fee schedule,398.33,914.4,
Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,650.81,,,,,,,fee schedule,398.33,914.4,
Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.29,,,,,,,fee schedule,398.33,914.4,
Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,914.4,,,,,,,fee schedule,398.33,914.4,
Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,914.4,APC
Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,914.4,APC
Gastric emptying imag study,78264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,914.4,APC
Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1008.24,,,,,,,fee schedule,398.33,1159.48,
Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,661,,,,,,,fee schedule,398.33,1159.48,
Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,825.24,,,,,,,fee schedule,398.33,1159.48,
Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1159.48,,,,,,,fee schedule,398.33,1159.48,
Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,1159.48,APC
Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,1159.48,APC
Gastric emptying imag study,78265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,1159.48,APC
Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1206.18,,,,,,,fee schedule,541.02,1387.11,
Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.77,,,,,,,fee schedule,541.02,1387.11,
Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,987.26,,,,,,,fee schedule,541.02,1387.11,
Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1387.11,,,,,,,fee schedule,541.02,1387.11,
Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1387.11,APC
Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1387.11,APC
Gastric emptying imag study,78266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1387.11,APC
Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.42,,,,,,,fee schedule,11.06,33.83,
Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.29,,,,,,,fee schedule,11.06,33.83,
Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.08,,,,,,,fee schedule,11.06,33.83,
Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.83,,,,,,,fee schedule,11.06,33.83,
Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.61,,,,,,,fee schedule,11.06,33.83,APC
Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.06,,,,,,,fee schedule,11.06,33.83,APC
Breath tst attain/anal c-14,78267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.91,,,,,,,fee schedule,11.06,33.83,APC
Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.26,,,,,,,fee schedule,94.41,290.1,
Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.38,,,,,,,fee schedule,94.41,290.1,
Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.47,,,,,,,fee schedule,94.41,290.1,
Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.1,,,,,,,fee schedule,94.41,290.1,
Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.13,,,,,,,fee schedule,94.41,290.1,APC
Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.41,,,,,,,fee schedule,94.41,290.1,APC
Breath test analysis c-14,78268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,169.94,,,,,,,fee schedule,94.41,290.1,APC
Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1920.17,,,,,,,fee schedule,398.33,2208.2,
Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1258.86,,,,,,,fee schedule,398.33,2208.2,
Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1571.66,,,,,,,fee schedule,398.33,2208.2,
Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2208.2,,,,,,,fee schedule,398.33,2208.2,
Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,2208.2,APC
Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,2208.2,APC
Acute GI blood loss imaging,78278,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,2208.2,APC
GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.74,,,,,,,fee schedule,104.07,717,
GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.07,,,,,,,fee schedule,104.07,717,
GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.93,,,,,,,fee schedule,104.07,717,
GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.55,,,,,,,fee schedule,104.07,717,
GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,104.07,717,APC
GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,104.07,717,APC
GI protein loss exam,78282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,104.07,717,APC
Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.59,,,,,,,fee schedule,326.88,717,
Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.88,,,,,,,fee schedule,326.88,717,
Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408.1,,,,,,,fee schedule,326.88,717,
Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,573.38,,,,,,,fee schedule,326.88,717,
Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,326.88,717,APC
Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,326.88,717,APC
Meckels divert exam,78290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,326.88,717,APC
Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,613.36,,,,,,,fee schedule,398.33,717,
Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,402.12,,,,,,,fee schedule,398.33,717,
Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,502.04,,,,,,,fee schedule,398.33,717,
Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,705.36,,,,,,,fee schedule,398.33,717,
Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Leveen/shunt patency exam,78291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
GI nuclear procedure,78299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
GI nuclear procedure,78299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
GI nuclear procedure,78299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,800.25,,,,,,,fee schedule,398.33,920.29,
Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,524.64,,,,,,,fee schedule,398.33,920.29,
Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,655,,,,,,,fee schedule,398.33,920.29,
Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,920.29,,,,,,,fee schedule,398.33,920.29,
Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,920.29,APC
Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,920.29,APC
Bone imaging limited area,78300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,920.29,APC
Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,548.73,,,,,,,fee schedule,359.75,717,
Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,359.75,,,,,,,fee schedule,359.75,717,
Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,449.14,,,,,,,fee schedule,359.75,717,
Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,631.04,,,,,,,fee schedule,359.75,717,
Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,359.75,717,APC
Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,359.75,717,APC
Bone imaging multiple areas,78305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,359.75,717,APC
Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,812.06,,,,,,,fee schedule,398.33,933.87,
Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,532.39,,,,,,,fee schedule,398.33,933.87,
Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,664.67,,,,,,,fee schedule,398.33,933.87,
Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,933.87,,,,,,,fee schedule,398.33,933.87,
Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,933.87,APC
Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,933.87,APC
Bone imaging whole body,78306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,933.87,APC
Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,612.41,,,,,,,fee schedule,398.33,717,
Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,401.5,,,,,,,fee schedule,398.33,717,
Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,501.26,,,,,,,fee schedule,398.33,717,
Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,704.27,,,,,,,fee schedule,398.33,717,
Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Bone imaging 3 phase,78315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Bone mineral single photon,78350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.73,,,,,,,fee schedule,39.81,69.84,
Bone mineral single photon,78350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.81,,,,,,,fee schedule,39.81,69.84,
Bone mineral single photon,78350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.71,,,,,,,fee schedule,39.81,69.84,
Bone mineral single photon,78350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.84,,,,,,,fee schedule,39.81,69.84,
Bone mineral dual photon,78351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.4,,,,,,,fee schedule,19.27,33.81,
Bone mineral dual photon,78351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.27,,,,,,,fee schedule,19.27,33.81,
Bone mineral dual photon,78351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.06,,,,,,,fee schedule,19.27,33.81,
Bone mineral dual photon,78351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.81,,,,,,,fee schedule,19.27,33.81,
Musculoskeletal nuclear exam,78399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Musculoskeletal nuclear exam,78399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Musculoskeletal nuclear exam,78399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,973.83,
Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,973.83,
Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,973.83,
Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,973.83,
Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,94.43,973.83,APC
Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,94.43,973.83,APC
Non-imaging heart function,78414,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,94.43,973.83,APC
Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,413.5,,,,,,,fee schedule,271.09,717,
Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,271.09,,,,,,,fee schedule,271.09,717,
Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,338.45,,,,,,,fee schedule,271.09,717,
Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,475.53,,,,,,,fee schedule,271.09,717,
Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,271.09,717,APC
Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,271.09,717,APC
Cardiac shunt imaging,78428,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,271.09,717,APC
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2803.33,,,,,,,fee schedule,1424.81,3223.83,
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1837.86,,,,,,,fee schedule,1424.81,3223.83,
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2294.53,,,,,,,fee schedule,1424.81,3223.83,
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3223.83,,,,,,,fee schedule,1424.81,3223.83,
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1424.81,3223.83,APC
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1424.81,3223.83,APC
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1424.81,3223.83,APC
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2803.33,,,,,,,fee schedule,1424.81,3223.83,
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1837.86,,,,,,,fee schedule,1424.81,3223.83,
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2294.53,,,,,,,fee schedule,1424.81,3223.83,
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3223.83,,,,,,,fee schedule,1424.81,3223.83,
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1424.81,3223.83,APC
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1424.81,3223.83,APC
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1424.81,3223.83,APC
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4372.07,,,,,,,fee schedule,2194.87,5027.88,
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2866.33,,,,,,,fee schedule,2194.87,5027.88,
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3578.54,,,,,,,fee schedule,2194.87,5027.88,
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5027.88,,,,,,,fee schedule,2194.87,5027.88,
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2304.61,,,,,,,fee schedule,2194.87,5027.88,APC
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2194.87,,,,,,,fee schedule,2194.87,5027.88,APC
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3950.76,,,,,,,fee schedule,2194.87,5027.88,APC
Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5343.41,,,,,,,fee schedule,1512.17,6144.92,
Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3503.14,,,,,,,fee schedule,1512.17,6144.92,
Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4373.58,,,,,,,fee schedule,1512.17,6144.92,
Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6144.92,,,,,,,fee schedule,1512.17,6144.92,
Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1587.78,,,,,,,fee schedule,1512.17,6144.92,APC
Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1512.17,,,,,,,fee schedule,1512.17,6144.92,APC
Myocrd img pet 2rtracer,78432,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2721.91,,,,,,,fee schedule,1512.17,6144.92,APC
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5343.41,,,,,,,fee schedule,2194.87,6144.92,
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4373.58,,,,,,,fee schedule,2194.87,6144.92,
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3503.14,,,,,,,fee schedule,2194.87,6144.92,
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6144.92,,,,,,,fee schedule,2194.87,6144.92,
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2304.61,,,,,,,fee schedule,2194.87,6144.92,APC
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2194.87,,,,,,,fee schedule,2194.87,6144.92,APC
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3950.76,,,,,,,fee schedule,2194.87,6144.92,APC
Aqmbf pet rest & rx stress,78434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1101.3,,,,,,,fee schedule,722.01,1266.5,
Aqmbf pet rest & rx stress,78434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,901.41,,,,,,,fee schedule,722.01,1266.5,
Aqmbf pet rest & rx stress,78434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,722.01,,,,,,,fee schedule,722.01,1266.5,
Aqmbf pet rest & rx stress,78434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1266.5,,,,,,,fee schedule,722.01,1266.5,
Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,452.69,,,,,,,fee schedule,296.78,717,
Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,370.53,,,,,,,fee schedule,296.78,717,
Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,296.78,,,,,,,fee schedule,296.78,717,
Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,520.59,,,,,,,fee schedule,296.78,717,
Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,296.78,717,APC
Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,296.78,717,APC
Vascular flow imaging,78445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,296.78,717,APC
Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,928.63,,,,,,,fee schedule,608.81,2321.99,
Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,760.08,,,,,,,fee schedule,608.81,2321.99,
Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,608.81,,,,,,,fee schedule,608.81,2321.99,
Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1067.92,,,,,,,fee schedule,608.81,2321.99,
Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,608.81,2321.99,APC
Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,608.81,2321.99,APC
Ht muscle image spect sing,78451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,608.81,2321.99,APC
Ht muscle image spect mult,78452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,1289.99,2321.99,APC
Ht muscle image spect mult,78452,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,1289.99,2321.99,APC
Ht muscle image spect mult,78452,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,1289.99,2321.99,APC
Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,730.98,,,,,,,fee schedule,479.23,2321.99,
Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,598.31,,,,,,,fee schedule,479.23,2321.99,
Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,479.23,,,,,,,fee schedule,479.23,2321.99,
Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,840.63,,,,,,,fee schedule,479.23,2321.99,
Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,479.23,2321.99,APC
Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,479.23,2321.99,APC
Ht muscle image planar sing,78453,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,479.23,2321.99,APC
Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1064.1,,,,,,,fee schedule,697.62,2321.99,
Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,870.97,,,,,,,fee schedule,697.62,2321.99,
Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,697.62,,,,,,,fee schedule,697.62,2321.99,
Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1223.72,,,,,,,fee schedule,697.62,2321.99,
Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,697.62,2321.99,APC
Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,697.62,2321.99,APC
Ht musc image planar mult,78454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,697.62,2321.99,APC
Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,778.99,,,,,,,fee schedule,510.71,2321.99,
Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,637.6,,,,,,,fee schedule,510.71,2321.99,
Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,510.71,,,,,,,fee schedule,510.71,2321.99,
Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,895.84,,,,,,,fee schedule,510.71,2321.99,
Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,510.71,2321.99,APC
Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,510.71,2321.99,APC
Acute venous thrombus image,78456,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,510.71,2321.99,APC
Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,398.82,,,,,,,fee schedule,261.47,973.83,
Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,326.43,,,,,,,fee schedule,261.47,973.83,
Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,261.47,,,,,,,fee schedule,261.47,973.83,
Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,458.64,,,,,,,fee schedule,261.47,973.83,
Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,261.47,973.83,APC
Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,261.47,973.83,APC
Venous thrombosis imaging,78457,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,261.47,973.83,APC
Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,459.55,,,,,,,fee schedule,301.28,717,
Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.14,,,,,,,fee schedule,301.28,717,
Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.28,,,,,,,fee schedule,301.28,717,
Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,528.48,,,,,,,fee schedule,301.28,717,
Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,301.28,717,APC
Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,301.28,717,APC
Ven thrombosis images bilat,78458,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,301.28,717,APC
Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,961.24,,,,,,,fee schedule,630.19,2321.99,
Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,786.77,,,,,,,fee schedule,630.19,2321.99,
Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,630.19,,,,,,,fee schedule,630.19,2321.99,
Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1105.43,,,,,,,fee schedule,630.19,2321.99,
Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,630.19,2321.99,APC
Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,630.19,2321.99,APC
Heart muscle imaging (PET),78459,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,630.19,2321.99,APC
Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,461.51,,,,,,,fee schedule,302.57,717,
Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,377.75,,,,,,,fee schedule,302.57,717,
Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,302.57,,,,,,,fee schedule,302.57,717,
Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,530.74,,,,,,,fee schedule,302.57,717,
Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,302.57,717,APC
Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,302.57,717,APC
Heart infarct image,78466,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,302.57,717,APC
Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,446.8,,,,,,,fee schedule,292.92,973.83,
Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,365.71,,,,,,,fee schedule,292.92,973.83,
Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,292.92,,,,,,,fee schedule,292.92,973.83,
Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,513.82,,,,,,,fee schedule,292.92,973.83,
Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,292.92,973.83,APC
Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,292.92,973.83,APC
Heart infarct image (ef),78468,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,292.92,973.83,APC
Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,524.2,,,,,,,fee schedule,343.67,973.83,
Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,429.06,,,,,,,fee schedule,343.67,973.83,
Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.67,,,,,,,fee schedule,343.67,973.83,
Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,602.83,,,,,,,fee schedule,343.67,973.83,
Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,343.67,973.83,APC
Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,343.67,973.83,APC
Heart infarct image (3D),78469,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,343.67,973.83,APC
Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2084.82,,,,,,,fee schedule,398.33,2397.54,
Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1706.43,,,,,,,fee schedule,398.33,2397.54,
Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1366.81,,,,,,,fee schedule,398.33,2397.54,
Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2397.54,,,,,,,fee schedule,398.33,2397.54,
Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,2397.54,APC
Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,2397.54,APC
Gated heart planar single,78472,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,2397.54,APC
Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,627.11,,,,,,,fee schedule,398.33,721.18,
Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,513.29,,,,,,,fee schedule,398.33,721.18,
Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,411.13,,,,,,,fee schedule,398.33,721.18,
Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,721.18,,,,,,,fee schedule,398.33,721.18,
Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,721.18,APC
Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,721.18,APC
Gated heart multiple,78473,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,721.18,APC
Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,365.46,,,,,,,fee schedule,239.6,973.83,
Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.13,,,,,,,fee schedule,239.6,973.83,
Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,239.6,,,,,,,fee schedule,239.6,973.83,
Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,420.28,,,,,,,fee schedule,239.6,973.83,
Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,239.6,973.83,APC
Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,239.6,973.83,APC
Heart first pass single,78481,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,239.6,973.83,APC
Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,492.85,,,,,,,fee schedule,323.11,973.83,
Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,403.4,,,,,,,fee schedule,323.11,973.83,
Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,323.11,,,,,,,fee schedule,323.11,973.83,
Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,566.78,,,,,,,fee schedule,323.11,973.83,
Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,323.11,973.83,APC
Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,323.11,973.83,APC
Heart first pass multiple,78483,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,323.11,973.83,APC
Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1044.51,,,,,,,fee schedule,684.78,2564.65,
Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,854.93,,,,,,,fee schedule,684.78,2564.65,
Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,684.78,,,,,,,fee schedule,684.78,2564.65,
Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1201.19,,,,,,,fee schedule,684.78,2564.65,
Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,684.78,2564.65,APC
Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,684.78,2564.65,APC
Heart image (pet) single,78491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,684.78,2564.65,APC
Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1312.01,,,,,,,fee schedule,860.15,2564.65,
Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1073.88,,,,,,,fee schedule,860.15,2564.65,
Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,860.15,,,,,,,fee schedule,860.15,2564.65,
Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1508.81,,,,,,,fee schedule,860.15,2564.65,
Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,860.15,2564.65,APC
Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,860.15,2564.65,APC
Heart image (pet) multiple,78492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,860.15,2564.65,APC
Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,479.15,,,,,,,fee schedule,314.13,717,
Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,392.18,,,,,,,fee schedule,314.13,717,
Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,314.13,,,,,,,fee schedule,314.13,717,
Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,551.02,,,,,,,fee schedule,314.13,717,
Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,314.13,717,APC
Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,314.13,717,APC
Heart image spect,78494,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,314.13,717,APC
Heart first pass add-on,78496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.83,,,,,,,fee schedule,37.26,65.35,
Heart first pass add-on,78496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.52,,,,,,,fee schedule,37.26,65.35,
Heart first pass add-on,78496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.26,,,,,,,fee schedule,37.26,65.35,
Heart first pass add-on,78496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.35,,,,,,,fee schedule,37.26,65.35,
Cardiovascular nuclear exam,78499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Cardiovascular nuclear exam,78499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Cardiovascular nuclear exam,78499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,466.41,,,,,,,fee schedule,305.78,717,
Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,381.76,,,,,,,fee schedule,305.78,717,
Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,305.78,,,,,,,fee schedule,305.78,717,
Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,536.37,,,,,,,fee schedule,305.78,717,
Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,305.78,717,APC
Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,305.78,717,APC
Lung ventilation imaging,78579,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,305.78,717,APC
Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,583,,,,,,,fee schedule,382.21,717,
Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,477.19,,,,,,,fee schedule,382.21,717,
Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,382.21,,,,,,,fee schedule,382.21,717,
Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,670.45,,,,,,,fee schedule,382.21,717,
Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,382.21,717,APC
Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,382.21,717,APC
Lung perfusion imaging,78580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,382.21,717,APC
Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1074.01,,,,,,,fee schedule,541.02,1235.11,
Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,879.08,,,,,,,fee schedule,541.02,1235.11,
Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,704.12,,,,,,,fee schedule,541.02,1235.11,
Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1235.11,,,,,,,fee schedule,541.02,1235.11,
Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1235.11,APC
Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1235.11,APC
Lung ventilat&perfus imaging,78582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1235.11,APC
Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1463.64,,,,,,,fee schedule,398.33,1683.19,
Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1197.99,,,,,,,fee schedule,398.33,1683.19,
Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,959.56,,,,,,,fee schedule,398.33,1683.19,
Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1683.19,,,,,,,fee schedule,398.33,1683.19,
Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,1683.19,APC
Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,1683.19,APC
Lung perfusion differential,78597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,1683.19,APC
Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1060.47,,,,,,,fee schedule,541.02,1219.54,
Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,867.99,,,,,,,fee schedule,541.02,1219.54,
Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,695.24,,,,,,,fee schedule,541.02,1219.54,
Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1219.54,,,,,,,fee schedule,541.02,1219.54,
Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1219.54,APC
Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1219.54,APC
Lung perf&ventilat diferentl,78598,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1219.54,APC
Respiratory nuclear exam,78599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Respiratory nuclear exam,78599,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Respiratory nuclear exam,78599,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,468.36,,,,,,,fee schedule,307.06,717,
Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,383.35,,,,,,,fee schedule,307.06,717,
Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,307.06,,,,,,,fee schedule,307.06,717,
Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,538.61,,,,,,,fee schedule,307.06,717,
Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,307.06,717,APC
Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,307.06,717,APC
Brain image < 4 views,78600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,307.06,717,APC
Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,545.76,,,,,,,fee schedule,357.8,717,
Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,446.7,,,,,,,fee schedule,357.8,717,
Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,357.8,,,,,,,fee schedule,357.8,717,
Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,627.62,,,,,,,fee schedule,357.8,717,
Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,357.8,717,APC
Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,357.8,717,APC
Brain image w/flow < 4 views,78601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,357.8,717,APC
Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,499.7,,,,,,,fee schedule,327.6,973.83,
Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,409,,,,,,,fee schedule,327.6,973.83,
Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,327.6,,,,,,,fee schedule,327.6,973.83,
Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,574.66,,,,,,,fee schedule,327.6,973.83,
Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,327.6,973.83,APC
Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,327.6,973.83,APC
Brain image 4+ views,78605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,327.6,973.83,APC
Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,858.34,,,,,,,fee schedule,541.02,987.09,
Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,702.55,,,,,,,fee schedule,541.02,987.09,
Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,562.73,,,,,,,fee schedule,541.02,987.09,
Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,987.09,,,,,,,fee schedule,541.02,987.09,
Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,987.09,APC
Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,987.09,APC
Brain image w/flow 4 + views,78606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,987.09,APC
Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7187.38,,,,,,,fee schedule,1424.81,8265.49,
Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5882.87,,,,,,,fee schedule,1424.81,8265.49,
Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4712.05,,,,,,,fee schedule,1424.81,8265.49,
Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8265.49,,,,,,,fee schedule,1424.81,8265.49,
Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1424.81,8265.49,APC
Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1424.81,8265.49,APC
Brain imaging (PET),78608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1424.81,8265.49,APC
Brain imaging (PET),78609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.83,,,,,,,fee schedule,37.26,65.35,
Brain imaging (PET),78609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.52,,,,,,,fee schedule,37.26,65.35,
Brain imaging (PET),78609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.26,,,,,,,fee schedule,37.26,65.35,
Brain imaging (PET),78609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.35,,,,,,,fee schedule,37.26,65.35,
Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,459.55,,,,,,,fee schedule,301.28,973.83,
Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.14,,,,,,,fee schedule,301.28,973.83,
Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.28,,,,,,,fee schedule,301.28,973.83,
Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,528.48,,,,,,,fee schedule,301.28,973.83,
Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,301.28,973.83,APC
Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,301.28,973.83,APC
Brain flow imaging only,78610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,301.28,973.83,APC
Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2340,,,,,,,fee schedule,541.02,2691,
Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1915.29,,,,,,,fee schedule,541.02,2691,
Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1534.1,,,,,,,fee schedule,541.02,2691,
Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2691,,,,,,,fee schedule,541.02,2691,
Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,2691,APC
Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,2691,APC
Cerebrospinal fluid scan,78630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,2691,APC
CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,893.61,,,,,,,fee schedule,541.02,1027.65,
CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,731.42,,,,,,,fee schedule,541.02,1027.65,
CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,585.85,,,,,,,fee schedule,541.02,1027.65,
CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1027.65,,,,,,,fee schedule,541.02,1027.65,
CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1027.65,APC
CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1027.65,APC
CSF ventriculography,78635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1027.65,APC
CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2619.48,,,,,,,fee schedule,541.02,3012.4,
CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2144.04,,,,,,,fee schedule,541.02,3012.4,
CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1717.33,,,,,,,fee schedule,541.02,3012.4,
CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3012.4,,,,,,,fee schedule,541.02,3012.4,
CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,3012.4,APC
CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,3012.4,APC
CSF shunt evaluation,78645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,3012.4,APC
CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,866.19,,,,,,,fee schedule,567.87,2321.99,
CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,708.98,,,,,,,fee schedule,567.87,2321.99,
CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,567.87,,,,,,,fee schedule,567.87,2321.99,
CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,996.12,,,,,,,fee schedule,567.87,2321.99,
CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,567.87,2321.99,APC
CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,567.87,2321.99,APC
CSF leakage imaging,78650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,567.87,2321.99,APC
Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,440.93,,,,,,,fee schedule,289.07,717,
Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,360.9,,,,,,,fee schedule,289.07,717,
Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,289.07,,,,,,,fee schedule,289.07,717,
Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,507.07,,,,,,,fee schedule,289.07,717,
Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,289.07,717,APC
Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,289.07,717,APC
Nuclear exam of tear flow,78660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,289.07,717,APC
Nervous system nuclear exam,78699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Nervous system nuclear exam,78699,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Nervous system nuclear exam,78699,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,429.17,,,,,,,fee schedule,281.36,717,
Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,351.28,,,,,,,fee schedule,281.36,717,
Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,281.36,,,,,,,fee schedule,281.36,717,
Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,493.55,,,,,,,fee schedule,281.36,717,
Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,281.36,717,APC
Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,281.36,717,APC
Kidney imaging morphol,78700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,281.36,717,APC
Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,539.91,,,,,,,fee schedule,353.96,717,
Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,441.92,,,,,,,fee schedule,353.96,717,
Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,353.96,,,,,,,fee schedule,353.96,717,
Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,620.9,,,,,,,fee schedule,353.96,717,
Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,353.96,717,APC
Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,353.96,717,APC
Kidney imaging with flow,78701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,353.96,717,APC
K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1159.54,,,,,,,fee schedule,541.02,1333.47,
K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,949.08,,,,,,,fee schedule,541.02,1333.47,
K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,760.19,,,,,,,fee schedule,541.02,1333.47,
K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1333.47,,,,,,,fee schedule,541.02,1333.47,
K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1333.47,APC
K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1333.47,APC
K flow/funct image w/o drug,78707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1333.47,APC
K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1418.61,,,,,,,fee schedule,541.02,1631.4,
K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1161.13,,,,,,,fee schedule,541.02,1631.4,
K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,930.04,,,,,,,fee schedule,541.02,1631.4,
K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1631.4,,,,,,,fee schedule,541.02,1631.4,
K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1631.4,APC
K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1631.4,APC
K flow/funct image w/drug,78708,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1631.4,APC
K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,853.46,,,,,,,fee schedule,541.02,981.48,
K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,698.56,,,,,,,fee schedule,541.02,981.48,
K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,559.53,,,,,,,fee schedule,541.02,981.48,
K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,981.48,,,,,,,fee schedule,541.02,981.48,
K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,981.48,APC
K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,981.48,APC
K flow/funct image multiple,78709,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,981.48,APC
Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,510.83,,,,,,,fee schedule,334.9,717,
Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,418.11,,,,,,,fee schedule,334.9,717,
Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.9,,,,,,,fee schedule,334.9,717,
Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.45,,,,,,,fee schedule,334.9,717,
Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,334.9,717,APC
Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,334.9,717,APC
Kidney function study,78725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,334.9,717,APC
Urinary bladder retention,78730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,208.45,
Urinary bladder retention,78730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,208.45,
Urinary bladder retention,78730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,208.45,
Urinary bladder retention,78730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,208.45,
Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,550.67,,,,,,,fee schedule,361.02,717,
Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,450.72,,,,,,,fee schedule,361.02,717,
Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,361.02,,,,,,,fee schedule,361.02,717,
Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,633.27,,,,,,,fee schedule,361.02,717,
Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,361.02,717,APC
Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,361.02,717,APC
Ureteral reflux study,78740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,361.02,717,APC
Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,511.49,,,,,,,fee schedule,335.33,717,
Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,418.65,,,,,,,fee schedule,335.33,717,
Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,335.33,,,,,,,fee schedule,335.33,717,
Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,588.21,,,,,,,fee schedule,335.33,717,
Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,335.33,717,APC
Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,335.33,717,APC
Testicular imaging w/flow,78761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,335.33,717,APC
Genitourinary nuclear exam,78799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Genitourinary nuclear exam,78799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Genitourinary nuclear exam,78799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.58,,,,,,,fee schedule,299.99,717,
Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.53,,,,,,,fee schedule,299.99,717,
Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.99,,,,,,,fee schedule,299.99,717,
Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.22,,,,,,,fee schedule,299.99,717,
Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,299.99,717,APC
Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,299.99,717,APC
Tumor imaging limited area,78800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,299.99,717,APC
Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,640.81,,,,,,,fee schedule,398.33,736.93,
Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,524.5,,,,,,,fee schedule,398.33,736.93,
Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,420.12,,,,,,,fee schedule,398.33,736.93,
Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,736.93,,,,,,,fee schedule,398.33,736.93,
Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,736.93,APC
Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,736.93,APC
Tumor imaging mult areas,78801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,736.93,APC
Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5682.29,,,,,,,fee schedule,541.02,6534.63,
Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4650.95,,,,,,,fee schedule,541.02,6534.63,
Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3725.31,,,,,,,fee schedule,541.02,6534.63,
Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6534.63,,,,,,,fee schedule,541.02,6534.63,
Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,6534.63,APC
Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,6534.63,APC
Tumor imaging whole body,78802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,6534.63,APC
Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,781.7,,,,,,,fee schedule,512.48,973.83,
Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,639.82,,,,,,,fee schedule,512.48,973.83,
Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,512.48,,,,,,,fee schedule,512.48,973.83,
Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,898.96,,,,,,,fee schedule,512.48,973.83,
Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,512.48,973.83,APC
Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,512.48,973.83,APC
Tumor imaging (3D),78803,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,512.48,973.83,APC
Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1570.22,,,,,,,fee schedule,541.02,1805.75,
Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1285.23,,,,,,,fee schedule,541.02,1805.75,
Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1029.44,,,,,,,fee schedule,541.02,1805.75,
Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1805.75,,,,,,,fee schedule,541.02,1805.75,
Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.07,,,,,,,fee schedule,541.02,1805.75,APC
Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,541.02,,,,,,,fee schedule,541.02,1805.75,APC
Tumor imaging whole body,78804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,973.83,,,,,,,fee schedule,541.02,1805.75,APC
Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.14,,,,,,,fee schedule,326.58,717,
Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,407.73,,,,,,,fee schedule,326.58,717,
Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.58,,,,,,,fee schedule,326.58,717,
Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,572.86,,,,,,,fee schedule,326.58,717,
Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,326.58,717,APC
Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,326.58,717,APC
Iv inj ra drug dx study,78808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,326.58,717,APC
Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1573.63,,,,,,,fee schedule,1031.67,2321.99,
Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1288.02,,,,,,,fee schedule,1031.67,2321.99,
Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1031.67,,,,,,,fee schedule,1031.67,2321.99,
Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1809.67,,,,,,,fee schedule,1031.67,2321.99,
Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,1031.67,2321.99,APC
Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,1031.67,2321.99,APC
Pet image ltd area,78811,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,1031.67,2321.99,APC
Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1918.55,,,,,,,fee schedule,1257.8,2564.65,
Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1570.33,,,,,,,fee schedule,1257.8,2564.65,
Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1257.8,,,,,,,fee schedule,1257.8,2564.65,
Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2206.33,,,,,,,fee schedule,1257.8,2564.65,
Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1257.8,2564.65,APC
Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1257.8,2564.65,APC
Pet image skull-thigh,78812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1257.8,2564.65,APC
Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1997.92,,,,,,,fee schedule,1309.84,2564.65,
Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1635.3,,,,,,,fee schedule,1309.84,2564.65,
Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1309.84,,,,,,,fee schedule,1309.84,2564.65,
Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2297.61,,,,,,,fee schedule,1309.84,2564.65,
Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1309.84,2564.65,APC
Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1309.84,2564.65,APC
Pet image full body,78813,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1309.84,2564.65,APC
Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6237.02,,,,,,,fee schedule,1424.81,7172.57,
Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5105,,,,,,,fee schedule,1424.81,7172.57,
Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4088.99,,,,,,,fee schedule,1424.81,7172.57,
Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7172.57,,,,,,,fee schedule,1424.81,7172.57,
Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1424.81,7172.57,APC
Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1424.81,7172.57,APC
Pet image w/ct lmtd,78814,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1424.81,7172.57,APC
Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6400.39,,,,,,,fee schedule,1424.81,7360.45,
Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5238.72,,,,,,,fee schedule,1424.81,7360.45,
Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4196.1,,,,,,,fee schedule,1424.81,7360.45,
Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7360.45,,,,,,,fee schedule,1424.81,7360.45,
Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1424.81,7360.45,APC
Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1424.81,7360.45,APC
Pet image w/ct skull-thigh,78815,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1424.81,7360.45,APC
Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6450.96,,,,,,,fee schedule,1424.81,7418.6,
Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5280.11,,,,,,,fee schedule,1424.81,7418.6,
Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4229.25,,,,,,,fee schedule,1424.81,7418.6,
Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7418.6,,,,,,,fee schedule,1424.81,7418.6,
Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1424.81,7418.6,APC
Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1424.81,7418.6,APC
Pet image w/ct full body,78816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1424.81,7418.6,APC
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2471.23,,,,,,,fee schedule,1289.99,2841.91,
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2022.7,,,,,,,fee schedule,1289.99,2841.91,
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1620.14,,,,,,,fee schedule,1289.99,2841.91,
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2841.91,,,,,,,fee schedule,1289.99,2841.91,
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,1289.99,2841.91,APC
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,1289.99,2841.91,APC
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,1289.99,2841.91,APC
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2471.23,,,,,,,fee schedule,1289.99,2841.91,
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2022.7,,,,,,,fee schedule,1289.99,2841.91,
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1620.14,,,,,,,fee schedule,1289.99,2841.91,
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2841.91,,,,,,,fee schedule,1289.99,2841.91,
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1354.49,,,,,,,fee schedule,1289.99,2841.91,APC
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1289.99,,,,,,,fee schedule,1289.99,2841.91,APC
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2321.99,,,,,,,fee schedule,1289.99,2841.91,APC
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2803.33,,,,,,,fee schedule,1424.81,3223.83,
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2294.53,,,,,,,fee schedule,1424.81,3223.83,
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1837.86,,,,,,,fee schedule,1424.81,3223.83,
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3223.83,,,,,,,fee schedule,1424.81,3223.83,
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1496.05,,,,,,,fee schedule,1424.81,3223.83,APC
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.81,,,,,,,fee schedule,1424.81,3223.83,APC
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2564.65,,,,,,,fee schedule,1424.81,3223.83,APC
Rp quan meas single area,78835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,206.84,,,,,,,fee schedule,135.6,237.87,
Rp quan meas single area,78835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.3,,,,,,,fee schedule,135.6,237.87,
Rp quan meas single area,78835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.6,,,,,,,fee schedule,135.6,237.87,
Rp quan meas single area,78835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,237.87,,,,,,,fee schedule,135.6,237.87,
Nuclear diagnostic exam,78999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
Nuclear diagnostic exam,78999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
Nuclear diagnostic exam,78999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,642.24,,,,,,,fee schedule,232.5,738.58,
Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,525.67,,,,,,,fee schedule,232.5,738.58,
Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,421.05,,,,,,,fee schedule,232.5,738.58,
Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,738.58,,,,,,,fee schedule,232.5,738.58,
Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.12,,,,,,,fee schedule,232.5,738.58,APC
Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.5,,,,,,,fee schedule,232.5,738.58,APC
Nuclear rx oral admin,79005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.49,,,,,,,fee schedule,232.5,738.58,APC
Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,398.83,,,,,,,fee schedule,232.5,458.65,
Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,326.44,,,,,,,fee schedule,232.5,458.65,
Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,261.47,,,,,,,fee schedule,232.5,458.65,
Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,458.65,,,,,,,fee schedule,232.5,458.65,
Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.12,,,,,,,fee schedule,232.5,458.65,APC
Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.5,,,,,,,fee schedule,232.5,458.65,APC
Nuclear rx iv admin,79101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.49,,,,,,,fee schedule,232.5,458.65,APC
Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.87,,,,,,,fee schedule,99.57,418.49,
Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.31,,,,,,,fee schedule,99.57,418.49,
Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.57,,,,,,,fee schedule,99.57,418.49,
Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.65,,,,,,,fee schedule,99.57,418.49,
Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.12,,,,,,,fee schedule,99.57,418.49,APC
Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.5,,,,,,,fee schedule,99.57,418.49,APC
Nuclear rx intracav admin,79200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.49,,,,,,,fee schedule,99.57,418.49,APC
Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.91,,,,,,,fee schedule,98.28,418.49,
Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.7,,,,,,,fee schedule,98.28,418.49,
Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.28,,,,,,,fee schedule,98.28,418.49,
Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.4,,,,,,,fee schedule,98.28,418.49,
Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.12,,,,,,,fee schedule,98.28,418.49,APC
Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.5,,,,,,,fee schedule,98.28,418.49,APC
Nuclr rx interstit colloid,79300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.49,,,,,,,fee schedule,98.28,418.49,APC
Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.28,,,,,,,fee schedule,150.32,418.49,
Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.67,,,,,,,fee schedule,150.32,418.49,
Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.32,,,,,,,fee schedule,150.32,418.49,
Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.67,,,,,,,fee schedule,150.32,418.49,
Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.12,,,,,,,fee schedule,150.32,418.49,APC
Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.5,,,,,,,fee schedule,150.32,418.49,APC
Hematopoietic nuclear tx,79403,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.49,,,,,,,fee schedule,150.32,418.49,APC
Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.1,,,,,,,fee schedule,92.51,418.49,
Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.49,,,,,,,fee schedule,92.51,418.49,
Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.51,,,,,,,fee schedule,92.51,418.49,
Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.27,,,,,,,fee schedule,92.51,418.49,
Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.12,,,,,,,fee schedule,92.51,418.49,APC
Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.5,,,,,,,fee schedule,92.51,418.49,APC
Nuclear rx intra-articular,79440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.49,,,,,,,fee schedule,92.51,418.49,APC
Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,511.12,,,,,,,fee schedule,232.5,587.79,
Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,418.35,,,,,,,fee schedule,232.5,587.79,
Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,335.09,,,,,,,fee schedule,232.5,587.79,
Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.79,,,,,,,fee schedule,232.5,587.79,
Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.12,,,,,,,fee schedule,232.5,587.79,APC
Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.5,,,,,,,fee schedule,232.5,587.79,APC
Nuclear rx intra-arterial,79445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.49,,,,,,,fee schedule,232.5,587.79,APC
Nuclear medicine therapy,79999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.12,,,,,,,fee schedule,232.5,418.49,APC
Nuclear medicine therapy,79999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.5,,,,,,,fee schedule,232.5,418.49,APC
Nuclear medicine therapy,79999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.49,,,,,,,fee schedule,232.5,418.49,APC
Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.04,,,,,,,fee schedule,13.04,36.43,
Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.68,,,,,,,fee schedule,13.04,36.43,
Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.93,,,,,,,fee schedule,13.04,36.43,
Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.77,,,,,,,fee schedule,13.04,36.43,
Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.43,,,,,,,fee schedule,13.04,36.43,
Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,13.04,36.43,APC
Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.73,,,,,,,fee schedule,13.04,36.43,APC
Metabolic panel ionized ca,80047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.71,,,,,,,fee schedule,13.04,36.43,APC
Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.04,,,,,,,fee schedule,8.04,18.68,
Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.24,,,,,,,fee schedule,8.04,18.68,
Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.29,,,,,,,fee schedule,8.04,18.68,
Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.65,,,,,,,fee schedule,8.04,18.68,
Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.68,,,,,,,fee schedule,8.04,18.68,
Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.88,,,,,,,fee schedule,8.04,18.68,APC
Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.46,,,,,,,fee schedule,8.04,18.68,APC
Metabolic panel total ca,80048,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.23,,,,,,,fee schedule,8.04,18.68,APC
General health panel,80050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,35.19,,,,,,,fee schedule,35.19,74.84,
General health panel,80050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.08,,,,,,,fee schedule,35.19,74.84,
General health panel,80050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.27,,,,,,,fee schedule,35.19,74.84,
General health panel,80050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.67,,,,,,,fee schedule,35.19,74.84,
General health panel,80050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.84,,,,,,,fee schedule,35.19,74.84,
Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.66,,,,,,,fee schedule,6.66,27.21,
Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.66,,,,,,,fee schedule,6.66,27.21,
Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.37,,,,,,,fee schedule,6.66,27.21,
Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.51,,,,,,,fee schedule,6.66,27.21,
Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.21,,,,,,,fee schedule,6.66,27.21,
Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.36,,,,,,,fee schedule,6.66,27.21,APC
Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.01,,,,,,,fee schedule,6.66,27.21,APC
Electrolyte panel,80051,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.62,,,,,,,fee schedule,6.66,27.21,APC
Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.03,,,,,,,fee schedule,10.03,20.86,
Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.14,,,,,,,fee schedule,10.03,20.86,
Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.85,,,,,,,fee schedule,10.03,20.86,
Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.89,,,,,,,fee schedule,10.03,20.86,
Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.86,,,,,,,fee schedule,10.03,20.86,
Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.09,,,,,,,fee schedule,10.03,20.86,APC
Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.56,,,,,,,fee schedule,10.03,20.86,APC
Comprehen metabolic panel,80053,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.01,,,,,,,fee schedule,10.03,20.86,APC
Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.42,,,,,,,fee schedule,45.42,205.91,
Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,179.05,,,,,,,fee schedule,45.42,205.91,
Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.55,,,,,,,fee schedule,45.42,205.91,
Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.39,,,,,,,fee schedule,45.42,205.91,
Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.91,,,,,,,fee schedule,45.42,205.91,
Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.2,,,,,,,fee schedule,45.42,205.91,APC
Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.81,,,,,,,fee schedule,45.42,205.91,APC
Obstetric panel,80055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86.06,,,,,,,fee schedule,45.42,205.91,APC
Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.72,,,,,,,fee schedule,12.72,28.24,
Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.56,,,,,,,fee schedule,12.72,28.24,
Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.1,,,,,,,fee schedule,12.72,28.24,
Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.1,,,,,,,fee schedule,12.72,28.24,
Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.24,,,,,,,fee schedule,12.72,28.24,
Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.06,,,,,,,fee schedule,12.72,28.24,APC
Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.39,,,,,,,fee schedule,12.72,28.24,APC
Lipid panel,80061,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.1,,,,,,,fee schedule,12.72,28.24,APC
Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.25,,,,,,,fee schedule,8.25,47.74,
Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.51,,,,,,,fee schedule,8.25,47.74,
Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.98,,,,,,,fee schedule,8.25,47.74,
Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.21,,,,,,,fee schedule,8.25,47.74,
Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.74,,,,,,,fee schedule,8.25,47.74,
Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.11,,,,,,,fee schedule,8.25,47.74,APC
Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.68,,,,,,,fee schedule,8.25,47.74,APC
Renal function panel,80069,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.62,,,,,,,fee schedule,8.25,47.74,APC
Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.25,,,,,,,fee schedule,45.25,142.85,
Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.22,,,,,,,fee schedule,45.25,142.85,
Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.67,,,,,,,fee schedule,45.25,142.85,
Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.44,,,,,,,fee schedule,45.25,142.85,
Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.85,,,,,,,fee schedule,45.25,142.85,
Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.01,,,,,,,fee schedule,45.25,142.85,APC
Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.63,,,,,,,fee schedule,45.25,142.85,APC
Acute hepatitis panel,80074,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,85.73,,,,,,,fee schedule,45.25,142.85,APC
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.76,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.8,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.36,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.09,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.2,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.77,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.94,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.12,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.77,,,,,,,fee schedule,5.09,14.71,
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.58,,,,,,,fee schedule,5.09,14.71,APC
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.17,,,,,,,fee schedule,5.09,14.71,APC
Hepatic function panel,80076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.71,,,,,,,fee schedule,5.09,14.71,APC
Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,71.12,,,,,,,fee schedule,71.12,308.28,
Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.07,,,,,,,fee schedule,71.12,308.28,
Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,219.42,,,,,,,fee schedule,71.12,308.28,
Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.75,,,,,,,fee schedule,71.12,308.28,
Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.28,,,,,,,fee schedule,71.12,308.28,
Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.6,,,,,,,fee schedule,71.12,308.28,APC
Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.86,,,,,,,fee schedule,71.12,308.28,APC
Obstetric panel,80081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,134.75,,,,,,,fee schedule,71.12,308.28,APC
Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.71,,,,,,,fee schedule,17.71,41.64,
Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.21,,,,,,,fee schedule,17.71,41.64,
Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.64,,,,,,,fee schedule,17.71,41.64,
Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.74,,,,,,,fee schedule,17.71,41.64,
Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.64,,,,,,,fee schedule,17.71,41.64,
Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,17.71,41.64,APC
Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.64,,,,,,,fee schedule,17.71,41.64,APC
Drug assay acetaminophen,80143,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.55,,,,,,,fee schedule,17.71,41.64,APC
Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.64,,,,,,,fee schedule,36.64,86.18,
Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.94,,,,,,,fee schedule,36.64,86.18,
Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.34,,,,,,,fee schedule,36.64,86.18,
Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.13,,,,,,,fee schedule,36.64,86.18,
Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.18,,,,,,,fee schedule,36.64,86.18,
Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,36.64,86.18,APC
Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.57,,,,,,,fee schedule,36.64,86.18,APC
Drug assay adalimumab,80145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.43,,,,,,,fee schedule,36.64,86.18,APC
Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.33,,,,,,,fee schedule,14.33,59.02,
Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.32,,,,,,,fee schedule,14.33,59.02,
Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.01,,,,,,,fee schedule,14.33,59.02,
Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.65,,,,,,,fee schedule,14.33,59.02,
Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.02,,,,,,,fee schedule,14.33,59.02,
Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.83,,,,,,,fee schedule,14.33,59.02,APC
Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.08,,,,,,,fee schedule,14.33,59.02,APC
Assay of amikacin,80150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.14,,,,,,,fee schedule,14.33,59.02,APC
Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.71,,,,,,,fee schedule,17.71,41.64,
Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.21,,,,,,,fee schedule,17.71,41.64,
Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.64,,,,,,,fee schedule,17.71,41.64,
Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.74,,,,,,,fee schedule,17.71,41.64,
Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.64,,,,,,,fee schedule,17.71,41.64,
Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,17.71,41.64,APC
Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.64,,,,,,,fee schedule,17.71,41.64,APC
Drug assay amiodarone,80151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.55,,,,,,,fee schedule,17.71,41.64,APC
Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.64,,,,,,,fee schedule,23.27,69.43,
Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.5,,,,,,,fee schedule,23.27,69.43,
Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.06,,,,,,,fee schedule,23.27,69.43,
Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.27,,,,,,,fee schedule,23.27,69.43,
Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.83,,,,,,,fee schedule,23.27,69.43,
Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,23.27,69.43,APC
Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.57,,,,,,,fee schedule,23.27,69.43,APC
Drug assay caffeine,80155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.43,,,,,,,fee schedule,23.27,69.43,APC
Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.84,,,,,,,fee schedule,13.84,57.62,
Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.1,,,,,,,fee schedule,13.84,57.62,
Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.01,,,,,,,fee schedule,13.84,57.62,
Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.85,,,,,,,fee schedule,13.84,57.62,
Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.62,,,,,,,fee schedule,13.84,57.62,
Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.3,,,,,,,fee schedule,13.84,57.62,APC
Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.57,,,,,,,fee schedule,13.84,57.62,APC
Assay carbamazepine total,80156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.23,,,,,,,fee schedule,13.84,57.62,APC
Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.59,,,,,,,fee schedule,12.59,57.09,
Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.64,,,,,,,fee schedule,12.59,57.09,
Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.63,,,,,,,fee schedule,12.59,57.09,
Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.54,,,,,,,fee schedule,12.59,57.09,
Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.09,,,,,,,fee schedule,12.59,57.09,
Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,12.59,57.09,APC
Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.25,,,,,,,fee schedule,12.59,57.09,APC
Assay carbamazepine free,80157,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.85,,,,,,,fee schedule,12.59,57.09,APC
Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.15,,,,,,,fee schedule,17.15,71.21,
Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.92,,,,,,,fee schedule,17.15,71.21,
Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.68,,,,,,,fee schedule,17.15,71.21,
Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.59,,,,,,,fee schedule,17.15,71.21,
Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.21,,,,,,,fee schedule,17.15,71.21,
Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.95,,,,,,,fee schedule,17.15,71.21,APC
Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.05,,,,,,,fee schedule,17.15,71.21,APC
Drug assay cyclosporine,80158,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.49,,,,,,,fee schedule,17.15,71.21,APC
Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.14,,,,,,,fee schedule,19.14,56.97,
Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.54,,,,,,,fee schedule,19.14,56.97,
Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.55,,,,,,,fee schedule,19.14,56.97,
Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.48,,,,,,,fee schedule,19.14,56.97,
Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.97,,,,,,,fee schedule,19.14,56.97,
Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.16,,,,,,,fee schedule,19.14,56.97,APC
Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.15,,,,,,,fee schedule,19.14,56.97,APC
Drug assay clozapine,80159,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.27,,,,,,,fee schedule,19.14,56.97,APC
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.71,,,,,,,fee schedule,17.71,41.64,
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.21,,,,,,,fee schedule,17.71,41.64,
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.64,,,,,,,fee schedule,17.71,41.64,
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.74,,,,,,,fee schedule,17.71,41.64,
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.64,,,,,,,fee schedule,17.71,41.64,
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,17.71,41.64,APC
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.64,,,,,,,fee schedule,17.71,41.64,APC
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.55,,,,,,,fee schedule,17.71,41.64,APC
Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.62,,,,,,,fee schedule,12.62,52.36,
Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.53,,,,,,,fee schedule,12.62,52.36,
Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.27,,,,,,,fee schedule,12.62,52.36,
Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.85,,,,,,,fee schedule,12.62,52.36,
Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.36,,,,,,,fee schedule,12.62,52.36,
Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.94,,,,,,,fee schedule,12.62,52.36,APC
Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.28,,,,,,,fee schedule,12.62,52.36,APC
Assay of digoxin total,80162,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.9,,,,,,,fee schedule,12.62,52.36,APC
Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.62,,,,,,,fee schedule,12.62,57.17,
Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.71,,,,,,,fee schedule,12.62,57.17,
Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.69,,,,,,,fee schedule,12.62,57.17,
Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.59,,,,,,,fee schedule,12.62,57.17,
Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.17,,,,,,,fee schedule,12.62,57.17,
Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.94,,,,,,,fee schedule,12.62,57.17,APC
Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.28,,,,,,,fee schedule,12.62,57.17,APC
Assay of digoxin free,80163,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.9,,,,,,,fee schedule,12.62,57.17,APC
Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.86,,,,,,,fee schedule,12.86,53.39,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.43,,,,,,,fee schedule,12.86,53.39,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38,,,,,,,fee schedule,12.86,53.39,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.44,,,,,,,fee schedule,12.86,53.39,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.39,,,,,,,fee schedule,12.86,53.39,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.22,,,,,,,fee schedule,12.86,53.39,APC
Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.54,,,,,,,fee schedule,12.86,53.39,APC
Assay dipropylacetic acd tot,80164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.37,,,,,,,fee schedule,12.86,53.39,APC
Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.86,,,,,,,fee schedule,12.86,53.39,
Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.43,,,,,,,fee schedule,12.86,53.39,
Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38,,,,,,,fee schedule,12.86,53.39,
Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.44,,,,,,,fee schedule,12.86,53.39,
Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.39,,,,,,,fee schedule,12.86,53.39,
Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.22,,,,,,,fee schedule,12.86,53.39,APC
Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.54,,,,,,,fee schedule,12.86,53.39,APC
Dipropylacetic acid free,80165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.37,,,,,,,fee schedule,12.86,53.39,APC
Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.71,,,,,,,fee schedule,17.71,41.64,
Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.21,,,,,,,fee schedule,17.71,41.64,
Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.64,,,,,,,fee schedule,17.71,41.64,
Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.74,,,,,,,fee schedule,17.71,41.64,
Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.64,,,,,,,fee schedule,17.71,41.64,
Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,17.71,41.64,APC
Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.64,,,,,,,fee schedule,17.71,41.64,APC
Drug assay felbamate,80167,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.55,,,,,,,fee schedule,17.71,41.64,APC
Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.52,,,,,,,fee schedule,15.52,64.11,
Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.75,,,,,,,fee schedule,15.52,64.11,
Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.63,,,,,,,fee schedule,15.52,64.11,
Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.55,,,,,,,fee schedule,15.52,64.11,
Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.11,,,,,,,fee schedule,15.52,64.11,
Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.16,,,,,,,fee schedule,15.52,64.11,APC
Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.34,,,,,,,fee schedule,15.52,64.11,APC
Assay of ethosuximide,80168,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.41,,,,,,,fee schedule,15.52,64.11,APC
Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.04,,,,,,,fee schedule,13.04,60.09,
Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.25,,,,,,,fee schedule,13.04,60.09,
Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.77,,,,,,,fee schedule,13.04,60.09,
Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.26,,,,,,,fee schedule,13.04,60.09,
Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.09,,,,,,,fee schedule,13.04,60.09,
Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,13.04,60.09,APC
Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.73,,,,,,,fee schedule,13.04,60.09,APC
Drug assay everolimus,80169,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.71,,,,,,,fee schedule,13.04,60.09,APC
Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.56,,,,,,,fee schedule,15.56,40.83,
Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.5,,,,,,,fee schedule,15.56,40.83,
Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.06,,,,,,,fee schedule,15.56,40.83,
Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.27,,,,,,,fee schedule,15.56,40.83,
Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.83,,,,,,,fee schedule,15.56,40.83,
Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.2,,,,,,,fee schedule,15.56,40.83,APC
Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.38,,,,,,,fee schedule,15.56,40.83,APC
Assay of gentamicin,80170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.48,,,,,,,fee schedule,15.56,40.83,APC
Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.59,,,,,,,fee schedule,19.28,39.01,
Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.41,,,,,,,fee schedule,19.28,39.01,
Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.07,,,,,,,fee schedule,19.28,39.01,
Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.28,,,,,,,fee schedule,19.28,39.01,
Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.82,,,,,,,fee schedule,19.28,39.01,
Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.75,,,,,,,fee schedule,19.28,39.01,APC
Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.67,,,,,,,fee schedule,19.28,39.01,APC
Drug screen quant gabapentin,80171,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.01,,,,,,,fee schedule,19.28,39.01,APC
Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.99,,,,,,,fee schedule,14.99,62.73,
Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.55,,,,,,,fee schedule,14.99,62.73,
Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.65,,,,,,,fee schedule,14.99,62.73,
Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.76,,,,,,,fee schedule,14.99,62.73,
Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.73,,,,,,,fee schedule,14.99,62.73,
Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.57,,,,,,,fee schedule,14.99,62.73,APC
Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.78,,,,,,,fee schedule,14.99,62.73,APC
Assay Of Haloperidol,80173,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.4,,,,,,,fee schedule,14.99,62.73,APC
Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.59,,,,,,,fee schedule,12.59,56.97,
Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.54,,,,,,,fee schedule,12.59,56.97,
Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.55,,,,,,,fee schedule,12.59,56.97,
Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.48,,,,,,,fee schedule,12.59,56.97,
Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.97,,,,,,,fee schedule,12.59,56.97,
Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,12.59,56.97,APC
Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.25,,,,,,,fee schedule,12.59,56.97,APC
Drug screen quan lamotrigine,80175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.85,,,,,,,fee schedule,12.59,56.97,APC
Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.96,,,,,,,fee schedule,13.96,63.26,
Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.01,,,,,,,fee schedule,13.96,63.26,
Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.03,,,,,,,fee schedule,13.96,63.26,
Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.06,,,,,,,fee schedule,13.96,63.26,
Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.26,,,,,,,fee schedule,13.96,63.26,
Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.42,,,,,,,fee schedule,13.96,63.26,APC
Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.69,,,,,,,fee schedule,13.96,63.26,APC
Assay of lidocaine,80176,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.44,,,,,,,fee schedule,13.96,63.26,APC
Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.59,,,,,,,fee schedule,12.59,56.97,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.54,,,,,,,fee schedule,12.59,56.97,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.55,,,,,,,fee schedule,12.59,56.97,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.48,,,,,,,fee schedule,12.59,56.97,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.97,,,,,,,fee schedule,12.59,56.97,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,12.59,56.97,APC
Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.25,,,,,,,fee schedule,12.59,56.97,APC
Drug scrn quan levetiracetam,80177,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.85,,,,,,,fee schedule,12.59,56.97,APC
Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.28,,,,,,,fee schedule,6.28,24.23,
Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.07,,,,,,,fee schedule,6.28,24.23,
Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.25,,,,,,,fee schedule,6.28,24.23,
Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.81,,,,,,,fee schedule,6.28,24.23,
Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.23,,,,,,,fee schedule,6.28,24.23,
Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.94,,,,,,,fee schedule,6.28,24.23,APC
Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.61,,,,,,,fee schedule,6.28,24.23,APC
Assay of lithium,80178,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.9,,,,,,,fee schedule,6.28,24.23,APC
Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.71,,,,,,,fee schedule,17.71,41.64,
Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.21,,,,,,,fee schedule,17.71,41.64,
Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.64,,,,,,,fee schedule,17.71,41.64,
Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.74,,,,,,,fee schedule,17.71,41.64,
Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.64,,,,,,,fee schedule,17.71,41.64,
Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,17.71,41.64,APC
Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.64,,,,,,,fee schedule,17.71,41.64,APC
Drug assay salicylate,80179,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.55,,,,,,,fee schedule,17.71,41.64,APC
Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.15,,,,,,,fee schedule,17.15,33.4,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.04,,,,,,,fee schedule,17.15,33.4,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.77,,,,,,,fee schedule,17.15,33.4,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.04,,,,,,,fee schedule,17.15,33.4,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.4,,,,,,,fee schedule,17.15,33.4,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.95,,,,,,,fee schedule,17.15,33.4,APC
Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.05,,,,,,,fee schedule,17.15,33.4,APC
Drug scrn quan mycophenolate,80180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.49,,,,,,,fee schedule,17.15,33.4,APC
Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.71,,,,,,,fee schedule,17.71,41.64,
Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.21,,,,,,,fee schedule,17.71,41.64,
Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.64,,,,,,,fee schedule,17.71,41.64,
Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.74,,,,,,,fee schedule,17.71,41.64,
Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.64,,,,,,,fee schedule,17.71,41.64,
Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,17.71,41.64,APC
Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.64,,,,,,,fee schedule,17.71,41.64,APC
Drug assay flecainide,80181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.55,,,,,,,fee schedule,17.71,41.64,APC
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.59,,,,,,,fee schedule,12.56,23.85,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.16,,,,,,,fee schedule,12.56,23.85,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.68,,,,,,,fee schedule,12.56,23.85,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.56,,,,,,,fee schedule,12.56,23.85,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.03,,,,,,,fee schedule,12.56,23.85,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,12.56,23.85,APC
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.25,,,,,,,fee schedule,12.56,23.85,APC
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.85,,,,,,,fee schedule,12.56,23.85,APC
Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.54,,,,,,,fee schedule,14.54,44.46,
Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.66,,,,,,,fee schedule,14.54,44.46,
Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.64,,,,,,,fee schedule,14.54,44.46,
Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.35,,,,,,,fee schedule,14.54,44.46,
Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.46,,,,,,,fee schedule,14.54,44.46,
Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.06,,,,,,,fee schedule,14.54,44.46,APC
Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.3,,,,,,,fee schedule,14.54,44.46,APC
Assay of phenobarbital,80184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.54,,,,,,,fee schedule,14.54,44.46,APC
Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.59,,,,,,,fee schedule,12.59,52.36,
Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.53,,,,,,,fee schedule,12.59,52.36,
Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.27,,,,,,,fee schedule,12.59,52.36,
Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.85,,,,,,,fee schedule,12.59,52.36,
Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.36,,,,,,,fee schedule,12.59,52.36,
Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,12.59,52.36,APC
Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.25,,,,,,,fee schedule,12.59,52.36,APC
Assay of phenytoin total,80185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.85,,,,,,,fee schedule,12.59,52.36,APC
Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.07,,,,,,,fee schedule,13.07,54.44,
Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.34,,,,,,,fee schedule,13.07,54.44,
Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.75,,,,,,,fee schedule,13.07,54.44,
Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.04,,,,,,,fee schedule,13.07,54.44,
Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.44,,,,,,,fee schedule,13.07,54.44,
Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.45,,,,,,,fee schedule,13.07,54.44,APC
Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.76,,,,,,,fee schedule,13.07,54.44,APC
Assay of phenytoin free,80186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.77,,,,,,,fee schedule,13.07,54.44,APC
Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.75,,,,,,,fee schedule,25.75,60.58,
Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.68,,,,,,,fee schedule,25.75,60.58,
Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.12,,,,,,,fee schedule,25.75,60.58,
Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.54,,,,,,,fee schedule,25.75,60.58,
Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.58,,,,,,,fee schedule,25.75,60.58,
Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,25.75,60.58,APC
Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.11,,,,,,,fee schedule,25.75,60.58,APC
Drug assay posaconazole,80187,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.8,,,,,,,fee schedule,25.75,60.58,APC
Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.76,,,,,,,fee schedule,15.76,71.45,
Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.13,,,,,,,fee schedule,15.76,71.45,
Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.85,,,,,,,fee schedule,15.76,71.45,
Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.73,,,,,,,fee schedule,15.76,71.45,
Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.45,,,,,,,fee schedule,15.76,71.45,
Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.42,,,,,,,fee schedule,15.76,71.45,APC
Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.59,,,,,,,fee schedule,15.76,71.45,APC
Assay of primidone,80188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.86,,,,,,,fee schedule,15.76,71.45,APC
Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.75,,,,,,,fee schedule,25.75,60.58,
Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.68,,,,,,,fee schedule,25.75,60.58,
Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.12,,,,,,,fee schedule,25.75,60.58,
Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.54,,,,,,,fee schedule,25.75,60.58,
Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.58,,,,,,,fee schedule,25.75,60.58,
Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,25.75,60.58,APC
Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.11,,,,,,,fee schedule,25.75,60.58,APC
Drug assay itraconzaole,80189,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.8,,,,,,,fee schedule,25.75,60.58,APC
Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,57,,,,,,,fee schedule,41.12,108,
Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.72,,,,,,,fee schedule,41.12,108,
Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.34,,,,,,,fee schedule,41.12,108,
Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.12,,,,,,,fee schedule,41.12,108,
Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.13,,,,,,,fee schedule,41.12,108,
Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63,,,,,,,fee schedule,41.12,108,APC
Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60,,,,,,,fee schedule,41.12,108,APC
Assay of procainamide,80190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,108,,,,,,,fee schedule,41.12,108,APC
Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.91,,,,,,,fee schedule,15.91,72.13,
Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.72,,,,,,,fee schedule,15.91,72.13,
Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.34,,,,,,,fee schedule,15.91,72.13,
Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.12,,,,,,,fee schedule,15.91,72.13,
Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.13,,,,,,,fee schedule,15.91,72.13,
Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.59,,,,,,,fee schedule,15.91,72.13,APC
Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.75,,,,,,,fee schedule,15.91,72.13,APC
Assay of procainamide,80192,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.15,,,,,,,fee schedule,15.91,72.13,APC
Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.64,,,,,,,fee schedule,36.64,86.18,
Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.94,,,,,,,fee schedule,36.64,86.18,
Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.34,,,,,,,fee schedule,36.64,86.18,
Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.13,,,,,,,fee schedule,36.64,86.18,
Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.18,,,,,,,fee schedule,36.64,86.18,
Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,36.64,86.18,APC
Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.57,,,,,,,fee schedule,36.64,86.18,APC
Drug assay leflunomide,80193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.43,,,,,,,fee schedule,36.64,86.18,APC
Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.87,,,,,,,fee schedule,13.87,62.87,
Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.67,,,,,,,fee schedule,13.87,62.87,
Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.75,,,,,,,fee schedule,13.87,62.87,
Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.84,,,,,,,fee schedule,13.87,62.87,
Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.87,,,,,,,fee schedule,13.87,62.87,
Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.33,,,,,,,fee schedule,13.87,62.87,APC
Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.6,,,,,,,fee schedule,13.87,62.87,APC
Assay of quinidine,80194,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.28,,,,,,,fee schedule,13.87,62.87,APC
Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.04,,,,,,,fee schedule,13.04,60.09,
Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.25,,,,,,,fee schedule,13.04,60.09,
Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.77,,,,,,,fee schedule,13.04,60.09,
Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.26,,,,,,,fee schedule,13.04,60.09,
Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.09,,,,,,,fee schedule,13.04,60.09,
Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,13.04,60.09,APC
Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.73,,,,,,,fee schedule,13.04,60.09,APC
Assay of sirolimus,80195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.71,,,,,,,fee schedule,13.04,60.09,APC
Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.04,,,,,,,fee schedule,13.04,54.44,
Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.34,,,,,,,fee schedule,13.04,54.44,
Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.75,,,,,,,fee schedule,13.04,54.44,
Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.04,,,,,,,fee schedule,13.04,54.44,
Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.44,,,,,,,fee schedule,13.04,54.44,
Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,13.04,54.44,APC
Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.73,,,,,,,fee schedule,13.04,54.44,APC
Assay of tacrolimus,80197,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.71,,,,,,,fee schedule,13.04,54.44,APC
Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.43,,,,,,,fee schedule,13.43,40.83,
Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.5,,,,,,,fee schedule,13.43,40.83,
Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.06,,,,,,,fee schedule,13.43,40.83,
Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.27,,,,,,,fee schedule,13.43,40.83,
Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.83,,,,,,,fee schedule,13.43,40.83,
Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.85,,,,,,,fee schedule,13.43,40.83,APC
Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.14,,,,,,,fee schedule,13.43,40.83,APC
Assay of theophylline,80198,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.45,,,,,,,fee schedule,13.43,40.83,APC
Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.75,,,,,,,fee schedule,25.75,50.16,
Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.62,,,,,,,fee schedule,25.75,50.16,
Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.7,,,,,,,fee schedule,25.75,50.16,
Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.6,,,,,,,fee schedule,25.75,50.16,
Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.16,,,,,,,fee schedule,25.75,50.16,
Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,25.75,50.16,APC
Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.11,,,,,,,fee schedule,25.75,50.16,APC
Drug screen quant tiagabine,80199,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.8,,,,,,,fee schedule,25.75,50.16,APC
Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.32,,,,,,,fee schedule,15.32,63.08,
Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.85,,,,,,,fee schedule,15.32,63.08,
Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.89,,,,,,,fee schedule,15.32,63.08,
Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.96,,,,,,,fee schedule,15.32,63.08,
Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.08,,,,,,,fee schedule,15.32,63.08,
Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.94,,,,,,,fee schedule,15.32,63.08,APC
Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.13,,,,,,,fee schedule,15.32,63.08,APC
Assay of tobramycin,80200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.03,,,,,,,fee schedule,15.32,63.08,APC
Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.32,,,,,,,fee schedule,11.32,24.38,
Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.2,,,,,,,fee schedule,11.32,24.38,
Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.35,,,,,,,fee schedule,11.32,24.38,
Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.9,,,,,,,fee schedule,11.32,24.38,
Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.38,,,,,,,fee schedule,11.32,24.38,
Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.52,,,,,,,fee schedule,11.32,24.38,APC
Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.92,,,,,,,fee schedule,11.32,24.38,APC
Assay of topiramate,80201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.46,,,,,,,fee schedule,11.32,24.38,APC
Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.86,,,,,,,fee schedule,12.86,53.39,
Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.43,,,,,,,fee schedule,12.86,53.39,
Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38,,,,,,,fee schedule,12.86,53.39,
Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.44,,,,,,,fee schedule,12.86,53.39,
Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.39,,,,,,,fee schedule,12.86,53.39,
Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.22,,,,,,,fee schedule,12.86,53.39,APC
Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.54,,,,,,,fee schedule,12.86,53.39,APC
Assay of vancomycin,80202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.37,,,,,,,fee schedule,12.86,53.39,APC
Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.59,,,,,,,fee schedule,12.59,46.98,
Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.85,,,,,,,fee schedule,12.59,46.98,
Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.44,,,,,,,fee schedule,12.59,46.98,
Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.78,,,,,,,fee schedule,12.59,46.98,
Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.98,,,,,,,fee schedule,12.59,46.98,
Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,12.59,46.98,APC
Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.25,,,,,,,fee schedule,12.59,46.98,APC
Drug screen quant zonisamide,80203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.85,,,,,,,fee schedule,12.59,46.98,APC
Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.64,,,,,,,fee schedule,36.64,86.18,
Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.94,,,,,,,fee schedule,36.64,86.18,
Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.34,,,,,,,fee schedule,36.64,86.18,
Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.13,,,,,,,fee schedule,36.64,86.18,
Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.18,,,,,,,fee schedule,36.64,86.18,
Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,36.64,86.18,APC
Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.57,,,,,,,fee schedule,36.64,86.18,APC
Drug assay methotrexate,80204,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.43,,,,,,,fee schedule,36.64,86.18,APC
Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.75,,,,,,,fee schedule,25.75,60.58,
Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.68,,,,,,,fee schedule,25.75,60.58,
Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.12,,,,,,,fee schedule,25.75,60.58,
Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.54,,,,,,,fee schedule,25.75,60.58,
Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.58,,,,,,,fee schedule,25.75,60.58,
Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,25.75,60.58,APC
Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.11,,,,,,,fee schedule,25.75,60.58,APC
Drug assay rufinamide,80210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.8,,,,,,,fee schedule,25.75,60.58,APC
Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.71,,,,,,,fee schedule,17.71,41.64,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.21,,,,,,,fee schedule,17.71,41.64,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.64,,,,,,,fee schedule,17.71,41.64,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.74,,,,,,,fee schedule,17.71,41.64,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.64,,,,,,,fee schedule,17.71,41.64,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,17.71,41.64,APC
Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.64,,,,,,,fee schedule,17.71,41.64,APC
Drug asy hydroxychloroquine,80220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.55,,,,,,,fee schedule,17.71,41.64,APC
Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.64,,,,,,,fee schedule,36.64,86.18,
Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.94,,,,,,,fee schedule,36.64,86.18,
Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.34,,,,,,,fee schedule,36.64,86.18,
Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.13,,,,,,,fee schedule,36.64,86.18,
Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.18,,,,,,,fee schedule,36.64,86.18,
Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,36.64,86.18,APC
Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.57,,,,,,,fee schedule,36.64,86.18,APC
Drug assay infliximab,80230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.43,,,,,,,fee schedule,36.64,86.18,APC
Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.75,,,,,,,fee schedule,25.75,60.58,
Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.68,,,,,,,fee schedule,25.75,60.58,
Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.12,,,,,,,fee schedule,25.75,60.58,
Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.54,,,,,,,fee schedule,25.75,60.58,
Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.58,,,,,,,fee schedule,25.75,60.58,
Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,25.75,60.58,APC
Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.11,,,,,,,fee schedule,25.75,60.58,APC
Drug assay lacosamide,80235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.8,,,,,,,fee schedule,25.75,60.58,APC
Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.64,,,,,,,fee schedule,36.64,86.18,
Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.94,,,,,,,fee schedule,36.64,86.18,
Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.34,,,,,,,fee schedule,36.64,86.18,
Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.13,,,,,,,fee schedule,36.64,86.18,
Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.18,,,,,,,fee schedule,36.64,86.18,
Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,36.64,86.18,APC
Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.57,,,,,,,fee schedule,36.64,86.18,APC
Drug assay vedolizumab,80280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.43,,,,,,,fee schedule,36.64,86.18,APC
Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.75,,,,,,,fee schedule,25.75,60.58,
Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.68,,,,,,,fee schedule,25.75,60.58,
Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.12,,,,,,,fee schedule,25.75,60.58,
Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.54,,,,,,,fee schedule,25.75,60.58,
Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.58,,,,,,,fee schedule,25.75,60.58,
Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,25.75,60.58,APC
Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.11,,,,,,,fee schedule,25.75,60.58,APC
Drug assay voriconazole,80285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.8,,,,,,,fee schedule,25.75,60.58,APC
Quantitative assay drug,80299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.71,,,,,,,fee schedule,17.71,33.55,
Quantitative assay drug,80299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,17.71,33.55,APC
Quantitative assay drug,80299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.64,,,,,,,fee schedule,17.71,33.55,APC
Quantitative assay drug,80299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.55,,,,,,,fee schedule,17.71,33.55,APC
Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.97,,,,,,,fee schedule,11.97,28.59,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.86,,,,,,,fee schedule,11.97,28.59,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.35,,,,,,,fee schedule,11.97,28.59,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.3,,,,,,,fee schedule,11.97,28.59,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.59,,,,,,,fee schedule,11.97,28.59,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.23,,,,,,,fee schedule,11.97,28.59,APC
Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.6,,,,,,,fee schedule,11.97,28.59,APC
Drug test prsmv dir opt obs,80305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.68,,,,,,,fee schedule,11.97,28.59,APC
Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.28,,,,,,,fee schedule,16.28,38.11,
Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.14,,,,,,,fee schedule,16.28,38.11,
Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.13,,,,,,,fee schedule,16.28,38.11,
Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.73,,,,,,,fee schedule,16.28,38.11,
Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.11,,,,,,,fee schedule,16.28,38.11,
Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18,,,,,,,fee schedule,16.28,38.11,APC
Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.14,,,,,,,fee schedule,16.28,38.11,APC
Drug test prsmv instrmnt,80306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.85,,,,,,,fee schedule,16.28,38.11,APC
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,59.03,,,,,,,fee schedule,59.03,150.41,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.79,,,,,,,fee schedule,59.03,150.41,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.05,,,,,,,fee schedule,59.03,150.41,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.75,,,,,,,fee schedule,59.03,150.41,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.41,,,,,,,fee schedule,59.03,150.41,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,59.03,150.41,APC
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.14,,,,,,,fee schedule,59.03,150.41,APC
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,111.85,,,,,,,fee schedule,59.03,150.41,APC
Drug screen quantalcohols,80320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.79,
Drug screen quantalcohols,80320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.86,,,,,,,fee schedule,0.01,83.79,
Drug screen quantalcohols,80320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.64,,,,,,,fee schedule,0.01,83.79,
Drug screen quantalcohols,80320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.77,,,,,,,fee schedule,0.01,83.79,
Drug screen quantalcohols,80320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.79,,,,,,,fee schedule,0.01,83.79,
Alcohols biomarkers 1or 2,80321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Alcohols biomarkers 3/more,80322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Alkaloids nos,80323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Alkaloids nos,80323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Alkaloids nos,80323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Alkaloids nos,80323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Alkaloids nos,80323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Drug screen amphetamines 1/2,80324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Drug screen amphetamines 1/2,80324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Drug screen amphetamines 1/2,80324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Drug screen amphetamines 1/2,80324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Drug screen amphetamines 1/2,80324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Amphetamines 3or 4,80325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Amphetamines 5 or more,80326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Anabolic steroid 1 or 2,80327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,49.83,
Anabolic steroid 1 or 2,80327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.33,,,,,,,fee schedule,0.01,49.83,
Anabolic steroid 1 or 2,80327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.47,,,,,,,fee schedule,0.01,49.83,
Anabolic steroid 1 or 2,80327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.41,,,,,,,fee schedule,0.01,49.83,
Anabolic steroid 1 or 2,80327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.83,,,,,,,fee schedule,0.01,49.83,
Anabolic steroid 3 or more,80328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Analgesics non-opioid 1 or 2,80329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,107.07,
Analgesics non-opioid 1 or 2,80329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,93.1,,,,,,,fee schedule,0.01,107.07,
Analgesics non-opioid 1 or 2,80329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.2,,,,,,,fee schedule,0.01,107.07,
Analgesics non-opioid 1 or 2,80329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.04,,,,,,,fee schedule,0.01,107.07,
Analgesics non-opioid 1 or 2,80329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,107.07,,,,,,,fee schedule,0.01,107.07,
Analgesics non-opioid 3-5,80330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Analgesics non-opioid 6/more,80331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Antidepressants class 1 or 2,80332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,60.96,
Antidepressants class 1 or 2,80332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.01,,,,,,,fee schedule,0.01,60.96,
Antidepressants class 1 or 2,80332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.39,,,,,,,fee schedule,0.01,60.96,
Antidepressants class 1 or 2,80332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.75,,,,,,,fee schedule,0.01,60.96,
Antidepressants class 1 or 2,80332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.96,,,,,,,fee schedule,0.01,60.96,
Antidepressants class 3-5,80333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Antidepressants class 6/more,80334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Antidepressant tricyclic 1/2,80335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,64.48,
Antidepressant tricyclic 1/2,80335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.07,,,,,,,fee schedule,0.01,64.48,
Antidepressant tricyclic 1/2,80335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.89,,,,,,,fee schedule,0.01,64.48,
Antidepressant tricyclic 1/2,80335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.76,,,,,,,fee schedule,0.01,64.48,
Antidepressant tricyclic 1/2,80335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.48,,,,,,,fee schedule,0.01,64.48,
Antidepressant tricyclic 3-5,80336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Tricyclic & cyclicals 6/more,80337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Antidepressant not specified,80338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Antiepileptics nos 1-3,80339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,78.02,
Antiepileptics nos 1-3,80339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.84,,,,,,,fee schedule,0.01,78.02,
Antiepileptics nos 1-3,80339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.53,,,,,,,fee schedule,0.01,78.02,
Antiepileptics nos 1-3,80339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.48,,,,,,,fee schedule,0.01,78.02,
Antiepileptics nos 1-3,80339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.02,,,,,,,fee schedule,0.01,78.02,
Antiepileptics nos 4-6,80340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Antiepileptics nos 7/more,80341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Antipsychotics nos 1-3,80342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,64.06,
Antipsychotics nos 1-3,80342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.7,,,,,,,fee schedule,0.01,64.06,
Antipsychotics nos 1-3,80342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.59,,,,,,,fee schedule,0.01,64.06,
Antipsychotics nos 1-3,80342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.52,,,,,,,fee schedule,0.01,64.06,
Antipsychotics nos 1-3,80342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.06,,,,,,,fee schedule,0.01,64.06,
Antipsychotics nos 4-6,80343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Antipsychotics nos 7/more,80344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Drug screening barbiturates,80345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Drug screening barbiturates,80345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Drug screening barbiturates,80345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Drug screening barbiturates,80345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Drug screening barbiturates,80345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Benzodiazepines1-12,80346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Benzodiazepines1-12,80346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Benzodiazepines1-12,80346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Benzodiazepines1-12,80346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Benzodiazepines1-12,80346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Benzodiazepines 13 or more,80347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Drug screening buprenorphine,80348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Cannabinoids natural,80349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Cannabinoids natural,80349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Cannabinoids natural,80349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Cannabinoids natural,80349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Cannabinoids natural,80349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Cannabinoids synthetic 1-3,80350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Cannabinoids synthetic 1-3,80350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Cannabinoids synthetic 1-3,80350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Cannabinoids synthetic 1-3,80350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Cannabinoids synthetic 1-3,80350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Cannabinoids synthetic 4-6,80351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Cannabinoid synthetic 7/more,80352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Drug screening cocaine,80353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Drug screening cocaine,80353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Drug screening cocaine,80353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Drug screening cocaine,80353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Drug screening cocaine,80353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Drug screening fentanyl,80354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Drug screening fentanyl,80354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Drug screening fentanyl,80354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Drug screening fentanyl,80354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Drug screening fentanyl,80354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Gabapentin non-blood,80355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Gabapentin non-blood,80355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Gabapentin non-blood,80355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Gabapentin non-blood,80355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Gabapentin non-blood,80355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Heroin metabolite,80356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Heroin metabolite,80356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Heroin metabolite,80356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Heroin metabolite,80356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Heroin metabolite,80356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Ketamine and norketamine,80357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Ketamine and norketamine,80357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Ketamine and norketamine,80357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Ketamine and norketamine,80357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Ketamine and norketamine,80357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Drug screening methadone,80358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Drug screening methadone,80358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Drug screening methadone,80358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Drug screening methadone,80358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Drug screening methadone,80358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Methylenedioxyamphetamines,80359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Methylenedioxyamphetamines,80359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Methylenedioxyamphetamines,80359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Methylenedioxyamphetamines,80359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Methylenedioxyamphetamines,80359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Methylphenidate,80360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Methylphenidate,80360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Methylphenidate,80360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Methylphenidate,80360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Methylphenidate,80360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Opiates 1 or more,80361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Opiates 1 or more,80361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Opiates 1 or more,80361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Opiates 1 or more,80361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Opiates 1 or more,80361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Opioids & opiate analogs 1/2,80362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Opioids & opiate analogs 1/2,80362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Opioids & opiate analogs 1/2,80362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Opioids & opiate analogs 1/2,80362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Opioids & opiate analogs 1/2,80362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Opioids & opiate analogs 3/4,80363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Opioid &opiate analog 5/more,80364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Drug screening oxycodone,80365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Drug screening oxycodone,80365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Drug screening oxycodone,80365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Drug screening oxycodone,80365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Drug screening oxycodone,80365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Drug screening pregabalin,80366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Drug screening pregabalin,80366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Drug screening pregabalin,80366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Drug screening pregabalin,80366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Drug screening pregabalin,80366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Drug screening propoxyphene,80367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Drug screening propoxyphene,80367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Drug screening propoxyphene,80367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Drug screening propoxyphene,80367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Drug screening propoxyphene,80367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Sedative hypnotics,80368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Sedative hypnotics,80368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Sedative hypnotics,80368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Sedative hypnotics,80368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Sedative hypnotics,80368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Skeletal muscle relaxant 1/2,80369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Skeletal muscle relaxant 1/2,80369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Skeletal muscle relaxant 1/2,80369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Skeletal muscle relaxant 1/2,80369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Skeletal muscle relaxant 1/2,80369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Skel musc relaxant 3 or more,80370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,0.01,
Stimulants synthetic,80371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Stimulants synthetic,80371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Stimulants synthetic,80371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Stimulants synthetic,80371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Stimulants synthetic,80371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Drug screening tapentadol,80372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,89.73,
Drug screening tapentadol,80372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.03,,,,,,,fee schedule,0.01,89.73,
Drug screening tapentadol,80372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.87,,,,,,,fee schedule,0.01,89.73,
Drug screening tapentadol,80372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.16,,,,,,,fee schedule,0.01,89.73,
Drug screening tapentadol,80372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.73,,,,,,,fee schedule,0.01,89.73,
Drug screening tramadol,80373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,83.62,
Drug screening tramadol,80373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.71,,,,,,,fee schedule,0.01,83.62,
Drug screening tramadol,80373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.51,,,,,,,fee schedule,0.01,83.62,
Drug screening tramadol,80373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.67,,,,,,,fee schedule,0.01,83.62,
Drug screening tramadol,80373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.62,,,,,,,fee schedule,0.01,83.62,
Stereoisomer analysis,80374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Stereoisomer analysis,80374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Stereoisomer analysis,80374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Stereoisomer analysis,80374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Stereoisomer analysis,80374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 1-3,80375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,93.46,
Drug/substance nos 1-3,80375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.27,,,,,,,fee schedule,0.01,93.46,
Drug/substance nos 1-3,80375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.52,,,,,,,fee schedule,0.01,93.46,
Drug/substance nos 1-3,80375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.28,,,,,,,fee schedule,0.01,93.46,
Drug/substance nos 1-3,80375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.46,,,,,,,fee schedule,0.01,93.46,
Drug/substance nos 4-6,80376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 4-6,80376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 4-6,80376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 4-6,80376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 4-6,80376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 7/more,80377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 7/more,80377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 7/more,80377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 7/more,80377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,0.01,77.74,
Drug/substance nos 7/more,80377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,0.01,77.74,
Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,30.99,,,,,,,fee schedule,30.99,176.62,
Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.58,,,,,,,fee schedule,30.99,176.62,
Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.71,,,,,,,fee schedule,30.99,176.62,
Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.69,,,,,,,fee schedule,30.99,176.62,
Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.62,,,,,,,fee schedule,30.99,176.62,
Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.25,,,,,,,fee schedule,30.99,176.62,APC
Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.62,,,,,,,fee schedule,30.99,176.62,APC
Acth stimulation panel,80400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.72,,,,,,,fee schedule,30.99,176.62,APC
Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,82.61,,,,,,,fee schedule,82.61,279.98,
Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,243.46,,,,,,,fee schedule,82.61,279.98,
Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.27,,,,,,,fee schedule,82.61,279.98,
Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.61,,,,,,,fee schedule,82.61,279.98,
Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,279.98,,,,,,,fee schedule,82.61,279.98,
Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.31,,,,,,,fee schedule,82.61,279.98,APC
Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.96,,,,,,,fee schedule,82.61,279.98,APC
Acth stimulation panel,80402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.53,,,,,,,fee schedule,82.61,279.98,APC
Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,74.35,,,,,,,fee schedule,74.35,337.05,
Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,293.09,,,,,,,fee schedule,74.35,337.05,
Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.89,,,,,,,fee schedule,74.35,337.05,
Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.15,,,,,,,fee schedule,74.35,337.05,
Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,337.05,,,,,,,fee schedule,74.35,337.05,
Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.17,,,,,,,fee schedule,74.35,337.05,APC
Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,78.26,,,,,,,fee schedule,74.35,337.05,APC
Acth stimulation panel,80406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,140.87,,,,,,,fee schedule,74.35,337.05,APC
Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,119.23,,,,,,,fee schedule,119.23,540.51,
Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,470.01,,,,,,,fee schedule,119.23,540.51,
Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,384.7,,,,,,,fee schedule,119.23,540.51,
Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,308.14,,,,,,,fee schedule,119.23,540.51,
Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,540.51,,,,,,,fee schedule,119.23,540.51,
Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.78,,,,,,,fee schedule,119.23,540.51,APC
Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,125.5,,,,,,,fee schedule,119.23,540.51,APC
Aldosterone suppression eval,80408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,225.9,,,,,,,fee schedule,119.23,540.51,APC
Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,76.35,,,,,,,fee schedule,76.35,346.02,
Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,300.89,,,,,,,fee schedule,76.35,346.02,
Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,246.28,,,,,,,fee schedule,76.35,346.02,
Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.26,,,,,,,fee schedule,76.35,346.02,
Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,346.02,,,,,,,fee schedule,76.35,346.02,
Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.39,,,,,,,fee schedule,76.35,346.02,APC
Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,80.37,,,,,,,fee schedule,76.35,346.02,APC
Calcitonin stimul panel,80410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,144.67,,,,,,,fee schedule,76.35,346.02,APC
CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,761.54,,,,,,,fee schedule,761.54,1442.92,
CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1234.5,,,,,,,fee schedule,761.54,1442.92,
CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1010.44,,,,,,,fee schedule,761.54,1442.92,
CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,809.34,,,,,,,fee schedule,761.54,1442.92,
CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1419.68,,,,,,,fee schedule,761.54,1442.92,
CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,841.7,,,,,,,fee schedule,761.54,1442.92,APC
CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,801.62,,,,,,,fee schedule,761.54,1442.92,APC
CRH stimulation panel,80412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1442.92,,,,,,,fee schedule,761.54,1442.92,APC
Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,49.06,,,,,,,fee schedule,49.06,222.38,
Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.37,,,,,,,fee schedule,49.06,222.38,
Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.27,,,,,,,fee schedule,49.06,222.38,
Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.77,,,,,,,fee schedule,49.06,222.38,
Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.38,,,,,,,fee schedule,49.06,222.38,
Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.22,,,,,,,fee schedule,49.06,222.38,APC
Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.64,,,,,,,fee schedule,49.06,222.38,APC
Testosterone response,80414,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.95,,,,,,,fee schedule,49.06,222.38,APC
Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,53.1,,,,,,,fee schedule,53.1,240.68,
Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,209.29,,,,,,,fee schedule,53.1,240.68,
Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.3,,,,,,,fee schedule,53.1,240.68,
Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.21,,,,,,,fee schedule,53.1,240.68,
Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,240.68,,,,,,,fee schedule,53.1,240.68,
Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.68,,,,,,,fee schedule,53.1,240.68,APC
Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55.89,,,,,,,fee schedule,53.1,240.68,APC
Estradiol response panel,80415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,100.6,,,,,,,fee schedule,53.1,240.68,APC
Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,198.85,,,,,,,fee schedule,198.85,568.36,
Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,494.23,,,,,,,fee schedule,198.85,568.36,
Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,404.53,,,,,,,fee schedule,198.85,568.36,
Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,324.02,,,,,,,fee schedule,198.85,568.36,
Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,568.36,,,,,,,fee schedule,198.85,568.36,
Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,219.79,,,,,,,fee schedule,198.85,568.36,APC
Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,209.32,,,,,,,fee schedule,198.85,568.36,APC
Renin stimulation panel,80416,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,376.78,,,,,,,fee schedule,198.85,568.36,APC
Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,41.79,,,,,,,fee schedule,41.79,189.46,
Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.75,,,,,,,fee schedule,41.79,189.46,
Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.85,,,,,,,fee schedule,41.79,189.46,
Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.01,,,,,,,fee schedule,41.79,189.46,
Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.46,,,,,,,fee schedule,41.79,189.46,
Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.19,,,,,,,fee schedule,41.79,189.46,APC
Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.99,,,,,,,fee schedule,41.79,189.46,APC
Renin stimulation panel,80417,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,79.18,,,,,,,fee schedule,41.79,189.46,APC
Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,550.51,,,,,,,fee schedule,550.51,2496.31,
Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2170.7,,,,,,,fee schedule,550.51,2496.31,
Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1776.72,,,,,,,fee schedule,550.51,2496.31,
Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1423.11,,,,,,,fee schedule,550.51,2496.31,
Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2496.31,,,,,,,fee schedule,550.51,2496.31,
Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,608.45,,,,,,,fee schedule,550.51,2496.31,APC
Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,579.48,,,,,,,fee schedule,550.51,2496.31,APC
Pituitary evaluation panel,80418,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1043.06,,,,,,,fee schedule,550.51,2496.31,APC
Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,153.79,,,,,,,fee schedule,153.79,310.3,
Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,269.83,,,,,,,fee schedule,153.79,310.3,
Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.86,,,,,,,fee schedule,153.79,310.3,
Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.9,,,,,,,fee schedule,153.79,310.3,
Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,310.3,,,,,,,fee schedule,153.79,310.3,
Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,169.97,,,,,,,fee schedule,153.79,310.3,APC
Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.88,,,,,,,fee schedule,153.79,310.3,APC
Dexamethasone panel,80420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,291.38,,,,,,,fee schedule,153.79,310.3,APC
Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,43.77,,,,,,,fee schedule,43.77,196.21,
Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,170.62,,,,,,,fee schedule,43.77,196.21,
Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.65,,,,,,,fee schedule,43.77,196.21,
Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.86,,,,,,,fee schedule,43.77,196.21,
Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.21,,,,,,,fee schedule,43.77,196.21,
Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.37,,,,,,,fee schedule,43.77,196.21,APC
Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.07,,,,,,,fee schedule,43.77,196.21,APC
Glucagon tolerance panel,80422,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,82.93,,,,,,,fee schedule,43.77,196.21,APC
Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,47.98,,,,,,,fee schedule,47.98,217.47,
Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.1,,,,,,,fee schedule,47.98,217.47,
Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.78,,,,,,,fee schedule,47.98,217.47,
Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.97,,,,,,,fee schedule,47.98,217.47,
Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.47,,,,,,,fee schedule,47.98,217.47,
Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.02,,,,,,,fee schedule,47.98,217.47,APC
Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50.5,,,,,,,fee schedule,47.98,217.47,APC
Glucagon tolerance panel,80424,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,90.9,,,,,,,fee schedule,47.98,217.47,APC
Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,140.99,,,,,,,fee schedule,140.99,639.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,555.83,,,,,,,fee schedule,140.99,639.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,454.95,,,,,,,fee schedule,140.99,639.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,364.4,,,,,,,fee schedule,140.99,639.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,639.2,,,,,,,fee schedule,140.99,639.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,155.83,,,,,,,fee schedule,140.99,639.2,APC
Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,148.41,,,,,,,fee schedule,140.99,639.2,APC
Gonadotropin hormone panel,80426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,267.14,,,,,,,fee schedule,140.99,639.2,APC
Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,63.37,,,,,,,fee schedule,63.37,287.28,
Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,249.81,,,,,,,fee schedule,63.37,287.28,
Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,204.47,,,,,,,fee schedule,63.37,287.28,
Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.78,,,,,,,fee schedule,63.37,287.28,
Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,287.28,,,,,,,fee schedule,63.37,287.28,
Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.04,,,,,,,fee schedule,63.37,287.28,APC
Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,66.7,,,,,,,fee schedule,63.37,287.28,APC
Growth hormone panel,80428,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120.06,,,,,,,fee schedule,63.37,287.28,APC
Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,122.86,,,,,,,fee schedule,122.86,335.83,
Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.03,,,,,,,fee schedule,122.86,335.83,
Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.03,,,,,,,fee schedule,122.86,335.83,
Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.45,,,,,,,fee schedule,122.86,335.83,
Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.83,,,,,,,fee schedule,122.86,335.83,
Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.8,,,,,,,fee schedule,122.86,335.83,APC
Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,129.33,,,,,,,fee schedule,122.86,335.83,APC
Growth hormone panel,80430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,232.79,,,,,,,fee schedule,122.86,335.83,APC
Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,157.33,,,,,,,fee schedule,157.33,578.2,
Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,502.78,,,,,,,fee schedule,157.33,578.2,
Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,411.53,,,,,,,fee schedule,157.33,578.2,
Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,329.62,,,,,,,fee schedule,157.33,578.2,
Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,578.2,,,,,,,fee schedule,157.33,578.2,
Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.89,,,,,,,fee schedule,157.33,578.2,APC
Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,165.61,,,,,,,fee schedule,157.33,578.2,APC
Insulin suppression panel,80432,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,298.1,,,,,,,fee schedule,157.33,578.2,APC
Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,270.78,,,,,,,fee schedule,246.37,513.05,
Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.79,,,,,,,fee schedule,246.37,513.05,
Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.58,,,,,,,fee schedule,246.37,513.05,
Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.37,,,,,,,fee schedule,246.37,513.05,
Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,432.16,,,,,,,fee schedule,246.37,513.05,
Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,299.28,,,,,,,fee schedule,246.37,513.05,APC
Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,285.03,,,,,,,fee schedule,246.37,513.05,APC
Insulin tolerance panel,80434,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,513.05,,,,,,,fee schedule,246.37,513.05,APC
Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,97.85,,,,,,,fee schedule,97.85,440,
Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,382.61,,,,,,,fee schedule,97.85,440,
Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,313.17,,,,,,,fee schedule,97.85,440,
Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,250.84,,,,,,,fee schedule,97.85,440,
Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,440,,,,,,,fee schedule,97.85,440,
Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.15,,,,,,,fee schedule,97.85,440,APC
Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,103,,,,,,,fee schedule,97.85,440,APC
Insulin tolerance panel,80435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,185.4,,,,,,,fee schedule,97.85,440,APC
Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,86.6,,,,,,,fee schedule,86.6,392.62,
Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,341.41,,,,,,,fee schedule,86.6,392.62,
Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.44,,,,,,,fee schedule,86.6,392.62,
Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.83,,,,,,,fee schedule,86.6,392.62,
Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.62,,,,,,,fee schedule,86.6,392.62,
Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.72,,,,,,,fee schedule,86.6,392.62,APC
Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,91.16,,,,,,,fee schedule,86.6,392.62,APC
Metyrapone panel,80436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,164.09,,,,,,,fee schedule,86.6,392.62,APC
TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,47.89,,,,,,,fee schedule,47.89,217.12,
TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.8,,,,,,,fee schedule,47.89,217.12,
TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.53,,,,,,,fee schedule,47.89,217.12,
TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.78,,,,,,,fee schedule,47.89,217.12,
TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.12,,,,,,,fee schedule,47.89,217.12,
TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.93,,,,,,,fee schedule,47.89,217.12,APC
TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50.41,,,,,,,fee schedule,47.89,217.12,APC
TRH stimulation panel,80438,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,90.74,,,,,,,fee schedule,47.89,217.12,APC
TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,63.85,,,,,,,fee schedule,63.85,289.48,
TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,251.72,,,,,,,fee schedule,63.85,289.48,
TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.03,,,,,,,fee schedule,63.85,289.48,
TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.03,,,,,,,fee schedule,63.85,289.48,
TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,289.48,,,,,,,fee schedule,63.85,289.48,
TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.57,,,,,,,fee schedule,63.85,289.48,APC
TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67.21,,,,,,,fee schedule,63.85,289.48,APC
TRH stimulation panel,80439,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120.98,,,,,,,fee schedule,63.85,289.48,APC
Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.4,,,,,,,fee schedule,20.4,113.39,
Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.6,,,,,,,fee schedule,20.4,113.39,
Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.7,,,,,,,fee schedule,20.4,113.39,
Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.64,,,,,,,fee schedule,20.4,113.39,
Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.39,,,,,,,fee schedule,20.4,113.39,
Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,20.4,113.39,APC
Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,20.4,113.39,APC
Path clin consltj sf 5-20,80503,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,20.4,113.39,APC
Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,43.88,,,,,,,fee schedule,43.88,340.3,
Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.91,,,,,,,fee schedule,43.88,340.3,
Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.2,,,,,,,fee schedule,43.88,340.3,
Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,194,,,,,,,fee schedule,43.88,340.3,
Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.3,,,,,,,fee schedule,43.88,340.3,
Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,43.88,340.3,APC
Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,43.88,340.3,APC
Path clin consltj mod 21-40,80504,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,43.88,340.3,APC
Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,83.44,,,,,,,fee schedule,83.44,340.3,
Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.91,,,,,,,fee schedule,83.44,340.3,
Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.2,,,,,,,fee schedule,83.44,340.3,
Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,194,,,,,,,fee schedule,83.44,340.3,
Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.3,,,,,,,fee schedule,83.44,340.3,
Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,83.44,340.3,APC
Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,83.44,340.3,APC
Path clin consltj high 41-60,80505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,83.44,340.3,APC
Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.75,,,,,,,fee schedule,18.08,39.75,
Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.58,,,,,,,fee schedule,18.08,39.75,
Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.57,,,,,,,fee schedule,18.08,39.75,
Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.08,,,,,,,fee schedule,18.08,39.75,
Path clin consltj prolng svc,80506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.72,,,,,,,fee schedule,18.08,39.75,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.82,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.29,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.25,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.4,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.33,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.47,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.97,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.08,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.19,,,,,,,fee schedule,3.4,7.24,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.22,,,,,,,fee schedule,3.4,7.24,APC
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.02,,,,,,,fee schedule,3.4,7.24,APC
Urinalysis nonauto w/scope,81000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.24,,,,,,,fee schedule,3.4,7.24,APC
Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.01,,,,,,,fee schedule,3.01,12.56,
Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.92,,,,,,,fee schedule,3.01,12.56,
Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.94,,,,,,,fee schedule,3.01,12.56,
Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.16,,,,,,,fee schedule,3.01,12.56,
Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.56,,,,,,,fee schedule,3.01,12.56,
Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.33,,,,,,,fee schedule,3.01,12.56,APC
Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.17,,,,,,,fee schedule,3.01,12.56,APC
Urinalysis auto w/scope,81001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.71,,,,,,,fee schedule,3.01,12.56,APC
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.31,,,,,,,fee schedule,2.6,6.26,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.96,,,,,,,fee schedule,2.6,6.26,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.24,,,,,,,fee schedule,2.6,6.26,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.6,,,,,,,fee schedule,2.6,6.26,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.55,,,,,,,fee schedule,2.6,6.26,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.65,,,,,,,fee schedule,2.6,6.26,APC
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.48,,,,,,,fee schedule,2.6,6.26,APC
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.26,,,,,,,fee schedule,2.6,6.26,APC
Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.14,,,,,,,fee schedule,2.14,11.83,
Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.29,,,,,,,fee schedule,2.14,11.83,
Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.42,,,,,,,fee schedule,2.14,11.83,
Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.75,,,,,,,fee schedule,2.14,11.83,
Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.83,,,,,,,fee schedule,2.14,11.83,
Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.36,,,,,,,fee schedule,2.14,11.83,APC
Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.25,,,,,,,fee schedule,2.14,11.83,APC
Urinalysis auto w/o scope,81003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.05,,,,,,,fee schedule,2.14,11.83,APC
Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.06,,,,,,,fee schedule,2.06,9.33,
Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.11,,,,,,,fee schedule,2.06,9.33,
Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.64,,,,,,,fee schedule,2.06,9.33,
Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.32,,,,,,,fee schedule,2.06,9.33,
Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.33,,,,,,,fee schedule,2.06,9.33,
Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.28,,,,,,,fee schedule,2.06,9.33,APC
Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.17,,,,,,,fee schedule,2.06,9.33,APC
Urinalysis,81005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.91,,,,,,,fee schedule,2.06,9.33,APC
Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.48,,,,,,,fee schedule,5.34,53.96,
Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.14,,,,,,,fee schedule,5.34,53.96,
Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.66,,,,,,,fee schedule,5.34,53.96,
Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.34,,,,,,,fee schedule,5.34,53.96,
Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.36,,,,,,,fee schedule,5.34,53.96,
Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.48,,,,,,,fee schedule,5.34,53.96,APC
Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.98,,,,,,,fee schedule,5.34,53.96,APC
Urine screen for bacteria,81007,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.96,,,,,,,fee schedule,5.34,53.96,APC
Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.9,,,,,,,fee schedule,2.9,13.1,
Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.39,,,,,,,fee schedule,2.9,13.1,
Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.32,,,,,,,fee schedule,2.9,13.1,
Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.47,,,,,,,fee schedule,2.9,13.1,
Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.1,,,,,,,fee schedule,2.9,13.1,
Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.2,,,,,,,fee schedule,2.9,13.1,APC
Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.05,,,,,,,fee schedule,2.9,13.1,APC
Microscopic exam of urine,81015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.49,,,,,,,fee schedule,2.9,13.1,APC
Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.47,,,,,,,fee schedule,4.47,15.88,
Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.81,,,,,,,fee schedule,4.47,15.88,
Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.3,,,,,,,fee schedule,4.47,15.88,
Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.05,,,,,,,fee schedule,4.47,15.88,
Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.88,,,,,,,fee schedule,4.47,15.88,
Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.94,,,,,,,fee schedule,4.47,15.88,APC
Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.7,,,,,,,fee schedule,4.47,15.88,APC
Urinalysis glass test,81020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.46,,,,,,,fee schedule,4.47,15.88,APC
Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.18,,,,,,,fee schedule,8.18,32.89,
Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.6,,,,,,,fee schedule,8.18,32.89,
Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.41,,,,,,,fee schedule,8.18,32.89,
Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.75,,,,,,,fee schedule,8.18,32.89,
Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.89,,,,,,,fee schedule,8.18,32.89,
Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.04,,,,,,,fee schedule,8.18,32.89,APC
Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.61,,,,,,,fee schedule,8.18,32.89,APC
Urine pregnancy test,81025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.5,,,,,,,fee schedule,8.18,32.89,APC
Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.46,,,,,,,fee schedule,3.46,12.93,
Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.24,,,,,,,fee schedule,3.46,12.93,
Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.2,,,,,,,fee schedule,3.46,12.93,
Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.37,,,,,,,fee schedule,3.46,12.93,
Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.93,,,,,,,fee schedule,3.46,12.93,
Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.82,,,,,,,fee schedule,3.46,12.93,APC
Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.64,,,,,,,fee schedule,3.46,12.93,APC
Urinalysis volume measure,81050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.55,,,,,,,fee schedule,3.46,12.93,APC
Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hpa-1 genotyping,81105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hpa-2 genotyping,81106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hpa-3 genotyping,81107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hpa-4 genotyping,81108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hpa-5 genotyping,81109,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hpa-6 genotyping,81110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hpa-9 genotyping,81111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hpa-15 genotyping,81112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,183.59,,,,,,,fee schedule,183.59,623.48,
Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,542.16,,,,,,,fee schedule,183.59,623.48,
Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,443.76,,,,,,,fee schedule,183.59,623.48,
Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,355.44,,,,,,,fee schedule,183.59,623.48,
Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,623.48,,,,,,,fee schedule,183.59,623.48,
Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,183.59,623.48,APC
Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,193.25,,,,,,,fee schedule,183.59,623.48,APC
Idh1 common variants,81120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,347.85,,,,,,,fee schedule,183.59,623.48,APC
Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,281,,,,,,,fee schedule,281,935.21,
Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,813.23,,,,,,,fee schedule,281,935.21,
Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,665.63,,,,,,,fee schedule,281,935.21,
Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,533.15,,,,,,,fee schedule,281,935.21,
Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,935.21,,,,,,,fee schedule,281,935.21,
Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,310.58,,,,,,,fee schedule,281,935.21,APC
Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,295.79,,,,,,,fee schedule,281,935.21,APC
Idh2 common variants,81121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,532.42,,,,,,,fee schedule,281,935.21,APC
DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,265.05,,,,,,,fee schedule,252.6,502.2,
DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,385.29,,,,,,,fee schedule,252.6,502.2,
DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,315.36,,,,,,,fee schedule,252.6,502.2,
DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,252.6,,,,,,,fee schedule,252.6,502.2,
DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,443.08,,,,,,,fee schedule,252.6,502.2,
DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.95,,,,,,,fee schedule,252.6,502.2,APC
DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,279,,,,,,,fee schedule,252.6,502.2,APC
DMD dup/delet analysis,81161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,502.2,,,,,,,fee schedule,252.6,502.2,APC
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1733.64,,,,,,,fee schedule,1733.64,7859.71,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6834.53,,,,,,,fee schedule,1733.64,7859.71,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5594.06,,,,,,,fee schedule,1733.64,7859.71,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4480.72,,,,,,,fee schedule,1733.64,7859.71,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7859.71,,,,,,,fee schedule,1733.64,7859.71,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1916.12,,,,,,,fee schedule,1733.64,7859.71,APC
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1824.88,,,,,,,fee schedule,1733.64,7859.71,APC
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3284.78,,,,,,,fee schedule,1733.64,7859.71,APC
Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,444.6,,,,,,,fee schedule,444.6,854,
Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,742.61,,,,,,,fee schedule,444.6,854,
Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,607.83,,,,,,,fee schedule,444.6,854,
Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,486.86,,,,,,,fee schedule,444.6,854,
Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,854,,,,,,,fee schedule,444.6,854,
Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,491.4,,,,,,,fee schedule,444.6,854,APC
Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,468,,,,,,,fee schedule,444.6,854,APC
Brca1&2 gene full seq alys,81163,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,842.4,,,,,,,fee schedule,444.6,854,APC
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,555.02,,,,,,,fee schedule,555.02,1763.81,
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.75,,,,,,,fee schedule,555.02,1763.81,
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1255.37,,,,,,,fee schedule,555.02,1763.81,
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.53,,,,,,,fee schedule,555.02,1763.81,
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.81,,,,,,,fee schedule,555.02,1763.81,
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,613.44,,,,,,,fee schedule,555.02,1763.81,APC
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.23,,,,,,,fee schedule,555.02,1763.81,APC
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1051.61,,,,,,,fee schedule,555.02,1763.81,APC
Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,268.74,,,,,,,fee schedule,268.74,854,
Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,742.61,,,,,,,fee schedule,268.74,854,
Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,607.83,,,,,,,fee schedule,268.74,854,
Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,486.86,,,,,,,fee schedule,268.74,854,
Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,854,,,,,,,fee schedule,268.74,854,
Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,268.74,854,APC
Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,268.74,854,APC
Brca1 gene full seq alys,81165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,268.74,854,APC
Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,286.28,,,,,,,fee schedule,286.28,909.79,
Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,791.12,,,,,,,fee schedule,286.28,909.79,
Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,647.53,,,,,,,fee schedule,286.28,909.79,
Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,518.66,,,,,,,fee schedule,286.28,909.79,
Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,909.79,,,,,,,fee schedule,286.28,909.79,
Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,286.28,909.79,APC
Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,301.35,,,,,,,fee schedule,286.28,909.79,APC
Brca1 gene full dup/del alys,81166,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,542.43,,,,,,,fee schedule,286.28,909.79,APC
Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,268.74,,,,,,,fee schedule,268.74,854,
Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,742.61,,,,,,,fee schedule,268.74,854,
Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,607.83,,,,,,,fee schedule,268.74,854,
Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,486.86,,,,,,,fee schedule,268.74,854,
Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,854,,,,,,,fee schedule,268.74,854,
Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,268.74,854,APC
Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,268.74,854,APC
Brca2 gene full dup/del alys,81167,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,268.74,854,APC
Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,196.94,,,,,,,fee schedule,196.94,463.17,
Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,402.76,,,,,,,fee schedule,196.94,463.17,
Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,329.66,,,,,,,fee schedule,196.94,463.17,
Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.05,,,,,,,fee schedule,196.94,463.17,
Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,463.17,,,,,,,fee schedule,196.94,463.17,
Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,196.94,463.17,APC
Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,207.31,,,,,,,fee schedule,196.94,463.17,APC
Ccnd1/igh translocation alys,81168,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,373.16,,,,,,,fee schedule,196.94,463.17,APC
Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,285,,,,,,,fee schedule,196,540,
Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,298.97,,,,,,,fee schedule,196,540,
Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,244.71,,,,,,,fee schedule,196,540,
Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,196,,,,,,,fee schedule,196,540,
Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,343.82,,,,,,,fee schedule,196,540,
Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315,,,,,,,fee schedule,196,540,APC
Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,300,,,,,,,fee schedule,196,540,APC
Abl1 gene,81170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,540,,,,,,,fee schedule,196,540,APC
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,261.09,,,,,,,fee schedule,261.09,829.73,
Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,721.5,,,,,,,fee schedule,261.09,829.73,
Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,590.55,,,,,,,fee schedule,261.09,829.73,
Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.02,,,,,,,fee schedule,261.09,829.73,
Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,829.73,,,,,,,fee schedule,261.09,829.73,
Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,261.09,829.73,APC
Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,261.09,829.73,APC
Aff2 gene charac alleles,81172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,261.09,829.73,APC
Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,286.28,,,,,,,fee schedule,286.28,909.79,
Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,791.12,,,,,,,fee schedule,286.28,909.79,
Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,647.53,,,,,,,fee schedule,286.28,909.79,
Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,518.66,,,,,,,fee schedule,286.28,909.79,
Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,909.79,,,,,,,fee schedule,286.28,909.79,
Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,286.28,909.79,APC
Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,301.35,,,,,,,fee schedule,286.28,909.79,APC
Ar gene full gene sequence,81173,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,542.43,,,,,,,fee schedule,286.28,909.79,APC
Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,559.14,
Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,486.21,,,,,,,fee schedule,175.94,559.14,
Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.96,,,,,,,fee schedule,175.94,559.14,
Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.76,,,,,,,fee schedule,175.94,559.14,
Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,559.14,,,,,,,fee schedule,175.94,559.14,
Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,559.14,APC
Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,559.14,APC
Ar gene known famil variant,81174,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,559.14,APC
Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,642.68,,,,,,,fee schedule,642.68,2466.55,
Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2144.83,,,,,,,fee schedule,642.68,2466.55,
Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1755.54,,,,,,,fee schedule,642.68,2466.55,
Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1406.15,,,,,,,fee schedule,642.68,2466.55,
Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2466.55,,,,,,,fee schedule,642.68,2466.55,
Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.32,,,,,,,fee schedule,642.68,2466.55,APC
Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,676.5,,,,,,,fee schedule,642.68,2466.55,APC
Asxl1 full gene sequence,81175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1217.7,,,,,,,fee schedule,642.68,2466.55,APC
Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,229.81,,,,,,,fee schedule,229.81,1041.84,
Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,905.95,,,,,,,fee schedule,229.81,1041.84,
Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,741.52,,,,,,,fee schedule,229.81,1041.84,
Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,593.94,,,,,,,fee schedule,229.81,1041.84,
Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1041.84,,,,,,,fee schedule,229.81,1041.84,
Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,254,,,,,,,fee schedule,229.81,1041.84,APC
Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,241.9,,,,,,,fee schedule,229.81,1041.84,APC
Asxl1 gene target seq alys,81176,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,435.42,,,,,,,fee schedule,229.81,1041.84,APC
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,803.96,,,,,,,fee schedule,803.96,2554.91,
Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2221.66,,,,,,,fee schedule,803.96,2554.91,
Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1818.43,,,,,,,fee schedule,803.96,2554.91,
Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1456.52,,,,,,,fee schedule,803.96,2554.91,
Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2554.91,,,,,,,fee schedule,803.96,2554.91,
Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,888.58,,,,,,,fee schedule,803.96,2554.91,APC
Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,846.27,,,,,,,fee schedule,803.96,2554.91,APC
Cacna1a gene full gene seq,81185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1523.29,,,,,,,fee schedule,803.96,2554.91,APC
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,559.14,
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,486.21,,,,,,,fee schedule,175.94,559.14,
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.96,,,,,,,fee schedule,175.94,559.14,
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.76,,,,,,,fee schedule,175.94,559.14,
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,559.14,,,,,,,fee schedule,175.94,559.14,
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,559.14,APC
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,559.14,APC
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,559.14,APC
Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Cnbp gene detc abnor allele,81187,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Cstb gene detc abnor allele,81188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,261.09,,,,,,,fee schedule,261.09,829.73,
Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,721.5,,,,,,,fee schedule,261.09,829.73,
Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,590.55,,,,,,,fee schedule,261.09,829.73,
Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.02,,,,,,,fee schedule,261.09,829.73,
Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,829.73,,,,,,,fee schedule,261.09,829.73,
Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,261.09,829.73,APC
Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,261.09,829.73,APC
Cstb gene full gene sequence,81189,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,261.09,829.73,APC
Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,559.14,
Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,486.21,,,,,,,fee schedule,175.94,559.14,
Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.96,,,,,,,fee schedule,175.94,559.14,
Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.76,,,,,,,fee schedule,175.94,559.14,
Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,559.14,,,,,,,fee schedule,175.94,559.14,
Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,559.14,APC
Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,559.14,APC
Cstb gene known famil vrnt,81190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,559.14,APC
Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,196.94,,,,,,,fee schedule,196.94,463.17,
Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,402.76,,,,,,,fee schedule,196.94,463.17,
Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,329.66,,,,,,,fee schedule,196.94,463.17,
Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.05,,,,,,,fee schedule,196.94,463.17,
Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,463.17,,,,,,,fee schedule,196.94,463.17,
Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,196.94,463.17,APC
Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,207.31,,,,,,,fee schedule,196.94,463.17,APC
Ntrk1 translocation analysis,81191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,373.16,,,,,,,fee schedule,196.94,463.17,APC
Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,196.94,,,,,,,fee schedule,196.94,463.17,
Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,402.76,,,,,,,fee schedule,196.94,463.17,
Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,329.66,,,,,,,fee schedule,196.94,463.17,
Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.05,,,,,,,fee schedule,196.94,463.17,
Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,463.17,,,,,,,fee schedule,196.94,463.17,
Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,196.94,463.17,APC
Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,207.31,,,,,,,fee schedule,196.94,463.17,APC
Ntrk2 translocation analysis,81192,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,373.16,,,,,,,fee schedule,196.94,463.17,APC
Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,196.94,,,,,,,fee schedule,196.94,463.17,
Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,402.76,,,,,,,fee schedule,196.94,463.17,
Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,329.66,,,,,,,fee schedule,196.94,463.17,
Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.05,,,,,,,fee schedule,196.94,463.17,
Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,463.17,,,,,,,fee schedule,196.94,463.17,
Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,196.94,463.17,APC
Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,207.31,,,,,,,fee schedule,196.94,463.17,APC
Ntrk3 translocation analysis,81193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,373.16,,,,,,,fee schedule,196.94,463.17,APC
Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,492.37,,,,,,,fee schedule,492.37,1157.9,
Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1006.87,,,,,,,fee schedule,492.37,1157.9,
Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,824.12,,,,,,,fee schedule,492.37,1157.9,
Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,660.1,,,,,,,fee schedule,492.37,1157.9,
Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1157.9,,,,,,,fee schedule,492.37,1157.9,
Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,544.19,,,,,,,fee schedule,492.37,1157.9,APC
Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,518.28,,,,,,,fee schedule,492.37,1157.9,APC
Ntrk translocation analysis,81194,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,932.9,,,,,,,fee schedule,492.37,1157.9,APC
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2065.88,,,,,,,fee schedule,1354.39,3353.8,
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1690.92,,,,,,,fee schedule,1354.39,3353.8,
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1354.39,,,,,,,fee schedule,1354.39,3353.8,
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2375.76,,,,,,,fee schedule,1354.39,3353.8,
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1956.38,,,,,,,fee schedule,1354.39,3353.8,APC
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1863.22,,,,,,,fee schedule,1354.39,3353.8,APC
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3353.8,,,,,,,fee schedule,1354.39,3353.8,APC
Aspa gene,81200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,44.89,,,,,,,fee schedule,44.89,85.05,
Aspa gene,81200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.61,,,,,,,fee schedule,44.89,85.05,APC
Aspa gene,81200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.25,,,,,,,fee schedule,44.89,85.05,APC
Aspa gene,81200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,85.05,,,,,,,fee schedule,44.89,85.05,APC
Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,741,,,,,,,fee schedule,741,2674.95,
Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2326.04,,,,,,,fee schedule,741,2674.95,
Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1903.86,,,,,,,fee schedule,741,2674.95,
Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1524.95,,,,,,,fee schedule,741,2674.95,
Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2674.95,,,,,,,fee schedule,741,2674.95,
Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,819,,,,,,,fee schedule,741,2674.95,APC
Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,780,,,,,,,fee schedule,741,2674.95,APC
Apc gene full sequence,81201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1404,,,,,,,fee schedule,741,2674.95,APC
Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,266,,,,,,,fee schedule,168.15,504,
Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.49,,,,,,,fee schedule,168.15,504,
Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.94,,,,,,,fee schedule,168.15,504,
Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.15,,,,,,,fee schedule,168.15,504,
Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.96,,,,,,,fee schedule,168.15,504,
Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,294,,,,,,,fee schedule,168.15,504,APC
Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,280,,,,,,,fee schedule,168.15,504,APC
Apc gene known fam variants,81202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,504,,,,,,,fee schedule,168.15,504,APC
Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,190,,,,,,,fee schedule,190,1808.05,
Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1572.22,,,,,,,fee schedule,190,1808.05,
Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1286.86,,,,,,,fee schedule,190,1808.05,
Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1030.75,,,,,,,fee schedule,190,1808.05,
Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1808.05,,,,,,,fee schedule,190,1808.05,
Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210,,,,,,,fee schedule,190,1808.05,APC
Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,200,,,,,,,fee schedule,190,1808.05,APC
Apc gene dup/delet variants,81203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,360,,,,,,,fee schedule,190,1808.05,APC
Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Ar gene charac alleles,81204,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Bckdhb gene,81205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,90.24,,,,,,,fee schedule,90.24,170.98,
Bckdhb gene,81205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.74,,,,,,,fee schedule,90.24,170.98,APC
Bckdhb gene,81205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.99,,,,,,,fee schedule,90.24,170.98,APC
Bckdhb gene,81205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.98,,,,,,,fee schedule,90.24,170.98,APC
Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,155.76,,,,,,,fee schedule,122.64,295.13,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,187.07,,,,,,,fee schedule,122.64,295.13,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.12,,,,,,,fee schedule,122.64,295.13,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.64,,,,,,,fee schedule,122.64,295.13,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,215.13,,,,,,,fee schedule,122.64,295.13,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,172.16,,,,,,,fee schedule,122.64,295.13,APC
Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,163.96,,,,,,,fee schedule,122.64,295.13,APC
Bcr/abl1 gene major bp,81206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,295.13,,,,,,,fee schedule,122.64,295.13,APC
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,137.6,,,,,,,fee schedule,122.64,260.71,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,187.07,,,,,,,fee schedule,122.64,260.71,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.12,,,,,,,fee schedule,122.64,260.71,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.64,,,,,,,fee schedule,122.64,260.71,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,215.13,,,,,,,fee schedule,122.64,260.71,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,152.08,,,,,,,fee schedule,122.64,260.71,APC
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,144.84,,,,,,,fee schedule,122.64,260.71,APC
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,260.71,,,,,,,fee schedule,122.64,260.71,APC
Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,203.89,,,,,,,fee schedule,117.6,386.32,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,179.38,,,,,,,fee schedule,117.6,386.32,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.82,,,,,,,fee schedule,117.6,386.32,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.6,,,,,,,fee schedule,117.6,386.32,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,206.29,,,,,,,fee schedule,117.6,386.32,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.35,,,,,,,fee schedule,117.6,386.32,APC
Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,214.62,,,,,,,fee schedule,117.6,386.32,APC
Bcr/abl1 gene other bp,81208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,386.32,,,,,,,fee schedule,117.6,386.32,APC
Blm gene,81209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.34,,,,,,,fee schedule,37.34,70.76,
Blm gene,81209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.28,,,,,,,fee schedule,37.34,70.76,APC
Blm gene,81209,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.31,,,,,,,fee schedule,37.34,70.76,APC
Blm gene,81209,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.76,,,,,,,fee schedule,37.34,70.76,APC
Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.63,,,,,,,fee schedule,166.63,315.72,
Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,269.31,,,,,,,fee schedule,166.63,315.72,
Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.43,,,,,,,fee schedule,166.63,315.72,
Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.56,,,,,,,fee schedule,166.63,315.72,
Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.71,,,,,,,fee schedule,166.63,315.72,
Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,166.63,315.72,APC
Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,175.4,,,,,,,fee schedule,166.63,315.72,APC
Braf gene,81210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,315.72,,,,,,,fee schedule,166.63,315.72,APC
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,418,,,,,,,fee schedule,318.02,792,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,485.08,,,,,,,fee schedule,318.02,792,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.04,,,,,,,fee schedule,318.02,792,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.02,,,,,,,fee schedule,318.02,792,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,557.84,,,,,,,fee schedule,318.02,792,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,462,,,,,,,fee schedule,318.02,792,APC
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,440,,,,,,,fee schedule,318.02,792,APC
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,792,,,,,,,fee schedule,318.02,792,APC
Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,356.49,,,,,,,fee schedule,167.8,675.45,
Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.95,,,,,,,fee schedule,167.8,675.45,
Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.5,,,,,,,fee schedule,167.8,675.45,
Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.8,,,,,,,fee schedule,167.8,675.45,
Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.34,,,,,,,fee schedule,167.8,675.45,
Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,167.8,675.45,APC
Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,375.25,,,,,,,fee schedule,167.8,675.45,APC
Brca1 gene known fam variant,81215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,675.45,,,,,,,fee schedule,167.8,675.45,APC
Brca2 gene full sequence,81216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.86,,,,,,,fee schedule,175.86,333.22,
Brca2 gene full sequence,81216,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.38,,,,,,,fee schedule,175.86,333.22,APC
Brca2 gene full sequence,81216,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.12,,,,,,,fee schedule,175.86,333.22,APC
Brca2 gene full sequence,81216,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.22,,,,,,,fee schedule,175.86,333.22,APC
Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,356.49,,,,,,,fee schedule,167.8,675.45,
Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.95,,,,,,,fee schedule,167.8,675.45,
Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.5,,,,,,,fee schedule,167.8,675.45,
Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.8,,,,,,,fee schedule,167.8,675.45,
Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.34,,,,,,,fee schedule,167.8,675.45,
Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,167.8,675.45,APC
Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,375.25,,,,,,,fee schedule,167.8,675.45,APC
Brca2 gene known fam variant,81217,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,675.45,,,,,,,fee schedule,167.8,675.45,APC
Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,229.81,,,,,,,fee schedule,229.81,575.49,
Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,500.43,,,,,,,fee schedule,229.81,575.49,
Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,409.6,,,,,,,fee schedule,229.81,575.49,
Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,328.08,,,,,,,fee schedule,229.81,575.49,
Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,575.49,,,,,,,fee schedule,229.81,575.49,
Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,254,,,,,,,fee schedule,229.81,575.49,APC
Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,241.9,,,,,,,fee schedule,229.81,575.49,APC
Cebpa gene full sequence,81218,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,435.42,,,,,,,fee schedule,229.81,575.49,APC
Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,115.55,,,,,,,fee schedule,115.55,436.4,
Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,379.48,,,,,,,fee schedule,115.55,436.4,
Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,310.6,,,,,,,fee schedule,115.55,436.4,
Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,248.79,,,,,,,fee schedule,115.55,436.4,
Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,436.4,,,,,,,fee schedule,115.55,436.4,
Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,127.71,,,,,,,fee schedule,115.55,436.4,APC
Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,121.63,,,,,,,fee schedule,115.55,436.4,APC
Calr gene com variants,81219,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,218.93,,,,,,,fee schedule,115.55,436.4,APC
Cftr gene com variants,81220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,528.77,,,,,,,fee schedule,528.77,1001.88,
Cftr gene com variants,81220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,584.43,,,,,,,fee schedule,528.77,1001.88,APC
Cftr gene com variants,81220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,556.6,,,,,,,fee schedule,528.77,1001.88,APC
Cftr gene com variants,81220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1001.88,,,,,,,fee schedule,528.77,1001.88,APC
Cftr gene known fam variants,81221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,92.36,,,,,,,fee schedule,92.36,175,
Cftr gene known fam variants,81221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.08,,,,,,,fee schedule,92.36,175,APC
Cftr gene known fam variants,81221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,97.22,,,,,,,fee schedule,92.36,175,APC
Cftr gene known fam variants,81221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,175,,,,,,,fee schedule,92.36,175,APC
Cftr gene dup/delet variants,81222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,413.32,,,,,,,fee schedule,413.32,783.13,
Cftr gene dup/delet variants,81222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,456.82,,,,,,,fee schedule,413.32,783.13,APC
Cftr gene dup/delet variants,81222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,435.07,,,,,,,fee schedule,413.32,783.13,APC
Cftr gene dup/delet variants,81222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,783.13,,,,,,,fee schedule,413.32,783.13,APC
Cftr gene full sequence,81223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,474.05,,,,,,,fee schedule,474.05,898.2,
Cftr gene full sequence,81223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,523.95,,,,,,,fee schedule,474.05,898.2,APC
Cftr gene full sequence,81223,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,499,,,,,,,fee schedule,474.05,898.2,APC
Cftr gene full sequence,81223,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,898.2,,,,,,,fee schedule,474.05,898.2,APC
Cftr gene intron poly t,81224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,160.31,,,,,,,fee schedule,160.31,303.75,
Cftr gene intron poly t,81224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.19,,,,,,,fee schedule,160.31,303.75,APC
Cftr gene intron poly t,81224,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,168.75,,,,,,,fee schedule,160.31,303.75,APC
Cftr gene intron poly t,81224,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,303.75,,,,,,,fee schedule,160.31,303.75,APC
Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,276.79,,,,,,,fee schedule,276.79,921.18,
Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,801.03,,,,,,,fee schedule,276.79,921.18,
Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,655.64,,,,,,,fee schedule,276.79,921.18,
Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,525.16,,,,,,,fee schedule,276.79,921.18,
Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,921.18,,,,,,,fee schedule,276.79,921.18,
Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,305.93,,,,,,,fee schedule,276.79,921.18,APC
Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,291.36,,,,,,,fee schedule,276.79,921.18,APC
Cyp2c19 gene com variants,81225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,524.45,,,,,,,fee schedule,276.79,921.18,APC
Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,428.36,,,,,,,fee schedule,428.36,1425.69,
Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1239.73,,,,,,,fee schedule,428.36,1425.69,
Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1014.72,,,,,,,fee schedule,428.36,1425.69,
Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,812.77,,,,,,,fee schedule,428.36,1425.69,
Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1425.69,,,,,,,fee schedule,428.36,1425.69,
Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,428.36,1425.69,APC
Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,450.91,,,,,,,fee schedule,428.36,1425.69,APC
Cyp2d6 gene com variants,81226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,811.64,,,,,,,fee schedule,428.36,1425.69,APC
Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
Cyp2c9 gene com variants,81227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,855,,,,,,,fee schedule,855,1620,
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,945,,,,,,,fee schedule,855,1620,APC
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,900,,,,,,,fee schedule,855,1620,APC
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1620,,,,,,,fee schedule,855,1620,APC
Cytogen m array copy no&snp,81229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1102,,,,,,,fee schedule,1102,2088,
Cytogen m array copy no&snp,81229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1102,2088,APC
Cytogen m array copy no&snp,81229,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1160,,,,,,,fee schedule,1102,2088,APC
Cytogen m array copy no&snp,81229,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2088,,,,,,,fee schedule,1102,2088,APC
Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
Cyp3a4 gene common variants,81230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
Cyp3a5 gene common variants,81231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
Dpyd gene common variants,81232,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.63,,,,,,,fee schedule,166.63,529.53,
Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,460.46,,,,,,,fee schedule,166.63,529.53,
Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.89,,,,,,,fee schedule,166.63,529.53,
Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.88,,,,,,,fee schedule,166.63,529.53,
Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,529.53,,,,,,,fee schedule,166.63,529.53,
Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,166.63,529.53,APC
Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,175.4,,,,,,,fee schedule,166.63,529.53,APC
Btk gene common variants,81233,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,315.72,,,,,,,fee schedule,166.63,529.53,APC
Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Dmpk gene detc abnor allele,81234,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,308.35,,,,,,,fee schedule,295.12,584.24,
Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,450.16,,,,,,,fee schedule,295.12,584.24,
Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,368.46,,,,,,,fee schedule,295.12,584.24,
Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,295.12,,,,,,,fee schedule,295.12,584.24,
Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,517.68,,,,,,,fee schedule,295.12,584.24,
Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,340.81,,,,,,,fee schedule,295.12,584.24,APC
Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,324.58,,,,,,,fee schedule,295.12,584.24,APC
Egfr gene com variants,81235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,584.24,,,,,,,fee schedule,295.12,584.24,APC
Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,268.74,,,,,,,fee schedule,268.74,854,
Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,742.61,,,,,,,fee schedule,268.74,854,
Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,607.83,,,,,,,fee schedule,268.74,854,
Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,486.86,,,,,,,fee schedule,268.74,854,
Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,854,,,,,,,fee schedule,268.74,854,
Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,268.74,854,APC
Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,268.74,854,APC
Ezh2 gene full gene sequence,81236,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,268.74,854,APC
Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.63,,,,,,,fee schedule,166.63,529.53,
Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,460.46,,,,,,,fee schedule,166.63,529.53,
Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.89,,,,,,,fee schedule,166.63,529.53,
Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.88,,,,,,,fee schedule,166.63,529.53,
Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,529.53,,,,,,,fee schedule,166.63,529.53,
Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,166.63,529.53,APC
Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,175.4,,,,,,,fee schedule,166.63,529.53,APC
Ezh2 gene common variants,81237,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,315.72,,,,,,,fee schedule,166.63,529.53,APC
F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,570,,,,,,,fee schedule,570,1896.44,
F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1649.08,,,,,,,fee schedule,570,1896.44,
F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1349.77,,,,,,,fee schedule,570,1896.44,
F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1081.14,,,,,,,fee schedule,570,1896.44,
F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1896.44,,,,,,,fee schedule,570,1896.44,
F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,570,1896.44,APC
F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,600,,,,,,,fee schedule,570,1896.44,APC
F9 full gene sequence,81238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1080,,,,,,,fee schedule,570,1896.44,APC
Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,261.09,,,,,,,fee schedule,261.09,829.73,
Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,721.5,,,,,,,fee schedule,261.09,829.73,
Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,590.55,,,,,,,fee schedule,261.09,829.73,
Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.02,,,,,,,fee schedule,261.09,829.73,
Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,829.73,,,,,,,fee schedule,261.09,829.73,
Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,261.09,829.73,APC
Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,261.09,829.73,APC
Dmpk gene charac alleles,81239,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,261.09,829.73,APC
F2 gene,81240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,62.41,,,,,,,fee schedule,62.41,118.24,
F2 gene,81240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.97,,,,,,,fee schedule,62.41,118.24,APC
F2 gene,81240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.69,,,,,,,fee schedule,62.41,118.24,APC
F2 gene,81240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,118.24,,,,,,,fee schedule,62.41,118.24,APC
F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,69.7,,,,,,,fee schedule,69.7,295.16,
F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.66,,,,,,,fee schedule,69.7,295.16,
F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.08,,,,,,,fee schedule,69.7,295.16,
F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.27,,,,,,,fee schedule,69.7,295.16,
F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,295.16,,,,,,,fee schedule,69.7,295.16,
F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.04,,,,,,,fee schedule,69.7,295.16,APC
F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.37,,,,,,,fee schedule,69.7,295.16,APC
F5 gene,81241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.07,,,,,,,fee schedule,69.7,295.16,APC
Fancc gene,81242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,34.79,,,,,,,fee schedule,34.79,65.92,
Fancc gene,81242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.45,,,,,,,fee schedule,34.79,65.92,APC
Fancc gene,81242,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.62,,,,,,,fee schedule,34.79,65.92,APC
Fancc gene,81242,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.92,,,,,,,fee schedule,34.79,65.92,APC
Fmr1 gene detection,81243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,54.19,,,,,,,fee schedule,54.19,102.67,
Fmr1 gene detection,81243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.89,,,,,,,fee schedule,54.19,102.67,APC
Fmr1 gene detection,81243,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57.04,,,,,,,fee schedule,54.19,102.67,APC
Fmr1 gene detection,81243,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,102.67,,,,,,,fee schedule,54.19,102.67,APC
Fmr1 gene characterization,81244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,42.65,,,,,,,fee schedule,42.65,80.8,
Fmr1 gene characterization,81244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,47.13,,,,,,,fee schedule,42.65,80.8,APC
Fmr1 gene characterization,81244,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,44.89,,,,,,,fee schedule,42.65,80.8,APC
Fmr1 gene characterization,81244,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,80.8,,,,,,,fee schedule,42.65,80.8,APC
Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,157.23,,,,,,,fee schedule,145.44,297.92,
Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.85,,,,,,,fee schedule,145.44,297.92,
Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.58,,,,,,,fee schedule,145.44,297.92,
Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.44,,,,,,,fee schedule,145.44,297.92,
Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.13,,,,,,,fee schedule,145.44,297.92,
Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.79,,,,,,,fee schedule,145.44,297.92,APC
Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,165.51,,,,,,,fee schedule,145.44,297.92,APC
Flt3 gene,81245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,297.92,,,,,,,fee schedule,145.44,297.92,APC
Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,78.85,,,,,,,fee schedule,72.9,149.4,
Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.2,,,,,,,fee schedule,72.9,149.4,
Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.02,,,,,,,fee schedule,72.9,149.4,
Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.9,,,,,,,fee schedule,72.9,149.4,
Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.88,,,,,,,fee schedule,72.9,149.4,
Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.15,,,,,,,fee schedule,72.9,149.4,APC
Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,83,,,,,,,fee schedule,72.9,149.4,APC
Flt3 gene analysis,81246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,149.4,,,,,,,fee schedule,72.9,149.4,APC
G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
G6pd gene alys cmn variant,81247,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,356.49,,,,,,,fee schedule,167.8,675.45,
G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.95,,,,,,,fee schedule,167.8,675.45,
G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.5,,,,,,,fee schedule,167.8,675.45,
G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.8,,,,,,,fee schedule,167.8,675.45,
G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.34,,,,,,,fee schedule,167.8,675.45,
G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,167.8,675.45,APC
G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,375.25,,,,,,,fee schedule,167.8,675.45,APC
G6pd known familial variant,81248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,675.45,,,,,,,fee schedule,167.8,675.45,APC
G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,570,,,,,,,fee schedule,570,1896.44,
G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1649.08,,,,,,,fee schedule,570,1896.44,
G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1349.77,,,,,,,fee schedule,570,1896.44,
G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1081.14,,,,,,,fee schedule,570,1896.44,
G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1896.44,,,,,,,fee schedule,570,1896.44,
G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,570,1896.44,APC
G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,600,,,,,,,fee schedule,570,1896.44,APC
G6pd full gene sequence,81249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1080,,,,,,,fee schedule,570,1896.44,APC
G6pc gene,81250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,55.57,,,,,,,fee schedule,55.57,105.28,
G6pc gene,81250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.41,,,,,,,fee schedule,55.57,105.28,APC
G6pc gene,81250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.49,,,,,,,fee schedule,55.57,105.28,APC
G6pc gene,81250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.28,,,,,,,fee schedule,55.57,105.28,APC
Gba gene,81251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,44.89,,,,,,,fee schedule,44.89,85.05,
Gba gene,81251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.61,,,,,,,fee schedule,44.89,85.05,APC
Gba gene,81251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.25,,,,,,,fee schedule,44.89,85.05,APC
Gba gene,81251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,85.05,,,,,,,fee schedule,44.89,85.05,APC
Gjb2 gene full sequence,81252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,96.06,,,,,,,fee schedule,96.06,182.02,
Gjb2 gene full sequence,81252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.18,,,,,,,fee schedule,96.06,182.02,APC
Gjb2 gene full sequence,81252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.12,,,,,,,fee schedule,96.06,182.02,APC
Gjb2 gene full sequence,81252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.02,,,,,,,fee schedule,96.06,182.02,APC
Gjb2 gene known fam variants,81253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,58.44,,,,,,,fee schedule,58.44,110.74,
Gjb2 gene known fam variants,81253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.6,,,,,,,fee schedule,58.44,110.74,APC
Gjb2 gene known fam variants,81253,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,61.52,,,,,,,fee schedule,58.44,110.74,APC
Gjb2 gene known fam variants,81253,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,110.74,,,,,,,fee schedule,58.44,110.74,APC
Gjb6 gene com variants,81254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.25,,,,,,,fee schedule,33.25,63,
Gjb6 gene com variants,81254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.75,,,,,,,fee schedule,33.25,63,APC
Gjb6 gene com variants,81254,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35,,,,,,,fee schedule,33.25,63,APC
Gjb6 gene com variants,81254,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63,,,,,,,fee schedule,33.25,63,APC
Hexa gene,81255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.88,,,,,,,fee schedule,48.88,92.61,
Hexa gene,81255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.02,,,,,,,fee schedule,48.88,92.61,APC
Hexa gene,81255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.45,,,,,,,fee schedule,48.88,92.61,APC
Hexa gene,81255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.61,,,,,,,fee schedule,48.88,92.61,APC
Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,62.09,,,,,,,fee schedule,62.09,260.05,
Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.13,,,,,,,fee schedule,62.09,260.05,
Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.09,,,,,,,fee schedule,62.09,260.05,
Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.25,,,,,,,fee schedule,62.09,260.05,
Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.05,,,,,,,fee schedule,62.09,260.05,
Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.63,,,,,,,fee schedule,62.09,260.05,APC
Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.36,,,,,,,fee schedule,62.09,260.05,APC
Hfe gene,81256,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,117.65,,,,,,,fee schedule,62.09,260.05,APC
Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,97.15,,,,,,,fee schedule,97.15,352.41,
Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,306.44,,,,,,,fee schedule,97.15,352.41,
Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,250.82,,,,,,,fee schedule,97.15,352.41,
Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,200.9,,,,,,,fee schedule,97.15,352.41,
Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,352.41,,,,,,,fee schedule,97.15,352.41,
Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.37,,,,,,,fee schedule,97.15,352.41,APC
Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,102.26,,,,,,,fee schedule,97.15,352.41,APC
Hba1/hba2 gene,81257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,184.07,,,,,,,fee schedule,97.15,352.41,APC
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,356.49,,,,,,,fee schedule,167.8,675.45,
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.95,,,,,,,fee schedule,167.8,675.45,
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.5,,,,,,,fee schedule,167.8,675.45,
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.8,,,,,,,fee schedule,167.8,675.45,
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.34,,,,,,,fee schedule,167.8,675.45,
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,167.8,675.45,APC
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,375.25,,,,,,,fee schedule,167.8,675.45,APC
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,675.45,,,,,,,fee schedule,167.8,675.45,APC
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,570,,,,,,,fee schedule,570,1896.44,
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1649.08,,,,,,,fee schedule,570,1896.44,
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1349.77,,,,,,,fee schedule,570,1896.44,
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1081.14,,,,,,,fee schedule,570,1896.44,
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1896.44,,,,,,,fee schedule,570,1896.44,
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,570,1896.44,APC
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,600,,,,,,,fee schedule,570,1896.44,APC
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1080,,,,,,,fee schedule,570,1896.44,APC
Ikbkap gene,81260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.34,,,,,,,fee schedule,37.34,70.76,
Ikbkap gene,81260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.28,,,,,,,fee schedule,37.34,70.76,APC
Ikbkap gene,81260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.31,,,,,,,fee schedule,37.34,70.76,APC
Ikbkap gene,81260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.76,,,,,,,fee schedule,37.34,70.76,APC
Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,188.09,,,,,,,fee schedule,188.09,852.74,
Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,741.51,,,,,,,fee schedule,188.09,852.74,
Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,606.93,,,,,,,fee schedule,188.09,852.74,
Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,486.13,,,,,,,fee schedule,188.09,852.74,
Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,852.74,,,,,,,fee schedule,188.09,852.74,
Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.89,,,,,,,fee schedule,188.09,852.74,APC
Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,197.99,,,,,,,fee schedule,188.09,852.74,APC
Igh gene rearrange amp meth,81261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,356.38,,,,,,,fee schedule,188.09,852.74,APC
Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,65.12,,,,,,,fee schedule,65.12,188,
Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.48,,,,,,,fee schedule,65.12,188,
Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.81,,,,,,,fee schedule,65.12,188,
Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.18,,,,,,,fee schedule,65.12,188,
Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188,,,,,,,fee schedule,65.12,188,
Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,71.98,,,,,,,fee schedule,65.12,188,APC
Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,68.55,,,,,,,fee schedule,65.12,188,APC
Igh gene rearrang dir probe,81262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,123.39,,,,,,,fee schedule,65.12,188,APC
Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,279.79,,,,,,,fee schedule,279.79,1268.46,
Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.01,,,,,,,fee schedule,279.79,1268.46,
Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,902.81,,,,,,,fee schedule,279.79,1268.46,
Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,723.13,,,,,,,fee schedule,279.79,1268.46,
Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1268.46,,,,,,,fee schedule,279.79,1268.46,
Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,309.25,,,,,,,fee schedule,279.79,1268.46,APC
Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,294.52,,,,,,,fee schedule,279.79,1268.46,APC
Igh vari regional mutation,81263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,530.14,,,,,,,fee schedule,279.79,1268.46,APC
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,164.09,,,,,,,fee schedule,164.09,643.13,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,559.24,,,,,,,fee schedule,164.09,643.13,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,457.74,,,,,,,fee schedule,164.09,643.13,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,366.64,,,,,,,fee schedule,164.09,643.13,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,643.13,,,,,,,fee schedule,164.09,643.13,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.37,,,,,,,fee schedule,164.09,643.13,APC
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,172.73,,,,,,,fee schedule,164.09,643.13,APC
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,310.91,,,,,,,fee schedule,164.09,643.13,APC
Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,221.42,,,,,,,fee schedule,221.42,1791.24,
Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1557.6,,,,,,,fee schedule,221.42,1791.24,
Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1274.9,,,,,,,fee schedule,221.42,1791.24,
Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1021.16,,,,,,,fee schedule,221.42,1791.24,
Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1791.24,,,,,,,fee schedule,221.42,1791.24,
Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.72,,,,,,,fee schedule,221.42,1791.24,APC
Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,233.07,,,,,,,fee schedule,221.42,1791.24,APC
Str markers specimen anal,81265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,419.53,,,,,,,fee schedule,221.42,1791.24,APC
Str markers spec anal addl,81266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,289.57,,,,,,,fee schedule,289.57,548.66,
Str markers spec anal addl,81266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,320.05,,,,,,,fee schedule,289.57,548.66,APC
Str markers spec anal addl,81266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,304.81,,,,,,,fee schedule,289.57,548.66,APC
Str markers spec anal addl,81266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,548.66,,,,,,,fee schedule,289.57,548.66,APC
Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,197.09,,,,,,,fee schedule,197.09,850.09,
Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,739.21,,,,,,,fee schedule,197.09,850.09,
Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,605.04,,,,,,,fee schedule,197.09,850.09,
Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,484.63,,,,,,,fee schedule,197.09,850.09,
Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,850.09,,,,,,,fee schedule,197.09,850.09,
Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.83,,,,,,,fee schedule,197.09,850.09,APC
Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,207.46,,,,,,,fee schedule,197.09,850.09,APC
Chimerism anal no cell selec,81267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,373.43,,,,,,,fee schedule,197.09,850.09,APC
Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,247.75,,,,,,,fee schedule,247.75,909.32,
Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,790.71,,,,,,,fee schedule,247.75,909.32,
Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,647.2,,,,,,,fee schedule,247.75,909.32,
Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,518.39,,,,,,,fee schedule,247.75,909.32,
Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,909.32,,,,,,,fee schedule,247.75,909.32,
Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.83,,,,,,,fee schedule,247.75,909.32,APC
Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.79,,,,,,,fee schedule,247.75,909.32,APC
Chimerism anal w/cell select,81268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,469.42,,,,,,,fee schedule,247.75,909.32,APC
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,192.28,,,,,,,fee schedule,192.28,601.97,
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.45,,,,,,,fee schedule,192.28,601.97,
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,428.44,,,,,,,fee schedule,192.28,601.97,
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.17,,,,,,,fee schedule,192.28,601.97,
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,601.97,,,,,,,fee schedule,192.28,601.97,
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,212.52,,,,,,,fee schedule,192.28,601.97,APC
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,202.4,,,,,,,fee schedule,192.28,601.97,APC
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,364.32,,,,,,,fee schedule,192.28,601.97,APC
Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,87.08,,,,,,,fee schedule,87.08,298.29,
Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.38,,,,,,,fee schedule,87.08,298.29,
Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.3,,,,,,,fee schedule,87.08,298.29,
Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.05,,,,,,,fee schedule,87.08,298.29,
Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.29,,,,,,,fee schedule,87.08,298.29,
Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.24,,,,,,,fee schedule,87.08,298.29,APC
Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,91.66,,,,,,,fee schedule,87.08,298.29,APC
Jak2 gene,81270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,164.99,,,,,,,fee schedule,87.08,298.29,APC
Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Htt gene detc abnor alleles,81271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,313.03,,,,,,,fee schedule,313.03,593.12,
Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,504.16,,,,,,,fee schedule,313.03,593.12,
Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,412.65,,,,,,,fee schedule,313.03,593.12,
Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,330.53,,,,,,,fee schedule,313.03,593.12,
Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,579.78,,,,,,,fee schedule,313.03,593.12,
Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.99,,,,,,,fee schedule,313.03,593.12,APC
Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.51,,,,,,,fee schedule,313.03,593.12,APC
Kit gene targeted seq analys,81272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,593.12,,,,,,,fee schedule,313.03,593.12,APC
Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,118.63,,,,,,,fee schedule,118.63,620.21,
Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,539.31,,,,,,,fee schedule,118.63,620.21,
Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,441.43,,,,,,,fee schedule,118.63,620.21,
Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,353.57,,,,,,,fee schedule,118.63,620.21,
Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,620.21,,,,,,,fee schedule,118.63,620.21,
Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.11,,,,,,,fee schedule,118.63,620.21,APC
Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124.87,,,,,,,fee schedule,118.63,620.21,APC
Kit gene analys d816 variant,81273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,224.77,,,,,,,fee schedule,118.63,620.21,APC
Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,261.09,,,,,,,fee schedule,261.09,829.73,
Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,721.5,,,,,,,fee schedule,261.09,829.73,
Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,590.55,,,,,,,fee schedule,261.09,829.73,
Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.02,,,,,,,fee schedule,261.09,829.73,
Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,829.73,,,,,,,fee schedule,261.09,829.73,
Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,261.09,829.73,APC
Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,261.09,829.73,APC
Htt gene charac alleles,81274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,261.09,829.73,APC
Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,183.59,,,,,,,fee schedule,170.06,347.85,
Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.4,,,,,,,fee schedule,170.06,347.85,
Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.32,,,,,,,fee schedule,170.06,347.85,
Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.06,,,,,,,fee schedule,170.06,347.85,
Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.31,,,,,,,fee schedule,170.06,347.85,
Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,170.06,347.85,APC
Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,193.25,,,,,,,fee schedule,170.06,347.85,APC
Kras gene variants exon 2,81275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,347.85,,,,,,,fee schedule,170.06,347.85,APC
Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,183.59,,,,,,,fee schedule,183.59,347.85,
Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,294.04,,,,,,,fee schedule,183.59,347.85,
Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,240.67,,,,,,,fee schedule,183.59,347.85,
Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.77,,,,,,,fee schedule,183.59,347.85,
Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,338.15,,,,,,,fee schedule,183.59,347.85,
Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,183.59,347.85,APC
Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,193.25,,,,,,,fee schedule,183.59,347.85,APC
Kras gene addl variants,81276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,347.85,,,,,,,fee schedule,183.59,347.85,APC
Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1102,,,,,,,fee schedule,1102,2591.57,
Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2253.54,,,,,,,fee schedule,1102,2591.57,
Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1844.52,,,,,,,fee schedule,1102,2591.57,
Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1477.42,,,,,,,fee schedule,1102,2591.57,
Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2591.57,,,,,,,fee schedule,1102,2591.57,
Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1102,2591.57,APC
Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1160,,,,,,,fee schedule,1102,2591.57,APC
Cytogenomic neo microra alys,81277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2088,,,,,,,fee schedule,1102,2591.57,APC
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,196.94,,,,,,,fee schedule,196.94,463.17,
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,402.76,,,,,,,fee schedule,196.94,463.17,
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,329.66,,,,,,,fee schedule,196.94,463.17,
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.05,,,,,,,fee schedule,196.94,463.17,
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,463.17,,,,,,,fee schedule,196.94,463.17,
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,196.94,463.17,APC
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,207.31,,,,,,,fee schedule,196.94,463.17,APC
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,373.16,,,,,,,fee schedule,196.94,463.17,APC
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,413.76,
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.79,,,,,,,fee schedule,175.94,413.76,
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.49,,,,,,,fee schedule,175.94,413.76,
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.88,,,,,,,fee schedule,175.94,413.76,
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.76,,,,,,,fee schedule,175.94,413.76,
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,413.76,APC
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,413.76,APC
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,413.76,APC
Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,69.7,,,,,,,fee schedule,69.7,263.19,
Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.86,,,,,,,fee schedule,69.7,263.19,
Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.32,,,,,,,fee schedule,69.7,263.19,
Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.04,,,,,,,fee schedule,69.7,263.19,
Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.19,,,,,,,fee schedule,69.7,263.19,
Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.04,,,,,,,fee schedule,69.7,263.19,APC
Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.37,,,,,,,fee schedule,69.7,263.19,APC
Ifnl3 gene,81283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.07,,,,,,,fee schedule,69.7,263.19,APC
Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Fxn gene detc abnor alleles,81284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,261.09,,,,,,,fee schedule,261.09,829.73,
Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,721.5,,,,,,,fee schedule,261.09,829.73,
Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,590.55,,,,,,,fee schedule,261.09,829.73,
Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.02,,,,,,,fee schedule,261.09,829.73,
Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,829.73,,,,,,,fee schedule,261.09,829.73,
Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,261.09,829.73,APC
Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,261.09,829.73,APC
Fxn gene charac alleles,81285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,261.09,829.73,APC
Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,261.09,,,,,,,fee schedule,261.09,829.73,
Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,721.5,,,,,,,fee schedule,261.09,829.73,
Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,590.55,,,,,,,fee schedule,261.09,829.73,
Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.02,,,,,,,fee schedule,261.09,829.73,
Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,829.73,,,,,,,fee schedule,261.09,829.73,
Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,261.09,829.73,APC
Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,261.09,829.73,APC
Fxn gene full gene sequence,81286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,261.09,829.73,APC
Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,118.41,,,,,,,fee schedule,118.41,496.09,
Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.38,,,,,,,fee schedule,118.41,496.09,
Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.08,,,,,,,fee schedule,118.41,496.09,
Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,282.81,,,,,,,fee schedule,118.41,496.09,
Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.09,,,,,,,fee schedule,118.41,496.09,
Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.87,,,,,,,fee schedule,118.41,496.09,APC
Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124.64,,,,,,,fee schedule,118.41,496.09,APC
Mgmt gene methylation anal,81287,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,224.35,,,,,,,fee schedule,118.41,496.09,APC
Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,182.7,,,,,,,fee schedule,182.7,463.78,
Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,403.29,,,,,,,fee schedule,182.7,463.78,
Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,330.09,,,,,,,fee schedule,182.7,463.78,
Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.4,,,,,,,fee schedule,182.7,463.78,
Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,463.78,,,,,,,fee schedule,182.7,463.78,
Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.94,,,,,,,fee schedule,182.7,463.78,APC
Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,192.32,,,,,,,fee schedule,182.7,463.78,APC
Mlh1 gene,81288,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,346.18,,,,,,,fee schedule,182.7,463.78,APC
Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,559.14,
Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,486.21,,,,,,,fee schedule,175.94,559.14,
Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.96,,,,,,,fee schedule,175.94,559.14,
Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.76,,,,,,,fee schedule,175.94,559.14,
Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,559.14,,,,,,,fee schedule,175.94,559.14,
Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,559.14,APC
Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,559.14,APC
Fxn gene known famil variant,81289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,559.14,APC
Mcoln1 gene,81290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.34,,,,,,,fee schedule,37.34,70.76,
Mcoln1 gene,81290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.28,,,,,,,fee schedule,37.34,70.76,APC
Mcoln1 gene,81290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.31,,,,,,,fee schedule,37.34,70.76,APC
Mcoln1 gene,81290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.76,,,,,,,fee schedule,37.34,70.76,APC
Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,62.07,,,,,,,fee schedule,62.07,295.16,
Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.66,,,,,,,fee schedule,62.07,295.16,
Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.08,,,,,,,fee schedule,62.07,295.16,
Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.27,,,,,,,fee schedule,62.07,295.16,
Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,295.16,,,,,,,fee schedule,62.07,295.16,
Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.61,,,,,,,fee schedule,62.07,295.16,APC
Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.34,,,,,,,fee schedule,62.07,295.16,APC
Mthfr gene,81291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,117.61,,,,,,,fee schedule,62.07,295.16,APC
Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,641.63,,,,,,,fee schedule,641.63,2040.16,
Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1774.05,,,,,,,fee schedule,641.63,2040.16,
Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1452.06,,,,,,,fee schedule,641.63,2040.16,
Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1163.07,,,,,,,fee schedule,641.63,2040.16,
Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2040.16,,,,,,,fee schedule,641.63,2040.16,
Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,709.17,,,,,,,fee schedule,641.63,2040.16,APC
Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,675.4,,,,,,,fee schedule,641.63,2040.16,APC
Mlh1 gene full seq,81292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1215.72,,,,,,,fee schedule,641.63,2040.16,APC
Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,314.45,,,,,,,fee schedule,314.45,817.85,
Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,711.17,,,,,,,fee schedule,314.45,817.85,
Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,582.09,,,,,,,fee schedule,314.45,817.85,
Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,466.24,,,,,,,fee schedule,314.45,817.85,
Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,817.85,,,,,,,fee schedule,314.45,817.85,
Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,347.55,,,,,,,fee schedule,314.45,817.85,APC
Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,331,,,,,,,fee schedule,314.45,817.85,APC
Mlh1 gene known variants,81293,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,595.8,,,,,,,fee schedule,314.45,817.85,APC
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,192.28,,,,,,,fee schedule,192.28,601.97,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.45,,,,,,,fee schedule,192.28,601.97,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,428.44,,,,,,,fee schedule,192.28,601.97,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.17,,,,,,,fee schedule,192.28,601.97,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,601.97,,,,,,,fee schedule,192.28,601.97,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,212.52,,,,,,,fee schedule,192.28,601.97,APC
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,202.4,,,,,,,fee schedule,192.28,601.97,APC
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,364.32,,,,,,,fee schedule,192.28,601.97,APC
Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,362.62,,,,,,,fee schedule,273.03,687.06,
Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,416.46,,,,,,,fee schedule,273.03,687.06,
Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,340.87,,,,,,,fee schedule,273.03,687.06,
Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.03,,,,,,,fee schedule,273.03,687.06,
Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,478.93,,,,,,,fee schedule,273.03,687.06,
Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,400.78,,,,,,,fee schedule,273.03,687.06,APC
Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,381.7,,,,,,,fee schedule,273.03,687.06,APC
Msh2 gene full seq,81295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,687.06,,,,,,,fee schedule,273.03,687.06,APC
Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,320.84,,,,,,,fee schedule,233.14,607.91,
Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,355.61,,,,,,,fee schedule,233.14,607.91,
Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.07,,,,,,,fee schedule,233.14,607.91,
Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.14,,,,,,,fee schedule,233.14,607.91,
Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,408.95,,,,,,,fee schedule,233.14,607.91,
Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,354.62,,,,,,,fee schedule,233.14,607.91,APC
Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,337.73,,,,,,,fee schedule,233.14,607.91,APC
Msh2 gene known variants,81296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,607.91,,,,,,,fee schedule,233.14,607.91,APC
Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,202.64,,,,,,,fee schedule,202.64,478.93,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,416.46,,,,,,,fee schedule,202.64,478.93,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,340.87,,,,,,,fee schedule,202.64,478.93,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.03,,,,,,,fee schedule,202.64,478.93,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,478.93,,,,,,,fee schedule,202.64,478.93,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,223.96,,,,,,,fee schedule,202.64,478.93,APC
Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,213.3,,,,,,,fee schedule,202.64,478.93,APC
Msh2 gene dup/delete variant,81297,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,383.94,,,,,,,fee schedule,202.64,478.93,APC
Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,609.76,,,,,,,fee schedule,518.03,1155.33,
Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,790.16,,,,,,,fee schedule,518.03,1155.33,
Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.75,,,,,,,fee schedule,518.03,1155.33,
Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,518.03,,,,,,,fee schedule,518.03,1155.33,
Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,908.68,,,,,,,fee schedule,518.03,1155.33,
Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,673.94,,,,,,,fee schedule,518.03,1155.33,APC
Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,641.85,,,,,,,fee schedule,518.03,1155.33,APC
Msh6 gene full seq,81298,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1155.33,,,,,,,fee schedule,518.03,1155.33,APC
Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,292.6,,,,,,,fee schedule,290.21,554.4,
Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,442.66,,,,,,,fee schedule,290.21,554.4,
Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,362.32,,,,,,,fee schedule,290.21,554.4,
Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,290.21,,,,,,,fee schedule,290.21,554.4,
Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,509.06,,,,,,,fee schedule,290.21,554.4,
Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,323.4,,,,,,,fee schedule,290.21,554.4,APC
Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,308,,,,,,,fee schedule,290.21,554.4,APC
Msh6 gene known variants,81299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,554.4,,,,,,,fee schedule,290.21,554.4,APC
Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,226.1,,,,,,,fee schedule,226.1,510.44,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,443.86,,,,,,,fee schedule,226.1,510.44,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,363.3,,,,,,,fee schedule,226.1,510.44,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,290.99,,,,,,,fee schedule,226.1,510.44,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,510.44,,,,,,,fee schedule,226.1,510.44,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.9,,,,,,,fee schedule,226.1,510.44,APC
Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,238,,,,,,,fee schedule,226.1,510.44,APC
Msh6 gene dup/delete variant,81300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,428.4,,,,,,,fee schedule,226.1,510.44,APC
Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,331.13,,,,,,,fee schedule,138.25,627.41,
Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,210.87,,,,,,,fee schedule,138.25,627.41,
Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,172.6,,,,,,,fee schedule,138.25,627.41,
Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.25,,,,,,,fee schedule,138.25,627.41,
Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,242.5,,,,,,,fee schedule,138.25,627.41,
Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365.99,,,,,,,fee schedule,138.25,627.41,APC
Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,348.56,,,,,,,fee schedule,138.25,627.41,APC
Microsatellite instability,81301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,627.41,,,,,,,fee schedule,138.25,627.41,APC
Mecp2 gene full seq,81302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,501.48,,,,,,,fee schedule,501.48,950.17,
Mecp2 gene full seq,81302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,554.26,,,,,,,fee schedule,501.48,950.17,APC
Mecp2 gene full seq,81302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,527.87,,,,,,,fee schedule,501.48,950.17,APC
Mecp2 gene full seq,81302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,950.17,,,,,,,fee schedule,501.48,950.17,APC
Mecp2 gene known variant,81303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,114,,,,,,,fee schedule,114,216,
Mecp2 gene known variant,81303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,126,,,,,,,fee schedule,114,216,APC
Mecp2 gene known variant,81303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,120,,,,,,,fee schedule,114,216,APC
Mecp2 gene known variant,81303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,216,,,,,,,fee schedule,114,216,APC
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,142.5,,,,,,,fee schedule,142.5,270,
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.5,,,,,,,fee schedule,142.5,270,APC
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150,,,,,,,fee schedule,142.5,270,APC
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270,,,,,,,fee schedule,142.5,270,APC
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.63,,,,,,,fee schedule,166.63,529.53,
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,460.46,,,,,,,fee schedule,166.63,529.53,
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,376.89,,,,,,,fee schedule,166.63,529.53,
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,301.88,,,,,,,fee schedule,166.63,529.53,
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,529.53,,,,,,,fee schedule,166.63,529.53,
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,166.63,529.53,APC
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,175.4,,,,,,,fee schedule,166.63,529.53,APC
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,315.72,,,,,,,fee schedule,166.63,529.53,APC
Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,276.79,,,,,,,fee schedule,276.79,879.62,
Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,764.89,,,,,,,fee schedule,276.79,879.62,
Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,626.06,,,,,,,fee schedule,276.79,879.62,
Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,501.46,,,,,,,fee schedule,276.79,879.62,
Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,879.62,,,,,,,fee schedule,276.79,879.62,
Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,305.93,,,,,,,fee schedule,276.79,879.62,APC
Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,291.36,,,,,,,fee schedule,276.79,879.62,APC
Nudt15 gene common variants,81306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,524.45,,,,,,,fee schedule,276.79,879.62,APC
Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,642.68,,,,,,,fee schedule,360.29,1217.7,
Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,549.56,,,,,,,fee schedule,360.29,1217.7,
Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,449.81,,,,,,,fee schedule,360.29,1217.7,
Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,360.29,,,,,,,fee schedule,360.29,1217.7,
Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,631.99,,,,,,,fee schedule,360.29,1217.7,
Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.32,,,,,,,fee schedule,360.29,1217.7,APC
Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,676.5,,,,,,,fee schedule,360.29,1217.7,APC
Palb2 gene full gene seq,81307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1217.7,,,,,,,fee schedule,360.29,1217.7,APC
Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,286.28,,,,,,,fee schedule,286.28,673.26,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,585.44,,,,,,,fee schedule,286.28,673.26,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,479.18,,,,,,,fee schedule,286.28,673.26,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,383.81,,,,,,,fee schedule,286.28,673.26,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,673.26,,,,,,,fee schedule,286.28,673.26,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,286.28,673.26,APC
Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,301.35,,,,,,,fee schedule,286.28,673.26,APC
Palb2 gene known famil vrnt,81308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,542.43,,,,,,,fee schedule,286.28,673.26,APC
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,261.09,,,,,,,fee schedule,261.09,614.02,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,533.93,,,,,,,fee schedule,261.09,614.02,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.02,,,,,,,fee schedule,261.09,614.02,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.04,,,,,,,fee schedule,261.09,614.02,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.02,,,,,,,fee schedule,261.09,614.02,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,261.09,614.02,APC
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,261.09,614.02,APC
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,261.09,614.02,APC
Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,234.19,,,,,,,fee schedule,234.19,476.82,
Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,414.63,,,,,,,fee schedule,234.19,476.82,
Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,339.37,,,,,,,fee schedule,234.19,476.82,
Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,271.83,,,,,,,fee schedule,234.19,476.82,
Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,476.82,,,,,,,fee schedule,234.19,476.82,
Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.85,,,,,,,fee schedule,234.19,476.82,APC
Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.52,,,,,,,fee schedule,234.19,476.82,APC
Npm1 gene,81310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,443.74,,,,,,,fee schedule,234.19,476.82,APC
Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,281,,,,,,,fee schedule,281,532.42,
Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.3,,,,,,,fee schedule,281,532.42,
Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.3,,,,,,,fee schedule,281,532.42,
Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.81,,,,,,,fee schedule,281,532.42,
Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,525.9,,,,,,,fee schedule,281,532.42,
Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,310.58,,,,,,,fee schedule,281,532.42,APC
Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,295.79,,,,,,,fee schedule,281,532.42,APC
Nras gene variants exon 2&3,81311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,532.42,,,,,,,fee schedule,281,532.42,APC
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,242.3,,,,,,,fee schedule,242.3,822.87,
Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,715.54,,,,,,,fee schedule,242.3,822.87,
Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,585.67,,,,,,,fee schedule,242.3,822.87,
Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,469.11,,,,,,,fee schedule,242.3,822.87,
Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,822.87,,,,,,,fee schedule,242.3,822.87,
Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,267.8,,,,,,,fee schedule,242.3,822.87,APC
Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,255.05,,,,,,,fee schedule,242.3,822.87,APC
Pca3/klk3 antigen,81313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,459.09,,,,,,,fee schedule,242.3,822.87,APC
Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,313.03,,,,,,,fee schedule,313.03,1041.84,
Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,905.95,,,,,,,fee schedule,313.03,1041.84,
Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,741.52,,,,,,,fee schedule,313.03,1041.84,
Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,593.94,,,,,,,fee schedule,313.03,1041.84,
Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1041.84,,,,,,,fee schedule,313.03,1041.84,
Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.99,,,,,,,fee schedule,313.03,1041.84,APC
Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.51,,,,,,,fee schedule,313.03,1041.84,APC
Pdgfra gene,81314,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,593.12,,,,,,,fee schedule,313.03,1041.84,APC
Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,196.94,,,,,,,fee schedule,196.94,468.25,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.17,,,,,,,fee schedule,196.94,468.25,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.27,,,,,,,fee schedule,196.94,468.25,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.94,,,,,,,fee schedule,196.94,468.25,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.25,,,,,,,fee schedule,196.94,468.25,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,196.94,468.25,APC
Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,207.31,,,,,,,fee schedule,196.94,468.25,APC
Pml/raralpha com breakpoints,81315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,373.16,,,,,,,fee schedule,196.94,468.25,APC
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,196.94,,,,,,,fee schedule,196.94,1361.9,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1184.26,,,,,,,fee schedule,196.94,1361.9,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,969.32,,,,,,,fee schedule,196.94,1361.9,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,776.4,,,,,,,fee schedule,196.94,1361.9,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1361.9,,,,,,,fee schedule,196.94,1361.9,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,196.94,1361.9,APC
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,207.31,,,,,,,fee schedule,196.94,1361.9,APC
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,373.16,,,,,,,fee schedule,196.94,1361.9,APC
Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,642.68,,,,,,,fee schedule,642.68,2466.55,
Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2144.83,,,,,,,fee schedule,642.68,2466.55,
Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1755.54,,,,,,,fee schedule,642.68,2466.55,
Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1406.15,,,,,,,fee schedule,642.68,2466.55,
Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2466.55,,,,,,,fee schedule,642.68,2466.55,
Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.32,,,,,,,fee schedule,642.68,2466.55,APC
Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,676.5,,,,,,,fee schedule,642.68,2466.55,APC
Pms2 gene full seq analysis,81317,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1217.7,,,,,,,fee schedule,642.68,2466.55,APC
Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,314.45,,,,,,,fee schedule,314.45,595.8,
Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,506.8,,,,,,,fee schedule,314.45,595.8,
Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,414.82,,,,,,,fee schedule,314.45,595.8,
Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.26,,,,,,,fee schedule,314.45,595.8,
Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,582.82,,,,,,,fee schedule,314.45,595.8,
Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,347.55,,,,,,,fee schedule,314.45,595.8,APC
Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,331,,,,,,,fee schedule,314.45,595.8,APC
Pms2 known familial variants,81318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,595.8,,,,,,,fee schedule,314.45,595.8,APC
Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,193.33,,,,,,,fee schedule,193.33,699.81,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,608.53,,,,,,,fee schedule,193.33,699.81,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,498.08,,,,,,,fee schedule,193.33,699.81,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,398.95,,,,,,,fee schedule,193.33,699.81,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,699.81,,,,,,,fee schedule,193.33,699.81,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,213.68,,,,,,,fee schedule,193.33,699.81,APC
Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,203.5,,,,,,,fee schedule,193.33,699.81,APC
Pms2 gene dup/delet variants,81319,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,366.3,,,,,,,fee schedule,193.33,699.81,APC
Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,276.79,,,,,,,fee schedule,276.79,879.62,
Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,764.89,,,,,,,fee schedule,276.79,879.62,
Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,626.06,,,,,,,fee schedule,276.79,879.62,
Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,501.46,,,,,,,fee schedule,276.79,879.62,
Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,879.62,,,,,,,fee schedule,276.79,879.62,
Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,305.93,,,,,,,fee schedule,276.79,879.62,APC
Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,291.36,,,,,,,fee schedule,276.79,879.62,APC
Plcg2 gene common variants,81320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,524.45,,,,,,,fee schedule,276.79,879.62,APC
Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,570,,,,,,,fee schedule,570,1896.44,
Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1649.08,,,,,,,fee schedule,570,1896.44,
Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1349.77,,,,,,,fee schedule,570,1896.44,
Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1081.14,,,,,,,fee schedule,570,1896.44,
Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1896.44,,,,,,,fee schedule,570,1896.44,
Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,570,1896.44,APC
Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,600,,,,,,,fee schedule,570,1896.44,APC
Pten gene full sequence,81321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1080,,,,,,,fee schedule,570,1896.44,APC
Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,44.27,,,,,,,fee schedule,44.27,184.37,
Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.32,,,,,,,fee schedule,44.27,184.37,
Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.22,,,,,,,fee schedule,44.27,184.37,
Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.11,,,,,,,fee schedule,44.27,184.37,
Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.37,,,,,,,fee schedule,44.27,184.37,
Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.93,,,,,,,fee schedule,44.27,184.37,APC
Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.6,,,,,,,fee schedule,44.27,184.37,APC
Pten gene known fam variant,81322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.88,,,,,,,fee schedule,44.27,184.37,APC
Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,285,,,,,,,fee schedule,157.67,540,
Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,240.49,,,,,,,fee schedule,157.67,540,
Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,196.84,,,,,,,fee schedule,157.67,540,
Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,157.67,,,,,,,fee schedule,157.67,540,
Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,276.56,,,,,,,fee schedule,157.67,540,
Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315,,,,,,,fee schedule,157.67,540,APC
Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,300,,,,,,,fee schedule,157.67,540,APC
Pten gene dup/delet variant,81323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,540,,,,,,,fee schedule,157.67,540,APC
Pmp22 gene dup/delet,81324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,720.44,,,,,,,fee schedule,720.44,1365.05,
Pmp22 gene dup/delet,81324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,796.28,,,,,,,fee schedule,720.44,1365.05,APC
Pmp22 gene dup/delet,81324,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,758.36,,,,,,,fee schedule,720.44,1365.05,APC
Pmp22 gene dup/delet,81324,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1365.05,,,,,,,fee schedule,720.44,1365.05,APC
Pmp22 gene full sequence,81325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,731.1,,,,,,,fee schedule,731.1,1385.24,
Pmp22 gene full sequence,81325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,808.06,,,,,,,fee schedule,731.1,1385.24,APC
Pmp22 gene full sequence,81325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,769.58,,,,,,,fee schedule,731.1,1385.24,APC
Pmp22 gene full sequence,81325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1385.24,,,,,,,fee schedule,731.1,1385.24,APC
Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,44.27,,,,,,,fee schedule,44.27,294.96,
Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.49,,,,,,,fee schedule,44.27,294.96,
Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.94,,,,,,,fee schedule,44.27,294.96,
Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.15,,,,,,,fee schedule,44.27,294.96,
Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.96,,,,,,,fee schedule,44.27,294.96,
Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.93,,,,,,,fee schedule,44.27,294.96,APC
Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.6,,,,,,,fee schedule,44.27,294.96,APC
Pmp22 gene known fam variant,81326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.88,,,,,,,fee schedule,44.27,294.96,APC
Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,182.4,,,,,,,fee schedule,149.75,345.6,
Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.42,,,,,,,fee schedule,149.75,345.6,
Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.96,,,,,,,fee schedule,149.75,345.6,
Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.75,,,,,,,fee schedule,149.75,345.6,
Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,262.68,,,,,,,fee schedule,149.75,345.6,
Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.6,,,,,,,fee schedule,149.75,345.6,APC
Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,192,,,,,,,fee schedule,149.75,345.6,APC
Sept9 methylation analysis,81327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,345.6,,,,,,,fee schedule,149.75,345.6,APC
Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
Slco1b1 gene com variants,81328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Smpd1 gene common variants,81330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,44.65,,,,,,,fee schedule,44.65,84.6,
Smpd1 gene common variants,81330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.35,,,,,,,fee schedule,44.65,84.6,APC
Smpd1 gene common variants,81330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47,,,,,,,fee schedule,44.65,84.6,APC
Smpd1 gene common variants,81330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84.6,,,,,,,fee schedule,44.65,84.6,APC
Snrpn/ube3a gene,81331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.52,,,,,,,fee schedule,48.52,91.93,
Snrpn/ube3a gene,81331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.62,,,,,,,fee schedule,48.52,91.93,APC
Snrpn/ube3a gene,81331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.07,,,,,,,fee schedule,48.52,91.93,APC
Snrpn/ube3a gene,81331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,91.93,,,,,,,fee schedule,48.52,91.93,APC
Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,41.47,,,,,,,fee schedule,41.47,188,
Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.48,,,,,,,fee schedule,41.47,188,
Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.81,,,,,,,fee schedule,41.47,188,
Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.18,,,,,,,fee schedule,41.47,188,
Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188,,,,,,,fee schedule,41.47,188,
Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.83,,,,,,,fee schedule,41.47,188,APC
Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.65,,,,,,,fee schedule,41.47,188,APC
Serpina1 gene,81332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78.57,,,,,,,fee schedule,41.47,188,APC
Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Tgfbi gene common variants,81333,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,313.03,,,,,,,fee schedule,313.03,1041.84,
Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,905.95,,,,,,,fee schedule,313.03,1041.84,
Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,741.52,,,,,,,fee schedule,313.03,1041.84,
Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,593.94,,,,,,,fee schedule,313.03,1041.84,
Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1041.84,,,,,,,fee schedule,313.03,1041.84,
Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.99,,,,,,,fee schedule,313.03,1041.84,APC
Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.51,,,,,,,fee schedule,313.03,1041.84,APC
Runx1 gene targeted seq alys,81334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,593.12,,,,,,,fee schedule,313.03,1041.84,APC
Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
Tpmt gene com variants,81335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,286.28,,,,,,,fee schedule,286.28,909.79,
Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,791.12,,,,,,,fee schedule,286.28,909.79,
Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,647.53,,,,,,,fee schedule,286.28,909.79,
Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,518.66,,,,,,,fee schedule,286.28,909.79,
Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,909.79,,,,,,,fee schedule,286.28,909.79,
Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,286.28,909.79,APC
Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,301.35,,,,,,,fee schedule,286.28,909.79,APC
Smn1 gene full gene sequence,81336,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,542.43,,,,,,,fee schedule,286.28,909.79,APC
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,559.14,
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,486.21,,,,,,,fee schedule,175.94,559.14,
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.96,,,,,,,fee schedule,175.94,559.14,
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.76,,,,,,,fee schedule,175.94,559.14,
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,559.14,,,,,,,fee schedule,175.94,559.14,
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,559.14,APC
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,559.14,APC
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,559.14,APC
Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,142.81,,,,,,,fee schedule,142.81,335.86,
Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.05,,,,,,,fee schedule,142.81,335.86,
Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.04,,,,,,,fee schedule,142.81,335.86,
Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.47,,,,,,,fee schedule,142.81,335.86,
Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.86,,,,,,,fee schedule,142.81,335.86,
Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.85,,,,,,,fee schedule,142.81,335.86,APC
Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150.33,,,,,,,fee schedule,142.81,335.86,APC
Mpl gene common variants,81338,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270.59,,,,,,,fee schedule,142.81,335.86,APC
Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,413.76,
Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.79,,,,,,,fee schedule,175.94,413.76,
Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.49,,,,,,,fee schedule,175.94,413.76,
Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.88,,,,,,,fee schedule,175.94,413.76,
Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.76,,,,,,,fee schedule,175.94,413.76,
Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,413.76,APC
Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,413.76,APC
Mpl gene seq alys exon 10,81339,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,413.76,APC
Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,198.47,,,,,,,fee schedule,198.47,899.79,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,782.43,,,,,,,fee schedule,198.47,899.79,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,640.42,,,,,,,fee schedule,198.47,899.79,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,512.96,,,,,,,fee schedule,198.47,899.79,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,899.79,,,,,,,fee schedule,198.47,899.79,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,219.37,,,,,,,fee schedule,198.47,899.79,APC
Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,208.92,,,,,,,fee schedule,198.47,899.79,APC
Trb@ gene rearrange amplify,81340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,376.06,,,,,,,fee schedule,198.47,899.79,APC
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,47.11,,,,,,,fee schedule,47.11,213.54,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,185.69,,,,,,,fee schedule,47.11,213.54,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.99,,,,,,,fee schedule,47.11,213.54,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.74,,,,,,,fee schedule,47.11,213.54,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,213.54,,,,,,,fee schedule,47.11,213.54,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.07,,,,,,,fee schedule,47.11,213.54,APC
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.59,,,,,,,fee schedule,47.11,213.54,APC
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,89.26,,,,,,,fee schedule,47.11,213.54,APC
Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,191.43,,,,,,,fee schedule,191.43,485.97,
Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,422.58,,,,,,,fee schedule,191.43,485.97,
Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,345.88,,,,,,,fee schedule,191.43,485.97,
Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.04,,,,,,,fee schedule,191.43,485.97,
Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,485.97,,,,,,,fee schedule,191.43,485.97,
Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.58,,,,,,,fee schedule,191.43,485.97,APC
Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.5,,,,,,,fee schedule,191.43,485.97,APC
Trg gene rearrangement anal,81342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.7,,,,,,,fee schedule,191.43,485.97,APC
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,413.57,
Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.63,,,,,,,fee schedule,130.15,413.57,
Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.36,,,,,,,fee schedule,130.15,413.57,
Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.77,,,,,,,fee schedule,130.15,413.57,
Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.57,,,,,,,fee schedule,130.15,413.57,
Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,413.57,APC
Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,413.57,APC
Tbp gene detc abnor alleles,81344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,413.57,APC
Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,559.14,
Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,486.21,,,,,,,fee schedule,175.94,559.14,
Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.96,,,,,,,fee schedule,175.94,559.14,
Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.76,,,,,,,fee schedule,175.94,559.14,
Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,559.14,,,,,,,fee schedule,175.94,559.14,
Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,559.14,APC
Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,559.14,APC
Tert gene targeted seq alys,81345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,559.14,APC
Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
Tyms gene com variants,81346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,183.59,,,,,,,fee schedule,183.59,431.74,
Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.43,,,,,,,fee schedule,183.59,431.74,
Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.29,,,,,,,fee schedule,183.59,431.74,
Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.13,,,,,,,fee schedule,183.59,431.74,
Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.74,,,,,,,fee schedule,183.59,431.74,
Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,183.59,431.74,APC
Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,193.25,,,,,,,fee schedule,183.59,431.74,APC
Sf3b1 gene common variants,81347,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,347.85,,,,,,,fee schedule,183.59,431.74,APC
Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.63,,,,,,,fee schedule,166.63,391.85,
Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,340.74,,,,,,,fee schedule,166.63,391.85,
Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,278.9,,,,,,,fee schedule,166.63,391.85,
Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.39,,,,,,,fee schedule,166.63,391.85,
Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,391.85,,,,,,,fee schedule,166.63,391.85,
Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,166.63,391.85,APC
Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,175.4,,,,,,,fee schedule,166.63,391.85,APC
Srsf2 gene common variants,81348,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,315.72,,,,,,,fee schedule,166.63,391.85,APC
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1102,,,,,,,fee schedule,1102,2591.57,
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2253.54,,,,,,,fee schedule,1102,2591.57,
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1844.52,,,,,,,fee schedule,1102,2591.57,
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1477.42,,,,,,,fee schedule,1102,2591.57,
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2591.57,,,,,,,fee schedule,1102,2591.57,
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1257.84,,,,,,,fee schedule,1102,2591.57,APC
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1197.94,,,,,,,fee schedule,1102,2591.57,APC
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2156.29,,,,,,,fee schedule,1102,2591.57,APC
Ugt1a1 gene,81350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,222.3,,,,,,,fee schedule,222.3,421.2,
Ugt1a1 gene,81350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,245.7,,,,,,,fee schedule,222.3,421.2,APC
Ugt1a1 gene,81350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,234,,,,,,,fee schedule,222.3,421.2,APC
Ugt1a1 gene,81350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,421.2,,,,,,,fee schedule,222.3,421.2,APC
Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,609.76,,,,,,,fee schedule,609.76,1433.98,
Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1246.94,,,,,,,fee schedule,609.76,1433.98,
Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1020.62,,,,,,,fee schedule,609.76,1433.98,
Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,817.49,,,,,,,fee schedule,609.76,1433.98,
Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1433.98,,,,,,,fee schedule,609.76,1433.98,
Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,673.94,,,,,,,fee schedule,609.76,1433.98,APC
Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,641.85,,,,,,,fee schedule,609.76,1433.98,APC
Tp53 gene full gene sequence,81351,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1155.33,,,,,,,fee schedule,609.76,1433.98,APC
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,313.03,,,,,,,fee schedule,313.03,736.17,
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,640.15,,,,,,,fee schedule,313.03,736.17,
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,523.96,,,,,,,fee schedule,313.03,736.17,
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,419.68,,,,,,,fee schedule,313.03,736.17,
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,736.17,,,,,,,fee schedule,313.03,736.17,
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.99,,,,,,,fee schedule,313.03,736.17,APC
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.51,,,,,,,fee schedule,313.03,736.17,APC
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,593.12,,,,,,,fee schedule,313.03,736.17,APC
Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,292.6,,,,,,,fee schedule,292.6,688.13,
Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,598.37,,,,,,,fee schedule,292.6,688.13,
Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,489.77,,,,,,,fee schedule,292.6,688.13,
Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,392.29,,,,,,,fee schedule,292.6,688.13,
Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,688.13,,,,,,,fee schedule,292.6,688.13,
Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,323.4,,,,,,,fee schedule,292.6,688.13,APC
Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,308,,,,,,,fee schedule,292.6,688.13,APC
Tp53 gene known famil vrnt,81353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,554.4,,,,,,,fee schedule,292.6,688.13,APC
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1263.53,2274.35,APC
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1263.53,,,,,,,fee schedule,1263.53,2274.35,APC
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2274.35,,,,,,,fee schedule,1263.53,2274.35,APC
Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,83.79,,,,,,,fee schedule,83.79,267.81,
Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,232.88,,,,,,,fee schedule,83.79,267.81,
Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.61,,,,,,,fee schedule,83.79,267.81,
Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.68,,,,,,,fee schedule,83.79,267.81,
Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,267.81,,,,,,,fee schedule,83.79,267.81,
Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.61,,,,,,,fee schedule,83.79,267.81,APC
Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,88.2,,,,,,,fee schedule,83.79,267.81,APC
Vkorc1 gene,81355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,158.76,,,,,,,fee schedule,83.79,267.81,APC
U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,183.59,,,,,,,fee schedule,183.59,431.74,
U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.43,,,,,,,fee schedule,183.59,431.74,
U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.29,,,,,,,fee schedule,183.59,431.74,
U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.13,,,,,,,fee schedule,183.59,431.74,
U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.74,,,,,,,fee schedule,183.59,431.74,
U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,183.59,431.74,APC
U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,193.25,,,,,,,fee schedule,183.59,431.74,APC
U2af1 gene common variants,81357,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,347.85,,,,,,,fee schedule,183.59,431.74,APC
Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,183.59,,,,,,,fee schedule,183.59,431.74,
Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.43,,,,,,,fee schedule,183.59,431.74,
Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.29,,,,,,,fee schedule,183.59,431.74,
Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.13,,,,,,,fee schedule,183.59,431.74,
Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.74,,,,,,,fee schedule,183.59,431.74,
Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,183.59,431.74,APC
Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,193.25,,,,,,,fee schedule,183.59,431.74,APC
Zrsr2 gene common variants,81360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,347.85,,,,,,,fee schedule,183.59,431.74,APC
Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,166.07,,,,,,,fee schedule,166.07,552.69,
Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.6,,,,,,,fee schedule,166.07,552.69,
Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.37,,,,,,,fee schedule,166.07,552.69,
Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.08,,,,,,,fee schedule,166.07,552.69,
Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.69,,,,,,,fee schedule,166.07,552.69,
Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,166.07,552.69,APC
Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.81,,,,,,,fee schedule,166.07,552.69,APC
Hbb gene com variants,81361,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.66,,,,,,,fee schedule,166.07,552.69,APC
Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,356.49,,,,,,,fee schedule,167.8,675.45,
Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.95,,,,,,,fee schedule,167.8,675.45,
Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.5,,,,,,,fee schedule,167.8,675.45,
Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.8,,,,,,,fee schedule,167.8,675.45,
Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.34,,,,,,,fee schedule,167.8,675.45,
Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,167.8,675.45,APC
Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,375.25,,,,,,,fee schedule,167.8,675.45,APC
Hbb gene known fam variant,81362,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,675.45,,,,,,,fee schedule,167.8,675.45,APC
Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,192.28,,,,,,,fee schedule,192.28,601.97,
Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.45,,,,,,,fee schedule,192.28,601.97,
Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,428.44,,,,,,,fee schedule,192.28,601.97,
Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.17,,,,,,,fee schedule,192.28,601.97,
Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,601.97,,,,,,,fee schedule,192.28,601.97,
Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,212.52,,,,,,,fee schedule,192.28,601.97,APC
Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,202.4,,,,,,,fee schedule,192.28,601.97,APC
Hbb gene dup/del variants,81363,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,364.32,,,,,,,fee schedule,192.28,601.97,APC
Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,308.35,,,,,,,fee schedule,308.35,1041.84,
Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,905.95,,,,,,,fee schedule,308.35,1041.84,
Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,741.52,,,,,,,fee schedule,308.35,1041.84,
Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,593.94,,,,,,,fee schedule,308.35,1041.84,
Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1041.84,,,,,,,fee schedule,308.35,1041.84,
Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,340.81,,,,,,,fee schedule,308.35,1041.84,APC
Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,324.58,,,,,,,fee schedule,308.35,1041.84,APC
Hbb full gene sequence,81364,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,584.24,,,,,,,fee schedule,308.35,1041.84,APC
Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,382.01,,,,,,,fee schedule,335.94,723.82,
Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,512.41,,,,,,,fee schedule,335.94,723.82,
Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,419.41,,,,,,,fee schedule,335.94,723.82,
Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,335.94,,,,,,,fee schedule,335.94,723.82,
Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,589.27,,,,,,,fee schedule,335.94,723.82,
Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.23,,,,,,,fee schedule,335.94,723.82,APC
Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,402.12,,,,,,,fee schedule,335.94,723.82,APC
Hla i & ii typing lr,81370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,723.82,,,,,,,fee schedule,335.94,723.82,APC
Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,384.29,,,,,,,fee schedule,384.29,1036.64,
Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,901.43,,,,,,,fee schedule,384.29,1036.64,
Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,737.82,,,,,,,fee schedule,384.29,1036.64,
Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,590.98,,,,,,,fee schedule,384.29,1036.64,
Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1036.64,,,,,,,fee schedule,384.29,1036.64,
Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,424.75,,,,,,,fee schedule,384.29,1036.64,APC
Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,404.52,,,,,,,fee schedule,384.29,1036.64,APC
Hla i & ii type verify lr,81371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,728.14,,,,,,,fee schedule,384.29,1036.64,APC
Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,383.41,,,,,,,fee schedule,383.41,951.42,
Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,827.32,,,,,,,fee schedule,383.41,951.42,
Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,677.16,,,,,,,fee schedule,383.41,951.42,
Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,542.39,,,,,,,fee schedule,383.41,951.42,
Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,951.42,,,,,,,fee schedule,383.41,951.42,
Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,423.77,,,,,,,fee schedule,383.41,951.42,APC
Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,403.59,,,,,,,fee schedule,383.41,951.42,APC
Hla i typing complete lr,81372,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,726.46,,,,,,,fee schedule,383.41,951.42,APC
Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,121.06,,,,,,,fee schedule,121.06,479.62,
Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.06,,,,,,,fee schedule,121.06,479.62,
Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,341.36,,,,,,,fee schedule,121.06,479.62,
Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.42,,,,,,,fee schedule,121.06,479.62,
Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,479.62,,,,,,,fee schedule,121.06,479.62,
Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.8,,,,,,,fee schedule,121.06,479.62,APC
Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,127.43,,,,,,,fee schedule,121.06,479.62,APC
Hla i typing 1 locus lr,81373,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,229.37,,,,,,,fee schedule,121.06,479.62,APC
Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,70.61,,,,,,,fee schedule,70.61,313.32,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,272.45,,,,,,,fee schedule,70.61,313.32,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,223,,,,,,,fee schedule,70.61,313.32,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,178.62,,,,,,,fee schedule,70.61,313.32,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,313.32,,,,,,,fee schedule,70.61,313.32,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.05,,,,,,,fee schedule,70.61,313.32,APC
Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.33,,,,,,,fee schedule,70.61,313.32,APC
Hla i typing 1 antigen lr,81374,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,133.79,,,,,,,fee schedule,70.61,313.32,APC
Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,209.7,,,,,,,fee schedule,209.7,950.73,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,826.72,,,,,,,fee schedule,209.7,950.73,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,676.67,,,,,,,fee schedule,209.7,950.73,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,542,,,,,,,fee schedule,209.7,950.73,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,950.73,,,,,,,fee schedule,209.7,950.73,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,231.78,,,,,,,fee schedule,209.7,950.73,APC
Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,220.74,,,,,,,fee schedule,209.7,950.73,APC
Hla ii typing ag equiv lr,81375,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,397.33,,,,,,,fee schedule,209.7,950.73,APC
Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,116.11,,,,,,,fee schedule,116.11,526.41,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.75,,,,,,,fee schedule,116.11,526.41,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.67,,,,,,,fee schedule,116.11,526.41,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.1,,,,,,,fee schedule,116.11,526.41,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.41,,,,,,,fee schedule,116.11,526.41,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,116.11,526.41,APC
Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.22,,,,,,,fee schedule,116.11,526.41,APC
Hla ii typing 1 locus lr,81376,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,220,,,,,,,fee schedule,116.11,526.41,APC
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,90,,,,,,,fee schedule,90,395.42,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,343.84,,,,,,,fee schedule,90,395.42,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,281.43,,,,,,,fee schedule,90,395.42,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,225.42,,,,,,,fee schedule,90,395.42,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,395.42,,,,,,,fee schedule,90,395.42,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.48,,,,,,,fee schedule,90,395.42,APC
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.74,,,,,,,fee schedule,90,395.42,APC
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.53,,,,,,,fee schedule,90,395.42,APC
Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,328.29,,,,,,,fee schedule,328.29,1296.4,
Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1127.3,,,,,,,fee schedule,328.29,1296.4,
Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,922.7,,,,,,,fee schedule,328.29,1296.4,
Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,739.06,,,,,,,fee schedule,328.29,1296.4,
Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1296.4,,,,,,,fee schedule,328.29,1296.4,
Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.85,,,,,,,fee schedule,328.29,1296.4,APC
Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,345.57,,,,,,,fee schedule,328.29,1296.4,APC
Hla i & ii typing hr,81378,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,622.03,,,,,,,fee schedule,328.29,1296.4,APC
Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,318.61,,,,,,,fee schedule,318.61,1444.48,
Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1256.07,,,,,,,fee schedule,318.61,1444.48,
Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1028.09,,,,,,,fee schedule,318.61,1444.48,
Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,823.48,,,,,,,fee schedule,318.61,1444.48,
Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1444.48,,,,,,,fee schedule,318.61,1444.48,
Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,352.15,,,,,,,fee schedule,318.61,1444.48,APC
Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,335.38,,,,,,,fee schedule,318.61,1444.48,APC
Hla i typing complete hr,81379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,603.68,,,,,,,fee schedule,318.61,1444.48,APC
Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,168.39,,,,,,,fee schedule,168.39,324.09,
Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,281.82,,,,,,,fee schedule,168.39,324.09,
Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,230.67,,,,,,,fee schedule,168.39,324.09,
Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,184.76,,,,,,,fee schedule,168.39,324.09,
Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,324.09,,,,,,,fee schedule,168.39,324.09,
Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,186.11,,,,,,,fee schedule,168.39,324.09,APC
Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,177.25,,,,,,,fee schedule,168.39,324.09,APC
Hla i typing 1 locus hr,81380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,319.05,,,,,,,fee schedule,168.39,324.09,APC
Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,161.41,,,,,,,fee schedule,161.41,407.36,
Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,354.23,,,,,,,fee schedule,161.41,407.36,
Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,289.94,,,,,,,fee schedule,161.41,407.36,
Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,232.23,,,,,,,fee schedule,161.41,407.36,
Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,407.36,,,,,,,fee schedule,161.41,407.36,
Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.4,,,,,,,fee schedule,161.41,407.36,APC
Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.9,,,,,,,fee schedule,161.41,407.36,APC
Hla i typing 1 allele hr,81381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.82,,,,,,,fee schedule,161.41,407.36,APC
Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,117.5,,,,,,,fee schedule,117.5,412.48,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,358.68,,,,,,,fee schedule,117.5,412.48,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,293.58,,,,,,,fee schedule,117.5,412.48,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.15,,,,,,,fee schedule,117.5,412.48,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,412.48,,,,,,,fee schedule,117.5,412.48,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.86,,,,,,,fee schedule,117.5,412.48,APC
Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,123.68,,,,,,,fee schedule,117.5,412.48,APC
Hla ii typing 1 loc hr,81382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,222.62,,,,,,,fee schedule,117.5,412.48,APC
Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,103.67,,,,,,,fee schedule,103.67,470.03,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,408.72,,,,,,,fee schedule,103.67,470.03,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,334.54,,,,,,,fee schedule,103.67,470.03,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,267.96,,,,,,,fee schedule,103.67,470.03,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,470.03,,,,,,,fee schedule,103.67,470.03,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.59,,,,,,,fee schedule,103.67,470.03,APC
Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,109.13,,,,,,,fee schedule,103.67,470.03,APC
Hla ii typing 1 allele hr,81383,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,196.43,,,,,,,fee schedule,103.67,470.03,APC
Mopath procedure level 1,81400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,60.76,,,,,,,fee schedule,60.76,115.13,
Mopath procedure level 1,81400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.16,,,,,,,fee schedule,60.76,115.13,APC
Mopath procedure level 1,81400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,63.96,,,,,,,fee schedule,60.76,115.13,APC
Mopath procedure level 1,81400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.13,,,,,,,fee schedule,60.76,115.13,APC
Mopath procedure level 2,81401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,130.15,,,,,,,fee schedule,130.15,246.6,
Mopath procedure level 2,81401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,130.15,246.6,APC
Mopath procedure level 2,81401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137,,,,,,,fee schedule,130.15,246.6,APC
Mopath procedure level 2,81401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.6,,,,,,,fee schedule,130.15,246.6,APC
Mopath procedure level 3,81402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,142.81,,,,,,,fee schedule,142.81,270.59,
Mopath procedure level 3,81402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.85,,,,,,,fee schedule,142.81,270.59,APC
Mopath procedure level 3,81402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150.33,,,,,,,fee schedule,142.81,270.59,APC
Mopath procedure level 3,81402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270.59,,,,,,,fee schedule,142.81,270.59,APC
Mopath procedure level 4,81403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,175.94,,,,,,,fee schedule,175.94,333.36,
Mopath procedure level 4,81403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,175.94,333.36,APC
Mopath procedure level 4,81403,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185.2,,,,,,,fee schedule,175.94,333.36,APC
Mopath procedure level 4,81403,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333.36,,,,,,,fee schedule,175.94,333.36,APC
Mopath procedure level 5,81404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,261.09,,,,,,,fee schedule,261.09,494.69,
Mopath procedure level 5,81404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,261.09,494.69,APC
Mopath procedure level 5,81404,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,274.83,,,,,,,fee schedule,261.09,494.69,APC
Mopath procedure level 5,81404,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,494.69,,,,,,,fee schedule,261.09,494.69,APC
Mopath procedure level 6,81405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,286.28,,,,,,,fee schedule,286.28,542.43,
Mopath procedure level 6,81405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,286.28,542.43,APC
Mopath procedure level 6,81405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,301.35,,,,,,,fee schedule,286.28,542.43,APC
Mopath procedure level 6,81405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,542.43,,,,,,,fee schedule,286.28,542.43,APC
Mopath procedure level 7,81406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,268.74,,,,,,,fee schedule,268.74,509.18,
Mopath procedure level 7,81406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,268.74,509.18,APC
Mopath procedure level 7,81406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,282.88,,,,,,,fee schedule,268.74,509.18,APC
Mopath procedure level 7,81406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,509.18,,,,,,,fee schedule,268.74,509.18,APC
Mopath procedure level 8,81407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,803.96,,,,,,,fee schedule,803.96,1523.29,
Mopath procedure level 8,81407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,888.58,,,,,,,fee schedule,803.96,1523.29,APC
Mopath procedure level 8,81407,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,846.27,,,,,,,fee schedule,803.96,1523.29,APC
Mopath procedure level 8,81407,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1523.29,,,,,,,fee schedule,803.96,1523.29,APC
Mopath procedure level 9,81408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1900,,,,,,,fee schedule,1900,3600,
Mopath procedure level 9,81408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2100,,,,,,,fee schedule,1900,3600,APC
Mopath procedure level 9,81408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2000,,,,,,,fee schedule,1900,3600,APC
Mopath procedure level 9,81408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3600,,,,,,,fee schedule,1900,3600,APC
Aortic dysfunction/dilation,81410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,478.8,,,,,,,fee schedule,478.8,907.2,
Aortic dysfunction/dilation,81410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,529.2,,,,,,,fee schedule,478.8,907.2,APC
Aortic dysfunction/dilation,81410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,504,,,,,,,fee schedule,478.8,907.2,APC
Aortic dysfunction/dilation,81410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,907.2,,,,,,,fee schedule,478.8,907.2,APC
Aortic dysfunction/dilation,81411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1282.68,,,,,,,fee schedule,1282.68,2430.34,
Aortic dysfunction/dilation,81411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1417.7,,,,,,,fee schedule,1282.68,2430.34,APC
Aortic dysfunction/dilation,81411,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1350.19,,,,,,,fee schedule,1282.68,2430.34,APC
Aortic dysfunction/dilation,81411,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2430.34,,,,,,,fee schedule,1282.68,2430.34,APC
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2326.13,,,,,,,fee schedule,1077.73,4407.41,
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.89,,,,,,,fee schedule,1077.73,4407.41,
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1345.52,,,,,,,fee schedule,1077.73,4407.41,
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1077.73,,,,,,,fee schedule,1077.73,4407.41,
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.47,,,,,,,fee schedule,1077.73,4407.41,
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,1077.73,4407.41,APC
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2448.56,,,,,,,fee schedule,1077.73,4407.41,APC
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4407.41,,,,,,,fee schedule,1077.73,4407.41,APC
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,555.66,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2190.56,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1792.97,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1436.13,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2519.14,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,555.66,2519.14,APC
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.9,,,,,,,fee schedule,555.66,2519.14,APC
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1052.82,,,,,,,fee schedule,555.66,2519.14,APC
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,555.66,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2190.56,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1792.97,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1436.13,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2519.14,,,,,,,fee schedule,555.66,2519.14,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,555.66,2519.14,APC
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.9,,,,,,,fee schedule,555.66,2519.14,APC
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1052.82,,,,,,,fee schedule,555.66,2519.14,APC
Exome sequence analysis,81415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4541,,,,,,,fee schedule,4541,8604,
Exome sequence analysis,81415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5019,,,,,,,fee schedule,4541,8604,APC
Exome sequence analysis,81415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4780,,,,,,,fee schedule,4541,8604,APC
Exome sequence analysis,81415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8604,,,,,,,fee schedule,4541,8604,APC
Exome sequence analysis,81416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11400,,,,,,,fee schedule,11400,21600,
Exome sequence analysis,81416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12600,,,,,,,fee schedule,11400,21600,APC
Exome sequence analysis,81416,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12000,,,,,,,fee schedule,11400,21600,APC
Exome sequence analysis,81416,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21600,,,,,,,fee schedule,11400,21600,APC
Exome re-evaluation,81417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,304,,,,,,,fee schedule,304,576,
Exome re-evaluation,81417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,336,,,,,,,fee schedule,304,576,APC
Exome re-evaluation,81417,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,320,,,,,,,fee schedule,304,576,APC
Exome re-evaluation,81417,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,576,,,,,,,fee schedule,304,576,APC
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1418.75,,,,,,,fee schedule,917.08,1650.74,
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1161.25,,,,,,,fee schedule,917.08,1650.74,
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,930.13,,,,,,,fee schedule,917.08,1650.74,
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1631.56,,,,,,,fee schedule,917.08,1650.74,
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,962.93,,,,,,,fee schedule,917.08,1650.74,APC
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.08,,,,,,,fee schedule,917.08,1650.74,APC
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1650.74,,,,,,,fee schedule,917.08,1650.74,APC
Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2326.13,,,,,,,fee schedule,2326.13,5470.35,
Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4756.83,,,,,,,fee schedule,2326.13,5470.35,
Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3893.47,,,,,,,fee schedule,2326.13,5470.35,
Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3118.58,,,,,,,fee schedule,2326.13,5470.35,
Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5470.35,,,,,,,fee schedule,2326.13,5470.35,
Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2326.13,5470.35,APC
Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2448.56,,,,,,,fee schedule,2326.13,5470.35,APC
Epilepsy gen seq alys panel,81419,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4407.41,,,,,,,fee schedule,2326.13,5470.35,APC
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,721.1,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2190.56,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1792.97,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1436.13,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2519.14,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,721.1,2519.14,APC
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,721.1,2519.14,APC
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,721.1,2519.14,APC
Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,721.1,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2190.56,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1792.97,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1436.13,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2519.14,,,,,,,fee schedule,721.1,2519.14,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,721.1,2519.14,APC
Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.05,,,,,,,fee schedule,721.1,2519.14,APC
Fetal chrmoml microdeltj,81422,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1366.29,,,,,,,fee schedule,721.1,2519.14,APC
Genome sequence analysis,81425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,9056.16,
Genome sequence analysis,81425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5282.76,,,,,,,fee schedule,0.01,9056.16,APC
Genome sequence analysis,81425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5031.2,,,,,,,fee schedule,0.01,9056.16,APC
Genome sequence analysis,81425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9056.16,,,,,,,fee schedule,0.01,9056.16,APC
Genome sequence analysis,81426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,4877.91,
Genome sequence analysis,81426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2845.45,,,,,,,fee schedule,0.01,4877.91,APC
Genome sequence analysis,81426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2709.95,,,,,,,fee schedule,0.01,4877.91,APC
Genome sequence analysis,81426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4877.91,,,,,,,fee schedule,0.01,4877.91,APC
Genome re-evaluation,81427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,4207.77,
Genome re-evaluation,81427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2454.53,,,,,,,fee schedule,0.01,4207.77,APC
Genome re-evaluation,81427,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2337.65,,,,,,,fee schedule,0.01,4207.77,APC
Genome re-evaluation,81427,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4207.77,,,,,,,fee schedule,0.01,4207.77,APC
Hearing loss sequence analys,81430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1543.75,,,,,,,fee schedule,1543.75,2925,
Hearing loss sequence analys,81430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1706.25,,,,,,,fee schedule,1543.75,2925,APC
Hearing loss sequence analys,81430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1625,,,,,,,fee schedule,1543.75,2925,APC
Hearing loss sequence analys,81430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2925,,,,,,,fee schedule,1543.75,2925,APC
Hearing loss dup/del analys,81431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,645.59,,,,,,,fee schedule,645.59,1223.23,
Hearing loss dup/del analys,81431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.55,,,,,,,fee schedule,645.59,1223.23,APC
Hearing loss dup/del analys,81431,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,679.57,,,,,,,fee schedule,645.59,1223.23,APC
Hearing loss dup/del analys,81431,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1223.23,,,,,,,fee schedule,645.59,1223.23,APC
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,645.1,,,,,,,fee schedule,645.1,2924.65,
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2543.17,,,,,,,fee schedule,645.1,2924.65,
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2081.58,,,,,,,fee schedule,645.1,2924.65,
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1667.3,,,,,,,fee schedule,645.1,2924.65,
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2924.65,,,,,,,fee schedule,645.1,2924.65,
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,645.1,2924.65,APC
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1303.95,,,,,,,fee schedule,645.1,2924.65,APC
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2347.11,,,,,,,fee schedule,645.1,2924.65,APC
Hrdtry brst ca-rlatd dsordrs,81433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,416.98,,,,,,,fee schedule,416.98,416.98,
Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,568.01,,,,,,,fee schedule,568.01,1890.47,
Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.89,,,,,,,fee schedule,568.01,1890.47,
Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1345.52,,,,,,,fee schedule,568.01,1890.47,
Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1077.73,,,,,,,fee schedule,568.01,1890.47,
Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.47,,,,,,,fee schedule,568.01,1890.47,
Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,568.01,1890.47,APC
Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,597.91,,,,,,,fee schedule,568.01,1890.47,APC
Hereditary retinal disorders,81434,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1076.24,,,,,,,fee schedule,568.01,1890.47,APC
Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,555.66,,,,,,,fee schedule,555.66,2519.14,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2190.56,,,,,,,fee schedule,555.66,2519.14,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1792.97,,,,,,,fee schedule,555.66,2519.14,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1436.13,,,,,,,fee schedule,555.66,2519.14,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2519.14,,,,,,,fee schedule,555.66,2519.14,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,555.66,2519.14,APC
Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1303.95,,,,,,,fee schedule,555.66,2519.14,APC
Hereditary colon ca dsordrs,81435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2347.11,,,,,,,fee schedule,555.66,2519.14,APC
Hereditary colon ca dsordrs,81436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,555.66,,,,,,,fee schedule,555.66,555.66,
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,416.98,,,,,,,fee schedule,416.98,2347.11,
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.89,,,,,,,fee schedule,416.98,2347.11,
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1345.52,,,,,,,fee schedule,416.98,2347.11,
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1077.73,,,,,,,fee schedule,416.98,2347.11,
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.47,,,,,,,fee schedule,416.98,2347.11,
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,416.98,2347.11,APC
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1303.95,,,,,,,fee schedule,416.98,2347.11,APC
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2347.11,,,,,,,fee schedule,416.98,2347.11,APC
Heredtry nurondcrn tum dsrdr,81438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,416.98,,,,,,,fee schedule,416.98,416.98,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,555.66,,,,,,,fee schedule,555.66,2519.14,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2190.56,,,,,,,fee schedule,555.66,2519.14,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1792.97,,,,,,,fee schedule,555.66,2519.14,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1436.13,,,,,,,fee schedule,555.66,2519.14,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2519.14,,,,,,,fee schedule,555.66,2519.14,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,555.66,2519.14,APC
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.9,,,,,,,fee schedule,555.66,2519.14,APC
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1052.82,,,,,,,fee schedule,555.66,2519.14,APC
Mitochondrial gene,81440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3157.8,,,,,,,fee schedule,3157.8,5983.2,
Mitochondrial gene,81440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3490.2,,,,,,,fee schedule,3157.8,5983.2,APC
Mitochondrial gene,81440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3324,,,,,,,fee schedule,3157.8,5983.2,APC
Mitochondrial gene,81440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5983.2,,,,,,,fee schedule,3157.8,5983.2,APC
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2326.13,,,,,,,fee schedule,2326.13,5382.09,
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4680.08,,,,,,,fee schedule,2326.13,5382.09,
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3830.65,,,,,,,fee schedule,2326.13,5382.09,
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3068.26,,,,,,,fee schedule,2326.13,5382.09,
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5382.09,,,,,,,fee schedule,2326.13,5382.09,
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2326.13,5382.09,APC
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2448.56,,,,,,,fee schedule,2326.13,5382.09,APC
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4407.41,,,,,,,fee schedule,2326.13,5382.09,APC
Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2036.42,,,,,,,fee schedule,1077.73,3858.48,
Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.89,,,,,,,fee schedule,1077.73,3858.48,
Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1345.52,,,,,,,fee schedule,1077.73,3858.48,
Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1077.73,,,,,,,fee schedule,1077.73,3858.48,
Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.47,,,,,,,fee schedule,1077.73,3858.48,
Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2250.78,,,,,,,fee schedule,1077.73,3858.48,APC
Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2143.6,,,,,,,fee schedule,1077.73,3858.48,APC
Noonan spectrum disorders,81442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3858.48,,,,,,,fee schedule,1077.73,3858.48,APC
Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2326.13,,,,,,,fee schedule,2326.13,7392.29,
Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6428.08,,,,,,,fee schedule,2326.13,7392.29,
Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5261.38,,,,,,,fee schedule,2326.13,7392.29,
Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4214.25,,,,,,,fee schedule,2326.13,7392.29,
Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7392.29,,,,,,,fee schedule,2326.13,7392.29,
Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2326.13,7392.29,APC
Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2448.56,,,,,,,fee schedule,2326.13,7392.29,APC
Genetic tstg severe inh cond,81443,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4407.41,,,,,,,fee schedule,2326.13,7392.29,APC
Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,568.01,,,,,,,fee schedule,568.01,1890.47,
Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.89,,,,,,,fee schedule,568.01,1890.47,
Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1345.52,,,,,,,fee schedule,568.01,1890.47,
Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1077.73,,,,,,,fee schedule,568.01,1890.47,
Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.47,,,,,,,fee schedule,568.01,1890.47,
Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,568.01,1890.47,APC
Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,597.91,,,,,,,fee schedule,568.01,1890.47,APC
Targeted genomic seq analys,81445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1076.24,,,,,,,fee schedule,568.01,1890.47,APC
Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,555.66,,,,,,,fee schedule,555.66,2519.14,
Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2190.56,,,,,,,fee schedule,555.66,2519.14,
Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1792.97,,,,,,,fee schedule,555.66,2519.14,
Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1436.13,,,,,,,fee schedule,555.66,2519.14,
Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2519.14,,,,,,,fee schedule,555.66,2519.14,
Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,555.66,2519.14,APC
Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.9,,,,,,,fee schedule,555.66,2519.14,APC
Hrdtry perph neurphy panel,81448,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1052.82,,,,,,,fee schedule,555.66,2519.14,APC
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,568.01,,,,,,,fee schedule,568.01,1314.27,
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1142.84,,,,,,,fee schedule,568.01,1314.27,
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,935.41,,,,,,,fee schedule,568.01,1314.27,
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,749.25,,,,,,,fee schedule,568.01,1314.27,
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1314.27,,,,,,,fee schedule,568.01,1314.27,
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,568.01,1314.27,APC
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,597.91,,,,,,,fee schedule,568.01,1314.27,APC
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1076.24,,,,,,,fee schedule,568.01,1314.27,APC
Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,721.55,,,,,,,fee schedule,721.55,2995.61,
Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2604.88,,,,,,,fee schedule,721.55,2995.61,
Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2132.09,,,,,,,fee schedule,721.55,2995.61,
Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1707.76,,,,,,,fee schedule,721.55,2995.61,
Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2995.61,,,,,,,fee schedule,721.55,2995.61,
Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797.51,,,,,,,fee schedule,721.55,2995.61,APC
Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.53,,,,,,,fee schedule,721.55,2995.61,APC
Targeted genomic seq analys,81450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1367.15,,,,,,,fee schedule,721.55,2995.61,APC
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,721.55,,,,,,,fee schedule,721.55,1669.5,
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1451.74,,,,,,,fee schedule,721.55,1669.5,
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1188.25,,,,,,,fee schedule,721.55,1669.5,
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,951.76,,,,,,,fee schedule,721.55,1669.5,
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1669.5,,,,,,,fee schedule,721.55,1669.5,
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797.51,,,,,,,fee schedule,721.55,1669.5,APC
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,759.53,,,,,,,fee schedule,721.55,1669.5,APC
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1367.15,,,,,,,fee schedule,721.55,1669.5,APC
Targeted genomic seq analys,81455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2773.62,,,,,,,fee schedule,2773.62,5255.28,
Targeted genomic seq analys,81455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2773.62,5255.28,APC
Targeted genomic seq analys,81455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2773.62,5255.28,APC
Targeted genomic seq analys,81455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2773.62,5255.28,APC
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2773.62,,,,,,,fee schedule,2773.62,6417.46,
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5580.4,,,,,,,fee schedule,2773.62,6417.46,
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4567.56,,,,,,,fee schedule,2773.62,6417.46,
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3658.51,,,,,,,fee schedule,2773.62,6417.46,
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6417.46,,,,,,,fee schedule,2773.62,6417.46,
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2773.62,6417.46,APC
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2919.6,,,,,,,fee schedule,2773.62,6417.46,APC
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5255.28,,,,,,,fee schedule,2773.62,6417.46,APC
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5269.52,,,,,,,fee schedule,896.87,6059.95,
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4313.1,,,,,,,fee schedule,896.87,6059.95,
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3454.7,,,,,,,fee schedule,896.87,6059.95,
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6059.95,,,,,,,fee schedule,896.87,6059.95,
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.71,,,,,,,fee schedule,896.87,6059.95,APC
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,896.87,,,,,,,fee schedule,896.87,6059.95,APC
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1614.37,,,,,,,fee schedule,896.87,6059.95,APC
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5269.52,,,,,,,fee schedule,1046.35,6059.95,
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4313.1,,,,,,,fee schedule,1046.35,6059.95,
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3454.7,,,,,,,fee schedule,1046.35,6059.95,
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6059.95,,,,,,,fee schedule,1046.35,6059.95,
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1098.67,,,,,,,fee schedule,1046.35,6059.95,APC
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1046.35,,,,,,,fee schedule,1046.35,6059.95,APC
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1883.43,,,,,,,fee schedule,1046.35,6059.95,APC
So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5269.52,,,,,,,fee schedule,2989.55,6059.95,
So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4313.1,,,,,,,fee schedule,2989.55,6059.95,
So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3454.7,,,,,,,fee schedule,2989.55,6059.95,
So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6059.95,,,,,,,fee schedule,2989.55,6059.95,
So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3139.03,,,,,,,fee schedule,2989.55,6059.95,APC
So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2989.55,,,,,,,fee schedule,2989.55,6059.95,APC
So neo gsap dna/dna&rna,81459,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5381.19,,,,,,,fee schedule,2989.55,6059.95,APC
Whole mitochondrial genome,81460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1222.65,,,,,,,fee schedule,1222.65,2316.6,
Whole mitochondrial genome,81460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1351.35,,,,,,,fee schedule,1222.65,2316.6,APC
Whole mitochondrial genome,81460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1287,,,,,,,fee schedule,1222.65,2316.6,APC
Whole mitochondrial genome,81460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2316.6,,,,,,,fee schedule,1222.65,2316.6,APC
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1079.17,,,,,,,fee schedule,707.5,2152.49,
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,883.3,,,,,,,fee schedule,707.5,2152.49,
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,707.5,,,,,,,fee schedule,707.5,2152.49,
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1241.05,,,,,,,fee schedule,707.5,2152.49,
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1255.62,,,,,,,fee schedule,707.5,2152.49,APC
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1195.83,,,,,,,fee schedule,707.5,2152.49,APC
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2152.49,,,,,,,fee schedule,707.5,2152.49,APC
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1079.17,,,,,,,fee schedule,707.5,2421.56,
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,883.3,,,,,,,fee schedule,707.5,2421.56,
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,707.5,,,,,,,fee schedule,707.5,2421.56,
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1241.05,,,,,,,fee schedule,707.5,2421.56,
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1412.58,,,,,,,fee schedule,707.5,2421.56,APC
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1345.31,,,,,,,fee schedule,707.5,2421.56,APC
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2421.56,,,,,,,fee schedule,707.5,2421.56,APC
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1079.17,,,,,,,fee schedule,707.5,5919.32,
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,883.3,,,,,,,fee schedule,707.5,5919.32,
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,707.5,,,,,,,fee schedule,707.5,5919.32,
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1241.05,,,,,,,fee schedule,707.5,5919.32,
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3452.94,,,,,,,fee schedule,707.5,5919.32,APC
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3288.51,,,,,,,fee schedule,707.5,5919.32,APC
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5919.32,,,,,,,fee schedule,707.5,5919.32,APC
Whole mitochondrial genome,81465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,889.2,,,,,,,fee schedule,889.2,1684.8,
Whole mitochondrial genome,81465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,982.8,,,,,,,fee schedule,889.2,1684.8,APC
Whole mitochondrial genome,81465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,936,,,,,,,fee schedule,889.2,1684.8,APC
Whole mitochondrial genome,81465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1684.8,,,,,,,fee schedule,889.2,1684.8,APC
X-linked intellectual dblt,81470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,868.3,,,,,,,fee schedule,868.3,1645.2,
X-linked intellectual dblt,81470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,959.7,,,,,,,fee schedule,868.3,1645.2,APC
X-linked intellectual dblt,81470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,914,,,,,,,fee schedule,868.3,1645.2,APC
X-linked intellectual dblt,81470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1645.2,,,,,,,fee schedule,868.3,1645.2,APC
X-linked intellectual dblt,81471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,1645.2,
X-linked intellectual dblt,81471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,959.7,,,,,,,fee schedule,0.01,1645.2,APC
X-linked intellectual dblt,81471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,914,,,,,,,fee schedule,0.01,1645.2,APC
X-linked intellectual dblt,81471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1645.2,,,,,,,fee schedule,0.01,1645.2,APC
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,798.62,,,,,,,fee schedule,798.62,1854.38,
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1612.5,,,,,,,fee schedule,798.62,1854.38,
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1319.83,,,,,,,fee schedule,798.62,1854.38,
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1057.16,,,,,,,fee schedule,798.62,1854.38,
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1854.38,,,,,,,fee schedule,798.62,1854.38,
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,798.62,1854.38,APC
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,840.65,,,,,,,fee schedule,798.62,1854.38,APC
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1513.17,,,,,,,fee schedule,798.62,1854.38,APC
Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,997.5,,,,,,,fee schedule,997.5,3272.75,
Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2845.87,,,,,,,fee schedule,997.5,3272.75,
Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2329.34,,,,,,,fee schedule,997.5,3272.75,
Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1865.75,,,,,,,fee schedule,997.5,3272.75,
Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3272.75,,,,,,,fee schedule,997.5,3272.75,
Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1102.5,,,,,,,fee schedule,997.5,3272.75,APC
Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1050,,,,,,,fee schedule,997.5,3272.75,APC
Cor artery disease mrna,81493,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1890,,,,,,,fee schedule,997.5,3272.75,APC
Onco (ovar) two proteins,81500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,247.48,,,,,,,fee schedule,247.48,468.9,
Onco (ovar) two proteins,81500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.52,,,,,,,fee schedule,247.48,468.9,APC
Onco (ovar) two proteins,81500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,260.5,,,,,,,fee schedule,247.48,468.9,APC
Onco (ovar) two proteins,81500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,468.9,,,,,,,fee schedule,247.48,468.9,APC
Onco (ovar) five proteins,81503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,852.15,,,,,,,fee schedule,852.15,1614.6,
Onco (ovar) five proteins,81503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,852.15,1614.6,APC
Onco (ovar) five proteins,81503,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,897,,,,,,,fee schedule,852.15,1614.6,APC
Onco (ovar) five proteins,81503,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1614.6,,,,,,,fee schedule,852.15,1614.6,APC
Oncology tissue of origin,81504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,494,,,,,,,fee schedule,494,936,
Oncology tissue of origin,81504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,546,,,,,,,fee schedule,494,936,APC
Oncology tissue of origin,81504,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,520,,,,,,,fee schedule,494,936,APC
Oncology tissue of origin,81504,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,936,,,,,,,fee schedule,494,936,APC
Endo assay seven anal,81506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,65.47,,,,,,,fee schedule,65.47,124.06,
Endo assay seven anal,81506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72.37,,,,,,,fee schedule,65.47,124.06,APC
Endo assay seven anal,81506,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,68.92,,,,,,,fee schedule,65.47,124.06,APC
Endo assay seven anal,81506,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,124.06,,,,,,,fee schedule,65.47,124.06,APC
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,755.25,,,,,,,fee schedule,755.25,1431,
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.75,,,,,,,fee schedule,755.25,1431,APC
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,795,,,,,,,fee schedule,755.25,1431,APC
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1431,,,,,,,fee schedule,755.25,1431,APC
Ftl cgen abnor two proteins,81508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,51.59,,,,,,,fee schedule,51.59,97.74,
Ftl cgen abnor two proteins,81508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.02,,,,,,,fee schedule,51.59,97.74,APC
Ftl cgen abnor two proteins,81508,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.3,,,,,,,fee schedule,51.59,97.74,APC
Ftl cgen abnor two proteins,81508,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,97.74,,,,,,,fee schedule,51.59,97.74,APC
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1413,,,,,,,fee schedule,1413,2677.27,
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1561.74,,,,,,,fee schedule,1413,2677.27,APC
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1487.37,,,,,,,fee schedule,1413,2677.27,APC
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2677.27,,,,,,,fee schedule,1413,2677.27,APC
Ftl cgen abnor three anal,81510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,52.76,,,,,,,fee schedule,52.76,99.97,
Ftl cgen abnor three anal,81510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.32,,,,,,,fee schedule,52.76,99.97,APC
Ftl cgen abnor three anal,81510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55.54,,,,,,,fee schedule,52.76,99.97,APC
Ftl cgen abnor three anal,81510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,99.97,,,,,,,fee schedule,52.76,99.97,APC
Ftl cgen abnor four anal,81511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,145.83,,,,,,,fee schedule,145.83,276.3,
Ftl cgen abnor four anal,81511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,161.18,,,,,,,fee schedule,145.83,276.3,APC
Ftl cgen abnor four anal,81511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,153.5,,,,,,,fee schedule,145.83,276.3,APC
Ftl cgen abnor four anal,81511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,276.3,,,,,,,fee schedule,145.83,276.3,APC
Ftl cgen abnor five anal,81512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,66.04,,,,,,,fee schedule,66.04,125.14,
Ftl cgen abnor five anal,81512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73,,,,,,,fee schedule,66.04,125.14,APC
Ftl cgen abnor five anal,81512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,69.52,,,,,,,fee schedule,66.04,125.14,APC
Ftl cgen abnor five anal,81512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,125.14,,,,,,,fee schedule,66.04,125.14,APC
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,135.5,,,,,,,fee schedule,135.5,318.67,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,277.1,,,,,,,fee schedule,135.5,318.67,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,226.81,,,,,,,fee schedule,135.5,318.67,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,181.67,,,,,,,fee schedule,135.5,318.67,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,318.67,,,,,,,fee schedule,135.5,318.67,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,135.5,318.67,APC
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,135.5,318.67,APC
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,135.5,318.67,APC
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,249.84,,,,,,,fee schedule,249.84,587.56,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,510.92,,,,,,,fee schedule,249.84,587.56,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,418.19,,,,,,,fee schedule,249.84,587.56,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.96,,,,,,,fee schedule,249.84,587.56,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.56,,,,,,,fee schedule,249.84,587.56,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,249.84,587.56,APC
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,262.99,,,,,,,fee schedule,249.84,587.56,APC
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,473.38,,,,,,,fee schedule,249.84,587.56,APC
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,429.99,,,,,,,fee schedule,262.99,494.49,
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,351.95,,,,,,,fee schedule,262.99,494.49,
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,281.9,,,,,,,fee schedule,262.99,494.49,
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,494.49,,,,,,,fee schedule,262.99,494.49,
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,262.99,494.49,APC
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,262.99,,,,,,,fee schedule,262.99,494.49,APC
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,473.38,,,,,,,fee schedule,262.99,494.49,APC
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,318.01,,,,,,,fee schedule,176.19,365.71,
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,260.29,,,,,,,fee schedule,176.19,365.71,
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,208.49,,,,,,,fee schedule,176.19,365.71,
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,365.71,,,,,,,fee schedule,176.19,365.71,
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185,,,,,,,fee schedule,176.19,365.71,APC
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.19,,,,,,,fee schedule,176.19,365.71,APC
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,317.14,,,,,,,fee schedule,176.19,365.71,APC
Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3679.35,,,,,,,fee schedule,3679.35,11692.73,
Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10167.59,,,,,,,fee schedule,3679.35,11692.73,
Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8322.17,,,,,,,fee schedule,3679.35,11692.73,
Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6665.87,,,,,,,fee schedule,3679.35,11692.73,
Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11692.73,,,,,,,fee schedule,3679.35,11692.73,
Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3679.35,11692.73,APC
Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3679.35,11692.73,APC
Onc brst mrna 11 genes,81518,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3679.35,11692.73,APC
Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3679.35,,,,,,,fee schedule,3679.35,10811.44,
Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9401.25,,,,,,,fee schedule,3679.35,10811.44,
Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7694.92,,,,,,,fee schedule,3679.35,10811.44,
Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6163.46,,,,,,,fee schedule,3679.35,10811.44,
Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10811.44,,,,,,,fee schedule,3679.35,10811.44,
Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3679.35,10811.44,APC
Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3679.35,10811.44,APC
Oncology breast mrna,81519,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3679.35,10811.44,APC
Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2384.7,,,,,,,fee schedule,2384.7,10811.44,
Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9401.25,,,,,,,fee schedule,2384.7,10811.44,
Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7694.92,,,,,,,fee schedule,2384.7,10811.44,
Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6163.46,,,,,,,fee schedule,2384.7,10811.44,
Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10811.44,,,,,,,fee schedule,2384.7,10811.44,
Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2635.72,,,,,,,fee schedule,2384.7,10811.44,APC
Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2510.21,,,,,,,fee schedule,2384.7,10811.44,APC
Onc breast mrna 58 genes,81520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4518.38,,,,,,,fee schedule,2384.7,10811.44,APC
Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3679.35,,,,,,,fee schedule,3679.35,10811.44,
Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9401.25,,,,,,,fee schedule,3679.35,10811.44,
Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7694.92,,,,,,,fee schedule,3679.35,10811.44,
Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6163.46,,,,,,,fee schedule,3679.35,10811.44,
Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10811.44,,,,,,,fee schedule,3679.35,10811.44,
Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3679.35,10811.44,APC
Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3679.35,10811.44,APC
Onc breast mrna 70 genes,81521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3679.35,10811.44,APC
Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3679.35,,,,,,,fee schedule,3679.35,8652.73,
Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7524.11,,,,,,,fee schedule,3679.35,8652.73,
Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6158.48,,,,,,,fee schedule,3679.35,8652.73,
Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4932.81,,,,,,,fee schedule,3679.35,8652.73,
Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8652.73,,,,,,,fee schedule,3679.35,8652.73,
Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3679.35,8652.73,APC
Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3679.35,8652.73,APC
Onc breast mrna 12 genes,81522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3679.35,8652.73,APC
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3679.35,,,,,,,fee schedule,3679.35,8652.73,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7524.11,,,,,,,fee schedule,3679.35,8652.73,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6158.48,,,,,,,fee schedule,3679.35,8652.73,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4932.81,,,,,,,fee schedule,3679.35,8652.73,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8652.73,,,,,,,fee schedule,3679.35,8652.73,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3679.35,8652.73,APC
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3679.35,8652.73,APC
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3679.35,8652.73,APC
Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2960.2,,,,,,,fee schedule,2960.2,9814.15,
Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8534.04,,,,,,,fee schedule,2960.2,9814.15,
Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6985.11,,,,,,,fee schedule,2960.2,9814.15,
Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5594.92,,,,,,,fee schedule,2960.2,9814.15,
Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9814.15,,,,,,,fee schedule,2960.2,9814.15,
Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3271.8,,,,,,,fee schedule,2960.2,9814.15,APC
Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3116,,,,,,,fee schedule,2960.2,9814.15,APC
Oncology colon mrna,81525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5608.8,,,,,,,fee schedule,2960.2,9814.15,APC
Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,483.43,,,,,,,fee schedule,483.43,1606.87,
Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1397.28,,,,,,,fee schedule,483.43,1606.87,
Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1143.67,,,,,,,fee schedule,483.43,1606.87,
Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,916.06,,,,,,,fee schedule,483.43,1606.87,
Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1606.87,,,,,,,fee schedule,483.43,1606.87,
Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,534.31,,,,,,,fee schedule,483.43,1606.87,APC
Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,508.87,,,,,,,fee schedule,483.43,1606.87,APC
Oncology colorectal scr,81528,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,915.97,,,,,,,fee schedule,483.43,1606.87,APC
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6833.35,,,,,,,fee schedule,6833.35,12947.4,
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7552.65,,,,,,,fee schedule,6833.35,12947.4,APC
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7193,,,,,,,fee schedule,6833.35,12947.4,APC
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12947.4,,,,,,,fee schedule,6833.35,12947.4,APC
Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,550.49,,,,,,,fee schedule,550.49,1535.58,
Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1335.29,,,,,,,fee schedule,550.49,1535.58,
Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1092.93,,,,,,,fee schedule,550.49,1535.58,
Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,875.42,,,,,,,fee schedule,550.49,1535.58,
Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1535.58,,,,,,,fee schedule,550.49,1535.58,
Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,608.43,,,,,,,fee schedule,550.49,1535.58,APC
Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,579.46,,,,,,,fee schedule,550.49,1535.58,APC
Oncology gynecologic,81535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1043.03,,,,,,,fee schedule,550.49,1535.58,APC
Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,168.68,,,,,,,fee schedule,168.68,561.4,
Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,488.17,,,,,,,fee schedule,168.68,561.4,
Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,399.57,,,,,,,fee schedule,168.68,561.4,
Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,320.04,,,,,,,fee schedule,168.68,561.4,
Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,561.4,,,,,,,fee schedule,168.68,561.4,
Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,186.44,,,,,,,fee schedule,168.68,561.4,APC
Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,177.56,,,,,,,fee schedule,168.68,561.4,APC
Oncology gynecologic,81536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,319.61,,,,,,,fee schedule,168.68,561.4,APC
Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2727.45,,,,,,,fee schedule,2727.45,6677.64,
Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5806.64,,,,,,,fee schedule,2727.45,6677.64,
Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4752.73,,,,,,,fee schedule,2727.45,6677.64,
Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3806.83,,,,,,,fee schedule,2727.45,6677.64,
Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6677.64,,,,,,,fee schedule,2727.45,6677.64,
Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3014.55,,,,,,,fee schedule,2727.45,6677.64,APC
Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2871,,,,,,,fee schedule,2727.45,6677.64,APC
Oncology lung,81538,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5167.8,,,,,,,fee schedule,2727.45,6677.64,APC
Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,722,,,,,,,fee schedule,722,1890.47,
Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1643.89,,,,,,,fee schedule,722,1890.47,
Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1345.52,,,,,,,fee schedule,722,1890.47,
Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1077.73,,,,,,,fee schedule,722,1890.47,
Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1890.47,,,,,,,fee schedule,722,1890.47,
Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,722,1890.47,APC
Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760,,,,,,,fee schedule,722,1890.47,APC
Oncology prostate prob score,81539,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368,,,,,,,fee schedule,722,1890.47,APC
Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3562.5,,,,,,,fee schedule,3562.5,9169.12,
Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7973.15,,,,,,,fee schedule,3562.5,9169.12,
Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6526.02,,,,,,,fee schedule,3562.5,9169.12,
Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5227.2,,,,,,,fee schedule,3562.5,9169.12,
Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9169.12,,,,,,,fee schedule,3562.5,9169.12,
Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3937.5,,,,,,,fee schedule,3562.5,9169.12,APC
Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3750,,,,,,,fee schedule,3562.5,9169.12,APC
Oncology tum unknown origin,81540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6750,,,,,,,fee schedule,3562.5,9169.12,APC
Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3679.35,,,,,,,fee schedule,3679.35,10811.44,
Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9401.25,,,,,,,fee schedule,3679.35,10811.44,
Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7694.92,,,,,,,fee schedule,3679.35,10811.44,
Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6163.46,,,,,,,fee schedule,3679.35,10811.44,
Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10811.44,,,,,,,fee schedule,3679.35,10811.44,
Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3679.35,10811.44,APC
Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3679.35,10811.44,APC
Onc prostate mrna 46 genes,81541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3679.35,10811.44,APC
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3679.35,,,,,,,fee schedule,3679.35,8652.73,
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7524.11,,,,,,,fee schedule,3679.35,8652.73,
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6158.48,,,,,,,fee schedule,3679.35,8652.73,
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4932.81,,,,,,,fee schedule,3679.35,8652.73,
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8652.73,,,,,,,fee schedule,3679.35,8652.73,
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3679.35,8652.73,APC
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3873,,,,,,,fee schedule,3679.35,8652.73,APC
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6971.4,,,,,,,fee schedule,3679.35,8652.73,APC
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3420,,,,,,,fee schedule,3420,8042.82,
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6993.76,,,,,,,fee schedule,3420,8042.82,
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5724.39,,,,,,,fee schedule,3420,8042.82,
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4585.11,,,,,,,fee schedule,3420,8042.82,
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8042.82,,,,,,,fee schedule,3420,8042.82,
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3420,8042.82,APC
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3600,,,,,,,fee schedule,3420,8042.82,APC
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6480,,,,,,,fee schedule,3420,8042.82,APC
Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1928.5,,,,,,,fee schedule,916.06,3654,
Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1397.28,,,,,,,fee schedule,916.06,3654,
Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1143.67,,,,,,,fee schedule,916.06,3654,
Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,916.06,,,,,,,fee schedule,916.06,3654,
Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1606.87,,,,,,,fee schedule,916.06,3654,
Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2131.5,,,,,,,fee schedule,916.06,3654,APC
Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2030,,,,,,,fee schedule,916.06,3654,APC
Onc prostate 3 genes,81551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3654,,,,,,,fee schedule,916.06,3654,APC
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7387.2,,,,,,,fee schedule,7387.2,13996.8,
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8164.8,,,,,,,fee schedule,7387.2,13996.8,APC
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7776,,,,,,,fee schedule,7387.2,13996.8,APC
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13996.8,,,,,,,fee schedule,7387.2,13996.8,APC
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5244,,,,,,,fee schedule,864.86,9737.28,
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1319.19,,,,,,,fee schedule,864.86,9737.28,
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1079.76,,,,,,,fee schedule,864.86,9737.28,
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,864.86,,,,,,,fee schedule,864.86,9737.28,
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1517.07,,,,,,,fee schedule,864.86,9737.28,
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5680.08,,,,,,,fee schedule,864.86,9737.28,APC
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5409.6,,,,,,,fee schedule,864.86,9737.28,APC
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9737.28,,,,,,,fee schedule,864.86,9737.28,APC
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5297.4,,,,,,,fee schedule,3240,6092.01,
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4335.92,,,,,,,fee schedule,3240,6092.01,
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3472.98,,,,,,,fee schedule,3240,6092.01,
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6092.01,,,,,,,fee schedule,3240,6092.01,
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3402,,,,,,,fee schedule,3240,6092.01,APC
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3240,,,,,,,fee schedule,3240,6092.01,APC
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5832,,,,,,,fee schedule,3240,6092.01,APC
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,608.69,,,,,,,fee schedule,608.69,1153.31,
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672.77,,,,,,,fee schedule,608.69,1153.31,APC
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,640.73,,,,,,,fee schedule,608.69,1153.31,APC
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1153.31,,,,,,,fee schedule,608.69,1153.31,APC
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3078,,,,,,,fee schedule,3078,8919.35,
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7755.96,,,,,,,fee schedule,3078,8919.35,
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6348.25,,,,,,,fee schedule,3078,8919.35,
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5084.81,,,,,,,fee schedule,3078,8919.35,
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8919.35,,,,,,,fee schedule,3078,8919.35,
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3402,,,,,,,fee schedule,3078,8919.35,APC
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3240,,,,,,,fee schedule,3078,8919.35,APC
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5832,,,,,,,fee schedule,3078,8919.35,APC
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,68.58,,,,,,,fee schedule,68.58,217.94,
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.51,,,,,,,fee schedule,68.58,217.94,
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.11,,,,,,,fee schedule,68.58,217.94,
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.24,,,,,,,fee schedule,68.58,217.94,
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.94,,,,,,,fee schedule,68.58,217.94,
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.8,,,,,,,fee schedule,68.58,217.94,APC
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,72.19,,,,,,,fee schedule,68.58,217.94,APC
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.94,,,,,,,fee schedule,68.58,217.94,APC
Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.29,,,,,,,fee schedule,4.29,13.6,
Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.83,,,,,,,fee schedule,4.29,13.6,
Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.68,,,,,,,fee schedule,4.29,13.6,
Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.76,,,,,,,fee schedule,4.29,13.6,
Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.6,,,,,,,fee schedule,4.29,13.6,
Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.29,13.6,APC
Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.52,,,,,,,fee schedule,4.29,13.6,APC
Test for acetone/ketones,82009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.14,,,,,,,fee schedule,4.29,13.6,APC
Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.76,,,,,,,fee schedule,7.76,32.48,
Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.24,,,,,,,fee schedule,7.76,32.48,
Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.11,,,,,,,fee schedule,7.76,32.48,
Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.51,,,,,,,fee schedule,7.76,32.48,
Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.48,,,,,,,fee schedule,7.76,32.48,
Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.58,,,,,,,fee schedule,7.76,32.48,APC
Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.17,,,,,,,fee schedule,7.76,32.48,APC
Acetone assay,82010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.71,,,,,,,fee schedule,7.76,32.48,APC
Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.68,,,,,,,fee schedule,11.68,96.03,
Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.5,,,,,,,fee schedule,11.68,96.03,
Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.34,,,,,,,fee schedule,11.68,96.03,
Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.74,,,,,,,fee schedule,11.68,96.03,
Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.03,,,,,,,fee schedule,11.68,96.03,
Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.9,,,,,,,fee schedule,11.68,96.03,APC
Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.29,,,,,,,fee schedule,11.68,96.03,APC
Acetylcholinesterase assay,82013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.12,,,,,,,fee schedule,11.68,96.03,APC
Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.67,,,,,,,fee schedule,15.67,59.75,
Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.96,,,,,,,fee schedule,15.67,59.75,
Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.53,,,,,,,fee schedule,15.67,59.75,
Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.06,,,,,,,fee schedule,15.67,59.75,
Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.75,,,,,,,fee schedule,15.67,59.75,
Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.31,,,,,,,fee schedule,15.67,59.75,APC
Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.49,,,,,,,fee schedule,15.67,59.75,APC
Acylcarnitines qual,82016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.68,,,,,,,fee schedule,15.67,59.75,APC
Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.03,,,,,,,fee schedule,16.03,45.39,
Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.47,,,,,,,fee schedule,16.03,45.39,
Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.31,,,,,,,fee schedule,16.03,45.39,
Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.88,,,,,,,fee schedule,16.03,45.39,
Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.39,,,,,,,fee schedule,16.03,45.39,
Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,16.03,45.39,APC
Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.87,,,,,,,fee schedule,16.03,45.39,APC
Acylcarnitines quant,82017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.37,,,,,,,fee schedule,16.03,45.39,APC
Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.69,,,,,,,fee schedule,36.69,89.59,
Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.9,,,,,,,fee schedule,36.69,89.59,
Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.76,,,,,,,fee schedule,36.69,89.59,
Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.07,,,,,,,fee schedule,36.69,89.59,
Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.59,,,,,,,fee schedule,36.69,89.59,
Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.55,,,,,,,fee schedule,36.69,89.59,APC
Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.62,,,,,,,fee schedule,36.69,89.59,APC
Assay of acth,82024,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.52,,,,,,,fee schedule,36.69,89.59,APC
Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.51,,,,,,,fee schedule,24.51,98.89,
Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.99,,,,,,,fee schedule,24.51,98.89,
Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.38,,,,,,,fee schedule,24.51,98.89,
Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.38,,,,,,,fee schedule,24.51,98.89,
Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.89,,,,,,,fee schedule,24.51,98.89,
Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.09,,,,,,,fee schedule,24.51,98.89,APC
Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.8,,,,,,,fee schedule,24.51,98.89,APC
Assay of adp & amp,82030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.44,,,,,,,fee schedule,24.51,98.89,APC
Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.7,,,,,,,fee schedule,4.7,19.86,
Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.27,,,,,,,fee schedule,4.7,19.86,
Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.14,,,,,,,fee schedule,4.7,19.86,
Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.32,,,,,,,fee schedule,4.7,19.86,
Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.86,,,,,,,fee schedule,4.7,19.86,
Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.7,19.86,APC
Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.95,,,,,,,fee schedule,4.7,19.86,APC
Assay of serum albumin,82040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.91,,,,,,,fee schedule,4.7,19.86,APC
Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.39,,,,,,,fee schedule,7.39,19.88,
Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.29,,,,,,,fee schedule,7.39,19.88,
Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.15,,,,,,,fee schedule,7.39,19.88,
Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.34,,,,,,,fee schedule,7.39,19.88,
Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.88,,,,,,,fee schedule,7.39,19.88,
Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.17,,,,,,,fee schedule,7.39,19.88,APC
Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.78,,,,,,,fee schedule,7.39,19.88,APC
Assay of urine albumin,82042,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14,,,,,,,fee schedule,7.39,19.88,APC
Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.49,,,,,,,fee schedule,5.49,11.91,
Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.36,,,,,,,fee schedule,5.49,11.91,
Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.48,,,,,,,fee schedule,5.49,11.91,
Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.79,,,,,,,fee schedule,5.49,11.91,
Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.91,,,,,,,fee schedule,5.49,11.91,
Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.07,,,,,,,fee schedule,5.49,11.91,APC
Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.78,,,,,,,fee schedule,5.49,11.91,APC
Microalbumin quantitative,82043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.4,,,,,,,fee schedule,5.49,11.91,APC
Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.92,,,,,,,fee schedule,5.92,11.66,
Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.14,,,,,,,fee schedule,5.92,11.66,
Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.3,,,,,,,fee schedule,5.92,11.66,
Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.65,,,,,,,fee schedule,5.92,11.66,
Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.66,,,,,,,fee schedule,5.92,11.66,
Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.54,,,,,,,fee schedule,5.92,11.66,APC
Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.23,,,,,,,fee schedule,5.92,11.66,APC
Microalbumin semiquant,82044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.21,,,,,,,fee schedule,5.92,11.66,APC
Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.24,,,,,,,fee schedule,32.24,146.17,
Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.1,,,,,,,fee schedule,32.24,146.17,
Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.03,,,,,,,fee schedule,32.24,146.17,
Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.33,,,,,,,fee schedule,32.24,146.17,
Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.17,,,,,,,fee schedule,32.24,146.17,
Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.64,,,,,,,fee schedule,32.24,146.17,APC
Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.94,,,,,,,fee schedule,32.24,146.17,APC
Albumin ischemia modified,82045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.09,,,,,,,fee schedule,32.24,146.17,APC
Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,54,
Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.58,,,,,,,fee schedule,0.01,54,
Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.03,,,,,,,fee schedule,0.01,54,
Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.26,,,,,,,fee schedule,0.01,54,
Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.82,,,,,,,fee schedule,0.01,54,
Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.5,,,,,,,fee schedule,0.01,54,APC
Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30,,,,,,,fee schedule,0.01,54,APC
Assay of breath ethanol,82075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54,,,,,,,fee schedule,0.01,54,APC
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.41,,,,,,,fee schedule,16.41,38.57,
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.54,,,,,,,fee schedule,16.41,38.57,
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.45,,,,,,,fee schedule,16.41,38.57,
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.99,,,,,,,fee schedule,16.41,38.57,
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.57,,,,,,,fee schedule,16.41,38.57,
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,16.41,38.57,APC
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,16.41,38.57,APC
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,16.41,38.57,APC
Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.22,,,,,,,fee schedule,5.21,17.48,
Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.95,,,,,,,fee schedule,5.21,17.48,
Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.51,,,,,,,fee schedule,5.21,17.48,
Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.21,,,,,,,fee schedule,5.21,17.48,
Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.14,,,,,,,fee schedule,5.21,17.48,
Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.2,,,,,,,fee schedule,5.21,17.48,APC
Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.71,,,,,,,fee schedule,5.21,17.48,APC
Assay of aldolase,82085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.48,,,,,,,fee schedule,5.21,17.48,APC
Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,38.71,,,,,,,fee schedule,13.75,73.35,
Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.97,,,,,,,fee schedule,13.75,73.35,
Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.16,,,,,,,fee schedule,13.75,73.35,
Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.75,,,,,,,fee schedule,13.75,73.35,
Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.12,,,,,,,fee schedule,13.75,73.35,
Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.79,,,,,,,fee schedule,13.75,73.35,APC
Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40.75,,,,,,,fee schedule,13.75,73.35,APC
Assay of aldosterone,82088,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,73.35,,,,,,,fee schedule,13.75,73.35,APC
Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.77,,,,,,,fee schedule,12.77,47.27,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.1,,,,,,,fee schedule,12.77,47.27,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.64,,,,,,,fee schedule,12.77,47.27,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.95,,,,,,,fee schedule,12.77,47.27,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.27,,,,,,,fee schedule,12.77,47.27,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.11,,,,,,,fee schedule,12.77,47.27,APC
Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.44,,,,,,,fee schedule,12.77,47.27,APC
Alpha-1-antitrypsin total,82103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.19,,,,,,,fee schedule,12.77,47.27,APC
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.74,,,,,,,fee schedule,13.74,62.28,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.16,,,,,,,fee schedule,13.74,62.28,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.33,,,,,,,fee schedule,13.74,62.28,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.51,,,,,,,fee schedule,13.74,62.28,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.28,,,,,,,fee schedule,13.74,62.28,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.18,,,,,,,fee schedule,13.74,62.28,APC
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.46,,,,,,,fee schedule,13.74,62.28,APC
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.03,,,,,,,fee schedule,13.74,62.28,APC
Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.93,,,,,,,fee schedule,15.93,65.96,
Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.36,,,,,,,fee schedule,15.93,65.96,
Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.95,,,,,,,fee schedule,15.93,65.96,
Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.61,,,,,,,fee schedule,15.93,65.96,
Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.96,,,,,,,fee schedule,15.93,65.96,
Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.61,,,,,,,fee schedule,15.93,65.96,APC
Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.77,,,,,,,fee schedule,15.93,65.96,APC
Alpha-fetoprotein serum,82105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.19,,,,,,,fee schedule,15.93,65.96,APC
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.15,,,,,,,fee schedule,16.15,52.98,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.07,,,,,,,fee schedule,16.15,52.98,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.71,,,,,,,fee schedule,16.15,52.98,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.2,,,,,,,fee schedule,16.15,52.98,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.98,,,,,,,fee schedule,16.15,52.98,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.85,,,,,,,fee schedule,16.15,52.98,APC
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17,,,,,,,fee schedule,16.15,52.98,APC
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.6,,,,,,,fee schedule,16.15,52.98,APC
Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,61.19,,,,,,,fee schedule,61.19,277.43,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,241.24,,,,,,,fee schedule,61.19,277.43,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,197.45,,,,,,,fee schedule,61.19,277.43,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.16,,,,,,,fee schedule,61.19,277.43,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,277.43,,,,,,,fee schedule,61.19,277.43,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,61.19,277.43,APC
Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.41,,,,,,,fee schedule,61.19,277.43,APC
Alpha-Fetoprotein L3,82107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.94,,,,,,,fee schedule,61.19,277.43,APC
Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.21,,,,,,,fee schedule,24.21,67.36,
Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.57,,,,,,,fee schedule,24.21,67.36,
Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.94,,,,,,,fee schedule,24.21,67.36,
Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.4,,,,,,,fee schedule,24.21,67.36,
Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.36,,,,,,,fee schedule,24.21,67.36,
Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.75,,,,,,,fee schedule,24.21,67.36,APC
Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.48,,,,,,,fee schedule,24.21,67.36,APC
Assay of aluminum,82108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.86,,,,,,,fee schedule,24.21,67.36,APC
Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.69,,,,,,,fee schedule,5.69,16.22,
Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.1,,,,,,,fee schedule,5.69,16.22,
Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.54,,,,,,,fee schedule,5.69,16.22,
Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.24,,,,,,,fee schedule,5.69,16.22,
Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.22,,,,,,,fee schedule,5.69,16.22,
Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.29,,,,,,,fee schedule,5.69,16.22,APC
Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.99,,,,,,,fee schedule,5.69,16.22,APC
Amines vaginal fluid qual,82120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.78,,,,,,,fee schedule,5.69,16.22,APC
Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.47,,,,,,,fee schedule,13.47,59.75,
Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.96,,,,,,,fee schedule,13.47,59.75,
Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.53,,,,,,,fee schedule,13.47,59.75,
Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.06,,,,,,,fee schedule,13.47,59.75,
Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.75,,,,,,,fee schedule,13.47,59.75,
Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.89,,,,,,,fee schedule,13.47,59.75,APC
Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.18,,,,,,,fee schedule,13.47,59.75,APC
Amino acid single qual,82127,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.52,,,,,,,fee schedule,13.47,59.75,APC
Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.18,,,,,,,fee schedule,13.18,59.75,
Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.96,,,,,,,fee schedule,13.18,59.75,
Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.53,,,,,,,fee schedule,13.18,59.75,
Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.06,,,,,,,fee schedule,13.18,59.75,
Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.75,,,,,,,fee schedule,13.18,59.75,
Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.56,,,,,,,fee schedule,13.18,59.75,APC
Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.87,,,,,,,fee schedule,13.18,59.75,APC
Amino acids mult qual,82128,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.97,,,,,,,fee schedule,13.18,59.75,APC
Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.83,,,,,,,fee schedule,21.83,72.65,
Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.17,,,,,,,fee schedule,21.83,72.65,
Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.7,,,,,,,fee schedule,21.83,72.65,
Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.41,,,,,,,fee schedule,21.83,72.65,
Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.65,,,,,,,fee schedule,21.83,72.65,
Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.13,,,,,,,fee schedule,21.83,72.65,APC
Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.98,,,,,,,fee schedule,21.83,72.65,APC
Amino acids single quant,82131,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.36,,,,,,,fee schedule,21.83,72.65,APC
Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.63,,,,,,,fee schedule,15.63,60.55,
Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.65,,,,,,,fee schedule,15.63,60.55,
Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.09,,,,,,,fee schedule,15.63,60.55,
Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.52,,,,,,,fee schedule,15.63,60.55,
Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.55,,,,,,,fee schedule,15.63,60.55,
Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.27,,,,,,,fee schedule,15.63,60.55,APC
Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.45,,,,,,,fee schedule,15.63,60.55,APC
Assay aminolevulinic acid,82135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.61,,,,,,,fee schedule,15.63,60.55,APC
Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.63,,,,,,,fee schedule,18.63,97.51,
Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.79,,,,,,,fee schedule,18.63,97.51,
Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.4,,,,,,,fee schedule,18.63,97.51,
Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.59,,,,,,,fee schedule,18.63,97.51,
Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.51,,,,,,,fee schedule,18.63,97.51,
Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.59,,,,,,,fee schedule,18.63,97.51,APC
Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.61,,,,,,,fee schedule,18.63,97.51,APC
Amino acids quant 2-5,82136,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.3,,,,,,,fee schedule,18.63,97.51,APC
Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.03,,,,,,,fee schedule,16.03,105.49,
Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.73,,,,,,,fee schedule,16.03,105.49,
Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.08,,,,,,,fee schedule,16.03,105.49,
Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.14,,,,,,,fee schedule,16.03,105.49,
Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.49,,,,,,,fee schedule,16.03,105.49,
Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,16.03,105.49,APC
Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.87,,,,,,,fee schedule,16.03,105.49,APC
Amino acids quan 6 or more,82139,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.37,,,,,,,fee schedule,16.03,105.49,APC
Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.84,,,,,,,fee schedule,13.84,58.94,
Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.25,,,,,,,fee schedule,13.84,58.94,
Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.95,,,,,,,fee schedule,13.84,58.94,
Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.6,,,,,,,fee schedule,13.84,58.94,
Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.94,,,,,,,fee schedule,13.84,58.94,
Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.3,,,,,,,fee schedule,13.84,58.94,APC
Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.57,,,,,,,fee schedule,13.84,58.94,APC
Assay of ammonia,82140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.23,,,,,,,fee schedule,13.84,58.94,APC
Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.88,,,,,,,fee schedule,8.88,29.57,
Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.71,,,,,,,fee schedule,8.88,29.57,
Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.04,,,,,,,fee schedule,8.88,29.57,
Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.86,,,,,,,fee schedule,8.88,29.57,
Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.57,,,,,,,fee schedule,8.88,29.57,
Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.82,,,,,,,fee schedule,8.88,29.57,APC
Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.35,,,,,,,fee schedule,8.88,29.57,APC
Amniotic fluid scan,82143,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.83,,,,,,,fee schedule,8.88,29.57,APC
Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.16,,,,,,,fee schedule,6.16,13.41,
Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.66,,,,,,,fee schedule,6.16,13.41,
Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.54,,,,,,,fee schedule,6.16,13.41,
Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.64,,,,,,,fee schedule,6.16,13.41,
Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.41,,,,,,,fee schedule,6.16,13.41,
Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.8,,,,,,,fee schedule,6.16,13.41,APC
Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.48,,,,,,,fee schedule,6.16,13.41,APC
Assay of amylase,82150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.66,,,,,,,fee schedule,6.16,13.41,APC
Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.39,,,,,,,fee schedule,27.39,124.19,
Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.99,,,,,,,fee schedule,27.39,124.19,
Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.39,,,,,,,fee schedule,27.39,124.19,
Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.8,,,,,,,fee schedule,27.39,124.19,
Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.19,,,,,,,fee schedule,27.39,124.19,
Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.27,,,,,,,fee schedule,27.39,124.19,APC
Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.83,,,,,,,fee schedule,27.39,124.19,APC
Androstanediol glucuronide,82154,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.89,,,,,,,fee schedule,27.39,124.19,APC
Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.82,,,,,,,fee schedule,15.06,52.7,
Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.97,,,,,,,fee schedule,15.06,52.7,
Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.8,,,,,,,fee schedule,15.06,52.7,
Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.06,,,,,,,fee schedule,15.06,52.7,
Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.42,,,,,,,fee schedule,15.06,52.7,
Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.74,,,,,,,fee schedule,15.06,52.7,APC
Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.28,,,,,,,fee schedule,15.06,52.7,APC
Assay of androstenedione,82157,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.7,,,,,,,fee schedule,15.06,52.7,APC
Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.27,,,,,,,fee schedule,24.27,50.14,
Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.6,,,,,,,fee schedule,24.27,50.14,
Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.69,,,,,,,fee schedule,24.27,50.14,
Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.58,,,,,,,fee schedule,24.27,50.14,
Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.14,,,,,,,fee schedule,24.27,50.14,
Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.83,,,,,,,fee schedule,24.27,50.14,APC
Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.55,,,,,,,fee schedule,24.27,50.14,APC
Assay of androsterone,82160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.99,,,,,,,fee schedule,24.27,50.14,APC
Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.49,,,,,,,fee schedule,19.49,88.39,
Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.86,,,,,,,fee schedule,19.49,88.39,
Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.91,,,,,,,fee schedule,19.49,88.39,
Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.39,,,,,,,fee schedule,19.49,88.39,
Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.39,,,,,,,fee schedule,19.49,88.39,
Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.55,,,,,,,fee schedule,19.49,88.39,APC
Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.52,,,,,,,fee schedule,19.49,88.39,APC
Assay of angiotensin II,82163,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.94,,,,,,,fee schedule,19.49,88.39,APC
Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.87,,,,,,,fee schedule,13.87,58.1,
Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.52,,,,,,,fee schedule,13.87,58.1,
Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.35,,,,,,,fee schedule,13.87,58.1,
Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.12,,,,,,,fee schedule,13.87,58.1,
Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.1,,,,,,,fee schedule,13.87,58.1,
Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.33,,,,,,,fee schedule,13.87,58.1,APC
Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.6,,,,,,,fee schedule,13.87,58.1,APC
Angiotensin I enzyme test,82164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.28,,,,,,,fee schedule,13.87,58.1,APC
Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.48,,,,,,,fee schedule,16.7,69.52,
Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.86,,,,,,,fee schedule,16.7,69.52,
Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.7,,,,,,,fee schedule,16.7,69.52,
Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.3,,,,,,,fee schedule,16.7,69.52,
Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.55,,,,,,,fee schedule,16.7,69.52,APC
Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.62,,,,,,,fee schedule,16.7,69.52,APC
Assay anti-mullerian horm,82166,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.52,,,,,,,fee schedule,16.7,69.52,APC
Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.04,,,,,,,fee schedule,20.04,66.73,
Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.03,,,,,,,fee schedule,20.04,66.73,
Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.5,,,,,,,fee schedule,20.04,66.73,
Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.04,,,,,,,fee schedule,20.04,66.73,
Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.73,,,,,,,fee schedule,20.04,66.73,
Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.14,,,,,,,fee schedule,20.04,66.73,APC
Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.09,,,,,,,fee schedule,20.04,66.73,APC
Assay of apolipoprotein,82172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.96,,,,,,,fee schedule,20.04,66.73,APC
Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.02,,,,,,,fee schedule,8.45,34.15,
Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.89,,,,,,,fee schedule,8.45,34.15,
Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.55,,,,,,,fee schedule,8.45,34.15,
Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.45,,,,,,,fee schedule,8.45,34.15,
Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.82,,,,,,,fee schedule,8.45,34.15,
Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.92,,,,,,,fee schedule,8.45,34.15,APC
Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.97,,,,,,,fee schedule,8.45,34.15,APC
Assay of arsenic,82175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.15,,,,,,,fee schedule,8.45,34.15,APC
Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.4,,,,,,,fee schedule,9.4,33.03,
Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.72,,,,,,,fee schedule,9.4,33.03,
Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.51,,,,,,,fee schedule,9.4,33.03,
Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.83,,,,,,,fee schedule,9.4,33.03,
Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.03,,,,,,,fee schedule,9.4,33.03,
Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.38,,,,,,,fee schedule,9.4,33.03,APC
Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.89,,,,,,,fee schedule,9.4,33.03,APC
Assay of ascorbic acid,82180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.8,,,,,,,fee schedule,9.4,33.03,APC
Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.11,,,,,,,fee schedule,15.11,60.44,
Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.56,,,,,,,fee schedule,15.11,60.44,
Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.02,,,,,,,fee schedule,15.11,60.44,
Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.46,,,,,,,fee schedule,15.11,60.44,
Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.44,,,,,,,fee schedule,15.11,60.44,
Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.7,,,,,,,fee schedule,15.11,60.44,APC
Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.9,,,,,,,fee schedule,15.11,60.44,APC
Atomic absorption,82190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.62,,,,,,,fee schedule,15.11,60.44,APC
Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.37,,,,,,,fee schedule,6.96,29.12,
Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.62,,,,,,,fee schedule,6.96,29.12,
Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.69,,,,,,,fee schedule,6.96,29.12,
Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.96,,,,,,,fee schedule,6.96,29.12,
Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.21,,,,,,,fee schedule,6.96,29.12,
Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.99,,,,,,,fee schedule,6.96,29.12,APC
Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.18,,,,,,,fee schedule,6.96,29.12,APC
Assay of beta-2 protein,82232,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.12,,,,,,,fee schedule,6.96,29.12,APC
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.24,,,,,,,fee schedule,18.51,232.06,
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.11,,,,,,,fee schedule,18.51,232.06,
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.51,,,,,,,fee schedule,18.51,232.06,
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.48,,,,,,,fee schedule,18.51,232.06,
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.37,,,,,,,fee schedule,18.51,232.06,APC
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.92,,,,,,,fee schedule,18.51,232.06,APC
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,232.06,,,,,,,fee schedule,18.51,232.06,APC
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.24,,,,,,,fee schedule,18.51,232.06,
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.11,,,,,,,fee schedule,18.51,232.06,
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.51,,,,,,,fee schedule,18.51,232.06,
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.48,,,,,,,fee schedule,18.51,232.06,
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.37,,,,,,,fee schedule,18.51,232.06,APC
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.92,,,,,,,fee schedule,18.51,232.06,APC
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,232.06,,,,,,,fee schedule,18.51,232.06,APC
Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.26,,,,,,,fee schedule,16.26,73.73,
Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.11,,,,,,,fee schedule,16.26,73.73,
Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.47,,,,,,,fee schedule,16.26,73.73,
Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.03,,,,,,,fee schedule,16.26,73.73,
Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.73,,,,,,,fee schedule,16.26,73.73,
Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.98,,,,,,,fee schedule,16.26,73.73,APC
Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.12,,,,,,,fee schedule,16.26,73.73,APC
Bile acids total,82239,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.82,,,,,,,fee schedule,16.26,73.73,APC
Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.25,,,,,,,fee schedule,25.25,114.47,
Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.54,,,,,,,fee schedule,25.25,114.47,
Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.47,,,,,,,fee schedule,25.25,114.47,
Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.26,,,,,,,fee schedule,25.25,114.47,
Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.47,,,,,,,fee schedule,25.25,114.47,
Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.91,,,,,,,fee schedule,25.25,114.47,APC
Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.58,,,,,,,fee schedule,25.25,114.47,APC
Bile acids cholylglycine,82240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.84,,,,,,,fee schedule,25.25,114.47,APC
Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.77,,,,,,,fee schedule,4.77,10.42,
Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.06,,,,,,,fee schedule,4.77,10.42,
Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.42,,,,,,,fee schedule,4.77,10.42,
Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.94,,,,,,,fee schedule,4.77,10.42,
Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.42,,,,,,,fee schedule,4.77,10.42,
Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.77,10.42,APC
Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.02,,,,,,,fee schedule,4.77,10.42,APC
Bilirubin total,82247,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.04,,,,,,,fee schedule,4.77,10.42,APC
Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.77,,,,,,,fee schedule,4.77,20.93,
Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.2,,,,,,,fee schedule,4.77,20.93,
Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.9,,,,,,,fee schedule,4.77,20.93,
Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.93,,,,,,,fee schedule,4.77,20.93,
Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.93,,,,,,,fee schedule,4.77,20.93,
Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.77,20.93,APC
Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.02,,,,,,,fee schedule,4.77,20.93,APC
Bilirubin direct,82248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.04,,,,,,,fee schedule,4.77,20.93,APC
Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.33,,,,,,,fee schedule,4.33,19.62,
Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.06,,,,,,,fee schedule,4.33,19.62,
Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.96,,,,,,,fee schedule,4.33,19.62,
Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.18,,,,,,,fee schedule,4.33,19.62,
Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.62,,,,,,,fee schedule,4.33,19.62,
Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.79,,,,,,,fee schedule,4.33,19.62,APC
Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.56,,,,,,,fee schedule,4.33,19.62,APC
Fecal bilirubin test,82252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.21,,,,,,,fee schedule,4.33,19.62,APC
Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.03,,,,,,,fee schedule,16.03,51.83,
Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,16.03,51.83,
Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,16.03,51.83,
Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,16.03,51.83,
Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,16.03,51.83,
Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,16.03,51.83,APC
Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.87,,,,,,,fee schedule,16.03,51.83,APC
Assay of biotinidase,82261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.37,,,,,,,fee schedule,16.03,51.83,APC
Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.16,,,,,,,fee schedule,4.16,21.02,
Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.28,,,,,,,fee schedule,4.16,21.02,
Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.96,,,,,,,fee schedule,4.16,21.02,
Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.98,,,,,,,fee schedule,4.16,21.02,
Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.02,,,,,,,fee schedule,4.16,21.02,
Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.6,,,,,,,fee schedule,4.16,21.02,APC
Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.38,,,,,,,fee schedule,4.16,21.02,APC
Occult blood feces,82270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.88,,,,,,,fee schedule,4.16,21.02,APC
Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.05,,,,,,,fee schedule,5.05,11.12,
Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.67,,,,,,,fee schedule,5.05,11.12,
Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.91,,,,,,,fee schedule,5.05,11.12,
Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.34,,,,,,,fee schedule,5.05,11.12,
Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.12,,,,,,,fee schedule,5.05,11.12,
Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.59,,,,,,,fee schedule,5.05,11.12,APC
Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.32,,,,,,,fee schedule,5.05,11.12,APC
Occult blood other sources,82271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.58,,,,,,,fee schedule,5.05,11.12,APC
Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.02,,,,,,,fee schedule,4.02,21.83,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.98,,,,,,,fee schedule,4.02,21.83,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.54,,,,,,,fee schedule,4.02,21.83,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.44,,,,,,,fee schedule,4.02,21.83,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.83,,,,,,,fee schedule,4.02,21.83,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,4.02,21.83,APC
Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.23,,,,,,,fee schedule,4.02,21.83,APC
Occult bld feces 1-3 tests,82272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.61,,,,,,,fee schedule,4.02,21.83,APC
Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.12,,,,,,,fee schedule,15.12,53.05,
Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.13,,,,,,,fee schedule,15.12,53.05,
Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.76,,,,,,,fee schedule,15.12,53.05,
Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.24,,,,,,,fee schedule,15.12,53.05,
Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.05,,,,,,,fee schedule,15.12,53.05,
Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.72,,,,,,,fee schedule,15.12,53.05,APC
Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.92,,,,,,,fee schedule,15.12,53.05,APC
Assay test for blood fecal,82274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.66,,,,,,,fee schedule,15.12,53.05,APC
Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.9,,,,,,,fee schedule,4.9,29.67,
Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.8,,,,,,,fee schedule,4.9,29.67,
Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.12,,,,,,,fee schedule,4.9,29.67,
Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.91,,,,,,,fee schedule,4.9,29.67,
Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.67,,,,,,,fee schedule,4.9,29.67,
Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.42,,,,,,,fee schedule,4.9,29.67,APC
Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.16,,,,,,,fee schedule,4.9,29.67,APC
Assay of bradykinin,82286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.29,,,,,,,fee schedule,4.9,29.67,APC
Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.46,,,,,,,fee schedule,10.31,42.55,
Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.72,,,,,,,fee schedule,10.31,42.55,
Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.87,,,,,,,fee schedule,10.31,42.55,
Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.31,,,,,,,fee schedule,10.31,42.55,
Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.08,,,,,,,fee schedule,10.31,42.55,
Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.82,,,,,,,fee schedule,10.31,42.55,APC
Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.64,,,,,,,fee schedule,10.31,42.55,APC
Assay of cadmium,82300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42.55,,,,,,,fee schedule,10.31,42.55,APC
Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.12,,,,,,,fee schedule,28.12,61.05,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.09,,,,,,,fee schedule,28.12,61.05,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.45,,,,,,,fee schedule,28.12,61.05,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.81,,,,,,,fee schedule,28.12,61.05,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.05,,,,,,,fee schedule,28.12,61.05,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.08,,,,,,,fee schedule,28.12,61.05,APC
Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.6,,,,,,,fee schedule,28.12,61.05,APC
Vitamin d 25 hydroxy,82306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.28,,,,,,,fee schedule,28.12,61.05,APC
Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.45,,,,,,,fee schedule,12.56,48.22,
Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.16,,,,,,,fee schedule,12.56,48.22,
Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.68,,,,,,,fee schedule,12.56,48.22,
Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.56,,,,,,,fee schedule,12.56,48.22,
Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.03,,,,,,,fee schedule,12.56,48.22,
Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.13,,,,,,,fee schedule,12.56,48.22,APC
Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.79,,,,,,,fee schedule,12.56,48.22,APC
Assay of calcitonin,82308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.22,,,,,,,fee schedule,12.56,48.22,APC
Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.9,,,,,,,fee schedule,4.9,21.28,
Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.5,,,,,,,fee schedule,4.9,21.28,
Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.14,,,,,,,fee schedule,4.9,21.28,
Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.13,,,,,,,fee schedule,4.9,21.28,
Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.28,,,,,,,fee schedule,4.9,21.28,
Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.42,,,,,,,fee schedule,4.9,21.28,APC
Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.16,,,,,,,fee schedule,4.9,21.28,APC
Assay of calcium,82310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.29,,,,,,,fee schedule,4.9,21.28,APC
Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13,,,,,,,fee schedule,13,53.39,
Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.43,,,,,,,fee schedule,13,53.39,
Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38,,,,,,,fee schedule,13,53.39,
Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.44,,,,,,,fee schedule,13,53.39,
Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.39,,,,,,,fee schedule,13,53.39,
Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.36,,,,,,,fee schedule,13,53.39,APC
Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.68,,,,,,,fee schedule,13,53.39,APC
Assay of calcium,82330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.62,,,,,,,fee schedule,13,53.39,APC
Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.67,,,,,,,fee schedule,12.67,24.01,
Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.38,,,,,,,fee schedule,12.67,24.01,
Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.86,,,,,,,fee schedule,12.67,24.01,
Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.71,,,,,,,fee schedule,12.67,24.01,
Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.29,,,,,,,fee schedule,12.67,24.01,
Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.01,,,,,,,fee schedule,12.67,24.01,APC
Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.34,,,,,,,fee schedule,12.67,24.01,APC
Calcium infusion test,82331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.01,,,,,,,fee schedule,12.67,24.01,APC
Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.73,,,,,,,fee schedule,5.73,24.05,
Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.91,,,,,,,fee schedule,5.73,24.05,
Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.11,,,,,,,fee schedule,5.73,24.05,
Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.71,,,,,,,fee schedule,5.73,24.05,
Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.05,,,,,,,fee schedule,5.73,24.05,
Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.33,,,,,,,fee schedule,5.73,24.05,APC
Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.03,,,,,,,fee schedule,5.73,24.05,APC
Assay of calcium in urine,82340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.85,,,,,,,fee schedule,5.73,24.05,APC
Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11,,,,,,,fee schedule,11,49.86,
Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.36,,,,,,,fee schedule,11,49.86,
Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.49,,,,,,,fee schedule,11,49.86,
Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.43,,,,,,,fee schedule,11,49.86,
Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.86,,,,,,,fee schedule,11,49.86,
Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.16,,,,,,,fee schedule,11,49.86,APC
Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.58,,,,,,,fee schedule,11,49.86,APC
Calculus analysis qual,82355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.84,,,,,,,fee schedule,11,49.86,APC
Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.23,,,,,,,fee schedule,12.23,55.43,
Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.2,,,,,,,fee schedule,12.23,55.43,
Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.45,,,,,,,fee schedule,12.23,55.43,
Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.6,,,,,,,fee schedule,12.23,55.43,
Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.43,,,,,,,fee schedule,12.23,55.43,
Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,12.23,55.43,APC
Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.87,,,,,,,fee schedule,12.23,55.43,APC
Calculus assay quant,82360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.17,,,,,,,fee schedule,12.23,55.43,APC
Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.26,,,,,,,fee schedule,10.79,23.22,
Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.46,,,,,,,fee schedule,10.79,23.22,
Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.47,,,,,,,fee schedule,10.79,23.22,
Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.79,,,,,,,fee schedule,10.79,23.22,
Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.93,,,,,,,fee schedule,10.79,23.22,
Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.54,,,,,,,fee schedule,10.79,23.22,APC
Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.9,,,,,,,fee schedule,10.79,23.22,APC
Calculus spectroscopy,82365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.22,,,,,,,fee schedule,10.79,23.22,APC
X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.89,,,,,,,fee schedule,11.89,53.91,
X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.88,,,,,,,fee schedule,11.89,53.91,
X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.37,,,,,,,fee schedule,11.89,53.91,
X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.73,,,,,,,fee schedule,11.89,53.91,
X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.91,,,,,,,fee schedule,11.89,53.91,
X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.15,,,,,,,fee schedule,11.89,53.91,APC
X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.52,,,,,,,fee schedule,11.89,53.91,APC
X-ray assay calculus,82370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.54,,,,,,,fee schedule,11.89,53.91,APC
Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.16,,,,,,,fee schedule,17.16,57.13,
Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.68,,,,,,,fee schedule,17.16,57.13,
Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.66,,,,,,,fee schedule,17.16,57.13,
Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.57,,,,,,,fee schedule,17.16,57.13,
Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.13,,,,,,,fee schedule,17.16,57.13,
Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.96,,,,,,,fee schedule,17.16,57.13,APC
Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.06,,,,,,,fee schedule,17.16,57.13,APC
Assay c-d transfer measure,82373,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.51,,,,,,,fee schedule,17.16,57.13,APC
Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.64,,,,,,,fee schedule,4.64,21.03,
Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.29,,,,,,,fee schedule,4.64,21.03,
Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.97,,,,,,,fee schedule,4.64,21.03,
Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.99,,,,,,,fee schedule,4.64,21.03,
Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.03,,,,,,,fee schedule,4.64,21.03,
Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.12,,,,,,,fee schedule,4.64,21.03,APC
Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.88,,,,,,,fee schedule,4.64,21.03,APC
Assay blood carbon dioxide,82374,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.78,,,,,,,fee schedule,4.64,21.03,APC
Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.7,,,,,,,fee schedule,11.7,97.61,
Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.88,,,,,,,fee schedule,11.7,97.61,
Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.47,,,,,,,fee schedule,11.7,97.61,
Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.65,,,,,,,fee schedule,11.7,97.61,
Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.61,,,,,,,fee schedule,11.7,97.61,
Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.94,,,,,,,fee schedule,11.7,97.61,APC
Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.32,,,,,,,fee schedule,11.7,97.61,APC
Assay carboxyhb quant,82375,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.18,,,,,,,fee schedule,11.7,97.61,APC
Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.37,,,,,,,fee schedule,13.37,25.81,
Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.44,,,,,,,fee schedule,13.37,25.81,
Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.37,,,,,,,fee schedule,13.37,25.81,
Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.71,,,,,,,fee schedule,13.37,25.81,
Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.81,,,,,,,fee schedule,13.37,25.81,
Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.77,,,,,,,fee schedule,13.37,25.81,APC
Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.07,,,,,,,fee schedule,13.37,25.81,APC
Assay carboxyhb qual,82376,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.33,,,,,,,fee schedule,13.37,25.81,APC
Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.01,,,,,,,fee schedule,18.01,76.38,
Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.42,,,,,,,fee schedule,18.01,76.38,
Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.36,,,,,,,fee schedule,18.01,76.38,
Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.54,,,,,,,fee schedule,18.01,76.38,
Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.38,,,,,,,fee schedule,18.01,76.38,
Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.91,,,,,,,fee schedule,18.01,76.38,APC
Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.96,,,,,,,fee schedule,18.01,76.38,APC
Carcinoembryonic antigen,82378,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.13,,,,,,,fee schedule,18.01,76.38,APC
Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.03,,,,,,,fee schedule,16.03,35.45,
Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.83,,,,,,,fee schedule,16.03,35.45,
Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.23,,,,,,,fee schedule,16.03,35.45,
Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.21,,,,,,,fee schedule,16.03,35.45,
Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.45,,,,,,,fee schedule,16.03,35.45,
Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,16.03,35.45,APC
Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.87,,,,,,,fee schedule,16.03,35.45,APC
Assay of carnitine,82379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.37,,,,,,,fee schedule,16.03,35.45,APC
Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.76,,,,,,,fee schedule,8.76,25.66,
Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.31,,,,,,,fee schedule,8.76,25.66,
Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.26,,,,,,,fee schedule,8.76,25.66,
Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.63,,,,,,,fee schedule,8.76,25.66,
Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.66,,,,,,,fee schedule,8.76,25.66,
Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.68,,,,,,,fee schedule,8.76,25.66,APC
Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.22,,,,,,,fee schedule,8.76,25.66,APC
Assay of carotene,82380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.6,,,,,,,fee schedule,8.76,25.66,APC
Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.94,,,,,,,fee schedule,25.94,74.05,
Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.39,,,,,,,fee schedule,25.94,74.05,
Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.7,,,,,,,fee schedule,25.94,74.05,
Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.21,,,,,,,fee schedule,25.94,74.05,
Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.05,,,,,,,fee schedule,25.94,74.05,
Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.66,,,,,,,fee schedule,25.94,74.05,APC
Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.3,,,,,,,fee schedule,25.94,74.05,APC
Assay urine catecholamines,82382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49.14,,,,,,,fee schedule,25.94,74.05,APC
Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.63,,,,,,,fee schedule,27.63,107.9,
Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,93.83,,,,,,,fee schedule,27.63,107.9,
Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.8,,,,,,,fee schedule,27.63,107.9,
Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.51,,,,,,,fee schedule,27.63,107.9,
Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,107.9,,,,,,,fee schedule,27.63,107.9,
Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.53,,,,,,,fee schedule,27.63,107.9,APC
Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.08,,,,,,,fee schedule,27.63,107.9,APC
Assay blood catecholamines,82383,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.34,,,,,,,fee schedule,27.63,107.9,APC
Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.99,,,,,,,fee schedule,23.99,52.08,
Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.29,,,,,,,fee schedule,23.99,52.08,
Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.07,,,,,,,fee schedule,23.99,52.08,
Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.69,,,,,,,fee schedule,23.99,52.08,
Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.08,,,,,,,fee schedule,23.99,52.08,
Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.51,,,,,,,fee schedule,23.99,52.08,APC
Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.25,,,,,,,fee schedule,23.99,52.08,APC
Assay three catecholamines,82384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.45,,,,,,,fee schedule,23.99,52.08,APC
Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.16,,,,,,,fee schedule,17.16,86.66,
Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.36,,,,,,,fee schedule,17.16,86.66,
Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.68,,,,,,,fee schedule,17.16,86.66,
Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.41,,,,,,,fee schedule,17.16,86.66,
Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.66,,,,,,,fee schedule,17.16,86.66,
Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.96,,,,,,,fee schedule,17.16,86.66,APC
Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.06,,,,,,,fee schedule,17.16,86.66,APC
Assay of cathepsin-d,82387,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.51,,,,,,,fee schedule,17.16,86.66,APC
Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.2,,,,,,,fee schedule,10.2,47.52,
Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.32,,,,,,,fee schedule,10.2,47.52,
Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.82,,,,,,,fee schedule,10.2,47.52,
Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.09,,,,,,,fee schedule,10.2,47.52,
Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.52,,,,,,,fee schedule,10.2,47.52,
Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,10.2,47.52,APC
Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.74,,,,,,,fee schedule,10.2,47.52,APC
Assay of ceruloplasmin,82390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.33,,,,,,,fee schedule,10.2,47.52,APC
Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.41,,,,,,,fee schedule,13.41,33.61,
Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.23,,,,,,,fee schedule,13.41,33.61,
Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.92,,,,,,,fee schedule,13.41,33.61,
Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.16,,,,,,,fee schedule,13.41,33.61,
Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.61,,,,,,,fee schedule,13.41,33.61,
Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.83,,,,,,,fee schedule,13.41,33.61,APC
Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.12,,,,,,,fee schedule,13.41,33.61,APC
Chemiluminescent assay,82397,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.42,,,,,,,fee schedule,13.41,33.61,APC
Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.04,,,,,,,fee schedule,12.04,54.57,
Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.45,,,,,,,fee schedule,12.04,54.57,
Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.84,,,,,,,fee schedule,12.04,54.57,
Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.11,,,,,,,fee schedule,12.04,54.57,
Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.57,,,,,,,fee schedule,12.04,54.57,
Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.3,,,,,,,fee schedule,12.04,54.57,APC
Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.67,,,,,,,fee schedule,12.04,54.57,APC
Assay of chloramphenicol,82415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.81,,,,,,,fee schedule,12.04,54.57,APC
Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.37,,,,,,,fee schedule,4.37,17.73,
Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.42,,,,,,,fee schedule,4.37,17.73,
Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.62,,,,,,,fee schedule,4.37,17.73,
Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.11,,,,,,,fee schedule,4.37,17.73,
Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.73,,,,,,,fee schedule,4.37,17.73,
Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.83,,,,,,,fee schedule,4.37,17.73,APC
Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.6,,,,,,,fee schedule,4.37,17.73,APC
Assay of blood chloride,82435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.28,,,,,,,fee schedule,4.37,17.73,APC
Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.46,,,,,,,fee schedule,5.46,19.65,
Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.09,,,,,,,fee schedule,5.46,19.65,
Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.99,,,,,,,fee schedule,5.46,19.65,
Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.2,,,,,,,fee schedule,5.46,19.65,
Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.65,,,,,,,fee schedule,5.46,19.65,
Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.04,,,,,,,fee schedule,5.46,19.65,APC
Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.75,,,,,,,fee schedule,5.46,19.65,APC
Assay of urine chloride,82436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.35,,,,,,,fee schedule,5.46,19.65,APC
Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.75,,,,,,,fee schedule,4.75,37.29,
Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.43,,,,,,,fee schedule,4.75,37.29,
Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.54,,,,,,,fee schedule,4.75,37.29,
Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.26,,,,,,,fee schedule,4.75,37.29,
Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.29,,,,,,,fee schedule,4.75,37.29,
Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.25,,,,,,,fee schedule,4.75,37.29,APC
Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5,,,,,,,fee schedule,4.75,37.29,APC
Assay other fluid chlorides,82438,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9,,,,,,,fee schedule,4.75,37.29,APC
Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.71,,,,,,,fee schedule,5.71,25.86,
Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.49,,,,,,,fee schedule,5.71,25.86,
Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.41,,,,,,,fee schedule,5.71,25.86,
Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.74,,,,,,,fee schedule,5.71,25.86,
Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.86,,,,,,,fee schedule,5.71,25.86,
Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.31,,,,,,,fee schedule,5.71,25.86,APC
Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.01,,,,,,,fee schedule,5.71,25.86,APC
Test for chlorohydrocarbons,82441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.82,,,,,,,fee schedule,5.71,25.86,APC
Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.13,,,,,,,fee schedule,4.13,18.48,
Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.07,,,,,,,fee schedule,4.13,18.48,
Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.15,,,,,,,fee schedule,4.13,18.48,
Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.54,,,,,,,fee schedule,4.13,18.48,
Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.48,,,,,,,fee schedule,4.13,18.48,
Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.57,,,,,,,fee schedule,4.13,18.48,APC
Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.35,,,,,,,fee schedule,4.13,18.48,APC
Assay bld/serum cholesterol,82465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.83,,,,,,,fee schedule,4.13,18.48,APC
Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.48,,,,,,,fee schedule,7.48,29.3,
Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.48,,,,,,,fee schedule,7.48,29.3,
Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.86,,,,,,,fee schedule,7.48,29.3,
Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.7,,,,,,,fee schedule,7.48,29.3,
Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.3,,,,,,,fee schedule,7.48,29.3,
Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.26,,,,,,,fee schedule,7.48,29.3,APC
Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.87,,,,,,,fee schedule,7.48,29.3,APC
Assay serum cholinesterase,82480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.17,,,,,,,fee schedule,7.48,29.3,APC
Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.32,,,,,,,fee schedule,9.32,46.29,
Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.25,,,,,,,fee schedule,9.32,46.29,
Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.94,,,,,,,fee schedule,9.32,46.29,
Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.39,,,,,,,fee schedule,9.32,46.29,
Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.29,,,,,,,fee schedule,9.32,46.29,
Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.3,,,,,,,fee schedule,9.32,46.29,APC
Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.81,,,,,,,fee schedule,9.32,46.29,APC
Assay rbc cholinesterase,82482,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.66,,,,,,,fee schedule,9.32,46.29,APC
Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.62,,,,,,,fee schedule,19.62,88.95,
Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.35,,,,,,,fee schedule,19.62,88.95,
Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.31,,,,,,,fee schedule,19.62,88.95,
Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.71,,,,,,,fee schedule,19.62,88.95,
Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.95,,,,,,,fee schedule,19.62,88.95,
Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.68,,,,,,,fee schedule,19.62,88.95,APC
Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.65,,,,,,,fee schedule,19.62,88.95,APC
Assay chondroitin sulfate,82485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.17,,,,,,,fee schedule,19.62,88.95,APC
Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.27,,,,,,,fee schedule,19.27,64.04,
Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.69,,,,,,,fee schedule,19.27,64.04,
Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.58,,,,,,,fee schedule,19.27,64.04,
Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.51,,,,,,,fee schedule,19.27,64.04,
Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.04,,,,,,,fee schedule,19.27,64.04,
Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.29,,,,,,,fee schedule,19.27,64.04,APC
Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.28,,,,,,,fee schedule,19.27,64.04,APC
Assay of chromium,82495,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.5,,,,,,,fee schedule,19.27,64.04,APC
Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.41,,,,,,,fee schedule,26.41,50.04,
Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.72,,,,,,,fee schedule,26.41,50.04,
Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.33,,,,,,,fee schedule,26.41,50.04,
Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.7,,,,,,,fee schedule,26.41,50.04,
Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.83,,,,,,,fee schedule,26.41,50.04,
Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.19,,,,,,,fee schedule,26.41,50.04,APC
Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.8,,,,,,,fee schedule,26.41,50.04,APC
Assay of citrate,82507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.04,,,,,,,fee schedule,26.41,50.04,APC
Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.75,,,,,,,fee schedule,17.75,117.13,
Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.85,,,,,,,fee schedule,17.75,117.13,
Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.36,,,,,,,fee schedule,17.75,117.13,
Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.77,,,,,,,fee schedule,17.75,117.13,
Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.13,,,,,,,fee schedule,17.75,117.13,
Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.61,,,,,,,fee schedule,17.75,117.13,APC
Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.68,,,,,,,fee schedule,17.75,117.13,APC
Collagen crosslinks,82523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.62,,,,,,,fee schedule,17.75,117.13,APC
Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.79,,,,,,,fee schedule,11.79,22.34,
Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.39,,,,,,,fee schedule,11.79,22.34,
Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.05,,,,,,,fee schedule,11.79,22.34,
Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.06,,,,,,,fee schedule,11.79,22.34,
Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.15,,,,,,,fee schedule,11.79,22.34,
Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.03,,,,,,,fee schedule,11.79,22.34,APC
Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.41,,,,,,,fee schedule,11.79,22.34,APC
Assay of copper,82525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.34,,,,,,,fee schedule,11.79,22.34,APC
Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.39,,,,,,,fee schedule,21.39,96.97,
Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.32,,,,,,,fee schedule,21.39,96.97,
Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.02,,,,,,,fee schedule,21.39,96.97,
Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.28,,,,,,,fee schedule,21.39,96.97,
Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.97,,,,,,,fee schedule,21.39,96.97,
Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.65,,,,,,,fee schedule,21.39,96.97,APC
Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.52,,,,,,,fee schedule,21.39,96.97,APC
Assay of corticosterone,82528,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40.54,,,,,,,fee schedule,21.39,96.97,APC
Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.87,,,,,,,fee schedule,13.28,30.08,
Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.25,,,,,,,fee schedule,13.28,30.08,
Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.57,,,,,,,fee schedule,13.28,30.08,
Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.28,,,,,,,fee schedule,13.28,30.08,
Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.29,,,,,,,fee schedule,13.28,30.08,
Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.55,,,,,,,fee schedule,13.28,30.08,APC
Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.71,,,,,,,fee schedule,13.28,30.08,APC
Cortisol free,82530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.08,,,,,,,fee schedule,13.28,30.08,APC
Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.49,,,,,,,fee schedule,15.49,63.64,
Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.34,,,,,,,fee schedule,15.49,63.64,
Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.3,,,,,,,fee schedule,15.49,63.64,
Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.28,,,,,,,fee schedule,15.49,63.64,
Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.64,,,,,,,fee schedule,15.49,63.64,
Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.12,,,,,,,fee schedule,15.49,63.64,APC
Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.3,,,,,,,fee schedule,15.49,63.64,APC
Total cortisol,82533,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.34,,,,,,,fee schedule,15.49,63.64,APC
Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.41,,,,,,,fee schedule,4.41,112.78,
Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.07,,,,,,,fee schedule,4.41,112.78,
Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.27,,,,,,,fee schedule,4.41,112.78,
Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.29,,,,,,,fee schedule,4.41,112.78,
Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.78,,,,,,,fee schedule,4.41,112.78,
Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.87,,,,,,,fee schedule,4.41,112.78,APC
Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.64,,,,,,,fee schedule,4.41,112.78,APC
Assay of creatine,82540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.35,,,,,,,fee schedule,4.41,112.78,APC
Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.89,,,,,,,fee schedule,18.27,43.36,
Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.87,,,,,,,fee schedule,18.27,43.36,
Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.81,,,,,,,fee schedule,18.27,43.36,
Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.27,,,,,,,fee schedule,18.27,43.36,
Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.05,,,,,,,fee schedule,18.27,43.36,
Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.29,,,,,,,fee schedule,18.27,43.36,APC
Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.09,,,,,,,fee schedule,18.27,43.36,APC
Col chromotography qual/quan,82542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.36,,,,,,,fee schedule,18.27,43.36,APC
Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.18,,,,,,,fee schedule,6.18,13.41,
Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.66,,,,,,,fee schedule,6.18,13.41,
Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.54,,,,,,,fee schedule,6.18,13.41,
Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.64,,,,,,,fee schedule,6.18,13.41,
Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.41,,,,,,,fee schedule,6.18,13.41,
Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.84,,,,,,,fee schedule,6.18,13.41,APC
Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.51,,,,,,,fee schedule,6.18,13.41,APC
Assay of ck (cpk),82550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.72,,,,,,,fee schedule,6.18,13.41,APC
Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.72,,,,,,,fee schedule,12.72,57.67,
Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.15,,,,,,,fee schedule,12.72,57.67,
Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.05,,,,,,,fee schedule,12.72,57.67,
Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.88,,,,,,,fee schedule,12.72,57.67,
Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.67,,,,,,,fee schedule,12.72,57.67,
Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.06,,,,,,,fee schedule,12.72,57.67,APC
Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.39,,,,,,,fee schedule,12.72,57.67,APC
Assay of cpk in blood,82552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.1,,,,,,,fee schedule,12.72,57.67,APC
Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.97,,,,,,,fee schedule,8.49,20.79,
Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.95,,,,,,,fee schedule,8.49,20.79,
Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.6,,,,,,,fee schedule,8.49,20.79,
Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.49,,,,,,,fee schedule,8.49,20.79,
Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.89,,,,,,,fee schedule,8.49,20.79,
Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.13,,,,,,,fee schedule,8.49,20.79,APC
Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.55,,,,,,,fee schedule,8.49,20.79,APC
Creatine mb fraction,82553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.79,,,,,,,fee schedule,8.49,20.79,APC
Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.28,,,,,,,fee schedule,11.28,51.11,
Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.44,,,,,,,fee schedule,11.28,51.11,
Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.37,,,,,,,fee schedule,11.28,51.11,
Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.13,,,,,,,fee schedule,11.28,51.11,
Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.11,,,,,,,fee schedule,11.28,51.11,
Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,11.28,51.11,APC
Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.87,,,,,,,fee schedule,11.28,51.11,APC
Creatine isoforms,82554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.37,,,,,,,fee schedule,11.28,51.11,APC
Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.86,,,,,,,fee schedule,4.86,10.42,
Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.06,,,,,,,fee schedule,4.86,10.42,
Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.42,,,,,,,fee schedule,4.86,10.42,
Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.94,,,,,,,fee schedule,4.86,10.42,
Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.42,,,,,,,fee schedule,4.86,10.42,
Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.38,,,,,,,fee schedule,4.86,10.42,APC
Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.12,,,,,,,fee schedule,4.86,10.42,APC
Assay of creatinine,82565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.22,,,,,,,fee schedule,4.86,10.42,APC
Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.92,,,,,,,fee schedule,4.92,19.92,
Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.32,,,,,,,fee schedule,4.92,19.92,
Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.18,,,,,,,fee schedule,4.92,19.92,
Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.35,,,,,,,fee schedule,4.92,19.92,
Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.92,,,,,,,fee schedule,4.92,19.92,
Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.92,19.92,APC
Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.18,,,,,,,fee schedule,4.92,19.92,APC
Assay of urine creatinine,82570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.32,,,,,,,fee schedule,4.92,19.92,APC
Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.99,,,,,,,fee schedule,8.99,37.73,
Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.81,,,,,,,fee schedule,8.99,37.73,
Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.85,,,,,,,fee schedule,8.99,37.73,
Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.51,,,,,,,fee schedule,8.99,37.73,
Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.73,,,,,,,fee schedule,8.99,37.73,
Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.93,,,,,,,fee schedule,8.99,37.73,APC
Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.46,,,,,,,fee schedule,8.99,37.73,APC
Creatinine clearance test,82575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.03,,,,,,,fee schedule,8.99,37.73,APC
Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.43,,,,,,,fee schedule,5.65,25.45,
Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.62,,,,,,,fee schedule,5.65,25.45,
Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.06,,,,,,,fee schedule,5.65,25.45,
Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.65,,,,,,,fee schedule,5.65,25.45,
Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.91,,,,,,,fee schedule,5.65,25.45,
Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.85,,,,,,,fee schedule,5.65,25.45,APC
Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.14,,,,,,,fee schedule,5.65,25.45,APC
Assay of cryofibrinogen,82585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.45,,,,,,,fee schedule,5.65,25.45,APC
Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.15,,,,,,,fee schedule,4.16,11.65,
Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.34,,,,,,,fee schedule,4.16,11.65,
Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.19,,,,,,,fee schedule,4.16,11.65,
Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.16,,,,,,,fee schedule,4.16,11.65,
Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.29,,,,,,,fee schedule,4.16,11.65,
Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,4.16,11.65,APC
Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,4.16,11.65,APC
Assay of cryoglobulin,82595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,4.16,11.65,APC
Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.43,,,,,,,fee schedule,18.43,69.72,
Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.63,,,,,,,fee schedule,18.43,69.72,
Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.63,,,,,,,fee schedule,18.43,69.72,
Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.75,,,,,,,fee schedule,18.43,69.72,
Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.72,,,,,,,fee schedule,18.43,69.72,
Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.37,,,,,,,fee schedule,18.43,69.72,APC
Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.4,,,,,,,fee schedule,18.43,69.72,APC
Assay of cyanide,82600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.92,,,,,,,fee schedule,18.43,69.72,APC
Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.33,,,,,,,fee schedule,14.33,59.75,
Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.96,,,,,,,fee schedule,14.33,59.75,
Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.53,,,,,,,fee schedule,14.33,59.75,
Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.06,,,,,,,fee schedule,14.33,59.75,
Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.75,,,,,,,fee schedule,14.33,59.75,
Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.83,,,,,,,fee schedule,14.33,59.75,APC
Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.08,,,,,,,fee schedule,14.33,59.75,APC
Vitamin B-12,82607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.14,,,,,,,fee schedule,14.33,59.75,APC
B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.6,,,,,,,fee schedule,13.6,81.31,
B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.7,,,,,,,fee schedule,13.6,81.31,
B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.87,,,,,,,fee schedule,13.6,81.31,
B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.35,,,,,,,fee schedule,13.6,81.31,
B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.31,,,,,,,fee schedule,13.6,81.31,
B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.04,,,,,,,fee schedule,13.6,81.31,APC
B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.32,,,,,,,fee schedule,13.6,81.31,APC
B-12 binding capacity,82608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.78,,,,,,,fee schedule,13.6,81.31,APC
Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.59,,,,,,,fee schedule,17.59,55.87,
Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.58,,,,,,,fee schedule,17.59,55.87,
Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.76,,,,,,,fee schedule,17.59,55.87,
Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.85,,,,,,,fee schedule,17.59,55.87,
Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.87,,,,,,,fee schedule,17.59,55.87,
Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.45,,,,,,,fee schedule,17.59,55.87,APC
Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.52,,,,,,,fee schedule,17.59,55.87,APC
Cystatin c,82610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.34,,,,,,,fee schedule,17.59,55.87,APC
Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.07,,,,,,,fee schedule,9.07,30.48,
Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,9.07,30.48,
Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,9.07,30.48,
Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,9.07,30.48,
Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,9.07,30.48,
Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.03,,,,,,,fee schedule,9.07,30.48,APC
Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.55,,,,,,,fee schedule,9.07,30.48,APC
Test for urine cystines,82615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.19,,,,,,,fee schedule,9.07,30.48,APC
Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.01,,,,,,,fee schedule,13.75,45.49,
Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.97,,,,,,,fee schedule,13.75,45.49,
Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.16,,,,,,,fee schedule,13.75,45.49,
Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.75,,,,,,,fee schedule,13.75,45.49,
Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.12,,,,,,,fee schedule,13.75,45.49,
Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.53,,,,,,,fee schedule,13.75,45.49,APC
Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.27,,,,,,,fee schedule,13.75,45.49,APC
Dehydroepiandrosterone,82626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.49,,,,,,,fee schedule,13.75,45.49,APC
Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.12,,,,,,,fee schedule,21.12,87.99,
Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.51,,,,,,,fee schedule,21.12,87.99,
Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.62,,,,,,,fee schedule,21.12,87.99,
Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.16,,,,,,,fee schedule,21.12,87.99,
Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.99,,,,,,,fee schedule,21.12,87.99,
Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.34,,,,,,,fee schedule,21.12,87.99,APC
Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.12,87.99,APC
Dehydroepiandrosterone,82627,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40.01,,,,,,,fee schedule,21.12,87.99,APC
Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.43,,,,,,,fee schedule,29.43,88.03,
Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.55,,,,,,,fee schedule,29.43,88.03,
Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.66,,,,,,,fee schedule,29.43,88.03,
Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.19,,,,,,,fee schedule,29.43,88.03,
Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.03,,,,,,,fee schedule,29.43,88.03,
Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.53,,,,,,,fee schedule,29.43,88.03,APC
Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.98,,,,,,,fee schedule,29.43,88.03,APC
Desoxycorticosterone,82633,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55.76,,,,,,,fee schedule,29.43,88.03,APC
Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.82,,,,,,,fee schedule,27.82,88.03,
Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.55,,,,,,,fee schedule,27.82,88.03,
Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.66,,,,,,,fee schedule,27.82,88.03,
Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.19,,,,,,,fee schedule,27.82,88.03,
Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.03,,,,,,,fee schedule,27.82,88.03,
Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.74,,,,,,,fee schedule,27.82,88.03,APC
Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.28,,,,,,,fee schedule,27.82,88.03,APC
Deoxycortisol,82634,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.7,,,,,,,fee schedule,27.82,88.03,APC
Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.64,,,,,,,fee schedule,11.64,52.74,
Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.86,,,,,,,fee schedule,11.64,52.74,
Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.54,,,,,,,fee schedule,11.64,52.74,
Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.07,,,,,,,fee schedule,11.64,52.74,
Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.74,,,,,,,fee schedule,11.64,52.74,
Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.86,,,,,,,fee schedule,11.64,52.74,APC
Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.25,,,,,,,fee schedule,11.64,52.74,APC
Assay of dibucaine number,82638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.05,,,,,,,fee schedule,11.64,52.74,APC
Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.86,,,,,,,fee schedule,27.82,109.09,
Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.82,,,,,,,fee schedule,27.82,109.09,
Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.64,,,,,,,fee schedule,27.82,109.09,
Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.19,,,,,,,fee schedule,27.82,109.09,
Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.09,,,,,,,fee schedule,27.82,109.09,
Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.74,,,,,,,fee schedule,27.82,109.09,APC
Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.28,,,,,,,fee schedule,27.82,109.09,APC
Dihydrotestosterone,82642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.7,,,,,,,fee schedule,27.82,109.09,APC
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.08,,,,,,,fee schedule,13.82,69.3,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.58,,,,,,,fee schedule,13.82,69.3,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.25,,,,,,,fee schedule,13.82,69.3,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.82,,,,,,,fee schedule,13.82,69.3,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.24,,,,,,,fee schedule,13.82,69.3,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.42,,,,,,,fee schedule,13.82,69.3,APC
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.5,,,,,,,fee schedule,13.82,69.3,APC
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.3,,,,,,,fee schedule,13.82,69.3,APC
El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.65,,,,,,,fee schedule,21.82,51.35,
El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.82,,,,,,,fee schedule,21.82,51.35,
El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.55,,,,,,,fee schedule,21.82,51.35,
El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.27,,,,,,,fee schedule,21.82,51.35,
El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.35,,,,,,,fee schedule,21.82,51.35,
El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.12,,,,,,,fee schedule,21.82,51.35,APC
El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.97,,,,,,,fee schedule,21.82,51.35,APC
El-1 fecal quantitative,82653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.35,,,,,,,fee schedule,21.82,51.35,APC
Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,186.83,,,,,,,fee schedule,10.95,214.85,
Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.95,,,,,,,fee schedule,10.95,214.85,
Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,152.92,,,,,,,fee schedule,10.95,214.85,
Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.49,,,,,,,fee schedule,10.95,214.85,
Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,214.85,,,,,,,fee schedule,10.95,214.85,
Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.95,214.85,APC
Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.53,,,,,,,fee schedule,10.95,214.85,APC
Pancreatic elastase fecal,82656,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.75,,,,,,,fee schedule,10.95,214.85,APC
Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,167.52,,,,,,,fee schedule,21.06,192.65,
Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.06,,,,,,,fee schedule,21.06,192.65,
Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.12,,,,,,,fee schedule,21.06,192.65,
Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.83,,,,,,,fee schedule,21.06,192.65,
Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,192.65,,,,,,,fee schedule,21.06,192.65,
Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.28,,,,,,,fee schedule,21.06,192.65,APC
Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.17,,,,,,,fee schedule,21.06,192.65,APC
Enzyme cell activity,82657,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.91,,,,,,,fee schedule,21.06,192.65,APC
Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.62,,,,,,,fee schedule,28.6,79.25,
Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,41.83,,,,,,,fee schedule,28.6,79.25,
Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.7,,,,,,,fee schedule,28.6,79.25,
Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.6,,,,,,,fee schedule,28.6,79.25,
Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.16,,,,,,,fee schedule,28.6,79.25,
Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.23,,,,,,,fee schedule,28.6,79.25,APC
Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,44.03,,,,,,,fee schedule,28.6,79.25,APC
Enzyme cell activity ra,82658,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,79.25,,,,,,,fee schedule,28.6,79.25,APC
Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.17,,,,,,,fee schedule,37.48,110.7,
Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,58.43,,,,,,,fee schedule,37.48,110.7,
Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.79,,,,,,,fee schedule,37.48,110.7,
Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.48,,,,,,,fee schedule,37.48,110.7,
Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.75,,,,,,,fee schedule,37.48,110.7,
Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.58,,,,,,,fee schedule,37.48,110.7,APC
Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,61.5,,,,,,,fee schedule,37.48,110.7,APC
Electrophoretic test,82664,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,110.7,,,,,,,fee schedule,37.48,110.7,APC
Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.86,,,,,,,fee schedule,9.74,33.82,
Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.85,,,,,,,fee schedule,9.74,33.82,
Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.16,,,,,,,fee schedule,9.74,33.82,
Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.74,,,,,,,fee schedule,9.74,33.82,
Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.09,,,,,,,fee schedule,9.74,33.82,
Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.73,,,,,,,fee schedule,9.74,33.82,APC
Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.79,,,,,,,fee schedule,9.74,33.82,APC
Assay of erythropoietin,82668,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.82,,,,,,,fee schedule,9.74,33.82,APC
Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.2,,,,,,,fee schedule,26.54,56.58,
Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.54,,,,,,,fee schedule,26.54,56.58,
Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.27,,,,,,,fee schedule,26.54,56.58,
Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.26,,,,,,,fee schedule,26.54,56.58,
Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.58,,,,,,,fee schedule,26.54,56.58,
Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.34,,,,,,,fee schedule,26.54,56.58,APC
Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.94,,,,,,,fee schedule,26.54,56.58,APC
Assay of estradiol,82670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.29,,,,,,,fee schedule,26.54,56.58,APC
Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.71,,,,,,,fee schedule,16.86,58.14,
Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,30.69,,,,,,,fee schedule,16.86,58.14,
Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.04,,,,,,,fee schedule,16.86,58.14,
Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.86,,,,,,,fee schedule,16.86,58.14,
Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.57,,,,,,,fee schedule,16.86,58.14,
Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.92,,,,,,,fee schedule,16.86,58.14,APC
Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.3,,,,,,,fee schedule,16.86,58.14,APC
Assay of estrogens,82671,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.14,,,,,,,fee schedule,16.86,58.14,APC
Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.24,,,,,,,fee schedule,20.62,93.43,
Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.62,,,,,,,fee schedule,20.62,93.43,
Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.49,,,,,,,fee schedule,20.62,93.43,
Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.26,,,,,,,fee schedule,20.62,93.43,
Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.43,,,,,,,fee schedule,20.62,93.43,
Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.78,,,,,,,fee schedule,20.62,93.43,APC
Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.7,,,,,,,fee schedule,20.62,93.43,APC
Assay of estrogen,82672,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.06,,,,,,,fee schedule,20.62,93.43,APC
Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.99,,,,,,,fee schedule,13.76,43.52,
Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.97,,,,,,,fee schedule,13.76,43.52,
Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.18,,,,,,,fee schedule,13.76,43.52,
Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.76,,,,,,,fee schedule,13.76,43.52,
Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.14,,,,,,,fee schedule,13.76,43.52,
Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.39,,,,,,,fee schedule,13.76,43.52,APC
Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.18,,,,,,,fee schedule,13.76,43.52,APC
Assay of estriol,82677,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.52,,,,,,,fee schedule,13.76,43.52,APC
Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.7,,,,,,,fee schedule,20.57,44.91,
Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.37,,,,,,,fee schedule,20.57,44.91,
Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.68,,,,,,,fee schedule,20.57,44.91,
Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.57,,,,,,,fee schedule,20.57,44.91,
Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.08,,,,,,,fee schedule,20.57,44.91,
Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.2,,,,,,,fee schedule,20.57,44.91,APC
Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.95,,,,,,,fee schedule,20.57,44.91,APC
Assay of estrone,82679,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.91,,,,,,,fee schedule,20.57,44.91,APC
Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.54,,,,,,,fee schedule,26.54,62.42,
Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.28,,,,,,,fee schedule,26.54,62.42,
Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.43,,,,,,,fee schedule,26.54,62.42,
Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.59,,,,,,,fee schedule,26.54,62.42,
Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.42,,,,,,,fee schedule,26.54,62.42,
Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.34,,,,,,,fee schedule,26.54,62.42,APC
Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.94,,,,,,,fee schedule,26.54,62.42,APC
Assay dir meas fr estradiol,82681,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.29,,,,,,,fee schedule,26.54,62.42,APC
Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.16,,,,,,,fee schedule,14.16,64.18,
Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.81,,,,,,,fee schedule,14.16,64.18,
Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.68,,,,,,,fee schedule,14.16,64.18,
Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.59,,,,,,,fee schedule,14.16,64.18,
Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.18,,,,,,,fee schedule,14.16,64.18,
Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.64,,,,,,,fee schedule,14.16,64.18,APC
Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.9,,,,,,,fee schedule,14.16,64.18,APC
Assay of ethylene glycol,82693,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.82,,,,,,,fee schedule,14.16,64.18,APC
Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.93,,,,,,,fee schedule,24.93,80.14,
Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.69,,,,,,,fee schedule,24.93,80.14,
Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.04,,,,,,,fee schedule,24.93,80.14,
Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.69,,,,,,,fee schedule,24.93,80.14,
Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.14,,,,,,,fee schedule,24.93,80.14,
Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.55,,,,,,,fee schedule,24.93,80.14,APC
Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.24,,,,,,,fee schedule,24.93,80.14,APC
Assay of etiocholanolone,82696,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.23,,,,,,,fee schedule,24.93,80.14,APC
Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.85,,,,,,,fee schedule,4.85,21.94,
Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.08,,,,,,,fee schedule,4.85,21.94,
Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.62,,,,,,,fee schedule,4.85,21.94,
Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.51,,,,,,,fee schedule,4.85,21.94,
Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.94,,,,,,,fee schedule,4.85,21.94,
Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.36,,,,,,,fee schedule,4.85,21.94,APC
Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.1,,,,,,,fee schedule,4.85,21.94,APC
Fats/lipids feces qual,82705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.18,,,,,,,fee schedule,4.85,21.94,APC
Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.96,,,,,,,fee schedule,15.96,30.87,
Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.84,,,,,,,fee schedule,15.96,30.87,
Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.97,,,,,,,fee schedule,15.96,30.87,
Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.6,,,,,,,fee schedule,15.96,30.87,
Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.87,,,,,,,fee schedule,15.96,30.87,
Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.64,,,,,,,fee schedule,15.96,30.87,APC
Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.8,,,,,,,fee schedule,15.96,30.87,APC
Fats/lipids feces quant,82710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.24,,,,,,,fee schedule,15.96,30.87,APC
Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.82,,,,,,,fee schedule,21.82,74.12,
Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.45,,,,,,,fee schedule,21.82,74.12,
Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.75,,,,,,,fee schedule,21.82,74.12,
Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.25,,,,,,,fee schedule,21.82,74.12,
Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.12,,,,,,,fee schedule,21.82,74.12,
Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.12,,,,,,,fee schedule,21.82,74.12,APC
Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.97,,,,,,,fee schedule,21.82,74.12,APC
Assay of fecal fat,82715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.35,,,,,,,fee schedule,21.82,74.12,APC
Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.83,,,,,,,fee schedule,17.83,57.33,
Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.85,,,,,,,fee schedule,17.83,57.33,
Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.8,,,,,,,fee schedule,17.83,57.33,
Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.68,,,,,,,fee schedule,17.83,57.33,
Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.33,,,,,,,fee schedule,17.83,57.33,
Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.71,,,,,,,fee schedule,17.83,57.33,APC
Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.77,,,,,,,fee schedule,17.83,57.33,APC
Assay of blood fatty acids,82725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.79,,,,,,,fee schedule,17.83,57.33,APC
Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.76,,,,,,,fee schedule,18.76,99.31,
Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.36,,,,,,,fee schedule,18.76,99.31,
Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.69,,,,,,,fee schedule,18.76,99.31,
Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.62,,,,,,,fee schedule,18.76,99.31,
Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.31,,,,,,,fee schedule,18.76,99.31,
Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.74,,,,,,,fee schedule,18.76,99.31,APC
Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.75,,,,,,,fee schedule,18.76,99.31,APC
Long chain fatty acids,82726,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.55,,,,,,,fee schedule,18.76,99.31,APC
Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.95,,,,,,,fee schedule,12.95,28.29,
Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.6,,,,,,,fee schedule,12.95,28.29,
Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.14,,,,,,,fee schedule,12.95,28.29,
Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.13,,,,,,,fee schedule,12.95,28.29,
Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.29,,,,,,,fee schedule,12.95,28.29,
Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.31,,,,,,,fee schedule,12.95,28.29,APC
Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.63,,,,,,,fee schedule,12.95,28.29,APC
Assay of ferritin,82728,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.53,,,,,,,fee schedule,12.95,28.29,APC
Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,61.19,,,,,,,fee schedule,61.19,261.72,
Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.58,,,,,,,fee schedule,61.19,261.72,
Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.27,,,,,,,fee schedule,61.19,261.72,
Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.2,,,,,,,fee schedule,61.19,261.72,
Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.72,,,,,,,fee schedule,61.19,261.72,
Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,61.19,261.72,APC
Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.41,,,,,,,fee schedule,61.19,261.72,APC
Assay of fetal fibronectin,82731,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.94,,,,,,,fee schedule,61.19,261.72,APC
Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.61,,,,,,,fee schedule,17.61,57.64,
Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.12,,,,,,,fee schedule,17.61,57.64,
Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.02,,,,,,,fee schedule,17.61,57.64,
Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.86,,,,,,,fee schedule,17.61,57.64,
Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.64,,,,,,,fee schedule,17.61,57.64,
Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,17.61,57.64,APC
Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,17.61,57.64,APC
Assay of fluoride,82735,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,17.61,57.64,APC
Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.97,,,,,,,fee schedule,13.97,29.8,
Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.91,,,,,,,fee schedule,13.97,29.8,
Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.21,,,,,,,fee schedule,13.97,29.8,
Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.99,,,,,,,fee schedule,13.97,29.8,
Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.8,,,,,,,fee schedule,13.97,29.8,
Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.44,,,,,,,fee schedule,13.97,29.8,APC
Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.7,,,,,,,fee schedule,13.97,29.8,APC
Assay of folic acid serum,82746,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.46,,,,,,,fee schedule,13.97,29.8,APC
Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.77,,,,,,,fee schedule,16.77,74.59,
Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.86,,,,,,,fee schedule,16.77,74.59,
Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.09,,,,,,,fee schedule,16.77,74.59,
Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.52,,,,,,,fee schedule,16.77,74.59,
Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.59,,,,,,,fee schedule,16.77,74.59,
Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.53,,,,,,,fee schedule,16.77,74.59,APC
Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.65,,,,,,,fee schedule,16.77,74.59,APC
Assay of folic acid rbc,82747,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.77,,,,,,,fee schedule,16.77,74.59,APC
Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.47,,,,,,,fee schedule,16.47,74.66,
Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.92,,,,,,,fee schedule,16.47,74.66,
Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.14,,,,,,,fee schedule,16.47,74.66,
Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.56,,,,,,,fee schedule,16.47,74.66,
Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.66,,,,,,,fee schedule,16.47,74.66,
Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.21,,,,,,,fee schedule,16.47,74.66,APC
Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.34,,,,,,,fee schedule,16.47,74.66,APC
Assay of semen fructose,82757,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.21,,,,,,,fee schedule,16.47,74.66,APC
Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.41,,,,,,,fee schedule,20.41,92.53,
Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.46,,,,,,,fee schedule,20.41,92.53,
Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.86,,,,,,,fee schedule,20.41,92.53,
Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.75,,,,,,,fee schedule,20.41,92.53,
Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.53,,,,,,,fee schedule,20.41,92.53,
Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.55,,,,,,,fee schedule,20.41,92.53,APC
Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.48,,,,,,,fee schedule,20.41,92.53,APC
Assay of rbc galactokinase,82759,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.66,,,,,,,fee schedule,20.41,92.53,APC
Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.64,,,,,,,fee schedule,10.64,35.35,
Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.74,,,,,,,fee schedule,10.64,35.35,
Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.16,,,,,,,fee schedule,10.64,35.35,
Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.15,,,,,,,fee schedule,10.64,35.35,
Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.35,,,,,,,fee schedule,10.64,35.35,
Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.76,,,,,,,fee schedule,10.64,35.35,APC
Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.2,,,,,,,fee schedule,10.64,35.35,APC
Assay of galactose,82760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.16,,,,,,,fee schedule,10.64,35.35,APC
Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.02,,,,,,,fee schedule,20.02,90.72,
Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.89,,,,,,,fee schedule,20.02,90.72,
Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.57,,,,,,,fee schedule,20.02,90.72,
Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.72,,,,,,,fee schedule,20.02,90.72,
Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.72,,,,,,,fee schedule,20.02,90.72,
Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.12,,,,,,,fee schedule,20.02,90.72,APC
Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.07,,,,,,,fee schedule,20.02,90.72,APC
Assay galactose transferase,82775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.93,,,,,,,fee schedule,20.02,90.72,APC
Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.15,,,,,,,fee schedule,11.15,36.13,
Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.42,,,,,,,fee schedule,11.15,36.13,
Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.72,,,,,,,fee schedule,11.15,36.13,
Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.6,,,,,,,fee schedule,11.15,36.13,
Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.13,,,,,,,fee schedule,11.15,36.13,
Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.33,,,,,,,fee schedule,11.15,36.13,APC
Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.74,,,,,,,fee schedule,11.15,36.13,APC
Galactose transferase test,82776,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.13,,,,,,,fee schedule,11.15,36.13,APC
Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,42.04,,,,,,,fee schedule,42.04,94.7,
Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.35,,,,,,,fee schedule,42.04,94.7,
Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.4,,,,,,,fee schedule,42.04,94.7,
Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.99,,,,,,,fee schedule,42.04,94.7,
Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.7,,,,,,,fee schedule,42.04,94.7,
Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.46,,,,,,,fee schedule,42.04,94.7,APC
Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,44.25,,,,,,,fee schedule,42.04,94.7,APC
Galectin-3,82777,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,79.65,,,,,,,fee schedule,42.04,94.7,APC
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.84,,,,,,,fee schedule,8.84,36.77,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.97,,,,,,,fee schedule,8.84,36.77,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.17,,,,,,,fee schedule,8.84,36.77,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.96,,,,,,,fee schedule,8.84,36.77,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.77,,,,,,,fee schedule,8.84,36.77,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.76,,,,,,,fee schedule,8.84,36.77,APC
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.3,,,,,,,fee schedule,8.84,36.77,APC
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.74,,,,,,,fee schedule,8.84,36.77,APC
Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.64,,,,,,,fee schedule,15.64,64.89,
Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.43,,,,,,,fee schedule,15.64,64.89,
Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.19,,,,,,,fee schedule,15.64,64.89,
Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37,,,,,,,fee schedule,15.64,64.89,
Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.89,,,,,,,fee schedule,15.64,64.89,
Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.28,,,,,,,fee schedule,15.64,64.89,APC
Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.46,,,,,,,fee schedule,15.64,64.89,APC
Assay of ige,82785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.63,,,,,,,fee schedule,15.64,64.89,APC
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.62,,,,,,,fee schedule,7.62,19.83,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.24,,,,,,,fee schedule,7.62,19.83,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.11,,,,,,,fee schedule,7.62,19.83,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.3,,,,,,,fee schedule,7.62,19.83,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.83,,,,,,,fee schedule,7.62,19.83,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.42,,,,,,,fee schedule,7.62,19.83,APC
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.02,,,,,,,fee schedule,7.62,19.83,APC
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.44,,,,,,,fee schedule,7.62,19.83,APC
Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.45,,,,,,,fee schedule,10.45,33.49,
Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.12,,,,,,,fee schedule,10.45,33.49,
Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.83,,,,,,,fee schedule,10.45,33.49,
Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.09,,,,,,,fee schedule,10.45,33.49,
Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.49,,,,,,,fee schedule,10.45,33.49,
Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.55,,,,,,,fee schedule,10.45,33.49,APC
Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11,,,,,,,fee schedule,10.45,33.49,APC
Blood pH,82800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.8,,,,,,,fee schedule,10.45,33.49,APC
Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.77,,,,,,,fee schedule,24.77,76.43,
Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.46,,,,,,,fee schedule,24.77,76.43,
Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.4,,,,,,,fee schedule,24.77,76.43,
Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.57,,,,,,,fee schedule,24.77,76.43,
Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.43,,,,,,,fee schedule,24.77,76.43,
Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.37,,,,,,,fee schedule,24.77,76.43,APC
Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.07,,,,,,,fee schedule,24.77,76.43,APC
Blood gases any combination,82803,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.93,,,,,,,fee schedule,24.77,76.43,APC
Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,74.83,,,,,,,fee schedule,63.91,141.79,
Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.49,,,,,,,fee schedule,63.91,141.79,
Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.8,,,,,,,fee schedule,63.91,141.79,
Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.91,,,,,,,fee schedule,63.91,141.79,
Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.11,,,,,,,fee schedule,63.91,141.79,
Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.71,,,,,,,fee schedule,63.91,141.79,APC
Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,78.77,,,,,,,fee schedule,63.91,141.79,APC
Blood gases w/o2 saturation,82805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,141.79,,,,,,,fee schedule,63.91,141.79,APC
Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.28,,,,,,,fee schedule,9.28,37.58,
Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.68,,,,,,,fee schedule,9.28,37.58,
Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.75,,,,,,,fee schedule,9.28,37.58,
Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.43,,,,,,,fee schedule,9.28,37.58,
Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.58,,,,,,,fee schedule,9.28,37.58,
Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.26,,,,,,,fee schedule,9.28,37.58,APC
Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.77,,,,,,,fee schedule,9.28,37.58,APC
Blood gases o2 sat only,82810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.59,,,,,,,fee schedule,9.28,37.58,APC
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.67,,,,,,,fee schedule,12.67,41.07,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.71,,,,,,,fee schedule,12.67,41.07,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.23,,,,,,,fee schedule,12.67,41.07,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.41,,,,,,,fee schedule,12.67,41.07,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.07,,,,,,,fee schedule,12.67,41.07,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.01,,,,,,,fee schedule,12.67,41.07,APC
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.34,,,,,,,fee schedule,12.67,41.07,APC
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.01,,,,,,,fee schedule,12.67,41.07,APC
Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.37,,,,,,,fee schedule,6.37,23.45,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.39,,,,,,,fee schedule,6.37,23.45,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.69,,,,,,,fee schedule,6.37,23.45,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.37,,,,,,,fee schedule,6.37,23.45,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.45,,,,,,,fee schedule,6.37,23.45,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.05,,,,,,,fee schedule,6.37,23.45,APC
Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.71,,,,,,,fee schedule,6.37,23.45,APC
Gastric analy w/ph ea spec,82930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.08,,,,,,,fee schedule,6.37,23.45,APC
Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.81,,,,,,,fee schedule,16.81,62.5,
Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.35,,,,,,,fee schedule,16.81,62.5,
Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.49,,,,,,,fee schedule,16.81,62.5,
Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.63,,,,,,,fee schedule,16.81,62.5,
Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.5,,,,,,,fee schedule,16.81,62.5,
Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.57,,,,,,,fee schedule,16.81,62.5,APC
Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.69,,,,,,,fee schedule,16.81,62.5,APC
Gastrin test,82938,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.84,,,,,,,fee schedule,16.81,62.5,APC
Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.75,,,,,,,fee schedule,9.86,31.73,
Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.04,,,,,,,fee schedule,9.86,31.73,
Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.31,,,,,,,fee schedule,9.86,31.73,
Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.86,,,,,,,fee schedule,9.86,31.73,
Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.3,,,,,,,fee schedule,9.86,31.73,
Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.51,,,,,,,fee schedule,9.86,31.73,APC
Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.63,,,,,,,fee schedule,9.86,31.73,APC
Assay of gastrin,82941,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.73,,,,,,,fee schedule,9.86,31.73,APC
Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.58,,,,,,,fee schedule,13.58,61.55,
Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.52,,,,,,,fee schedule,13.58,61.55,
Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.81,,,,,,,fee schedule,13.58,61.55,
Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.09,,,,,,,fee schedule,13.58,61.55,
Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.55,,,,,,,fee schedule,13.58,61.55,
Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15,,,,,,,fee schedule,13.58,61.55,APC
Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.29,,,,,,,fee schedule,13.58,61.55,APC
Assay of glucagon,82943,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.72,,,,,,,fee schedule,13.58,61.55,APC
Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.73,,,,,,,fee schedule,3.73,20.62,
Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.93,,,,,,,fee schedule,3.73,20.62,
Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.68,,,,,,,fee schedule,3.73,20.62,
Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.75,,,,,,,fee schedule,3.73,20.62,
Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.62,,,,,,,fee schedule,3.73,20.62,
Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.13,,,,,,,fee schedule,3.73,20.62,APC
Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.93,,,,,,,fee schedule,3.73,20.62,APC
Glucose Other Fluid,82945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.07,,,,,,,fee schedule,3.73,20.62,APC
Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.88,,,,,,,fee schedule,16.88,64.91,
Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.44,,,,,,,fee schedule,16.88,64.91,
Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.2,,,,,,,fee schedule,16.88,64.91,
Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37,,,,,,,fee schedule,16.88,64.91,
Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.91,,,,,,,fee schedule,16.88,64.91,
Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.66,,,,,,,fee schedule,16.88,64.91,APC
Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.77,,,,,,,fee schedule,16.88,64.91,APC
Glucagon tolerance test,82946,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.99,,,,,,,fee schedule,16.88,64.91,APC
Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.73,,,,,,,fee schedule,3.73,7.44,
Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.47,,,,,,,fee schedule,3.73,7.44,
Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.3,,,,,,,fee schedule,3.73,7.44,
Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.24,,,,,,,fee schedule,3.73,7.44,
Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.44,,,,,,,fee schedule,3.73,7.44,
Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.13,,,,,,,fee schedule,3.73,7.44,APC
Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.93,,,,,,,fee schedule,3.73,7.44,APC
Assay glucose blood quant,82947,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.07,,,,,,,fee schedule,3.73,7.44,APC
Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.79,,,,,,,fee schedule,4.79,13.66,
Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.88,,,,,,,fee schedule,4.79,13.66,
Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.72,,,,,,,fee schedule,4.79,13.66,
Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.79,,,,,,,fee schedule,4.79,13.66,
Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.66,,,,,,,fee schedule,4.79,13.66,
Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.29,,,,,,,fee schedule,4.79,13.66,APC
Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.04,,,,,,,fee schedule,4.79,13.66,APC
Reagent strip/blood glucose,82948,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.07,,,,,,,fee schedule,4.79,13.66,APC
Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.51,,,,,,,fee schedule,4.51,8.94,
Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.77,,,,,,,fee schedule,4.51,8.94,
Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.36,,,,,,,fee schedule,4.51,8.94,
Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.09,,,,,,,fee schedule,4.51,8.94,
Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.94,,,,,,,fee schedule,4.51,8.94,
Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.99,,,,,,,fee schedule,4.51,8.94,APC
Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.51,8.94,APC
Glucose test,82950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.55,,,,,,,fee schedule,4.51,8.94,APC
Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.23,,,,,,,fee schedule,12.23,51.35,
Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.65,,,,,,,fee schedule,12.23,51.35,
Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.55,,,,,,,fee schedule,12.23,51.35,
Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.27,,,,,,,fee schedule,12.23,51.35,
Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.35,,,,,,,fee schedule,12.23,51.35,
Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,12.23,51.35,APC
Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.87,,,,,,,fee schedule,12.23,51.35,APC
Glucose tolerance test (GTT),82951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.17,,,,,,,fee schedule,12.23,51.35,APC
GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.72,,,,,,,fee schedule,3.72,15.72,
GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.67,,,,,,,fee schedule,3.72,15.72,
GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.19,,,,,,,fee schedule,3.72,15.72,
GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.96,,,,,,,fee schedule,3.72,15.72,
GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.72,,,,,,,fee schedule,3.72,15.72,
GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.12,,,,,,,fee schedule,3.72,15.72,APC
GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.92,,,,,,,fee schedule,3.72,15.72,APC
GTT-added samples,82952,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.06,,,,,,,fee schedule,3.72,15.72,APC
Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.22,,,,,,,fee schedule,9.22,33.99,
Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.56,,,,,,,fee schedule,9.22,33.99,
Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.19,,,,,,,fee schedule,9.22,33.99,
Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.38,,,,,,,fee schedule,9.22,33.99,
Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.99,,,,,,,fee schedule,9.22,33.99,
Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.18,,,,,,,fee schedule,9.22,33.99,APC
Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.7,,,,,,,fee schedule,9.22,33.99,APC
Assay of g6pd enzyme,82955,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.46,,,,,,,fee schedule,9.22,33.99,APC
Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.75,,,,,,,fee schedule,5.75,26.05,
Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.65,,,,,,,fee schedule,5.75,26.05,
Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.54,,,,,,,fee schedule,5.75,26.05,
Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.85,,,,,,,fee schedule,5.75,26.05,
Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.05,,,,,,,fee schedule,5.75,26.05,
Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.35,,,,,,,fee schedule,5.75,26.05,APC
Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.05,,,,,,,fee schedule,5.75,26.05,APC
Test for G6PD enzyme,82960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.89,,,,,,,fee schedule,5.75,26.05,APC
Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.12,,,,,,,fee schedule,3.12,9.69,
Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.43,,,,,,,fee schedule,3.12,9.69,
Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.9,,,,,,,fee schedule,3.12,9.69,
Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.53,,,,,,,fee schedule,3.12,9.69,
Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.69,,,,,,,fee schedule,3.12,9.69,
Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.44,,,,,,,fee schedule,3.12,9.69,APC
Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.28,,,,,,,fee schedule,3.12,9.69,APC
Glucose blood test,82962,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.9,,,,,,,fee schedule,3.12,9.69,APC
Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.41,,,,,,,fee schedule,20.41,92.53,
Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.46,,,,,,,fee schedule,20.41,92.53,
Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.86,,,,,,,fee schedule,20.41,92.53,
Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.75,,,,,,,fee schedule,20.41,92.53,
Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.53,,,,,,,fee schedule,20.41,92.53,
Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.55,,,,,,,fee schedule,20.41,92.53,APC
Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.48,,,,,,,fee schedule,20.41,92.53,APC
Assay of glucosidase,82963,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.66,,,,,,,fee schedule,20.41,92.53,APC
Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.49,,,,,,,fee schedule,12.49,30.48,
Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,12.49,30.48,
Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,12.49,30.48,
Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,12.49,30.48,
Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,12.49,30.48,
Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.81,,,,,,,fee schedule,12.49,30.48,APC
Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.15,,,,,,,fee schedule,12.49,30.48,APC
Assay of gdh enzyme,82965,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.67,,,,,,,fee schedule,12.49,30.48,APC
Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.84,,,,,,,fee schedule,6.84,28.23,
Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.55,,,,,,,fee schedule,6.84,28.23,
Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.09,,,,,,,fee schedule,6.84,28.23,
Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.09,,,,,,,fee schedule,6.84,28.23,
Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.23,,,,,,,fee schedule,6.84,28.23,
Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.56,,,,,,,fee schedule,6.84,28.23,APC
Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.2,,,,,,,fee schedule,6.84,28.23,APC
Assay of GGT,82977,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.96,,,,,,,fee schedule,6.84,28.23,APC
Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.68,,,,,,,fee schedule,14.68,359.39,
Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,312.51,,,,,,,fee schedule,14.68,359.39,
Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,255.79,,,,,,,fee schedule,14.68,359.39,
Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,204.88,,,,,,,fee schedule,14.68,359.39,
Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,359.39,,,,,,,fee schedule,14.68,359.39,
Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.22,,,,,,,fee schedule,14.68,359.39,APC
Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.45,,,,,,,fee schedule,14.68,359.39,APC
Assay of glutathione,82978,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.81,,,,,,,fee schedule,14.68,359.39,APC
Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.97,,,,,,,fee schedule,8.97,29.67,
Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.8,,,,,,,fee schedule,8.97,29.67,
Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.12,,,,,,,fee schedule,8.97,29.67,
Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.91,,,,,,,fee schedule,8.97,29.67,
Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.67,,,,,,,fee schedule,8.97,29.67,
Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.97,29.67,APC
Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.44,,,,,,,fee schedule,8.97,29.67,APC
Assay rbc glutathione,82979,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.99,,,,,,,fee schedule,8.97,29.67,APC
Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.92,,,,,,,fee schedule,13.91,30.17,
Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.22,,,,,,,fee schedule,13.91,30.17,
Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.37,,,,,,,fee schedule,13.91,30.17,
Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.91,,,,,,,fee schedule,13.91,30.17,
Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.4,,,,,,,fee schedule,13.91,30.17,
Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.6,,,,,,,fee schedule,13.91,30.17,APC
Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.76,,,,,,,fee schedule,13.91,30.17,APC
Assay of glycated protein,82985,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.17,,,,,,,fee schedule,13.91,30.17,APC
Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.65,,,,,,,fee schedule,17.65,73.31,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.75,,,,,,,fee schedule,17.65,73.31,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.18,,,,,,,fee schedule,17.65,73.31,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.79,,,,,,,fee schedule,17.65,73.31,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.31,,,,,,,fee schedule,17.65,73.31,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.51,,,,,,,fee schedule,17.65,73.31,APC
Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.58,,,,,,,fee schedule,17.65,73.31,APC
Assay of gonadotropin (fsh),83001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.44,,,,,,,fee schedule,17.65,73.31,APC
Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.59,,,,,,,fee schedule,17.59,40.91,
Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.57,,,,,,,fee schedule,17.59,40.91,
Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.11,,,,,,,fee schedule,17.59,40.91,
Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.32,,,,,,,fee schedule,17.59,40.91,
Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.91,,,,,,,fee schedule,17.59,40.91,
Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.45,,,,,,,fee schedule,17.59,40.91,APC
Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.52,,,,,,,fee schedule,17.59,40.91,APC
Assay of gonadotropin (lh),83002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.34,,,,,,,fee schedule,17.59,40.91,APC
Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.84,,,,,,,fee schedule,15.84,65.96,
Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.36,,,,,,,fee schedule,15.84,65.96,
Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.95,,,,,,,fee schedule,15.84,65.96,
Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.61,,,,,,,fee schedule,15.84,65.96,
Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.96,,,,,,,fee schedule,15.84,65.96,
Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.5,,,,,,,fee schedule,15.84,65.96,APC
Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.67,,,,,,,fee schedule,15.84,65.96,APC
Assay growth hormone (hgh),83003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.01,,,,,,,fee schedule,15.84,65.96,APC
Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,71.82,,,,,,,fee schedule,53.99,136.08,
Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.35,,,,,,,fee schedule,53.99,136.08,
Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.4,,,,,,,fee schedule,53.99,136.08,
Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.99,,,,,,,fee schedule,53.99,136.08,
Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.7,,,,,,,fee schedule,53.99,136.08,
Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.38,,,,,,,fee schedule,53.99,136.08,APC
Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,75.6,,,,,,,fee schedule,53.99,136.08,APC
Growth stimulation gene 2,83006,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,136.08,,,,,,,fee schedule,53.99,136.08,APC
H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,63.99,,,,,,,fee schedule,63.99,290.1,
H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.26,,,,,,,fee schedule,63.99,290.1,
H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.47,,,,,,,fee schedule,63.99,290.1,
H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.38,,,,,,,fee schedule,63.99,290.1,
H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.1,,,,,,,fee schedule,63.99,290.1,
H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.73,,,,,,,fee schedule,63.99,290.1,APC
H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67.36,,,,,,,fee schedule,63.99,290.1,APC
H pylori (c-13) blood,83009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,121.25,,,,,,,fee schedule,63.99,290.1,APC
Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.95,,,,,,,fee schedule,11.95,49.27,
Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.84,,,,,,,fee schedule,11.95,49.27,
Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.06,,,,,,,fee schedule,11.95,49.27,
Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.09,,,,,,,fee schedule,11.95,49.27,
Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.27,,,,,,,fee schedule,11.95,49.27,
Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.21,,,,,,,fee schedule,11.95,49.27,APC
Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.95,49.27,APC
Assay of haptoglobin quant,83010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.64,,,,,,,fee schedule,11.95,49.27,APC
Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.55,,,,,,,fee schedule,25.55,60.55,
Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.65,,,,,,,fee schedule,25.55,60.55,
Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.09,,,,,,,fee schedule,25.55,60.55,
Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.52,,,,,,,fee schedule,25.55,60.55,
Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.55,,,,,,,fee schedule,25.55,60.55,
Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.23,,,,,,,fee schedule,25.55,60.55,APC
Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.89,,,,,,,fee schedule,25.55,60.55,APC
Assay of haptoglobins,83012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.4,,,,,,,fee schedule,25.55,60.55,APC
H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,63.99,,,,,,,fee schedule,63.99,268.16,
H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,233.18,,,,,,,fee schedule,63.99,268.16,
H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.86,,,,,,,fee schedule,63.99,268.16,
H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.87,,,,,,,fee schedule,63.99,268.16,
H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,268.16,,,,,,,fee schedule,63.99,268.16,
H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.73,,,,,,,fee schedule,63.99,268.16,APC
H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67.36,,,,,,,fee schedule,63.99,268.16,APC
H pylori (c-13) breath,83013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,121.25,,,,,,,fee schedule,63.99,268.16,APC
H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.47,,,,,,,fee schedule,7.47,32.48,
H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.24,,,,,,,fee schedule,7.47,32.48,
H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.11,,,,,,,fee schedule,7.47,32.48,
H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.51,,,,,,,fee schedule,7.47,32.48,
H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.48,,,,,,,fee schedule,7.47,32.48,
H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.25,,,,,,,fee schedule,7.47,32.48,APC
H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.86,,,,,,,fee schedule,7.47,32.48,APC
H pylori drug admin,83014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.15,,,,,,,fee schedule,7.47,32.48,APC
Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.89,,,,,,,fee schedule,19.89,50.14,
Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.6,,,,,,,fee schedule,19.89,50.14,
Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.69,,,,,,,fee schedule,19.89,50.14,
Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.58,,,,,,,fee schedule,19.89,50.14,
Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.14,,,,,,,fee schedule,19.89,50.14,
Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.99,,,,,,,fee schedule,19.89,50.14,APC
Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.94,,,,,,,fee schedule,19.89,50.14,APC
Heavy metal qual any anal,83015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.69,,,,,,,fee schedule,19.89,50.14,APC
Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.86,,,,,,,fee schedule,20.86,56.44,
Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.08,,,,,,,fee schedule,20.86,56.44,
Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.17,,,,,,,fee schedule,20.86,56.44,
Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.18,,,,,,,fee schedule,20.86,56.44,
Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.44,,,,,,,fee schedule,20.86,56.44,
Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.06,,,,,,,fee schedule,20.86,56.44,APC
Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.96,,,,,,,fee schedule,20.86,56.44,APC
Heavy metal quant each nes,83018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.53,,,,,,,fee schedule,20.86,56.44,APC
Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.23,,,,,,,fee schedule,12.23,78.43,
Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.2,,,,,,,fee schedule,12.23,78.43,
Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.82,,,,,,,fee schedule,12.23,78.43,
Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.71,,,,,,,fee schedule,12.23,78.43,
Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.43,,,,,,,fee schedule,12.23,78.43,
Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,12.23,78.43,APC
Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.87,,,,,,,fee schedule,12.23,78.43,APC
Hemoglobin electrophoresis,83020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.17,,,,,,,fee schedule,12.23,78.43,APC
Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.16,,,,,,,fee schedule,17.16,76.68,
Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.68,,,,,,,fee schedule,17.16,76.68,
Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.58,,,,,,,fee schedule,17.16,76.68,
Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.72,,,,,,,fee schedule,17.16,76.68,
Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.68,,,,,,,fee schedule,17.16,76.68,
Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.96,,,,,,,fee schedule,17.16,76.68,APC
Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.06,,,,,,,fee schedule,17.16,76.68,APC
Hemoglobin chromotography,83021,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.51,,,,,,,fee schedule,17.16,76.68,APC
Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.81,,,,,,,fee schedule,3.81,10.18,
Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.85,,,,,,,fee schedule,3.81,10.18,
Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.24,,,,,,,fee schedule,3.81,10.18,
Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.8,,,,,,,fee schedule,3.81,10.18,
Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.18,,,,,,,fee schedule,3.81,10.18,
Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.21,,,,,,,fee schedule,3.81,10.18,APC
Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.01,,,,,,,fee schedule,3.81,10.18,APC
Hemoglobin copper sulfate,83026,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.22,,,,,,,fee schedule,3.81,10.18,APC
Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.2,,,,,,,fee schedule,10.2,35.59,
Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.95,,,,,,,fee schedule,10.2,35.59,
Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.33,,,,,,,fee schedule,10.2,35.59,
Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.29,,,,,,,fee schedule,10.2,35.59,
Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.59,,,,,,,fee schedule,10.2,35.59,
Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,10.2,35.59,APC
Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.74,,,,,,,fee schedule,10.2,35.59,APC
Fetal hemoglobin chemical,83030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.33,,,,,,,fee schedule,10.2,35.59,APC
Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.6,,,,,,,fee schedule,7.6,25.65,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.3,,,,,,,fee schedule,7.6,25.65,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.25,,,,,,,fee schedule,7.6,25.65,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.62,,,,,,,fee schedule,7.6,25.65,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.65,,,,,,,fee schedule,7.6,25.65,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.4,,,,,,,fee schedule,7.6,25.65,APC
Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8,,,,,,,fee schedule,7.6,25.65,APC
Fetal hemoglobin assay qual,83033,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.4,,,,,,,fee schedule,7.6,25.65,APC
Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.22,,,,,,,fee schedule,9.22,21.44,
Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.64,,,,,,,fee schedule,9.22,21.44,
Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.26,,,,,,,fee schedule,9.22,21.44,
Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.22,,,,,,,fee schedule,9.22,21.44,
Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.44,,,,,,,fee schedule,9.22,21.44,
Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.2,,,,,,,fee schedule,9.22,21.44,APC
Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.71,,,,,,,fee schedule,9.22,21.44,APC
Glycosylated hemoglobin test,83036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.48,,,,,,,fee schedule,9.22,21.44,APC
Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.22,,,,,,,fee schedule,9.22,41.81,
Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.36,,,,,,,fee schedule,9.22,41.81,
Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.76,,,,,,,fee schedule,9.22,41.81,
Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.84,,,,,,,fee schedule,9.22,41.81,
Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.81,,,,,,,fee schedule,9.22,41.81,
Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.2,,,,,,,fee schedule,9.22,41.81,APC
Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.71,,,,,,,fee schedule,9.22,41.81,APC
Glycosylated hb home device,83037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.48,,,,,,,fee schedule,9.22,41.81,APC
Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.17,,,,,,,fee schedule,6.17,21.31,
Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.53,,,,,,,fee schedule,6.17,21.31,
Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.17,,,,,,,fee schedule,6.17,21.31,
Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.15,,,,,,,fee schedule,6.17,21.31,
Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.31,,,,,,,fee schedule,6.17,21.31,
Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.81,,,,,,,fee schedule,6.17,21.31,APC
Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.49,,,,,,,fee schedule,6.17,21.31,APC
Blood methemoglobin test,83045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.68,,,,,,,fee schedule,6.17,21.31,APC
Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.79,,,,,,,fee schedule,7.79,31.56,
Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,7.79,31.56,
Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,7.79,31.56,
Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,7.79,31.56,
Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,7.79,31.56,
Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.61,,,,,,,fee schedule,7.79,31.56,APC
Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.2,,,,,,,fee schedule,7.79,31.56,APC
Blood methemoglobin assay,83050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.76,,,,,,,fee schedule,7.79,31.56,APC
Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.94,,,,,,,fee schedule,6.94,29.35,
Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.52,,,,,,,fee schedule,6.94,29.35,
Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.89,,,,,,,fee schedule,6.94,29.35,
Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.73,,,,,,,fee schedule,6.94,29.35,
Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.35,,,,,,,fee schedule,6.94,29.35,
Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.68,,,,,,,fee schedule,6.94,29.35,APC
Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.31,,,,,,,fee schedule,6.94,29.35,APC
Assay of plasma hemoglobin,83051,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.16,,,,,,,fee schedule,6.94,29.35,APC
Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.36,,,,,,,fee schedule,8.36,35.59,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.95,,,,,,,fee schedule,8.36,35.59,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.33,,,,,,,fee schedule,8.36,35.59,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.29,,,,,,,fee schedule,8.36,35.59,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.59,,,,,,,fee schedule,8.36,35.59,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.24,,,,,,,fee schedule,8.36,35.59,APC
Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.8,,,,,,,fee schedule,8.36,35.59,APC
Blood sulfhemoglobin assay,83060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.84,,,,,,,fee schedule,8.36,35.59,APC
Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.55,,,,,,,fee schedule,8.55,29.67,
Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.8,,,,,,,fee schedule,8.55,29.67,
Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.12,,,,,,,fee schedule,8.55,29.67,
Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.91,,,,,,,fee schedule,8.55,29.67,
Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.67,,,,,,,fee schedule,8.55,29.67,
Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.45,,,,,,,fee schedule,8.55,29.67,APC
Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9,,,,,,,fee schedule,8.55,29.67,APC
Assay of hemoglobin heat,83065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.2,,,,,,,fee schedule,8.55,29.67,APC
Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9,,,,,,,fee schedule,9,96.84,
Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.21,,,,,,,fee schedule,9,96.84,
Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.93,,,,,,,fee schedule,9,96.84,
Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.21,,,,,,,fee schedule,9,96.84,
Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.84,,,,,,,fee schedule,9,96.84,
Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.94,,,,,,,fee schedule,9,96.84,APC
Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.47,,,,,,,fee schedule,9,96.84,APC
Hemoglobin stability screen,83068,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.05,,,,,,,fee schedule,9,96.84,APC
Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.75,,,,,,,fee schedule,3.75,10.38,
Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.03,,,,,,,fee schedule,3.75,10.38,
Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.39,,,,,,,fee schedule,3.75,10.38,
Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.92,,,,,,,fee schedule,3.75,10.38,
Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.38,,,,,,,fee schedule,3.75,10.38,
Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.15,,,,,,,fee schedule,3.75,10.38,APC
Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.95,,,,,,,fee schedule,3.75,10.38,APC
Assay of urine hemoglobin,83069,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.11,,,,,,,fee schedule,3.75,10.38,APC
Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.51,,,,,,,fee schedule,4.51,20.45,
Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.78,,,,,,,fee schedule,4.51,20.45,
Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.55,,,,,,,fee schedule,4.51,20.45,
Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.66,,,,,,,fee schedule,4.51,20.45,
Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.45,,,,,,,fee schedule,4.51,20.45,
Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.99,,,,,,,fee schedule,4.51,20.45,APC
Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.51,20.45,APC
Assay of hemosiderin qual,83070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.55,,,,,,,fee schedule,4.51,20.45,APC
Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.03,,,,,,,fee schedule,16.03,60.75,
Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.83,,,,,,,fee schedule,16.03,60.75,
Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.24,,,,,,,fee schedule,16.03,60.75,
Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.64,,,,,,,fee schedule,16.03,60.75,
Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.75,,,,,,,fee schedule,16.03,60.75,
Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,16.03,60.75,APC
Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.87,,,,,,,fee schedule,16.03,60.75,APC
Assay of b hexosaminidase,83080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.37,,,,,,,fee schedule,16.03,60.75,APC
Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.05,,,,,,,fee schedule,28.05,147.3,
Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.09,,,,,,,fee schedule,28.05,147.3,
Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.84,,,,,,,fee schedule,28.05,147.3,
Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.98,,,,,,,fee schedule,28.05,147.3,
Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.3,,,,,,,fee schedule,28.05,147.3,
Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.01,,,,,,,fee schedule,28.05,147.3,APC
Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.53,,,,,,,fee schedule,28.05,147.3,APC
Assay of histamine,83088,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.15,,,,,,,fee schedule,28.05,147.3,APC
Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.02,,,,,,,fee schedule,17.02,92.68,
Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.59,,,,,,,fee schedule,17.02,92.68,
Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.96,,,,,,,fee schedule,17.02,92.68,
Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.83,,,,,,,fee schedule,17.02,92.68,
Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.68,,,,,,,fee schedule,17.02,92.68,
Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.82,,,,,,,fee schedule,17.02,92.68,APC
Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.92,,,,,,,fee schedule,17.02,92.68,APC
Assay Of Homocystine,83090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.26,,,,,,,fee schedule,17.02,92.68,APC
Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.29,,,,,,,fee schedule,21.29,70.59,
Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.38,,,,,,,fee schedule,21.29,70.59,
Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.24,,,,,,,fee schedule,21.29,70.59,
Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.24,,,,,,,fee schedule,21.29,70.59,
Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.59,,,,,,,fee schedule,21.29,70.59,
Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.53,,,,,,,fee schedule,21.29,70.59,APC
Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.41,,,,,,,fee schedule,21.29,70.59,APC
Assay of homovanillic acid,83150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40.34,,,,,,,fee schedule,21.29,70.59,APC
Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.01,,,,,,,fee schedule,17.01,37,
Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.17,,,,,,,fee schedule,17.01,37,
Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.33,,,,,,,fee schedule,17.01,37,
Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.09,,,,,,,fee schedule,17.01,37,
Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37,,,,,,,fee schedule,17.01,37,
Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.8,,,,,,,fee schedule,17.01,37,APC
Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.9,,,,,,,fee schedule,17.01,37,APC
Assay of corticosteroids 17,83491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.22,,,,,,,fee schedule,17.01,37,APC
Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.26,,,,,,,fee schedule,12.26,47.39,
Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.21,,,,,,,fee schedule,12.26,47.39,
Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.73,,,,,,,fee schedule,12.26,47.39,
Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.02,,,,,,,fee schedule,12.26,47.39,
Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.39,,,,,,,fee schedule,12.26,47.39,
Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.54,,,,,,,fee schedule,12.26,47.39,APC
Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.9,,,,,,,fee schedule,12.26,47.39,APC
Assay of 5-hiaa,83497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.22,,,,,,,fee schedule,12.26,47.39,APC
Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.81,,,,,,,fee schedule,12.52,48.91,
Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.1,,,,,,,fee schedule,12.52,48.91,
Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.63,,,,,,,fee schedule,12.52,48.91,
Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.52,,,,,,,fee schedule,12.52,48.91,
Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.97,,,,,,,fee schedule,12.52,48.91,
Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.53,,,,,,,fee schedule,12.52,48.91,APC
Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.17,,,,,,,fee schedule,12.52,48.91,APC
Assay of progesterone 17-d,83498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.91,,,,,,,fee schedule,12.52,48.91,APC
Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.52,,,,,,,fee schedule,21.52,97.55,
Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.83,,,,,,,fee schedule,21.52,97.55,
Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.43,,,,,,,fee schedule,21.52,97.55,
Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.61,,,,,,,fee schedule,21.52,97.55,
Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.55,,,,,,,fee schedule,21.52,97.55,
Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.78,,,,,,,fee schedule,21.52,97.55,APC
Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.65,,,,,,,fee schedule,21.52,97.55,APC
Assay free hydroxyproline,83500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40.77,,,,,,,fee schedule,21.52,97.55,APC
Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.09,,,,,,,fee schedule,23.09,104.67,
Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.02,,,,,,,fee schedule,23.09,104.67,
Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.5,,,,,,,fee schedule,23.09,104.67,
Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.67,,,,,,,fee schedule,23.09,104.67,
Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,104.67,,,,,,,fee schedule,23.09,104.67,
Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.52,,,,,,,fee schedule,23.09,104.67,APC
Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.3,,,,,,,fee schedule,23.09,104.67,APC
Assay total hydroxyproline,83505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.74,,,,,,,fee schedule,23.09,104.67,APC
Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.95,,,,,,,fee schedule,10.95,26.66,
Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.18,,,,,,,fee schedule,10.95,26.66,
Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.97,,,,,,,fee schedule,10.95,26.66,
Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.2,,,,,,,fee schedule,10.95,26.66,
Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.66,,,,,,,fee schedule,10.95,26.66,
Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.95,26.66,APC
Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.53,,,,,,,fee schedule,10.95,26.66,APC
Immunoassay nonantibody,83516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.75,,,,,,,fee schedule,10.95,26.66,APC
Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.16,,,,,,,fee schedule,9.16,36.5,
Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.74,,,,,,,fee schedule,9.16,36.5,
Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.98,,,,,,,fee schedule,9.16,36.5,
Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.81,,,,,,,fee schedule,9.16,36.5,
Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.5,,,,,,,fee schedule,9.16,36.5,
Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.12,,,,,,,fee schedule,9.16,36.5,APC
Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.64,,,,,,,fee schedule,9.16,36.5,APC
Immunoassay dipstick,83518,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.35,,,,,,,fee schedule,9.16,36.5,APC
Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.48,,,,,,,fee schedule,17.48,149.56,
Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.05,,,,,,,fee schedule,17.48,149.56,
Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.45,,,,,,,fee schedule,17.48,149.56,
Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.26,,,,,,,fee schedule,17.48,149.56,
Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.56,,,,,,,fee schedule,17.48,149.56,
Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,17.48,149.56,APC
Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.4,,,,,,,fee schedule,17.48,149.56,APC
Ria nonantibody,83519,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.12,,,,,,,fee schedule,17.48,149.56,APC
Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.41,,,,,,,fee schedule,16.41,52.11,
Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.31,,,,,,,fee schedule,16.41,52.11,
Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.09,,,,,,,fee schedule,16.41,52.11,
Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.71,,,,,,,fee schedule,16.41,52.11,
Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.11,,,,,,,fee schedule,16.41,52.11,
Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,16.41,52.11,APC
Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,16.41,52.11,APC
Immunoassay quant nos nonab,83520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,16.41,52.11,APC
Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.41,,,,,,,fee schedule,16.41,38.57,
Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.54,,,,,,,fee schedule,16.41,38.57,
Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.45,,,,,,,fee schedule,16.41,38.57,
Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.99,,,,,,,fee schedule,16.41,38.57,
Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.57,,,,,,,fee schedule,16.41,38.57,
Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,16.41,38.57,APC
Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,16.41,38.57,APC
Ig light chains free each,83521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,16.41,38.57,APC
Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.86,,,,,,,fee schedule,10.86,22.34,
Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.43,,,,,,,fee schedule,10.86,22.34,
Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.9,,,,,,,fee schedule,10.86,22.34,
Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.74,,,,,,,fee schedule,10.86,22.34,
Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.34,,,,,,,fee schedule,10.86,22.34,
Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12,,,,,,,fee schedule,10.86,22.34,APC
Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.43,,,,,,,fee schedule,10.86,22.34,APC
Assay of insulin,83525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.57,,,,,,,fee schedule,10.86,22.34,APC
Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.3,,,,,,,fee schedule,11.55,23.31,
Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.61,,,,,,,fee schedule,11.55,23.31,
Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.41,,,,,,,fee schedule,11.55,23.31,
Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.55,,,,,,,fee schedule,11.55,23.31,
Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.25,,,,,,,fee schedule,11.55,23.31,
Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.6,,,,,,,fee schedule,11.55,23.31,APC
Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.95,,,,,,,fee schedule,11.55,23.31,APC
Assay of insulin,83527,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.31,,,,,,,fee schedule,11.55,23.31,APC
Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.83,,,,,,,fee schedule,18.83,68.52,
Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.58,,,,,,,fee schedule,18.83,68.52,
Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.77,,,,,,,fee schedule,18.83,68.52,
Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.06,,,,,,,fee schedule,18.83,68.52,
Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.52,,,,,,,fee schedule,18.83,68.52,
Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.81,,,,,,,fee schedule,18.83,68.52,APC
Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.82,,,,,,,fee schedule,18.83,68.52,APC
Assay of intrinsic factor,83528,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.68,,,,,,,fee schedule,18.83,68.52,APC
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.41,,,,,,,fee schedule,16.41,38.57,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.54,,,,,,,fee schedule,16.41,38.57,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.45,,,,,,,fee schedule,16.41,38.57,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.99,,,,,,,fee schedule,16.41,38.57,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.57,,,,,,,fee schedule,16.41,38.57,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,16.41,38.57,APC
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,16.41,38.57,APC
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,16.41,38.57,APC
Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.15,,,,,,,fee schedule,6.15,13.41,
Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.66,,,,,,,fee schedule,6.15,13.41,
Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.54,,,,,,,fee schedule,6.15,13.41,
Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.64,,,,,,,fee schedule,6.15,13.41,
Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.41,,,,,,,fee schedule,6.15,13.41,
Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.15,13.41,APC
Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,6.15,13.41,APC
Assay of iron,83540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,6.15,13.41,APC
Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.3,,,,,,,fee schedule,8.3,19.06,
Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.57,,,,,,,fee schedule,8.3,19.06,
Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.56,,,,,,,fee schedule,8.3,19.06,
Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.86,,,,,,,fee schedule,8.3,19.06,
Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.06,,,,,,,fee schedule,8.3,19.06,
Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.18,,,,,,,fee schedule,8.3,19.06,APC
Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.74,,,,,,,fee schedule,8.3,19.06,APC
Iron binding test,83550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.73,,,,,,,fee schedule,8.3,19.06,APC
Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.41,,,,,,,fee schedule,8.41,38.11,
Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.14,,,,,,,fee schedule,8.41,38.11,
Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.13,,,,,,,fee schedule,8.41,38.11,
Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.73,,,,,,,fee schedule,8.41,38.11,
Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.11,,,,,,,fee schedule,8.41,38.11,
Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.29,,,,,,,fee schedule,8.41,38.11,APC
Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.85,,,,,,,fee schedule,8.41,38.11,APC
Assay of idh enzyme,83570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.93,,,,,,,fee schedule,8.41,38.11,APC
Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.7,,,,,,,fee schedule,14.7,61.03,
Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.07,,,,,,,fee schedule,14.7,61.03,
Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.44,,,,,,,fee schedule,14.7,61.03,
Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.79,,,,,,,fee schedule,14.7,61.03,
Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.03,,,,,,,fee schedule,14.7,61.03,
Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.24,,,,,,,fee schedule,14.7,61.03,APC
Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.47,,,,,,,fee schedule,14.7,61.03,APC
Assay of ketogenic steroids,83582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.85,,,,,,,fee schedule,14.7,61.03,APC
Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.16,,,,,,,fee schedule,12.16,55.11,
Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.92,,,,,,,fee schedule,12.16,55.11,
Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.22,,,,,,,fee schedule,12.16,55.11,
Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.42,,,,,,,fee schedule,12.16,55.11,
Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.11,,,,,,,fee schedule,12.16,55.11,
Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.44,,,,,,,fee schedule,12.16,55.11,APC
Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.8,,,,,,,fee schedule,12.16,55.11,APC
Assay 17- ketosteroids,83586,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.04,,,,,,,fee schedule,12.16,55.11,APC
Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.08,,,,,,,fee schedule,27.08,113.28,
Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.5,,,,,,,fee schedule,27.08,113.28,
Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.62,,,,,,,fee schedule,27.08,113.28,
Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.58,,,,,,,fee schedule,27.08,113.28,
Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.28,,,,,,,fee schedule,27.08,113.28,
Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.92,,,,,,,fee schedule,27.08,113.28,APC
Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.5,,,,,,,fee schedule,27.08,113.28,APC
Fractionation ketosteroids,83593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.3,,,,,,,fee schedule,27.08,113.28,APC
Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.99,,,,,,,fee schedule,10.99,41.96,
Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.49,,,,,,,fee schedule,10.99,41.96,
Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.87,,,,,,,fee schedule,10.99,41.96,
Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.92,,,,,,,fee schedule,10.99,41.96,
Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.96,,,,,,,fee schedule,10.99,41.96,
Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.15,,,,,,,fee schedule,10.99,41.96,APC
Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.57,,,,,,,fee schedule,10.99,41.96,APC
Assay of lactic acid,83605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.83,,,,,,,fee schedule,10.99,41.96,APC
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.74,,,,,,,fee schedule,5.74,24.12,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.97,,,,,,,fee schedule,5.74,24.12,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.16,,,,,,,fee schedule,5.74,24.12,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.75,,,,,,,fee schedule,5.74,24.12,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.12,,,,,,,fee schedule,5.74,24.12,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.34,,,,,,,fee schedule,5.74,24.12,APC
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.04,,,,,,,fee schedule,5.74,24.12,APC
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.87,,,,,,,fee schedule,5.74,24.12,APC
Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.15,,,,,,,fee schedule,12.15,55.11,
Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.92,,,,,,,fee schedule,12.15,55.11,
Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.22,,,,,,,fee schedule,12.15,55.11,
Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.42,,,,,,,fee schedule,12.15,55.11,
Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.11,,,,,,,fee schedule,12.15,55.11,
Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.43,,,,,,,fee schedule,12.15,55.11,APC
Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.79,,,,,,,fee schedule,12.15,55.11,APC
Assay of ldh enzymes,83625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.02,,,,,,,fee schedule,12.15,55.11,APC
Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.72,,,,,,,fee schedule,18.72,53.21,
Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.27,,,,,,,fee schedule,18.72,53.21,
Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.87,,,,,,,fee schedule,18.72,53.21,
Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.33,,,,,,,fee schedule,18.72,53.21,
Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.21,,,,,,,fee schedule,18.72,53.21,
Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.68,,,,,,,fee schedule,18.72,53.21,APC
Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.7,,,,,,,fee schedule,18.72,53.21,APC
Lactoferrin fecal (qual),83630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.46,,,,,,,fee schedule,18.72,53.21,APC
Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.65,,,,,,,fee schedule,18.65,68.57,
Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.63,,,,,,,fee schedule,18.65,68.57,
Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.81,,,,,,,fee schedule,18.65,68.57,
Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.09,,,,,,,fee schedule,18.65,68.57,
Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.57,,,,,,,fee schedule,18.65,68.57,
Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.61,,,,,,,fee schedule,18.65,68.57,APC
Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.63,,,,,,,fee schedule,18.65,68.57,APC
Lactoferrin fecal (quant),83631,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.33,,,,,,,fee schedule,18.65,68.57,APC
Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.21,,,,,,,fee schedule,19.21,80.14,
Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.69,,,,,,,fee schedule,19.21,80.14,
Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.04,,,,,,,fee schedule,19.21,80.14,
Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.69,,,,,,,fee schedule,19.21,80.14,
Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.14,,,,,,,fee schedule,19.21,80.14,
Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.23,,,,,,,fee schedule,19.21,80.14,APC
Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.22,,,,,,,fee schedule,19.21,80.14,APC
Placental lactogen,83632,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.4,,,,,,,fee schedule,19.21,80.14,APC
Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.69,,,,,,,fee schedule,10.69,23.67,
Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,10.69,23.67,
Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,10.69,23.67,
Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,10.69,23.67,
Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,10.69,23.67,
Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.81,,,,,,,fee schedule,10.69,23.67,APC
Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.25,,,,,,,fee schedule,10.69,23.67,APC
Test urine for lactose,83633,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.25,,,,,,,fee schedule,10.69,23.67,APC
Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.5,,,,,,,fee schedule,6.53,21.8,
Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.96,,,,,,,fee schedule,6.53,21.8,
Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.15,,,,,,,fee schedule,6.53,21.8,
Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.53,,,,,,,fee schedule,6.53,21.8,
Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.45,,,,,,,fee schedule,6.53,21.8,
Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.72,,,,,,,fee schedule,6.53,21.8,APC
Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.11,,,,,,,fee schedule,6.53,21.8,APC
Assay of lead,83655,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.8,,,,,,,fee schedule,6.53,21.8,APC
L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.89,,,,,,,fee schedule,20.89,175.12,
L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.28,,,,,,,fee schedule,20.89,175.12,
L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.64,,,,,,,fee schedule,20.89,175.12,
L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.83,,,,,,,fee schedule,20.89,175.12,
L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.12,,,,,,,fee schedule,20.89,175.12,
L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.09,,,,,,,fee schedule,20.89,175.12,APC
L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.99,,,,,,,fee schedule,20.89,175.12,APC
L/s ratio fetal lung,83661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.58,,,,,,,fee schedule,20.89,175.12,APC
Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.96,,,,,,,fee schedule,5.61,34.04,
Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.55,,,,,,,fee schedule,5.61,34.04,
Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7,,,,,,,fee schedule,5.61,34.04,
Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.61,,,,,,,fee schedule,5.61,34.04,
Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.83,,,,,,,fee schedule,5.61,34.04,
Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.86,,,,,,,fee schedule,5.61,34.04,APC
Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.91,,,,,,,fee schedule,5.61,34.04,APC
Foam stability fetal lung,83662,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.04,,,,,,,fee schedule,5.61,34.04,APC
Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.96,,,,,,,fee schedule,5.61,34.04,
Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.55,,,,,,,fee schedule,5.61,34.04,
Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7,,,,,,,fee schedule,5.61,34.04,
Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.61,,,,,,,fee schedule,5.61,34.04,
Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.83,,,,,,,fee schedule,5.61,34.04,
Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.86,,,,,,,fee schedule,5.61,34.04,APC
Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.91,,,,,,,fee schedule,5.61,34.04,APC
Fluoro polarize fetal lung,83663,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.04,,,,,,,fee schedule,5.61,34.04,APC
Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.35,,,,,,,fee schedule,18.35,66.79,
Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.08,,,,,,,fee schedule,18.35,66.79,
Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.54,,,,,,,fee schedule,18.35,66.79,
Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.08,,,,,,,fee schedule,18.35,66.79,
Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.79,,,,,,,fee schedule,18.35,66.79,
Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.29,,,,,,,fee schedule,18.35,66.79,APC
Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.32,,,,,,,fee schedule,18.35,66.79,APC
Lamellar bdy fetal lung,83664,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.78,,,,,,,fee schedule,18.35,66.79,APC
Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.32,,,,,,,fee schedule,9.32,39.47,
Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.32,,,,,,,fee schedule,9.32,39.47,
Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.09,,,,,,,fee schedule,9.32,39.47,
Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.5,,,,,,,fee schedule,9.32,39.47,
Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.47,,,,,,,fee schedule,9.32,39.47,
Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.3,,,,,,,fee schedule,9.32,39.47,APC
Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.81,,,,,,,fee schedule,9.32,39.47,APC
Assay of lap enzyme,83670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.66,,,,,,,fee schedule,9.32,39.47,APC
Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.55,,,,,,,fee schedule,6.55,13.41,
Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.66,,,,,,,fee schedule,6.55,13.41,
Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.54,,,,,,,fee schedule,6.55,13.41,
Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.64,,,,,,,fee schedule,6.55,13.41,
Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.41,,,,,,,fee schedule,6.55,13.41,
Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.23,,,,,,,fee schedule,6.55,13.41,APC
Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.89,,,,,,,fee schedule,6.55,13.41,APC
Assay of lipase,83690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.4,,,,,,,fee schedule,6.55,13.41,APC
Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.6,,,,,,,fee schedule,9.2,25.78,
Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.03,,,,,,,fee schedule,9.2,25.78,
Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.48,,,,,,,fee schedule,9.2,25.78,
Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.2,,,,,,,fee schedule,9.2,25.78,
Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.13,,,,,,,fee schedule,9.2,25.78,
Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.04,,,,,,,fee schedule,9.2,25.78,APC
Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.32,,,,,,,fee schedule,9.2,25.78,APC
Assay of lipoprotein(a),83695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.78,,,,,,,fee schedule,9.2,25.78,APC
Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,43.99,,,,,,,fee schedule,43.99,146.17,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.1,,,,,,,fee schedule,43.99,146.17,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.03,,,,,,,fee schedule,43.99,146.17,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.33,,,,,,,fee schedule,43.99,146.17,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.17,,,,,,,fee schedule,43.99,146.17,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.63,,,,,,,fee schedule,43.99,146.17,APC
Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.31,,,,,,,fee schedule,43.99,146.17,APC
Assay Lipoprotein Pla2,83698,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.36,,,,,,,fee schedule,43.99,146.17,APC
Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.7,,,,,,,fee schedule,10.7,48.47,
Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.15,,,,,,,fee schedule,10.7,48.47,
Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.5,,,,,,,fee schedule,10.7,48.47,
Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.63,,,,,,,fee schedule,10.7,48.47,
Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.47,,,,,,,fee schedule,10.7,48.47,
Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.82,,,,,,,fee schedule,10.7,48.47,APC
Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.26,,,,,,,fee schedule,10.7,48.47,APC
Lipopro bld electrophoretic,83700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.27,,,,,,,fee schedule,10.7,48.47,APC
Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.17,,,,,,,fee schedule,32.17,62.5,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.35,,,,,,,fee schedule,32.17,62.5,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.49,,,,,,,fee schedule,32.17,62.5,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.63,,,,,,,fee schedule,32.17,62.5,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.5,,,,,,,fee schedule,32.17,62.5,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.55,,,,,,,fee schedule,32.17,62.5,APC
Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.86,,,,,,,fee schedule,32.17,62.5,APC
Lipoprotein bld hr fraction,83701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,60.95,,,,,,,fee schedule,32.17,62.5,APC
Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.31,,,,,,,fee schedule,25.12,61.54,
Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.48,,,,,,,fee schedule,25.12,61.54,
Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.36,,,,,,,fee schedule,25.12,61.54,
Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.12,,,,,,,fee schedule,25.12,61.54,
Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.06,,,,,,,fee schedule,25.12,61.54,
Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.9,,,,,,,fee schedule,25.12,61.54,APC
Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.19,,,,,,,fee schedule,25.12,61.54,APC
Lipoprotein bld quan part,83704,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.54,,,,,,,fee schedule,25.12,61.54,APC
Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.24,,,,,,,fee schedule,7.78,32.48,
Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.78,,,,,,,fee schedule,7.78,32.48,
Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.11,,,,,,,fee schedule,7.78,32.48,
Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.51,,,,,,,fee schedule,7.78,32.48,
Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.48,,,,,,,fee schedule,7.78,32.48,
Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.6,,,,,,,fee schedule,7.78,32.48,APC
Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.19,,,,,,,fee schedule,7.78,32.48,APC
Assay of lipoprotein,83718,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.74,,,,,,,fee schedule,7.78,32.48,APC
Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.44,,,,,,,fee schedule,12.11,28.11,
Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.11,,,,,,,fee schedule,12.11,28.11,
Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20,,,,,,,fee schedule,12.11,28.11,
Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.02,,,,,,,fee schedule,12.11,28.11,
Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.11,,,,,,,fee schedule,12.11,28.11,
Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.39,,,,,,,fee schedule,12.11,28.11,APC
Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.75,,,,,,,fee schedule,12.11,28.11,APC
Assay of blood lipoprotein,83719,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.95,,,,,,,fee schedule,12.11,28.11,APC
Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.53,,,,,,,fee schedule,9.98,81.11,
Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.98,,,,,,,fee schedule,9.98,81.11,
Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.73,,,,,,,fee schedule,9.98,81.11,
Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.24,,,,,,,fee schedule,9.98,81.11,
Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.11,,,,,,,fee schedule,9.98,81.11,
Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.02,,,,,,,fee schedule,9.98,81.11,APC
Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.5,,,,,,,fee schedule,9.98,81.11,APC
Assay of blood lipoprotein,83721,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.9,,,,,,,fee schedule,9.98,81.11,APC
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.23,,,,,,,fee schedule,32.48,117.56,
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.48,,,,,,,fee schedule,32.48,117.56,
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.68,,,,,,,fee schedule,32.48,117.56,
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.02,,,,,,,fee schedule,32.48,117.56,
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.56,,,,,,,fee schedule,32.48,117.56,
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.9,,,,,,,fee schedule,32.48,117.56,APC
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.19,,,,,,,fee schedule,32.48,117.56,APC
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.54,,,,,,,fee schedule,32.48,117.56,APC
Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.39,,,,,,,fee schedule,16.33,74.05,
Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.33,,,,,,,fee schedule,16.33,74.05,
Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.7,,,,,,,fee schedule,16.33,74.05,
Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.21,,,,,,,fee schedule,16.33,74.05,
Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.05,,,,,,,fee schedule,16.33,74.05,
Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.05,,,,,,,fee schedule,16.33,74.05,APC
Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.19,,,,,,,fee schedule,16.33,74.05,APC
Assay of lrh hormone,83727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.94,,,,,,,fee schedule,16.33,74.05,APC
Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.66,,,,,,,fee schedule,6.37,13.41,
Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.37,,,,,,,fee schedule,6.37,13.41,
Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.54,,,,,,,fee schedule,6.37,13.41,
Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.64,,,,,,,fee schedule,6.37,13.41,
Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.41,,,,,,,fee schedule,6.37,13.41,
Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.04,,,,,,,fee schedule,6.37,13.41,APC
Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.7,,,,,,,fee schedule,6.37,13.41,APC
Assay of magnesium,83735,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.06,,,,,,,fee schedule,6.37,13.41,APC
Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,7,30.48,
Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7,,,,,,,fee schedule,7,30.48,
Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,7,30.48,
Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,7,30.48,
Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,7,30.48,
Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.74,,,,,,,fee schedule,7,30.48,APC
Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.37,,,,,,,fee schedule,7,30.48,APC
Assay malate dehydrogenase,83775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.27,,,,,,,fee schedule,7,30.48,APC
Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.11,,,,,,,fee schedule,21.71,47.97,
Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.32,,,,,,,fee schedule,21.71,47.97,
Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.1,,,,,,,fee schedule,21.71,47.97,
Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.71,,,,,,,fee schedule,21.71,47.97,
Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.08,,,,,,,fee schedule,21.71,47.97,
Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.98,,,,,,,fee schedule,21.71,47.97,APC
Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.65,,,,,,,fee schedule,21.71,47.97,APC
Assay of manganese,83785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.97,,,,,,,fee schedule,21.71,47.97,APC
Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.02,,,,,,,fee schedule,22.9,118.47,
Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.9,,,,,,,fee schedule,22.9,118.47,
Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.32,,,,,,,fee schedule,22.9,118.47,
Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.54,,,,,,,fee schedule,22.9,118.47,
Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.47,,,,,,,fee schedule,22.9,118.47,
Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.32,,,,,,,fee schedule,22.9,118.47,APC
Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.11,,,,,,,fee schedule,22.9,118.47,APC
Mass spectrometry qual/quan,83789,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.4,,,,,,,fee schedule,22.9,118.47,APC
Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.03,,,,,,,fee schedule,7.23,29.27,
Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.45,,,,,,,fee schedule,7.23,29.27,
Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.03,,,,,,,fee schedule,7.23,29.27,
Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.23,,,,,,,fee schedule,7.23,29.27,
Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.68,,,,,,,fee schedule,7.23,29.27,
Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.07,,,,,,,fee schedule,7.23,29.27,APC
Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.26,,,,,,,fee schedule,7.23,29.27,APC
Assay of mercury,83825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.27,,,,,,,fee schedule,7.23,29.27,APC
Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.89,,,,,,,fee schedule,16.09,32.07,
Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.09,,,,,,,fee schedule,16.09,32.07,
Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.83,,,,,,,fee schedule,16.09,32.07,
Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.28,,,,,,,fee schedule,16.09,32.07,
Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.07,,,,,,,fee schedule,16.09,32.07,
Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.79,,,,,,,fee schedule,16.09,32.07,APC
Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.94,,,,,,,fee schedule,16.09,32.07,APC
Assay of metanephrines,83835,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.49,,,,,,,fee schedule,16.09,32.07,APC
Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.21,,,,,,,fee schedule,10.2,46.24,
Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.2,,,,,,,fee schedule,10.2,46.24,
Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.91,,,,,,,fee schedule,10.2,46.24,
Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.36,,,,,,,fee schedule,10.2,46.24,
Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.24,,,,,,,fee schedule,10.2,46.24,
Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,10.2,46.24,APC
Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.74,,,,,,,fee schedule,10.2,46.24,APC
Assay of methemalbumin,83857,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.33,,,,,,,fee schedule,10.2,46.24,APC
Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.85,,,,,,,fee schedule,21.36,71.13,
Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.36,,,,,,,fee schedule,21.36,71.13,
Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.62,,,,,,,fee schedule,21.36,71.13,
Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.55,,,,,,,fee schedule,21.36,71.13,
Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.13,,,,,,,fee schedule,21.36,71.13,
Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.6,,,,,,,fee schedule,21.36,71.13,APC
Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.48,,,,,,,fee schedule,21.36,71.13,APC
Microfluid analy tears,83861,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40.46,,,,,,,fee schedule,21.36,71.13,APC
Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.58,,,,,,,fee schedule,27.08,85.77,
Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.08,,,,,,,fee schedule,27.08,85.77,
Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.04,,,,,,,fee schedule,27.08,85.77,
Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.89,,,,,,,fee schedule,27.08,85.77,
Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.77,,,,,,,fee schedule,27.08,85.77,
Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.92,,,,,,,fee schedule,27.08,85.77,APC
Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.5,,,,,,,fee schedule,27.08,85.77,APC
Mucopolysaccharides,83864,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.3,,,,,,,fee schedule,27.08,85.77,APC
Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.94,,,,,,,fee schedule,5.57,25.23,
Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.57,,,,,,,fee schedule,5.57,25.23,
Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.96,,,,,,,fee schedule,5.57,25.23,
Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.38,,,,,,,fee schedule,5.57,25.23,
Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.23,,,,,,,fee schedule,5.57,25.23,
Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.15,,,,,,,fee schedule,5.57,25.23,APC
Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.86,,,,,,,fee schedule,5.57,25.23,APC
Assay synovial fluid mucin,83872,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.55,,,,,,,fee schedule,5.57,25.23,APC
Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.28,,,,,,,fee schedule,16.34,95.77,
Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.34,,,,,,,fee schedule,16.34,95.77,
Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.16,,,,,,,fee schedule,16.34,95.77,
Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.6,,,,,,,fee schedule,16.34,95.77,
Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.77,,,,,,,fee schedule,16.34,95.77,
Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.06,,,,,,,fee schedule,16.34,95.77,APC
Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.2,,,,,,,fee schedule,16.34,95.77,APC
Assay of csf protein,83873,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.96,,,,,,,fee schedule,16.34,95.77,APC
Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.4,,,,,,,fee schedule,12.27,31.51,
Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.27,,,,,,,fee schedule,12.27,31.51,
Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.43,,,,,,,fee schedule,12.27,31.51,
Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.96,,,,,,,fee schedule,12.27,31.51,
Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.51,,,,,,,fee schedule,12.27,31.51,
Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.57,,,,,,,fee schedule,12.27,31.51,APC
Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.92,,,,,,,fee schedule,12.27,31.51,APC
Assay of myoglobin,83874,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.26,,,,,,,fee schedule,12.27,31.51,APC
Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.1,,,,,,,fee schedule,48.32,146.17,
Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.32,,,,,,,fee schedule,48.32,146.17,
Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.03,,,,,,,fee schedule,48.32,146.17,
Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.33,,,,,,,fee schedule,48.32,146.17,
Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.17,,,,,,,fee schedule,48.32,146.17,
Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.4,,,,,,,fee schedule,48.32,146.17,APC
Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50.86,,,,,,,fee schedule,48.32,146.17,APC
Assay myeloperoxidase,83876,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,91.55,,,,,,,fee schedule,48.32,146.17,APC
Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.62,,,,,,,fee schedule,37.3,90.41,
Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.3,,,,,,,fee schedule,37.3,90.41,
Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.35,,,,,,,fee schedule,37.3,90.41,
Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.54,,,,,,,fee schedule,37.3,90.41,
Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.41,,,,,,,fee schedule,37.3,90.41,
Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.22,,,,,,,fee schedule,37.3,90.41,APC
Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.26,,,,,,,fee schedule,37.3,90.41,APC
Assay of natriuretic peptide,83880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.67,,,,,,,fee schedule,37.3,90.41,APC
Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.2,,,,,,,fee schedule,12.92,30.13,
Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.92,,,,,,,fee schedule,12.92,30.13,
Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.44,,,,,,,fee schedule,12.92,30.13,
Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.18,,,,,,,fee schedule,12.92,30.13,
Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.13,,,,,,,fee schedule,12.92,30.13,
Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.28,,,,,,,fee schedule,12.92,30.13,APC
Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.6,,,,,,,fee schedule,12.92,30.13,APC
Assay nephelometry not spec,83883,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.48,,,,,,,fee schedule,12.92,30.13,APC
Assay neurflmnt light chain,83884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.24,,,,,,,fee schedule,18.51,209.21,
Assay neurflmnt light chain,83884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.11,,,,,,,fee schedule,18.51,209.21,
Assay neurflmnt light chain,83884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.51,,,,,,,fee schedule,18.51,209.21,
Assay neurflmnt light chain,83884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.48,,,,,,,fee schedule,18.51,209.21,
Assay neurflmnt light chain,83884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,18.51,209.21,APC
Assay neurflmnt light chain,83884,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.23,,,,,,,fee schedule,18.51,209.21,APC
Assay neurflmnt light chain,83884,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,209.21,,,,,,,fee schedule,18.51,209.21,APC
Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.5,,,,,,,fee schedule,23.27,44.12,
Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.28,,,,,,,fee schedule,23.27,44.12,
Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.06,,,,,,,fee schedule,23.27,44.12,
Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.27,,,,,,,fee schedule,23.27,44.12,
Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.83,,,,,,,fee schedule,23.27,44.12,
Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.74,,,,,,,fee schedule,23.27,44.12,APC
Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.51,,,,,,,fee schedule,23.27,44.12,APC
Assay of nickel,83885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.12,,,,,,,fee schedule,23.27,44.12,APC
Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,310.53,,,,,,,fee schedule,10.59,357.11,
Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.59,,,,,,,fee schedule,10.59,357.11,
Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.17,,,,,,,fee schedule,10.59,357.11,
Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.58,,,,,,,fee schedule,10.59,357.11,
Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.11,,,,,,,fee schedule,10.59,357.11,
Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.71,,,,,,,fee schedule,10.59,357.11,APC
Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.15,,,,,,,fee schedule,10.59,357.11,APC
Assay of nucleotidase,83915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.07,,,,,,,fee schedule,10.59,357.11,APC
Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.24,,,,,,,fee schedule,26.02,79.63,
Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.02,,,,,,,fee schedule,26.02,79.63,
Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.67,,,,,,,fee schedule,26.02,79.63,
Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.39,,,,,,,fee schedule,26.02,79.63,
Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.63,,,,,,,fee schedule,26.02,79.63,
Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.76,,,,,,,fee schedule,26.02,79.63,APC
Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.39,,,,,,,fee schedule,26.02,79.63,APC
Oligoclonal bands,83916,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49.3,,,,,,,fee schedule,26.02,79.63,APC
Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.62,,,,,,,fee schedule,22.42,70.86,
Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.42,,,,,,,fee schedule,22.42,70.86,
Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.44,,,,,,,fee schedule,22.42,70.86,
Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.4,,,,,,,fee schedule,22.42,70.86,
Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.86,,,,,,,fee schedule,22.42,70.86,
Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.78,,,,,,,fee schedule,22.42,70.86,APC
Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.6,,,,,,,fee schedule,22.42,70.86,APC
Organic acids total quant,83918,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42.48,,,,,,,fee schedule,22.42,70.86,APC
Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.96,,,,,,,fee schedule,15.63,49.4,
Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.63,,,,,,,fee schedule,15.63,49.4,
Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.16,,,,,,,fee schedule,15.63,49.4,
Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.16,,,,,,,fee schedule,15.63,49.4,
Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.4,,,,,,,fee schedule,15.63,49.4,
Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.27,,,,,,,fee schedule,15.63,49.4,APC
Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.45,,,,,,,fee schedule,15.63,49.4,APC
Organic acids qual each,83919,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.61,,,,,,,fee schedule,15.63,49.4,APC
Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.95,,,,,,,fee schedule,15.7,38.18,
Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.15,,,,,,,fee schedule,15.7,38.18,
Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.6,,,,,,,fee schedule,15.7,38.18,
Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.7,,,,,,,fee schedule,15.7,38.18,
Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.54,,,,,,,fee schedule,15.7,38.18,
Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.27,,,,,,,fee schedule,15.7,38.18,APC
Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.21,,,,,,,fee schedule,15.7,38.18,APC
Organic acid single quant,83921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.18,,,,,,,fee schedule,15.7,38.18,APC
Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.81,,,,,,,fee schedule,6.28,26.23,
Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.28,,,,,,,fee schedule,6.28,26.23,
Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.67,,,,,,,fee schedule,6.28,26.23,
Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.95,,,,,,,fee schedule,6.28,26.23,
Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.23,,,,,,,fee schedule,6.28,26.23,
Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.94,,,,,,,fee schedule,6.28,26.23,APC
Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.61,,,,,,,fee schedule,6.28,26.23,APC
Assay of blood osmolality,83930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.9,,,,,,,fee schedule,6.28,26.23,APC
Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.66,,,,,,,fee schedule,6.48,27.21,
Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.48,,,,,,,fee schedule,6.48,27.21,
Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.37,,,,,,,fee schedule,6.48,27.21,
Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.51,,,,,,,fee schedule,6.48,27.21,
Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.21,,,,,,,fee schedule,6.48,27.21,
Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.16,,,,,,,fee schedule,6.48,27.21,APC
Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.82,,,,,,,fee schedule,6.48,27.21,APC
Assay of urine osmolality,83935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.28,,,,,,,fee schedule,6.48,27.21,APC
Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.26,,,,,,,fee schedule,28.36,106.1,
Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.36,,,,,,,fee schedule,28.36,106.1,
Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.51,,,,,,,fee schedule,28.36,106.1,
Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.49,,,,,,,fee schedule,28.36,106.1,
Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.1,,,,,,,fee schedule,28.36,106.1,
Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.34,,,,,,,fee schedule,28.36,106.1,APC
Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.85,,,,,,,fee schedule,28.36,106.1,APC
Assay of osteocalcin,83937,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.73,,,,,,,fee schedule,28.36,106.1,APC
Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.11,,,,,,,fee schedule,13.73,32.33,
Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.73,,,,,,,fee schedule,13.73,32.33,
Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.01,,,,,,,fee schedule,13.73,32.33,
Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.43,,,,,,,fee schedule,13.73,32.33,
Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.33,,,,,,,fee schedule,13.73,32.33,
Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.17,,,,,,,fee schedule,13.73,32.33,APC
Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.45,,,,,,,fee schedule,13.73,32.33,APC
Assay of oxalate,83945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.01,,,,,,,fee schedule,13.73,32.33,APC
Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,241.24,,,,,,,fee schedule,61.19,277.43,
Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,61.19,,,,,,,fee schedule,61.19,277.43,
Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,197.45,,,,,,,fee schedule,61.19,277.43,
Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.16,,,,,,,fee schedule,61.19,277.43,
Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,277.43,,,,,,,fee schedule,61.19,277.43,
Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,61.19,277.43,APC
Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.41,,,,,,,fee schedule,61.19,277.43,APC
Oncoprotein her-2/neu,83950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.94,,,,,,,fee schedule,61.19,277.43,APC
Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,241.24,,,,,,,fee schedule,61.19,277.43,
Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,61.19,,,,,,,fee schedule,61.19,277.43,
Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,197.45,,,,,,,fee schedule,61.19,277.43,
Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.16,,,,,,,fee schedule,61.19,277.43,
Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,277.43,,,,,,,fee schedule,61.19,277.43,
Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,61.19,277.43,APC
Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.41,,,,,,,fee schedule,61.19,277.43,APC
Oncoprotein dcp,83951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.94,,,,,,,fee schedule,61.19,277.43,APC
Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.83,,,,,,,fee schedule,39.22,84.9,
Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.22,,,,,,,fee schedule,39.22,84.9,
Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.43,,,,,,,fee schedule,39.22,84.9,
Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.4,,,,,,,fee schedule,39.22,84.9,
Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.9,,,,,,,fee schedule,39.22,84.9,
Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.34,,,,,,,fee schedule,39.22,84.9,APC
Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.28,,,,,,,fee schedule,39.22,84.9,APC
Assay of parathormone,83970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74.3,,,,,,,fee schedule,39.22,84.9,APC
Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.85,,,,,,,fee schedule,3.4,13.63,
Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.4,,,,,,,fee schedule,3.4,13.63,
Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.7,,,,,,,fee schedule,3.4,13.63,
Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.77,,,,,,,fee schedule,3.4,13.63,
Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.63,,,,,,,fee schedule,3.4,13.63,
Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.76,,,,,,,fee schedule,3.4,13.63,APC
Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.58,,,,,,,fee schedule,3.4,13.63,APC
Assay ph body fluid nos,83986,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.44,,,,,,,fee schedule,3.4,13.63,APC
Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.91,,,,,,,fee schedule,3.4,59.7,
Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.4,,,,,,,fee schedule,3.4,59.7,
Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.49,,,,,,,fee schedule,3.4,59.7,
Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.03,,,,,,,fee schedule,3.4,59.7,
Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.7,,,,,,,fee schedule,3.4,59.7,
Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.76,,,,,,,fee schedule,3.4,59.7,APC
Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.58,,,,,,,fee schedule,3.4,59.7,APC
Exhaled breath condensate,83987,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.44,,,,,,,fee schedule,3.4,59.7,APC
Assay for phencyclidine,83992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.06,,,,,,,fee schedule,0.01,63.32,
Assay for phencyclidine,83992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,63.32,
Assay for phencyclidine,83992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.07,,,,,,,fee schedule,0.01,63.32,
Assay for phencyclidine,83992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.1,,,,,,,fee schedule,0.01,63.32,
Assay for phencyclidine,83992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.32,,,,,,,fee schedule,0.01,63.32,
Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.29,,,,,,,fee schedule,18.65,228.03,
Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.65,,,,,,,fee schedule,18.65,228.03,
Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.3,,,,,,,fee schedule,18.65,228.03,
Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,130,,,,,,,fee schedule,18.65,228.03,
Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.03,,,,,,,fee schedule,18.65,228.03,
Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.61,,,,,,,fee schedule,18.65,228.03,APC
Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.63,,,,,,,fee schedule,18.65,228.03,APC
Assay for calprotectin fecal,83993,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.33,,,,,,,fee schedule,18.65,228.03,APC
Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,5.23,23.67,
Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.23,,,,,,,fee schedule,5.23,23.67,
Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,5.23,23.67,
Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,5.23,23.67,
Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,5.23,23.67,
Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.78,,,,,,,fee schedule,5.23,23.67,APC
Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.5,,,,,,,fee schedule,5.23,23.67,APC
Assay of blood pku,84030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.9,,,,,,,fee schedule,5.23,23.67,APC
Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.52,,,,,,,fee schedule,3.78,13.25,
Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.78,,,,,,,fee schedule,3.78,13.25,
Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.43,,,,,,,fee schedule,3.78,13.25,
Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.55,,,,,,,fee schedule,3.78,13.25,
Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.25,,,,,,,fee schedule,3.78,13.25,
Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.18,,,,,,,fee schedule,3.78,13.25,APC
Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.98,,,,,,,fee schedule,3.78,13.25,APC
Assay of phenylketones,84035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.16,,,,,,,fee schedule,3.78,13.25,APC
Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.64,,,,,,,fee schedule,7.26,31.79,
Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.26,,,,,,,fee schedule,7.26,31.79,
Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.62,,,,,,,fee schedule,7.26,31.79,
Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.12,,,,,,,fee schedule,7.26,31.79,
Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.79,,,,,,,fee schedule,7.26,31.79,
Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.02,,,,,,,fee schedule,7.26,31.79,APC
Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.64,,,,,,,fee schedule,7.26,31.79,APC
Assay acid phosphatase,84060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.75,,,,,,,fee schedule,7.26,31.79,APC
Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.5,,,,,,,fee schedule,9.18,40.83,
Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.18,,,,,,,fee schedule,9.18,40.83,
Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.06,,,,,,,fee schedule,9.18,40.83,
Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.27,,,,,,,fee schedule,9.18,40.83,
Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.83,,,,,,,fee schedule,9.18,40.83,
Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.14,,,,,,,fee schedule,9.18,40.83,APC
Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.66,,,,,,,fee schedule,9.18,40.83,APC
Assay prostate phosphatase,84066,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.39,,,,,,,fee schedule,9.18,40.83,APC
Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.39,,,,,,,fee schedule,4.92,9.65,
Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.92,,,,,,,fee schedule,4.92,9.65,
Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.87,,,,,,,fee schedule,4.92,9.65,
Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.5,,,,,,,fee schedule,4.92,9.65,
Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.65,,,,,,,fee schedule,4.92,9.65,
Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.92,9.65,APC
Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.18,,,,,,,fee schedule,4.92,9.65,APC
Assay alkaline phosphatase,84075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.32,,,,,,,fee schedule,4.92,9.65,APC
Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,7.85,30.48,
Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.85,,,,,,,fee schedule,7.85,30.48,
Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,7.85,30.48,
Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,7.85,30.48,
Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,7.85,30.48,
Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.67,,,,,,,fee schedule,7.85,30.48,APC
Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.26,,,,,,,fee schedule,7.85,30.48,APC
Assay alkaline phosphatase,84078,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.87,,,,,,,fee schedule,7.85,30.48,APC
Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.59,,,,,,,fee schedule,13.5,26.6,
Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.04,,,,,,,fee schedule,13.5,26.6,
Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.85,,,,,,,fee schedule,13.5,26.6,
Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.5,,,,,,,fee schedule,13.5,26.6,
Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.68,,,,,,,fee schedule,13.5,26.6,
Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.52,,,,,,,fee schedule,13.5,26.6,APC
Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.78,,,,,,,fee schedule,13.5,26.6,APC
Assay alkaline phosphatases,84080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.6,,,,,,,fee schedule,13.5,26.6,APC
Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.75,,,,,,,fee schedule,15.69,64.11,
Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.69,,,,,,,fee schedule,15.69,64.11,
Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.63,,,,,,,fee schedule,15.69,64.11,
Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.55,,,,,,,fee schedule,15.69,64.11,
Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.11,,,,,,,fee schedule,15.69,64.11,
Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.35,,,,,,,fee schedule,15.69,64.11,APC
Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.52,,,,,,,fee schedule,15.69,64.11,APC
Assay phosphatidylglycerol,84081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.74,,,,,,,fee schedule,15.69,64.11,APC
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.24,,,,,,,fee schedule,8.97,29.03,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.97,,,,,,,fee schedule,8.97,29.03,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.66,,,,,,,fee schedule,8.97,29.03,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.55,,,,,,,fee schedule,8.97,29.03,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.03,,,,,,,fee schedule,8.97,29.03,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.97,29.03,APC
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.44,,,,,,,fee schedule,8.97,29.03,APC
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.99,,,,,,,fee schedule,8.97,29.03,APC
Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.77,,,,,,,fee schedule,10.19,117.04,
Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.19,,,,,,,fee schedule,10.19,117.04,
Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.3,,,,,,,fee schedule,10.19,117.04,
Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.72,,,,,,,fee schedule,10.19,117.04,
Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.04,,,,,,,fee schedule,10.19,117.04,
Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.27,,,,,,,fee schedule,10.19,117.04,APC
Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.73,,,,,,,fee schedule,10.19,117.04,APC
Assay phosphohexose enzymes,84087,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.31,,,,,,,fee schedule,10.19,117.04,APC
Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.77,,,,,,,fee schedule,4.5,8.94,
Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.5,,,,,,,fee schedule,4.5,8.94,
Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.36,,,,,,,fee schedule,4.5,8.94,
Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.09,,,,,,,fee schedule,4.5,8.94,
Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.94,,,,,,,fee schedule,4.5,8.94,
Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.98,,,,,,,fee schedule,4.5,8.94,APC
Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.74,,,,,,,fee schedule,4.5,8.94,APC
Assay of phosphorus,84100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.53,,,,,,,fee schedule,4.5,8.94,APC
Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.09,,,,,,,fee schedule,5.49,19.65,
Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.49,,,,,,,fee schedule,5.49,19.65,
Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.99,,,,,,,fee schedule,5.49,19.65,
Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.2,,,,,,,fee schedule,5.49,19.65,
Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.65,,,,,,,fee schedule,5.49,19.65,
Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.07,,,,,,,fee schedule,5.49,19.65,APC
Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.78,,,,,,,fee schedule,5.49,19.65,APC
Assay of urine phosphorus,84105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.4,,,,,,,fee schedule,5.49,19.65,APC
Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.03,,,,,,,fee schedule,5.53,18.43,
Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.53,,,,,,,fee schedule,5.53,18.43,
Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.12,,,,,,,fee schedule,5.53,18.43,
Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.51,,,,,,,fee schedule,5.53,18.43,
Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.43,,,,,,,fee schedule,5.53,18.43,
Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.11,,,,,,,fee schedule,5.53,18.43,APC
Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.82,,,,,,,fee schedule,5.53,18.43,APC
Test for porphobilinogen,84106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.48,,,,,,,fee schedule,5.53,18.43,APC
Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.21,,,,,,,fee schedule,8.02,15.19,
Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.02,,,,,,,fee schedule,8.02,15.19,
Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.81,,,,,,,fee schedule,8.02,15.19,
Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.66,,,,,,,fee schedule,8.02,15.19,
Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.19,,,,,,,fee schedule,8.02,15.19,
Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.86,,,,,,,fee schedule,8.02,15.19,APC
Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.44,,,,,,,fee schedule,8.02,15.19,APC
Assay of porphobilinogen,84110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.19,,,,,,,fee schedule,8.02,15.19,APC
Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,248.08,,,,,,,fee schedule,93.2,285.29,
Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,93.2,,,,,,,fee schedule,93.2,285.29,
Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,203.05,,,,,,,fee schedule,93.2,285.29,
Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,162.64,,,,,,,fee schedule,93.2,285.29,
Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,285.29,,,,,,,fee schedule,93.2,285.29,
Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,103.02,,,,,,,fee schedule,93.2,285.29,APC
Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,98.11,,,,,,,fee schedule,93.2,285.29,APC
Eval amniotic fluid protein,84112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,176.6,,,,,,,fee schedule,93.2,285.29,APC
Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.13,,,,,,,fee schedule,11.89,24.05,
Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.69,,,,,,,fee schedule,11.89,24.05,
Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.84,,,,,,,fee schedule,11.89,24.05,
Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.89,,,,,,,fee schedule,11.89,24.05,
Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.85,,,,,,,fee schedule,11.89,24.05,
Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.03,,,,,,,fee schedule,11.89,24.05,APC
Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.36,,,,,,,fee schedule,11.89,24.05,APC
Test urine for porphyrins,84119,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.05,,,,,,,fee schedule,11.89,24.05,APC
Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.06,,,,,,,fee schedule,13.97,26.52,
Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.97,,,,,,,fee schedule,13.97,26.52,
Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.87,,,,,,,fee schedule,13.97,26.52,
Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.12,,,,,,,fee schedule,13.97,26.52,
Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.52,,,,,,,fee schedule,13.97,26.52,
Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.45,,,,,,,fee schedule,13.97,26.52,APC
Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.71,,,,,,,fee schedule,13.97,26.52,APC
Assay of urine porphyrins,84120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.48,,,,,,,fee schedule,13.97,26.52,APC
Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.41,,,,,,,fee schedule,37.15,109.72,
Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.15,,,,,,,fee schedule,37.15,109.72,
Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.09,,,,,,,fee schedule,37.15,109.72,
Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.55,,,,,,,fee schedule,37.15,109.72,
Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.72,,,,,,,fee schedule,37.15,109.72,
Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.07,,,,,,,fee schedule,37.15,109.72,APC
Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.11,,,,,,,fee schedule,37.15,109.72,APC
Assay of feces porphyrins,84126,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.4,,,,,,,fee schedule,37.15,109.72,APC
Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.77,,,,,,,fee schedule,4.52,8.94,
Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.52,,,,,,,fee schedule,4.52,8.94,
Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.36,,,,,,,fee schedule,4.52,8.94,
Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.09,,,,,,,fee schedule,4.52,8.94,
Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.94,,,,,,,fee schedule,4.52,8.94,
Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5,,,,,,,fee schedule,4.52,8.94,APC
Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.76,,,,,,,fee schedule,4.52,8.94,APC
Assay of serum potassium,84132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.57,,,,,,,fee schedule,4.52,8.94,APC
Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.39,,,,,,,fee schedule,4.49,16.55,
Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.49,,,,,,,fee schedule,4.49,16.55,
Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.78,,,,,,,fee schedule,4.49,16.55,
Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.43,,,,,,,fee schedule,4.49,16.55,
Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.55,,,,,,,fee schedule,4.49,16.55,
Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.97,,,,,,,fee schedule,4.49,16.55,APC
Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.73,,,,,,,fee schedule,4.49,16.55,APC
Assay of urine potassium,84133,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.51,,,,,,,fee schedule,4.49,16.55,APC
Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.1,,,,,,,fee schedule,13.86,57.62,
Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.86,,,,,,,fee schedule,13.86,57.62,
Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.01,,,,,,,fee schedule,13.86,57.62,
Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.85,,,,,,,fee schedule,13.86,57.62,
Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.62,,,,,,,fee schedule,13.86,57.62,
Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.32,,,,,,,fee schedule,13.86,57.62,APC
Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.59,,,,,,,fee schedule,13.86,57.62,APC
Assay of prealbumin,84134,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.26,,,,,,,fee schedule,13.86,57.62,APC
Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.67,,,,,,,fee schedule,20.21,82.42,
Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.21,,,,,,,fee schedule,20.21,82.42,
Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.66,,,,,,,fee schedule,20.21,82.42,
Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.99,,,,,,,fee schedule,20.21,82.42,
Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.42,,,,,,,fee schedule,20.21,82.42,
Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.33,,,,,,,fee schedule,20.21,82.42,APC
Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.27,,,,,,,fee schedule,20.21,82.42,APC
Assay of pregnanediol,84135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.29,,,,,,,fee schedule,20.21,82.42,APC
Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.99,,,,,,,fee schedule,20,72.44,
Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20,,,,,,,fee schedule,20,72.44,
Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.56,,,,,,,fee schedule,20,72.44,
Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.3,,,,,,,fee schedule,20,72.44,
Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.44,,,,,,,fee schedule,20,72.44,
Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.1,,,,,,,fee schedule,20,72.44,APC
Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.05,,,,,,,fee schedule,20,72.44,APC
Assay of pregnanetriol,84138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.89,,,,,,,fee schedule,20,72.44,APC
Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.61,,,,,,,fee schedule,19.64,37.21,
Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.64,,,,,,,fee schedule,19.64,37.21,
Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.87,,,,,,,fee schedule,19.64,37.21,
Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.72,,,,,,,fee schedule,19.64,37.21,
Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.35,,,,,,,fee schedule,19.64,37.21,
Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.7,,,,,,,fee schedule,19.64,37.21,APC
Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.67,,,,,,,fee schedule,19.64,37.21,APC
Assay of pregnenolone,84140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.21,,,,,,,fee schedule,19.64,37.21,APC
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.59,,,,,,,fee schedule,21.67,84.63,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.67,,,,,,,fee schedule,21.67,84.63,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.23,,,,,,,fee schedule,21.67,84.63,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.25,,,,,,,fee schedule,21.67,84.63,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.63,,,,,,,fee schedule,21.67,84.63,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.95,,,,,,,fee schedule,21.67,84.63,APC
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.81,,,,,,,fee schedule,21.67,84.63,APC
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.06,,,,,,,fee schedule,21.67,84.63,APC
Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.56,,,,,,,fee schedule,19.82,43.19,
Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.82,,,,,,,fee schedule,19.82,43.19,
Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.74,,,,,,,fee schedule,19.82,43.19,
Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.62,,,,,,,fee schedule,19.82,43.19,
Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.19,,,,,,,fee schedule,19.82,43.19,
Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.9,,,,,,,fee schedule,19.82,43.19,APC
Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.86,,,,,,,fee schedule,19.82,43.19,APC
Assay of progesterone,84144,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.55,,,,,,,fee schedule,19.82,43.19,APC
Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.82,,,,,,,fee schedule,25.86,64.19,
Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.86,,,,,,,fee schedule,25.86,64.19,
Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.69,,,,,,,fee schedule,25.86,64.19,
Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.6,,,,,,,fee schedule,25.86,64.19,
Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.19,,,,,,,fee schedule,25.86,64.19,
Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.58,,,,,,,fee schedule,25.86,64.19,APC
Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.22,,,,,,,fee schedule,25.86,64.19,APC
Procalcitonin (PCT),84145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49,,,,,,,fee schedule,25.86,64.19,APC
Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.96,,,,,,,fee schedule,18.41,40.2,
Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.41,,,,,,,fee schedule,18.41,40.2,
Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.61,,,,,,,fee schedule,18.41,40.2,
Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.92,,,,,,,fee schedule,18.41,40.2,
Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.2,,,,,,,fee schedule,18.41,40.2,
Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.35,,,,,,,fee schedule,18.41,40.2,APC
Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.38,,,,,,,fee schedule,18.41,40.2,APC
Assay of prolactin,84146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.88,,,,,,,fee schedule,18.41,40.2,APC
Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.62,,,,,,,fee schedule,39.68,174.36,
Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.68,,,,,,,fee schedule,39.68,174.36,
Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.1,,,,,,,fee schedule,39.68,174.36,
Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.4,,,,,,,fee schedule,39.68,174.36,
Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.36,,,,,,,fee schedule,39.68,174.36,
Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.86,,,,,,,fee schedule,39.68,174.36,APC
Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.77,,,,,,,fee schedule,39.68,174.36,APC
Assay of prostaglandin,84150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.19,,,,,,,fee schedule,39.68,174.36,APC
Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.88,,,,,,,fee schedule,17.47,79.21,
Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.47,,,,,,,fee schedule,17.47,79.21,
Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.38,,,,,,,fee schedule,17.47,79.21,
Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.16,,,,,,,fee schedule,17.47,79.21,
Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.21,,,,,,,fee schedule,17.47,79.21,
Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.31,,,,,,,fee schedule,17.47,79.21,APC
Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.39,,,,,,,fee schedule,17.47,79.21,APC
Assay of psa complexed,84152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.1,,,,,,,fee schedule,17.47,79.21,APC
Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.38,,,,,,,fee schedule,17.47,37.24,
Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.47,,,,,,,fee schedule,17.47,37.24,
Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.5,,,,,,,fee schedule,17.47,37.24,
Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.23,,,,,,,fee schedule,17.47,37.24,
Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.24,,,,,,,fee schedule,17.47,37.24,
Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.31,,,,,,,fee schedule,17.47,37.24,APC
Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.39,,,,,,,fee schedule,17.47,37.24,APC
Assay of psa total,84153,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.1,,,,,,,fee schedule,17.47,37.24,APC
Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.46,,,,,,,fee schedule,17.47,76.43,
Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.47,,,,,,,fee schedule,17.47,76.43,
Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.4,,,,,,,fee schedule,17.47,76.43,
Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.57,,,,,,,fee schedule,17.47,76.43,
Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.43,,,,,,,fee schedule,17.47,76.43,
Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.31,,,,,,,fee schedule,17.47,76.43,APC
Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.39,,,,,,,fee schedule,17.47,76.43,APC
Assay of psa free,84154,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.1,,,,,,,fee schedule,17.47,76.43,APC
Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.75,,,,,,,fee schedule,3.49,14.66,
Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.49,,,,,,,fee schedule,3.49,14.66,
Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.44,,,,,,,fee schedule,3.49,14.66,
Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.36,,,,,,,fee schedule,3.49,14.66,
Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.66,,,,,,,fee schedule,3.49,14.66,
Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.85,,,,,,,fee schedule,3.49,14.66,APC
Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.67,,,,,,,fee schedule,3.49,14.66,APC
Assay of protein serum,84155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.61,,,,,,,fee schedule,3.49,14.66,APC
Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.61,,,,,,,fee schedule,3.49,16.8,
Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.49,,,,,,,fee schedule,3.49,16.8,
Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.96,,,,,,,fee schedule,3.49,16.8,
Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.58,,,,,,,fee schedule,3.49,16.8,
Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.8,,,,,,,fee schedule,3.49,16.8,
Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.85,,,,,,,fee schedule,3.49,16.8,APC
Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.67,,,,,,,fee schedule,3.49,16.8,APC
Assay of protein urine,84156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.61,,,,,,,fee schedule,3.49,16.8,APC
Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.61,,,,,,,fee schedule,3.8,16.8,
Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.8,,,,,,,fee schedule,3.8,16.8,
Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.96,,,,,,,fee schedule,3.8,16.8,
Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.58,,,,,,,fee schedule,3.8,16.8,
Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.8,,,,,,,fee schedule,3.8,16.8,
Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.2,,,,,,,fee schedule,3.8,16.8,APC
Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4,,,,,,,fee schedule,3.8,16.8,APC
Assay of protein other,84157,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.2,,,,,,,fee schedule,3.8,16.8,APC
Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.52,,,,,,,fee schedule,5.33,14.4,
Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.33,,,,,,,fee schedule,5.33,14.4,
Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.25,,,,,,,fee schedule,5.33,14.4,
Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.21,,,,,,,fee schedule,5.33,14.4,
Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.4,,,,,,,fee schedule,5.33,14.4,
Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.89,,,,,,,fee schedule,5.33,14.4,APC
Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.61,,,,,,,fee schedule,5.33,14.4,APC
Assay of protein any source,84160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.1,,,,,,,fee schedule,5.33,14.4,APC
Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.9,,,,,,,fee schedule,13.7,27.09,
Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.3,,,,,,,fee schedule,13.7,27.09,
Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.11,,,,,,,fee schedule,13.7,27.09,
Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.7,,,,,,,fee schedule,13.7,27.09,
Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.04,,,,,,,fee schedule,13.7,27.09,
Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,13.7,27.09,APC
Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.05,,,,,,,fee schedule,13.7,27.09,APC
Pappa serum,84163,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.09,,,,,,,fee schedule,13.7,27.09,APC
Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.96,,,,,,,fee schedule,10.2,47.1,
Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.2,,,,,,,fee schedule,10.2,47.1,
Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.53,,,,,,,fee schedule,10.2,47.1,
Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.85,,,,,,,fee schedule,10.2,47.1,
Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.1,,,,,,,fee schedule,10.2,47.1,
Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,10.2,47.1,APC
Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.74,,,,,,,fee schedule,10.2,47.1,APC
Protein e-phoresis serum,84165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.33,,,,,,,fee schedule,10.2,47.1,APC
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.35,,,,,,,fee schedule,16.94,77.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.94,,,,,,,fee schedule,16.94,77.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.13,,,,,,,fee schedule,16.94,77.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.15,,,,,,,fee schedule,16.94,77.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.45,,,,,,,fee schedule,16.94,77.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.72,,,,,,,fee schedule,16.94,77.45,APC
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.83,,,,,,,fee schedule,16.94,77.45,APC
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.09,,,,,,,fee schedule,16.94,77.45,APC
Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.22,,,,,,,fee schedule,16.18,153.2,
Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.18,,,,,,,fee schedule,16.18,153.2,
Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.04,,,,,,,fee schedule,16.18,153.2,
Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.34,,,,,,,fee schedule,16.18,153.2,
Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.2,,,,,,,fee schedule,16.18,153.2,
Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.88,,,,,,,fee schedule,16.18,153.2,APC
Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.03,,,,,,,fee schedule,16.18,153.2,APC
Western blot test,84181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.65,,,,,,,fee schedule,16.18,153.2,APC
Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.62,,,,,,,fee schedule,25.97,52.58,
Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.75,,,,,,,fee schedule,25.97,52.58,
Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.43,,,,,,,fee schedule,25.97,52.58,
Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.97,,,,,,,fee schedule,25.97,52.58,
Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.56,,,,,,,fee schedule,25.97,52.58,
Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.67,,,,,,,fee schedule,25.97,52.58,APC
Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.21,,,,,,,fee schedule,25.97,52.58,APC
Protein western blot test,84182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.58,,,,,,,fee schedule,25.97,52.58,APC
Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.63,,,,,,,fee schedule,13.63,44.42,
Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.63,,,,,,,fee schedule,13.63,44.42,
Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.62,,,,,,,fee schedule,13.63,44.42,
Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.33,,,,,,,fee schedule,13.63,44.42,
Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.42,,,,,,,fee schedule,13.63,44.42,
Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.07,,,,,,,fee schedule,13.63,44.42,APC
Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.35,,,,,,,fee schedule,13.63,44.42,APC
Assay RBC protoporphyrin,84202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.83,,,,,,,fee schedule,13.63,44.42,APC
Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.23,,,,,,,fee schedule,9.25,37.06,
Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.25,,,,,,,fee schedule,9.25,37.06,
Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.38,,,,,,,fee schedule,9.25,37.06,
Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.13,,,,,,,fee schedule,9.25,37.06,
Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.06,,,,,,,fee schedule,9.25,37.06,
Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.23,,,,,,,fee schedule,9.25,37.06,APC
Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.74,,,,,,,fee schedule,9.25,37.06,APC
Test RBC protoporphyrin,84203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.53,,,,,,,fee schedule,9.25,37.06,APC
Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.35,,,,,,,fee schedule,25.36,62.5,
Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.36,,,,,,,fee schedule,25.36,62.5,
Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.49,,,,,,,fee schedule,25.36,62.5,
Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.63,,,,,,,fee schedule,25.36,62.5,
Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.5,,,,,,,fee schedule,25.36,62.5,
Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.02,,,,,,,fee schedule,25.36,62.5,APC
Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.69,,,,,,,fee schedule,25.36,62.5,APC
Assay of proinsulin,84206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.04,,,,,,,fee schedule,25.36,62.5,APC
Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.11,,,,,,,fee schedule,18.43,50.58,
Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.7,,,,,,,fee schedule,18.43,50.58,
Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.01,,,,,,,fee schedule,18.43,50.58,
Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.43,,,,,,,fee schedule,18.43,50.58,
Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.33,,,,,,,fee schedule,18.43,50.58,
Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.5,,,,,,,fee schedule,18.43,50.58,APC
Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.1,,,,,,,fee schedule,18.43,50.58,APC
Assay of vitamin b-6,84207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.58,,,,,,,fee schedule,18.43,50.58,APC
Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.32,,,,,,,fee schedule,13.76,55.57,
Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.76,,,,,,,fee schedule,13.76,55.57,
Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.55,,,,,,,fee schedule,13.76,55.57,
Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.68,,,,,,,fee schedule,13.76,55.57,
Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.57,,,,,,,fee schedule,13.76,55.57,
Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.2,,,,,,,fee schedule,13.76,55.57,APC
Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.48,,,,,,,fee schedule,13.76,55.57,APC
Assay of pyruvate,84210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.06,,,,,,,fee schedule,13.76,55.57,APC
Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.77,,,,,,,fee schedule,8.97,117.04,
Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.97,,,,,,,fee schedule,8.97,117.04,
Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.3,,,,,,,fee schedule,8.97,117.04,
Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.72,,,,,,,fee schedule,8.97,117.04,
Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.04,,,,,,,fee schedule,8.97,117.04,
Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.97,117.04,APC
Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.44,,,,,,,fee schedule,8.97,117.04,APC
Assay of pyruvate kinase,84220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.99,,,,,,,fee schedule,8.97,117.04,APC
Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.5,,,,,,,fee schedule,11.05,40.83,
Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.05,,,,,,,fee schedule,11.05,40.83,
Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.06,,,,,,,fee schedule,11.05,40.83,
Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.27,,,,,,,fee schedule,11.05,40.83,
Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.83,,,,,,,fee schedule,11.05,40.83,
Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.21,,,,,,,fee schedule,11.05,40.83,APC
Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.63,,,,,,,fee schedule,11.05,40.83,APC
Assay of quinine,84228,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.93,,,,,,,fee schedule,11.05,40.83,APC
Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,241.24,,,,,,,fee schedule,83.49,277.43,
Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,83.49,,,,,,,fee schedule,83.49,277.43,
Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,197.45,,,,,,,fee schedule,83.49,277.43,
Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.16,,,,,,,fee schedule,83.49,277.43,
Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,277.43,,,,,,,fee schedule,83.49,277.43,
Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.27,,,,,,,fee schedule,83.49,277.43,APC
Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,87.88,,,,,,,fee schedule,83.49,277.43,APC
Assay of estrogen,84233,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,158.18,,,,,,,fee schedule,83.49,277.43,APC
Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.98,,,,,,,fee schedule,61.64,279.43,
Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,61.64,,,,,,,fee schedule,61.64,279.43,
Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.88,,,,,,,fee schedule,61.64,279.43,
Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.3,,,,,,,fee schedule,61.64,279.43,
Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,279.43,,,,,,,fee schedule,61.64,279.43,
Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.12,,,,,,,fee schedule,61.64,279.43,APC
Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.88,,,,,,,fee schedule,61.64,279.43,APC
Assay of progesterone,84234,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,116.78,,,,,,,fee schedule,61.64,279.43,APC
Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.98,,,,,,,fee schedule,67.67,225.38,
Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,67.67,,,,,,,fee schedule,67.67,225.38,
Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.41,,,,,,,fee schedule,67.67,225.38,
Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.48,,,,,,,fee schedule,67.67,225.38,
Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.38,,,,,,,fee schedule,67.67,225.38,
Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.79,,,,,,,fee schedule,67.67,225.38,APC
Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.23,,,,,,,fee schedule,67.67,225.38,APC
Assay of endocrine hormone,84235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,128.21,,,,,,,fee schedule,67.67,225.38,APC
Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.14,,,,,,,fee schedule,22.38,65.83,
Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,34.74,,,,,,,fee schedule,22.38,65.83,
Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.94,,,,,,,fee schedule,22.38,65.83,
Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.38,,,,,,,fee schedule,22.38,65.83,
Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.26,,,,,,,fee schedule,22.38,65.83,
Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.4,,,,,,,fee schedule,22.38,65.83,APC
Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.57,,,,,,,fee schedule,22.38,65.83,APC
Assay nonendocrine receptor,84238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.83,,,,,,,fee schedule,22.38,65.83,APC
Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.45,,,,,,,fee schedule,8.16,39.58,
Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.89,,,,,,,fee schedule,8.16,39.58,
Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.19,,,,,,,fee schedule,8.16,39.58,
Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.16,,,,,,,fee schedule,8.16,39.58,
Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.32,,,,,,,fee schedule,8.16,39.58,
Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.09,,,,,,,fee schedule,8.16,39.58,APC
Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.99,,,,,,,fee schedule,8.16,39.58,APC
Assay of renin,84244,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.58,,,,,,,fee schedule,8.16,39.58,APC
Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.66,,,,,,,fee schedule,19.23,46.76,
Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.23,,,,,,,fee schedule,19.23,46.76,
Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.28,,,,,,,fee schedule,19.23,46.76,
Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.66,,,,,,,fee schedule,19.23,46.76,
Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.76,,,,,,,fee schedule,19.23,46.76,
Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.25,,,,,,,fee schedule,19.23,46.76,APC
Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.24,,,,,,,fee schedule,19.23,46.76,APC
Assay of vitamin b-2,84252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.43,,,,,,,fee schedule,19.23,46.76,APC
Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.48,,,,,,,fee schedule,18.02,45.95,
Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.25,,,,,,,fee schedule,18.02,45.95,
Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.49,,,,,,,fee schedule,18.02,45.95,
Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.02,,,,,,,fee schedule,18.02,45.95,
Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.6,,,,,,,fee schedule,18.02,45.95,
Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.81,,,,,,,fee schedule,18.02,45.95,APC
Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.53,,,,,,,fee schedule,18.02,45.95,APC
Assay of selenium,84255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.95,,,,,,,fee schedule,18.02,45.95,APC
Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.21,,,,,,,fee schedule,16.53,55.76,
Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.43,,,,,,,fee schedule,16.53,55.76,
Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.63,,,,,,,fee schedule,16.53,55.76,
Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.53,,,,,,,fee schedule,16.53,55.76,
Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.99,,,,,,,fee schedule,16.53,55.76,
Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.53,,,,,,,fee schedule,16.53,55.76,APC
Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.98,,,,,,,fee schedule,16.53,55.76,APC
Assay of serotonin,84260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55.76,,,,,,,fee schedule,16.53,55.76,APC
Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.81,,,,,,,fee schedule,20.64,76.83,
Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.64,,,,,,,fee schedule,20.64,76.83,
Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.68,,,,,,,fee schedule,20.64,76.83,
Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.8,,,,,,,fee schedule,20.64,76.83,
Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.83,,,,,,,fee schedule,20.64,76.83,
Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.82,,,,,,,fee schedule,20.64,76.83,APC
Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.73,,,,,,,fee schedule,20.64,76.83,APC
Assay of sex hormone globul,84270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.11,,,,,,,fee schedule,20.64,76.83,APC
Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.31,,,,,,,fee schedule,12.77,57.86,
Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.77,,,,,,,fee schedule,12.77,57.86,
Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.18,,,,,,,fee schedule,12.77,57.86,
Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.98,,,,,,,fee schedule,12.77,57.86,
Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.86,,,,,,,fee schedule,12.77,57.86,
Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.11,,,,,,,fee schedule,12.77,57.86,APC
Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.44,,,,,,,fee schedule,12.77,57.86,APC
Assay of sialic acid,84275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.19,,,,,,,fee schedule,12.77,57.86,APC
Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.03,,,,,,,fee schedule,5.92,45.38,
Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.95,,,,,,,fee schedule,5.92,45.38,
Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.39,,,,,,,fee schedule,5.92,45.38,
Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.92,,,,,,,fee schedule,5.92,45.38,
Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.38,,,,,,,fee schedule,5.92,45.38,
Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.47,,,,,,,fee schedule,5.92,45.38,APC
Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.21,,,,,,,fee schedule,5.92,45.38,APC
Assay of silica,84285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.38,,,,,,,fee schedule,5.92,45.38,APC
Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.39,,,,,,,fee schedule,4.57,18.85,
Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.57,,,,,,,fee schedule,4.57,18.85,
Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.42,,,,,,,fee schedule,4.57,18.85,
Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.75,,,,,,,fee schedule,4.57,18.85,
Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.85,,,,,,,fee schedule,4.57,18.85,
Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.05,,,,,,,fee schedule,4.57,18.85,APC
Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.81,,,,,,,fee schedule,4.57,18.85,APC
Assay of serum sodium,84295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.66,,,,,,,fee schedule,4.57,18.85,APC
Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.39,,,,,,,fee schedule,4.81,18.85,
Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.81,,,,,,,fee schedule,4.81,18.85,
Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.42,,,,,,,fee schedule,4.81,18.85,
Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.75,,,,,,,fee schedule,4.81,18.85,
Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.85,,,,,,,fee schedule,4.81,18.85,
Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.31,,,,,,,fee schedule,4.81,18.85,APC
Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.06,,,,,,,fee schedule,4.81,18.85,APC
Assay of urine sodium,84300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.11,,,,,,,fee schedule,4.81,18.85,APC
Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.1,,,,,,,fee schedule,4.62,27.72,
Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.62,,,,,,,fee schedule,4.62,27.72,
Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.73,,,,,,,fee schedule,4.62,27.72,
Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.8,,,,,,,fee schedule,4.62,27.72,
Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.72,,,,,,,fee schedule,4.62,27.72,
Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.1,,,,,,,fee schedule,4.62,27.72,APC
Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.86,,,,,,,fee schedule,4.62,27.72,APC
Assay of sweat sodium,84302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.75,,,,,,,fee schedule,4.62,27.72,APC
Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.93,,,,,,,fee schedule,20.2,47.07,
Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.2,,,,,,,fee schedule,20.2,47.07,
Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.5,,,,,,,fee schedule,20.2,47.07,
Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.83,,,,,,,fee schedule,20.2,47.07,
Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.07,,,,,,,fee schedule,20.2,47.07,
Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.32,,,,,,,fee schedule,20.2,47.07,APC
Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.26,,,,,,,fee schedule,20.2,47.07,APC
Assay of somatomedin,84305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.27,,,,,,,fee schedule,20.2,47.07,APC
Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.09,,,,,,,fee schedule,17.37,74.85,
Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.37,,,,,,,fee schedule,17.37,74.85,
Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.28,,,,,,,fee schedule,17.37,74.85,
Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.67,,,,,,,fee schedule,17.37,74.85,
Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.85,,,,,,,fee schedule,17.37,74.85,
Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.19,,,,,,,fee schedule,17.37,74.85,APC
Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.28,,,,,,,fee schedule,17.37,74.85,APC
Assay of somatostatin,84307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.9,,,,,,,fee schedule,17.37,74.85,APC
Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.42,,,,,,,fee schedule,7.7,74.08,
Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.7,,,,,,,fee schedule,7.7,74.08,
Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.73,,,,,,,fee schedule,7.7,74.08,
Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.23,,,,,,,fee schedule,7.7,74.08,
Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.08,,,,,,,fee schedule,7.7,74.08,
Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.5,,,,,,,fee schedule,7.7,74.08,APC
Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.1,,,,,,,fee schedule,7.7,74.08,APC
Spectrophotometry,84311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.58,,,,,,,fee schedule,7.7,74.08,APC
Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.03,,,,,,,fee schedule,3.12,10.38,
Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.12,,,,,,,fee schedule,3.12,10.38,
Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.39,,,,,,,fee schedule,3.12,10.38,
Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.92,,,,,,,fee schedule,3.12,10.38,
Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.38,,,,,,,fee schedule,3.12,10.38,
Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.44,,,,,,,fee schedule,3.12,10.38,APC
Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.28,,,,,,,fee schedule,3.12,10.38,APC
Body fluid specific gravity,84315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.9,,,,,,,fee schedule,3.12,10.38,APC
Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,70.2,
Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.05,,,,,,,fee schedule,17.36,70.2,
Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,70.2,
Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,70.2,
Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,70.2,
Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.95,,,,,,,fee schedule,17.36,70.2,APC
Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39,,,,,,,fee schedule,17.36,70.2,APC
Chromatogram assay sugars,84375,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.2,,,,,,,fee schedule,17.36,70.2,APC
Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.8,,,,,,,fee schedule,5.23,59.57,
Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.23,,,,,,,fee schedule,5.23,59.57,
Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.4,,,,,,,fee schedule,5.23,59.57,
Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.96,,,,,,,fee schedule,5.23,59.57,
Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.57,,,,,,,fee schedule,5.23,59.57,
Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.78,,,,,,,fee schedule,5.23,59.57,APC
Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.5,,,,,,,fee schedule,5.23,59.57,APC
Sugars single qual,84376,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.9,,,,,,,fee schedule,5.23,59.57,APC
Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,5.23,23.67,
Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.23,,,,,,,fee schedule,5.23,23.67,
Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,5.23,23.67,
Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,5.23,23.67,
Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,5.23,23.67,
Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.78,,,,,,,fee schedule,5.23,23.67,APC
Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.5,,,,,,,fee schedule,5.23,23.67,APC
Sugars multiple qual,84377,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.9,,,,,,,fee schedule,5.23,23.67,APC
Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.15,,,,,,,fee schedule,10.95,49.62,
Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.95,,,,,,,fee schedule,10.95,49.62,
Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.32,,,,,,,fee schedule,10.95,49.62,
Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.29,,,,,,,fee schedule,10.95,49.62,
Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.62,,,,,,,fee schedule,10.95,49.62,
Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.95,49.62,APC
Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.53,,,,,,,fee schedule,10.95,49.62,APC
Sugars single quant,84378,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.75,,,,,,,fee schedule,10.95,49.62,APC
Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.15,,,,,,,fee schedule,10.95,49.62,
Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.95,,,,,,,fee schedule,10.95,49.62,
Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.32,,,,,,,fee schedule,10.95,49.62,
Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.29,,,,,,,fee schedule,10.95,49.62,
Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.62,,,,,,,fee schedule,10.95,49.62,
Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.95,49.62,APC
Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.53,,,,,,,fee schedule,10.95,49.62,APC
Sugars multiple quant,84379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.75,,,,,,,fee schedule,10.95,49.62,APC
Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.78,,,,,,,fee schedule,5.22,20.45,
Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.22,,,,,,,fee schedule,5.22,20.45,
Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.55,,,,,,,fee schedule,5.22,20.45,
Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.66,,,,,,,fee schedule,5.22,20.45,
Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.45,,,,,,,fee schedule,5.22,20.45,
Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.76,,,,,,,fee schedule,5.22,20.45,APC
Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.49,,,,,,,fee schedule,5.22,20.45,APC
Assay of urine sulfate,84392,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.88,,,,,,,fee schedule,5.22,20.45,APC
Tau phosphorylated ea,84393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.24,,,,,,,fee schedule,18.51,232.06,
Tau phosphorylated ea,84393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.11,,,,,,,fee schedule,18.51,232.06,
Tau phosphorylated ea,84393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.51,,,,,,,fee schedule,18.51,232.06,
Tau phosphorylated ea,84393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.48,,,,,,,fee schedule,18.51,232.06,
Tau phosphorylated ea,84393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.37,,,,,,,fee schedule,18.51,232.06,APC
Tau phosphorylated ea,84393,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.92,,,,,,,fee schedule,18.51,232.06,APC
Tau phosphorylated ea,84393,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,232.06,,,,,,,fee schedule,18.51,232.06,APC
Total tau,84394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.24,,,,,,,fee schedule,18.51,232.06,
Total tau,84394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.11,,,,,,,fee schedule,18.51,232.06,
Total tau,84394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.51,,,,,,,fee schedule,18.51,232.06,
Total tau,84394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.48,,,,,,,fee schedule,18.51,232.06,
Total tau,84394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.37,,,,,,,fee schedule,18.51,232.06,APC
Total tau,84394,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.92,,,,,,,fee schedule,18.51,232.06,APC
Total tau,84394,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,232.06,,,,,,,fee schedule,18.51,232.06,APC
Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.99,,,,,,,fee schedule,24.2,78.19,
Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.2,,,,,,,fee schedule,24.2,78.19,
Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.65,,,,,,,fee schedule,24.2,78.19,
Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.57,,,,,,,fee schedule,24.2,78.19,
Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.19,,,,,,,fee schedule,24.2,78.19,
Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.74,,,,,,,fee schedule,24.2,78.19,APC
Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.47,,,,,,,fee schedule,24.2,78.19,APC
Assay of free testosterone,84402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.85,,,,,,,fee schedule,24.2,78.19,APC
Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.33,,,,,,,fee schedule,24.52,52.13,
Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.52,,,,,,,fee schedule,24.52,52.13,
Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.1,,,,,,,fee schedule,24.52,52.13,
Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.72,,,,,,,fee schedule,24.52,52.13,
Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.13,,,,,,,fee schedule,24.52,52.13,
Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.1,,,,,,,fee schedule,24.52,52.13,APC
Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.81,,,,,,,fee schedule,24.52,52.13,APC
Assay of total testosterone,84403,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.46,,,,,,,fee schedule,24.52,52.13,APC
Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.07,,,,,,,fee schedule,48.72,227.78,
Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.72,,,,,,,fee schedule,48.72,227.78,
Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.12,,,,,,,fee schedule,48.72,227.78,
Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.85,,,,,,,fee schedule,48.72,227.78,
Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227.78,,,,,,,fee schedule,48.72,227.78,
Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.84,,,,,,,fee schedule,48.72,227.78,APC
Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.28,,,,,,,fee schedule,48.72,227.78,APC
Testosterone bioavailable,84410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.3,,,,,,,fee schedule,48.72,227.78,APC
Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.82,,,,,,,fee schedule,20.17,68.79,
Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.17,,,,,,,fee schedule,20.17,68.79,
Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.96,,,,,,,fee schedule,20.17,68.79,
Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.22,,,,,,,fee schedule,20.17,68.79,
Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.79,,,,,,,fee schedule,20.17,68.79,
Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.29,,,,,,,fee schedule,20.17,68.79,APC
Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.23,,,,,,,fee schedule,20.17,68.79,APC
Assay of vitamin b-1,84425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.21,,,,,,,fee schedule,20.17,68.79,APC
Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.37,,,,,,,fee schedule,11.05,20.93,
Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.05,,,,,,,fee schedule,11.05,20.93,
Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.22,,,,,,,fee schedule,11.05,20.93,
Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.39,,,,,,,fee schedule,11.05,20.93,
Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.98,,,,,,,fee schedule,11.05,20.93,
Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.21,,,,,,,fee schedule,11.05,20.93,APC
Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.63,,,,,,,fee schedule,11.05,20.93,APC
Assay of thiocyanate,84430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.93,,,,,,,fee schedule,11.05,20.93,APC
Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.91,,,,,,,fee schedule,33.35,72.35,
Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.35,,,,,,,fee schedule,33.35,72.35,
Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.49,,,,,,,fee schedule,33.35,72.35,
Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.24,,,,,,,fee schedule,33.35,72.35,
Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.35,,,,,,,fee schedule,33.35,72.35,
Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.87,,,,,,,fee schedule,33.35,72.35,APC
Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.11,,,,,,,fee schedule,33.35,72.35,APC
Thromboxane urine,84431,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.2,,,,,,,fee schedule,33.35,72.35,APC
Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.3,,,,,,,fee schedule,12,28.91,
Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.26,,,,,,,fee schedule,12,28.91,
Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.98,,,,,,,fee schedule,12,28.91,
Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12,,,,,,,fee schedule,12,28.91,
Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.05,,,,,,,fee schedule,12,28.91,
Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.86,,,,,,,fee schedule,12,28.91,APC
Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.06,,,,,,,fee schedule,12,28.91,APC
Assay of thyroglobulin,84432,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.91,,,,,,,fee schedule,12,28.91,APC
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.38,,,,,,,fee schedule,21.06,48.74,
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.06,,,,,,,fee schedule,21.06,48.74,
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.69,,,,,,,fee schedule,21.06,48.74,
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.78,,,,,,,fee schedule,21.06,48.74,
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.74,,,,,,,fee schedule,21.06,48.74,
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.28,,,,,,,fee schedule,21.06,48.74,APC
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.17,,,,,,,fee schedule,21.06,48.74,APC
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.91,,,,,,,fee schedule,21.06,48.74,APC
Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.66,,,,,,,fee schedule,6.53,13.41,
Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.53,,,,,,,fee schedule,6.53,13.41,
Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.54,,,,,,,fee schedule,6.53,13.41,
Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.64,,,,,,,fee schedule,6.53,13.41,
Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.41,,,,,,,fee schedule,6.53,13.41,
Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.21,,,,,,,fee schedule,6.53,13.41,APC
Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.87,,,,,,,fee schedule,6.53,13.41,APC
Assay of total thyroxine,84436,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.37,,,,,,,fee schedule,6.53,13.41,APC
Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.37,,,,,,,fee schedule,6.15,19.98,
Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.15,,,,,,,fee schedule,6.15,19.98,
Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.22,,,,,,,fee schedule,6.15,19.98,
Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.39,,,,,,,fee schedule,6.15,19.98,
Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.98,,,,,,,fee schedule,6.15,19.98,
Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.15,19.98,APC
Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,6.15,19.98,APC
Assay of neonatal thyroxine,84437,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,6.15,19.98,APC
Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.54,,,,,,,fee schedule,8.57,17.87,
Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.57,,,,,,,fee schedule,8.57,17.87,
Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.72,,,,,,,fee schedule,8.57,17.87,
Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.19,,,,,,,fee schedule,8.57,17.87,
Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.87,,,,,,,fee schedule,8.57,17.87,
Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.47,,,,,,,fee schedule,8.57,17.87,APC
Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.02,,,,,,,fee schedule,8.57,17.87,APC
Assay of free thyroxine,84439,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.24,,,,,,,fee schedule,8.57,17.87,APC
Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.35,,,,,,,fee schedule,14.04,63.65,
Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.04,,,,,,,fee schedule,14.04,63.65,
Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.3,,,,,,,fee schedule,14.04,63.65,
Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.29,,,,,,,fee schedule,14.04,63.65,
Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.65,,,,,,,fee schedule,14.04,63.65,
Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.52,,,,,,,fee schedule,14.04,63.65,APC
Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.78,,,,,,,fee schedule,14.04,63.65,APC
Assay of thyroid activity,84442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.6,,,,,,,fee schedule,14.04,63.65,APC
Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.79,,,,,,,fee schedule,15.96,34.26,
Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.96,,,,,,,fee schedule,15.96,34.26,
Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.38,,,,,,,fee schedule,15.96,34.26,
Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.53,,,,,,,fee schedule,15.96,34.26,
Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.26,,,,,,,fee schedule,15.96,34.26,
Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.64,,,,,,,fee schedule,15.96,34.26,APC
Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.8,,,,,,,fee schedule,15.96,34.26,APC
Assay thyroid stim hormone,84443,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.24,,,,,,,fee schedule,15.96,34.26,APC
Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.35,,,,,,,fee schedule,29.73,91.55,
Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.32,,,,,,,fee schedule,29.73,91.55,
Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.12,,,,,,,fee schedule,29.73,91.55,
Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.73,,,,,,,fee schedule,29.73,91.55,
Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.15,,,,,,,fee schedule,29.73,91.55,
Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.4,,,,,,,fee schedule,29.73,91.55,APC
Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50.86,,,,,,,fee schedule,29.73,91.55,APC
Assay of tsi globulin,84445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,91.55,,,,,,,fee schedule,29.73,91.55,APC
Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.79,,,,,,,fee schedule,13.47,51.51,
Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.47,,,,,,,fee schedule,13.47,51.51,
Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.66,,,,,,,fee schedule,13.47,51.51,
Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.36,,,,,,,fee schedule,13.47,51.51,
Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.51,,,,,,,fee schedule,13.47,51.51,
Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.89,,,,,,,fee schedule,13.47,51.51,APC
Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.18,,,,,,,fee schedule,13.47,51.51,APC
Assay of vitamin e,84446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.52,,,,,,,fee schedule,13.47,51.51,APC
Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.86,,,,,,,fee schedule,17.1,88.39,
Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.1,,,,,,,fee schedule,17.1,88.39,
Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.91,,,,,,,fee schedule,17.1,88.39,
Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.39,,,,,,,fee schedule,17.1,88.39,
Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.39,,,,,,,fee schedule,17.1,88.39,
Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.9,,,,,,,fee schedule,17.1,88.39,APC
Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18,,,,,,,fee schedule,17.1,88.39,APC
Assay of transcortin,84449,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.4,,,,,,,fee schedule,17.1,88.39,APC
Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.06,,,,,,,fee schedule,4.92,10.42,
Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.92,,,,,,,fee schedule,4.92,10.42,
Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.42,,,,,,,fee schedule,4.92,10.42,
Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.94,,,,,,,fee schedule,4.92,10.42,
Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.42,,,,,,,fee schedule,4.92,10.42,
Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.92,10.42,APC
Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.18,,,,,,,fee schedule,4.92,10.42,APC
Transferase (AST) (SGOT),84450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.32,,,,,,,fee schedule,4.92,10.42,APC
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.2,,,,,,,fee schedule,5.04,20.93,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.04,,,,,,,fee schedule,5.04,20.93,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.9,,,,,,,fee schedule,5.04,20.93,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.93,,,,,,,fee schedule,5.04,20.93,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.93,,,,,,,fee schedule,5.04,20.93,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.56,,,,,,,fee schedule,5.04,20.93,APC
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.3,,,,,,,fee schedule,5.04,20.93,APC
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.54,,,,,,,fee schedule,5.04,20.93,APC
Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.69,,,,,,,fee schedule,12.12,50.24,
Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.12,,,,,,,fee schedule,12.12,50.24,
Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.76,,,,,,,fee schedule,12.12,50.24,
Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.64,,,,,,,fee schedule,12.12,50.24,
Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.24,,,,,,,fee schedule,12.12,50.24,
Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.4,,,,,,,fee schedule,12.12,50.24,APC
Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.76,,,,,,,fee schedule,12.12,50.24,APC
Assay of transferrin,84466,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.97,,,,,,,fee schedule,12.12,50.24,APC
Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.05,,,,,,,fee schedule,5.45,23.06,
Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.45,,,,,,,fee schedule,5.45,23.06,
Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.41,,,,,,,fee schedule,5.45,23.06,
Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.14,,,,,,,fee schedule,5.45,23.06,
Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.06,,,,,,,fee schedule,5.45,23.06,
Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.03,,,,,,,fee schedule,5.45,23.06,APC
Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.74,,,,,,,fee schedule,5.45,23.06,APC
Assay of triglycerides,84478,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.33,,,,,,,fee schedule,5.45,23.06,APC
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.74,,,,,,,fee schedule,6.15,12.35,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.15,,,,,,,fee schedule,6.15,12.35,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.79,,,,,,,fee schedule,6.15,12.35,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.04,,,,,,,fee schedule,6.15,12.35,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.35,,,,,,,fee schedule,6.15,12.35,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.15,12.35,APC
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,6.15,12.35,APC
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,6.15,12.35,APC
Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.25,,,,,,,fee schedule,13.47,55.49,
Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.47,,,,,,,fee schedule,13.47,55.49,
Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.49,,,,,,,fee schedule,13.47,55.49,
Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.63,,,,,,,fee schedule,13.47,55.49,
Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.49,,,,,,,fee schedule,13.47,55.49,
Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.89,,,,,,,fee schedule,13.47,55.49,APC
Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.18,,,,,,,fee schedule,13.47,55.49,APC
Assay triiodothyronine (t3),84480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.52,,,,,,,fee schedule,13.47,55.49,APC
Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.79,,,,,,,fee schedule,16.09,34.26,
Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.09,,,,,,,fee schedule,16.09,34.26,
Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.38,,,,,,,fee schedule,16.09,34.26,
Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.53,,,,,,,fee schedule,16.09,34.26,
Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.26,,,,,,,fee schedule,16.09,34.26,
Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.79,,,,,,,fee schedule,16.09,34.26,APC
Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.94,,,,,,,fee schedule,16.09,34.26,APC
Free assay (FT-3),84481,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.49,,,,,,,fee schedule,16.09,34.26,APC
T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.31,,,,,,,fee schedule,14.97,91.21,
T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.97,,,,,,,fee schedule,14.97,91.21,
T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.92,,,,,,,fee schedule,14.97,91.21,
T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52,,,,,,,fee schedule,14.97,91.21,
T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.21,,,,,,,fee schedule,14.97,91.21,
T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.55,,,,,,,fee schedule,14.97,91.21,APC
T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.76,,,,,,,fee schedule,14.97,91.21,APC
T3 reverse,84482,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.37,,,,,,,fee schedule,14.97,91.21,APC
Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.14,,,,,,,fee schedule,11.85,22.45,
Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.85,,,,,,,fee schedule,11.85,22.45,
Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.85,,,,,,,fee schedule,11.85,22.45,
Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.89,,,,,,,fee schedule,11.85,22.45,
Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.86,,,,,,,fee schedule,11.85,22.45,
Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.09,,,,,,,fee schedule,11.85,22.45,APC
Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.47,,,,,,,fee schedule,11.85,22.45,APC
Assay of troponin quant,84484,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.45,,,,,,,fee schedule,11.85,22.45,APC
Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.13,,,,,,,fee schedule,6.84,32.35,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.84,,,,,,,fee schedule,6.84,32.35,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.02,,,,,,,fee schedule,6.84,32.35,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.44,,,,,,,fee schedule,6.84,32.35,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.35,,,,,,,fee schedule,6.84,32.35,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.56,,,,,,,fee schedule,6.84,32.35,APC
Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.2,,,,,,,fee schedule,6.84,32.35,APC
Assay duodenal fluid trypsin,84485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.96,,,,,,,fee schedule,6.84,32.35,APC
Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.34,,,,,,,fee schedule,6.94,31.44,
Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.94,,,,,,,fee schedule,6.94,31.44,
Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.38,,,,,,,fee schedule,6.94,31.44,
Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.92,,,,,,,fee schedule,6.94,31.44,
Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.44,,,,,,,fee schedule,6.94,31.44,
Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.66,,,,,,,fee schedule,6.94,31.44,APC
Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.3,,,,,,,fee schedule,6.94,31.44,APC
Test feces for trypsin,84488,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.14,,,,,,,fee schedule,6.94,31.44,APC
Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.47,,,,,,,fee schedule,9.43,32.74,
Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.43,,,,,,,fee schedule,9.43,32.74,
Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.3,,,,,,,fee schedule,9.43,32.74,
Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.66,,,,,,,fee schedule,9.43,32.74,
Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.74,,,,,,,fee schedule,9.43,32.74,
Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.43,,,,,,,fee schedule,9.43,32.74,APC
Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.93,,,,,,,fee schedule,9.43,32.74,APC
Assay of feces for trypsin,84490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.87,,,,,,,fee schedule,9.43,32.74,APC
Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.96,,,,,,,fee schedule,10.1,44.8,
Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.1,,,,,,,fee schedule,10.1,44.8,
Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.89,,,,,,,fee schedule,10.1,44.8,
Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.54,,,,,,,fee schedule,10.1,44.8,
Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.8,,,,,,,fee schedule,10.1,44.8,
Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.16,,,,,,,fee schedule,10.1,44.8,APC
Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.63,,,,,,,fee schedule,10.1,44.8,APC
Assay of tyrosine,84510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.13,,,,,,,fee schedule,10.1,44.8,APC
Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.81,,,,,,,fee schedule,9.59,33.13,
Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.59,,,,,,,fee schedule,9.59,33.13,
Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.58,,,,,,,fee schedule,9.59,33.13,
Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.89,,,,,,,fee schedule,9.59,33.13,
Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.13,,,,,,,fee schedule,9.59,33.13,
Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.59,,,,,,,fee schedule,9.59,33.13,APC
Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.09,,,,,,,fee schedule,9.59,33.13,APC
Assay of troponin qual,84512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.16,,,,,,,fee schedule,9.59,33.13,APC
Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.72,,,,,,,fee schedule,3.75,15.78,
Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.75,,,,,,,fee schedule,3.75,15.78,
Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.23,,,,,,,fee schedule,3.75,15.78,
Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.99,,,,,,,fee schedule,3.75,15.78,
Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.78,,,,,,,fee schedule,3.75,15.78,
Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.15,,,,,,,fee schedule,3.75,15.78,APC
Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.95,,,,,,,fee schedule,3.75,15.78,APC
Assay of urea nitrogen,84520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.11,,,,,,,fee schedule,3.75,15.78,APC
Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.1,,,,,,,fee schedule,4.87,16.22,
Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.87,,,,,,,fee schedule,4.87,16.22,
Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.54,,,,,,,fee schedule,4.87,16.22,
Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.24,,,,,,,fee schedule,4.87,16.22,
Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.22,,,,,,,fee schedule,4.87,16.22,
Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,4.87,16.22,APC
Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.13,,,,,,,fee schedule,4.87,16.22,APC
Urea nitrogen semi-quant,84525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.23,,,,,,,fee schedule,4.87,16.22,APC
Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.78,,,,,,,fee schedule,5.28,20.45,
Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.28,,,,,,,fee schedule,5.28,20.45,
Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.55,,,,,,,fee schedule,5.28,20.45,
Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.66,,,,,,,fee schedule,5.28,20.45,
Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.45,,,,,,,fee schedule,5.28,20.45,
Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.84,,,,,,,fee schedule,5.28,20.45,APC
Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.56,,,,,,,fee schedule,5.28,20.45,APC
Assay of urine/urea-n,84540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.01,,,,,,,fee schedule,5.28,20.45,APC
Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.76,,,,,,,fee schedule,6.84,28.47,
Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.84,,,,,,,fee schedule,6.84,28.47,
Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.27,,,,,,,fee schedule,6.84,28.47,
Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.23,,,,,,,fee schedule,6.84,28.47,
Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.47,,,,,,,fee schedule,6.84,28.47,
Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.56,,,,,,,fee schedule,6.84,28.47,APC
Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.2,,,,,,,fee schedule,6.84,28.47,APC
Urea-N clearance test,84545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.96,,,,,,,fee schedule,6.84,28.47,APC
Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.77,,,,,,,fee schedule,4.29,8.94,
Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.29,,,,,,,fee schedule,4.29,8.94,
Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.36,,,,,,,fee schedule,4.29,8.94,
Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.09,,,,,,,fee schedule,4.29,8.94,
Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.94,,,,,,,fee schedule,4.29,8.94,
Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.29,8.94,APC
Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.52,,,,,,,fee schedule,4.29,8.94,APC
Assay of blood/uric acid,84550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.14,,,,,,,fee schedule,4.29,8.94,APC
Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.39,,,,,,,fee schedule,4.83,18.85,
Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.83,,,,,,,fee schedule,4.83,18.85,
Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.42,,,,,,,fee schedule,4.83,18.85,
Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.75,,,,,,,fee schedule,4.83,18.85,
Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.85,,,,,,,fee schedule,4.83,18.85,
Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.33,,,,,,,fee schedule,4.83,18.85,APC
Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.08,,,,,,,fee schedule,4.83,18.85,APC
Assay of urine/uric acid,84560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.14,,,,,,,fee schedule,4.83,18.85,APC
Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.47,,,,,,,fee schedule,15.96,35.04,
Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.96,,,,,,,fee schedule,15.96,35.04,
Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.94,,,,,,,fee schedule,15.96,35.04,
Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.98,,,,,,,fee schedule,15.96,35.04,
Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.04,,,,,,,fee schedule,15.96,35.04,
Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.64,,,,,,,fee schedule,15.96,35.04,APC
Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.8,,,,,,,fee schedule,15.96,35.04,APC
Assay of feces/urobilinogen,84577,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.24,,,,,,,fee schedule,15.96,35.04,APC
Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.16,,,,,,,fee schedule,4.25,13.98,
Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.25,,,,,,,fee schedule,4.25,13.98,
Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.95,,,,,,,fee schedule,4.25,13.98,
Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.97,,,,,,,fee schedule,4.25,13.98,
Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.98,,,,,,,fee schedule,4.25,13.98,
Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.69,,,,,,,fee schedule,4.25,13.98,APC
Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.47,,,,,,,fee schedule,4.25,13.98,APC
Test urine urobilinogen,84578,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.05,,,,,,,fee schedule,4.25,13.98,APC
Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.56,,,,,,,fee schedule,9.07,30.54,
Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.07,,,,,,,fee schedule,9.07,30.54,
Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.74,,,,,,,fee schedule,9.07,30.54,
Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.41,,,,,,,fee schedule,9.07,30.54,
Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.54,,,,,,,fee schedule,9.07,30.54,
Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.03,,,,,,,fee schedule,9.07,30.54,APC
Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.55,,,,,,,fee schedule,9.07,30.54,APC
Assay of urine urobilinogen,84580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.19,,,,,,,fee schedule,9.07,30.54,APC
Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.37,,,,,,,fee schedule,5.75,19.98,
Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.75,,,,,,,fee schedule,5.75,19.98,
Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.22,,,,,,,fee schedule,5.75,19.98,
Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.39,,,,,,,fee schedule,5.75,19.98,
Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.98,,,,,,,fee schedule,5.75,19.98,
Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.35,,,,,,,fee schedule,5.75,19.98,APC
Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.05,,,,,,,fee schedule,5.75,19.98,APC
Assay of urine urobilinogen,84583,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.89,,,,,,,fee schedule,5.75,19.98,APC
Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.81,,,,,,,fee schedule,14.73,56.13,
Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.73,,,,,,,fee schedule,14.73,56.13,
Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.95,,,,,,,fee schedule,14.73,56.13,
Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32,,,,,,,fee schedule,14.73,56.13,
Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.13,,,,,,,fee schedule,14.73,56.13,
Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.28,,,,,,,fee schedule,14.73,56.13,APC
Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.5,,,,,,,fee schedule,14.73,56.13,APC
Assay of urine vma,84585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.9,,,,,,,fee schedule,14.73,56.13,APC
Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.04,,,,,,,fee schedule,33.56,63.59,
Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.56,,,,,,,fee schedule,33.56,63.59,
Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.41,,,,,,,fee schedule,33.56,63.59,
Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.77,,,,,,,fee schedule,33.56,63.59,
Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61,,,,,,,fee schedule,33.56,63.59,
Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.1,,,,,,,fee schedule,33.56,63.59,APC
Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.33,,,,,,,fee schedule,33.56,63.59,APC
Assay of vip,84586,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.59,,,,,,,fee schedule,33.56,63.59,APC
Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.3,,,,,,,fee schedule,32.24,61.09,
Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.24,,,,,,,fee schedule,32.24,61.09,
Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.81,,,,,,,fee schedule,32.24,61.09,
Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.29,,,,,,,fee schedule,32.24,61.09,
Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.15,,,,,,,fee schedule,32.24,61.09,
Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.64,,,,,,,fee schedule,32.24,61.09,APC
Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.94,,,,,,,fee schedule,32.24,61.09,APC
Assay of vasopressin,84588,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.09,,,,,,,fee schedule,32.24,61.09,APC
Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.45,,,,,,,fee schedule,11.03,40.77,
Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.03,,,,,,,fee schedule,11.03,40.77,
Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.02,,,,,,,fee schedule,11.03,40.77,
Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.24,,,,,,,fee schedule,11.03,40.77,
Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.77,,,,,,,fee schedule,11.03,40.77,
Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.19,,,,,,,fee schedule,11.03,40.77,APC
Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.61,,,,,,,fee schedule,11.03,40.77,APC
Assay of vitamin a,84590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.9,,,,,,,fee schedule,11.03,40.77,APC
Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.45,,,,,,,fee schedule,16.21,49.97,
Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.21,,,,,,,fee schedule,16.21,49.97,
Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.56,,,,,,,fee schedule,16.21,49.97,
Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.49,,,,,,,fee schedule,16.21,49.97,
Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.97,,,,,,,fee schedule,16.21,49.97,
Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.91,,,,,,,fee schedule,16.21,49.97,APC
Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.06,,,,,,,fee schedule,16.21,49.97,APC
Assay Of Nos Vitamin,84591,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.71,,,,,,,fee schedule,16.21,49.97,APC
Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.2,,,,,,,fee schedule,13.03,41.63,
Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.03,,,,,,,fee schedule,13.03,41.63,
Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.63,,,,,,,fee schedule,13.03,41.63,
Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.73,,,,,,,fee schedule,13.03,41.63,
Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.63,,,,,,,fee schedule,13.03,41.63,
Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.41,,,,,,,fee schedule,13.03,41.63,APC
Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.72,,,,,,,fee schedule,13.03,41.63,APC
Assay of vitamin k,84597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.7,,,,,,,fee schedule,13.03,41.63,APC
Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.21,,,,,,,fee schedule,16.25,69.24,
Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.25,,,,,,,fee schedule,16.25,69.24,
Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.28,,,,,,,fee schedule,16.25,69.24,
Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.47,,,,,,,fee schedule,16.25,69.24,
Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.24,,,,,,,fee schedule,16.25,69.24,
Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.97,,,,,,,fee schedule,16.25,69.24,APC
Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.11,,,,,,,fee schedule,16.25,69.24,APC
Assay of volatiles,84600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.8,,,,,,,fee schedule,16.25,69.24,APC
Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.35,,,,,,,fee schedule,12.26,51,
Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.26,,,,,,,fee schedule,12.26,51,
Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.3,,,,,,,fee schedule,12.26,51,
Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.08,,,,,,,fee schedule,12.26,51,
Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51,,,,,,,fee schedule,12.26,51,
Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.56,,,,,,,fee schedule,12.26,51,APC
Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.91,,,,,,,fee schedule,12.26,51,APC
Xylose tolerance test,84620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.24,,,,,,,fee schedule,12.26,51,APC
Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.99,,,,,,,fee schedule,10.82,42.54,
Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.82,,,,,,,fee schedule,10.82,42.54,
Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.28,,,,,,,fee schedule,10.82,42.54,
Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.25,,,,,,,fee schedule,10.82,42.54,
Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.54,,,,,,,fee schedule,10.82,42.54,
Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.96,,,,,,,fee schedule,10.82,42.54,APC
Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.39,,,,,,,fee schedule,10.82,42.54,APC
Assay of zinc,84630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.5,,,,,,,fee schedule,10.82,42.54,APC
Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.86,,,,,,,fee schedule,19.77,81.49,
Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.77,,,,,,,fee schedule,19.77,81.49,
Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58,,,,,,,fee schedule,19.77,81.49,
Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.46,,,,,,,fee schedule,19.77,81.49,
Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.49,,,,,,,fee schedule,19.77,81.49,
Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,19.77,81.49,APC
Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.81,,,,,,,fee schedule,19.77,81.49,APC
Assay of c-peptide,84681,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.46,,,,,,,fee schedule,19.77,81.49,APC
Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.73,,,,,,,fee schedule,7.03,27.09,
Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.3,,,,,,,fee schedule,7.03,27.09,
Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.78,,,,,,,fee schedule,7.03,27.09,
Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.03,,,,,,,fee schedule,7.03,27.09,
Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.34,,,,,,,fee schedule,7.03,27.09,
Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,7.03,27.09,APC
Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.05,,,,,,,fee schedule,7.03,27.09,APC
Chorionic gonadotropin test,84702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.09,,,,,,,fee schedule,7.03,27.09,APC
Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.51,,,,,,,fee schedule,7.14,29.34,
Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.14,,,,,,,fee schedule,7.14,29.34,
Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.88,,,,,,,fee schedule,7.14,29.34,
Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.72,,,,,,,fee schedule,7.14,29.34,
Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.34,,,,,,,fee schedule,7.14,29.34,
Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.9,,,,,,,fee schedule,7.14,29.34,APC
Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.52,,,,,,,fee schedule,7.14,29.34,APC
Chorionic gonadotropin assay,84703,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.54,,,,,,,fee schedule,7.14,29.34,APC
Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.9,,,,,,,fee schedule,13.7,27.52,
Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.53,,,,,,,fee schedule,13.7,27.52,
Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.11,,,,,,,fee schedule,13.7,27.52,
Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.7,,,,,,,fee schedule,13.7,27.52,
Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.04,,,,,,,fee schedule,13.7,27.52,
Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.05,,,,,,,fee schedule,13.7,27.52,APC
Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.29,,,,,,,fee schedule,13.7,27.52,APC
Hcg free betachain test,84704,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.52,,,,,,,fee schedule,13.7,27.52,APC
Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.56,,,,,,,fee schedule,12.07,43.19,
Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.07,,,,,,,fee schedule,12.07,43.19,
Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.74,,,,,,,fee schedule,12.07,43.19,
Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.62,,,,,,,fee schedule,12.07,43.19,
Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.19,,,,,,,fee schedule,12.07,43.19,
Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.34,,,,,,,fee schedule,12.07,43.19,APC
Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.7,,,,,,,fee schedule,12.07,43.19,APC
Ovulation tests,84830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.86,,,,,,,fee schedule,12.07,43.19,APC
Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.9,,,,,,,fee schedule,4.58,19.44,
Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.58,,,,,,,fee schedule,4.58,19.44,
Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.83,,,,,,,fee schedule,4.58,19.44,
Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.08,,,,,,,fee schedule,4.58,19.44,
Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.44,,,,,,,fee schedule,4.58,19.44,
Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.06,,,,,,,fee schedule,4.58,19.44,APC
Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.82,,,,,,,fee schedule,4.58,19.44,APC
Bleeding time test,85002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.68,,,,,,,fee schedule,4.58,19.44,APC
Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.37,,,,,,,fee schedule,6.15,19.98,
Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.15,,,,,,,fee schedule,6.15,19.98,
Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.22,,,,,,,fee schedule,6.15,19.98,
Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.39,,,,,,,fee schedule,6.15,19.98,
Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.98,,,,,,,fee schedule,6.15,19.98,
Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.15,19.98,APC
Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,6.15,19.98,APC
Automated diff wbc count,85004,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,6.15,19.98,APC
Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.76,,,,,,,fee schedule,3.61,21.57,
Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.61,,,,,,,fee schedule,3.61,21.57,
Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.36,,,,,,,fee schedule,3.61,21.57,
Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.3,,,,,,,fee schedule,3.61,21.57,
Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.57,,,,,,,fee schedule,3.61,21.57,
Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.99,,,,,,,fee schedule,3.61,21.57,APC
Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.8,,,,,,,fee schedule,3.61,21.57,APC
Bl smear w/diff wbc count,85007,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.84,,,,,,,fee schedule,3.61,21.57,APC
Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.8,,,,,,,fee schedule,3.26,12.42,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.26,,,,,,,fee schedule,3.26,12.42,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.84,,,,,,,fee schedule,3.26,12.42,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.08,,,,,,,fee schedule,3.26,12.42,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.42,,,,,,,fee schedule,3.26,12.42,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.6,,,,,,,fee schedule,3.26,12.42,APC
Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.43,,,,,,,fee schedule,3.26,12.42,APC
Bl smear w/o diff wbc count,85008,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.17,,,,,,,fee schedule,3.26,12.42,APC
Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.8,,,,,,,fee schedule,4.82,12.42,
Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.82,,,,,,,fee schedule,4.82,12.42,
Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.84,,,,,,,fee schedule,4.82,12.42,
Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.08,,,,,,,fee schedule,4.82,12.42,
Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.42,,,,,,,fee schedule,4.82,12.42,
Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.32,,,,,,,fee schedule,4.82,12.42,APC
Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.07,,,,,,,fee schedule,4.82,12.42,APC
Manual diff wbc count b-coat,85009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.13,,,,,,,fee schedule,4.82,12.42,APC
Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.87,,,,,,,fee schedule,5.82,12.6,
Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.65,,,,,,,fee schedule,5.82,12.6,
Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.26,,,,,,,fee schedule,5.82,12.6,
Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.82,,,,,,,fee schedule,5.82,12.6,
Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.2,,,,,,,fee schedule,5.82,12.6,
Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.35,,,,,,,fee schedule,5.82,12.6,APC
Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7,,,,,,,fee schedule,5.82,12.6,APC
Spun microhematocrit,85013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.6,,,,,,,fee schedule,5.82,12.6,APC
Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.89,,,,,,,fee schedule,2.25,4.47,
Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.25,,,,,,,fee schedule,2.25,4.47,
Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.18,,,,,,,fee schedule,2.25,4.47,
Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.55,,,,,,,fee schedule,2.25,4.47,
Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.47,,,,,,,fee schedule,2.25,4.47,
Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.49,,,,,,,fee schedule,2.25,4.47,APC
Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.37,,,,,,,fee schedule,2.25,4.47,APC
Hematocrit,85014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.27,,,,,,,fee schedule,2.25,4.47,APC
Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.89,,,,,,,fee schedule,2.25,4.47,
Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.25,,,,,,,fee schedule,2.25,4.47,
Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.18,,,,,,,fee schedule,2.25,4.47,
Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.55,,,,,,,fee schedule,2.25,4.47,
Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.47,,,,,,,fee schedule,2.25,4.47,
Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.49,,,,,,,fee schedule,2.25,4.47,APC
Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.37,,,,,,,fee schedule,2.25,4.47,APC
Hemoglobin,85018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.27,,,,,,,fee schedule,2.25,4.47,APC
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.25,,,,,,,fee schedule,7.38,16.39,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.38,,,,,,,fee schedule,7.38,16.39,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.66,,,,,,,fee schedule,7.38,16.39,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.34,,,,,,,fee schedule,7.38,16.39,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.39,,,,,,,fee schedule,7.38,16.39,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.16,,,,,,,fee schedule,7.38,16.39,APC
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.77,,,,,,,fee schedule,7.38,16.39,APC
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.99,,,,,,,fee schedule,7.38,16.39,APC
Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.28,,,,,,,fee schedule,6.15,12.97,
Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.15,,,,,,,fee schedule,6.15,12.97,
Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.23,,,,,,,fee schedule,6.15,12.97,
Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.4,,,,,,,fee schedule,6.15,12.97,
Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.97,,,,,,,fee schedule,6.15,12.97,
Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.15,12.97,APC
Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,6.15,12.97,APC
Complete cbc automated,85027,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,6.15,12.97,APC
Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.13,,,,,,,fee schedule,4.09,18.55,
Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.09,,,,,,,fee schedule,4.09,18.55,
Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.2,,,,,,,fee schedule,4.09,18.55,
Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.57,,,,,,,fee schedule,4.09,18.55,
Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.55,,,,,,,fee schedule,4.09,18.55,
Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.53,,,,,,,fee schedule,4.09,18.55,APC
Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.31,,,,,,,fee schedule,4.09,18.55,APC
Manual cell count each,85032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.76,,,,,,,fee schedule,4.09,18.55,APC
Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.28,,,,,,,fee schedule,2.87,12.97,
Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.87,,,,,,,fee schedule,2.87,12.97,
Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.23,,,,,,,fee schedule,2.87,12.97,
Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.4,,,,,,,fee schedule,2.87,12.97,
Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.97,,,,,,,fee schedule,2.87,12.97,
Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.17,,,,,,,fee schedule,2.87,12.97,APC
Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.02,,,,,,,fee schedule,2.87,12.97,APC
Automated rbc count,85041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.44,,,,,,,fee schedule,2.87,12.97,APC
Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.42,,,,,,,fee schedule,4.09,17.73,
Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.09,,,,,,,fee schedule,4.09,17.73,
Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.62,,,,,,,fee schedule,4.09,17.73,
Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.11,,,,,,,fee schedule,4.09,17.73,
Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.73,,,,,,,fee schedule,4.09,17.73,
Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.53,,,,,,,fee schedule,4.09,17.73,APC
Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.31,,,,,,,fee schedule,4.09,17.73,APC
Manual reticulocyte count,85044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.76,,,,,,,fee schedule,4.09,17.73,APC
Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.13,,,,,,,fee schedule,3.79,16.25,
Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.79,,,,,,,fee schedule,3.79,16.25,
Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.57,,,,,,,fee schedule,3.79,16.25,
Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.26,,,,,,,fee schedule,3.79,16.25,
Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.25,,,,,,,fee schedule,3.79,16.25,
Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.19,,,,,,,fee schedule,3.79,16.25,APC
Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.99,,,,,,,fee schedule,3.79,16.25,APC
Automated reticulocyte count,85045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.18,,,,,,,fee schedule,3.79,16.25,APC
Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.54,,,,,,,fee schedule,5.29,16.72,
Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.29,,,,,,,fee schedule,5.29,16.72,
Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.9,,,,,,,fee schedule,5.29,16.72,
Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.53,,,,,,,fee schedule,5.29,16.72,
Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.72,,,,,,,fee schedule,5.29,16.72,
Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.85,,,,,,,fee schedule,5.29,16.72,APC
Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.57,,,,,,,fee schedule,5.29,16.72,APC
Reticyte/hgb concentrate,85046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.03,,,,,,,fee schedule,5.29,16.72,APC
Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.94,,,,,,,fee schedule,2.41,10.28,
Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.41,,,,,,,fee schedule,2.41,10.28,
Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.32,,,,,,,fee schedule,2.41,10.28,
Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.86,,,,,,,fee schedule,2.41,10.28,
Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.28,,,,,,,fee schedule,2.41,10.28,
Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.67,,,,,,,fee schedule,2.41,10.28,APC
Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.54,,,,,,,fee schedule,2.41,10.28,APC
Automated leukocyte count,85048,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.57,,,,,,,fee schedule,2.41,10.28,APC
Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.42,,,,,,,fee schedule,4.26,24.63,
Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.26,,,,,,,fee schedule,4.26,24.63,
Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.53,,,,,,,fee schedule,4.26,24.63,
Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.04,,,,,,,fee schedule,4.26,24.63,
Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.63,,,,,,,fee schedule,4.26,24.63,
Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.7,,,,,,,fee schedule,4.26,24.63,APC
Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.26,24.63,APC
Automated platelet count,85049,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.06,,,,,,,fee schedule,4.26,24.63,APC
Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.4,,,,,,,fee schedule,29.11,64.33,
Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.95,,,,,,,fee schedule,29.11,64.33,
Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.34,,,,,,,fee schedule,29.11,64.33,
Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.11,,,,,,,fee schedule,29.11,64.33,
Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.06,,,,,,,fee schedule,29.11,64.33,
Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.53,,,,,,,fee schedule,29.11,64.33,APC
Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.74,,,,,,,fee schedule,29.11,64.33,APC
Reticulated platelet assay,85055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,64.33,,,,,,,fee schedule,29.11,64.33,APC
Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.77,,,,,,,fee schedule,22.32,117.04,
Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.32,,,,,,,fee schedule,22.32,117.04,
Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.3,,,,,,,fee schedule,22.32,117.04,
Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.72,,,,,,,fee schedule,22.32,117.04,
Blood smear interpretation,85060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.04,,,,,,,fee schedule,22.32,117.04,
Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.56,,,,,,,fee schedule,44.26,1445.01,
Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,44.26,,,,,,,fee schedule,44.26,1445.01,
Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.61,,,,,,,fee schedule,44.26,1445.01,
Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.24,,,,,,,fee schedule,44.26,1445.01,
Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.44,,,,,,,fee schedule,44.26,1445.01,
Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,44.26,1445.01,APC
Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,44.26,1445.01,APC
Bone marrow interpretation,85097,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,44.26,1445.01,APC
Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.16,,,,,,,fee schedule,9.94,21.4,
Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.3,,,,,,,fee schedule,9.94,21.4,
Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.41,,,,,,,fee schedule,9.94,21.4,
Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.94,,,,,,,fee schedule,9.94,21.4,
Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.43,,,,,,,fee schedule,9.94,21.4,
Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.48,,,,,,,fee schedule,9.94,21.4,APC
Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.89,,,,,,,fee schedule,9.94,21.4,APC
Chromogenic substrate assay,85130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.4,,,,,,,fee schedule,9.94,21.4,APC
Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.56,,,,,,,fee schedule,8.89,29.34,
Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.49,,,,,,,fee schedule,8.89,29.34,
Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.1,,,,,,,fee schedule,8.89,29.34,
Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.89,,,,,,,fee schedule,8.89,29.34,
Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.59,,,,,,,fee schedule,8.89,29.34,
Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.12,,,,,,,fee schedule,8.89,29.34,APC
Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.3,,,,,,,fee schedule,8.89,29.34,APC
Blood clot retraction,85170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.34,,,,,,,fee schedule,8.89,29.34,APC
Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.06,,,,,,,fee schedule,11.18,36.67,
Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.35,,,,,,,fee schedule,11.18,36.67,
Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.96,,,,,,,fee schedule,11.18,36.67,
Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.18,,,,,,,fee schedule,11.18,36.67,
Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.62,,,,,,,fee schedule,11.18,36.67,
Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.39,,,,,,,fee schedule,11.18,36.67,APC
Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.37,,,,,,,fee schedule,11.18,36.67,APC
Blood clot lysis time,85175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.67,,,,,,,fee schedule,11.18,36.67,APC
Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.65,,,,,,,fee schedule,12.33,51.35,
Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.33,,,,,,,fee schedule,12.33,51.35,
Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.55,,,,,,,fee schedule,12.33,51.35,
Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.27,,,,,,,fee schedule,12.33,51.35,
Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.35,,,,,,,fee schedule,12.33,51.35,
Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.63,,,,,,,fee schedule,12.33,51.35,APC
Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.98,,,,,,,fee schedule,12.33,51.35,APC
Clot factor ii prothrom spec,85210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.36,,,,,,,fee schedule,12.33,51.35,APC
Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.38,,,,,,,fee schedule,16.77,68.29,
Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.77,,,,,,,fee schedule,16.77,68.29,
Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.6,,,,,,,fee schedule,16.77,68.29,
Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.93,,,,,,,fee schedule,16.77,68.29,
Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.29,,,,,,,fee schedule,16.77,68.29,
Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.53,,,,,,,fee schedule,16.77,68.29,APC
Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.65,,,,,,,fee schedule,16.77,68.29,APC
Blooc clot factor v test,85220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.77,,,,,,,fee schedule,16.77,68.29,APC
Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.06,,,,,,,fee schedule,17.01,69.07,
Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.01,,,,,,,fee schedule,17.01,69.07,
Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.16,,,,,,,fee schedule,17.01,69.07,
Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.38,,,,,,,fee schedule,17.01,69.07,
Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.07,,,,,,,fee schedule,17.01,69.07,
Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.8,,,,,,,fee schedule,17.01,69.07,APC
Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.9,,,,,,,fee schedule,17.01,69.07,APC
Clot factor vii proconvertin,85230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.22,,,,,,,fee schedule,17.01,69.07,APC
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.41,,,,,,,fee schedule,17.01,71.77,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.01,,,,,,,fee schedule,17.01,71.77,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.08,,,,,,,fee schedule,17.01,71.77,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.92,,,,,,,fee schedule,17.01,71.77,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.77,,,,,,,fee schedule,17.01,71.77,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.8,,,,,,,fee schedule,17.01,71.77,APC
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.9,,,,,,,fee schedule,17.01,71.77,APC
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.22,,,,,,,fee schedule,17.01,71.77,APC
Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.47,,,,,,,fee schedule,19.4,87.94,
Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.4,,,,,,,fee schedule,19.4,87.94,
Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.59,,,,,,,fee schedule,19.4,87.94,
Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.13,,,,,,,fee schedule,19.4,87.94,
Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.94,,,,,,,fee schedule,19.4,87.94,
Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.44,,,,,,,fee schedule,19.4,87.94,APC
Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.42,,,,,,,fee schedule,19.4,87.94,APC
Clot factor viii reltd antgn,85244,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.76,,,,,,,fee schedule,19.4,87.94,APC
Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.34,,,,,,,fee schedule,21.79,90.09,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.79,,,,,,,fee schedule,21.79,90.09,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.12,,,,,,,fee schedule,21.79,90.09,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.36,,,,,,,fee schedule,21.79,90.09,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.09,,,,,,,fee schedule,21.79,90.09,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.09,,,,,,,fee schedule,21.79,90.09,APC
Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.94,,,,,,,fee schedule,21.79,90.09,APC
Clot factor viii vw ristoctn,85245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.29,,,,,,,fee schedule,21.79,90.09,APC
Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.12,,,,,,,fee schedule,21.79,80.64,
Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.79,,,,,,,fee schedule,21.79,80.64,
Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.39,,,,,,,fee schedule,21.79,80.64,
Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.97,,,,,,,fee schedule,21.79,80.64,
Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.64,,,,,,,fee schedule,21.79,80.64,
Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.09,,,,,,,fee schedule,21.79,80.64,APC
Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.94,,,,,,,fee schedule,21.79,80.64,APC
Clot factor viii vw antigen,85246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.29,,,,,,,fee schedule,21.79,80.64,APC
Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.82,,,,,,,fee schedule,21.79,161.94,
Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.79,,,,,,,fee schedule,21.79,161.94,
Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.26,,,,,,,fee schedule,21.79,161.94,
Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.32,,,,,,,fee schedule,21.79,161.94,
Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.94,,,,,,,fee schedule,21.79,161.94,
Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.09,,,,,,,fee schedule,21.79,161.94,APC
Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.94,,,,,,,fee schedule,21.79,161.94,APC
Clot factor viii multimetric,85247,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.29,,,,,,,fee schedule,21.79,161.94,APC
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.56,,,,,,,fee schedule,18.09,75.39,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.09,,,,,,,fee schedule,18.09,75.39,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.66,,,,,,,fee schedule,18.09,75.39,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.98,,,,,,,fee schedule,18.09,75.39,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.39,,,,,,,fee schedule,18.09,75.39,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.99,,,,,,,fee schedule,18.09,75.39,APC
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.04,,,,,,,fee schedule,18.09,75.39,APC
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.27,,,,,,,fee schedule,18.09,75.39,APC
Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.16,,,,,,,fee schedule,17.01,65.73,
Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.01,,,,,,,fee schedule,17.01,65.73,
Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.79,,,,,,,fee schedule,17.01,65.73,
Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.47,,,,,,,fee schedule,17.01,65.73,
Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.73,,,,,,,fee schedule,17.01,65.73,
Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.8,,,,,,,fee schedule,17.01,65.73,APC
Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.9,,,,,,,fee schedule,17.01,65.73,APC
Clot factor x stuart-power,85260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.22,,,,,,,fee schedule,17.01,65.73,APC
Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.06,,,,,,,fee schedule,17.01,69.07,
Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.01,,,,,,,fee schedule,17.01,69.07,
Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.16,,,,,,,fee schedule,17.01,69.07,
Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.38,,,,,,,fee schedule,17.01,69.07,
Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.07,,,,,,,fee schedule,17.01,69.07,
Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.8,,,,,,,fee schedule,17.01,69.07,APC
Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.9,,,,,,,fee schedule,17.01,69.07,APC
Clot factor xi pta,85270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.22,,,,,,,fee schedule,17.01,69.07,APC
Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.65,,,,,,,fee schedule,18.38,75.5,
Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.38,,,,,,,fee schedule,18.38,75.5,
Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.73,,,,,,,fee schedule,18.38,75.5,
Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.04,,,,,,,fee schedule,18.38,75.5,
Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.5,,,,,,,fee schedule,18.38,75.5,
Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.32,,,,,,,fee schedule,18.38,75.5,APC
Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.35,,,,,,,fee schedule,18.38,75.5,APC
Clot factor xii hageman,85280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.83,,,,,,,fee schedule,18.38,75.5,APC
Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.4,,,,,,,fee schedule,15.52,163.76,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.52,,,,,,,fee schedule,15.52,163.76,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,116.55,,,,,,,fee schedule,15.52,163.76,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.36,,,,,,,fee schedule,15.52,163.76,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,163.76,,,,,,,fee schedule,15.52,163.76,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.16,,,,,,,fee schedule,15.52,163.76,APC
Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.34,,,,,,,fee schedule,15.52,163.76,APC
Clot factor xiii fibrin stab,85290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.41,,,,,,,fee schedule,15.52,163.76,APC
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,8.65,30.48,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.65,,,,,,,fee schedule,8.65,30.48,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,8.65,30.48,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,8.65,30.48,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,8.65,30.48,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.57,,,,,,,fee schedule,8.65,30.48,APC
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.11,,,,,,,fee schedule,8.65,30.48,APC
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.4,,,,,,,fee schedule,8.65,30.48,APC
Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.7,,,,,,,fee schedule,17.98,62.91,
Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.98,,,,,,,fee schedule,17.98,62.91,
Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.77,,,,,,,fee schedule,17.98,62.91,
Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.86,,,,,,,fee schedule,17.98,62.91,
Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.91,,,,,,,fee schedule,17.98,62.91,
Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.88,,,,,,,fee schedule,17.98,62.91,APC
Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.93,,,,,,,fee schedule,17.98,62.91,APC
Clot factor fletcher fact,85292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.07,,,,,,,fee schedule,17.98,62.91,APC
Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.7,,,,,,,fee schedule,17.98,62.91,
Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.98,,,,,,,fee schedule,17.98,62.91,
Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.77,,,,,,,fee schedule,17.98,62.91,
Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.86,,,,,,,fee schedule,17.98,62.91,
Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.91,,,,,,,fee schedule,17.98,62.91,
Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.88,,,,,,,fee schedule,17.98,62.91,APC
Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.93,,,,,,,fee schedule,17.98,62.91,APC
Clot factor wght kininogen,85293,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.07,,,,,,,fee schedule,17.98,62.91,APC
Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.99,,,,,,,fee schedule,11.26,47.14,
Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.26,,,,,,,fee schedule,11.26,47.14,
Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.55,,,,,,,fee schedule,11.26,47.14,
Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.87,,,,,,,fee schedule,11.26,47.14,
Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.14,,,,,,,fee schedule,11.26,47.14,
Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.44,,,,,,,fee schedule,11.26,47.14,APC
Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.85,,,,,,,fee schedule,11.26,47.14,APC
Antithrombin iii activity,85300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.33,,,,,,,fee schedule,11.26,47.14,APC
Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.47,,,,,,,fee schedule,10.27,46.54,
Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.27,,,,,,,fee schedule,10.27,46.54,
Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.12,,,,,,,fee schedule,10.27,46.54,
Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.53,,,,,,,fee schedule,10.27,46.54,
Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.54,,,,,,,fee schedule,10.27,46.54,
Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.35,,,,,,,fee schedule,10.27,46.54,APC
Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.81,,,,,,,fee schedule,10.27,46.54,APC
Antithrombin iii antigen,85301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.46,,,,,,,fee schedule,10.27,46.54,APC
Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.39,,,,,,,fee schedule,11.41,113.15,
Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.41,,,,,,,fee schedule,11.41,113.15,
Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.53,,,,,,,fee schedule,11.41,113.15,
Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.5,,,,,,,fee schedule,11.41,113.15,
Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.15,,,,,,,fee schedule,11.41,113.15,
Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.61,,,,,,,fee schedule,11.41,113.15,APC
Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.01,,,,,,,fee schedule,11.41,113.15,APC
Clot inhibit prot c antigen,85302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.62,,,,,,,fee schedule,11.41,113.15,APC
Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.34,,,,,,,fee schedule,13.15,54.44,
Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.15,,,,,,,fee schedule,13.15,54.44,
Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.75,,,,,,,fee schedule,13.15,54.44,
Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.04,,,,,,,fee schedule,13.15,54.44,
Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.44,,,,,,,fee schedule,13.15,54.44,
Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.53,,,,,,,fee schedule,13.15,54.44,APC
Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.84,,,,,,,fee schedule,13.15,54.44,APC
Clot inhibit prot c activity,85303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.91,,,,,,,fee schedule,13.15,54.44,APC
Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.16,,,,,,,fee schedule,11.03,103.68,
Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.03,,,,,,,fee schedule,11.03,103.68,
Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.8,,,,,,,fee schedule,11.03,103.68,
Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.11,,,,,,,fee schedule,11.03,103.68,
Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.68,,,,,,,fee schedule,11.03,103.68,
Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.19,,,,,,,fee schedule,11.03,103.68,APC
Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.61,,,,,,,fee schedule,11.03,103.68,APC
Clot inhibit prot s total,85305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.9,,,,,,,fee schedule,11.03,103.68,APC
Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.48,,,,,,,fee schedule,14.55,50,
Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.55,,,,,,,fee schedule,14.55,50,
Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.59,,,,,,,fee schedule,14.55,50,
Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.51,,,,,,,fee schedule,14.55,50,
Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50,,,,,,,fee schedule,14.55,50,
Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.09,,,,,,,fee schedule,14.55,50,APC
Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.32,,,,,,,fee schedule,14.55,50,APC
Clot inhibit prot s free,85306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.58,,,,,,,fee schedule,14.55,50,APC
Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.93,,,,,,,fee schedule,14.55,67.77,
Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.55,,,,,,,fee schedule,14.55,67.77,
Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.23,,,,,,,fee schedule,14.55,67.77,
Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.63,,,,,,,fee schedule,14.55,67.77,
Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.77,,,,,,,fee schedule,14.55,67.77,
Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.09,,,,,,,fee schedule,14.55,67.77,APC
Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.32,,,,,,,fee schedule,14.55,67.77,APC
Assay Activated Protein C,85307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.58,,,,,,,fee schedule,14.55,67.77,APC
Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.18,,,,,,,fee schedule,12.23,199.16,
Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.23,,,,,,,fee schedule,12.23,199.16,
Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.75,,,,,,,fee schedule,12.23,199.16,
Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.54,,,,,,,fee schedule,12.23,199.16,
Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.16,,,,,,,fee schedule,12.23,199.16,
Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,12.23,199.16,APC
Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.87,,,,,,,fee schedule,12.23,199.16,APC
Factor inhibitor test,85335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.17,,,,,,,fee schedule,12.23,199.16,APC
Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.03,,,,,,,fee schedule,16.41,44.88,
Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.41,,,,,,,fee schedule,16.41,44.88,
Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.95,,,,,,,fee schedule,16.41,44.88,
Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.59,,,,,,,fee schedule,16.41,44.88,
Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.88,,,,,,,fee schedule,16.41,44.88,
Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,16.41,44.88,APC
Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.27,,,,,,,fee schedule,16.41,44.88,APC
Thrombomodulin,85337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.09,,,,,,,fee schedule,16.41,44.88,APC
Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.13,,,,,,,fee schedule,4.46,18.55,
Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.46,,,,,,,fee schedule,4.46,18.55,
Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.2,,,,,,,fee schedule,4.46,18.55,
Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.57,,,,,,,fee schedule,4.46,18.55,
Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.55,,,,,,,fee schedule,4.46,18.55,
Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.92,,,,,,,fee schedule,4.46,18.55,APC
Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.69,,,,,,,fee schedule,4.46,18.55,APC
Coagulation time lee & white,85345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.44,,,,,,,fee schedule,4.46,18.55,APC
Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.63,,,,,,,fee schedule,4.07,184.72,
Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.07,,,,,,,fee schedule,4.07,184.72,
Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.48,,,,,,,fee schedule,4.07,184.72,
Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.31,,,,,,,fee schedule,4.07,184.72,
Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.72,,,,,,,fee schedule,4.07,184.72,
Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.49,,,,,,,fee schedule,4.07,184.72,APC
Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.28,,,,,,,fee schedule,4.07,184.72,APC
Coagulation time activated,85347,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.7,,,,,,,fee schedule,4.07,184.72,APC
Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.95,,,,,,,fee schedule,4.27,16.04,
Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.27,,,,,,,fee schedule,4.27,16.04,
Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.42,,,,,,,fee schedule,4.27,16.04,
Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.15,,,,,,,fee schedule,4.27,16.04,
Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.04,,,,,,,fee schedule,4.27,16.04,
Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.71,,,,,,,fee schedule,4.27,16.04,APC
Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.49,,,,,,,fee schedule,4.27,16.04,APC
Coagulation time otr method,85348,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.08,,,,,,,fee schedule,4.27,16.04,APC
Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.48,,,,,,,fee schedule,7.99,36.2,
Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.99,,,,,,,fee schedule,7.99,36.2,
Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.77,,,,,,,fee schedule,7.99,36.2,
Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.64,,,,,,,fee schedule,7.99,36.2,
Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.2,,,,,,,fee schedule,7.99,36.2,
Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.83,,,,,,,fee schedule,7.99,36.2,APC
Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.41,,,,,,,fee schedule,7.99,36.2,APC
Euglobulin lysis,85360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.14,,,,,,,fee schedule,7.99,36.2,APC
Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.66,,,,,,,fee schedule,6.55,27.21,
Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.55,,,,,,,fee schedule,6.55,27.21,
Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.37,,,,,,,fee schedule,6.55,27.21,
Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.51,,,,,,,fee schedule,6.55,27.21,
Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.21,,,,,,,fee schedule,6.55,27.21,
Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.23,,,,,,,fee schedule,6.55,27.21,APC
Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.89,,,,,,,fee schedule,6.55,27.21,APC
Fibrin degradation products,85362,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.4,,,,,,,fee schedule,6.55,27.21,APC
Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.26,,,,,,,fee schedule,21.15,144.83,
Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,76.44,,,,,,,fee schedule,21.15,144.83,
Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.4,,,,,,,fee schedule,21.15,144.83,
Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.15,,,,,,,fee schedule,21.15,144.83,
Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.1,,,,,,,fee schedule,21.15,144.83,
Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.48,,,,,,,fee schedule,21.15,144.83,APC
Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,80.46,,,,,,,fee schedule,21.15,144.83,APC
Fibrinogen test,85366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,144.83,,,,,,,fee schedule,21.15,144.83,APC
Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.32,,,,,,,fee schedule,11.81,29.12,
Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.81,,,,,,,fee schedule,11.81,29.12,
Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.72,,,,,,,fee schedule,11.81,29.12,
Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.6,,,,,,,fee schedule,11.81,29.12,
Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.12,,,,,,,fee schedule,11.81,29.12,
Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.05,,,,,,,fee schedule,11.81,29.12,APC
Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.43,,,,,,,fee schedule,11.81,29.12,APC
Fibrinogen test,85370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.37,,,,,,,fee schedule,11.81,29.12,APC
Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.32,,,,,,,fee schedule,9.23,27.97,
Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.23,,,,,,,fee schedule,9.23,27.97,
Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.91,,,,,,,fee schedule,9.23,27.97,
Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.94,,,,,,,fee schedule,9.23,27.97,
Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.97,,,,,,,fee schedule,9.23,27.97,
Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.21,,,,,,,fee schedule,9.23,27.97,APC
Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.72,,,,,,,fee schedule,9.23,27.97,APC
Fibrin degrade semiquant,85378,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.5,,,,,,,fee schedule,9.23,27.97,APC
Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.6,,,,,,,fee schedule,9.67,39.79,
Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.67,,,,,,,fee schedule,9.67,39.79,
Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.32,,,,,,,fee schedule,9.67,39.79,
Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.68,,,,,,,fee schedule,9.67,39.79,
Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.79,,,,,,,fee schedule,9.67,39.79,
Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.67,39.79,APC
Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.18,,,,,,,fee schedule,9.67,39.79,APC
Fibrin degradation quant,85379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.32,,,,,,,fee schedule,9.67,39.79,APC
Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.89,,,,,,,fee schedule,9.67,38.97,
Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.67,,,,,,,fee schedule,9.67,38.97,
Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.74,,,,,,,fee schedule,9.67,38.97,
Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.22,,,,,,,fee schedule,9.67,38.97,
Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.97,,,,,,,fee schedule,9.67,38.97,
Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.67,38.97,APC
Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.18,,,,,,,fee schedule,9.67,38.97,APC
Fibrin degradj d-dimer,85380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.32,,,,,,,fee schedule,9.67,38.97,APC
Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.12,,,,,,,fee schedule,9.23,33.49,
Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.23,,,,,,,fee schedule,9.23,33.49,
Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.83,,,,,,,fee schedule,9.23,33.49,
Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.09,,,,,,,fee schedule,9.23,33.49,
Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.49,,,,,,,fee schedule,9.23,33.49,
Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.21,,,,,,,fee schedule,9.23,33.49,APC
Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.72,,,,,,,fee schedule,9.23,33.49,APC
Fibrinogen activity,85384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.5,,,,,,,fee schedule,9.23,33.49,APC
Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.8,,,,,,,fee schedule,13.74,36.57,
Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.74,,,,,,,fee schedule,13.74,36.57,
Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.03,,,,,,,fee schedule,13.74,36.57,
Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.85,,,,,,,fee schedule,13.74,36.57,
Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.57,,,,,,,fee schedule,13.74,36.57,
Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.18,,,,,,,fee schedule,13.74,36.57,APC
Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.46,,,,,,,fee schedule,13.74,36.57,APC
Fibrinogen antigen,85385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.03,,,,,,,fee schedule,13.74,36.57,APC
Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1049.51,,,,,,,fee schedule,14.71,1206.94,
Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.71,,,,,,,fee schedule,14.71,1206.94,
Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,859.02,,,,,,,fee schedule,14.71,1206.94,
Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,688.06,,,,,,,fee schedule,14.71,1206.94,
Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1206.94,,,,,,,fee schedule,14.71,1206.94,
Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.25,,,,,,,fee schedule,14.71,1206.94,APC
Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.48,,,,,,,fee schedule,14.71,1206.94,APC
Fibrinolysins screen i&r,85390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.86,,,,,,,fee schedule,14.71,1206.94,APC
Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,12.85,22.54,
Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.88,,,,,,,fee schedule,12.85,22.54,
Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,12.85,22.54,
Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,12.85,22.54,
Clotting assay whole blood,85396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,12.85,22.54,
Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.43,,,,,,,fee schedule,29.32,162.64,
Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.32,,,,,,,fee schedule,29.32,162.64,
Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.76,,,,,,,fee schedule,29.32,162.64,
Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.72,,,,,,,fee schedule,29.32,162.64,
Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.64,,,,,,,fee schedule,29.32,162.64,
Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.4,,,,,,,fee schedule,29.32,162.64,APC
Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.86,,,,,,,fee schedule,29.32,162.64,APC
Clotting funct activity,85397,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55.55,,,,,,,fee schedule,29.32,162.64,APC
Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.32,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.1,,,,,,,fee schedule,7.32,30.48,APC
Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.71,,,,,,,fee schedule,7.32,30.48,APC
Fibrinolytic plasmin,85400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.88,,,,,,,fee schedule,7.32,30.48,APC
Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.32,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,7.32,30.48,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.1,,,,,,,fee schedule,7.32,30.48,APC
Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.71,,,,,,,fee schedule,7.32,30.48,APC
Fibrinolytic antiplasmin,85410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.88,,,,,,,fee schedule,7.32,30.48,APC
Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,184.43,,,,,,,fee schedule,16.33,212.09,
Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.33,,,,,,,fee schedule,16.33,212.09,
Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.96,,,,,,,fee schedule,16.33,212.09,
Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,120.91,,,,,,,fee schedule,16.33,212.09,
Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,212.09,,,,,,,fee schedule,16.33,212.09,
Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.05,,,,,,,fee schedule,16.33,212.09,APC
Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.19,,,,,,,fee schedule,16.33,212.09,APC
Fibrinolytic plasminogen,85415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.94,,,,,,,fee schedule,16.33,212.09,APC
Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.84,,,,,,,fee schedule,6.2,69.97,
Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.2,,,,,,,fee schedule,6.2,69.97,
Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.8,,,,,,,fee schedule,6.2,69.97,
Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.89,,,,,,,fee schedule,6.2,69.97,
Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.97,,,,,,,fee schedule,6.2,69.97,
Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.86,,,,,,,fee schedule,6.2,69.97,APC
Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.53,,,,,,,fee schedule,6.2,69.97,APC
Fibrinolytic plasminogen,85420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.75,,,,,,,fee schedule,6.2,69.97,APC
Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.24,,,,,,,fee schedule,9.67,29.03,
Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.67,,,,,,,fee schedule,9.67,29.03,
Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.66,,,,,,,fee schedule,9.67,29.03,
Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.55,,,,,,,fee schedule,9.67,29.03,
Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.03,,,,,,,fee schedule,9.67,29.03,
Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.67,29.03,APC
Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.18,,,,,,,fee schedule,9.67,29.03,APC
Fibrinolytic plasminogen,85421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.32,,,,,,,fee schedule,9.67,29.03,APC
Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.72,,,,,,,fee schedule,3.99,18.08,
Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.99,,,,,,,fee schedule,3.99,18.08,
Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.87,,,,,,,fee schedule,3.99,18.08,
Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.31,,,,,,,fee schedule,3.99,18.08,
Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.08,,,,,,,fee schedule,3.99,18.08,
Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.41,,,,,,,fee schedule,3.99,18.08,APC
Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.2,,,,,,,fee schedule,3.99,18.08,APC
Heinz bodies direct,85441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.56,,,,,,,fee schedule,3.99,18.08,APC
Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.52,,,,,,,fee schedule,6.48,29.35,
Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.48,,,,,,,fee schedule,6.48,29.35,
Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.89,,,,,,,fee schedule,6.48,29.35,
Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.73,,,,,,,fee schedule,6.48,29.35,
Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.35,,,,,,,fee schedule,6.48,29.35,
Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.16,,,,,,,fee schedule,6.48,29.35,APC
Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.82,,,,,,,fee schedule,6.48,29.35,APC
Heinz bodies induced,85445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.28,,,,,,,fee schedule,6.48,29.35,APC
Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.41,,,,,,,fee schedule,7.34,30.37,
Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.34,,,,,,,fee schedule,7.34,30.37,
Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.62,,,,,,,fee schedule,7.34,30.37,
Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.31,,,,,,,fee schedule,7.34,30.37,
Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.37,,,,,,,fee schedule,7.34,30.37,
Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.12,,,,,,,fee schedule,7.34,30.37,APC
Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.73,,,,,,,fee schedule,7.34,30.37,APC
Hemoglobin fetal,85460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.91,,,,,,,fee schedule,7.34,30.37,APC
Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.84,,,,,,,fee schedule,8.89,28.57,
Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.89,,,,,,,fee schedule,8.89,28.57,
Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.33,,,,,,,fee schedule,8.89,28.57,
Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.29,,,,,,,fee schedule,8.89,28.57,
Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.57,,,,,,,fee schedule,8.89,28.57,
Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.83,,,,,,,fee schedule,8.89,28.57,APC
Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.36,,,,,,,fee schedule,8.89,28.57,APC
Hemoglobin fetal,85461,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.85,,,,,,,fee schedule,8.89,28.57,APC
Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,8.43,30.48,
Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.43,,,,,,,fee schedule,8.43,30.48,
Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,8.43,30.48,
Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,8.43,30.48,
Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,8.43,30.48,
Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.31,,,,,,,fee schedule,8.43,30.48,APC
Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.87,,,,,,,fee schedule,8.43,30.48,APC
Hemolysin acid,85475,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.97,,,,,,,fee schedule,8.43,30.48,APC
Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.99,,,,,,,fee schedule,12.44,47.14,
Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.44,,,,,,,fee schedule,12.44,47.14,
Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.55,,,,,,,fee schedule,12.44,47.14,
Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.87,,,,,,,fee schedule,12.44,47.14,
Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.14,,,,,,,fee schedule,12.44,47.14,
Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.74,,,,,,,fee schedule,12.44,47.14,APC
Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.09,,,,,,,fee schedule,12.44,47.14,APC
Heparin assay,85520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.56,,,,,,,fee schedule,12.44,47.14,APC
Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.82,,,,,,,fee schedule,11.25,25.09,
Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.25,,,,,,,fee schedule,11.25,25.09,
Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.86,,,,,,,fee schedule,11.25,25.09,
Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.31,,,,,,,fee schedule,11.25,25.09,
Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.09,,,,,,,fee schedule,11.25,25.09,
Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.43,,,,,,,fee schedule,11.25,25.09,APC
Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.84,,,,,,,fee schedule,11.25,25.09,APC
Heparin neutralization,85525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.31,,,,,,,fee schedule,11.25,25.09,APC
Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.09,,,,,,,fee schedule,12.44,61.05,
Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.44,,,,,,,fee schedule,12.44,61.05,
Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.45,,,,,,,fee schedule,12.44,61.05,
Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.81,,,,,,,fee schedule,12.44,61.05,
Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.05,,,,,,,fee schedule,12.44,61.05,
Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.74,,,,,,,fee schedule,12.44,61.05,APC
Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.09,,,,,,,fee schedule,12.44,61.05,APC
Heparin-protamine tolerance,85530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.56,,,,,,,fee schedule,12.44,61.05,APC
Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.21,,,,,,,fee schedule,6.54,27.84,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.54,,,,,,,fee schedule,6.54,27.84,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.82,,,,,,,fee schedule,6.54,27.84,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.87,,,,,,,fee schedule,6.54,27.84,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.84,,,,,,,fee schedule,6.54,27.84,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.22,,,,,,,fee schedule,6.54,27.84,APC
Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.88,,,,,,,fee schedule,6.54,27.84,APC
Iron Stain Peripheral Blood,85536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.38,,,,,,,fee schedule,6.54,27.84,APC
Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.21,,,,,,,fee schedule,8.17,37.04,
Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.17,,,,,,,fee schedule,8.17,37.04,
Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.36,,,,,,,fee schedule,8.17,37.04,
Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.12,,,,,,,fee schedule,8.17,37.04,
Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.04,,,,,,,fee schedule,8.17,37.04,
Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.03,,,,,,,fee schedule,8.17,37.04,APC
Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.6,,,,,,,fee schedule,8.17,37.04,APC
Wbc alkaline phosphatase,85540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.48,,,,,,,fee schedule,8.17,37.04,APC
RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,8.17,30.48,
RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.17,,,,,,,fee schedule,8.17,30.48,
RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,8.17,30.48,
RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,8.17,30.48,
RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,8.17,30.48,
RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.03,,,,,,,fee schedule,8.17,30.48,APC
RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.6,,,,,,,fee schedule,8.17,30.48,APC
RBC mechanical fragility,85547,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.48,,,,,,,fee schedule,8.17,30.48,APC
Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.16,,,,,,,fee schedule,12.56,33.75,
Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.81,,,,,,,fee schedule,12.56,33.75,
Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.68,,,,,,,fee schedule,12.56,33.75,
Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.56,,,,,,,fee schedule,12.56,33.75,
Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.03,,,,,,,fee schedule,12.56,33.75,
Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.69,,,,,,,fee schedule,12.56,33.75,APC
Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.75,,,,,,,fee schedule,12.56,33.75,APC
Muramidase,85549,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.75,,,,,,,fee schedule,12.56,33.75,APC
RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.04,,,,,,,fee schedule,7.1,28.8,
RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.1,,,,,,,fee schedule,7.1,28.8,
RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.5,,,,,,,fee schedule,7.1,28.8,
RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.42,,,,,,,fee schedule,7.1,28.8,
RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.8,,,,,,,fee schedule,7.1,28.8,
RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.84,,,,,,,fee schedule,7.1,28.8,APC
RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.47,,,,,,,fee schedule,7.1,28.8,APC
RBC osmotic fragility,85555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.45,,,,,,,fee schedule,7.1,28.8,APC
RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.72,,,,,,,fee schedule,12.69,85.93,
RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.69,,,,,,,fee schedule,12.69,85.93,
RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.16,,,,,,,fee schedule,12.69,85.93,
RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.99,,,,,,,fee schedule,12.69,85.93,
RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.93,,,,,,,fee schedule,12.69,85.93,
RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.03,,,,,,,fee schedule,12.69,85.93,APC
RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.36,,,,,,,fee schedule,12.69,85.93,APC
RBC osmotic fragility,85557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.05,,,,,,,fee schedule,12.69,85.93,APC
Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.87,,,,,,,fee schedule,23.66,121.75,
Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.66,,,,,,,fee schedule,23.66,121.75,
Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.65,,,,,,,fee schedule,23.66,121.75,
Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.41,,,,,,,fee schedule,23.66,121.75,
Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.75,,,,,,,fee schedule,23.66,121.75,
Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.16,,,,,,,fee schedule,23.66,121.75,APC
Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.91,,,,,,,fee schedule,23.66,121.75,APC
Blood platelet aggregation,85576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.84,,,,,,,fee schedule,23.66,121.75,APC
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.36,,,,,,,fee schedule,14,32.36,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.08,,,,,,,fee schedule,14,32.36,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.48,,,,,,,fee schedule,14,32.36,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14,,,,,,,fee schedule,14,32.36,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.56,,,,,,,fee schedule,14,32.36,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.88,,,,,,,fee schedule,14,32.36,APC
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.98,,,,,,,fee schedule,14,32.36,APC
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.36,,,,,,,fee schedule,14,32.36,APC
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.36,,,,,,,fee schedule,14,32.36,
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.08,,,,,,,fee schedule,14,32.36,
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.48,,,,,,,fee schedule,14,32.36,
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14,,,,,,,fee schedule,14,32.36,
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.56,,,,,,,fee schedule,14,32.36,
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.88,,,,,,,fee schedule,14,32.36,APC
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.98,,,,,,,fee schedule,14,32.36,APC
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.36,,,,,,,fee schedule,14,32.36,APC
Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.47,,,,,,,fee schedule,4.08,7.72,
Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.08,,,,,,,fee schedule,4.08,7.72,
Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.3,,,,,,,fee schedule,4.08,7.72,
Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.24,,,,,,,fee schedule,4.08,7.72,
Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.44,,,,,,,fee schedule,4.08,7.72,
Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.5,,,,,,,fee schedule,4.08,7.72,APC
Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.29,,,,,,,fee schedule,4.08,7.72,APC
Prothrombin time,85610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.72,,,,,,,fee schedule,4.08,7.72,APC
Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.01,,,,,,,fee schedule,3.74,20.71,
Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.74,,,,,,,fee schedule,3.74,20.71,
Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.74,,,,,,,fee schedule,3.74,20.71,
Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.81,,,,,,,fee schedule,3.74,20.71,
Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.71,,,,,,,fee schedule,3.74,20.71,
Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.14,,,,,,,fee schedule,3.74,20.71,APC
Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.94,,,,,,,fee schedule,3.74,20.71,APC
Prothrombin test,85611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.09,,,,,,,fee schedule,3.74,20.71,APC
Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.44,,,,,,,fee schedule,16.62,38.46,
Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.62,,,,,,,fee schedule,16.62,38.46,
Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.37,,,,,,,fee schedule,16.62,38.46,
Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.92,,,,,,,fee schedule,16.62,38.46,
Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.46,,,,,,,fee schedule,16.62,38.46,
Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.36,,,,,,,fee schedule,16.62,38.46,APC
Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.49,,,,,,,fee schedule,16.62,38.46,APC
Viper venom prothrombin time,85612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.48,,,,,,,fee schedule,16.62,38.46,APC
Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.81,,,,,,,fee schedule,9.1,37.73,
Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.1,,,,,,,fee schedule,9.1,37.73,
Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.85,,,,,,,fee schedule,9.1,37.73,
Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.51,,,,,,,fee schedule,9.1,37.73,
Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.73,,,,,,,fee schedule,9.1,37.73,
Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.06,,,,,,,fee schedule,9.1,37.73,APC
Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.58,,,,,,,fee schedule,9.1,37.73,APC
Russell viper venom diluted,85613,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.24,,,,,,,fee schedule,9.1,37.73,APC
Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.37,,,,,,,fee schedule,9.36,19.98,
Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.36,,,,,,,fee schedule,9.36,19.98,
Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.22,,,,,,,fee schedule,9.36,19.98,
Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.39,,,,,,,fee schedule,9.36,19.98,
Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.98,,,,,,,fee schedule,9.36,19.98,
Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.34,,,,,,,fee schedule,9.36,19.98,APC
Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.85,,,,,,,fee schedule,9.36,19.98,APC
Reptilase test,85635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.73,,,,,,,fee schedule,9.36,19.98,APC
Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.47,,,,,,,fee schedule,4.06,7.69,
Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.06,,,,,,,fee schedule,4.06,7.69,
Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.3,,,,,,,fee schedule,4.06,7.69,
Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.24,,,,,,,fee schedule,4.06,7.69,
Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.44,,,,,,,fee schedule,4.06,7.69,
Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.06,7.69,APC
Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.27,,,,,,,fee schedule,4.06,7.69,APC
Rbc sed rate nonautomated,85651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.69,,,,,,,fee schedule,4.06,7.69,APC
Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.27,,,,,,,fee schedule,2.57,22.16,
Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.57,,,,,,,fee schedule,2.57,22.16,
Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.77,,,,,,,fee schedule,2.57,22.16,
Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.63,,,,,,,fee schedule,2.57,22.16,
Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.16,,,,,,,fee schedule,2.57,22.16,
Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.84,,,,,,,fee schedule,2.57,22.16,APC
Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.7,,,,,,,fee schedule,2.57,22.16,APC
Rbc sed rate automated,85652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.86,,,,,,,fee schedule,2.57,22.16,APC
RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.02,,,,,,,fee schedule,5.23,47.17,
RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.23,,,,,,,fee schedule,5.23,47.17,
RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.57,,,,,,,fee schedule,5.23,47.17,
RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.89,,,,,,,fee schedule,5.23,47.17,
RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.17,,,,,,,fee schedule,5.23,47.17,
RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.79,,,,,,,fee schedule,5.23,47.17,APC
RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.51,,,,,,,fee schedule,5.23,47.17,APC
RBC sickle cell test,85660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.92,,,,,,,fee schedule,5.23,47.17,APC
Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,5.48,48.81,
Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.48,,,,,,,fee schedule,5.48,48.81,
Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,5.48,48.81,
Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,5.48,48.81,
Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,5.48,48.81,
Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.06,,,,,,,fee schedule,5.48,48.81,APC
Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.77,,,,,,,fee schedule,5.48,48.81,APC
Thrombin time plasma,85670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.39,,,,,,,fee schedule,5.48,48.81,APC
Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.63,,,,,,,fee schedule,6.51,29.47,
Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.51,,,,,,,fee schedule,6.51,29.47,
Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.98,,,,,,,fee schedule,6.51,29.47,
Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.8,,,,,,,fee schedule,6.51,29.47,
Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.47,,,,,,,fee schedule,6.51,29.47,
Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.19,,,,,,,fee schedule,6.51,29.47,APC
Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.85,,,,,,,fee schedule,6.51,29.47,APC
Thrombin time titer,85675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.33,,,,,,,fee schedule,6.51,29.47,APC
Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.84,,,,,,,fee schedule,9.15,36.62,
Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.15,,,,,,,fee schedule,9.15,36.62,
Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.06,,,,,,,fee schedule,9.15,36.62,
Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.87,,,,,,,fee schedule,9.15,36.62,
Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.62,,,,,,,fee schedule,9.15,36.62,
Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.11,,,,,,,fee schedule,9.15,36.62,APC
Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.63,,,,,,,fee schedule,9.15,36.62,APC
Thromboplastin inhibition,85705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.33,,,,,,,fee schedule,9.15,36.62,APC
Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.36,,,,,,,fee schedule,5.71,11.91,
Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.71,,,,,,,fee schedule,5.71,11.91,
Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.48,,,,,,,fee schedule,5.71,11.91,
Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.79,,,,,,,fee schedule,5.71,11.91,
Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.91,,,,,,,fee schedule,5.71,11.91,
Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.31,,,,,,,fee schedule,5.71,11.91,APC
Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.01,,,,,,,fee schedule,5.71,11.91,APC
Thromboplastin time partial,85730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.82,,,,,,,fee schedule,5.71,11.91,APC
Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.58,,,,,,,fee schedule,6.15,24.82,
Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.15,,,,,,,fee schedule,6.15,24.82,
Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.66,,,,,,,fee schedule,6.15,24.82,
Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.15,,,,,,,fee schedule,6.15,24.82,
Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.82,,,,,,,fee schedule,6.15,24.82,
Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.15,24.82,APC
Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,6.15,24.82,APC
Thromboplastin time partial,85732,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,6.15,24.82,APC
Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.69,,,,,,,fee schedule,11.09,50.24,
Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.09,,,,,,,fee schedule,11.09,50.24,
Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.76,,,,,,,fee schedule,11.09,50.24,
Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.64,,,,,,,fee schedule,11.09,50.24,
Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.24,,,,,,,fee schedule,11.09,50.24,
Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.25,,,,,,,fee schedule,11.09,50.24,APC
Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.67,,,,,,,fee schedule,11.09,50.24,APC
Blood viscosity examination,85810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.01,,,,,,,fee schedule,11.09,50.24,APC
Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.15,,,,,,,fee schedule,6.63,30.07,
Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.63,,,,,,,fee schedule,6.63,30.07,
Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.4,,,,,,,fee schedule,6.63,30.07,
Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.14,,,,,,,fee schedule,6.63,30.07,
Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.07,,,,,,,fee schedule,6.63,30.07,
Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.33,,,,,,,fee schedule,6.63,30.07,APC
Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.98,,,,,,,fee schedule,6.63,30.07,APC
Agglutinins febrile antigen,86000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.56,,,,,,,fee schedule,6.63,30.07,APC
Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.94,,,,,,,fee schedule,7.43,19.48,
Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.43,,,,,,,fee schedule,7.43,19.48,
Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.87,,,,,,,fee schedule,7.43,19.48,
Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.11,,,,,,,fee schedule,7.43,19.48,
Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.48,,,,,,,fee schedule,7.43,19.48,
Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.21,,,,,,,fee schedule,7.43,19.48,APC
Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.82,,,,,,,fee schedule,7.43,19.48,APC
Allergen Specific Igg,86001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.08,,,,,,,fee schedule,7.43,19.48,APC
Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.08,,,,,,,fee schedule,4.96,24.24,
Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.96,,,,,,,fee schedule,4.96,24.24,
Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.25,,,,,,,fee schedule,4.96,24.24,
Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.82,,,,,,,fee schedule,4.96,24.24,
Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.24,,,,,,,fee schedule,4.96,24.24,
Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.48,,,,,,,fee schedule,4.96,24.24,APC
Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.22,,,,,,,fee schedule,4.96,24.24,APC
Allergen specific IgE,86003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.4,,,,,,,fee schedule,4.96,24.24,APC
Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.83,,,,,,,fee schedule,7.57,34.3,
Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.57,,,,,,,fee schedule,7.57,34.3,
Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.42,,,,,,,fee schedule,7.57,34.3,
Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.56,,,,,,,fee schedule,7.57,34.3,
Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.3,,,,,,,fee schedule,7.57,34.3,
Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.37,,,,,,,fee schedule,7.57,34.3,APC
Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.97,,,,,,,fee schedule,7.57,34.3,APC
Allergen specific IgE,86005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.35,,,,,,,fee schedule,7.57,34.3,APC
Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.35,,,,,,,fee schedule,17.03,62.5,
Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.03,,,,,,,fee schedule,17.03,62.5,
Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.49,,,,,,,fee schedule,17.03,62.5,
Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.63,,,,,,,fee schedule,17.03,62.5,
Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.5,,,,,,,fee schedule,17.03,62.5,
Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.83,,,,,,,fee schedule,17.03,62.5,APC
Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.93,,,,,,,fee schedule,17.03,62.5,APC
Allg spec ige recomb ea,86008,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.27,,,,,,,fee schedule,17.03,62.5,APC
Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.41,,,,,,,fee schedule,11.45,25.77,
Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,25.77,
Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.34,,,,,,,fee schedule,11.45,25.77,
Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.69,,,,,,,fee schedule,11.45,25.77,
Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.77,,,,,,,fee schedule,11.45,25.77,
Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,25.77,APC
Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,25.77,APC
Actin antibody each,86015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,25.77,APC
WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.78,,,,,,,fee schedule,14.3,74.5,
WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.3,,,,,,,fee schedule,14.3,74.5,
WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.02,,,,,,,fee schedule,14.3,74.5,
WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.47,,,,,,,fee schedule,14.3,74.5,
WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.5,,,,,,,fee schedule,14.3,74.5,
WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,14.3,74.5,APC
WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.05,,,,,,,fee schedule,14.3,74.5,APC
WBC antibody identification,86021,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.09,,,,,,,fee schedule,14.3,74.5,APC
Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.5,,,,,,,fee schedule,17.45,61.53,
Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.45,,,,,,,fee schedule,17.45,61.53,
Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.79,,,,,,,fee schedule,17.45,61.53,
Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.07,,,,,,,fee schedule,17.45,61.53,
Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.53,,,,,,,fee schedule,17.45,61.53,
Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.29,,,,,,,fee schedule,17.45,61.53,APC
Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.37,,,,,,,fee schedule,17.45,61.53,APC
Platelet antibodies,86022,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.07,,,,,,,fee schedule,17.45,61.53,APC
Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.65,,,,,,,fee schedule,11.84,53.65,
Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.84,,,,,,,fee schedule,11.84,53.65,
Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.18,,,,,,,fee schedule,11.84,53.65,
Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.58,,,,,,,fee schedule,11.84,53.65,
Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.65,,,,,,,fee schedule,11.84,53.65,
Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.08,,,,,,,fee schedule,11.84,53.65,APC
Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.46,,,,,,,fee schedule,11.84,53.65,APC
Immunoglobulin assay,86023,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.43,,,,,,,fee schedule,11.84,53.65,APC
Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.42,,,,,,,fee schedule,11.45,26.93,
Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,26.93,
Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.17,,,,,,,fee schedule,11.45,26.93,
Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.35,,,,,,,fee schedule,11.45,26.93,
Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.93,,,,,,,fee schedule,11.45,26.93,
Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,26.93,APC
Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,26.93,APC
Anca screen each antibody,86036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,26.93,APC
Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.42,,,,,,,fee schedule,11.45,26.93,
Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,26.93,
Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.17,,,,,,,fee schedule,11.45,26.93,
Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.35,,,,,,,fee schedule,11.45,26.93,
Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.93,,,,,,,fee schedule,11.45,26.93,
Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,26.93,APC
Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,26.93,APC
Anca titer each antibody,86037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,26.93,APC
Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.9,,,,,,,fee schedule,11.49,61.99,
Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.49,,,,,,,fee schedule,11.49,61.99,
Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.12,,,,,,,fee schedule,11.49,61.99,
Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.34,,,,,,,fee schedule,11.49,61.99,
Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.99,,,,,,,fee schedule,11.49,61.99,
Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.69,,,,,,,fee schedule,11.49,61.99,APC
Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.09,,,,,,,fee schedule,11.49,61.99,APC
Antinuclear antibodies,86038,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.76,,,,,,,fee schedule,11.49,61.99,APC
Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.34,,,,,,,fee schedule,10.6,47.54,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.6,,,,,,,fee schedule,10.6,47.54,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.84,,,,,,,fee schedule,10.6,47.54,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.1,,,,,,,fee schedule,10.6,47.54,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.54,,,,,,,fee schedule,10.6,47.54,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.72,,,,,,,fee schedule,10.6,47.54,APC
Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.16,,,,,,,fee schedule,10.6,47.54,APC
Antinuclear antibodies (ANA),86039,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.09,,,,,,,fee schedule,10.6,47.54,APC
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.21,,,,,,,fee schedule,18.4,38.19,
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.18,,,,,,,fee schedule,18.4,38.19,
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.77,,,,,,,fee schedule,18.4,38.19,
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.19,,,,,,,fee schedule,18.4,38.19,
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,18.4,38.19,APC
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.4,,,,,,,fee schedule,18.4,38.19,APC
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.12,,,,,,,fee schedule,18.4,38.19,APC
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.21,,,,,,,fee schedule,18.4,38.19,
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.18,,,,,,,fee schedule,18.4,38.19,
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.77,,,,,,,fee schedule,18.4,38.19,
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.19,,,,,,,fee schedule,18.4,38.19,
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,18.4,38.19,APC
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.4,,,,,,,fee schedule,18.4,38.19,APC
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.12,,,,,,,fee schedule,18.4,38.19,APC
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.76,,,,,,,fee schedule,12.05,25.02,
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.81,,,,,,,fee schedule,12.05,25.02,
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.27,,,,,,,fee schedule,12.05,25.02,
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.02,,,,,,,fee schedule,12.05,25.02,
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,12.05,25.02,APC
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,12.05,25.02,APC
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,12.05,25.02,APC
Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.41,,,,,,,fee schedule,10.95,25.77,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.95,,,,,,,fee schedule,10.95,25.77,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.34,,,,,,,fee schedule,10.95,25.77,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.69,,,,,,,fee schedule,10.95,25.77,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.77,,,,,,,fee schedule,10.95,25.77,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.95,25.77,APC
Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.53,,,,,,,fee schedule,10.95,25.77,APC
Aquaporin-4 antb elisa,86051,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.75,,,,,,,fee schedule,10.95,25.77,APC
Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.42,,,,,,,fee schedule,11.45,26.93,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,26.93,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.17,,,,,,,fee schedule,11.45,26.93,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.35,,,,,,,fee schedule,11.45,26.93,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.93,,,,,,,fee schedule,11.45,26.93,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,26.93,APC
Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,26.93,APC
Aquaporin-4 antb cba each,86052,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,26.93,APC
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.42,,,,,,,fee schedule,15.35,67.91,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,35.84,,,,,,,fee schedule,15.35,67.91,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.17,,,,,,,fee schedule,15.35,67.91,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.35,,,,,,,fee schedule,15.35,67.91,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.93,,,,,,,fee schedule,15.35,67.91,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,15.35,67.91,APC
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.73,,,,,,,fee schedule,15.35,67.91,APC
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.91,,,,,,,fee schedule,15.35,67.91,APC
Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.53,,,,,,,fee schedule,6.94,30.51,
Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.94,,,,,,,fee schedule,6.94,30.51,
Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.71,,,,,,,fee schedule,6.94,30.51,
Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.39,,,,,,,fee schedule,6.94,30.51,
Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.51,,,,,,,fee schedule,6.94,30.51,
Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.66,,,,,,,fee schedule,6.94,30.51,APC
Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.3,,,,,,,fee schedule,6.94,30.51,APC
Antistreptolysin o titer,86060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.14,,,,,,,fee schedule,6.94,30.51,APC
Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.37,,,,,,,fee schedule,5.48,19.98,
Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.48,,,,,,,fee schedule,5.48,19.98,
Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.22,,,,,,,fee schedule,5.48,19.98,
Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.39,,,,,,,fee schedule,5.48,19.98,
Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.98,,,,,,,fee schedule,5.48,19.98,
Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.06,,,,,,,fee schedule,5.48,19.98,APC
Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.77,,,,,,,fee schedule,5.48,19.98,APC
Antistreptolysin o screen,86063,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.39,,,,,,,fee schedule,5.48,19.98,APC
Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,51.88,
Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.14,,,,,,,fee schedule,27.82,51.88,
Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,51.88,
Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,51.88,
Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,51.88,
Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,27.82,51.88,APC
Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,27.82,51.88,APC
Phys blood bank serv xmatch,86077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,27.82,51.88,APC
Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,45.14,305.56,
Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.14,,,,,,,fee schedule,45.14,305.56,
Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,45.14,305.56,
Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,45.14,305.56,
Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,45.14,305.56,
Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,45.14,305.56,APC
Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,45.14,305.56,APC
Phys blood bank serv reactj,86078,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,45.14,305.56,APC
Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,45.43,178.65,
Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.43,,,,,,,fee schedule,45.43,178.65,
Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,45.43,178.65,
Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,45.43,178.65,
Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,45.43,178.65,
Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,45.43,178.65,APC
Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,45.43,178.65,APC
Phys blood bank serv authrj,86079,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,45.43,178.65,APC
C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.06,,,,,,,fee schedule,4.92,10.42,
C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.92,,,,,,,fee schedule,4.92,10.42,
C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.42,,,,,,,fee schedule,4.92,10.42,
C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.94,,,,,,,fee schedule,4.92,10.42,
C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.42,,,,,,,fee schedule,4.92,10.42,
C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.92,10.42,APC
C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.18,,,,,,,fee schedule,4.92,10.42,APC
C-reactive protein,86140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.32,,,,,,,fee schedule,4.92,10.42,APC
C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.32,,,,,,,fee schedule,12.3,26.82,
C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.3,,,,,,,fee schedule,12.3,26.82,
C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.09,,,,,,,fee schedule,12.3,26.82,
C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.29,,,,,,,fee schedule,12.3,26.82,
C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.82,,,,,,,fee schedule,12.3,26.82,
C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.6,,,,,,,fee schedule,12.3,26.82,APC
C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.95,,,,,,,fee schedule,12.3,26.82,APC
C-reactive protein hs,86141,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.31,,,,,,,fee schedule,12.3,26.82,APC
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.36,,,,,,,fee schedule,15.31,45.81,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.18,,,,,,,fee schedule,15.31,45.81,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.12,,,,,,,fee schedule,15.31,45.81,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.31,,,,,,,fee schedule,15.31,45.81,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.86,,,,,,,fee schedule,15.31,45.81,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.72,,,,,,,fee schedule,15.31,45.81,APC
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.45,,,,,,,fee schedule,15.31,45.81,APC
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.81,,,,,,,fee schedule,15.31,45.81,APC
Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.64,,,,,,,fee schedule,17.47,45.81,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.18,,,,,,,fee schedule,17.47,45.81,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.8,,,,,,,fee schedule,17.47,45.81,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.47,,,,,,,fee schedule,17.47,45.81,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.64,,,,,,,fee schedule,17.47,45.81,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.72,,,,,,,fee schedule,17.47,45.81,APC
Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.45,,,,,,,fee schedule,17.47,45.81,APC
Cardiolipin antibody ea ig,86147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.81,,,,,,,fee schedule,17.47,45.81,APC
Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.16,,,,,,,fee schedule,15.27,69.18,
Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.27,,,,,,,fee schedule,15.27,69.18,
Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.24,,,,,,,fee schedule,15.27,69.18,
Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.44,,,,,,,fee schedule,15.27,69.18,
Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.18,,,,,,,fee schedule,15.27,69.18,
Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.87,,,,,,,fee schedule,15.27,69.18,APC
Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.07,,,,,,,fee schedule,15.27,69.18,APC
Anti-phospholipid antibody,86148,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.93,,,,,,,fee schedule,15.27,69.18,APC
Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,920.2,,,,,,,fee schedule,238.24,1058.23,
Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,238.24,,,,,,,fee schedule,238.24,1058.23,
Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,753.18,,,,,,,fee schedule,238.24,1058.23,
Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,603.28,,,,,,,fee schedule,238.24,1058.23,
Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1058.23,,,,,,,fee schedule,238.24,1058.23,
Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,263.32,,,,,,,fee schedule,238.24,1058.23,APC
Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,250.78,,,,,,,fee schedule,238.24,1058.23,APC
Cell enumeration & id,86152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,451.4,,,,,,,fee schedule,238.24,1058.23,APC
Cell enumeration phys interp,86153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,30.82,,,,,,,fee schedule,30.82,30.82,
Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.86,,,,,,,fee schedule,15.19,68.84,
Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.19,,,,,,,fee schedule,15.19,68.84,
Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49,,,,,,,fee schedule,15.19,68.84,
Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.24,,,,,,,fee schedule,15.19,68.84,
Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.84,,,,,,,fee schedule,15.19,68.84,
Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.79,,,,,,,fee schedule,15.19,68.84,APC
Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.99,,,,,,,fee schedule,15.19,68.84,APC
Chemotaxis assay,86155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.78,,,,,,,fee schedule,15.19,68.84,APC
Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.1,,,,,,,fee schedule,7.67,51.87,
Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.67,,,,,,,fee schedule,7.67,51.87,
Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.91,,,,,,,fee schedule,7.67,51.87,
Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.57,,,,,,,fee schedule,7.67,51.87,
Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.87,,,,,,,fee schedule,7.67,51.87,
Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.47,,,,,,,fee schedule,7.67,51.87,APC
Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.07,,,,,,,fee schedule,7.67,51.87,APC
Cold agglutinin screen,86156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.53,,,,,,,fee schedule,7.67,51.87,APC
Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.17,,,,,,,fee schedule,7.66,30.1,
Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.66,,,,,,,fee schedule,7.66,30.1,
Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.42,,,,,,,fee schedule,7.66,30.1,
Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.16,,,,,,,fee schedule,7.66,30.1,
Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.1,,,,,,,fee schedule,7.66,30.1,
Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.46,,,,,,,fee schedule,7.66,30.1,APC
Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.06,,,,,,,fee schedule,7.66,30.1,APC
Cold agglutinin titer,86157,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.51,,,,,,,fee schedule,7.66,30.1,APC
Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.07,,,,,,,fee schedule,11.4,47.23,
Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.4,,,,,,,fee schedule,11.4,47.23,
Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.62,,,,,,,fee schedule,11.4,47.23,
Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.93,,,,,,,fee schedule,11.4,47.23,
Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.23,,,,,,,fee schedule,11.4,47.23,
Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.6,,,,,,,fee schedule,11.4,47.23,APC
Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12,,,,,,,fee schedule,11.4,47.23,APC
Complement antigen,86160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.6,,,,,,,fee schedule,11.4,47.23,APC
Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.67,,,,,,,fee schedule,11.4,59.42,
Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.4,,,,,,,fee schedule,11.4,59.42,
Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.29,,,,,,,fee schedule,11.4,59.42,
Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.87,,,,,,,fee schedule,11.4,59.42,
Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.42,,,,,,,fee schedule,11.4,59.42,
Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.6,,,,,,,fee schedule,11.4,59.42,APC
Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12,,,,,,,fee schedule,11.4,59.42,APC
Complement/function activity,86161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.6,,,,,,,fee schedule,11.4,59.42,APC
Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.83,,,,,,,fee schedule,8.41,36.58,
Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.3,,,,,,,fee schedule,8.41,36.58,
Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.5,,,,,,,fee schedule,8.41,36.58,
Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.41,,,,,,,fee schedule,8.41,36.58,
Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.75,,,,,,,fee schedule,8.41,36.58,
Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.34,,,,,,,fee schedule,8.41,36.58,APC
Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.32,,,,,,,fee schedule,8.41,36.58,APC
Complement total (ch50),86162,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.58,,,,,,,fee schedule,8.41,36.58,APC
Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.49,,,,,,,fee schedule,9.51,43.11,
Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.51,,,,,,,fee schedule,9.51,43.11,
Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.69,,,,,,,fee schedule,9.51,43.11,
Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.58,,,,,,,fee schedule,9.51,43.11,
Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.11,,,,,,,fee schedule,9.51,43.11,
Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.51,,,,,,,fee schedule,9.51,43.11,APC
Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.01,,,,,,,fee schedule,9.51,43.11,APC
Complement fixation each,86171,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.02,,,,,,,fee schedule,9.51,43.11,APC
Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.56,,,,,,,fee schedule,12.3,42.04,
Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.3,,,,,,,fee schedule,12.3,42.04,
Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.92,,,,,,,fee schedule,12.3,42.04,
Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.97,,,,,,,fee schedule,12.3,42.04,
Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.04,,,,,,,fee schedule,12.3,42.04,
Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.6,,,,,,,fee schedule,12.3,42.04,APC
Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.95,,,,,,,fee schedule,12.3,42.04,APC
Ccp antibody,86200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.31,,,,,,,fee schedule,12.3,42.04,APC
Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.66,,,,,,,fee schedule,9.61,23.85,
Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.59,,,,,,,fee schedule,9.61,23.85,
Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12,,,,,,,fee schedule,9.61,23.85,
Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.61,,,,,,,fee schedule,9.61,23.85,
Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.86,,,,,,,fee schedule,9.61,23.85,
Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,9.61,23.85,APC
Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.25,,,,,,,fee schedule,9.61,23.85,APC
Deoxyribonuclease antibody,86215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.85,,,,,,,fee schedule,9.61,23.85,APC
Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.6,,,,,,,fee schedule,13.05,71.99,
Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.05,,,,,,,fee schedule,13.05,71.99,
Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.24,,,,,,,fee schedule,13.05,71.99,
Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.04,,,,,,,fee schedule,13.05,71.99,
Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.99,,,,,,,fee schedule,13.05,71.99,
Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.43,,,,,,,fee schedule,13.05,71.99,APC
Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.74,,,,,,,fee schedule,13.05,71.99,APC
Dna antibody native,86225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.73,,,,,,,fee schedule,13.05,71.99,APC
Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.67,,,,,,,fee schedule,11.5,50.22,
Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.5,,,,,,,fee schedule,11.5,50.22,
Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.74,,,,,,,fee schedule,11.5,50.22,
Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.63,,,,,,,fee schedule,11.5,50.22,
Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.22,,,,,,,fee schedule,11.5,50.22,
Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.72,,,,,,,fee schedule,11.5,50.22,APC
Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.11,,,,,,,fee schedule,11.5,50.22,APC
Dna antibody single strand,86226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.8,,,,,,,fee schedule,11.5,50.22,APC
Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.5,,,,,,,fee schedule,11.49,27.03,
Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.49,,,,,,,fee schedule,11.49,27.03,
Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.23,,,,,,,fee schedule,11.49,27.03,
Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.41,,,,,,,fee schedule,11.49,27.03,
Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.03,,,,,,,fee schedule,11.49,27.03,
Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.69,,,,,,,fee schedule,11.49,27.03,APC
Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.09,,,,,,,fee schedule,11.49,27.03,APC
Ema each ig class,86231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.76,,,,,,,fee schedule,11.49,27.03,APC
Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.12,,,,,,,fee schedule,16.47,32.27,
Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.03,,,,,,,fee schedule,16.47,32.27,
Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.56,,,,,,,fee schedule,16.47,32.27,
Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.47,,,,,,,fee schedule,16.47,32.27,
Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.89,,,,,,,fee schedule,16.47,32.27,
Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.83,,,,,,,fee schedule,16.47,32.27,APC
Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.93,,,,,,,fee schedule,16.47,32.27,APC
Nuclear antigen antibody,86235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.27,,,,,,,fee schedule,16.47,32.27,APC
Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.33,,,,,,,fee schedule,11.45,45.23,
Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,45.23,
Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.19,,,,,,,fee schedule,11.45,45.23,
Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.78,,,,,,,fee schedule,11.45,45.23,
Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.23,,,,,,,fee schedule,11.45,45.23,
Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,45.23,APC
Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,45.23,APC
Fluorescent antibody screen,86255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,45.23,APC
Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.73,,,,,,,fee schedule,11.45,60.64,
Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,60.64,
Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.16,,,,,,,fee schedule,11.45,60.64,
Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.57,,,,,,,fee schedule,11.45,60.64,
Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.64,,,,,,,fee schedule,11.45,60.64,
Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,60.64,APC
Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,60.64,APC
Fluorescent antibody titer,86256,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,60.64,APC
Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.41,,,,,,,fee schedule,11.45,25.77,
Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,25.77,
Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.34,,,,,,,fee schedule,11.45,25.77,
Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.69,,,,,,,fee schedule,11.45,25.77,
Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.77,,,,,,,fee schedule,11.45,25.77,
Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,25.77,APC
Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,25.77,APC
Dgp antibody each ig class,86258,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,25.77,APC
Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.95,,,,,,,fee schedule,14.95,67.79,
Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.95,,,,,,,fee schedule,14.95,67.79,
Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.25,,,,,,,fee schedule,14.95,67.79,
Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.65,,,,,,,fee schedule,14.95,67.79,
Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.79,,,,,,,fee schedule,14.95,67.79,
Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.53,,,,,,,fee schedule,14.95,67.79,APC
Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.74,,,,,,,fee schedule,14.95,67.79,APC
Growth hormone antibody,86277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.33,,,,,,,fee schedule,14.95,67.79,APC
Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.68,,,,,,,fee schedule,7.78,35.28,
Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.78,,,,,,,fee schedule,7.78,35.28,
Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.11,,,,,,,fee schedule,7.78,35.28,
Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.11,,,,,,,fee schedule,7.78,35.28,
Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.28,,,,,,,fee schedule,7.78,35.28,
Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.6,,,,,,,fee schedule,7.78,35.28,APC
Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.19,,,,,,,fee schedule,7.78,35.28,APC
Hemagglutination inhibition,86280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.74,,,,,,,fee schedule,7.78,35.28,APC
Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.63,,,,,,,fee schedule,24.29,68.57,
Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.29,,,,,,,fee schedule,24.29,68.57,
Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.81,,,,,,,fee schedule,24.29,68.57,
Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.09,,,,,,,fee schedule,24.29,68.57,
Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.57,,,,,,,fee schedule,24.29,68.57,
Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.85,,,,,,,fee schedule,24.29,68.57,APC
Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.57,,,,,,,fee schedule,24.29,68.57,APC
Immunoassay tumor qual,86294,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.03,,,,,,,fee schedule,24.29,68.57,APC
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.43,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.77,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.38,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.19,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.34,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,19.77,114.34,APC
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.81,,,,,,,fee schedule,19.77,114.34,APC
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.46,,,,,,,fee schedule,19.77,114.34,APC
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.43,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.77,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.38,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.19,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.34,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,19.77,114.34,APC
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.81,,,,,,,fee schedule,19.77,114.34,APC
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.46,,,,,,,fee schedule,19.77,114.34,APC
Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.43,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.77,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.38,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.19,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.34,,,,,,,fee schedule,19.77,114.34,
Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,19.77,114.34,APC
Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.81,,,,,,,fee schedule,19.77,114.34,APC
Immunoassay tumor ca 125,86304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.46,,,,,,,fee schedule,19.77,114.34,APC
Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.95,,,,,,,fee schedule,19.77,89.64,
Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.77,,,,,,,fee schedule,19.77,89.64,
Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.8,,,,,,,fee schedule,19.77,89.64,
Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.1,,,,,,,fee schedule,19.77,89.64,
Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.64,,,,,,,fee schedule,19.77,89.64,
Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,19.77,89.64,APC
Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.81,,,,,,,fee schedule,19.77,89.64,APC
Human epididymis protein 4,86305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.46,,,,,,,fee schedule,19.77,89.64,APC
Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.29,,,,,,,fee schedule,4.92,29.08,
Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.92,,,,,,,fee schedule,4.92,29.08,
Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.7,,,,,,,fee schedule,4.92,29.08,
Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.58,,,,,,,fee schedule,4.92,29.08,
Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.08,,,,,,,fee schedule,4.92,29.08,
Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.92,29.08,APC
Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.18,,,,,,,fee schedule,4.92,29.08,APC
Heterophile antibody screen,86308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.32,,,,,,,fee schedule,4.92,29.08,APC
Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.21,,,,,,,fee schedule,6.15,27.84,
Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.15,,,,,,,fee schedule,6.15,27.84,
Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.82,,,,,,,fee schedule,6.15,27.84,
Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.87,,,,,,,fee schedule,6.15,27.84,
Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.84,,,,,,,fee schedule,6.15,27.84,
Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.15,27.84,APC
Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,6.15,27.84,APC
Heterophile antibody titer,86309,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,6.15,27.84,APC
Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.6,,,,,,,fee schedule,7,31.74,
Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7,,,,,,,fee schedule,7,31.74,
Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.59,,,,,,,fee schedule,7,31.74,
Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.09,,,,,,,fee schedule,7,31.74,
Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.74,,,,,,,fee schedule,7,31.74,
Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.74,,,,,,,fee schedule,7,31.74,APC
Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.37,,,,,,,fee schedule,7,31.74,APC
Heterophile antibody absrbj,86310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.27,,,,,,,fee schedule,7,31.74,APC
Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.75,,,,,,,fee schedule,19.77,37.66,
Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.77,,,,,,,fee schedule,19.77,37.66,
Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.81,,,,,,,fee schedule,19.77,37.66,
Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.47,,,,,,,fee schedule,19.77,37.66,
Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.66,,,,,,,fee schedule,19.77,37.66,
Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,19.77,37.66,APC
Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.81,,,,,,,fee schedule,19.77,37.66,APC
Immunoassay tumor other,86316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.46,,,,,,,fee schedule,19.77,37.66,APC
Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.73,,,,,,,fee schedule,3.76,26.98,
Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.24,,,,,,,fee schedule,3.76,26.98,
Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.69,,,,,,,fee schedule,3.76,26.98,
Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.76,,,,,,,fee schedule,3.76,26.98,
Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.59,,,,,,,fee schedule,3.76,26.98,
Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.74,,,,,,,fee schedule,3.76,26.98,APC
Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.99,,,,,,,fee schedule,3.76,26.98,APC
Immunoassay infectious agent,86317,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.98,,,,,,,fee schedule,3.76,26.98,APC
Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.46,,,,,,,fee schedule,17.19,55.73,
Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.19,,,,,,,fee schedule,17.19,55.73,
Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.66,,,,,,,fee schedule,17.19,55.73,
Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.77,,,,,,,fee schedule,17.19,55.73,
Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.73,,,,,,,fee schedule,17.19,55.73,
Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.99,,,,,,,fee schedule,17.19,55.73,APC
Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.09,,,,,,,fee schedule,17.19,55.73,APC
Immunoassay infectious agent,86318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.56,,,,,,,fee schedule,17.19,55.73,APC
Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.95,,,,,,,fee schedule,28.42,96.54,
Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.42,,,,,,,fee schedule,28.42,96.54,
Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.71,,,,,,,fee schedule,28.42,96.54,
Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.04,,,,,,,fee schedule,28.42,96.54,
Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.54,,,,,,,fee schedule,28.42,96.54,
Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.42,,,,,,,fee schedule,28.42,96.54,APC
Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.92,,,,,,,fee schedule,28.42,96.54,APC
Serum immunoelectrophoresis,86320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.86,,,,,,,fee schedule,28.42,96.54,APC
Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.77,,,,,,,fee schedule,21.97,96.34,
Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.97,,,,,,,fee schedule,21.97,96.34,
Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.57,,,,,,,fee schedule,21.97,96.34,
Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.92,,,,,,,fee schedule,21.97,96.34,
Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.34,,,,,,,fee schedule,21.97,96.34,
Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.29,,,,,,,fee schedule,21.97,96.34,APC
Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.13,,,,,,,fee schedule,21.97,96.34,APC
Other immunoelectrophoresis,86325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.63,,,,,,,fee schedule,21.97,96.34,APC
Immunoelectrophoresis assay,86327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.42,,,,,,,fee schedule,28.42,28.42,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.58,,,,,,,fee schedule,38.41,81.5,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.23,,,,,,,fee schedule,38.41,81.5,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.95,,,,,,,fee schedule,38.41,81.5,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.41,,,,,,,fee schedule,38.41,81.5,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.37,,,,,,,fee schedule,38.41,81.5,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,47.54,,,,,,,fee schedule,38.41,81.5,APC
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,45.28,,,,,,,fee schedule,38.41,81.5,APC
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,81.5,,,,,,,fee schedule,38.41,81.5,APC
Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.6,,,,,,,fee schedule,13.35,50.14,
Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.35,,,,,,,fee schedule,13.35,50.14,
Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.69,,,,,,,fee schedule,13.35,50.14,
Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.58,,,,,,,fee schedule,13.35,50.14,
Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.14,,,,,,,fee schedule,13.35,50.14,
Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.75,,,,,,,fee schedule,13.35,50.14,APC
Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.05,,,,,,,fee schedule,13.35,50.14,APC
Immunodiffusion nes,86329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.29,,,,,,,fee schedule,13.35,50.14,APC
Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.02,,,,,,,fee schedule,11.38,80.52,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,80.52,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.31,,,,,,,fee schedule,11.38,80.52,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.91,,,,,,,fee schedule,11.38,80.52,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.52,,,,,,,fee schedule,11.38,80.52,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,80.52,APC
Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,80.52,APC
Immunodiffusion ouchterlony,86331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,80.52,APC
Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.97,,,,,,,fee schedule,23.15,141.42,
Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.15,,,,,,,fee schedule,23.15,141.42,
Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.65,,,,,,,fee schedule,23.15,141.42,
Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.62,,,,,,,fee schedule,23.15,141.42,
Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.42,,,,,,,fee schedule,23.15,141.42,
Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.59,,,,,,,fee schedule,23.15,141.42,APC
Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.37,,,,,,,fee schedule,23.15,141.42,APC
Immune complex assay,86332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.87,,,,,,,fee schedule,23.15,141.42,APC
Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.09,,,,,,,fee schedule,21.22,95.55,
Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.22,,,,,,,fee schedule,21.22,95.55,
Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.01,,,,,,,fee schedule,21.22,95.55,
Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.47,,,,,,,fee schedule,21.22,95.55,
Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.55,,,,,,,fee schedule,21.22,95.55,
Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.46,,,,,,,fee schedule,21.22,95.55,APC
Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.34,,,,,,,fee schedule,21.22,95.55,APC
Immunofix e-phoresis serum,86334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40.21,,,,,,,fee schedule,21.22,95.55,APC
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.2,,,,,,,fee schedule,27.88,127.88,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.88,,,,,,,fee schedule,27.88,127.88,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.02,,,,,,,fee schedule,27.88,127.88,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.9,,,,,,,fee schedule,27.88,127.88,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.88,,,,,,,fee schedule,27.88,127.88,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.82,,,,,,,fee schedule,27.88,127.88,APC
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.35,,,,,,,fee schedule,27.88,127.88,APC
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.83,,,,,,,fee schedule,27.88,127.88,APC
Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.37,,,,,,,fee schedule,14.81,67.13,
Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.81,,,,,,,fee schedule,14.81,67.13,
Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.78,,,,,,,fee schedule,14.81,67.13,
Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.27,,,,,,,fee schedule,14.81,67.13,
Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.13,,,,,,,fee schedule,14.81,67.13,
Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.37,,,,,,,fee schedule,14.81,67.13,APC
Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.59,,,,,,,fee schedule,14.81,67.13,APC
Inhibin A,86336,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.06,,,,,,,fee schedule,14.81,67.13,APC
Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.78,,,,,,,fee schedule,20.34,43.45,
Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.34,,,,,,,fee schedule,20.34,43.45,
Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.92,,,,,,,fee schedule,20.34,43.45,
Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.77,,,,,,,fee schedule,20.34,43.45,
Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.45,,,,,,,fee schedule,20.34,43.45,
Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.48,,,,,,,fee schedule,20.34,43.45,APC
Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.41,,,,,,,fee schedule,20.34,43.45,APC
Insulin antibodies,86337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.54,,,,,,,fee schedule,20.34,43.45,APC
Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.54,,,,,,,fee schedule,14.12,27.14,
Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.33,,,,,,,fee schedule,14.12,27.14,
Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.63,,,,,,,fee schedule,14.12,27.14,
Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.12,,,,,,,fee schedule,14.12,27.14,
Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.77,,,,,,,fee schedule,14.12,27.14,
Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.83,,,,,,,fee schedule,14.12,27.14,APC
Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.08,,,,,,,fee schedule,14.12,27.14,APC
Intrinsic factor antibody,86340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.14,,,,,,,fee schedule,14.12,27.14,APC
Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.41,,,,,,,fee schedule,21.9,42.43,
Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.39,,,,,,,fee schedule,21.9,42.43,
Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.35,,,,,,,fee schedule,21.9,42.43,
Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.9,,,,,,,fee schedule,21.9,42.43,
Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.42,,,,,,,fee schedule,21.9,42.43,
Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.75,,,,,,,fee schedule,21.9,42.43,APC
Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.57,,,,,,,fee schedule,21.9,42.43,APC
Islet cell antibody,86341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42.43,,,,,,,fee schedule,21.9,42.43,APC
Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.65,,,,,,,fee schedule,11.84,53.65,
Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.84,,,,,,,fee schedule,11.84,53.65,
Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.18,,,,,,,fee schedule,11.84,53.65,
Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.58,,,,,,,fee schedule,11.84,53.65,
Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.65,,,,,,,fee schedule,11.84,53.65,
Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.08,,,,,,,fee schedule,11.84,53.65,APC
Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.46,,,,,,,fee schedule,11.84,53.65,APC
Leukocyte histamine release,86343,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.43,,,,,,,fee schedule,11.84,53.65,APC
Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.89,,,,,,,fee schedule,9.87,34.37,
Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.87,,,,,,,fee schedule,9.87,34.37,
Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.46,,,,,,,fee schedule,9.87,34.37,
Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.6,,,,,,,fee schedule,9.87,34.37,
Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.37,,,,,,,fee schedule,9.87,34.37,
Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.91,,,,,,,fee schedule,9.87,34.37,APC
Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.39,,,,,,,fee schedule,9.87,34.37,APC
Leukocyte phagocytosis,86344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.7,,,,,,,fee schedule,9.87,34.37,APC
Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,508.83,,,,,,,fee schedule,129.07,585.15,
Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,129.07,,,,,,,fee schedule,129.07,585.15,
Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.48,,,,,,,fee schedule,129.07,585.15,
Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,333.59,,,,,,,fee schedule,129.07,585.15,
Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,585.15,,,,,,,fee schedule,129.07,585.15,
Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,142.65,,,,,,,fee schedule,129.07,585.15,APC
Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,135.86,,,,,,,fee schedule,129.07,585.15,APC
Cell function assay w/stim,86352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,244.55,,,,,,,fee schedule,129.07,585.15,APC
Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.34,,,,,,,fee schedule,46.58,253.39,
Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,46.58,,,,,,,fee schedule,46.58,253.39,
Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.35,,,,,,,fee schedule,46.58,253.39,
Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,144.45,,,,,,,fee schedule,46.58,253.39,
Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,253.39,,,,,,,fee schedule,46.58,253.39,
Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.48,,,,,,,fee schedule,46.58,253.39,APC
Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.03,,,,,,,fee schedule,46.58,253.39,APC
Lymphocyte transformation,86353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88.25,,,,,,,fee schedule,46.58,253.39,APC
B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.06,,,,,,,fee schedule,35.84,134.62,
B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,35.84,,,,,,,fee schedule,35.84,134.62,
B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95.81,,,,,,,fee schedule,35.84,134.62,
B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.74,,,,,,,fee schedule,35.84,134.62,
B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,134.62,,,,,,,fee schedule,35.84,134.62,
B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,35.84,134.62,APC
B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.73,,,,,,,fee schedule,35.84,134.62,APC
B cells total count,86355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.91,,,,,,,fee schedule,35.84,134.62,APC
Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.1,,,,,,,fee schedule,25.44,123.17,
Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.44,,,,,,,fee schedule,25.44,123.17,
Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.66,,,,,,,fee schedule,25.44,123.17,
Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.21,,,,,,,fee schedule,25.44,123.17,
Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.17,,,,,,,fee schedule,25.44,123.17,
Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.12,,,,,,,fee schedule,25.44,123.17,APC
Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.78,,,,,,,fee schedule,25.44,123.17,APC
Mononuclear cell antigen,86356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.2,,,,,,,fee schedule,25.44,123.17,APC
Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.87,,,,,,,fee schedule,35.84,109.1,
Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,35.84,,,,,,,fee schedule,35.84,109.1,
Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.65,,,,,,,fee schedule,35.84,109.1,
Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.2,,,,,,,fee schedule,35.84,109.1,
Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.1,,,,,,,fee schedule,35.84,109.1,
Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,35.84,109.1,APC
Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.73,,,,,,,fee schedule,35.84,109.1,APC
Nk cells total count,86357,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.91,,,,,,,fee schedule,35.84,109.1,APC
T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.04,,,,,,,fee schedule,35.84,156.45,
T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,35.84,,,,,,,fee schedule,35.84,156.45,
T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,111.35,,,,,,,fee schedule,35.84,156.45,
T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.19,,,,,,,fee schedule,35.84,156.45,
T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,156.45,,,,,,,fee schedule,35.84,156.45,
T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,35.84,156.45,APC
T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.73,,,,,,,fee schedule,35.84,156.45,APC
T cells total count,86359,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.91,,,,,,,fee schedule,35.84,156.45,APC
T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.34,,,,,,,fee schedule,44.63,167.14,
T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,44.63,,,,,,,fee schedule,44.63,167.14,
T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.96,,,,,,,fee schedule,44.63,167.14,
T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.28,,,,,,,fee schedule,44.63,167.14,
T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.14,,,,,,,fee schedule,44.63,167.14,
T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.33,,,,,,,fee schedule,44.63,167.14,APC
T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.98,,,,,,,fee schedule,44.63,167.14,APC
T cell absolute count/ratio,86360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84.56,,,,,,,fee schedule,44.63,167.14,APC
T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.82,,,,,,,fee schedule,25.44,89.49,
T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.44,,,,,,,fee schedule,25.44,89.49,
T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.7,,,,,,,fee schedule,25.44,89.49,
T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.02,,,,,,,fee schedule,25.44,89.49,
T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.49,,,,,,,fee schedule,25.44,89.49,
T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.12,,,,,,,fee schedule,25.44,89.49,APC
T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.78,,,,,,,fee schedule,25.44,89.49,APC
T cell absolute count,86361,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.2,,,,,,,fee schedule,25.44,89.49,APC
Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.42,,,,,,,fee schedule,11.45,26.93,
Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,26.93,
Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.17,,,,,,,fee schedule,11.45,26.93,
Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.35,,,,,,,fee schedule,11.45,26.93,
Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.93,,,,,,,fee schedule,11.45,26.93,
Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,26.93,APC
Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,26.93,APC
Mog-igg1 antb cba each,86362,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,26.93,APC
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.42,,,,,,,fee schedule,15.35,67.91,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,35.84,,,,,,,fee schedule,15.35,67.91,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.17,,,,,,,fee schedule,15.35,67.91,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.35,,,,,,,fee schedule,15.35,67.91,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.93,,,,,,,fee schedule,15.35,67.91,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,15.35,67.91,APC
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.73,,,,,,,fee schedule,15.35,67.91,APC
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.91,,,,,,,fee schedule,15.35,67.91,APC
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.41,,,,,,,fee schedule,10.95,25.77,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.95,,,,,,,fee schedule,10.95,25.77,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.34,,,,,,,fee schedule,10.95,25.77,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.69,,,,,,,fee schedule,10.95,25.77,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.77,,,,,,,fee schedule,10.95,25.77,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.95,25.77,APC
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.53,,,,,,,fee schedule,10.95,25.77,APC
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.75,,,,,,,fee schedule,10.95,25.77,APC
Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.21,,,,,,,fee schedule,18.4,38.19,
Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.18,,,,,,,fee schedule,18.4,38.19,
Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.77,,,,,,,fee schedule,18.4,38.19,
Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.19,,,,,,,fee schedule,18.4,38.19,
Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,18.4,38.19,APC
Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.4,,,,,,,fee schedule,18.4,38.19,APC
Muscle-specific kinase antb,86366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.12,,,,,,,fee schedule,18.4,38.19,APC
Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.98,,,,,,,fee schedule,73.89,229.98,
Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,73.89,,,,,,,fee schedule,73.89,229.98,
Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.68,,,,,,,fee schedule,73.89,229.98,
Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.11,,,,,,,fee schedule,73.89,229.98,
Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.98,,,,,,,fee schedule,73.89,229.98,
Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.67,,,,,,,fee schedule,73.89,229.98,APC
Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,77.78,,,,,,,fee schedule,73.89,229.98,APC
Stem cells total count,86367,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,140,,,,,,,fee schedule,73.89,229.98,APC
Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.17,,,,,,,fee schedule,13.82,32.4,
Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.82,,,,,,,fee schedule,13.82,32.4,
Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.06,,,,,,,fee schedule,13.82,32.4,
Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.47,,,,,,,fee schedule,13.82,32.4,
Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.4,,,,,,,fee schedule,13.82,32.4,
Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.28,,,,,,,fee schedule,13.82,32.4,APC
Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.55,,,,,,,fee schedule,13.82,32.4,APC
Microsomal antibody each,86376,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.19,,,,,,,fee schedule,13.82,32.4,APC
Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.45,,,,,,,fee schedule,24.18,56.87,
Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.18,,,,,,,fee schedule,24.18,56.87,
Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.47,,,,,,,fee schedule,24.18,56.87,
Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.42,,,,,,,fee schedule,24.18,56.87,
Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.87,,,,,,,fee schedule,24.18,56.87,
Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.72,,,,,,,fee schedule,24.18,56.87,APC
Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.45,,,,,,,fee schedule,24.18,56.87,APC
Mitochondrial antibody each,86381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.81,,,,,,,fee schedule,24.18,56.87,APC
Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.06,,,,,,,fee schedule,16.06,103.57,
Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.06,,,,,,,fee schedule,16.06,103.57,
Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.71,,,,,,,fee schedule,16.06,103.57,
Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.04,,,,,,,fee schedule,16.06,103.57,
Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.57,,,,,,,fee schedule,16.06,103.57,
Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.76,,,,,,,fee schedule,16.06,103.57,APC
Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.91,,,,,,,fee schedule,16.06,103.57,APC
Neutralization test viral,86382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.44,,,,,,,fee schedule,16.06,103.57,APC
Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.37,,,,,,,fee schedule,12.93,253.43,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.93,,,,,,,fee schedule,12.93,253.43,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.37,,,,,,,fee schedule,12.93,253.43,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,144.47,,,,,,,fee schedule,12.93,253.43,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,253.43,,,,,,,fee schedule,12.93,253.43,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.29,,,,,,,fee schedule,12.93,253.43,APC
Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.61,,,,,,,fee schedule,12.93,253.43,APC
Nitroblue tetrazolium dye,86384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.5,,,,,,,fee schedule,12.93,253.43,APC
Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.5,,,,,,,fee schedule,20.69,40.83,
Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.69,,,,,,,fee schedule,20.69,40.83,
Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.06,,,,,,,fee schedule,20.69,40.83,
Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.27,,,,,,,fee schedule,20.69,40.83,
Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.83,,,,,,,fee schedule,20.69,40.83,
Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.87,,,,,,,fee schedule,20.69,40.83,APC
Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.78,,,,,,,fee schedule,20.69,40.83,APC
Nuclear matrix protein 22,86386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.2,,,,,,,fee schedule,20.69,40.83,APC
Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.11,,,,,,,fee schedule,10.96,48.43,
Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.96,,,,,,,fee schedule,10.96,48.43,
Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.47,,,,,,,fee schedule,10.96,48.43,
Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.61,,,,,,,fee schedule,10.96,48.43,
Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.43,,,,,,,fee schedule,10.96,48.43,
Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.12,,,,,,,fee schedule,10.96,48.43,APC
Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.54,,,,,,,fee schedule,10.96,48.43,APC
Particle agglut antbdy scrn,86403,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.77,,,,,,,fee schedule,10.96,48.43,APC
Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.82,,,,,,,fee schedule,10.11,45.79,
Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.11,,,,,,,fee schedule,10.11,45.79,
Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.59,,,,,,,fee schedule,10.11,45.79,
Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.11,,,,,,,fee schedule,10.11,45.79,
Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.79,,,,,,,fee schedule,10.11,45.79,
Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.17,,,,,,,fee schedule,10.11,45.79,APC
Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.64,,,,,,,fee schedule,10.11,45.79,APC
Particle agglut antbdy titr,86406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.15,,,,,,,fee schedule,10.11,45.79,APC
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.58,,,,,,,fee schedule,35.78,75.83,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,42.13,,,,,,,fee schedule,35.78,75.83,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.67,,,,,,,fee schedule,35.78,75.83,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.78,,,,,,,fee schedule,35.78,75.83,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.77,,,,,,,fee schedule,35.78,75.83,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.24,,,,,,,fee schedule,35.78,75.83,APC
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.13,,,,,,,fee schedule,35.78,75.83,APC
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.83,,,,,,,fee schedule,35.78,75.83,APC
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.1,,,,,,,fee schedule,67.59,143.3,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,105.33,,,,,,,fee schedule,67.59,143.3,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.39,,,,,,,fee schedule,67.59,143.3,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.59,,,,,,,fee schedule,67.59,143.3,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.57,,,,,,,fee schedule,67.59,143.3,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.59,,,,,,,fee schedule,67.59,143.3,APC
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.61,,,,,,,fee schedule,67.59,143.3,APC
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,143.3,,,,,,,fee schedule,67.59,143.3,APC
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.6,,,,,,,fee schedule,42.13,92.57,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,42.13,,,,,,,fee schedule,42.13,92.57,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.51,,,,,,,fee schedule,42.13,92.57,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.66,,,,,,,fee schedule,42.13,92.57,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.59,,,,,,,fee schedule,42.13,92.57,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54,,,,,,,fee schedule,42.13,92.57,APC
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.43,,,,,,,fee schedule,42.13,92.57,APC
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.57,,,,,,,fee schedule,42.13,92.57,APC
Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.22,,,,,,,fee schedule,5.83,24.4,
Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.83,,,,,,,fee schedule,5.83,24.4,
Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.37,,,,,,,fee schedule,5.83,24.4,
Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.91,,,,,,,fee schedule,5.83,24.4,
Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.4,,,,,,,fee schedule,5.83,24.4,
Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.45,,,,,,,fee schedule,5.83,24.4,APC
Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.14,,,,,,,fee schedule,5.83,24.4,APC
Rheumatoid factor test qual,86430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.05,,,,,,,fee schedule,5.83,24.4,APC
Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.29,,,,,,,fee schedule,5.39,29.08,
Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.39,,,,,,,fee schedule,5.39,29.08,
Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.7,,,,,,,fee schedule,5.39,29.08,
Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.58,,,,,,,fee schedule,5.39,29.08,
Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.08,,,,,,,fee schedule,5.39,29.08,
Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.95,,,,,,,fee schedule,5.39,29.08,APC
Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.67,,,,,,,fee schedule,5.39,29.08,APC
Rheumatoid factor quant,86431,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.21,,,,,,,fee schedule,5.39,29.08,APC
Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.4,,,,,,,fee schedule,58.88,131.56,
Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,58.88,,,,,,,fee schedule,58.88,131.56,
Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.64,,,,,,,fee schedule,58.88,131.56,
Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75,,,,,,,fee schedule,58.88,131.56,
Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.56,,,,,,,fee schedule,58.88,131.56,
Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.08,,,,,,,fee schedule,58.88,131.56,APC
Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,61.98,,,,,,,fee schedule,58.88,131.56,APC
Tb test cell immun measure,86480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,111.56,,,,,,,fee schedule,58.88,131.56,APC
Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.43,,,,,,,fee schedule,34.37,180,
Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,95,,,,,,,fee schedule,34.37,180,
Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.91,,,,,,,fee schedule,34.37,180,
Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.37,,,,,,,fee schedule,34.37,180,
Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.29,,,,,,,fee schedule,34.37,180,
Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105,,,,,,,fee schedule,34.37,180,APC
Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,100,,,,,,,fee schedule,34.37,180,APC
Tb ag response t-cell susp,86481,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,180,,,,,,,fee schedule,34.37,180,APC
Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.9,,,,,,,fee schedule,16.72,61.99,
Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.72,,,,,,,fee schedule,16.72,61.99,
Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.12,,,,,,,fee schedule,16.72,61.99,
Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.34,,,,,,,fee schedule,16.72,61.99,
Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.99,,,,,,,fee schedule,16.72,61.99,
Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,16.72,61.99,APC
Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,16.72,61.99,APC
Skin test candida,86485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,16.72,61.99,APC
Skin test nos antigen,86486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.63,,,,,,,fee schedule,5.63,51.88,
Skin test nos antigen,86486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,5.63,51.88,APC
Skin test nos antigen,86486,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,5.63,51.88,APC
Skin test nos antigen,86486,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,5.63,51.88,APC
Coccidioidomycosis skin test,86490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,68.39,,,,,,,fee schedule,68.39,68.39,
Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.66,,,,,,,fee schedule,6.51,66.99,
Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.51,,,,,,,fee schedule,6.51,66.99,
Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.64,,,,,,,fee schedule,6.51,66.99,
Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.92,,,,,,,fee schedule,6.51,66.99,
Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.16,,,,,,,fee schedule,6.51,66.99,
Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,6.51,66.99,APC
Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,6.51,66.99,APC
Histoplasmosis skin test,86510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,6.51,66.99,APC
TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.24,,,,,,,fee schedule,8.85,69.28,
TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.85,,,,,,,fee schedule,8.85,69.28,
TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.31,,,,,,,fee schedule,8.85,69.28,
TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.49,,,,,,,fee schedule,8.85,69.28,
TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.28,,,,,,,fee schedule,8.85,69.28,
TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,8.85,69.28,APC
TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,8.85,69.28,APC
TB intradermal test,86580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,8.85,69.28,APC
Strptcs pneum antb serot ia,86581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.63,,,,,,,fee schedule,92.03,180.12,
Strptcs pneum antb serot ia,86581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.2,,,,,,,fee schedule,92.03,180.12,
Strptcs pneum antb serot ia,86581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.69,,,,,,,fee schedule,92.03,180.12,
Strptcs pneum antb serot ia,86581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.12,,,,,,,fee schedule,92.03,180.12,
Strptcs pneum antb serot ia,86581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.63,,,,,,,fee schedule,92.03,180.12,APC
Strptcs pneum antb serot ia,86581,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,92.03,,,,,,,fee schedule,92.03,180.12,APC
Strptcs pneum antb serot ia,86581,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,165.65,,,,,,,fee schedule,92.03,180.12,APC
Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.28,,,,,,,fee schedule,12.03,25.62,
Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.03,,,,,,,fee schedule,12.03,25.62,
Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.24,,,,,,,fee schedule,12.03,25.62,
Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.61,,,,,,,fee schedule,12.03,25.62,
Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.62,,,,,,,fee schedule,12.03,25.62,
Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.29,,,,,,,fee schedule,12.03,25.62,APC
Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.66,,,,,,,fee schedule,12.03,25.62,APC
Streptokinase antibody,86590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.79,,,,,,,fee schedule,12.03,25.62,APC
Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.77,,,,,,,fee schedule,4.06,8.94,
Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.06,,,,,,,fee schedule,4.06,8.94,
Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.36,,,,,,,fee schedule,4.06,8.94,
Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.09,,,,,,,fee schedule,4.06,8.94,
Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.94,,,,,,,fee schedule,4.06,8.94,
Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.06,8.94,APC
Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.27,,,,,,,fee schedule,4.06,8.94,APC
Syphilis test non-trep qual,86592,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.69,,,,,,,fee schedule,4.06,8.94,APC
Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.49,,,,,,,fee schedule,4.18,23.56,
Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.18,,,,,,,fee schedule,4.18,23.56,
Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.77,,,,,,,fee schedule,4.18,23.56,
Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.43,,,,,,,fee schedule,4.18,23.56,
Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.56,,,,,,,fee schedule,4.18,23.56,
Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.62,,,,,,,fee schedule,4.18,23.56,APC
Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.4,,,,,,,fee schedule,4.18,23.56,APC
Syphilis test non-trep quant,86593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.92,,,,,,,fee schedule,4.18,23.56,APC
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.74,,,,,,,fee schedule,11.45,41.1,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,41.1,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.25,,,,,,,fee schedule,11.45,41.1,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.43,,,,,,,fee schedule,11.45,41.1,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.1,,,,,,,fee schedule,11.45,41.1,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,41.1,APC
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,41.1,APC
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,41.1,APC
Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.11,,,,,,,fee schedule,9.67,43.83,
Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.67,,,,,,,fee schedule,9.67,43.83,
Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.19,,,,,,,fee schedule,9.67,43.83,
Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.98,,,,,,,fee schedule,9.67,43.83,
Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.83,,,,,,,fee schedule,9.67,43.83,
Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.67,43.83,APC
Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.18,,,,,,,fee schedule,9.67,43.83,APC
Antinomyces antibody,86602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.32,,,,,,,fee schedule,9.67,43.83,APC
Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.43,,,,,,,fee schedule,12.23,94.79,
Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.23,,,,,,,fee schedule,12.23,94.79,
Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.47,,,,,,,fee schedule,12.23,94.79,
Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.04,,,,,,,fee schedule,12.23,94.79,
Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.79,,,,,,,fee schedule,12.23,94.79,
Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,12.23,94.79,APC
Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.87,,,,,,,fee schedule,12.23,94.79,APC
Adenovirus antibody,86603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.17,,,,,,,fee schedule,12.23,94.79,APC
Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.64,,,,,,,fee schedule,14.3,61.69,
Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.3,,,,,,,fee schedule,14.3,61.69,
Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.9,,,,,,,fee schedule,14.3,61.69,
Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.17,,,,,,,fee schedule,14.3,61.69,
Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.69,,,,,,,fee schedule,14.3,61.69,
Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,14.3,61.69,APC
Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.05,,,,,,,fee schedule,14.3,61.69,APC
Aspergillus antibody,86606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.09,,,,,,,fee schedule,14.3,61.69,APC
Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.22,,,,,,,fee schedule,12.24,55.45,
Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.24,,,,,,,fee schedule,12.24,55.45,
Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.47,,,,,,,fee schedule,12.24,55.45,
Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.61,,,,,,,fee schedule,12.24,55.45,
Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.45,,,,,,,fee schedule,12.24,55.45,
Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.52,,,,,,,fee schedule,12.24,55.45,APC
Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.88,,,,,,,fee schedule,12.24,55.45,APC
Bacterium antibody,86609,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.18,,,,,,,fee schedule,12.24,55.45,APC
Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.75,,,,,,,fee schedule,9.67,25.01,
Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.67,,,,,,,fee schedule,9.67,25.01,
Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.8,,,,,,,fee schedule,9.67,25.01,
Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.26,,,,,,,fee schedule,9.67,25.01,
Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.01,,,,,,,fee schedule,9.67,25.01,
Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.67,25.01,APC
Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.18,,,,,,,fee schedule,9.67,25.01,APC
Bartonella Antibody,86611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.32,,,,,,,fee schedule,9.67,25.01,APC
Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.39,,,,,,,fee schedule,12.26,49.9,
Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.26,,,,,,,fee schedule,12.26,49.9,
Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.51,,,,,,,fee schedule,12.26,49.9,
Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.45,,,,,,,fee schedule,12.26,49.9,
Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.9,,,,,,,fee schedule,12.26,49.9,
Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.54,,,,,,,fee schedule,12.26,49.9,APC
Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.9,,,,,,,fee schedule,12.26,49.9,APC
Blastomyces antibody,86612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.22,,,,,,,fee schedule,12.26,49.9,APC
Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.71,,,,,,,fee schedule,12.53,104.32,
Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,104.32,
Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.25,,,,,,,fee schedule,12.53,104.32,
Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.47,,,,,,,fee schedule,12.53,104.32,
Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,104.32,,,,,,,fee schedule,12.53,104.32,
Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,104.32,APC
Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,104.32,APC
Bordetella antibody,86615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,104.32,APC
Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.36,,,,,,,fee schedule,9.41,27.88,
Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.72,,,,,,,fee schedule,9.41,27.88,
Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.75,,,,,,,fee schedule,9.41,27.88,
Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.41,,,,,,,fee schedule,9.41,27.88,
Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.51,,,,,,,fee schedule,9.41,27.88,
Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.26,,,,,,,fee schedule,9.41,27.88,APC
Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.49,,,,,,,fee schedule,9.41,27.88,APC
Lyme disease antibody,86617,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.88,,,,,,,fee schedule,9.41,27.88,APC
Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.3,,,,,,,fee schedule,6.1,30.65,
Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.18,,,,,,,fee schedule,6.1,30.65,
Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.61,,,,,,,fee schedule,6.1,30.65,
Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.1,,,,,,,fee schedule,6.1,30.65,
Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.7,,,,,,,fee schedule,6.1,30.65,
Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.88,,,,,,,fee schedule,6.1,30.65,APC
Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.03,,,,,,,fee schedule,6.1,30.65,APC
Lyme disease antibody,86618,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.65,,,,,,,fee schedule,6.1,30.65,APC
Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.77,,,,,,,fee schedule,12.71,57.24,
Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.71,,,,,,,fee schedule,12.71,57.24,
Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.74,,,,,,,fee schedule,12.71,57.24,
Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.63,,,,,,,fee schedule,12.71,57.24,
Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.24,,,,,,,fee schedule,12.71,57.24,
Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.05,,,,,,,fee schedule,12.71,57.24,APC
Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.38,,,,,,,fee schedule,12.71,57.24,APC
Borrelia antibody,86619,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.08,,,,,,,fee schedule,12.71,57.24,APC
Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.44,,,,,,,fee schedule,8.48,38.46,
Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.48,,,,,,,fee schedule,8.48,38.46,
Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.37,,,,,,,fee schedule,8.48,38.46,
Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.92,,,,,,,fee schedule,8.48,38.46,
Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.46,,,,,,,fee schedule,8.48,38.46,
Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.38,,,,,,,fee schedule,8.48,38.46,APC
Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.93,,,,,,,fee schedule,8.48,38.46,APC
Brucella antibody,86622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.07,,,,,,,fee schedule,8.48,38.46,APC
Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.14,,,,,,,fee schedule,12.46,56.51,
Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.46,,,,,,,fee schedule,12.46,56.51,
Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.22,,,,,,,fee schedule,12.46,56.51,
Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.22,,,,,,,fee schedule,12.46,56.51,
Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.51,,,,,,,fee schedule,12.46,56.51,
Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,12.46,56.51,APC
Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.12,,,,,,,fee schedule,12.46,56.51,APC
Campylobacter antibody,86625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.62,,,,,,,fee schedule,12.46,56.51,APC
Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.97,,,,,,,fee schedule,11.41,51.72,
Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.41,,,,,,,fee schedule,11.41,51.72,
Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.81,,,,,,,fee schedule,11.41,51.72,
Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.48,,,,,,,fee schedule,11.41,51.72,
Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.72,,,,,,,fee schedule,11.41,51.72,
Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.61,,,,,,,fee schedule,11.41,51.72,APC
Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.01,,,,,,,fee schedule,11.41,51.72,APC
Candida antibody,86628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.62,,,,,,,fee schedule,11.41,51.72,APC
Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.64,,,,,,,fee schedule,8.29,21.28,
Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.23,,,,,,,fee schedule,8.29,21.28,
Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.35,,,,,,,fee schedule,8.29,21.28,
Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.29,,,,,,,fee schedule,8.29,21.28,
Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.54,,,,,,,fee schedule,8.29,21.28,
Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.41,,,,,,,fee schedule,8.29,21.28,APC
Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.82,,,,,,,fee schedule,8.29,21.28,APC
Chlamydia antibody,86631,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.28,,,,,,,fee schedule,8.29,21.28,APC
Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.54,,,,,,,fee schedule,8.88,22.82,
Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.05,,,,,,,fee schedule,8.88,22.82,
Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.08,,,,,,,fee schedule,8.88,22.82,
Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.88,,,,,,,fee schedule,8.88,22.82,
Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.57,,,,,,,fee schedule,8.88,22.82,
Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.31,,,,,,,fee schedule,8.88,22.82,APC
Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.68,,,,,,,fee schedule,8.88,22.82,APC
Chlamydia igm antibody,86632,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.82,,,,,,,fee schedule,8.88,22.82,APC
Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.51,,,,,,,fee schedule,10.9,27.04,
Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.9,,,,,,,fee schedule,10.9,27.04,
Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.24,,,,,,,fee schedule,10.9,27.04,
Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.41,,,,,,,fee schedule,10.9,27.04,
Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.04,,,,,,,fee schedule,10.9,27.04,
Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.04,,,,,,,fee schedule,10.9,27.04,APC
Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.47,,,,,,,fee schedule,10.9,27.04,APC
Coccidioides antibody,86635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.65,,,,,,,fee schedule,10.9,27.04,APC
Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.87,,,,,,,fee schedule,11.51,34.35,
Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.51,,,,,,,fee schedule,11.51,34.35,
Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.45,,,,,,,fee schedule,11.51,34.35,
Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.58,,,,,,,fee schedule,11.51,34.35,
Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.35,,,,,,,fee schedule,11.51,34.35,
Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.73,,,,,,,fee schedule,11.51,34.35,APC
Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.12,,,,,,,fee schedule,11.51,34.35,APC
Q fever antibody,86638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.82,,,,,,,fee schedule,11.51,34.35,APC
Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.77,,,,,,,fee schedule,13.69,57.24,
Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.69,,,,,,,fee schedule,13.69,57.24,
Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.74,,,,,,,fee schedule,13.69,57.24,
Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.63,,,,,,,fee schedule,13.69,57.24,
Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.24,,,,,,,fee schedule,13.69,57.24,
Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.13,,,,,,,fee schedule,13.69,57.24,APC
Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.41,,,,,,,fee schedule,13.69,57.24,APC
Cryptococcus antibody,86641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.94,,,,,,,fee schedule,13.69,57.24,APC
CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.77,,,,,,,fee schedule,6.41,25.9,
CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.67,,,,,,,fee schedule,6.41,25.9,
CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8,,,,,,,fee schedule,6.41,25.9,
CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.41,,,,,,,fee schedule,6.41,25.9,
CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.24,,,,,,,fee schedule,6.41,25.9,
CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,6.41,25.9,APC
CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.39,,,,,,,fee schedule,6.41,25.9,APC
CMV antibody,86644,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.9,,,,,,,fee schedule,6.41,25.9,APC
Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.85,,,,,,,fee schedule,16.01,87.23,
Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.01,,,,,,,fee schedule,16.01,87.23,
Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.08,,,,,,,fee schedule,16.01,87.23,
Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.73,,,,,,,fee schedule,16.01,87.23,
Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.23,,,,,,,fee schedule,16.01,87.23,
Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.69,,,,,,,fee schedule,16.01,87.23,APC
Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.85,,,,,,,fee schedule,16.01,87.23,APC
Cmv antibody igm,86645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.33,,,,,,,fee schedule,16.01,87.23,APC
Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.9,,,,,,,fee schedule,14.36,27.38,
Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.45,,,,,,,fee schedule,14.36,27.38,
Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.93,,,,,,,fee schedule,14.36,27.38,
Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.36,,,,,,,fee schedule,14.36,27.38,
Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.19,,,,,,,fee schedule,14.36,27.38,
Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.97,,,,,,,fee schedule,14.36,27.38,APC
Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.21,,,,,,,fee schedule,14.36,27.38,APC
Diphtheria antibody,86648,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.38,,,,,,,fee schedule,14.36,27.38,APC
Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Encephalitis californ antbdy,86651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis east eqne anbdy,86652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis st louis antbody,86653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Encephaltis west eqne antbdy,86654,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.03,,,,,,,fee schedule,5.92,23.45,
Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.38,,,,,,,fee schedule,5.92,23.45,
Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.39,,,,,,,fee schedule,5.92,23.45,
Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.92,,,,,,,fee schedule,5.92,23.45,
Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.38,,,,,,,fee schedule,5.92,23.45,
Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.68,,,,,,,fee schedule,5.92,23.45,APC
Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.03,,,,,,,fee schedule,5.92,23.45,APC
Enterovirus antibody,86658,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.45,,,,,,,fee schedule,5.92,23.45,APC
Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.08,,,,,,,fee schedule,12.46,67.94,
Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.46,,,,,,,fee schedule,12.46,67.94,
Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.36,,,,,,,fee schedule,12.46,67.94,
Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.73,,,,,,,fee schedule,12.46,67.94,
Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.94,,,,,,,fee schedule,12.46,67.94,
Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,12.46,67.94,APC
Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.12,,,,,,,fee schedule,12.46,67.94,APC
Epstein-barr antibody,86663,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.62,,,,,,,fee schedule,12.46,67.94,APC
Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.91,,,,,,,fee schedule,14.53,80.4,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.53,,,,,,,fee schedule,14.53,80.4,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.22,,,,,,,fee schedule,14.53,80.4,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.83,,,,,,,fee schedule,14.53,80.4,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.4,,,,,,,fee schedule,14.53,80.4,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.05,,,,,,,fee schedule,14.53,80.4,APC
Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.29,,,,,,,fee schedule,14.53,80.4,APC
Epstein-barr nuclear antigen,86664,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.52,,,,,,,fee schedule,14.53,80.4,APC
Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.91,,,,,,,fee schedule,17.23,94.2,
Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.23,,,,,,,fee schedule,17.23,94.2,
Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.04,,,,,,,fee schedule,17.23,94.2,
Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.7,,,,,,,fee schedule,17.23,94.2,
Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.2,,,,,,,fee schedule,17.23,94.2,
Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.05,,,,,,,fee schedule,17.23,94.2,APC
Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.14,,,,,,,fee schedule,17.23,94.2,APC
Epstein-barr capsid vca,86665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.65,,,,,,,fee schedule,17.23,94.2,APC
Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.33,,,,,,,fee schedule,9.67,78.58,
Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.67,,,,,,,fee schedule,9.67,78.58,
Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.93,,,,,,,fee schedule,9.67,78.58,
Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.8,,,,,,,fee schedule,9.67,78.58,
Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.58,,,,,,,fee schedule,9.67,78.58,
Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.67,78.58,APC
Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.18,,,,,,,fee schedule,9.67,78.58,APC
Ehrlichia Antibody,86666,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.32,,,,,,,fee schedule,9.67,78.58,APC
Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.96,,,,,,,fee schedule,13.45,44.8,
Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.45,,,,,,,fee schedule,13.45,44.8,
Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.89,,,,,,,fee schedule,13.45,44.8,
Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.54,,,,,,,fee schedule,13.45,44.8,
Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.8,,,,,,,fee schedule,13.45,44.8,
Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.87,,,,,,,fee schedule,13.45,44.8,APC
Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.16,,,,,,,fee schedule,13.45,44.8,APC
Francisella tularensis,86668,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.49,,,,,,,fee schedule,13.45,44.8,APC
Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.88,,,,,,,fee schedule,11.64,22.05,
Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.64,,,,,,,fee schedule,11.64,22.05,
Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.63,,,,,,,fee schedule,11.64,22.05,
Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.72,,,,,,,fee schedule,11.64,22.05,
Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.56,,,,,,,fee schedule,11.64,22.05,
Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.86,,,,,,,fee schedule,11.64,22.05,APC
Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.25,,,,,,,fee schedule,11.64,22.05,APC
Fungus nes antibody,86671,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.05,,,,,,,fee schedule,11.64,22.05,APC
Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.77,,,,,,,fee schedule,13.98,57.24,
Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.98,,,,,,,fee schedule,13.98,57.24,
Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.74,,,,,,,fee schedule,13.98,57.24,
Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.63,,,,,,,fee schedule,13.98,57.24,
Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.24,,,,,,,fee schedule,13.98,57.24,
Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.46,,,,,,,fee schedule,13.98,57.24,APC
Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.72,,,,,,,fee schedule,13.98,57.24,APC
Giardia lamblia antibody,86674,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.5,,,,,,,fee schedule,13.98,57.24,APC
Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.26,,,,,,,fee schedule,16.01,76.2,
Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.01,,,,,,,fee schedule,16.01,76.2,
Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.23,,,,,,,fee schedule,16.01,76.2,
Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.44,,,,,,,fee schedule,16.01,76.2,
Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.2,,,,,,,fee schedule,16.01,76.2,
Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.69,,,,,,,fee schedule,16.01,76.2,APC
Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.85,,,,,,,fee schedule,16.01,76.2,APC
Helicobacter pylori antibody,86677,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.33,,,,,,,fee schedule,16.01,76.2,APC
Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.72,,,,,,,fee schedule,12.36,56.03,
Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.36,,,,,,,fee schedule,12.36,56.03,
Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.88,,,,,,,fee schedule,12.36,56.03,
Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.94,,,,,,,fee schedule,12.36,56.03,
Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.03,,,,,,,fee schedule,12.36,56.03,
Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.66,,,,,,,fee schedule,12.36,56.03,APC
Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.01,,,,,,,fee schedule,12.36,56.03,APC
Helminth antibody,86682,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.42,,,,,,,fee schedule,12.36,56.03,APC
Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.37,,,,,,,fee schedule,10.73,28.51,
Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.05,,,,,,,fee schedule,10.73,28.51,
Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.4,,,,,,,fee schedule,10.73,28.51,
Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.73,,,,,,,fee schedule,10.73,28.51,
Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.83,,,,,,,fee schedule,10.73,28.51,
Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.63,,,,,,,fee schedule,10.73,28.51,APC
Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.84,,,,,,,fee schedule,10.73,28.51,APC
Hemophilus influenza antibdy,86684,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.51,,,,,,,fee schedule,10.73,28.51,APC
Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.06,,,,,,,fee schedule,5.28,16.36,
Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.64,,,,,,,fee schedule,5.28,16.36,
Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.6,,,,,,,fee schedule,5.28,16.36,
Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.28,,,,,,,fee schedule,5.28,16.36,
Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.27,,,,,,,fee schedule,5.28,16.36,
Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.54,,,,,,,fee schedule,5.28,16.36,APC
Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.09,,,,,,,fee schedule,5.28,16.36,APC
Htlv-i antibody,86687,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.36,,,,,,,fee schedule,5.28,16.36,APC
Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.06,,,,,,,fee schedule,5.28,25.2,
Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.3,,,,,,,fee schedule,5.28,25.2,
Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.6,,,,,,,fee schedule,5.28,25.2,
Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.28,,,,,,,fee schedule,5.28,25.2,
Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.27,,,,,,,fee schedule,5.28,25.2,
Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.7,,,,,,,fee schedule,5.28,25.2,APC
Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14,,,,,,,fee schedule,5.28,25.2,APC
Htlv-ii antibody,86688,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.2,,,,,,,fee schedule,5.28,25.2,APC
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.75,,,,,,,fee schedule,18.38,125.06,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.38,,,,,,,fee schedule,18.38,125.06,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.01,,,,,,,fee schedule,18.38,125.06,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.3,,,,,,,fee schedule,18.38,125.06,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.06,,,,,,,fee schedule,18.38,125.06,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.32,,,,,,,fee schedule,18.38,125.06,APC
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.35,,,,,,,fee schedule,18.38,125.06,APC
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.83,,,,,,,fee schedule,18.38,125.06,APC
Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.77,,,,,,,fee schedule,16.3,57.24,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.3,,,,,,,fee schedule,16.3,57.24,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.74,,,,,,,fee schedule,16.3,57.24,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.63,,,,,,,fee schedule,16.3,57.24,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.24,,,,,,,fee schedule,16.3,57.24,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.02,,,,,,,fee schedule,16.3,57.24,APC
Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.16,,,,,,,fee schedule,16.3,57.24,APC
Hepatitis delta agent antbdy,86692,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.89,,,,,,,fee schedule,16.3,57.24,APC
Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.03,,,,,,,fee schedule,13.67,74.78,
Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.67,,,,,,,fee schedule,13.67,74.78,
Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.23,,,,,,,fee schedule,13.67,74.78,
Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.63,,,,,,,fee schedule,13.67,74.78,
Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.78,,,,,,,fee schedule,13.67,74.78,
Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,13.67,74.78,APC
Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.39,,,,,,,fee schedule,13.67,74.78,APC
Herpes simplex nes antbdy,86694,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.9,,,,,,,fee schedule,13.67,74.78,APC
Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.21,,,,,,,fee schedule,12.53,69.24,
Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,69.24,
Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.28,,,,,,,fee schedule,12.53,69.24,
Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.47,,,,,,,fee schedule,12.53,69.24,
Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.24,,,,,,,fee schedule,12.53,69.24,
Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,69.24,APC
Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,69.24,APC
Herpes simplex type 1 test,86695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,69.24,APC
Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.44,,,,,,,fee schedule,18.38,140.81,
Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.38,,,,,,,fee schedule,18.38,140.81,
Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.22,,,,,,,fee schedule,18.38,140.81,
Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.27,,,,,,,fee schedule,18.38,140.81,
Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,140.81,,,,,,,fee schedule,18.38,140.81,
Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.32,,,,,,,fee schedule,18.38,140.81,APC
Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.35,,,,,,,fee schedule,18.38,140.81,APC
Herpes simplex type 2 test,86696,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.83,,,,,,,fee schedule,18.38,140.81,APC
Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.57,,,,,,,fee schedule,6.27,24.82,
Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.1,,,,,,,fee schedule,6.27,24.82,
Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.83,,,,,,,fee schedule,6.27,24.82,
Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.27,,,,,,,fee schedule,6.27,24.82,
Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.01,,,,,,,fee schedule,6.27,24.82,
Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.48,,,,,,,fee schedule,6.27,24.82,APC
Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.79,,,,,,,fee schedule,6.27,24.82,APC
Histoplasma antibody,86698,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.82,,,,,,,fee schedule,6.27,24.82,APC
Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.75,,,,,,,fee schedule,8.45,125.06,
Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.45,,,,,,,fee schedule,8.45,125.06,
Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.01,,,,,,,fee schedule,8.45,125.06,
Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.3,,,,,,,fee schedule,8.45,125.06,
Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.06,,,,,,,fee schedule,8.45,125.06,
Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.33,,,,,,,fee schedule,8.45,125.06,APC
Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.89,,,,,,,fee schedule,8.45,125.06,APC
Hiv-1antibody,86701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16,,,,,,,fee schedule,8.45,125.06,APC
Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.76,,,,,,,fee schedule,12.84,125.07,
Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.84,,,,,,,fee schedule,12.84,125.07,
Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.02,,,,,,,fee schedule,12.84,125.07,
Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.3,,,,,,,fee schedule,12.84,125.07,
Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.07,,,,,,,fee schedule,12.84,125.07,
Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.2,,,,,,,fee schedule,12.84,125.07,APC
Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.52,,,,,,,fee schedule,12.84,125.07,APC
Hiv-2 antibody,86702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.34,,,,,,,fee schedule,12.84,125.07,APC
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.77,,,,,,,fee schedule,6.41,24.68,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.02,,,,,,,fee schedule,6.41,24.68,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8,,,,,,,fee schedule,6.41,24.68,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.41,,,,,,,fee schedule,6.41,24.68,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.24,,,,,,,fee schedule,6.41,24.68,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.4,,,,,,,fee schedule,6.41,24.68,APC
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.71,,,,,,,fee schedule,6.41,24.68,APC
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.68,,,,,,,fee schedule,6.41,24.68,APC
Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.77,,,,,,,fee schedule,6.41,21.69,
Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,6.41,21.69,
Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8,,,,,,,fee schedule,6.41,21.69,
Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.41,,,,,,,fee schedule,6.41,21.69,
Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.24,,,,,,,fee schedule,6.41,21.69,
Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,6.41,21.69,APC
Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,6.41,21.69,APC
Hep b core antibody total,86704,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,6.41,21.69,APC
Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.06,,,,,,,fee schedule,11.18,52.97,
Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.18,,,,,,,fee schedule,11.18,52.97,
Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.7,,,,,,,fee schedule,11.18,52.97,
Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.2,,,,,,,fee schedule,11.18,52.97,
Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.97,,,,,,,fee schedule,11.18,52.97,
Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.36,,,,,,,fee schedule,11.18,52.97,APC
Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.77,,,,,,,fee schedule,11.18,52.97,APC
Hep b core antibody igm,86705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.19,,,,,,,fee schedule,11.18,52.97,APC
Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.77,,,,,,,fee schedule,6.41,19.33,
Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.2,,,,,,,fee schedule,6.41,19.33,
Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8,,,,,,,fee schedule,6.41,19.33,
Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.41,,,,,,,fee schedule,6.41,19.33,
Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.24,,,,,,,fee schedule,6.41,19.33,
Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,6.41,19.33,APC
Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.74,,,,,,,fee schedule,6.41,19.33,APC
Hep b surface antibody,86706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.33,,,,,,,fee schedule,6.41,19.33,APC
Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.27,,,,,,,fee schedule,10.01,20.83,
Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.99,,,,,,,fee schedule,10.01,20.83,
Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.5,,,,,,,fee schedule,10.01,20.83,
Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.01,,,,,,,fee schedule,10.01,20.83,
Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.56,,,,,,,fee schedule,10.01,20.83,
Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.15,,,,,,,fee schedule,10.01,20.83,APC
Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.57,,,,,,,fee schedule,10.01,20.83,APC
Hepatitis be antibody,86707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.83,,,,,,,fee schedule,10.01,20.83,APC
Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.24,,,,,,,fee schedule,11.77,56.63,
Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.77,,,,,,,fee schedule,11.77,56.63,
Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.3,,,,,,,fee schedule,11.77,56.63,
Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.28,,,,,,,fee schedule,11.77,56.63,
Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.63,,,,,,,fee schedule,11.77,56.63,
Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.01,,,,,,,fee schedule,11.77,56.63,APC
Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.39,,,,,,,fee schedule,11.77,56.63,APC
Hepatitis a antibody,86708,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.3,,,,,,,fee schedule,11.77,56.63,APC
Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.84,,,,,,,fee schedule,10.7,49.27,
Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.7,,,,,,,fee schedule,10.7,49.27,
Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.06,,,,,,,fee schedule,10.7,49.27,
Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.09,,,,,,,fee schedule,10.7,49.27,
Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.27,,,,,,,fee schedule,10.7,49.27,
Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.82,,,,,,,fee schedule,10.7,49.27,APC
Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.26,,,,,,,fee schedule,10.7,49.27,APC
Hepatitis a igm antibody,86709,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.27,,,,,,,fee schedule,10.7,49.27,APC
Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.66,,,,,,,fee schedule,10.27,24.39,
Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.87,,,,,,,fee schedule,10.27,24.39,
Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.82,,,,,,,fee schedule,10.27,24.39,
Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,24.39,
Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.01,,,,,,,fee schedule,10.27,24.39,
Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.23,,,,,,,fee schedule,10.27,24.39,APC
Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.55,,,,,,,fee schedule,10.27,24.39,APC
Influenza virus antibody,86710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.39,,,,,,,fee schedule,10.27,24.39,APC
John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.56,,,,,,,fee schedule,16.05,59.29,
John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.05,,,,,,,fee schedule,16.05,59.29,
John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.2,,,,,,,fee schedule,16.05,59.29,
John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.8,,,,,,,fee schedule,16.05,59.29,
John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.29,,,,,,,fee schedule,16.05,59.29,
John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.73,,,,,,,fee schedule,16.05,59.29,APC
John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.89,,,,,,,fee schedule,16.05,59.29,APC
John cunningham antibody,86711,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.4,,,,,,,fee schedule,16.05,59.29,APC
Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.77,,,,,,,fee schedule,14.54,57.24,
Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.54,,,,,,,fee schedule,14.54,57.24,
Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.74,,,,,,,fee schedule,14.54,57.24,
Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.63,,,,,,,fee schedule,14.54,57.24,
Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.24,,,,,,,fee schedule,14.54,57.24,
Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.06,,,,,,,fee schedule,14.54,57.24,APC
Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.3,,,,,,,fee schedule,14.54,57.24,APC
Legionella antibody,86713,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.54,,,,,,,fee schedule,14.54,57.24,APC
Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.86,,,,,,,fee schedule,11.64,52.74,
Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.64,,,,,,,fee schedule,11.64,52.74,
Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.54,,,,,,,fee schedule,11.64,52.74,
Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.07,,,,,,,fee schedule,11.64,52.74,
Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.74,,,,,,,fee schedule,11.64,52.74,
Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.86,,,,,,,fee schedule,11.64,52.74,APC
Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.25,,,,,,,fee schedule,11.64,52.74,APC
Leishmania antibody,86717,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.05,,,,,,,fee schedule,11.64,52.74,APC
Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,15.39,56.8,
Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.39,,,,,,,fee schedule,15.39,56.8,
Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,15.39,56.8,
Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,15.39,56.8,
Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,15.39,56.8,
Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.01,,,,,,,fee schedule,15.39,56.8,APC
Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.2,,,,,,,fee schedule,15.39,56.8,APC
Leptospira antibody,86720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.16,,,,,,,fee schedule,15.39,56.8,APC
Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Listeria monocytogenes,86723,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.18,,,,,,,fee schedule,12.23,55.41,
Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.23,,,,,,,fee schedule,12.23,55.41,
Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.44,,,,,,,fee schedule,12.23,55.41,
Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.59,,,,,,,fee schedule,12.23,55.41,
Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.41,,,,,,,fee schedule,12.23,55.41,
Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,12.23,55.41,APC
Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.87,,,,,,,fee schedule,12.23,55.41,APC
Lymph choriomeningitis ab,86727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.17,,,,,,,fee schedule,12.23,55.41,APC
Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,14.25,56.8,
Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.25,,,,,,,fee schedule,14.25,56.8,
Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,14.25,56.8,
Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,14.25,56.8,
Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,14.25,56.8,
Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.75,,,,,,,fee schedule,14.25,56.8,APC
Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15,,,,,,,fee schedule,14.25,56.8,APC
Mucormycosis antibody,86732,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27,,,,,,,fee schedule,14.25,56.8,APC
Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.87,,,,,,,fee schedule,12.4,34.35,
Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.4,,,,,,,fee schedule,12.4,34.35,
Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.45,,,,,,,fee schedule,12.4,34.35,
Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.58,,,,,,,fee schedule,12.4,34.35,
Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.35,,,,,,,fee schedule,12.4,34.35,
Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.7,,,,,,,fee schedule,12.4,34.35,APC
Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.05,,,,,,,fee schedule,12.4,34.35,APC
Mumps antibody,86735,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.49,,,,,,,fee schedule,12.4,34.35,APC
Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.77,,,,,,,fee schedule,12.58,33.09,
Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.58,,,,,,,fee schedule,12.58,33.09,
Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.55,,,,,,,fee schedule,12.58,33.09,
Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.86,,,,,,,fee schedule,12.58,33.09,
Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.09,,,,,,,fee schedule,12.58,33.09,
Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.9,,,,,,,fee schedule,12.58,33.09,APC
Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.24,,,,,,,fee schedule,12.58,33.09,APC
Mycoplasma antibody,86738,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.83,,,,,,,fee schedule,12.58,33.09,APC
Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Neisseria meningitidis,86741,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,15.19,56.8,
Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.19,,,,,,,fee schedule,15.19,56.8,
Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,15.19,56.8,
Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,15.19,56.8,
Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,15.19,56.8,
Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.79,,,,,,,fee schedule,15.19,56.8,APC
Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.99,,,,,,,fee schedule,15.19,56.8,APC
Nocardia antibody,86744,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.78,,,,,,,fee schedule,15.19,56.8,APC
Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.78,,,,,,,fee schedule,7.07,27.05,
Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.28,,,,,,,fee schedule,7.07,27.05,
Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.82,,,,,,,fee schedule,7.07,27.05,
Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.07,,,,,,,fee schedule,7.07,27.05,
Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.4,,,,,,,fee schedule,7.07,27.05,
Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.78,,,,,,,fee schedule,7.07,27.05,APC
Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.03,,,,,,,fee schedule,7.07,27.05,APC
Parvovirus antibody,86747,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.05,,,,,,,fee schedule,7.07,27.05,APC
Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Malaria antibody,86750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.44,,,,,,,fee schedule,11.77,32.71,
Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.77,,,,,,,fee schedule,11.77,32.71,
Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.28,,,,,,,fee schedule,11.77,32.71,
Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.65,,,,,,,fee schedule,11.77,32.71,
Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.71,,,,,,,fee schedule,11.77,32.71,
Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.01,,,,,,,fee schedule,11.77,32.71,APC
Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.39,,,,,,,fee schedule,11.77,32.71,APC
Protozoa antibody nos,86753,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.3,,,,,,,fee schedule,11.77,32.71,APC
Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.25,,,,,,,fee schedule,15.1,55.49,
Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.1,,,,,,,fee schedule,15.1,55.49,
Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.49,,,,,,,fee schedule,15.1,55.49,
Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.63,,,,,,,fee schedule,15.1,55.49,
Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.49,,,,,,,fee schedule,15.1,55.49,
Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.68,,,,,,,fee schedule,15.1,55.49,APC
Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.89,,,,,,,fee schedule,15.1,55.49,APC
Respiratory virus antibody,86756,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.6,,,,,,,fee schedule,15.1,55.49,APC
Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.74,,,,,,,fee schedule,18.38,37.65,
Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.38,,,,,,,fee schedule,18.38,37.65,
Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.8,,,,,,,fee schedule,18.38,37.65,
Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.46,,,,,,,fee schedule,18.38,37.65,
Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.65,,,,,,,fee schedule,18.38,37.65,
Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.32,,,,,,,fee schedule,18.38,37.65,APC
Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.35,,,,,,,fee schedule,18.38,37.65,APC
Rickettsia Antibody,86757,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.83,,,,,,,fee schedule,18.38,37.65,APC
Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,17.32,56.8,
Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.32,,,,,,,fee schedule,17.32,56.8,
Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,17.32,56.8,
Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,17.32,56.8,
Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,17.32,56.8,
Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.14,,,,,,,fee schedule,17.32,56.8,APC
Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.23,,,,,,,fee schedule,17.32,56.8,APC
Rotavirus antibody,86759,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.81,,,,,,,fee schedule,17.32,56.8,APC
Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.56,,,,,,,fee schedule,13.67,65.04,
Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.67,,,,,,,fee schedule,13.67,65.04,
Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.29,,,,,,,fee schedule,13.67,65.04,
Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.08,,,,,,,fee schedule,13.67,65.04,
Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.04,,,,,,,fee schedule,13.67,65.04,
Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,13.67,65.04,APC
Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.39,,,,,,,fee schedule,13.67,65.04,APC
Rubella antibody,86762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.9,,,,,,,fee schedule,13.67,65.04,APC
Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.03,,,,,,,fee schedule,12.24,74.78,
Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.24,,,,,,,fee schedule,12.24,74.78,
Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.23,,,,,,,fee schedule,12.24,74.78,
Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.63,,,,,,,fee schedule,12.24,74.78,
Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.78,,,,,,,fee schedule,12.24,74.78,
Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.52,,,,,,,fee schedule,12.24,74.78,APC
Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.88,,,,,,,fee schedule,12.24,74.78,APC
Rubeola antibody,86765,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.18,,,,,,,fee schedule,12.24,74.78,APC
Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Salmonella antibody,86768,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.58,,,,,,,fee schedule,35.78,75.83,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,42.13,,,,,,,fee schedule,35.78,75.83,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.67,,,,,,,fee schedule,35.78,75.83,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.78,,,,,,,fee schedule,35.78,75.83,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.77,,,,,,,fee schedule,35.78,75.83,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.24,,,,,,,fee schedule,35.78,75.83,APC
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.13,,,,,,,fee schedule,35.78,75.83,APC
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.83,,,,,,,fee schedule,35.78,75.83,APC
Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,23.26,56.8,
Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.26,,,,,,,fee schedule,23.26,56.8,
Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,23.26,56.8,
Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,23.26,56.8,
Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,23.26,56.8,
Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.7,,,,,,,fee schedule,23.26,56.8,APC
Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.48,,,,,,,fee schedule,23.26,56.8,APC
Shigella antibody,86771,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.06,,,,,,,fee schedule,23.26,56.8,APC
Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.21,,,,,,,fee schedule,11.94,26.64,
Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.06,,,,,,,fee schedule,11.94,26.64,
Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.9,,,,,,,fee schedule,11.94,26.64,
Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.94,,,,,,,fee schedule,11.94,26.64,
Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.94,,,,,,,fee schedule,11.94,26.64,
Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.54,,,,,,,fee schedule,11.94,26.64,APC
Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.8,,,,,,,fee schedule,11.94,26.64,APC
Tetanus antibody,86774,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.64,,,,,,,fee schedule,11.94,26.64,APC
Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.03,,,,,,,fee schedule,13.67,74.78,
Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.67,,,,,,,fee schedule,13.67,74.78,
Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.23,,,,,,,fee schedule,13.67,74.78,
Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.63,,,,,,,fee schedule,13.67,74.78,
Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.78,,,,,,,fee schedule,13.67,74.78,
Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,13.67,74.78,APC
Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.39,,,,,,,fee schedule,13.67,74.78,APC
Toxoplasma antibody,86777,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.9,,,,,,,fee schedule,13.67,74.78,APC
Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.03,,,,,,,fee schedule,13.69,74.78,
Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.69,,,,,,,fee schedule,13.69,74.78,
Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.23,,,,,,,fee schedule,13.69,74.78,
Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.63,,,,,,,fee schedule,13.69,74.78,
Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.78,,,,,,,fee schedule,13.69,74.78,
Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.13,,,,,,,fee schedule,13.69,74.78,APC
Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.41,,,,,,,fee schedule,13.69,74.78,APC
Toxoplasma antibody igm,86778,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.94,,,,,,,fee schedule,13.69,74.78,APC
Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.66,,,,,,,fee schedule,12.58,60.56,
Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.58,,,,,,,fee schedule,12.58,60.56,
Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.1,,,,,,,fee schedule,12.58,60.56,
Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.52,,,,,,,fee schedule,12.58,60.56,
Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.56,,,,,,,fee schedule,12.58,60.56,
Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.9,,,,,,,fee schedule,12.58,60.56,APC
Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.24,,,,,,,fee schedule,12.58,60.56,APC
Treponema pallidum,86780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.83,,,,,,,fee schedule,12.58,60.56,APC
Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.04,,,,,,,fee schedule,11.93,54.1,
Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.93,,,,,,,fee schedule,11.93,54.1,
Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.5,,,,,,,fee schedule,11.93,54.1,
Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.84,,,,,,,fee schedule,11.93,54.1,
Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.1,,,,,,,fee schedule,11.93,54.1,
Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.19,,,,,,,fee schedule,11.93,54.1,APC
Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.56,,,,,,,fee schedule,11.93,54.1,APC
Trichinella antibody,86784,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.61,,,,,,,fee schedule,11.93,54.1,APC
Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.73,,,,,,,fee schedule,12.24,65.24,
Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.24,,,,,,,fee schedule,12.24,65.24,
Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.43,,,,,,,fee schedule,12.24,65.24,
Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.19,,,,,,,fee schedule,12.24,65.24,
Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.24,,,,,,,fee schedule,12.24,65.24,
Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.52,,,,,,,fee schedule,12.24,65.24,APC
Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.88,,,,,,,fee schedule,12.24,65.24,APC
Varicella-zoster antibody,86787,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.18,,,,,,,fee schedule,12.24,65.24,APC
West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.37,,,,,,,fee schedule,16.01,51.03,
West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.01,,,,,,,fee schedule,16.01,51.03,
West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.32,,,,,,,fee schedule,16.01,51.03,
West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.09,,,,,,,fee schedule,16.01,51.03,
West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.03,,,,,,,fee schedule,16.01,51.03,
West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.69,,,,,,,fee schedule,16.01,51.03,APC
West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.85,,,,,,,fee schedule,16.01,51.03,APC
West nile virus ab igm,86788,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.33,,,,,,,fee schedule,16.01,51.03,APC
West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.19,,,,,,,fee schedule,13.67,48.52,
West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.67,,,,,,,fee schedule,13.67,48.52,
West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.53,,,,,,,fee schedule,13.67,48.52,
West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.66,,,,,,,fee schedule,13.67,48.52,
West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.52,,,,,,,fee schedule,13.67,48.52,
West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,13.67,48.52,APC
West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.39,,,,,,,fee schedule,13.67,48.52,APC
West Nile Virus Antibody,86789,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.9,,,,,,,fee schedule,13.67,48.52,APC
Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.18,,,,,,,fee schedule,12.24,23.18,
Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.24,,,,,,,fee schedule,12.24,23.18,
Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.7,,,,,,,fee schedule,12.24,23.18,
Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.57,,,,,,,fee schedule,12.24,23.18,
Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.06,,,,,,,fee schedule,12.24,23.18,
Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.52,,,,,,,fee schedule,12.24,23.18,APC
Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.88,,,,,,,fee schedule,12.24,23.18,APC
Virus antibody nos,86790,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.18,,,,,,,fee schedule,12.24,23.18,APC
Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.39,,,,,,,fee schedule,12.53,56.8,
Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.53,,,,,,,fee schedule,12.53,56.8,
Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.43,,,,,,,fee schedule,12.53,56.8,
Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,12.53,56.8,
Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.8,,,,,,,fee schedule,12.53,56.8,
Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,12.53,56.8,APC
Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.19,,,,,,,fee schedule,12.53,56.8,APC
Yersinia antibody,86793,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.74,,,,,,,fee schedule,12.53,56.8,APC
Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.77,,,,,,,fee schedule,16.01,57.24,
Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.01,,,,,,,fee schedule,16.01,57.24,
Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.74,,,,,,,fee schedule,16.01,57.24,
Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.63,,,,,,,fee schedule,16.01,57.24,
Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.24,,,,,,,fee schedule,16.01,57.24,
Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.69,,,,,,,fee schedule,16.01,57.24,APC
Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.85,,,,,,,fee schedule,16.01,57.24,APC
Zika virus igm antibody,86794,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.33,,,,,,,fee schedule,16.01,57.24,APC
Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.23,,,,,,,fee schedule,8.67,28.64,
Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.11,,,,,,,fee schedule,8.67,28.64,
Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.83,,,,,,,fee schedule,8.67,28.64,
Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.67,,,,,,,fee schedule,8.67,28.64,
Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.21,,,,,,,fee schedule,8.67,28.64,
Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.71,,,,,,,fee schedule,8.67,28.64,APC
Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.91,,,,,,,fee schedule,8.67,28.64,APC
Thyroglobulin antibody,86800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.64,,,,,,,fee schedule,8.67,28.64,APC
Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.32,,,,,,,fee schedule,13.56,26.82,
Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.56,,,,,,,fee schedule,13.56,26.82,
Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.09,,,,,,,fee schedule,13.56,26.82,
Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.29,,,,,,,fee schedule,13.56,26.82,
Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.82,,,,,,,fee schedule,13.56,26.82,
Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.98,,,,,,,fee schedule,13.56,26.82,APC
Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.27,,,,,,,fee schedule,13.56,26.82,APC
Hepatitis c ab test,86803,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.69,,,,,,,fee schedule,13.56,26.82,APC
Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.01,,,,,,,fee schedule,14.72,66.71,
Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.72,,,,,,,fee schedule,14.72,66.71,
Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.48,,,,,,,fee schedule,14.72,66.71,
Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.03,,,,,,,fee schedule,14.72,66.71,
Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.71,,,,,,,fee schedule,14.72,66.71,
Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.26,,,,,,,fee schedule,14.72,66.71,APC
Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.49,,,,,,,fee schedule,14.72,66.71,APC
Hep c ab test confirm,86804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.88,,,,,,,fee schedule,14.72,66.71,APC
Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,180.63,,,,,,,fee schedule,118.42,341.12,
Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,180.03,,,,,,,fee schedule,118.42,341.12,
Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.85,,,,,,,fee schedule,118.42,341.12,
Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.42,,,,,,,fee schedule,118.42,341.12,
Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,207.72,,,,,,,fee schedule,118.42,341.12,
Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,198.99,,,,,,,fee schedule,118.42,341.12,APC
Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,189.51,,,,,,,fee schedule,118.42,341.12,APC
Lymphocytotoxicity assay,86805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,341.12,,,,,,,fee schedule,118.42,341.12,APC
Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.23,,,,,,,fee schedule,45.21,204.96,
Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.21,,,,,,,fee schedule,45.21,204.96,
Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.88,,,,,,,fee schedule,45.21,204.96,
Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.85,,,,,,,fee schedule,45.21,204.96,
Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,204.96,,,,,,,fee schedule,45.21,204.96,
Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.97,,,,,,,fee schedule,45.21,204.96,APC
Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.59,,,,,,,fee schedule,45.21,204.96,APC
Lymphocytotoxicity assay,86806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,85.66,,,,,,,fee schedule,45.21,204.96,APC
Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.22,,,,,,,fee schedule,74.72,170.45,
Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,74.72,,,,,,,fee schedule,74.72,170.45,
Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.32,,,,,,,fee schedule,74.72,170.45,
Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.17,,,,,,,fee schedule,74.72,170.45,
Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.45,,,,,,,fee schedule,74.72,170.45,
Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.58,,,,,,,fee schedule,74.72,170.45,APC
Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,78.65,,,,,,,fee schedule,74.72,170.45,APC
Cytotoxic antibody screening,86807,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,141.57,,,,,,,fee schedule,74.72,170.45,APC
Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.15,,,,,,,fee schedule,28.2,127.82,
Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.2,,,,,,,fee schedule,28.2,127.82,
Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.98,,,,,,,fee schedule,28.2,127.82,
Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.87,,,,,,,fee schedule,28.2,127.82,
Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.82,,,,,,,fee schedule,28.2,127.82,
Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.16,,,,,,,fee schedule,28.2,127.82,APC
Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.68,,,,,,,fee schedule,28.2,127.82,APC
Cytotoxic antibody screening,86808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.42,,,,,,,fee schedule,28.2,127.82,APC
Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.91,,,,,,,fee schedule,24.52,91.9,
Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.52,,,,,,,fee schedule,24.52,91.9,
Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.41,,,,,,,fee schedule,24.52,91.9,
Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.39,,,,,,,fee schedule,24.52,91.9,
Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.9,,,,,,,fee schedule,24.52,91.9,
Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.1,,,,,,,fee schedule,24.52,91.9,APC
Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.81,,,,,,,fee schedule,24.52,91.9,APC
Hla typing a b or c,86812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.46,,,,,,,fee schedule,24.52,91.9,APC
Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,208.69,,,,,,,fee schedule,55.1,239.99,
Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,55.1,,,,,,,fee schedule,55.1,239.99,
Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,170.81,,,,,,,fee schedule,55.1,239.99,
Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.82,,,,,,,fee schedule,55.1,239.99,
Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,239.99,,,,,,,fee schedule,55.1,239.99,
Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.9,,,,,,,fee schedule,55.1,239.99,APC
Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58,,,,,,,fee schedule,55.1,239.99,APC
Hla typing a b or c,86813,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.4,,,,,,,fee schedule,55.1,239.99,APC
Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.08,,,,,,,fee schedule,28.66,100.14,
Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.66,,,,,,,fee schedule,28.66,100.14,
Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.27,,,,,,,fee schedule,28.66,100.14,
Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.09,,,,,,,fee schedule,28.66,100.14,
Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.14,,,,,,,fee schedule,28.66,100.14,
Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.68,,,,,,,fee schedule,28.66,100.14,APC
Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.17,,,,,,,fee schedule,28.66,100.14,APC
Hla typing dr/dq,86816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54.31,,,,,,,fee schedule,28.66,100.14,APC
Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,208.69,,,,,,,fee schedule,100.83,239.99,
Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,100.83,,,,,,,fee schedule,100.83,239.99,
Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,170.81,,,,,,,fee schedule,100.83,239.99,
Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.82,,,,,,,fee schedule,100.83,239.99,
Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,239.99,,,,,,,fee schedule,100.83,239.99,
Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,111.45,,,,,,,fee schedule,100.83,239.99,APC
Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,106.14,,,,,,,fee schedule,100.83,239.99,APC
Hla typing dr/dq,86817,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,191.05,,,,,,,fee schedule,100.83,239.99,APC
Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.46,,,,,,,fee schedule,34.73,243.18,
Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,34.73,,,,,,,fee schedule,34.73,243.18,
Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.08,,,,,,,fee schedule,34.73,243.18,
Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.63,,,,,,,fee schedule,34.73,243.18,
Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.18,,,,,,,fee schedule,34.73,243.18,
Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.39,,,,,,,fee schedule,34.73,243.18,APC
Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.56,,,,,,,fee schedule,34.73,243.18,APC
Lymphocyte culture mixed,86821,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.81,,,,,,,fee schedule,34.73,243.18,APC
Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,307.42,,,,,,,fee schedule,104.02,353.53,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,104.02,,,,,,,fee schedule,104.02,353.53,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.62,,,,,,,fee schedule,104.02,353.53,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.54,,,,,,,fee schedule,104.02,353.53,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,353.53,,,,,,,fee schedule,104.02,353.53,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.96,,,,,,,fee schedule,104.02,353.53,APC
Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,109.49,,,,,,,fee schedule,104.02,353.53,APC
Hla x-math non-cytotoxic,86825,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,197.08,,,,,,,fee schedule,104.02,353.53,APC
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.61,,,,,,,fee schedule,33.18,65.75,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,34.7,,,,,,,fee schedule,33.18,65.75,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.42,,,,,,,fee schedule,33.18,65.75,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.18,,,,,,,fee schedule,33.18,65.75,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.2,,,,,,,fee schedule,33.18,65.75,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.36,,,,,,,fee schedule,33.18,65.75,APC
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.53,,,,,,,fee schedule,33.18,65.75,APC
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.75,,,,,,,fee schedule,33.18,65.75,APC
Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.12,,,,,,,fee schedule,60.98,184.14,
Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,60.98,,,,,,,fee schedule,60.98,184.14,
Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.06,,,,,,,fee schedule,60.98,184.14,
Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.97,,,,,,,fee schedule,60.98,184.14,
Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.14,,,,,,,fee schedule,60.98,184.14,
Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.4,,,,,,,fee schedule,60.98,184.14,APC
Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.19,,,,,,,fee schedule,60.98,184.14,APC
Hla class i&ii antibody qual,86828,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.54,,,,,,,fee schedule,60.98,184.14,APC
Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.15,,,,,,,fee schedule,60.98,127.82,
Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,60.98,,,,,,,fee schedule,60.98,127.82,
Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.98,,,,,,,fee schedule,60.98,127.82,
Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.87,,,,,,,fee schedule,60.98,127.82,
Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.82,,,,,,,fee schedule,60.98,127.82,
Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.4,,,,,,,fee schedule,60.98,127.82,APC
Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.19,,,,,,,fee schedule,60.98,127.82,APC
Hla class i/ii antibody qual,86829,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.54,,,,,,,fee schedule,60.98,127.82,APC
Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.16,,,,,,,fee schedule,90.74,220.98,
Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,90.74,,,,,,,fee schedule,90.74,220.98,
Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.28,,,,,,,fee schedule,90.74,220.98,
Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.98,,,,,,,fee schedule,90.74,220.98,
Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.98,,,,,,,fee schedule,90.74,220.98,
Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.3,,,,,,,fee schedule,90.74,220.98,APC
Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,95.52,,,,,,,fee schedule,90.74,220.98,APC
Hla class i phenotype qual,86830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,171.94,,,,,,,fee schedule,90.74,220.98,APC
Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.17,,,,,,,fee schedule,77.79,298.05,
Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,77.79,,,,,,,fee schedule,77.79,298.05,
Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.13,,,,,,,fee schedule,77.79,298.05,
Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.91,,,,,,,fee schedule,77.79,298.05,
Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.05,,,,,,,fee schedule,77.79,298.05,
Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.97,,,,,,,fee schedule,77.79,298.05,APC
Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,81.88,,,,,,,fee schedule,77.79,298.05,APC
Hla class ii phenotype qual,86831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,147.38,,,,,,,fee schedule,77.79,298.05,APC
Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,398.17,,,,,,,fee schedule,261.04,582.75,
Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,307.56,,,,,,,fee schedule,261.04,582.75,
Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,325.9,,,,,,,fee schedule,261.04,582.75,
Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,261.04,,,,,,,fee schedule,261.04,582.75,
Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,457.9,,,,,,,fee schedule,261.04,582.75,
Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.94,,,,,,,fee schedule,261.04,582.75,APC
Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,323.75,,,,,,,fee schedule,261.04,582.75,APC
Hla class i high defin qual,86832,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,582.75,,,,,,,fee schedule,261.04,582.75,APC
Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,349.6,,,,,,,fee schedule,229.2,586.44,
Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,309.51,,,,,,,fee schedule,229.2,586.44,
Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,286.15,,,,,,,fee schedule,229.2,586.44,
Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,229.2,,,,,,,fee schedule,229.2,586.44,
Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,402.04,,,,,,,fee schedule,229.2,586.44,
Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,342.09,,,,,,,fee schedule,229.2,586.44,APC
Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,325.8,,,,,,,fee schedule,229.2,586.44,APC
Hla class ii high defin qual,86833,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,586.44,,,,,,,fee schedule,229.2,586.44,APC
Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1339.13,,,,,,,fee schedule,339.68,1540,
Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,339.68,,,,,,,fee schedule,339.68,1540,
Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1096.08,,,,,,,fee schedule,339.68,1540,
Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,877.93,,,,,,,fee schedule,339.68,1540,
Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1540,,,,,,,fee schedule,339.68,1540,
Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.44,,,,,,,fee schedule,339.68,1540,APC
Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.56,,,,,,,fee schedule,339.68,1540,APC
Hla class i semiquant panel,86834,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,643.61,,,,,,,fee schedule,339.68,1540,APC
Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1209.54,,,,,,,fee schedule,306.81,1390.97,
Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,306.81,,,,,,,fee schedule,306.81,1390.97,
Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,990.01,,,,,,,fee schedule,306.81,1390.97,
Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,792.97,,,,,,,fee schedule,306.81,1390.97,
Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1390.97,,,,,,,fee schedule,306.81,1390.97,
Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.11,,,,,,,fee schedule,306.81,1390.97,APC
Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,322.96,,,,,,,fee schedule,306.81,1390.97,APC
Hla class ii semiquant panel,86835,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,581.33,,,,,,,fee schedule,306.81,1390.97,APC
RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,9.28,93.46,
RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.28,,,,,,,fee schedule,9.28,93.46,
RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,9.28,93.46,
RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,9.28,93.46,
RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,9.28,93.46,
RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,9.28,93.46,APC
RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,9.28,93.46,APC
RBC antibody screen,86850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,9.28,93.46,APC
RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.29,,,,,,,fee schedule,26.69,305.56,
RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.69,,,,,,,fee schedule,26.69,305.56,
RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.34,,,,,,,fee schedule,26.69,305.56,
RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.31,,,,,,,fee schedule,26.69,305.56,
RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.68,,,,,,,fee schedule,26.69,305.56,
RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,26.69,305.56,APC
RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,26.69,305.56,APC
RBC antibody elution,86860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,26.69,305.56,APC
RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.74,,,,,,,fee schedule,36.66,642.88,
RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.66,,,,,,,fee schedule,36.66,642.88,
RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.18,,,,,,,fee schedule,36.66,642.88,
RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.21,,,,,,,fee schedule,36.66,642.88,
RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.6,,,,,,,fee schedule,36.66,642.88,
RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,36.66,642.88,APC
RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,36.66,642.88,APC
RBC antibody identification,86870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,36.66,642.88,APC
Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.38,,,,,,,fee schedule,5.12,105.8,
Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.12,,,,,,,fee schedule,5.12,105.8,
Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.23,,,,,,,fee schedule,5.12,105.8,
Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.82,,,,,,,fee schedule,5.12,105.8,
Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.29,,,,,,,fee schedule,5.12,105.8,
Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,5.12,105.8,APC
Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,5.12,105.8,APC
Coombs test direct,86880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,5.12,105.8,APC
Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.43,,,,,,,fee schedule,5.43,305.56,
Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.43,,,,,,,fee schedule,5.43,305.56,
Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.54,,,,,,,fee schedule,5.43,305.56,
Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.05,,,,,,,fee schedule,5.43,305.56,
Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.64,,,,,,,fee schedule,5.43,305.56,
Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,5.43,305.56,APC
Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,5.43,305.56,APC
Coombs test indirect qual,86885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,5.43,305.56,APC
Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.87,,,,,,,fee schedule,4.92,305.56,
Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.92,,,,,,,fee schedule,4.92,305.56,
Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.82,,,,,,,fee schedule,4.92,305.56,
Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.91,,,,,,,fee schedule,4.92,305.56,
Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70,,,,,,,fee schedule,4.92,305.56,
Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,4.92,305.56,APC
Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,4.92,305.56,APC
Coombs test indirect titer,86886,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,4.92,305.56,APC
Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,267.52,,,,,,,fee schedule,83.88,307.65,
Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,83.88,,,,,,,fee schedule,83.88,307.65,
Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.97,,,,,,,fee schedule,83.88,307.65,
Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.39,,,,,,,fee schedule,83.88,307.65,
Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,307.65,,,,,,,fee schedule,83.88,307.65,
Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,83.88,307.65,APC
Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,83.88,307.65,APC
Autologous blood process,86890,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,83.88,307.65,APC
Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,377.23,,,,,,,fee schedule,118.48,1445.01,
Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,118.48,,,,,,,fee schedule,118.48,1445.01,
Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,308.76,,,,,,,fee schedule,118.48,1445.01,
Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,247.31,,,,,,,fee schedule,118.48,1445.01,
Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,433.81,,,,,,,fee schedule,118.48,1445.01,
Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,118.48,1445.01,APC
Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,118.48,1445.01,APC
Autologous blood op salvage,86891,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,118.48,1445.01,APC
Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.79,,,,,,,fee schedule,2.84,238.63,
Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.84,,,,,,,fee schedule,2.84,238.63,
Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.74,,,,,,,fee schedule,2.84,238.63,
Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.8,,,,,,,fee schedule,2.84,238.63,
Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.66,,,,,,,fee schedule,2.84,238.63,
Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,2.84,238.63,APC
Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,2.84,238.63,APC
Blood typing serologic abo,86900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,2.84,238.63,APC
Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.79,,,,,,,fee schedule,2.84,66.99,
Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.84,,,,,,,fee schedule,2.84,66.99,
Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.74,,,,,,,fee schedule,2.84,66.99,
Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.8,,,,,,,fee schedule,2.84,66.99,
Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.66,,,,,,,fee schedule,2.84,66.99,
Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,2.84,66.99,APC
Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,2.84,66.99,APC
Blood typing serologic rh(d),86901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,2.84,66.99,APC
Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.31,,,,,,,fee schedule,6.03,642.88,
Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.03,,,,,,,fee schedule,6.03,642.88,
Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.71,,,,,,,fee schedule,6.03,642.88,
Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.38,,,,,,,fee schedule,6.03,642.88,
Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.46,,,,,,,fee schedule,6.03,642.88,
Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,6.03,642.88,APC
Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,6.03,642.88,APC
Blood type antigen donor ea,86902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,6.03,642.88,APC
Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.55,,,,,,,fee schedule,12.82,105.8,
Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.52,,,,,,,fee schedule,12.82,105.8,
Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16,,,,,,,fee schedule,12.82,105.8,
Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.82,,,,,,,fee schedule,12.82,105.8,
Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.48,,,,,,,fee schedule,12.82,105.8,
Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,12.82,105.8,APC
Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,12.82,105.8,APC
Blood typing patient serum,86904,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,12.82,105.8,APC
Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.19,,,,,,,fee schedule,3.64,642.88,
Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,3.64,,,,,,,fee schedule,3.64,642.88,
Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.62,,,,,,,fee schedule,3.64,642.88,
Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.73,,,,,,,fee schedule,3.64,642.88,
Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.62,,,,,,,fee schedule,3.64,642.88,
Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,3.64,642.88,APC
Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,3.64,642.88,APC
Blood typing rbc antigens,86905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,3.64,642.88,APC
Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.4,,,,,,,fee schedule,7.36,67.16,
Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.36,,,,,,,fee schedule,7.36,67.16,
Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.8,,,,,,,fee schedule,7.36,67.16,
Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.29,,,,,,,fee schedule,7.36,67.16,
Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.16,,,,,,,fee schedule,7.36,67.16,
Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,7.36,67.16,APC
Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,7.36,67.16,APC
Bld typing serologic rh phnt,86906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,7.36,67.16,APC
Blood typing paternity test,86910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,21.7,79.99,
Blood typing paternity test,86910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.7,,,,,,,fee schedule,21.7,79.99,
Blood typing paternity test,86910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,21.7,79.99,
Blood typing paternity test,86910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,21.7,79.99,
Blood typing paternity test,86910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,21.7,79.99,
Blood typing antigen system,86911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.76,,,,,,,fee schedule,18.77,68.72,
Blood typing antigen system,86911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.77,,,,,,,fee schedule,18.77,68.72,
Blood typing antigen system,86911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.91,,,,,,,fee schedule,18.77,68.72,
Blood typing antigen system,86911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.18,,,,,,,fee schedule,18.77,68.72,
Blood typing antigen system,86911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.72,,,,,,,fee schedule,18.77,68.72,
Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,17.37,305.56,
Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.62,,,,,,,fee schedule,17.37,305.56,
Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,17.37,305.56,
Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,17.37,305.56,
Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,17.37,305.56,
Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,17.37,305.56,APC
Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,17.37,305.56,APC
Compatibility test spin,86920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,17.37,305.56,APC
Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,17.37,305.56,
Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.69,,,,,,,fee schedule,17.37,305.56,
Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,17.37,305.56,
Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,17.37,305.56,
Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,17.37,305.56,
Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,17.37,305.56,APC
Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,17.37,305.56,APC
Compatibility test incubate,86921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,17.37,305.56,APC
Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.44,,,,,,,fee schedule,31.67,305.56,
Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,31.67,,,,,,,fee schedule,31.67,305.56,
Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.38,,,,,,,fee schedule,31.67,305.56,
Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.77,,,,,,,fee schedule,31.67,305.56,
Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.06,,,,,,,fee schedule,31.67,305.56,
Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,31.67,305.56,APC
Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,31.67,305.56,APC
Compatibility test antiglob,86922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,31.67,305.56,APC
Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.35,,,,,,,fee schedule,21.21,305.56,
Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.76,,,,,,,fee schedule,21.21,305.56,
Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.48,,,,,,,fee schedule,21.21,305.56,
Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.21,,,,,,,fee schedule,21.21,305.56,
Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.2,,,,,,,fee schedule,21.21,305.56,
Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,21.21,305.56,APC
Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,21.21,305.56,APC
Compatibility test electric,86923,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,21.21,305.56,APC
Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.9,,,,,,,fee schedule,16.72,305.56,
Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.72,,,,,,,fee schedule,16.72,305.56,
Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.12,,,,,,,fee schedule,16.72,305.56,
Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.34,,,,,,,fee schedule,16.72,305.56,
Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.99,,,,,,,fee schedule,16.72,305.56,
Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,16.72,305.56,APC
Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,16.72,305.56,APC
Plasma fresh frozen,86927,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,16.72,305.56,APC
Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,314.52,,,,,,,fee schedule,98.83,361.7,
Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,98.83,,,,,,,fee schedule,98.83,361.7,
Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,257.43,,,,,,,fee schedule,98.83,361.7,
Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.2,,,,,,,fee schedule,98.83,361.7,
Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,361.7,,,,,,,fee schedule,98.83,361.7,
Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,98.83,361.7,APC
Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,98.83,361.7,APC
Frozen blood prep,86930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,98.83,361.7,APC
Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.13,,,,,,,fee schedule,74.2,305.56,
Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,74.2,,,,,,,fee schedule,74.2,305.56,
Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.27,,,,,,,fee schedule,74.2,305.56,
Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.81,,,,,,,fee schedule,74.2,305.56,
Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,271.55,,,,,,,fee schedule,74.2,305.56,
Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,74.2,305.56,APC
Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,74.2,305.56,APC
Frozen blood thaw,86931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,74.2,305.56,APC
Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,267.52,,,,,,,fee schedule,37.22,307.65,
Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,83.88,,,,,,,fee schedule,37.22,307.65,
Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.97,,,,,,,fee schedule,37.22,307.65,
Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.39,,,,,,,fee schedule,37.22,307.65,
Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,307.65,,,,,,,fee schedule,37.22,307.65,
Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,307.65,APC
Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,307.65,APC
Frozen blood freeze/thaw,86932,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,307.65,APC
Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,8.33,30.48,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.33,,,,,,,fee schedule,8.33,30.48,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,8.33,30.48,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,8.33,30.48,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,8.33,30.48,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.21,,,,,,,fee schedule,8.33,30.48,APC
Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.77,,,,,,,fee schedule,8.33,30.48,APC
Hemolysins/agglutinins auto,86940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.79,,,,,,,fee schedule,8.33,30.48,APC
Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,11.5,30.48,
Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.5,,,,,,,fee schedule,11.5,30.48,
Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,11.5,30.48,
Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,11.5,30.48,
Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,11.5,30.48,
Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.72,,,,,,,fee schedule,11.5,30.48,APC
Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.11,,,,,,,fee schedule,11.5,30.48,APC
Hemolysins/agglutinins,86941,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.8,,,,,,,fee schedule,11.5,30.48,APC
Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,24.64,90.13,
Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.64,,,,,,,fee schedule,24.64,90.13,
Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,24.64,90.13,
Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,24.64,90.13,
Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,24.64,90.13,
Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,24.64,90.13,APC
Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,24.64,90.13,APC
Blood product/irradiation,86945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,24.64,90.13,APC
Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.78,,,,,,,fee schedule,64.23,305.56,
Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,64.23,,,,,,,fee schedule,64.23,305.56,
Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.61,,,,,,,fee schedule,64.23,305.56,
Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.25,,,,,,,fee schedule,64.23,305.56,
Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.5,,,,,,,fee schedule,64.23,305.56,
Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,64.23,305.56,APC
Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,64.23,305.56,APC
Leukacyte transfusion,86950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,64.23,305.56,APC
Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.83,,,,,,,fee schedule,22.18,305.56,
Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.57,,,,,,,fee schedule,22.18,305.56,
Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.69,,,,,,,fee schedule,22.18,305.56,
Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.18,,,,,,,fee schedule,22.18,305.56,
Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.9,,,,,,,fee schedule,22.18,305.56,
Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,22.18,305.56,APC
Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,22.18,305.56,APC
Vol reduction of blood/prod,86960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,22.18,305.56,APC
Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.17,,,,,,,fee schedule,27.57,305.56,
Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.57,,,,,,,fee schedule,27.57,305.56,
Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.17,,,,,,,fee schedule,27.57,305.56,
Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.8,,,,,,,fee schedule,27.57,305.56,
Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.4,,,,,,,fee schedule,27.57,305.56,
Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,27.57,305.56,APC
Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,27.57,305.56,APC
Pooling blood platelets,86965,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,27.57,305.56,APC
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,24.64,105.8,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.64,,,,,,,fee schedule,24.64,105.8,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,24.64,105.8,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,24.64,105.8,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,24.64,105.8,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,24.64,105.8,APC
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,24.64,105.8,APC
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,24.64,105.8,APC
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.7,,,,,,,fee schedule,19.65,305.56,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.65,,,,,,,fee schedule,19.65,305.56,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.32,,,,,,,fee schedule,19.65,305.56,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.11,,,,,,,fee schedule,19.65,305.56,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.11,,,,,,,fee schedule,19.65,305.56,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,19.65,305.56,APC
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,19.65,305.56,APC
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,19.65,305.56,APC
Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.75,,,,,,,fee schedule,34.61,305.56,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,34.61,,,,,,,fee schedule,34.61,305.56,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.83,,,,,,,fee schedule,34.61,305.56,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.95,,,,,,,fee schedule,34.61,305.56,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.21,,,,,,,fee schedule,34.61,305.56,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,34.61,305.56,APC
Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,34.61,305.56,APC
Rbc pretx incubatj w/density,86972,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,34.61,305.56,APC
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.24,,,,,,,fee schedule,26.69,801.21,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.69,,,,,,,fee schedule,26.69,801.21,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.77,,,,,,,fee schedule,26.69,801.21,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.88,,,,,,,fee schedule,26.69,801.21,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.03,,,,,,,fee schedule,26.69,801.21,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,26.69,801.21,APC
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,26.69,801.21,APC
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,26.69,801.21,APC
Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.05,,,,,,,fee schedule,28.82,108.16,
Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.62,,,,,,,fee schedule,28.82,108.16,
Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.98,,,,,,,fee schedule,28.82,108.16,
Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.66,,,,,,,fee schedule,28.82,108.16,
Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.16,,,,,,,fee schedule,28.82,108.16,
Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,108.16,APC
Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,108.16,APC
Rbc serum pretx id dilution,86976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,108.16,APC
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.05,,,,,,,fee schedule,29.62,305.56,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.62,,,,,,,fee schedule,29.62,305.56,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.98,,,,,,,fee schedule,29.62,305.56,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.66,,,,,,,fee schedule,29.62,305.56,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.16,,,,,,,fee schedule,29.62,305.56,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,29.62,305.56,APC
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,29.62,305.56,APC
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,29.62,305.56,APC
Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.84,,,,,,,fee schedule,29.62,105.8,
Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.62,,,,,,,fee schedule,29.62,105.8,
Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.89,,,,,,,fee schedule,29.62,105.8,
Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.95,,,,,,,fee schedule,29.62,105.8,
Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.07,,,,,,,fee schedule,29.62,105.8,
Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,29.62,105.8,APC
Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,29.62,105.8,APC
Rbc pretreatment serum,86978,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,29.62,105.8,APC
Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.67,,,,,,,fee schedule,21.7,305.56,
Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.7,,,,,,,fee schedule,21.7,305.56,
Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.93,,,,,,,fee schedule,21.7,305.56,
Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.4,,,,,,,fee schedule,21.7,305.56,
Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.37,,,,,,,fee schedule,21.7,305.56,
Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,21.7,305.56,APC
Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,21.7,305.56,APC
Split blood or products,86985,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,21.7,305.56,APC
Transfusion procedure,86999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Transfusion procedure,86999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Transfusion procedure,86999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.06,,,,,,,fee schedule,16,72.52,
Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16,,,,,,,fee schedule,16,72.52,
Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.61,,,,,,,fee schedule,16,72.52,
Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.34,,,,,,,fee schedule,16,72.52,
Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.52,,,,,,,fee schedule,16,72.52,
Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.68,,,,,,,fee schedule,16,72.52,APC
Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.84,,,,,,,fee schedule,16,72.52,APC
Small animal inoculation,87003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.31,,,,,,,fee schedule,16,72.52,APC
Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.89,,,,,,,fee schedule,5.17,12.02,
Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.35,,,,,,,fee schedule,5.17,12.02,
Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.46,,,,,,,fee schedule,5.17,12.02,
Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.17,,,,,,,fee schedule,5.17,12.02,
Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.07,,,,,,,fee schedule,5.17,12.02,
Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.01,,,,,,,fee schedule,5.17,12.02,APC
Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.68,,,,,,,fee schedule,5.17,12.02,APC
Specimen infect agnt concntj,87015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.02,,,,,,,fee schedule,5.17,12.02,APC
Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.56,,,,,,,fee schedule,9.8,40.89,
Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.8,,,,,,,fee schedule,9.8,40.89,
Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.11,,,,,,,fee schedule,9.8,40.89,
Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.31,,,,,,,fee schedule,9.8,40.89,
Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.89,,,,,,,fee schedule,9.8,40.89,
Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.84,,,,,,,fee schedule,9.8,40.89,APC
Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.32,,,,,,,fee schedule,9.8,40.89,APC
Blood culture for bacteria,87040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.58,,,,,,,fee schedule,9.8,40.89,APC
Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.42,,,,,,,fee schedule,8.97,37.28,
Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.97,,,,,,,fee schedule,8.97,37.28,
Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.54,,,,,,,fee schedule,8.97,37.28,
Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.25,,,,,,,fee schedule,8.97,37.28,
Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.28,,,,,,,fee schedule,8.97,37.28,
Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.97,37.28,APC
Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.44,,,,,,,fee schedule,8.97,37.28,APC
Feces culture aerobic bact,87045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.99,,,,,,,fee schedule,8.97,37.28,APC
Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.57,,,,,,,fee schedule,8.97,24.81,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.97,,,,,,,fee schedule,8.97,24.81,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.66,,,,,,,fee schedule,8.97,24.81,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.14,,,,,,,fee schedule,8.97,24.81,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.81,,,,,,,fee schedule,8.97,24.81,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.97,24.81,APC
Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.44,,,,,,,fee schedule,8.97,24.81,APC
Stool cultr aerobic bact ea,87046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.99,,,,,,,fee schedule,8.97,24.81,APC
Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.44,,,,,,,fee schedule,8.19,35.01,
Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.19,,,,,,,fee schedule,8.19,35.01,
Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.92,,,,,,,fee schedule,8.19,35.01,
Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.96,,,,,,,fee schedule,8.19,35.01,
Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.01,,,,,,,fee schedule,8.19,35.01,
Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.05,,,,,,,fee schedule,8.19,35.01,APC
Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.62,,,,,,,fee schedule,8.19,35.01,APC
Culture othr specimn aerobic,87070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.52,,,,,,,fee schedule,8.19,35.01,APC
Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.56,,,,,,,fee schedule,9.4,25.94,
Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.4,,,,,,,fee schedule,9.4,25.94,
Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.47,,,,,,,fee schedule,9.4,25.94,
Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.79,,,,,,,fee schedule,9.4,25.94,
Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.94,,,,,,,fee schedule,9.4,25.94,
Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.38,,,,,,,fee schedule,9.4,25.94,APC
Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.89,,,,,,,fee schedule,9.4,25.94,APC
Culture aerobic quant other,87071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.8,,,,,,,fee schedule,9.4,25.94,APC
Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.37,,,,,,,fee schedule,9.18,40.68,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.18,,,,,,,fee schedule,9.18,40.68,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.95,,,,,,,fee schedule,9.18,40.68,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.19,,,,,,,fee schedule,9.18,40.68,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.68,,,,,,,fee schedule,9.18,40.68,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.14,,,,,,,fee schedule,9.18,40.68,APC
Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.66,,,,,,,fee schedule,9.18,40.68,APC
Culture Bacteria Anaerobic,87073,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.39,,,,,,,fee schedule,9.18,40.68,APC
Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.81,,,,,,,fee schedule,9,37.73,
Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9,,,,,,,fee schedule,9,37.73,
Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.85,,,,,,,fee schedule,9,37.73,
Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.51,,,,,,,fee schedule,9,37.73,
Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.73,,,,,,,fee schedule,9,37.73,
Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.94,,,,,,,fee schedule,9,37.73,APC
Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.47,,,,,,,fee schedule,9,37.73,APC
Cultr bacteria except blood,87075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.05,,,,,,,fee schedule,9,37.73,APC
Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.65,,,,,,,fee schedule,7.68,51.35,
Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.68,,,,,,,fee schedule,7.68,51.35,
Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.55,,,,,,,fee schedule,7.68,51.35,
Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.27,,,,,,,fee schedule,7.68,51.35,
Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.35,,,,,,,fee schedule,7.68,51.35,
Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.48,,,,,,,fee schedule,7.68,51.35,APC
Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.08,,,,,,,fee schedule,7.68,51.35,APC
Culture anaerobe ident each,87076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.54,,,,,,,fee schedule,7.68,51.35,APC
Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.64,,,,,,,fee schedule,7.68,44.44,
Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.68,,,,,,,fee schedule,7.68,44.44,
Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.63,,,,,,,fee schedule,7.68,44.44,
Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.33,,,,,,,fee schedule,7.68,44.44,
Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.44,,,,,,,fee schedule,7.68,44.44,
Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.48,,,,,,,fee schedule,7.68,44.44,APC
Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.08,,,,,,,fee schedule,7.68,44.44,APC
Culture Aerobic Identify,87077,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.54,,,,,,,fee schedule,7.68,44.44,APC
Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.81,,,,,,,fee schedule,6.3,26.23,
Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.3,,,,,,,fee schedule,6.3,26.23,
Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.67,,,,,,,fee schedule,6.3,26.23,
Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.95,,,,,,,fee schedule,6.3,26.23,
Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.23,,,,,,,fee schedule,6.3,26.23,
Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.96,,,,,,,fee schedule,6.3,26.23,APC
Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.63,,,,,,,fee schedule,6.3,26.23,APC
Culture screen only,87081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.93,,,,,,,fee schedule,6.3,26.23,APC
Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.13,,,,,,,fee schedule,11.89,48.73,
Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.72,,,,,,,fee schedule,11.89,48.73,
Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.84,,,,,,,fee schedule,11.89,48.73,
Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.89,,,,,,,fee schedule,11.89,48.73,
Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.85,,,,,,,fee schedule,11.89,48.73,
Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.42,,,,,,,fee schedule,11.89,48.73,APC
Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.07,,,,,,,fee schedule,11.89,48.73,APC
Culture of specimen by kit,87084,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.73,,,,,,,fee schedule,11.89,48.73,APC
Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.53,,,,,,,fee schedule,7.67,32.81,
Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.67,,,,,,,fee schedule,7.67,32.81,
Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.35,,,,,,,fee schedule,7.67,32.81,
Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.7,,,,,,,fee schedule,7.67,32.81,
Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.81,,,,,,,fee schedule,7.67,32.81,
Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.47,,,,,,,fee schedule,7.67,32.81,APC
Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.07,,,,,,,fee schedule,7.67,32.81,APC
Urine culture/colony count,87086,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.53,,,,,,,fee schedule,7.67,32.81,APC
Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.25,,,,,,,fee schedule,7.69,16.39,
Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.69,,,,,,,fee schedule,7.69,16.39,
Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.66,,,,,,,fee schedule,7.69,16.39,
Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.34,,,,,,,fee schedule,7.69,16.39,
Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.39,,,,,,,fee schedule,7.69,16.39,
Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.49,,,,,,,fee schedule,7.69,16.39,APC
Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.09,,,,,,,fee schedule,7.69,16.39,APC
Urine bacteria culture,87088,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.56,,,,,,,fee schedule,7.69,16.39,APC
Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.41,,,,,,,fee schedule,7.32,30.37,
Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.32,,,,,,,fee schedule,7.32,30.37,
Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.62,,,,,,,fee schedule,7.32,30.37,
Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.31,,,,,,,fee schedule,7.32,30.37,
Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.37,,,,,,,fee schedule,7.32,30.37,
Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.1,,,,,,,fee schedule,7.32,30.37,APC
Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.71,,,,,,,fee schedule,7.32,30.37,APC
Skin fungi culture,87101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.88,,,,,,,fee schedule,7.32,30.37,APC
Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.12,,,,,,,fee schedule,7.99,33.49,
Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.99,,,,,,,fee schedule,7.99,33.49,
Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.83,,,,,,,fee schedule,7.99,33.49,
Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.09,,,,,,,fee schedule,7.99,33.49,
Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.49,,,,,,,fee schedule,7.99,33.49,
Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.83,,,,,,,fee schedule,7.99,33.49,APC
Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.41,,,,,,,fee schedule,7.99,33.49,APC
Fungus isolation culture,87102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.14,,,,,,,fee schedule,7.99,33.49,APC
Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.98,,,,,,,fee schedule,19.44,36.83,
Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.44,,,,,,,fee schedule,19.44,36.83,
Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.36,,,,,,,fee schedule,19.44,36.83,
Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.31,,,,,,,fee schedule,19.44,36.83,
Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.63,,,,,,,fee schedule,19.44,36.83,
Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.48,,,,,,,fee schedule,19.44,36.83,APC
Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.46,,,,,,,fee schedule,19.44,36.83,APC
Blood fungus culture,87103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.83,,,,,,,fee schedule,19.44,36.83,APC
Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.56,,,,,,,fee schedule,9.8,40.89,
Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.8,,,,,,,fee schedule,9.8,40.89,
Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.11,,,,,,,fee schedule,9.8,40.89,
Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.31,,,,,,,fee schedule,9.8,40.89,
Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.89,,,,,,,fee schedule,9.8,40.89,
Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.84,,,,,,,fee schedule,9.8,40.89,APC
Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.32,,,,,,,fee schedule,9.8,40.89,APC
Fungi identification yeast,87106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.58,,,,,,,fee schedule,9.8,40.89,APC
Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.33,,,,,,,fee schedule,9.8,56.73,
Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.8,,,,,,,fee schedule,9.8,56.73,
Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.38,,,,,,,fee schedule,9.8,56.73,
Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.34,,,,,,,fee schedule,9.8,56.73,
Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.73,,,,,,,fee schedule,9.8,56.73,
Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.84,,,,,,,fee schedule,9.8,56.73,APC
Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.32,,,,,,,fee schedule,9.8,56.73,APC
Fungi identification mold,87107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.58,,,,,,,fee schedule,9.8,56.73,APC
Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.85,,,,,,,fee schedule,14.62,60.78,
Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.62,,,,,,,fee schedule,14.62,60.78,
Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.26,,,,,,,fee schedule,14.62,60.78,
Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.65,,,,,,,fee schedule,14.62,60.78,
Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.78,,,,,,,fee schedule,14.62,60.78,
Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.16,,,,,,,fee schedule,14.62,60.78,APC
Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.39,,,,,,,fee schedule,14.62,60.78,APC
Mycoplasma,87109,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.7,,,,,,,fee schedule,14.62,60.78,APC
Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.38,,,,,,,fee schedule,18.62,77.49,
Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.62,,,,,,,fee schedule,18.62,77.49,
Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.15,,,,,,,fee schedule,18.62,77.49,
Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.17,,,,,,,fee schedule,18.62,77.49,
Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.49,,,,,,,fee schedule,18.62,77.49,
Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.58,,,,,,,fee schedule,18.62,77.49,APC
Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.6,,,,,,,fee schedule,18.62,77.49,APC
Chlamydia culture,87110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.28,,,,,,,fee schedule,18.62,77.49,APC
Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.38,,,,,,,fee schedule,10.26,42.99,
Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.26,,,,,,,fee schedule,10.26,42.99,
Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.6,,,,,,,fee schedule,10.26,42.99,
Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.51,,,,,,,fee schedule,10.26,42.99,
Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.99,,,,,,,fee schedule,10.26,42.99,
Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.34,,,,,,,fee schedule,10.26,42.99,APC
Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.8,,,,,,,fee schedule,10.26,42.99,APC
Mycobacteria culture,87116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.44,,,,,,,fee schedule,10.26,42.99,APC
Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.98,,,,,,,fee schedule,13.88,47.13,
Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.88,,,,,,,fee schedule,13.88,47.13,
Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.54,,,,,,,fee schedule,13.88,47.13,
Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.87,,,,,,,fee schedule,13.88,47.13,
Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.13,,,,,,,fee schedule,13.88,47.13,
Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.34,,,,,,,fee schedule,13.88,47.13,APC
Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.61,,,,,,,fee schedule,13.88,47.13,APC
Mycobacteric identification,87118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.3,,,,,,,fee schedule,13.88,47.13,APC
Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.85,,,,,,,fee schedule,5.29,23.98,
Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.29,,,,,,,fee schedule,5.29,23.98,
Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.07,,,,,,,fee schedule,5.29,23.98,
Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.67,,,,,,,fee schedule,5.29,23.98,
Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.98,,,,,,,fee schedule,5.29,23.98,
Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.85,,,,,,,fee schedule,5.29,23.98,APC
Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.57,,,,,,,fee schedule,5.29,23.98,APC
Culture type immunofluoresc,87140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.03,,,,,,,fee schedule,5.29,23.98,APC
Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.13,,,,,,,fee schedule,11.89,22.54,
Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.89,,,,,,,fee schedule,11.89,22.54,
Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.84,,,,,,,fee schedule,11.89,22.54,
Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.89,,,,,,,fee schedule,11.89,22.54,
Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.85,,,,,,,fee schedule,11.89,22.54,
Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.15,,,,,,,fee schedule,11.89,22.54,APC
Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.52,,,,,,,fee schedule,11.89,22.54,APC
Culture typing glc/hplc,87143,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.54,,,,,,,fee schedule,11.89,22.54,APC
Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.48,,,,,,,fee schedule,4.92,18.95,
Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.92,,,,,,,fee schedule,4.92,18.95,
Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.49,,,,,,,fee schedule,4.92,18.95,
Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.8,,,,,,,fee schedule,4.92,18.95,
Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.95,,,,,,,fee schedule,4.92,18.95,
Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.92,18.95,APC
Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.18,,,,,,,fee schedule,4.92,18.95,APC
Culture type immunologic,87147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.32,,,,,,,fee schedule,4.92,18.95,APC
Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Dna/rna direct probe,87149,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Dna/rna amplified probe,87150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,7.35,22.54,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.35,,,,,,,fee schedule,7.35,22.54,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,7.35,22.54,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,7.35,22.54,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,7.35,22.54,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.13,,,,,,,fee schedule,7.35,22.54,APC
Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.74,,,,,,,fee schedule,7.35,22.54,APC
Culture Type Pulse Field Gel,87152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.93,,,,,,,fee schedule,7.35,22.54,APC
Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,432.02,,,,,,,fee schedule,109.59,496.82,
Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,109.59,,,,,,,fee schedule,109.59,496.82,
Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.61,,,,,,,fee schedule,109.59,496.82,
Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.23,,,,,,,fee schedule,109.59,496.82,
Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.82,,,,,,,fee schedule,109.59,496.82,
Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,121.13,,,,,,,fee schedule,109.59,496.82,APC
Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,115.36,,,,,,,fee schedule,109.59,496.82,APC
Dna/rna sequencing,87153,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,207.65,,,,,,,fee schedule,109.59,496.82,APC
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.62,,,,,,,fee schedule,207.16,487.16,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,207.16,,,,,,,fee schedule,207.16,487.16,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.73,,,,,,,fee schedule,207.16,487.16,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.73,,,,,,,fee schedule,207.16,487.16,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,487.16,,,,,,,fee schedule,207.16,487.16,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,228.96,,,,,,,fee schedule,207.16,487.16,APC
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.06,,,,,,,fee schedule,207.16,487.16,APC
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.51,,,,,,,fee schedule,207.16,487.16,APC
Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,7.35,22.54,
Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.35,,,,,,,fee schedule,7.35,22.54,
Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,7.35,22.54,
Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,7.35,22.54,
Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,7.35,22.54,
Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.13,,,,,,,fee schedule,7.35,22.54,APC
Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.74,,,,,,,fee schedule,7.35,22.54,APC
Culture typing added method,87158,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.93,,,,,,,fee schedule,7.35,22.54,APC
Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.21,,,,,,,fee schedule,10.2,46.24,
Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.2,,,,,,,fee schedule,10.2,46.24,
Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.91,,,,,,,fee schedule,10.2,46.24,
Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.36,,,,,,,fee schedule,10.2,46.24,
Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.24,,,,,,,fee schedule,10.2,46.24,
Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,10.2,46.24,APC
Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.74,,,,,,,fee schedule,10.2,46.24,APC
Dark field examination,87164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.33,,,,,,,fee schedule,10.2,46.24,APC
Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,10.74,30.48,
Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.74,,,,,,,fee schedule,10.74,30.48,
Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,10.74,30.48,
Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,10.74,30.48,
Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,10.74,30.48,
Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.86,,,,,,,fee schedule,10.74,30.48,APC
Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.3,,,,,,,fee schedule,10.74,30.48,APC
Dark field examination,87166,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.34,,,,,,,fee schedule,10.74,30.48,APC
Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.72,,,,,,,fee schedule,4.06,19.23,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.06,,,,,,,fee schedule,4.06,19.23,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.69,,,,,,,fee schedule,4.06,19.23,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.96,,,,,,,fee schedule,4.06,19.23,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.23,,,,,,,fee schedule,4.06,19.23,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.06,19.23,APC
Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.27,,,,,,,fee schedule,4.06,19.23,APC
Macroscopic Exam Arthropod,87168,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.69,,,,,,,fee schedule,4.06,19.23,APC
Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.32,,,,,,,fee schedule,4.09,36.02,
Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.09,,,,,,,fee schedule,4.09,36.02,
Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.64,,,,,,,fee schedule,4.09,36.02,
Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.53,,,,,,,fee schedule,4.09,36.02,
Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.02,,,,,,,fee schedule,4.09,36.02,
Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.53,,,,,,,fee schedule,4.09,36.02,APC
Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.31,,,,,,,fee schedule,4.09,36.02,APC
Macroscopic exam parasite,87169,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.76,,,,,,,fee schedule,4.09,36.02,APC
Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.4,,,,,,,fee schedule,4.06,23.46,
Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.06,,,,,,,fee schedule,4.06,23.46,
Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.7,,,,,,,fee schedule,4.06,23.46,
Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.37,,,,,,,fee schedule,4.06,23.46,
Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.46,,,,,,,fee schedule,4.06,23.46,
Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.06,23.46,APC
Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.27,,,,,,,fee schedule,4.06,23.46,APC
Pinworm Exam,87172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.69,,,,,,,fee schedule,4.06,23.46,APC
Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.05,,,,,,,fee schedule,5.59,23.06,
Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.59,,,,,,,fee schedule,5.59,23.06,
Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.41,,,,,,,fee schedule,5.59,23.06,
Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.14,,,,,,,fee schedule,5.59,23.06,
Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.06,,,,,,,fee schedule,5.59,23.06,
Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.17,,,,,,,fee schedule,5.59,23.06,APC
Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.88,,,,,,,fee schedule,5.59,23.06,APC
Tissue homogenization cultr,87176,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.58,,,,,,,fee schedule,5.59,23.06,APC
Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.98,,,,,,,fee schedule,8.46,35.63,
Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.46,,,,,,,fee schedule,8.46,35.63,
Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.36,,,,,,,fee schedule,8.46,35.63,
Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.31,,,,,,,fee schedule,8.46,35.63,
Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.63,,,,,,,fee schedule,8.46,35.63,
Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.34,,,,,,,fee schedule,8.46,35.63,APC
Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.9,,,,,,,fee schedule,8.46,35.63,APC
Ova and parasites smears,87177,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.02,,,,,,,fee schedule,8.46,35.63,APC
Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.97,,,,,,,fee schedule,4.51,10.32,
Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.51,,,,,,,fee schedule,4.51,10.32,
Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.34,,,,,,,fee schedule,4.51,10.32,
Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.88,,,,,,,fee schedule,4.51,10.32,
Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.32,,,,,,,fee schedule,4.51,10.32,
Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.99,,,,,,,fee schedule,4.51,10.32,APC
Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.51,10.32,APC
Microbe susceptible diffuse,87181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.55,,,,,,,fee schedule,4.51,10.32,APC
Sc std carbapenem resist gen,87183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,63.16,APC
Sc std carbapenem resist gen,87183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,63.16,APC
Sc std carbapenem resist gen,87183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,63.16,APC
Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.66,,,,,,,fee schedule,7.11,27.21,
Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.11,,,,,,,fee schedule,7.11,27.21,
Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.37,,,,,,,fee schedule,7.11,27.21,
Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.51,,,,,,,fee schedule,7.11,27.21,
Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.21,,,,,,,fee schedule,7.11,27.21,
Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.85,,,,,,,fee schedule,7.11,27.21,APC
Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.48,,,,,,,fee schedule,7.11,27.21,APC
Microbe susceptible disk,87184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.46,,,,,,,fee schedule,7.11,27.21,APC
Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.6,,,,,,,fee schedule,4.51,13.34,
Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.51,,,,,,,fee schedule,4.51,13.34,
Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.49,,,,,,,fee schedule,4.51,13.34,
Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.6,,,,,,,fee schedule,4.51,13.34,
Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.34,,,,,,,fee schedule,4.51,13.34,
Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.99,,,,,,,fee schedule,4.51,13.34,APC
Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.51,13.34,APC
Microbe susceptible enzyme,87185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.55,,,,,,,fee schedule,4.51,13.34,APC
Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.07,,,,,,,fee schedule,8.22,34.58,
Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.22,,,,,,,fee schedule,8.22,34.58,
Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.61,,,,,,,fee schedule,8.22,34.58,
Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.71,,,,,,,fee schedule,8.22,34.58,
Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.58,,,,,,,fee schedule,8.22,34.58,
Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.08,,,,,,,fee schedule,8.22,34.58,APC
Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.65,,,,,,,fee schedule,8.22,34.58,APC
Microbe susceptible mic,87186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.57,,,,,,,fee schedule,8.22,34.58,APC
Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.81,,,,,,,fee schedule,25.44,72.31,
Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,38.16,,,,,,,fee schedule,25.44,72.31,
Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.77,,,,,,,fee schedule,25.44,72.31,
Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.44,,,,,,,fee schedule,25.44,72.31,
Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.63,,,,,,,fee schedule,25.44,72.31,
Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.18,,,,,,,fee schedule,25.44,72.31,APC
Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40.17,,,,,,,fee schedule,25.44,72.31,APC
Microbe susceptible mlc,87187,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,72.31,,,,,,,fee schedule,25.44,72.31,APC
Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.86,,,,,,,fee schedule,6.31,28.59,
Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.31,,,,,,,fee schedule,6.31,28.59,
Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.35,,,,,,,fee schedule,6.31,28.59,
Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.3,,,,,,,fee schedule,6.31,28.59,
Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.59,,,,,,,fee schedule,6.31,28.59,
Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.97,,,,,,,fee schedule,6.31,28.59,APC
Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.64,,,,,,,fee schedule,6.31,28.59,APC
Microbe suscept macrobroth,87188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.95,,,,,,,fee schedule,6.31,28.59,APC
Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.16,,,,,,,fee schedule,6.94,24.33,
Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.94,,,,,,,fee schedule,6.94,24.33,
Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.32,,,,,,,fee schedule,6.94,24.33,
Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.87,,,,,,,fee schedule,6.94,24.33,
Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.33,,,,,,,fee schedule,6.94,24.33,
Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.68,,,,,,,fee schedule,6.94,24.33,APC
Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.31,,,,,,,fee schedule,6.94,24.33,APC
Microbe suscept mycobacteri,87190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.16,,,,,,,fee schedule,6.94,24.33,APC
Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.31,,,,,,,fee schedule,14.27,50.96,
Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.27,,,,,,,fee schedule,14.27,50.96,
Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.27,,,,,,,fee schedule,14.27,50.96,
Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.05,,,,,,,fee schedule,14.27,50.96,
Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.96,,,,,,,fee schedule,14.27,50.96,
Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.77,,,,,,,fee schedule,14.27,50.96,APC
Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.02,,,,,,,fee schedule,14.27,50.96,APC
Bactericidal level serum,87197,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.04,,,,,,,fee schedule,14.27,50.96,APC
Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.55,,,,,,,fee schedule,4.06,16.73,
Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.06,,,,,,,fee schedule,4.06,16.73,
Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.91,,,,,,,fee schedule,4.06,16.73,
Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.54,,,,,,,fee schedule,4.06,16.73,
Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.73,,,,,,,fee schedule,4.06,16.73,
Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.06,16.73,APC
Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.27,,,,,,,fee schedule,4.06,16.73,APC
Smear gram stain,87205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.69,,,,,,,fee schedule,4.06,16.73,APC
Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.71,,,,,,,fee schedule,5.12,22.67,
Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.12,,,,,,,fee schedule,5.12,22.67,
Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.13,,,,,,,fee schedule,5.12,22.67,
Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.92,,,,,,,fee schedule,5.12,22.67,
Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.67,,,,,,,fee schedule,5.12,22.67,
Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.66,,,,,,,fee schedule,5.12,22.67,APC
Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.39,,,,,,,fee schedule,5.12,22.67,APC
Smear fluorescent/acid stai,87206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.7,,,,,,,fee schedule,5.12,22.67,APC
Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.79,,,,,,,fee schedule,5.69,53.81,
Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.69,,,,,,,fee schedule,5.69,53.81,
Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.3,,,,,,,fee schedule,5.69,53.81,
Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.68,,,,,,,fee schedule,5.69,53.81,
Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.81,,,,,,,fee schedule,5.69,53.81,
Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.29,,,,,,,fee schedule,5.69,53.81,APC
Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.99,,,,,,,fee schedule,5.69,53.81,APC
Smear special stain,87207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.78,,,,,,,fee schedule,5.69,53.81,APC
Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.75,,,,,,,fee schedule,17.08,72.16,
Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.08,,,,,,,fee schedule,17.08,72.16,
Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.36,,,,,,,fee schedule,17.08,72.16,
Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.14,,,,,,,fee schedule,17.08,72.16,
Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.16,,,,,,,fee schedule,17.08,72.16,
Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.88,,,,,,,fee schedule,17.08,72.16,APC
Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.98,,,,,,,fee schedule,17.08,72.16,APC
Smear complex stain,87209,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.36,,,,,,,fee schedule,17.08,72.16,APC
Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.44,,,,,,,fee schedule,5.53,47.66,
Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.53,,,,,,,fee schedule,5.53,47.66,
Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.92,,,,,,,fee schedule,5.53,47.66,
Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.17,,,,,,,fee schedule,5.53,47.66,
Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.66,,,,,,,fee schedule,5.53,47.66,
Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.11,,,,,,,fee schedule,5.53,47.66,APC
Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.82,,,,,,,fee schedule,5.53,47.66,APC
Smear wet mount saline/ink,87210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.48,,,,,,,fee schedule,5.53,47.66,APC
Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.46,,,,,,,fee schedule,4.06,37.33,
Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.06,,,,,,,fee schedule,4.06,37.33,
Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.57,,,,,,,fee schedule,4.06,37.33,
Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.28,,,,,,,fee schedule,4.06,37.33,
Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.33,,,,,,,fee schedule,4.06,37.33,
Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.06,37.33,APC
Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.27,,,,,,,fee schedule,4.06,37.33,APC
Tissue exam for fungi,87220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.69,,,,,,,fee schedule,4.06,37.33,APC
Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.24,,,,,,,fee schedule,18.75,78.48,
Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.75,,,,,,,fee schedule,18.75,78.48,
Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.85,,,,,,,fee schedule,18.75,78.48,
Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.74,,,,,,,fee schedule,18.75,78.48,
Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.48,,,,,,,fee schedule,18.75,78.48,
Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.73,,,,,,,fee schedule,18.75,78.48,APC
Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.74,,,,,,,fee schedule,18.75,78.48,APC
Assay toxin or antitoxin,87230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.53,,,,,,,fee schedule,18.75,78.48,APC
Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.26,,,,,,,fee schedule,18.58,84.25,
Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.58,,,,,,,fee schedule,18.58,84.25,
Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.96,,,,,,,fee schedule,18.58,84.25,
Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.03,,,,,,,fee schedule,18.58,84.25,
Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.25,,,,,,,fee schedule,18.58,84.25,
Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.54,,,,,,,fee schedule,18.58,84.25,APC
Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.56,,,,,,,fee schedule,18.58,84.25,APC
Virus inoculate eggs/animal,87250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.21,,,,,,,fee schedule,18.58,84.25,APC
Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.25,,,,,,,fee schedule,24.77,102.64,
Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.77,,,,,,,fee schedule,24.77,102.64,
Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.05,,,,,,,fee schedule,24.77,102.64,
Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.51,,,,,,,fee schedule,24.77,102.64,
Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.64,,,,,,,fee schedule,24.77,102.64,
Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.37,,,,,,,fee schedule,24.77,102.64,APC
Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.07,,,,,,,fee schedule,24.77,102.64,APC
Virus inoculation tissue,87252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.93,,,,,,,fee schedule,24.77,102.64,APC
Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.24,,,,,,,fee schedule,19.19,79.63,
Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.19,,,,,,,fee schedule,19.19,79.63,
Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.67,,,,,,,fee schedule,19.19,79.63,
Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.39,,,,,,,fee schedule,19.19,79.63,
Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.63,,,,,,,fee schedule,19.19,79.63,
Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.21,,,,,,,fee schedule,19.19,79.63,APC
Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.2,,,,,,,fee schedule,19.19,79.63,APC
Virus inoculate tissue addl,87253,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.36,,,,,,,fee schedule,19.19,79.63,APC
Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.13,,,,,,,fee schedule,18.58,79.5,
Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.58,,,,,,,fee schedule,18.58,79.5,
Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.58,,,,,,,fee schedule,18.58,79.5,
Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.32,,,,,,,fee schedule,18.58,79.5,
Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.5,,,,,,,fee schedule,18.58,79.5,
Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.54,,,,,,,fee schedule,18.58,79.5,APC
Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.56,,,,,,,fee schedule,18.58,79.5,APC
Virus inoculation shell via,87254,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.21,,,,,,,fee schedule,18.58,79.5,APC
Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.83,,,,,,,fee schedule,32.17,145.85,
Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.17,,,,,,,fee schedule,32.17,145.85,
Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.81,,,,,,,fee schedule,32.17,145.85,
Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.15,,,,,,,fee schedule,32.17,145.85,
Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.85,,,,,,,fee schedule,32.17,145.85,
Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.55,,,,,,,fee schedule,32.17,145.85,APC
Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.86,,,,,,,fee schedule,32.17,145.85,APC
Genet virus isolate hsv,87255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,60.95,,,,,,,fee schedule,32.17,145.85,APC
Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,13.71,51.62,
Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.71,,,,,,,fee schedule,13.71,51.62,
Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,13.71,51.62,
Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,13.71,51.62,
Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,13.71,51.62,
Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.15,,,,,,,fee schedule,13.71,51.62,APC
Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.43,,,,,,,fee schedule,13.71,51.62,APC
Adenovirus ag if,87260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.97,,,,,,,fee schedule,13.71,51.62,APC
Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.38,51.62,
Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,51.62,
Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.38,51.62,
Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.38,51.62,
Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.38,51.62,
Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,51.62,APC
Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,51.62,APC
Pertussis ag if,87265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,51.62,APC
Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,12.75,51.62,
Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.75,,,,,,,fee schedule,12.75,51.62,
Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,12.75,51.62,
Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,12.75,51.62,
Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,12.75,51.62,
Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.75,51.62,APC
Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.42,,,,,,,fee schedule,12.75,51.62,APC
Enterovirus antibody dfa,87267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.16,,,,,,,fee schedule,12.75,51.62,APC
Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.46,,,,,,,fee schedule,12.93,38.48,
Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.93,,,,,,,fee schedule,12.93,38.48,
Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.39,,,,,,,fee schedule,12.93,38.48,
Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,12.93,38.48,
Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.48,,,,,,,fee schedule,12.93,38.48,
Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.29,,,,,,,fee schedule,12.93,38.48,APC
Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.61,,,,,,,fee schedule,12.93,38.48,APC
Giardia ag if,87269,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.5,,,,,,,fee schedule,12.93,38.48,APC
Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.38,51.62,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,51.62,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.38,51.62,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.38,51.62,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.38,51.62,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,51.62,APC
Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,51.62,APC
Chlamydia trachomatis ag if,87270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,51.62,APC
Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,12.75,51.62,
Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.75,,,,,,,fee schedule,12.75,51.62,
Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,12.75,51.62,
Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,12.75,51.62,
Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,12.75,51.62,
Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.75,51.62,APC
Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.42,,,,,,,fee schedule,12.75,51.62,APC
Cytomegalovirus dfa,87271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.16,,,,,,,fee schedule,12.75,51.62,APC
Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.46,,,,,,,fee schedule,11.38,38.48,
Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,38.48,
Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.39,,,,,,,fee schedule,11.38,38.48,
Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,11.38,38.48,
Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.48,,,,,,,fee schedule,11.38,38.48,
Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,38.48,APC
Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,38.48,APC
Cryptosporidium ag if,87272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,38.48,APC
Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,51.62,APC
Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,51.62,APC
Herpes simplex 2 ag if,87273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,51.62,APC
Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.38,51.62,
Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,51.62,APC
Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,51.62,APC
Herpes simplex 1 ag if,87274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,51.62,APC
Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.64,51.62,
Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.64,,,,,,,fee schedule,11.64,51.62,
Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.64,51.62,
Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.64,51.62,
Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.64,51.62,
Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.86,,,,,,,fee schedule,11.64,51.62,APC
Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.25,,,,,,,fee schedule,11.64,51.62,APC
Influenza b ag if,87275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.05,,,,,,,fee schedule,11.64,51.62,APC
Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,15.27,51.62,
Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.27,,,,,,,fee schedule,15.27,51.62,
Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,15.27,51.62,
Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,15.27,51.62,
Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,15.27,51.62,
Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.87,,,,,,,fee schedule,15.27,51.62,APC
Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.07,,,,,,,fee schedule,15.27,51.62,APC
Influenza a ag if,87276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.93,,,,,,,fee schedule,15.27,51.62,APC
Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.47,,,,,,,fee schedule,14.82,38.49,
Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.82,,,,,,,fee schedule,14.82,38.49,
Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.4,,,,,,,fee schedule,14.82,38.49,
Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,14.82,38.49,
Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.49,,,,,,,fee schedule,14.82,38.49,
Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.38,,,,,,,fee schedule,14.82,38.49,APC
Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.6,,,,,,,fee schedule,14.82,38.49,APC
Legion pneumophilia ag if,87278,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.08,,,,,,,fee schedule,14.82,38.49,APC
Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,15.61,51.62,
Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.61,,,,,,,fee schedule,15.61,51.62,
Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,15.61,51.62,
Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,15.61,51.62,
Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,15.61,51.62,
Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.25,,,,,,,fee schedule,15.61,51.62,APC
Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.43,,,,,,,fee schedule,15.61,51.62,APC
Parainfluenza ag if,87279,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.57,,,,,,,fee schedule,15.61,51.62,APC
Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,12.75,51.62,
Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.75,,,,,,,fee schedule,12.75,51.62,
Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,12.75,51.62,
Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,12.75,51.62,
Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,12.75,51.62,
Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.75,51.62,APC
Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.42,,,,,,,fee schedule,12.75,51.62,APC
Respiratory syncytial ag if,87280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.16,,,,,,,fee schedule,12.75,51.62,APC
Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.46,,,,,,,fee schedule,11.38,38.48,
Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,38.48,
Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.39,,,,,,,fee schedule,11.38,38.48,
Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,11.38,38.48,
Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.48,,,,,,,fee schedule,11.38,38.48,
Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,38.48,APC
Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,38.48,APC
Pneumocystis carinii ag if,87281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,38.48,APC
Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,29.43,109.44,
Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,57.76,,,,,,,fee schedule,29.43,109.44,
Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,29.43,109.44,
Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,29.43,109.44,
Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,29.43,109.44,
Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.84,,,,,,,fee schedule,29.43,109.44,APC
Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.8,,,,,,,fee schedule,29.43,109.44,APC
Rubeola ag if,87283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,109.44,,,,,,,fee schedule,29.43,109.44,APC
Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.57,51.62,
Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.57,,,,,,,fee schedule,11.57,51.62,
Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.57,51.62,
Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.57,51.62,
Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.57,51.62,
Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.79,,,,,,,fee schedule,11.57,51.62,APC
Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.18,,,,,,,fee schedule,11.57,51.62,APC
Treponema pallidum ag if,87285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.92,,,,,,,fee schedule,11.57,51.62,APC
Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.47,,,,,,,fee schedule,12.75,38.49,
Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.75,,,,,,,fee schedule,12.75,38.49,
Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.4,,,,,,,fee schedule,12.75,38.49,
Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,12.75,38.49,
Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.49,,,,,,,fee schedule,12.75,38.49,
Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.75,38.49,APC
Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.42,,,,,,,fee schedule,12.75,38.49,APC
Varicella zoster ag if,87290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.16,,,,,,,fee schedule,12.75,38.49,APC
Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,15.3,51.62,
Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.3,,,,,,,fee schedule,15.3,51.62,
Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,15.3,51.62,
Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,15.3,51.62,
Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,15.3,51.62,
Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.9,,,,,,,fee schedule,15.3,51.62,APC
Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.1,,,,,,,fee schedule,15.3,51.62,APC
Antibody detection nos if,87299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.98,,,,,,,fee schedule,15.3,51.62,APC
Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.38,51.62,
Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,51.62,
Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.38,51.62,
Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.38,51.62,
Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.38,51.62,
Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,51.62,APC
Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,51.62,APC
Ag detection polyval if,87300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,51.62,APC
Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.38,51.62,
Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,51.62,
Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.38,51.62,
Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.38,51.62,
Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.38,51.62,
Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,51.62,APC
Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,51.62,APC
Adenovirus ag ia,87301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,51.62,APC
Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.77,,,,,,,fee schedule,11.38,137.74,
Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,137.74,
Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.03,,,,,,,fee schedule,11.38,137.74,
Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.52,,,,,,,fee schedule,11.38,137.74,
Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.74,,,,,,,fee schedule,11.38,137.74,
Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,137.74,APC
Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,137.74,APC
Aspergillus ag ia,87305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,137.74,APC
Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,14.25,51.62,
Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.25,,,,,,,fee schedule,14.25,51.62,
Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,14.25,51.62,
Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,14.25,51.62,
Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,14.25,51.62,
Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.75,,,,,,,fee schedule,14.25,51.62,APC
Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15,,,,,,,fee schedule,14.25,51.62,APC
Chylmd trach ag ia,87320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27,,,,,,,fee schedule,14.25,51.62,APC
Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.47,,,,,,,fee schedule,11.38,38.49,
Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,38.49,
Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.4,,,,,,,fee schedule,11.38,38.49,
Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,11.38,38.49,
Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.49,,,,,,,fee schedule,11.38,38.49,
Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,38.49,APC
Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,38.49,APC
Clostridium ag ia,87324,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,38.49,APC
Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,12.75,51.62,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.75,,,,,,,fee schedule,12.75,51.62,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,12.75,51.62,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,12.75,51.62,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,12.75,51.62,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.75,51.62,APC
Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.42,,,,,,,fee schedule,12.75,51.62,APC
Cryptococcus neoform ag ia,87327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.16,,,,,,,fee schedule,12.75,51.62,APC
Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.47,,,,,,,fee schedule,13.13,38.49,
Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.13,,,,,,,fee schedule,13.13,38.49,
Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.4,,,,,,,fee schedule,13.13,38.49,
Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,13.13,38.49,
Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.49,,,,,,,fee schedule,13.13,38.49,
Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.51,,,,,,,fee schedule,13.13,38.49,APC
Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.82,,,,,,,fee schedule,13.13,38.49,APC
Cryptosporidium ag ia,87328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.88,,,,,,,fee schedule,13.13,38.49,APC
Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.47,,,,,,,fee schedule,11.38,38.49,
Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,38.49,
Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.4,,,,,,,fee schedule,11.38,38.49,
Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,11.38,38.49,
Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.49,,,,,,,fee schedule,11.38,38.49,
Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,38.49,APC
Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,38.49,APC
Giardia ag ia,87329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,38.49,APC
Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.38,51.62,
Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,51.62,
Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.38,51.62,
Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.38,51.62,
Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.38,51.62,
Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,51.62,APC
Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,51.62,APC
Cytomegalovirus ag ia,87332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,51.62,APC
E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,12.03,51.62,
E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.03,,,,,,,fee schedule,12.03,51.62,
E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,12.03,51.62,
E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,12.03,51.62,
E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,12.03,51.62,
E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.29,,,,,,,fee schedule,12.03,51.62,APC
E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.66,,,,,,,fee schedule,12.03,51.62,APC
E coli 0157 ag ia,87335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.79,,,,,,,fee schedule,12.03,51.62,APC
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,15.2,51.62,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.2,,,,,,,fee schedule,15.2,51.62,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,15.2,51.62,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,15.2,51.62,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,15.2,51.62,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.8,,,,,,,fee schedule,15.2,51.62,APC
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16,,,,,,,fee schedule,15.2,51.62,APC
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.8,,,,,,,fee schedule,15.2,51.62,APC
Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.38,51.62,
Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,51.62,
Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.38,51.62,
Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.38,51.62,
Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.38,51.62,
Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,51.62,APC
Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,51.62,APC
Entamoeb hist group ag ia,87337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,51.62,APC
Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.88,,,,,,,fee schedule,13.66,50.46,
Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.66,,,,,,,fee schedule,13.66,50.46,
Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.92,,,,,,,fee schedule,13.66,50.46,
Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.77,,,,,,,fee schedule,13.66,50.46,
Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.46,,,,,,,fee schedule,13.66,50.46,
Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.1,,,,,,,fee schedule,13.66,50.46,APC
Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.38,,,,,,,fee schedule,13.66,50.46,APC
Hpylori stool ia,87338,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.88,,,,,,,fee schedule,13.66,50.46,APC
H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,15.2,51.62,
H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.2,,,,,,,fee schedule,15.2,51.62,
H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,15.2,51.62,
H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,15.2,51.62,
H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,15.2,51.62,
H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.8,,,,,,,fee schedule,15.2,51.62,APC
H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16,,,,,,,fee schedule,15.2,51.62,APC
H pylori ag ia,87339,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.8,,,,,,,fee schedule,15.2,51.62,APC
Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.17,,,,,,,fee schedule,9.81,56.55,
Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.81,,,,,,,fee schedule,9.81,56.55,
Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.25,,,,,,,fee schedule,9.81,56.55,
Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.24,,,,,,,fee schedule,9.81,56.55,
Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.55,,,,,,,fee schedule,9.81,56.55,
Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.85,,,,,,,fee schedule,9.81,56.55,APC
Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.33,,,,,,,fee schedule,9.81,56.55,APC
Hepatitis b surface ag ia,87340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.59,,,,,,,fee schedule,9.81,56.55,APC
Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,132.04,,,,,,,fee schedule,9.81,151.85,
Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.81,,,,,,,fee schedule,9.81,151.85,
Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.07,,,,,,,fee schedule,9.81,151.85,
Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.57,,,,,,,fee schedule,9.81,151.85,
Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.85,,,,,,,fee schedule,9.81,151.85,
Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.85,,,,,,,fee schedule,9.81,151.85,APC
Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.33,,,,,,,fee schedule,9.81,151.85,APC
Hepatitis b surface ag ia,87341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.59,,,,,,,fee schedule,9.81,151.85,APC
Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.29,,,,,,,fee schedule,10.95,20.75,
Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.95,,,,,,,fee schedule,10.95,20.75,
Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.15,,,,,,,fee schedule,10.95,20.75,
Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.34,,,,,,,fee schedule,10.95,20.75,
Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.88,,,,,,,fee schedule,10.95,20.75,
Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.95,20.75,APC
Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.53,,,,,,,fee schedule,10.95,20.75,APC
Hepatitis be ag ia,87350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.75,,,,,,,fee schedule,10.95,20.75,APC
Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.01,,,,,,,fee schedule,17.44,56.36,
Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.44,,,,,,,fee schedule,17.44,56.36,
Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.11,,,,,,,fee schedule,17.44,56.36,
Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.13,,,,,,,fee schedule,17.44,56.36,
Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.36,,,,,,,fee schedule,17.44,56.36,
Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,17.44,56.36,APC
Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.36,,,,,,,fee schedule,17.44,56.36,APC
Hepatitis delta ag ia,87380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.05,,,,,,,fee schedule,17.44,56.36,APC
Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.14,,,,,,,fee schedule,12.59,101.36,
Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.59,,,,,,,fee schedule,12.59,101.36,
Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.14,,,,,,,fee schedule,12.59,101.36,
Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.78,,,,,,,fee schedule,12.59,101.36,
Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.36,,,,,,,fee schedule,12.59,101.36,
Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,12.59,101.36,APC
Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.25,,,,,,,fee schedule,12.59,101.36,APC
Histoplasma capsul ag ia,87385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.85,,,,,,,fee schedule,12.59,101.36,APC
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.19,,,,,,,fee schedule,22.88,146.27,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.88,,,,,,,fee schedule,22.88,146.27,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.11,,,,,,,fee schedule,22.88,146.27,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.39,,,,,,,fee schedule,22.88,146.27,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.27,,,,,,,fee schedule,22.88,146.27,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.28,,,,,,,fee schedule,22.88,146.27,APC
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.08,,,,,,,fee schedule,22.88,146.27,APC
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.34,,,,,,,fee schedule,22.88,146.27,APC
Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.92,,,,,,,fee schedule,22.86,60.86,
Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.86,,,,,,,fee schedule,22.86,60.86,
Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.32,,,,,,,fee schedule,22.86,60.86,
Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.69,,,,,,,fee schedule,22.86,60.86,
Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.86,,,,,,,fee schedule,22.86,60.86,
Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.26,,,,,,,fee schedule,22.86,60.86,APC
Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.06,,,,,,,fee schedule,22.86,60.86,APC
Hiv-1 ag ia,87390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.31,,,,,,,fee schedule,22.86,60.86,APC
Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.22,,,,,,,fee schedule,20.81,43.95,
Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.81,,,,,,,fee schedule,20.81,43.95,
Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.28,,,,,,,fee schedule,20.81,43.95,
Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.06,,,,,,,fee schedule,20.81,43.95,
Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.95,,,,,,,fee schedule,20.81,43.95,
Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23,,,,,,,fee schedule,20.81,43.95,APC
Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.9,,,,,,,fee schedule,20.81,43.95,APC
Hiv-2 ag ia,87391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.42,,,,,,,fee schedule,20.81,43.95,APC
Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.06,,,,,,,fee schedule,13.42,52.97,
Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.42,,,,,,,fee schedule,13.42,52.97,
Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.7,,,,,,,fee schedule,13.42,52.97,
Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.2,,,,,,,fee schedule,13.42,52.97,
Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.97,,,,,,,fee schedule,13.42,52.97,
Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.84,,,,,,,fee schedule,13.42,52.97,APC
Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.13,,,,,,,fee schedule,13.42,52.97,APC
Influenza a/b ag ia,87400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.43,,,,,,,fee schedule,13.42,52.97,APC
Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.46,,,,,,,fee schedule,13.21,38.48,
Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.21,,,,,,,fee schedule,13.21,38.48,
Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.39,,,,,,,fee schedule,13.21,38.48,
Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,13.21,38.48,
Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.48,,,,,,,fee schedule,13.21,38.48,
Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.61,,,,,,,fee schedule,13.21,38.48,APC
Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.91,,,,,,,fee schedule,13.21,38.48,APC
Resp syncytial ag ia,87420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.04,,,,,,,fee schedule,13.21,38.48,APC
Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.46,,,,,,,fee schedule,11.38,38.48,
Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,38.48,
Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.39,,,,,,,fee schedule,11.38,38.48,
Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,11.38,38.48,
Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.48,,,,,,,fee schedule,11.38,38.48,
Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,38.48,APC
Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,38.48,APC
Rotavirus ag ia,87425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,38.48,APC
Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.76,,,,,,,fee schedule,30,63.59,
Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.23,,,,,,,fee schedule,30,63.59,
Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.45,,,,,,,fee schedule,30,63.59,
Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30,,,,,,,fee schedule,30,63.59,
Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.62,,,,,,,fee schedule,30,63.59,
Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.1,,,,,,,fee schedule,30,63.59,APC
Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.33,,,,,,,fee schedule,30,63.59,APC
Coronavirus ag ia,87426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.59,,,,,,,fee schedule,30,63.59,APC
Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.46,,,,,,,fee schedule,11.38,38.48,
Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,38.48,
Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.39,,,,,,,fee schedule,11.38,38.48,
Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,11.38,38.48,
Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.48,,,,,,,fee schedule,11.38,38.48,
Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,38.48,APC
Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,38.48,APC
Shiga-like toxin ag ia,87427,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,38.48,APC
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.35,,,,,,,fee schedule,53.99,126.52,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,73.49,,,,,,,fee schedule,53.99,126.52,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.4,,,,,,,fee schedule,53.99,126.52,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.99,,,,,,,fee schedule,53.99,126.52,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.7,,,,,,,fee schedule,53.99,126.52,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.8,,,,,,,fee schedule,53.99,126.52,APC
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.29,,,,,,,fee schedule,53.99,126.52,APC
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,126.52,,,,,,,fee schedule,53.99,126.52,APC
Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,15.97,51.62,
Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.97,,,,,,,fee schedule,15.97,51.62,
Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,15.97,51.62,
Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,15.97,51.62,
Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,15.97,51.62,
Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.65,,,,,,,fee schedule,15.97,51.62,APC
Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.81,,,,,,,fee schedule,15.97,51.62,APC
Strep a ag ia,87430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.26,,,,,,,fee schedule,15.97,51.62,APC
Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.48,,,,,,,fee schedule,11.38,112.1,
Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.38,,,,,,,fee schedule,11.38,112.1,
Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.79,,,,,,,fee schedule,11.38,112.1,
Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.91,,,,,,,fee schedule,11.38,112.1,
Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.1,,,,,,,fee schedule,11.38,112.1,
Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.38,112.1,APC
Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.38,112.1,APC
Ag detect nos ia mult,87449,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.38,112.1,APC
Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.9,,,,,,,fee schedule,9.98,41.29,
Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.98,,,,,,,fee schedule,9.98,41.29,
Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.38,,,,,,,fee schedule,9.98,41.29,
Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.54,,,,,,,fee schedule,9.98,41.29,
Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.29,,,,,,,fee schedule,9.98,41.29,
Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.04,,,,,,,fee schedule,9.98,41.29,APC
Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.51,,,,,,,fee schedule,9.98,41.29,APC
Ag detect polyval ia mult,87451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.92,,,,,,,fee schedule,9.98,41.29,APC
Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.78,,,,,,,fee schedule,14.3,45.58,
Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.3,,,,,,,fee schedule,14.3,45.58,
Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.56,,,,,,,fee schedule,14.3,45.58,
Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.87,,,,,,,fee schedule,14.3,45.58,
Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.1,,,,,,,fee schedule,14.3,45.58,
Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.59,,,,,,,fee schedule,14.3,45.58,APC
Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.32,,,,,,,fee schedule,14.3,45.58,APC
Hepatitis b surface ag quan,87467,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.58,,,,,,,fee schedule,14.3,45.58,APC
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.08,,,,,,,fee schedule,33.34,77.14,
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,77.14,
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.9,,,,,,,fee schedule,33.34,77.14,
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.98,,,,,,,fee schedule,33.34,77.14,
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.14,,,,,,,fee schedule,33.34,77.14,
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,77.14,APC
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,77.14,APC
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,77.14,APC
Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.08,,,,,,,fee schedule,33.34,77.14,
Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,77.14,
Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.9,,,,,,,fee schedule,33.34,77.14,
Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.98,,,,,,,fee schedule,33.34,77.14,
Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.14,,,,,,,fee schedule,33.34,77.14,
Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,77.14,APC
Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,77.14,APC
Babesia microti amp prb,87469,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,77.14,APC
Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Bartonella dna amp probe,87471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.42,,,,,,,fee schedule,40.7,184.48,
Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,184.48,
Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.3,,,,,,,fee schedule,40.7,184.48,
Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.17,,,,,,,fee schedule,40.7,184.48,
Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.48,,,,,,,fee schedule,40.7,184.48,
Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,184.48,APC
Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,184.48,APC
Bartonella dna quant,87472,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,184.48,APC
Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Lyme dis dna dir probe,87475,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Lyme dis dna amp probe,87476,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.08,,,,,,,fee schedule,33.34,77.14,
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,77.14,
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.9,,,,,,,fee schedule,33.34,77.14,
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.98,,,,,,,fee schedule,33.34,77.14,
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.14,,,,,,,fee schedule,33.34,77.14,
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,77.14,APC
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,77.14,APC
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,77.14,APC
Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Candida dna dir probe,87480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Candida dna amp probe,87481,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.38,,,,,,,fee schedule,52.95,179.84,
Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,52.95,,,,,,,fee schedule,52.95,179.84,
Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128,,,,,,,fee schedule,52.95,179.84,
Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.52,,,,,,,fee schedule,52.95,179.84,
Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.84,,,,,,,fee schedule,52.95,179.84,
Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.53,,,,,,,fee schedule,52.95,179.84,APC
Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55.74,,,,,,,fee schedule,52.95,179.84,APC
Candida dna quant,87482,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,100.33,,,,,,,fee schedule,52.95,179.84,APC
Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1560.96,,,,,,,fee schedule,395.94,1795.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,395.94,,,,,,,fee schedule,395.94,1795.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1277.65,,,,,,,fee schedule,395.94,1795.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1023.37,,,,,,,fee schedule,395.94,1795.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1795.1,,,,,,,fee schedule,395.94,1795.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,395.94,1795.1,APC
Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,395.94,1795.1,APC
Cns dna amp probe type 12-25,87483,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,395.94,1795.1,APC
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.08,,,,,,,fee schedule,33.34,77.14,
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,77.14,
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.9,,,,,,,fee schedule,33.34,77.14,
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.98,,,,,,,fee schedule,33.34,77.14,
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.14,,,,,,,fee schedule,33.34,77.14,
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,77.14,APC
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,77.14,APC
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,77.14,APC
Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Chylmd pneum dna dir probe,87485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Chylmd pneum dna amp probe,87486,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.42,,,,,,,fee schedule,40.7,184.48,
Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,184.48,
Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.3,,,,,,,fee schedule,40.7,184.48,
Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.17,,,,,,,fee schedule,40.7,184.48,
Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.48,,,,,,,fee schedule,40.7,184.48,
Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,184.48,APC
Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,184.48,APC
Chylmd pneum dna quant,87487,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,184.48,APC
Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,21.61,86.38,
Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.61,,,,,,,fee schedule,21.61,86.38,
Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,21.61,86.38,
Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,21.61,86.38,
Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,21.61,86.38,
Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.89,,,,,,,fee schedule,21.61,86.38,APC
Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.75,,,,,,,fee schedule,21.61,86.38,APC
Chylmd trach dna dir probe,87490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40.95,,,,,,,fee schedule,21.61,86.38,APC
Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.65,,,,,,,fee schedule,24.03,63.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,24.03,63.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30,,,,,,,fee schedule,24.03,63.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.03,,,,,,,fee schedule,24.03,63.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.15,,,,,,,fee schedule,24.03,63.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,24.03,63.16,APC
Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,24.03,63.16,APC
Chylmd trach dna amp probe,87491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,24.03,63.16,APC
Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.91,,,,,,,fee schedule,50.8,150.55,
Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,50.8,,,,,,,fee schedule,50.8,150.55,
Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.15,,,,,,,fee schedule,50.8,150.55,
Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.82,,,,,,,fee schedule,50.8,150.55,
Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.55,,,,,,,fee schedule,50.8,150.55,
Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.14,,,,,,,fee schedule,50.8,150.55,APC
Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.47,,,,,,,fee schedule,50.8,150.55,APC
Chylmd trach dna quant,87492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,96.25,,,,,,,fee schedule,50.8,150.55,APC
C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.58,,,,,,,fee schedule,35.41,105.32,
C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,35.41,,,,,,,fee schedule,35.41,105.32,
C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.96,,,,,,,fee schedule,35.41,105.32,
C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.04,,,,,,,fee schedule,35.41,105.32,
C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.32,,,,,,,fee schedule,35.41,105.32,
C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.13,,,,,,,fee schedule,35.41,105.32,APC
C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.27,,,,,,,fee schedule,35.41,105.32,APC
C diff amplified probe,87493,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.09,,,,,,,fee schedule,35.41,105.32,APC
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.69,,,,,,,fee schedule,70.18,126.32,APC
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.18,,,,,,,fee schedule,70.18,126.32,APC
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,126.32,,,,,,,fee schedule,70.18,126.32,APC
Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,28.53,86.38,
Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.53,,,,,,,fee schedule,28.53,86.38,
Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,28.53,86.38,
Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,28.53,86.38,
Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,28.53,86.38,
Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.53,,,,,,,fee schedule,28.53,86.38,APC
Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.03,,,,,,,fee schedule,28.53,86.38,APC
Cytomeg dna dir probe,87495,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54.05,,,,,,,fee schedule,28.53,86.38,APC
Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Cytomeg dna amp probe,87496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,218.04,,,,,,,fee schedule,40.7,250.75,
Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,250.75,
Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.47,,,,,,,fee schedule,40.7,250.75,
Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.95,,,,,,,fee schedule,40.7,250.75,
Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.75,,,,,,,fee schedule,40.7,250.75,
Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,250.75,APC
Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,250.75,APC
Cytomeg dna quant,87497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,250.75,APC
Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.58,,,,,,,fee schedule,33.34,105.32,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,105.32,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.96,,,,,,,fee schedule,33.34,105.32,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.04,,,,,,,fee schedule,33.34,105.32,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.32,,,,,,,fee schedule,33.34,105.32,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,105.32,APC
Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,105.32,APC
Enterovirus probe&revrs trns,87498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,105.32,APC
Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Vanomycin dna amp probe,87500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.18,,,,,,,fee schedule,48.74,221.01,
Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.74,,,,,,,fee schedule,48.74,221.01,
Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.3,,,,,,,fee schedule,48.74,221.01,
Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.99,,,,,,,fee schedule,48.74,221.01,
Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.01,,,,,,,fee schedule,48.74,221.01,
Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,48.74,221.01,APC
Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.31,,,,,,,fee schedule,48.74,221.01,APC
Influenza dna amp prob 1+,87501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.36,,,,,,,fee schedule,48.74,221.01,APC
Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,245.15,,,,,,,fee schedule,91.01,281.92,
Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,91.01,,,,,,,fee schedule,91.01,281.92,
Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,200.66,,,,,,,fee schedule,91.01,281.92,
Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,160.72,,,,,,,fee schedule,91.01,281.92,
Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,281.92,,,,,,,fee schedule,91.01,281.92,
Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.59,,,,,,,fee schedule,91.01,281.92,APC
Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,95.8,,,,,,,fee schedule,91.01,281.92,APC
Influenza dna amp probe,87502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,172.44,,,,,,,fee schedule,91.01,281.92,APC
Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.91,,,,,,,fee schedule,27.76,68.9,
Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.76,,,,,,,fee schedule,27.76,68.9,
Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.04,,,,,,,fee schedule,27.76,68.9,
Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.28,,,,,,,fee schedule,27.76,68.9,
Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.9,,,,,,,fee schedule,27.76,68.9,
Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.68,,,,,,,fee schedule,27.76,68.9,APC
Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.22,,,,,,,fee schedule,27.76,68.9,APC
Influenza dna amp prob addl,87503,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.6,,,,,,,fee schedule,27.76,68.9,APC
Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.46,,,,,,,fee schedule,121.88,552.53,
Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,121.88,,,,,,,fee schedule,121.88,552.53,
Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.26,,,,,,,fee schedule,121.88,552.53,
Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,314.99,,,,,,,fee schedule,121.88,552.53,
Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.53,,,,,,,fee schedule,121.88,552.53,
Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.7,,,,,,,fee schedule,121.88,552.53,APC
Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.29,,,,,,,fee schedule,121.88,552.53,APC
Nfct agent detection gi,87505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.92,,,,,,,fee schedule,121.88,552.53,APC
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.84,,,,,,,fee schedule,105.45,473.38,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,249.84,,,,,,,fee schedule,105.45,473.38,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.65,,,,,,,fee schedule,105.45,473.38,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.45,,,,,,,fee schedule,105.45,473.38,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.97,,,,,,,fee schedule,105.45,473.38,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,105.45,473.38,APC
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,262.99,,,,,,,fee schedule,105.45,473.38,APC
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,473.38,,,,,,,fee schedule,105.45,473.38,APC
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1560.96,,,,,,,fee schedule,395.94,1795.1,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,395.94,,,,,,,fee schedule,395.94,1795.1,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1277.65,,,,,,,fee schedule,395.94,1795.1,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1023.37,,,,,,,fee schedule,395.94,1795.1,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1795.1,,,,,,,fee schedule,395.94,1795.1,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,395.94,1795.1,APC
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,395.94,1795.1,APC
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,395.94,1795.1,APC
Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Gardner vag dna dir probe,87510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Gardner vag dna amp probe,87511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.38,,,,,,,fee schedule,39.67,179.84,
Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.67,,,,,,,fee schedule,39.67,179.84,
Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128,,,,,,,fee schedule,39.67,179.84,
Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.52,,,,,,,fee schedule,39.67,179.84,
Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.84,,,,,,,fee schedule,39.67,179.84,
Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,39.67,179.84,APC
Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.76,,,,,,,fee schedule,39.67,179.84,APC
Gardner vag dna quant,87512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.17,,,,,,,fee schedule,39.67,179.84,APC
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.38,,,,,,,fee schedule,35.09,65.99,
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.97,,,,,,,fee schedule,35.09,65.99,
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.62,,,,,,,fee schedule,35.09,65.99,
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.99,,,,,,,fee schedule,35.09,65.99,
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,65.99,APC
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,65.99,APC
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,65.99,APC
Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.06,,,,,,,fee schedule,5.28,63.16,
Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,5.28,63.16,
Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.6,,,,,,,fee schedule,5.28,63.16,
Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.28,,,,,,,fee schedule,5.28,63.16,
Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.27,,,,,,,fee schedule,5.28,63.16,
Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,5.28,63.16,APC
Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,5.28,63.16,APC
Hepatitis b dna amp probe,87516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,5.28,63.16,APC
Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.06,,,,,,,fee schedule,40.7,259.97,
Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,259.97,
Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.03,,,,,,,fee schedule,40.7,259.97,
Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.2,,,,,,,fee schedule,40.7,259.97,
Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.97,,,,,,,fee schedule,40.7,259.97,
Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,259.97,APC
Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,259.97,APC
Hepatitis b dna quant,87517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,259.97,APC
Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,29.66,86.38,
Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.66,,,,,,,fee schedule,29.66,86.38,
Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,29.66,86.38,
Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,29.66,86.38,
Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,29.66,86.38,
Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.78,,,,,,,fee schedule,29.66,86.38,APC
Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.22,,,,,,,fee schedule,29.66,86.38,APC
Hepatitis c rna dir probe,87520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56.2,,,,,,,fee schedule,29.66,86.38,APC
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.77,,,,,,,fee schedule,6.41,63.16,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,6.41,63.16,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8,,,,,,,fee schedule,6.41,63.16,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.41,,,,,,,fee schedule,6.41,63.16,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.24,,,,,,,fee schedule,6.41,63.16,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,6.41,63.16,APC
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,6.41,63.16,APC
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,6.41,63.16,APC
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.64,,,,,,,fee schedule,40.7,221.54,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,221.54,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.68,,,,,,,fee schedule,40.7,221.54,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.29,,,,,,,fee schedule,40.7,221.54,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.54,,,,,,,fee schedule,40.7,221.54,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,221.54,APC
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,221.54,APC
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,221.54,APC
Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.31,,,,,,,fee schedule,42.84,88.91,
Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.28,,,,,,,fee schedule,42.84,88.91,
Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.68,,,,,,,fee schedule,42.84,88.91,
Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.91,,,,,,,fee schedule,42.84,88.91,
Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,42.84,88.91,APC
Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,42.84,88.91,APC
Hepatitis d quantification,87523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,42.84,88.91,APC
Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,28.31,86.38,
Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.31,,,,,,,fee schedule,28.31,86.38,
Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,28.31,86.38,
Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,28.31,86.38,
Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,28.31,86.38,
Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.29,,,,,,,fee schedule,28.31,86.38,APC
Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.8,,,,,,,fee schedule,28.31,86.38,APC
Hepatitis g dna dir probe,87525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.64,,,,,,,fee schedule,28.31,86.38,APC
Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,37.3,151.13,
Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.3,,,,,,,fee schedule,37.3,151.13,
Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,37.3,151.13,
Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,37.3,151.13,
Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,37.3,151.13,
Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.22,,,,,,,fee schedule,37.3,151.13,APC
Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.26,,,,,,,fee schedule,37.3,151.13,APC
Hepatitis g dna amp probe,87526,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.67,,,,,,,fee schedule,37.3,151.13,APC
Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.38,,,,,,,fee schedule,39.67,179.84,
Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.67,,,,,,,fee schedule,39.67,179.84,
Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128,,,,,,,fee schedule,39.67,179.84,
Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.52,,,,,,,fee schedule,39.67,179.84,
Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.84,,,,,,,fee schedule,39.67,179.84,
Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,39.67,179.84,APC
Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.76,,,,,,,fee schedule,39.67,179.84,APC
Hepatitis g dna quant,87527,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.17,,,,,,,fee schedule,39.67,179.84,APC
Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Hsv dna dir probe,87528,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.9,,,,,,,fee schedule,33.34,126.39,
Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,126.39,
Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.95,,,,,,,fee schedule,33.34,126.39,
Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.05,,,,,,,fee schedule,33.34,126.39,
Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.39,,,,,,,fee schedule,33.34,126.39,
Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,126.39,APC
Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,126.39,APC
Hsv dna amp probe,87529,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,126.39,APC
Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.42,,,,,,,fee schedule,40.7,184.48,
Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,184.48,
Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.3,,,,,,,fee schedule,40.7,184.48,
Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.17,,,,,,,fee schedule,40.7,184.48,
Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.48,,,,,,,fee schedule,40.7,184.48,
Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,184.48,APC
Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,184.48,APC
Hsv dna quant,87530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,184.48,APC
Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,49.24,104.4,
Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,55.1,,,,,,,fee schedule,49.24,104.4,
Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,49.24,104.4,
Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,49.24,104.4,
Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,49.24,104.4,
Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.9,,,,,,,fee schedule,49.24,104.4,APC
Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58,,,,,,,fee schedule,49.24,104.4,APC
Hhv-6 dna dir probe,87531,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.4,,,,,,,fee schedule,49.24,104.4,APC
Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Hhv-6 dna amp probe,87532,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,230.59,,,,,,,fee schedule,39.67,265.18,
Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.67,,,,,,,fee schedule,39.67,265.18,
Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,188.74,,,,,,,fee schedule,39.67,265.18,
Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.17,,,,,,,fee schedule,39.67,265.18,
Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.18,,,,,,,fee schedule,39.67,265.18,
Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,39.67,265.18,APC
Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.76,,,,,,,fee schedule,39.67,265.18,APC
Hhv-6 dna quant,87533,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.17,,,,,,,fee schedule,39.67,265.18,APC
Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,20.82,86.38,
Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.82,,,,,,,fee schedule,20.82,86.38,
Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,20.82,86.38,
Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,20.82,86.38,
Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,20.82,86.38,
Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.02,,,,,,,fee schedule,20.82,86.38,APC
Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.92,,,,,,,fee schedule,20.82,86.38,APC
Hiv-1 dna dir probe,87534,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.46,,,,,,,fee schedule,20.82,86.38,APC
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.06,,,,,,,fee schedule,5.28,63.16,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,5.28,63.16,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.6,,,,,,,fee schedule,5.28,63.16,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.28,,,,,,,fee schedule,5.28,63.16,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.27,,,,,,,fee schedule,5.28,63.16,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,5.28,63.16,APC
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,5.28,63.16,APC
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,5.28,63.16,APC
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,277.66,,,,,,,fee schedule,80.85,319.31,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,80.85,,,,,,,fee schedule,80.85,319.31,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.26,,,,,,,fee schedule,80.85,319.31,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.03,,,,,,,fee schedule,80.85,319.31,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.31,,,,,,,fee schedule,80.85,319.31,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,89.36,,,,,,,fee schedule,80.85,319.31,APC
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,85.1,,,,,,,fee schedule,80.85,319.31,APC
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,153.18,,,,,,,fee schedule,80.85,319.31,APC
Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,20.82,86.38,
Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.82,,,,,,,fee schedule,20.82,86.38,
Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,20.82,86.38,
Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,20.82,86.38,
Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,20.82,86.38,
Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.02,,,,,,,fee schedule,20.82,86.38,APC
Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.92,,,,,,,fee schedule,20.82,86.38,APC
Hiv-2 dna dir probe,87537,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.46,,,,,,,fee schedule,20.82,86.38,APC
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.42,,,,,,,fee schedule,55.69,184.48,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,55.69,,,,,,,fee schedule,55.69,184.48,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.3,,,,,,,fee schedule,55.69,184.48,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.17,,,,,,,fee schedule,55.69,184.48,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.48,,,,,,,fee schedule,55.69,184.48,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.55,,,,,,,fee schedule,55.69,184.48,APC
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.62,,,,,,,fee schedule,55.69,184.48,APC
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.52,,,,,,,fee schedule,55.69,184.48,APC
Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Legion pneumo dna dir prob,87540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Legion pneumo dna amp prob,87541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.38,,,,,,,fee schedule,39.67,179.84,
Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.67,,,,,,,fee schedule,39.67,179.84,
Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128,,,,,,,fee schedule,39.67,179.84,
Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.52,,,,,,,fee schedule,39.67,179.84,
Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.84,,,,,,,fee schedule,39.67,179.84,
Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,39.67,179.84,APC
Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.76,,,,,,,fee schedule,39.67,179.84,APC
Legion pneumo dna quant,87542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.17,,,,,,,fee schedule,39.67,179.84,APC
Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Mycobacteria dna dir probe,87550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.9,,,,,,,fee schedule,45.83,382.84,
Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.83,,,,,,,fee schedule,45.83,382.84,
Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.48,,,,,,,fee schedule,45.83,382.84,
Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.25,,,,,,,fee schedule,45.83,382.84,
Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,382.84,,,,,,,fee schedule,45.83,382.84,
Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.65,,,,,,,fee schedule,45.83,382.84,APC
Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48.24,,,,,,,fee schedule,45.83,382.84,APC
Mycobacteria dna amp probe,87551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86.83,,,,,,,fee schedule,45.83,382.84,APC
Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.42,,,,,,,fee schedule,40.7,184.48,
Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,184.48,
Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.3,,,,,,,fee schedule,40.7,184.48,
Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.17,,,,,,,fee schedule,40.7,184.48,
Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.48,,,,,,,fee schedule,40.7,184.48,
Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,184.48,APC
Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,184.48,APC
Mycobacteria dna quant,87552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,184.48,APC
M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,25.54,86.38,
M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.54,,,,,,,fee schedule,25.54,86.38,
M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,25.54,86.38,
M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,25.54,86.38,
M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,25.54,86.38,
M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.22,,,,,,,fee schedule,25.54,86.38,APC
M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.88,,,,,,,fee schedule,25.54,86.38,APC
M.tuberculo dna dir probe,87555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.38,,,,,,,fee schedule,25.54,86.38,APC
M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.93,,,,,,,fee schedule,39.6,336.87,
M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.6,,,,,,,fee schedule,39.6,336.87,
M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.76,,,,,,,fee schedule,39.6,336.87,
M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.04,,,,,,,fee schedule,39.6,336.87,
M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,336.87,,,,,,,fee schedule,39.6,336.87,
M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.76,,,,,,,fee schedule,39.6,336.87,APC
M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.68,,,,,,,fee schedule,39.6,336.87,APC
M.tuberculo dna amp probe,87556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.02,,,,,,,fee schedule,39.6,336.87,APC
M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.42,,,,,,,fee schedule,40.7,184.48,
M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,184.48,
M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.3,,,,,,,fee schedule,40.7,184.48,
M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.17,,,,,,,fee schedule,40.7,184.48,
M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.48,,,,,,,fee schedule,40.7,184.48,
M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,184.48,APC
M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,184.48,APC
M.tuberculo dna quant,87557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,184.48,APC
M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,25.93,86.38,
M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.93,,,,,,,fee schedule,25.93,86.38,
M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,25.93,86.38,
M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,25.93,86.38,
M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,25.93,86.38,
M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.65,,,,,,,fee schedule,25.93,86.38,APC
M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.29,,,,,,,fee schedule,25.93,86.38,APC
M.avium-intra dna dir prob,87560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49.12,,,,,,,fee schedule,25.93,86.38,APC
M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
M.avium-intra dna amp prob,87561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.42,,,,,,,fee schedule,40.7,184.48,
M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,184.48,
M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.3,,,,,,,fee schedule,40.7,184.48,
M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.17,,,,,,,fee schedule,40.7,184.48,
M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.48,,,,,,,fee schedule,40.7,184.48,
M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,184.48,APC
M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,184.48,APC
M.avium-intra dna quant,87562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,184.48,APC
M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.77,,,,,,,fee schedule,33.34,87.14,
M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,87.14,
M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.02,,,,,,,fee schedule,33.34,87.14,
M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.67,,,,,,,fee schedule,33.34,87.14,
M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.14,,,,,,,fee schedule,33.34,87.14,
M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,87.14,APC
M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,87.14,APC
M. genitalium amp probe,87563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,87.14,APC
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.52,,,,,,,fee schedule,76.77,144.35,
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.74,,,,,,,fee schedule,76.77,144.35,
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.29,,,,,,,fee schedule,76.77,144.35,
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,144.35,,,,,,,fee schedule,76.77,144.35,
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.61,,,,,,,fee schedule,76.77,144.35,APC
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,76.77,,,,,,,fee schedule,76.77,144.35,APC
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,138.19,,,,,,,fee schedule,76.77,144.35,APC
M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
M.pneumon dna dir probe,87580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.97,,,,,,,fee schedule,33.34,112.67,
M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,112.67,
M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.19,,,,,,,fee schedule,33.34,112.67,
M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.23,,,,,,,fee schedule,33.34,112.67,
M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.67,,,,,,,fee schedule,33.34,112.67,
M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,112.67,APC
M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,112.67,APC
M.pneumon dna amp probe,87581,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,112.67,APC
M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.38,,,,,,,fee schedule,102.52,544.72,
M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,287.49,,,,,,,fee schedule,102.52,544.72,
M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128,,,,,,,fee schedule,102.52,544.72,
M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.52,,,,,,,fee schedule,102.52,544.72,
M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.84,,,,,,,fee schedule,102.52,544.72,
M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,317.75,,,,,,,fee schedule,102.52,544.72,APC
M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,302.62,,,,,,,fee schedule,102.52,544.72,APC
M.pneumon dna quant,87582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,544.72,,,,,,,fee schedule,102.52,544.72,APC
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,25.54,86.38,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.54,,,,,,,fee schedule,25.54,86.38,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,25.54,86.38,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,25.54,86.38,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,25.54,86.38,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.22,,,,,,,fee schedule,25.54,86.38,APC
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.88,,,,,,,fee schedule,25.54,86.38,APC
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.38,,,,,,,fee schedule,25.54,86.38,APC
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.39,,,,,,,fee schedule,23.2,63.16,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,23.2,63.16,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.97,,,,,,,fee schedule,23.2,63.16,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.2,,,,,,,fee schedule,23.2,63.16,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.7,,,,,,,fee schedule,23.2,63.16,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,23.2,63.16,APC
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,23.2,63.16,APC
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,23.2,63.16,APC
N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.42,,,,,,,fee schedule,40.7,184.48,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,184.48,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.3,,,,,,,fee schedule,40.7,184.48,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.17,,,,,,,fee schedule,40.7,184.48,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.48,,,,,,,fee schedule,40.7,184.48,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,184.48,APC
N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,184.48,APC
N.gonorrhoeae dna quant,87592,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,184.48,APC
Orthopoxvirus amp prb each,87593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,51.31,,,,,,,fee schedule,51.31,92.36,
Orthopoxvirus amp prb each,87593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,51.31,92.36,APC
Orthopoxvirus amp prb each,87593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.31,,,,,,,fee schedule,51.31,92.36,APC
Orthopoxvirus amp prb each,87593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.36,,,,,,,fee schedule,51.31,92.36,APC
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.38,,,,,,,fee schedule,35.09,65.99,
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.97,,,,,,,fee schedule,35.09,65.99,
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.62,,,,,,,fee schedule,35.09,65.99,
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.99,,,,,,,fee schedule,35.09,65.99,
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,65.99,APC
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,65.99,APC
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,65.99,APC
Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Hpv low-risk types,87623,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.94,,,,,,,fee schedule,33.34,122.98,
Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,122.98,
Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.53,,,,,,,fee schedule,33.34,122.98,
Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.11,,,,,,,fee schedule,33.34,122.98,
Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.98,,,,,,,fee schedule,33.34,122.98,
Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,122.98,APC
Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,122.98,APC
Hpv high-risk types,87624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,122.98,APC
Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,222.55,,,,,,,fee schedule,38.52,255.93,
Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,38.52,,,,,,,fee schedule,38.52,255.93,
Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.16,,,,,,,fee schedule,38.52,255.93,
Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.9,,,,,,,fee schedule,38.52,255.93,
Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.93,,,,,,,fee schedule,38.52,255.93,
Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.58,,,,,,,fee schedule,38.52,255.93,APC
Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40.55,,,,,,,fee schedule,38.52,255.93,APC
Hpv types 16 & 18 only,87625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,72.99,,,,,,,fee schedule,38.52,255.93,APC
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.78,,,,,,,fee schedule,70.2,132,
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.95,,,,,,,fee schedule,70.2,132,
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.25,,,,,,,fee schedule,70.2,132,
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132,,,,,,,fee schedule,70.2,132,
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.71,,,,,,,fee schedule,70.2,132,APC
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.2,,,,,,,fee schedule,70.2,132,APC
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,126.36,,,,,,,fee schedule,70.2,132,APC
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.76,,,,,,,fee schedule,679.77,1223.59,APC
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,679.77,,,,,,,fee schedule,679.77,1223.59,APC
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1223.59,,,,,,,fee schedule,679.77,1223.59,APC
Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.46,,,,,,,fee schedule,135.5,552.53,
Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,135.5,,,,,,,fee schedule,135.5,552.53,
Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.26,,,,,,,fee schedule,135.5,552.53,
Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,314.99,,,,,,,fee schedule,135.5,552.53,
Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.53,,,,,,,fee schedule,135.5,552.53,
Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,135.5,552.53,APC
Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,135.5,552.53,APC
Resp virus 3-5 targets,87631,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,135.5,552.53,APC
Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,799.33,,,,,,,fee schedule,207.16,919.23,
Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,207.16,,,,,,,fee schedule,207.16,919.23,
Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,654.25,,,,,,,fee schedule,207.16,919.23,
Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,524.04,,,,,,,fee schedule,207.16,919.23,
Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,919.23,,,,,,,fee schedule,207.16,919.23,
Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,228.96,,,,,,,fee schedule,207.16,919.23,APC
Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.06,,,,,,,fee schedule,207.16,919.23,APC
Resp virus 6-11 targets,87632,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.51,,,,,,,fee schedule,207.16,919.23,APC
Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.91,,,,,,,fee schedule,395.94,781.9,
Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,395.94,,,,,,,fee schedule,395.94,781.9,
Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,556.51,,,,,,,fee schedule,395.94,781.9,
Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.75,,,,,,,fee schedule,395.94,781.9,
Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.9,,,,,,,fee schedule,395.94,781.9,
Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,395.94,781.9,APC
Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,416.78,,,,,,,fee schedule,395.94,781.9,APC
Resp virus 12-25 targets,87633,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,750.2,,,,,,,fee schedule,395.94,781.9,APC
Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,262.89,,,,,,,fee schedule,66.69,302.32,
Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,66.69,,,,,,,fee schedule,66.69,302.32,
Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,215.18,,,,,,,fee schedule,66.69,302.32,
Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.35,,,,,,,fee schedule,66.69,302.32,
Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,302.32,,,,,,,fee schedule,66.69,302.32,
Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.71,,,,,,,fee schedule,66.69,302.32,APC
Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.2,,,,,,,fee schedule,66.69,302.32,APC
Rsv dna/rna amp probe,87634,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,126.36,,,,,,,fee schedule,66.69,302.32,APC
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.45,,,,,,,fee schedule,43.56,92.36,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,51.31,,,,,,,fee schedule,43.56,92.36,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.39,,,,,,,fee schedule,43.56,92.36,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.56,,,,,,,fee schedule,43.56,92.36,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.42,,,,,,,fee schedule,43.56,92.36,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,43.56,92.36,APC
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.31,,,,,,,fee schedule,43.56,92.36,APC
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.36,,,,,,,fee schedule,43.56,92.36,APC
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,184.72,,,,,,,fee schedule,121.1,256.73,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,142.63,,,,,,,fee schedule,121.1,256.73,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.19,,,,,,,fee schedule,121.1,256.73,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.1,,,,,,,fee schedule,121.1,256.73,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,212.43,,,,,,,fee schedule,121.1,256.73,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,121.1,256.73,APC
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,121.1,256.73,APC
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,121.1,256.73,APC
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,184.72,,,,,,,fee schedule,121.1,256.73,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,142.63,,,,,,,fee schedule,121.1,256.73,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.19,,,,,,,fee schedule,121.1,256.73,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.1,,,,,,,fee schedule,121.1,256.73,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,212.43,,,,,,,fee schedule,121.1,256.73,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,121.1,256.73,APC
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.63,,,,,,,fee schedule,121.1,256.73,APC
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.73,,,,,,,fee schedule,121.1,256.73,APC
Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Staph a dna amp probe,87640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Mr-staph dna amp probe,87641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Strep a dna dir probe,87650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,33.34,151.13,
Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,151.13,
Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,33.34,151.13,
Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,33.34,151.13,
Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,33.34,151.13,
Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,151.13,APC
Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,151.13,APC
Strep a dna amp probe,87651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,151.13,APC
Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.38,,,,,,,fee schedule,39.67,179.84,
Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,39.67,,,,,,,fee schedule,39.67,179.84,
Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128,,,,,,,fee schedule,39.67,179.84,
Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.52,,,,,,,fee schedule,39.67,179.84,
Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.84,,,,,,,fee schedule,39.67,179.84,
Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,39.67,179.84,APC
Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.76,,,,,,,fee schedule,39.67,179.84,APC
Strep a dna quant,87652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.17,,,,,,,fee schedule,39.67,179.84,APC
Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.58,,,,,,,fee schedule,33.34,105.32,
Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,105.32,
Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.96,,,,,,,fee schedule,33.34,105.32,
Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.04,,,,,,,fee schedule,33.34,105.32,
Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.32,,,,,,,fee schedule,33.34,105.32,
Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,105.32,APC
Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,105.32,APC
Strep b dna amp probe,87653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,105.32,APC
Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,19.05,86.38,
Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.05,,,,,,,fee schedule,19.05,86.38,
Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,19.05,86.38,
Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,19.05,86.38,
Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,19.05,86.38,
Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,19.05,86.38,APC
Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.05,,,,,,,fee schedule,19.05,86.38,APC
Trichomonas vagin dir probe,87660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.09,,,,,,,fee schedule,19.05,86.38,APC
Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.38,,,,,,,fee schedule,33.34,131.54,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,131.54,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.62,,,,,,,fee schedule,33.34,131.54,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.99,,,,,,,fee schedule,33.34,131.54,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.54,,,,,,,fee schedule,33.34,131.54,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,131.54,APC
Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,131.54,APC
Trichomonas vaginalis amplif,87661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,131.54,APC
Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.18,,,,,,,fee schedule,48.74,221.01,
Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.74,,,,,,,fee schedule,48.74,221.01,
Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.3,,,,,,,fee schedule,48.74,221.01,
Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.99,,,,,,,fee schedule,48.74,221.01,
Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.01,,,,,,,fee schedule,48.74,221.01,
Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,48.74,221.01,APC
Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.31,,,,,,,fee schedule,48.74,221.01,APC
Zika virus dna/rna amp probe,87662,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.36,,,,,,,fee schedule,48.74,221.01,APC
Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.11,,,,,,,fee schedule,28.53,86.38,
Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.53,,,,,,,fee schedule,28.53,86.38,
Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.48,,,,,,,fee schedule,28.53,86.38,
Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.24,,,,,,,fee schedule,28.53,86.38,
Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.38,,,,,,,fee schedule,28.53,86.38,
Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.53,,,,,,,fee schedule,28.53,86.38,APC
Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.03,,,,,,,fee schedule,28.53,86.38,APC
Detect agent nos dna dir,87797,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54.05,,,,,,,fee schedule,28.53,86.38,APC
Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.92,,,,,,,fee schedule,33.34,120.66,
Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.34,,,,,,,fee schedule,33.34,120.66,
Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.88,,,,,,,fee schedule,33.34,120.66,
Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.79,,,,,,,fee schedule,33.34,120.66,
Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.66,,,,,,,fee schedule,33.34,120.66,
Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,33.34,120.66,APC
Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,33.34,120.66,APC
Detect agent nos dna amp,87798,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,33.34,120.66,APC
Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,162.68,,,,,,,fee schedule,40.7,187.08,
Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.7,,,,,,,fee schedule,40.7,187.08,
Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.15,,,,,,,fee schedule,40.7,187.08,
Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.65,,,,,,,fee schedule,40.7,187.08,
Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.08,,,,,,,fee schedule,40.7,187.08,
Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,40.7,187.08,APC
Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.84,,,,,,,fee schedule,40.7,187.08,APC
Detect agent nos dna quant,87799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.11,,,,,,,fee schedule,40.7,187.08,APC
Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.23,,,,,,,fee schedule,41.49,172.76,
Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,41.49,,,,,,,fee schedule,41.49,172.76,
Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.96,,,,,,,fee schedule,41.49,172.76,
Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.49,,,,,,,fee schedule,41.49,172.76,
Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.76,,,,,,,fee schedule,41.49,172.76,
Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.85,,,,,,,fee schedule,41.49,172.76,APC
Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.67,,,,,,,fee schedule,41.49,172.76,APC
Detect agnt mult dna direc,87800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78.61,,,,,,,fee schedule,41.49,172.76,APC
Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,365.91,,,,,,,fee schedule,66.69,420.8,
Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,66.69,,,,,,,fee schedule,66.69,420.8,
Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,299.5,,,,,,,fee schedule,66.69,420.8,
Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,239.89,,,,,,,fee schedule,66.69,420.8,
Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,420.8,,,,,,,fee schedule,66.69,420.8,
Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.71,,,,,,,fee schedule,66.69,420.8,APC
Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.2,,,,,,,fee schedule,66.69,420.8,APC
Detect agnt mult dna ampli,87801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,126.36,,,,,,,fee schedule,66.69,420.8,APC
Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,12.09,51.62,
Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.09,,,,,,,fee schedule,12.09,51.62,
Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,12.09,51.62,
Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,12.09,51.62,
Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,12.09,51.62,
Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.37,,,,,,,fee schedule,12.09,51.62,APC
Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.73,,,,,,,fee schedule,12.09,51.62,APC
Strep b assay w/optic,87802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.91,,,,,,,fee schedule,12.09,51.62,APC
Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,15.2,51.62,
Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.2,,,,,,,fee schedule,15.2,51.62,
Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,15.2,51.62,
Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,15.2,51.62,
Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,15.2,51.62,
Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.8,,,,,,,fee schedule,15.2,51.62,APC
Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16,,,,,,,fee schedule,15.2,51.62,APC
Clostridium toxin a w/optic,87803,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.8,,,,,,,fee schedule,15.2,51.62,APC
Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.36,,,,,,,fee schedule,15.72,41.81,
Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.72,,,,,,,fee schedule,15.72,41.81,
Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.76,,,,,,,fee schedule,15.72,41.81,
Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.84,,,,,,,fee schedule,15.72,41.81,
Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.81,,,,,,,fee schedule,15.72,41.81,
Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.38,,,,,,,fee schedule,15.72,41.81,APC
Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.55,,,,,,,fee schedule,15.72,41.81,APC
Influenza assay w/optic,87804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.79,,,,,,,fee schedule,15.72,41.81,APC
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.92,,,,,,,fee schedule,31.13,79.26,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,31.13,,,,,,,fee schedule,31.13,79.26,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.41,,,,,,,fee schedule,31.13,79.26,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.18,,,,,,,fee schedule,31.13,79.26,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.26,,,,,,,fee schedule,31.13,79.26,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.41,,,,,,,fee schedule,31.13,79.26,APC
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.77,,,,,,,fee schedule,31.13,79.26,APC
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.99,,,,,,,fee schedule,31.13,79.26,APC
Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,12.45,51.62,
Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.45,,,,,,,fee schedule,12.45,51.62,
Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,12.45,51.62,
Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,12.45,51.62,
Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,12.45,51.62,
Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.76,,,,,,,fee schedule,12.45,51.62,APC
Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.1,,,,,,,fee schedule,12.45,51.62,APC
Rsv assay w/optic,87807,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.58,,,,,,,fee schedule,12.45,51.62,APC
Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.47,,,,,,,fee schedule,14.53,38.49,
Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.53,,,,,,,fee schedule,14.53,38.49,
Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.4,,,,,,,fee schedule,14.53,38.49,
Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.94,,,,,,,fee schedule,14.53,38.49,
Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.49,,,,,,,fee schedule,14.53,38.49,
Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.05,,,,,,,fee schedule,14.53,38.49,APC
Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.29,,,,,,,fee schedule,14.53,38.49,APC
Trichomonas assay w/optic,87808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.52,,,,,,,fee schedule,14.53,38.49,APC
Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,20.67,51.62,
Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.67,,,,,,,fee schedule,20.67,51.62,
Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,20.67,51.62,
Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,20.67,51.62,
Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,20.67,51.62,
Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.85,,,,,,,fee schedule,20.67,51.62,APC
Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.76,,,,,,,fee schedule,20.67,51.62,APC
Adenovirus assay w/optic,87809,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.17,,,,,,,fee schedule,20.67,51.62,APC
Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,29.43,63.52,
Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.53,,,,,,,fee schedule,29.43,63.52,
Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,29.43,63.52,
Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,29.43,63.52,
Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,29.43,63.52,
Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.05,,,,,,,fee schedule,29.43,63.52,APC
Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.29,,,,,,,fee schedule,29.43,63.52,APC
Chylmd trach assay w/optic,87810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.52,,,,,,,fee schedule,29.43,63.52,APC
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.6,,,,,,,fee schedule,35.14,74.48,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,41.38,,,,,,,fee schedule,35.14,74.48,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.87,,,,,,,fee schedule,35.14,74.48,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.14,,,,,,,fee schedule,35.14,74.48,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.64,,,,,,,fee schedule,35.14,74.48,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.45,,,,,,,fee schedule,35.14,74.48,APC
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.38,,,,,,,fee schedule,35.14,74.48,APC
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74.48,,,,,,,fee schedule,35.14,74.48,APC
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.2,,,,,,,fee schedule,74.48,134.06,APC
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.48,,,,,,,fee schedule,74.48,134.06,APC
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,134.06,,,,,,,fee schedule,74.48,134.06,APC
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,23.33,51.62,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,23.33,,,,,,,fee schedule,23.33,51.62,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,23.33,51.62,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,23.33,51.62,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,23.33,51.62,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.79,,,,,,,fee schedule,23.33,51.62,APC
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.56,,,,,,,fee schedule,23.33,51.62,APC
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.21,,,,,,,fee schedule,23.33,51.62,APC
Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.8,,,,,,,fee schedule,15.7,44.62,
Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.7,,,,,,,fee schedule,15.7,44.62,
Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.76,,,,,,,fee schedule,15.7,44.62,
Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.44,,,,,,,fee schedule,15.7,44.62,
Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.62,,,,,,,fee schedule,15.7,44.62,
Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.36,,,,,,,fee schedule,15.7,44.62,APC
Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.53,,,,,,,fee schedule,15.7,44.62,APC
Strep a assay w/optic,87880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.75,,,,,,,fee schedule,15.7,44.62,APC
Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.99,,,,,,,fee schedule,15.27,39.09,
Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.27,,,,,,,fee schedule,15.27,39.09,
Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.82,,,,,,,fee schedule,15.27,39.09,
Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.28,,,,,,,fee schedule,15.27,39.09,
Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.09,,,,,,,fee schedule,15.27,39.09,
Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.87,,,,,,,fee schedule,15.27,39.09,APC
Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.07,,,,,,,fee schedule,15.27,39.09,APC
Agent nos assay w/optic,87899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.93,,,,,,,fee schedule,15.27,39.09,APC
Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,488.17,,,,,,,fee schedule,123.83,561.4,
Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,123.83,,,,,,,fee schedule,123.83,561.4,
Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,399.57,,,,,,,fee schedule,123.83,561.4,
Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,320.04,,,,,,,fee schedule,123.83,561.4,
Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,561.4,,,,,,,fee schedule,123.83,561.4,
Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,136.87,,,,,,,fee schedule,123.83,561.4,APC
Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,130.35,,,,,,,fee schedule,123.83,561.4,APC
Phenotype infect agent drug,87900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,234.63,,,,,,,fee schedule,123.83,561.4,APC
Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,964.18,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,244.58,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,789.18,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,632.12,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1108.81,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,244.58,1108.81,APC
Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,257.45,,,,,,,fee schedule,244.58,1108.81,APC
Genotype dna hiv reverse t,87901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,463.41,,,,,,,fee schedule,244.58,1108.81,APC
Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,555.32,,,,,,,fee schedule,244.58,638.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,244.58,,,,,,,fee schedule,244.58,638.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,454.53,,,,,,,fee schedule,244.58,638.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,364.07,,,,,,,fee schedule,244.58,638.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,638.62,,,,,,,fee schedule,244.58,638.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,244.58,638.62,APC
Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,257.45,,,,,,,fee schedule,244.58,638.62,APC
Genotype dna/rna hep c,87902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,463.41,,,,,,,fee schedule,244.58,638.62,APC
Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1830.11,,,,,,,fee schedule,464.23,2104.63,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,464.23,,,,,,,fee schedule,464.23,2104.63,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1497.95,,,,,,,fee schedule,464.23,2104.63,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1199.82,,,,,,,fee schedule,464.23,2104.63,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2104.63,,,,,,,fee schedule,464.23,2104.63,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,513.09,,,,,,,fee schedule,464.23,2104.63,APC
Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,488.66,,,,,,,fee schedule,464.23,2104.63,APC
Phenotype dna hiv w/culture,87903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,879.59,,,,,,,fee schedule,464.23,2104.63,APC
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.64,,,,,,,fee schedule,24.77,112.29,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.77,,,,,,,fee schedule,24.77,112.29,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.92,,,,,,,fee schedule,24.77,112.29,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.01,,,,,,,fee schedule,24.77,112.29,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.29,,,,,,,fee schedule,24.77,112.29,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.37,,,,,,,fee schedule,24.77,112.29,APC
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.07,,,,,,,fee schedule,24.77,112.29,APC
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.93,,,,,,,fee schedule,24.77,112.29,APC
Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.88,,,,,,,fee schedule,9.1,22,
Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.61,,,,,,,fee schedule,9.1,22,
Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.36,,,,,,,fee schedule,9.1,22,
Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.1,,,,,,,fee schedule,9.1,22,
Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.96,,,,,,,fee schedule,9.1,22,
Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.83,,,,,,,fee schedule,9.1,22,APC
Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.22,,,,,,,fee schedule,9.1,22,APC
Sialidase enzyme assay,87905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22,,,,,,,fee schedule,9.1,22,APC
Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,482.09,,,,,,,fee schedule,122.29,554.4,
Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,122.29,,,,,,,fee schedule,122.29,554.4,
Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,394.59,,,,,,,fee schedule,122.29,554.4,
Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.06,,,,,,,fee schedule,122.29,554.4,
Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,554.4,,,,,,,fee schedule,122.29,554.4,
Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.17,,,,,,,fee schedule,122.29,554.4,APC
Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.73,,,,,,,fee schedule,122.29,554.4,APC
Genotype dna/rna hiv,87906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.71,,,,,,,fee schedule,122.29,554.4,APC
Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,964.18,,,,,,,fee schedule,244.58,1108.81,
Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,244.58,,,,,,,fee schedule,244.58,1108.81,
Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,789.18,,,,,,,fee schedule,244.58,1108.81,
Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,632.12,,,,,,,fee schedule,244.58,1108.81,
Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1108.81,,,,,,,fee schedule,244.58,1108.81,
Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,244.58,1108.81,APC
Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,257.45,,,,,,,fee schedule,244.58,1108.81,APC
Genotype cytomegalovirus,87910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,463.41,,,,,,,fee schedule,244.58,1108.81,APC
Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,964.18,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,244.58,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,789.18,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,632.12,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1108.81,,,,,,,fee schedule,244.58,1108.81,
Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,244.58,1108.81,APC
Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,257.45,,,,,,,fee schedule,244.58,1108.81,APC
Genotype dna hepatitis b,87912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,463.41,,,,,,,fee schedule,244.58,1108.81,APC
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.01,,,,,,,fee schedule,0.01,463.41,
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,0.01,463.41,APC
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,257.45,,,,,,,fee schedule,0.01,463.41,APC
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,463.41,,,,,,,fee schedule,0.01,463.41,APC
Autopsy (necropsy) gross,88000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,610.47,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,182.71,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,499.67,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,400.22,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,702.04,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,712.34,,,,,,,fee schedule,213.21,819.19,
Autopsy (necropsy) gross,88005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,213.21,,,,,,,fee schedule,213.21,819.19,
Autopsy (necropsy) gross,88005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,583.05,,,,,,,fee schedule,213.21,819.19,
Autopsy (necropsy) gross,88005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,467.01,,,,,,,fee schedule,213.21,819.19,
Autopsy (necropsy) gross,88005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,819.19,,,,,,,fee schedule,213.21,819.19,
Autopsy (necropsy) gross,88007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,745.65,,,,,,,fee schedule,223.18,857.5,
Autopsy (necropsy) gross,88007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,223.18,,,,,,,fee schedule,223.18,857.5,
Autopsy (necropsy) gross,88007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,610.31,,,,,,,fee schedule,223.18,857.5,
Autopsy (necropsy) gross,88007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,488.85,,,,,,,fee schedule,223.18,857.5,
Autopsy (necropsy) gross,88007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,857.5,,,,,,,fee schedule,223.18,857.5,
Autopsy (necropsy) gross,88012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,610.47,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,182.71,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,499.67,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,400.22,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,702.04,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) gross,88014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,559.46,,,,,,,fee schedule,167.46,643.38,
Autopsy (necropsy) gross,88014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,167.46,,,,,,,fee schedule,167.46,643.38,
Autopsy (necropsy) gross,88014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,457.92,,,,,,,fee schedule,167.46,643.38,
Autopsy (necropsy) gross,88014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,366.78,,,,,,,fee schedule,167.46,643.38,
Autopsy (necropsy) gross,88014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,643.38,,,,,,,fee schedule,167.46,643.38,
Autopsy (necropsy) gross,88016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,779.95,,,,,,,fee schedule,233.45,896.94,
Autopsy (necropsy) gross,88016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,233.45,,,,,,,fee schedule,233.45,896.94,
Autopsy (necropsy) gross,88016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,638.39,,,,,,,fee schedule,233.45,896.94,
Autopsy (necropsy) gross,88016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,511.34,,,,,,,fee schedule,233.45,896.94,
Autopsy (necropsy) gross,88016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,896.94,,,,,,,fee schedule,233.45,896.94,
Autopsy (necropsy) complete,88020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1051.39,,,,,,,fee schedule,314.69,1209.1,
Autopsy (necropsy) complete,88020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,314.69,,,,,,,fee schedule,314.69,1209.1,
Autopsy (necropsy) complete,88020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,860.56,,,,,,,fee schedule,314.69,1209.1,
Autopsy (necropsy) complete,88020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,689.29,,,,,,,fee schedule,314.69,1209.1,
Autopsy (necropsy) complete,88020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1209.1,,,,,,,fee schedule,314.69,1209.1,
Autopsy (necropsy) complete,88025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1017.07,,,,,,,fee schedule,304.42,1169.63,
Autopsy (necropsy) complete,88025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,304.42,,,,,,,fee schedule,304.42,1169.63,
Autopsy (necropsy) complete,88025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,832.47,,,,,,,fee schedule,304.42,1169.63,
Autopsy (necropsy) complete,88025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,666.79,,,,,,,fee schedule,304.42,1169.63,
Autopsy (necropsy) complete,88025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1169.63,,,,,,,fee schedule,304.42,1169.63,
Autopsy (necropsy) complete,88027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1084.69,,,,,,,fee schedule,324.66,1247.39,
Autopsy (necropsy) complete,88027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,324.66,,,,,,,fee schedule,324.66,1247.39,
Autopsy (necropsy) complete,88027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,887.82,,,,,,,fee schedule,324.66,1247.39,
Autopsy (necropsy) complete,88027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,711.12,,,,,,,fee schedule,324.66,1247.39,
Autopsy (necropsy) complete,88027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1247.39,,,,,,,fee schedule,324.66,1247.39,
Autopsy (necropsy) complete,88028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,610.47,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,182.71,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,499.67,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,400.22,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,702.04,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,610.47,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,182.71,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,499.67,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,400.22,,,,,,,fee schedule,182.71,702.04,
Autopsy (necropsy) complete,88029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,702.04,,,,,,,fee schedule,182.71,702.04,
Limited autopsy,88036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,304.72,,,,,,,fee schedule,91.21,350.43,
Limited autopsy,88036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,91.21,,,,,,,fee schedule,91.21,350.43,
Limited autopsy,88036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,249.41,,,,,,,fee schedule,91.21,350.43,
Limited autopsy,88036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.77,,,,,,,fee schedule,91.21,350.43,
Limited autopsy,88036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,350.43,,,,,,,fee schedule,91.21,350.43,
Limited autopsy,88037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.42,,,,,,,fee schedule,81.24,312.13,
Limited autopsy,88037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,81.24,,,,,,,fee schedule,81.24,312.13,
Limited autopsy,88037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.16,,,,,,,fee schedule,81.24,312.13,
Limited autopsy,88037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.94,,,,,,,fee schedule,81.24,312.13,
Limited autopsy,88037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.13,,,,,,,fee schedule,81.24,312.13,
Forensic autopsy (necropsy),88040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1695.12,,,,,,,fee schedule,507.37,1949.39,
Forensic autopsy (necropsy),88040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,507.37,,,,,,,fee schedule,507.37,1949.39,
Forensic autopsy (necropsy),88040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1387.46,,,,,,,fee schedule,507.37,1949.39,
Forensic autopsy (necropsy),88040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1111.32,,,,,,,fee schedule,507.37,1949.39,
Forensic autopsy (necropsy),88040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1949.39,,,,,,,fee schedule,507.37,1949.39,
Coroners autopsy (necropsy),88045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.52,,,,,,,fee schedule,50.74,194.95,
Coroners autopsy (necropsy),88045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,50.74,,,,,,,fee schedule,50.74,194.95,
Coroners autopsy (necropsy),88045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.75,,,,,,,fee schedule,50.74,194.95,
Coroners autopsy (necropsy),88045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.14,,,,,,,fee schedule,50.74,194.95,
Coroners autopsy (necropsy),88045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.95,,,,,,,fee schedule,50.74,194.95,
Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.54,,,,,,,fee schedule,37.22,96.07,
Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.35,,,,,,,fee schedule,37.22,96.07,
Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.38,,,,,,,fee schedule,37.22,96.07,
Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.77,,,,,,,fee schedule,37.22,96.07,
Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.07,,,,,,,fee schedule,37.22,96.07,
Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,96.07,APC
Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,96.07,APC
Cytopath fl nongyn smears,88104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,96.07,APC
Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.5,,,,,,,fee schedule,28.82,139.73,
Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,44.63,,,,,,,fee schedule,28.82,139.73,
Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.45,,,,,,,fee schedule,28.82,139.73,
Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.66,,,,,,,fee schedule,28.82,139.73,
Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.73,,,,,,,fee schedule,28.82,139.73,
Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,139.73,APC
Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,139.73,APC
Cytopath fl nongyn filter,88106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,139.73,APC
Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.79,,,,,,,fee schedule,37.22,114.76,
Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,38.77,,,,,,,fee schedule,37.22,114.76,
Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.68,,,,,,,fee schedule,37.22,114.76,
Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.42,,,,,,,fee schedule,37.22,114.76,
Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.76,,,,,,,fee schedule,37.22,114.76,
Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,114.76,APC
Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,114.76,APC
Cytopath concentrate tech,88108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,114.76,APC
Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,215.58,,,,,,,fee schedule,34.95,247.92,
Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,34.95,,,,,,,fee schedule,34.95,247.92,
Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,176.45,,,,,,,fee schedule,34.95,247.92,
Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.33,,,,,,,fee schedule,34.95,247.92,
Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,247.92,,,,,,,fee schedule,34.95,247.92,
Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,34.95,247.92,APC
Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,34.95,247.92,APC
Cytopath cell enhance tech,88112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,34.95,247.92,APC
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1584.41,,,,,,,fee schedule,169.76,1822.07,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,473.27,,,,,,,fee schedule,169.76,1822.07,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1296.84,,,,,,,fee schedule,169.76,1822.07,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1038.74,,,,,,,fee schedule,169.76,1822.07,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1822.07,,,,,,,fee schedule,169.76,1822.07,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,169.76,1822.07,APC
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,169.76,1822.07,APC
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,169.76,1822.07,APC
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1369.82,,,,,,,fee schedule,169.76,1575.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,326.18,,,,,,,fee schedule,169.76,1575.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1121.2,,,,,,,fee schedule,169.76,1575.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,898.05,,,,,,,fee schedule,169.76,1575.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1575.29,,,,,,,fee schedule,169.76,1575.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,169.76,1575.29,APC
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,169.76,1575.29,APC
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,169.76,1575.29,APC
Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.56,,,,,,,fee schedule,12.96,93.46,
Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.96,,,,,,,fee schedule,12.96,93.46,
Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.65,,,,,,,fee schedule,12.96,93.46,
Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.13,,,,,,,fee schedule,12.96,93.46,
Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.79,,,,,,,fee schedule,12.96,93.46,
Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,12.96,93.46,APC
Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,12.96,93.46,APC
Forensic cytopathology,88125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,12.96,93.46,APC
Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.25,,,,,,,fee schedule,17.08,60.09,
Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.08,,,,,,,fee schedule,17.08,60.09,
Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.77,,,,,,,fee schedule,17.08,60.09,
Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.26,,,,,,,fee schedule,17.08,60.09,
Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.09,,,,,,,fee schedule,17.08,60.09,
Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.88,,,,,,,fee schedule,17.08,60.09,APC
Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.98,,,,,,,fee schedule,17.08,60.09,APC
Sex chromatin identification,88130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.36,,,,,,,fee schedule,17.08,60.09,APC
Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.25,,,,,,,fee schedule,7.59,31.34,
Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.59,,,,,,,fee schedule,7.59,31.34,
Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.3,,,,,,,fee schedule,7.59,31.34,
Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.87,,,,,,,fee schedule,7.59,31.34,
Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.34,,,,,,,fee schedule,7.59,31.34,
Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.39,,,,,,,fee schedule,7.59,31.34,APC
Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.99,,,,,,,fee schedule,7.59,31.34,APC
Sex chromatin identification,88140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.38,,,,,,,fee schedule,7.59,31.34,APC
Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.04,,,,,,,fee schedule,20.74,54.1,
Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.74,,,,,,,fee schedule,20.74,54.1,
Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.5,,,,,,,fee schedule,20.74,54.1,
Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.84,,,,,,,fee schedule,20.74,54.1,
Cytopath c/v interpret,88141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.1,,,,,,,fee schedule,20.74,54.1,
Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.9,,,,,,,fee schedule,19.25,119.49,
Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,19.25,,,,,,,fee schedule,19.25,119.49,
Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.04,,,,,,,fee schedule,19.25,119.49,
Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.12,,,,,,,fee schedule,19.25,119.49,
Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.49,,,,,,,fee schedule,19.25,119.49,
Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.27,,,,,,,fee schedule,19.25,119.49,APC
Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.26,,,,,,,fee schedule,19.25,119.49,APC
Cytopath c/v thin layer,88142,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.47,,,,,,,fee schedule,19.25,119.49,APC
Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.86,,,,,,,fee schedule,21.89,87.24,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.89,,,,,,,fee schedule,21.89,87.24,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.09,,,,,,,fee schedule,21.89,87.24,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.73,,,,,,,fee schedule,21.89,87.24,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.24,,,,,,,fee schedule,21.89,87.24,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.19,,,,,,,fee schedule,21.89,87.24,APC
Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.04,,,,,,,fee schedule,21.89,87.24,APC
Cytopath c/v thin layer redo,88143,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.47,,,,,,,fee schedule,21.89,87.24,APC
Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,25.93,91.01,
Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.03,,,,,,,fee schedule,25.93,91.01,
Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,25.93,91.01,
Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,25.93,91.01,
Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,25.93,91.01,
Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.09,,,,,,,fee schedule,25.93,91.01,APC
Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50.56,,,,,,,fee schedule,25.93,91.01,APC
Cytopath c/v automated,88147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,91.01,,,,,,,fee schedule,25.93,91.01,APC
Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.44,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.44,45.48,APC
Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,16.44,45.48,APC
Cytopath c/v auto rescreen,88148,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,16.44,45.48,APC
Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.44,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,16.44,45.48,
Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.44,45.48,APC
Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,16.44,45.48,APC
Cytopath c/v manual,88150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,16.44,45.48,APC
Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,25.93,49.75,
Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,26.26,,,,,,,fee schedule,25.93,49.75,
Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,25.93,49.75,
Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,25.93,49.75,
Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,25.93,49.75,
Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.02,,,,,,,fee schedule,25.93,49.75,APC
Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.64,,,,,,,fee schedule,25.93,49.75,APC
Cytopath c/v auto redo,88152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49.75,,,,,,,fee schedule,25.93,49.75,APC
Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,22.83,45.48,
Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.83,,,,,,,fee schedule,22.83,45.48,
Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,22.83,45.48,
Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,22.83,45.48,
Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,22.83,45.48,
Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.23,,,,,,,fee schedule,22.83,45.48,APC
Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.03,,,,,,,fee schedule,22.83,45.48,APC
Cytopath c/v redo,88153,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.25,,,,,,,fee schedule,22.83,45.48,APC
Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.44,,,,,,,fee schedule,13.92,26.37,
Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.92,,,,,,,fee schedule,13.92,26.37,
Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.37,,,,,,,fee schedule,13.92,26.37,
Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.71,,,,,,,fee schedule,13.92,26.37,
Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.81,,,,,,,fee schedule,13.92,26.37,
Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.38,,,,,,,fee schedule,13.92,26.37,APC
Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.65,,,,,,,fee schedule,13.92,26.37,APC
Cytopath c/v index add-on,88155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.37,,,,,,,fee schedule,13.92,26.37,APC
Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.15,,,,,,,fee schedule,28.82,156.57,
Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,43.8,,,,,,,fee schedule,28.82,156.57,
Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,111.44,,,,,,,fee schedule,28.82,156.57,
Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.26,,,,,,,fee schedule,28.82,156.57,
Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,156.57,,,,,,,fee schedule,28.82,156.57,
Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,156.57,APC
Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,156.57,APC
Cytopath smear other source,88160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,156.57,APC
Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.75,,,,,,,fee schedule,28.82,126.21,
Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,45.56,,,,,,,fee schedule,28.82,126.21,
Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.83,,,,,,,fee schedule,28.82,126.21,
Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.95,,,,,,,fee schedule,28.82,126.21,
Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.21,,,,,,,fee schedule,28.82,126.21,
Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,126.21,APC
Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,126.21,APC
Cytopath smear other source,88161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,126.21,APC
Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.6,,,,,,,fee schedule,51.92,189.29,
Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,70.49,,,,,,,fee schedule,51.92,189.29,
Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.73,,,,,,,fee schedule,51.92,189.29,
Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.91,,,,,,,fee schedule,51.92,189.29,
Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.29,,,,,,,fee schedule,51.92,189.29,
Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,189.29,APC
Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,189.29,APC
Cytopath smear other source,88162,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,189.29,APC
Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.25,,,,,,,fee schedule,16.44,61.24,
Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.44,,,,,,,fee schedule,16.44,61.24,
Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.59,,,,,,,fee schedule,16.44,61.24,
Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.91,,,,,,,fee schedule,16.44,61.24,
Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.24,,,,,,,fee schedule,16.44,61.24,
Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.44,61.24,APC
Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,16.44,61.24,APC
Cytopath tbs c/v manual,88164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,16.44,61.24,APC
Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,25.93,76,
Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.11,,,,,,,fee schedule,25.93,76,
Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,25.93,76,
Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,25.93,76,
Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,25.93,76,
Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.33,,,,,,,fee schedule,25.93,76,APC
Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.22,,,,,,,fee schedule,25.93,76,APC
Cytopath tbs c/v redo,88165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,76,,,,,,,fee schedule,25.93,76,APC
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.44,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.44,45.48,APC
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,16.44,45.48,APC
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,16.44,45.48,APC
Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.44,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,16.44,45.48,
Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.44,45.48,APC
Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,16.44,45.48,APC
Cytopath tbs c/v select,88167,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,16.44,45.48,APC
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.87,,,,,,,fee schedule,18.24,305.56,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.24,,,,,,,fee schedule,18.24,305.56,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.91,,,,,,,fee schedule,18.24,305.56,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.97,,,,,,,fee schedule,18.24,305.56,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.1,,,,,,,fee schedule,18.24,305.56,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,18.24,305.56,APC
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,18.24,305.56,APC
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,18.24,305.56,APC
Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.08,,,,,,,fee schedule,51.92,194.44,
Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,81.74,,,,,,,fee schedule,51.92,194.44,
Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.39,,,,,,,fee schedule,51.92,194.44,
Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.85,,,,,,,fee schedule,51.92,194.44,
Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.44,,,,,,,fee schedule,51.92,194.44,
Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,194.44,APC
Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,194.44,APC
Cytopath eval fna report,88173,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,194.44,APC
Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80,,,,,,,fee schedule,24.1,92,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.1,,,,,,,fee schedule,24.1,92,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.48,,,,,,,fee schedule,24.1,92,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.45,,,,,,,fee schedule,24.1,92,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92,,,,,,,fee schedule,24.1,92,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.64,,,,,,,fee schedule,24.1,92,APC
Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.37,,,,,,,fee schedule,24.1,92,APC
Cytopath c/v auto in fluid,88174,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.67,,,,,,,fee schedule,24.1,92,APC
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.2,,,,,,,fee schedule,25.28,118.68,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.28,,,,,,,fee schedule,25.28,118.68,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.47,,,,,,,fee schedule,25.28,118.68,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.66,,,,,,,fee schedule,25.28,118.68,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.68,,,,,,,fee schedule,25.28,118.68,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.94,,,,,,,fee schedule,25.28,118.68,APC
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.61,,,,,,,fee schedule,25.28,118.68,APC
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.9,,,,,,,fee schedule,25.28,118.68,APC
Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,7.04,23.67,
Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.04,,,,,,,fee schedule,7.04,23.67,
Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,7.04,23.67,
Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,7.04,23.67,
Cytp fna eval ea addl,88177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,7.04,23.67,
Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,225.34,,,,,,,fee schedule,51.92,259.14,
Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,107.26,,,,,,,fee schedule,51.92,259.14,
Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,184.44,,,,,,,fee schedule,51.92,259.14,
Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.73,,,,,,,fee schedule,51.92,259.14,
Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.14,,,,,,,fee schedule,51.92,259.14,
Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,259.14,APC
Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,259.14,APC
Cell marker study,88182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,259.14,APC
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.97,,,,,,,fee schedule,65.21,642.88,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,65.21,,,,,,,fee schedule,65.21,642.88,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.48,,,,,,,fee schedule,65.21,642.88,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.7,,,,,,,fee schedule,65.21,642.88,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.87,,,,,,,fee schedule,65.21,642.88,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,65.21,642.88,APC
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,65.21,642.88,APC
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,65.21,642.88,APC
Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.64,,,,,,,fee schedule,20.82,85.84,
Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.82,,,,,,,fee schedule,20.82,85.84,
Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.09,,,,,,,fee schedule,20.82,85.84,
Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.93,,,,,,,fee schedule,20.82,85.84,
Flowcytometry/tc add-on,88185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.84,,,,,,,fee schedule,20.82,85.84,
Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.72,,,,,,,fee schedule,32.83,129.63,
Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.83,,,,,,,fee schedule,32.83,129.63,
Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.26,,,,,,,fee schedule,32.83,129.63,
Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.9,,,,,,,fee schedule,32.83,129.63,
Flowcytometry/read 2-8,88187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.63,,,,,,,fee schedule,32.83,129.63,
Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.3,,,,,,,fee schedule,53.96,94.65,
Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,57.13,,,,,,,fee schedule,53.96,94.65,
Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.36,,,,,,,fee schedule,53.96,94.65,
Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.96,,,,,,,fee schedule,53.96,94.65,
Flowcytometry/read 9-15,88188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.65,,,,,,,fee schedule,53.96,94.65,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,90.13,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,77.44,,,,,,,fee schedule,51.38,90.13,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,90.13,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,90.13,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,90.13,
Cytopathology procedure,88199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,93.46,APC
Cytopathology procedure,88199,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,93.46,APC
Cytopathology procedure,88199,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,93.46,APC
Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,287.74,,,,,,,fee schedule,110.67,330.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,110.67,,,,,,,fee schedule,110.67,330.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,235.52,,,,,,,fee schedule,110.67,330.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,188.64,,,,,,,fee schedule,110.67,330.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,330.9,,,,,,,fee schedule,110.67,330.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.31,,,,,,,fee schedule,110.67,330.9,APC
Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.49,,,,,,,fee schedule,110.67,330.9,APC
Tissue culture lymphocyte,88230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,209.68,,,,,,,fee schedule,110.67,330.9,APC
Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.68,,,,,,,fee schedule,133.69,413.63,
Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,133.69,,,,,,,fee schedule,133.69,413.63,
Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.4,,,,,,,fee schedule,133.69,413.63,
Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.81,,,,,,,fee schedule,133.69,413.63,
Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.63,,,,,,,fee schedule,133.69,413.63,
Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,147.77,,,,,,,fee schedule,133.69,413.63,APC
Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,140.73,,,,,,,fee schedule,133.69,413.63,APC
Tissue culture skin/biopsy,88233,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,253.31,,,,,,,fee schedule,133.69,413.63,APC
Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.68,,,,,,,fee schedule,142.79,413.63,
Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,142.79,,,,,,,fee schedule,142.79,413.63,
Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.4,,,,,,,fee schedule,142.79,413.63,
Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.81,,,,,,,fee schedule,142.79,413.63,
Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.63,,,,,,,fee schedule,142.79,413.63,
Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.82,,,,,,,fee schedule,142.79,413.63,APC
Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150.3,,,,,,,fee schedule,142.79,413.63,APC
Tissue culture placenta,88235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270.54,,,,,,,fee schedule,142.79,413.63,APC
Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,287.74,,,,,,,fee schedule,136.56,330.9,
Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,136.56,,,,,,,fee schedule,136.56,330.9,
Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,235.52,,,,,,,fee schedule,136.56,330.9,
Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,188.64,,,,,,,fee schedule,136.56,330.9,
Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,330.9,,,,,,,fee schedule,136.56,330.9,
Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,150.94,,,,,,,fee schedule,136.56,330.9,APC
Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,143.75,,,,,,,fee schedule,136.56,330.9,APC
Tissue culture bone marrow,88237,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,258.75,,,,,,,fee schedule,136.56,330.9,APC
Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.77,,,,,,,fee schedule,140.14,442.49,
Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,140.14,,,,,,,fee schedule,140.14,442.49,
Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.93,,,,,,,fee schedule,140.14,442.49,
Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,252.26,,,,,,,fee schedule,140.14,442.49,
Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,442.49,,,,,,,fee schedule,140.14,442.49,
Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,154.9,,,,,,,fee schedule,140.14,442.49,APC
Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,147.52,,,,,,,fee schedule,140.14,442.49,APC
Tissue culture tumor,88239,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,265.54,,,,,,,fee schedule,140.14,442.49,APC
Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.71,,,,,,,fee schedule,12.42,145.72,
Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.42,,,,,,,fee schedule,12.42,145.72,
Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.71,,,,,,,fee schedule,12.42,145.72,
Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.07,,,,,,,fee schedule,12.42,145.72,
Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.72,,,,,,,fee schedule,12.42,145.72,
Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,12.42,145.72,APC
Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.07,,,,,,,fee schedule,12.42,145.72,APC
Cell cryopreserve/storage,88240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.53,,,,,,,fee schedule,12.42,145.72,APC
Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.01,,,,,,,fee schedule,11.49,35.66,
Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.49,,,,,,,fee schedule,11.49,35.66,
Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.38,,,,,,,fee schedule,11.49,35.66,
Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.33,,,,,,,fee schedule,11.49,35.66,
Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.66,,,,,,,fee schedule,11.49,35.66,
Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.69,,,,,,,fee schedule,11.49,35.66,APC
Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.09,,,,,,,fee schedule,11.49,35.66,APC
Frozen cell preparation,88241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.76,,,,,,,fee schedule,11.49,35.66,APC
Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,297.73,,,,,,,fee schedule,164.51,342.39,
Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,164.51,,,,,,,fee schedule,164.51,342.39,
Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,243.69,,,,,,,fee schedule,164.51,342.39,
Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.19,,,,,,,fee schedule,164.51,342.39,
Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,342.39,,,,,,,fee schedule,164.51,342.39,
Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.83,,,,,,,fee schedule,164.51,342.39,APC
Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,173.17,,,,,,,fee schedule,164.51,342.39,APC
Chromosome analysis 20-25,88245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,311.71,,,,,,,fee schedule,164.51,342.39,APC
Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,600.62,,,,,,,fee schedule,164.51,690.71,
Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,164.51,,,,,,,fee schedule,164.51,690.71,
Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,491.61,,,,,,,fee schedule,164.51,690.71,
Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,393.77,,,,,,,fee schedule,164.51,690.71,
Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,690.71,,,,,,,fee schedule,164.51,690.71,
Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.83,,,,,,,fee schedule,164.51,690.71,APC
Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,173.17,,,,,,,fee schedule,164.51,690.71,APC
Chromosome analysis 50-100,88248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,311.71,,,,,,,fee schedule,164.51,690.71,APC
Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,634.72,,,,,,,fee schedule,164.51,729.93,
Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,164.51,,,,,,,fee schedule,164.51,729.93,
Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,519.52,,,,,,,fee schedule,164.51,729.93,
Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.12,,,,,,,fee schedule,164.51,729.93,
Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,729.93,,,,,,,fee schedule,164.51,729.93,
Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.83,,,,,,,fee schedule,164.51,729.93,APC
Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,173.17,,,,,,,fee schedule,164.51,729.93,APC
Chromosome analysis 100,88249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,311.71,,,,,,,fee schedule,164.51,729.93,APC
Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,661.95,,,,,,,fee schedule,251.12,761.24,
Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,251.12,,,,,,,fee schedule,251.12,761.24,
Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,541.81,,,,,,,fee schedule,251.12,761.24,
Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,433.97,,,,,,,fee schedule,251.12,761.24,
Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,761.24,,,,,,,fee schedule,251.12,761.24,
Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,277.56,,,,,,,fee schedule,251.12,761.24,APC
Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,264.34,,,,,,,fee schedule,251.12,761.24,APC
Chromosome analysis 5,88261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,475.81,,,,,,,fee schedule,251.12,761.24,APC
Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,406.68,,,,,,,fee schedule,119.22,467.68,
Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,119.22,,,,,,,fee schedule,119.22,467.68,
Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.87,,,,,,,fee schedule,119.22,467.68,
Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.62,,,,,,,fee schedule,119.22,467.68,
Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,467.68,,,,,,,fee schedule,119.22,467.68,
Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.76,,,,,,,fee schedule,119.22,467.68,APC
Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,125.49,,,,,,,fee schedule,119.22,467.68,APC
Chromosome analysis 15-20,88262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,225.88,,,,,,,fee schedule,119.22,467.68,APC
Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,496.14,,,,,,,fee schedule,142.78,570.56,
Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,142.78,,,,,,,fee schedule,142.78,570.56,
Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,406.09,,,,,,,fee schedule,142.78,570.56,
Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.27,,,,,,,fee schedule,142.78,570.56,
Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,570.56,,,,,,,fee schedule,142.78,570.56,
Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.8,,,,,,,fee schedule,142.78,570.56,APC
Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150.29,,,,,,,fee schedule,142.78,570.56,APC
Chromosome analysis 45,88263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270.52,,,,,,,fee schedule,142.78,570.56,APC
Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,406.68,,,,,,,fee schedule,137.38,467.68,
Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,137.38,,,,,,,fee schedule,137.38,467.68,
Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.87,,,,,,,fee schedule,137.38,467.68,
Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.62,,,,,,,fee schedule,137.38,467.68,
Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,467.68,,,,,,,fee schedule,137.38,467.68,
Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,151.84,,,,,,,fee schedule,137.38,467.68,APC
Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,144.61,,,,,,,fee schedule,137.38,467.68,APC
Chromosome analysis 20-25,88264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,260.3,,,,,,,fee schedule,137.38,467.68,APC
Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.83,,,,,,,fee schedule,179.14,340.2,
Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,179.14,,,,,,,fee schedule,179.14,340.2,
Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.14,,,,,,,fee schedule,179.14,340.2,
Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.95,,,,,,,fee schedule,179.14,340.2,
Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.2,,,,,,,fee schedule,179.14,340.2,
Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,198,,,,,,,fee schedule,179.14,340.2,APC
Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,188.57,,,,,,,fee schedule,179.14,340.2,APC
Chromosome analys placenta,88267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,339.43,,,,,,,fee schedule,179.14,340.2,APC
Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.32,,,,,,,fee schedule,164.98,312.59,
Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,164.98,,,,,,,fee schedule,164.98,312.59,
Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.25,,,,,,,fee schedule,164.98,312.59,
Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.01,,,,,,,fee schedule,164.98,312.59,
Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.22,,,,,,,fee schedule,164.98,312.59,
Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.34,,,,,,,fee schedule,164.98,312.59,APC
Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,173.66,,,,,,,fee schedule,164.98,312.59,APC
Chromosome analys amniotic,88269,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,312.59,,,,,,,fee schedule,164.98,312.59,APC
Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.07,,,,,,,fee schedule,20.35,77.13,
Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.35,,,,,,,fee schedule,20.35,77.13,
Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.9,,,,,,,fee schedule,20.35,77.13,
Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.97,,,,,,,fee schedule,20.35,77.13,
Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.13,,,,,,,fee schedule,20.35,77.13,
Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.49,,,,,,,fee schedule,20.35,77.13,APC
Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.42,,,,,,,fee schedule,20.35,77.13,APC
Cytogenetics dna probe,88271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.56,,,,,,,fee schedule,20.35,77.13,APC
Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.73,,,,,,,fee schedule,38.67,176.79,
Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,38.67,,,,,,,fee schedule,38.67,176.79,
Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.83,,,,,,,fee schedule,38.67,176.79,
Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.79,,,,,,,fee schedule,38.67,176.79,
Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.79,,,,,,,fee schedule,38.67,176.79,
Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.74,,,,,,,fee schedule,38.67,176.79,APC
Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40.7,,,,,,,fee schedule,38.67,176.79,APC
Cytogenetics 3-5,88272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,73.26,,,,,,,fee schedule,38.67,176.79,APC
Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,209.65,,,,,,,fee schedule,33.07,241.1,
Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,33.07,,,,,,,fee schedule,33.07,241.1,
Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.6,,,,,,,fee schedule,33.07,241.1,
Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.45,,,,,,,fee schedule,33.07,241.1,
Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,241.1,,,,,,,fee schedule,33.07,241.1,
Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.55,,,,,,,fee schedule,33.07,241.1,APC
Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.81,,,,,,,fee schedule,33.07,241.1,APC
Cytogenetics 10-30,88273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,62.66,,,,,,,fee schedule,33.07,241.1,APC
Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.38,,,,,,,fee schedule,40.26,209.74,
Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,40.26,,,,,,,fee schedule,40.26,209.74,
Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.28,,,,,,,fee schedule,40.26,209.74,
Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.57,,,,,,,fee schedule,40.26,209.74,
Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.74,,,,,,,fee schedule,40.26,209.74,
Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.5,,,,,,,fee schedule,40.26,209.74,APC
Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.38,,,,,,,fee schedule,40.26,209.74,APC
Cytogenetics 25-99,88274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,76.28,,,,,,,fee schedule,40.26,209.74,APC
Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,157.21,,,,,,,fee schedule,48.63,180.79,
Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,48.63,,,,,,,fee schedule,48.63,180.79,
Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.68,,,,,,,fee schedule,48.63,180.79,
Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.07,,,,,,,fee schedule,48.63,180.79,
Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.79,,,,,,,fee schedule,48.63,180.79,
Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.75,,,,,,,fee schedule,48.63,180.79,APC
Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.19,,,,,,,fee schedule,48.63,180.79,APC
Cytogenetics 100-300,88275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.14,,,,,,,fee schedule,48.63,180.79,APC
Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.89,,,,,,,fee schedule,31.8,94.17,
Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,31.8,,,,,,,fee schedule,31.8,94.17,
Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.03,,,,,,,fee schedule,31.8,94.17,
Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.69,,,,,,,fee schedule,31.8,94.17,
Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.17,,,,,,,fee schedule,31.8,94.17,
Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.14,,,,,,,fee schedule,31.8,94.17,APC
Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.47,,,,,,,fee schedule,31.8,94.17,APC
Chromosome karyotype study,88280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,60.25,,,,,,,fee schedule,31.8,94.17,APC
Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.53,,,,,,,fee schedule,65.17,254.76,
Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,65.17,,,,,,,fee schedule,65.17,254.76,
Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.32,,,,,,,fee schedule,65.17,254.76,
Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.24,,,,,,,fee schedule,65.17,254.76,
Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,254.76,,,,,,,fee schedule,65.17,254.76,
Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72.03,,,,,,,fee schedule,65.17,254.76,APC
Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,68.6,,,,,,,fee schedule,65.17,254.76,APC
Chromosome banding study,88283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,123.48,,,,,,,fee schedule,65.17,254.76,APC
Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.2,,,,,,,fee schedule,25.56,325.68,
Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,25.56,,,,,,,fee schedule,25.56,325.68,
Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,231.8,,,,,,,fee schedule,25.56,325.68,
Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.67,,,,,,,fee schedule,25.56,325.68,
Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.68,,,,,,,fee schedule,25.56,325.68,
Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.26,,,,,,,fee schedule,25.56,325.68,APC
Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.91,,,,,,,fee schedule,25.56,325.68,APC
Chromosome count additional,88285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.44,,,,,,,fee schedule,25.56,325.68,APC
Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.94,,,,,,,fee schedule,32.71,148.28,
Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.71,,,,,,,fee schedule,32.71,148.28,
Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.54,,,,,,,fee schedule,32.71,148.28,
Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.53,,,,,,,fee schedule,32.71,148.28,
Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.28,,,,,,,fee schedule,32.71,148.28,
Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.15,,,,,,,fee schedule,32.71,148.28,APC
Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.43,,,,,,,fee schedule,32.71,148.28,APC
Chromosome study additional,88289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.97,,,,,,,fee schedule,32.71,148.28,APC
Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,24.4,42.8,
Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,29.75,,,,,,,fee schedule,24.4,42.8,
Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,24.4,42.8,
Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,24.4,42.8,
Cyto/molecular report,88291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,24.4,42.8,
Cytogenetic study,88299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,93.46,APC
Cytogenetic study,88299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,93.46,APC
Cytogenetic study,88299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,93.46,APC
Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.78,,,,,,,fee schedule,10.32,68.75,
Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.32,,,,,,,fee schedule,10.32,68.75,
Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.93,,,,,,,fee schedule,10.32,68.75,
Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.19,,,,,,,fee schedule,10.32,68.75,
Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.75,,,,,,,fee schedule,10.32,68.75,
Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,10.32,68.75,APC
Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,10.32,68.75,APC
Surgical path gross,88300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,10.32,68.75,APC
Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.86,,,,,,,fee schedule,22.93,128.64,
Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,22.93,,,,,,,fee schedule,22.93,128.64,
Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.56,,,,,,,fee schedule,22.93,128.64,
Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.34,,,,,,,fee schedule,22.93,128.64,
Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.64,,,,,,,fee schedule,22.93,128.64,
Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,22.93,128.64,APC
Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,22.93,128.64,APC
Tissue exam by pathologist,88302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,22.93,128.64,APC
Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.29,,,,,,,fee schedule,27.62,153.28,
Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,27.62,,,,,,,fee schedule,27.62,153.28,
Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.1,,,,,,,fee schedule,27.62,153.28,
Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.38,,,,,,,fee schedule,27.62,153.28,
Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.28,,,,,,,fee schedule,27.62,153.28,
Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,27.62,153.28,APC
Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,27.62,153.28,APC
Tissue exam by pathologist,88304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,27.62,153.28,APC
Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,215.6,,,,,,,fee schedule,30.55,247.94,
Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,30.55,,,,,,,fee schedule,30.55,247.94,
Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,176.47,,,,,,,fee schedule,30.55,247.94,
Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.35,,,,,,,fee schedule,30.55,247.94,
Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,247.94,,,,,,,fee schedule,30.55,247.94,
Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,30.55,247.94,APC
Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,30.55,247.94,APC
Tissue exam by pathologist,88305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,30.55,247.94,APC
Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.93,,,,,,,fee schedule,165.82,642.88,
Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,183.51,,,,,,,fee schedule,165.82,642.88,
Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.02,,,,,,,fee schedule,165.82,642.88,
Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.82,,,,,,,fee schedule,165.82,642.88,
Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.87,,,,,,,fee schedule,165.82,642.88,
Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,165.82,642.88,APC
Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,165.82,642.88,APC
Tissue exam by pathologist,88307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,165.82,642.88,APC
Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.2,,,,,,,fee schedule,259.09,1445.01,
Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,259.18,,,,,,,fee schedule,259.09,1445.01,
Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,323.47,,,,,,,fee schedule,259.09,1445.01,
Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.09,,,,,,,fee schedule,259.09,1445.01,
Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,454.48,,,,,,,fee schedule,259.09,1445.01,
Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,259.09,1445.01,APC
Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,259.09,1445.01,APC
Tissue exam by pathologist,88309,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,259.09,1445.01,APC
Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.29,,,,,,,fee schedule,7.39,30.23,
Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.39,,,,,,,fee schedule,7.39,30.23,
Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.52,,,,,,,fee schedule,7.39,30.23,
Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.24,,,,,,,fee schedule,7.39,30.23,
Decalcify tissue,88311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.23,,,,,,,fee schedule,7.39,30.23,
Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.21,,,,,,,fee schedule,51.92,231.39,
Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,75.72,,,,,,,fee schedule,51.92,231.39,
Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.69,,,,,,,fee schedule,51.92,231.39,
Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.91,,,,,,,fee schedule,51.92,231.39,
Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.39,,,,,,,fee schedule,51.92,231.39,
Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,231.39,APC
Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,231.39,APC
Special stains group 1,88312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,231.39,APC
Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.52,,,,,,,fee schedule,61.35,238.63,
Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,61.35,,,,,,,fee schedule,61.35,238.63,
Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.39,,,,,,,fee schedule,61.35,238.63,
Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.66,,,,,,,fee schedule,61.35,238.63,
Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.9,,,,,,,fee schedule,61.35,238.63,
Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,61.35,238.63,APC
Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,61.35,238.63,APC
Special stains group 2,88313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,61.35,238.63,APC
Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.87,,,,,,,fee schedule,61.64,175.8,
Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,61.64,,,,,,,fee schedule,61.64,175.8,
Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.12,,,,,,,fee schedule,61.64,175.8,
Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.22,,,,,,,fee schedule,61.64,175.8,
Histochemical stains add-on,88314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.8,,,,,,,fee schedule,61.64,175.8,
Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.52,,,,,,,fee schedule,95.71,1445.01,
Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,95.71,,,,,,,fee schedule,95.71,1445.01,
Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.75,,,,,,,fee schedule,95.71,1445.01,
Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.14,,,,,,,fee schedule,95.71,1445.01,
Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.95,,,,,,,fee schedule,95.71,1445.01,
Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,95.71,1445.01,APC
Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,95.71,1445.01,APC
Enzyme histochemistry,88319,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,95.71,1445.01,APC
Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.63,,,,,,,fee schedule,37.22,95.02,
Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,76.95,,,,,,,fee schedule,37.22,95.02,
Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.63,,,,,,,fee schedule,37.22,95.02,
Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.17,,,,,,,fee schedule,37.22,95.02,
Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.02,,,,,,,fee schedule,37.22,95.02,
Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,95.02,APC
Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,95.02,APC
Microslide consultation,88321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,95.02,APC
Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.38,,,,,,,fee schedule,24.69,171.79,
Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.69,,,,,,,fee schedule,24.69,171.79,
Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.27,,,,,,,fee schedule,24.69,171.79,
Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.93,,,,,,,fee schedule,24.69,171.79,
Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.79,,,,,,,fee schedule,24.69,171.79,
Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,24.69,171.79,APC
Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,24.69,171.79,APC
Microslide consultation,88323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,24.69,171.79,APC
Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,473.23,,,,,,,fee schedule,123.77,544.21,
Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,123.77,,,,,,,fee schedule,123.77,544.21,
Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,387.34,,,,,,,fee schedule,123.77,544.21,
Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.25,,,,,,,fee schedule,123.77,544.21,
Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,544.21,,,,,,,fee schedule,123.77,544.21,
Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,123.77,544.21,APC
Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,123.77,544.21,APC
Comprehensive review of data,88325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,123.77,544.21,APC
Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.78,,,,,,,fee schedule,32.63,105.8,
Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,32.63,,,,,,,fee schedule,32.63,105.8,
Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.93,,,,,,,fee schedule,32.63,105.8,
Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.19,,,,,,,fee schedule,32.63,105.8,
Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.75,,,,,,,fee schedule,32.63,105.8,
Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,32.63,105.8,APC
Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,32.63,105.8,APC
Path consult introp,88329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,32.63,105.8,APC
Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.12,,,,,,,fee schedule,36.13,305.56,
Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,36.13,,,,,,,fee schedule,36.13,305.56,
Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.31,,,,,,,fee schedule,36.13,305.56,
Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.54,,,,,,,fee schedule,36.13,305.56,
Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.49,,,,,,,fee schedule,36.13,305.56,
Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,36.13,305.56,APC
Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,36.13,305.56,APC
Path consult intraop 1 bloc,88331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,36.13,305.56,APC
Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.78,,,,,,,fee schedule,21.76,68.75,
Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.76,,,,,,,fee schedule,21.76,68.75,
Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.93,,,,,,,fee schedule,21.76,68.75,
Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.19,,,,,,,fee schedule,21.76,68.75,
Path consult intraop addl,88332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.75,,,,,,,fee schedule,21.76,68.75,
Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.12,,,,,,,fee schedule,28.21,1445.01,
Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,28.21,,,,,,,fee schedule,28.21,1445.01,
Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.31,,,,,,,fee schedule,28.21,1445.01,
Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.54,,,,,,,fee schedule,28.21,1445.01,
Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.49,,,,,,,fee schedule,28.21,1445.01,
Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,28.21,1445.01,APC
Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,28.21,1445.01,APC
Intraop cyto path consult 1,88333,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,28.21,1445.01,APC
Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.69,,,,,,,fee schedule,17.01,68.64,
Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.01,,,,,,,fee schedule,17.01,68.64,
Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.86,,,,,,,fee schedule,17.01,68.64,
Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.13,,,,,,,fee schedule,17.01,68.64,
Intraop cyto path consult 2,88334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.64,,,,,,,fee schedule,17.01,68.64,
Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.13,,,,,,,fee schedule,51.32,196.8,
Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,51.32,,,,,,,fee schedule,51.32,196.8,
Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.07,,,,,,,fee schedule,51.32,196.8,
Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.19,,,,,,,fee schedule,51.32,196.8,
Immunohisto antb addl slide,88341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.8,,,,,,,fee schedule,51.32,196.8,
Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,179.73,,,,,,,fee schedule,57.83,305.56,
Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,57.83,,,,,,,fee schedule,57.83,305.56,
Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.11,,,,,,,fee schedule,57.83,305.56,
Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.83,,,,,,,fee schedule,57.83,305.56,
Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,206.69,,,,,,,fee schedule,57.83,305.56,
Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,57.83,305.56,APC
Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,57.83,305.56,APC
Immunohisto antb 1st stain,88342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,57.83,305.56,APC
Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.27,,,,,,,fee schedule,112.28,642.88,
Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,114.43,,,,,,,fee schedule,112.28,642.88,
Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.18,,,,,,,fee schedule,112.28,642.88,
Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.28,,,,,,,fee schedule,112.28,642.88,
Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.96,,,,,,,fee schedule,112.28,642.88,
Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,112.28,642.88,APC
Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,112.28,642.88,APC
Immunohisto antibody slide,88344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,112.28,642.88,APC
Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.14,,,,,,,fee schedule,46.64,305.56,
Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,102.41,,,,,,,fee schedule,46.64,305.56,
Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.23,,,,,,,fee schedule,46.64,305.56,
Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.64,,,,,,,fee schedule,46.64,305.56,
Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.81,,,,,,,fee schedule,46.64,305.56,
Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,46.64,305.56,APC
Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,46.64,305.56,APC
Immunofluor antb 1st stain,88346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,46.64,305.56,APC
Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.27,,,,,,,fee schedule,326.67,1445.01,
Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,348.25,,,,,,,fee schedule,326.67,1445.01,
Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,407.83,,,,,,,fee schedule,326.67,1445.01,
Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.67,,,,,,,fee schedule,326.67,1445.01,
Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,573.01,,,,,,,fee schedule,326.67,1445.01,
Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,326.67,1445.01,APC
Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,326.67,1445.01,APC
Electron microscopy,88348,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,326.67,1445.01,APC
Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.65,,,,,,,fee schedule,42.38,77.18,
Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,77.18,,,,,,,fee schedule,42.38,77.18,
Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.92,,,,,,,fee schedule,42.38,77.18,
Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.38,,,,,,,fee schedule,42.38,77.18,
Immunofluor antb addl stain,88350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.35,,,,,,,fee schedule,42.38,77.18,
Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.62,,,,,,,fee schedule,53.19,305.56,
Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,53.19,,,,,,,fee schedule,53.19,305.56,
Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.92,,,,,,,fee schedule,53.19,305.56,
Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.27,,,,,,,fee schedule,53.19,305.56,
Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.16,,,,,,,fee schedule,53.19,305.56,
Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,53.19,305.56,APC
Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,53.19,305.56,APC
Analysis skeletal muscle,88355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,53.19,305.56,APC
Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,238.09,,,,,,,fee schedule,51.92,273.8,
Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,98.46,,,,,,,fee schedule,51.92,273.8,
Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.88,,,,,,,fee schedule,51.92,273.8,
Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.09,,,,,,,fee schedule,51.92,273.8,
Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,273.8,,,,,,,fee schedule,51.92,273.8,
Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,273.8,APC
Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,273.8,APC
Analysis nerve,88356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,273.8,APC
Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.59,,,,,,,fee schedule,77.09,305.56,
Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,79.53,,,,,,,fee schedule,77.09,305.56,
Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.25,,,,,,,fee schedule,77.09,305.56,
Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.09,,,,,,,fee schedule,77.09,305.56,
Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.23,,,,,,,fee schedule,77.09,305.56,
Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,77.09,305.56,APC
Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,77.09,305.56,APC
Analysis tumor,88358,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,77.09,305.56,APC
Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,174.39,,,,,,,fee schedule,67.8,305.56,
Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,67.8,,,,,,,fee schedule,67.8,305.56,
Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.74,,,,,,,fee schedule,67.8,305.56,
Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.33,,,,,,,fee schedule,67.8,305.56,
Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,200.55,,,,,,,fee schedule,67.8,305.56,
Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,67.8,305.56,APC
Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,67.8,305.56,APC
Tumor immunohistochem/manual,88360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,67.8,305.56,APC
Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.61,,,,,,,fee schedule,66.04,642.88,
Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,66.04,,,,,,,fee schedule,66.04,642.88,
Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.13,,,,,,,fee schedule,66.04,642.88,
Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.51,,,,,,,fee schedule,66.04,642.88,
Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.85,,,,,,,fee schedule,66.04,642.88,
Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,66.04,642.88,APC
Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,66.04,642.88,APC
Tumor immunohistochem/comput,88361,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,66.04,642.88,APC
Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,328.25,,,,,,,fee schedule,105.5,1445.01,
Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,105.5,,,,,,,fee schedule,105.5,1445.01,
Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.67,,,,,,,fee schedule,105.5,1445.01,
Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,215.2,,,,,,,fee schedule,105.5,1445.01,
Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,377.49,,,,,,,fee schedule,105.5,1445.01,
Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,105.5,1445.01,APC
Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,105.5,1445.01,APC
Nerve teasing preparations,88362,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,105.5,1445.01,APC
Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.86,,,,,,,fee schedule,12.36,51.88,
Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,17.88,,,,,,,fee schedule,12.36,51.88,
Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.44,,,,,,,fee schedule,12.36,51.88,
Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.36,,,,,,,fee schedule,12.36,51.88,
Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.69,,,,,,,fee schedule,12.36,51.88,
Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,12.36,51.88,APC
Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,12.36,51.88,APC
Xm archive tissue molec anal,88363,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,12.36,51.88,APC
Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,213.89,,,,,,,fee schedule,90.38,245.97,
Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,90.38,,,,,,,fee schedule,90.38,245.97,
Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.07,,,,,,,fee schedule,90.38,245.97,
Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.23,,,,,,,fee schedule,90.38,245.97,
Insitu hybridization (fish),88364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,245.97,,,,,,,fee schedule,90.38,245.97,
Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,243.16,,,,,,,fee schedule,121.23,305.56,
Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,121.23,,,,,,,fee schedule,121.23,305.56,
Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.03,,,,,,,fee schedule,121.23,305.56,
Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.42,,,,,,,fee schedule,121.23,305.56,
Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,279.63,,,,,,,fee schedule,121.23,305.56,
Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,121.23,305.56,APC
Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,121.23,305.56,APC
Insitu hybridization (fish),88365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,121.23,305.56,APC
Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,533.03,,,,,,,fee schedule,169.76,612.98,
Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,191.03,,,,,,,fee schedule,169.76,612.98,
Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,436.29,,,,,,,fee schedule,169.76,612.98,
Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,349.45,,,,,,,fee schedule,169.76,612.98,
Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,612.98,,,,,,,fee schedule,169.76,612.98,
Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,169.76,612.98,APC
Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,169.76,612.98,APC
Insitu hybridization (fish),88366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,169.76,612.98,APC
Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194,,,,,,,fee schedule,71.03,642.88,
Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,71.03,,,,,,,fee schedule,71.03,642.88,
Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.79,,,,,,,fee schedule,71.03,642.88,
Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.19,,,,,,,fee schedule,71.03,642.88,
Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,223.1,,,,,,,fee schedule,71.03,642.88,
Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,71.03,642.88,APC
Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,71.03,642.88,APC
Insitu hybridization auto,88367,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,71.03,642.88,APC
Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,398.93,,,,,,,fee schedule,88.97,642.88,
Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,88.97,,,,,,,fee schedule,88.97,642.88,
Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,326.52,,,,,,,fee schedule,88.97,642.88,
Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,261.54,,,,,,,fee schedule,88.97,642.88,
Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,458.77,,,,,,,fee schedule,88.97,642.88,
Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,88.97,642.88,APC
Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,88.97,642.88,APC
Insitu hybridization manual,88368,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,88.97,642.88,APC
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,398.93,,,,,,,fee schedule,78.65,458.77,
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,78.65,,,,,,,fee schedule,78.65,458.77,
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,326.52,,,,,,,fee schedule,78.65,458.77,
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,261.54,,,,,,,fee schedule,78.65,458.77,
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,458.77,,,,,,,fee schedule,78.65,458.77,
Protein western blot tissue,88371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.23,,,,,,,fee schedule,21.12,95.71,
Protein western blot tissue,88371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.12,,,,,,,fee schedule,21.12,95.71,
Protein western blot tissue,88371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.12,,,,,,,fee schedule,21.12,95.71,
Protein western blot tissue,88371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.57,,,,,,,fee schedule,21.12,95.71,
Protein western blot tissue,88371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.71,,,,,,,fee schedule,21.12,95.71,
Protein analysis w/probe,88372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.18,,,,,,,fee schedule,24.91,97.96,
Protein analysis w/probe,88372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,24.91,,,,,,,fee schedule,24.91,97.96,
Protein analysis w/probe,88372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.72,,,,,,,fee schedule,24.91,97.96,
Protein analysis w/probe,88372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.84,,,,,,,fee schedule,24.91,97.96,
Protein analysis w/probe,88372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.96,,,,,,,fee schedule,24.91,97.96,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.12,,,,,,,fee schedule,38.42,161.14,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,38.42,,,,,,,fee schedule,38.42,161.14,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.69,,,,,,,fee schedule,38.42,161.14,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.86,,,,,,,fee schedule,38.42,161.14,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.14,,,,,,,fee schedule,38.42,161.14,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,811.31,,,,,,,fee schedule,169.76,933.01,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,228.81,,,,,,,fee schedule,169.76,933.01,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,664.06,,,,,,,fee schedule,169.76,933.01,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,531.89,,,,,,,fee schedule,169.76,933.01,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,933.01,,,,,,,fee schedule,169.76,933.01,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,169.76,933.01,APC
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,169.76,933.01,APC
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,169.76,933.01,APC
Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,22.47,43.88,
Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,43.88,,,,,,,fee schedule,22.47,43.88,
Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,22.47,43.88,
Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,22.47,43.88,
Optical endomicroscpy interp,88375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,22.47,43.88,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,937.71,,,,,,,fee schedule,169.76,1078.37,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,292.21,,,,,,,fee schedule,169.76,1078.37,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,767.52,,,,,,,fee schedule,169.76,1078.37,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,614.76,,,,,,,fee schedule,169.76,1078.37,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1078.37,,,,,,,fee schedule,169.76,1078.37,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,169.76,1078.37,APC
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,169.76,1078.37,APC
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,169.76,1078.37,APC
Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,389.58,,,,,,,fee schedule,62.28,448.02,
Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,62.28,,,,,,,fee schedule,62.28,448.02,
Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,318.87,,,,,,,fee schedule,62.28,448.02,
Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255.41,,,,,,,fee schedule,62.28,448.02,
Microdissection laser,88380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,448.02,,,,,,,fee schedule,62.28,448.02,
Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,264.55,,,,,,,fee schedule,156.53,304.23,
Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,156.53,,,,,,,fee schedule,156.53,304.23,
Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,216.53,,,,,,,fee schedule,156.53,304.23,
Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.44,,,,,,,fee schedule,156.53,304.23,
Microdissection manual,88381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,304.23,,,,,,,fee schedule,156.53,304.23,
Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,6.8,23.67,
Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.8,,,,,,,fee schedule,6.8,23.67,
Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,6.8,23.67,
Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,6.8,23.67,
Tiss exam molecular study,88387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,6.8,23.67,
Tiss ex molecul study add-on,88388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,12.08,,,,,,,fee schedule,12.08,12.08,
Surgical pathology procedure,88399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,93.46,APC
Surgical pathology procedure,88399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,93.46,APC
Surgical pathology procedure,88399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,93.46,APC
Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.17,,,,,,,fee schedule,4.77,20.9,
Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.77,,,,,,,fee schedule,4.77,20.9,
Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.87,,,,,,,fee schedule,4.77,20.9,
Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.91,,,,,,,fee schedule,4.77,20.9,
Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.9,,,,,,,fee schedule,4.77,20.9,
Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.77,20.9,APC
Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.02,,,,,,,fee schedule,4.77,20.9,APC
Bilirubin total transcut,88720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.04,,,,,,,fee schedule,4.77,20.9,APC
Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.79,,,,,,,fee schedule,4.77,21.61,
Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.77,,,,,,,fee schedule,4.77,21.61,
Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.38,,,,,,,fee schedule,4.77,21.61,
Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.32,,,,,,,fee schedule,4.77,21.61,
Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.61,,,,,,,fee schedule,4.77,21.61,
Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.77,21.61,APC
Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.02,,,,,,,fee schedule,4.77,21.61,APC
Hgb quant transcutaneous,88738,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.04,,,,,,,fee schedule,4.77,21.61,APC
Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.79,,,,,,,fee schedule,8.9,21.61,
Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.9,,,,,,,fee schedule,8.9,21.61,
Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.38,,,,,,,fee schedule,8.9,21.61,
Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.32,,,,,,,fee schedule,8.9,21.61,
Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.61,,,,,,,fee schedule,8.9,21.61,
Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.84,,,,,,,fee schedule,8.9,21.61,APC
Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.37,,,,,,,fee schedule,8.9,21.61,APC
Transcutaneous carboxyhb,88740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.87,,,,,,,fee schedule,8.9,21.61,APC
Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.79,,,,,,,fee schedule,8.9,21.61,
Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.9,,,,,,,fee schedule,8.9,21.61,
Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.38,,,,,,,fee schedule,8.9,21.61,
Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.32,,,,,,,fee schedule,8.9,21.61,
Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.61,,,,,,,fee schedule,8.9,21.61,
Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.84,,,,,,,fee schedule,8.9,21.61,APC
Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.37,,,,,,,fee schedule,8.9,21.61,APC
Transcutaneous methb,88741,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.87,,,,,,,fee schedule,8.9,21.61,APC
Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,58.58,305.56,
Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,58.58,,,,,,,fee schedule,58.58,305.56,
Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,58.58,305.56,
Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,58.58,305.56,
Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,58.58,305.56,
Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,58.58,305.56,APC
Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,58.58,305.56,APC
Chct for mal hyperthermia,89049,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,58.58,305.56,APC
Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.35,,,,,,,fee schedule,4.48,18.8,
Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.48,,,,,,,fee schedule,4.48,18.8,
Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.38,,,,,,,fee schedule,4.48,18.8,
Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.72,,,,,,,fee schedule,4.48,18.8,
Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.8,,,,,,,fee schedule,4.48,18.8,
Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.96,,,,,,,fee schedule,4.48,18.8,APC
Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.72,,,,,,,fee schedule,4.48,18.8,APC
Body fluid cell count,89050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.5,,,,,,,fee schedule,4.48,18.8,APC
Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.12,,,,,,,fee schedule,5.32,21.99,
Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.32,,,,,,,fee schedule,5.32,21.99,
Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.65,,,,,,,fee schedule,5.32,21.99,
Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.54,,,,,,,fee schedule,5.32,21.99,
Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.99,,,,,,,fee schedule,5.32,21.99,
Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.88,,,,,,,fee schedule,5.32,21.99,APC
Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.6,,,,,,,fee schedule,5.32,21.99,APC
Body fluid cell count,89051,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.08,,,,,,,fee schedule,5.32,21.99,APC
Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.15,,,,,,,fee schedule,4.06,23.17,
Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.06,,,,,,,fee schedule,4.06,23.17,
Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.49,,,,,,,fee schedule,4.06,23.17,
Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.21,,,,,,,fee schedule,4.06,23.17,
Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.17,,,,,,,fee schedule,4.06,23.17,
Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.06,23.17,APC
Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.27,,,,,,,fee schedule,4.06,23.17,APC
Leukocyte assessment fecal,89055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.69,,,,,,,fee schedule,4.06,23.17,APC
Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.46,,,,,,,fee schedule,6.96,89.08,
Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.96,,,,,,,fee schedule,6.96,89.08,
Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.4,,,,,,,fee schedule,6.96,89.08,
Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.78,,,,,,,fee schedule,6.96,89.08,
Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.08,,,,,,,fee schedule,6.96,89.08,
Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.7,,,,,,,fee schedule,6.96,89.08,APC
Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.33,,,,,,,fee schedule,6.96,89.08,APC
Exam synovial fluid crystals,89060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.19,,,,,,,fee schedule,6.96,89.08,APC
Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.18,,,,,,,fee schedule,5.59,18.61,
Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.59,,,,,,,fee schedule,5.59,18.61,
Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.24,,,,,,,fee schedule,5.59,18.61,
Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.61,,,,,,,fee schedule,5.59,18.61,
Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.61,,,,,,,fee schedule,5.59,18.61,
Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.17,,,,,,,fee schedule,5.59,18.61,APC
Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.88,,,,,,,fee schedule,5.59,18.61,APC
Specimen fat stain,89125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.58,,,,,,,fee schedule,5.59,18.61,APC
Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.81,,,,,,,fee schedule,4.61,15.88,
Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.61,,,,,,,fee schedule,4.61,15.88,
Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.3,,,,,,,fee schedule,4.61,15.88,
Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.05,,,,,,,fee schedule,4.61,15.88,
Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.88,,,,,,,fee schedule,4.61,15.88,
Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.09,,,,,,,fee schedule,4.61,15.88,APC
Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.85,,,,,,,fee schedule,4.61,15.88,APC
Exam feces for meat fibers,89160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.73,,,,,,,fee schedule,4.61,15.88,APC
Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2369.9,,,,,,,fee schedule,5.5,2725.39,
Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,5.5,,,,,,,fee schedule,5.5,2725.39,
Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1939.76,,,,,,,fee schedule,5.5,2725.39,
Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1553.71,,,,,,,fee schedule,5.5,2725.39,
Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2725.39,,,,,,,fee schedule,5.5,2725.39,
Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.08,,,,,,,fee schedule,5.5,2725.39,APC
Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.79,,,,,,,fee schedule,5.5,2725.39,APC
Nasal smear for eosinophils,89190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.42,,,,,,,fee schedule,5.5,2725.39,APC
Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,15.89,305.56,
Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.89,,,,,,,fee schedule,15.89,305.56,
Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,15.89,305.56,
Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,15.89,305.56,
Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,15.89,305.56,
Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,15.89,305.56,APC
Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,15.89,305.56,APC
Sputum specimen collection,89220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,15.89,305.56,APC
Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.62,,,,,,,fee schedule,2.4,93.46,
Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,2.4,,,,,,,fee schedule,2.4,93.46,
Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.89,,,,,,,fee schedule,2.4,93.46,
Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.58,,,,,,,fee schedule,2.4,93.46,
Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.96,,,,,,,fee schedule,2.4,93.46,
Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,2.4,93.46,APC
Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,2.4,93.46,APC
Collect sweat for test,89230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,2.4,93.46,APC
Pathology lab procedure,89240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,93.46,APC
Pathology lab procedure,89240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,93.46,APC
Pathology lab procedure,89240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,93.46,APC
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2848.42,,,,,,,fee schedule,169.76,3275.68,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,941.42,,,,,,,fee schedule,169.76,3275.68,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2331.43,,,,,,,fee schedule,169.76,3275.68,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1867.42,,,,,,,fee schedule,169.76,3275.68,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3275.68,,,,,,,fee schedule,169.76,3275.68,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,169.76,3275.68,APC
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,169.76,3275.68,APC
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,169.76,3275.68,APC
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.07,,,,,,,fee schedule,169.76,3407.53,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,979.25,,,,,,,fee schedule,169.76,3407.53,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2425.27,,,,,,,fee schedule,169.76,3407.53,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1942.59,,,,,,,fee schedule,169.76,3407.53,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.53,,,,,,,fee schedule,169.76,3407.53,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,169.76,3407.53,APC
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,169.76,3407.53,APC
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,169.76,3407.53,APC
Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,305.56,
Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,157.5,,,,,,,fee schedule,101.85,305.56,
Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,305.56,
Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,305.56,
Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,305.56,
Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,305.56,APC
Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,305.56,APC
Embryo hatching,89253,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,305.56,APC
Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,305.56,
Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,288.05,,,,,,,fee schedule,101.85,305.56,
Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,305.56,
Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,305.56,
Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,305.56,
Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,305.56,APC
Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,305.56,APC
Oocyte identification,89254,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,305.56,APC
Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,51.92,227.41,
Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,227.41,,,,,,,fee schedule,51.92,227.41,
Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,51.92,227.41,
Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,51.92,227.41,
Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,51.92,227.41,
Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,227.41,APC
Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,227.41,APC
Prepare embryo for transfer,89255,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,227.41,APC
Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.35,,,,,,,fee schedule,38.91,202.16,
Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,202.16,,,,,,,fee schedule,38.91,202.16,
Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.58,,,,,,,fee schedule,38.91,202.16,
Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.91,,,,,,,fee schedule,38.91,202.16,
Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.25,,,,,,,fee schedule,38.91,202.16,
Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,38.91,202.16,APC
Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,38.91,202.16,APC
Sperm identification,89257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,38.91,202.16,APC
Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.22,,,,,,,fee schedule,390.06,1445.01,
Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,390.06,,,,,,,fee schedule,390.06,1445.01,
Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,555.94,,,,,,,fee schedule,390.06,1445.01,
Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.3,,,,,,,fee schedule,390.06,1445.01,
Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.1,,,,,,,fee schedule,390.06,1445.01,
Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,390.06,1445.01,APC
Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,390.06,1445.01,APC
Cryopreservation embryo(s),89258,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,390.06,1445.01,APC
Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,305.56,
Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,196.98,,,,,,,fee schedule,101.85,305.56,
Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,305.56,
Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,305.56,
Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,305.56,
Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,305.56,APC
Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,305.56,APC
Cryopreservation sperm,89259,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,305.56,APC
Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.35,,,,,,,fee schedule,38.91,93.46,
Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,74.82,,,,,,,fee schedule,38.91,93.46,
Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.58,,,,,,,fee schedule,38.91,93.46,
Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.91,,,,,,,fee schedule,38.91,93.46,
Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.25,,,,,,,fee schedule,38.91,93.46,
Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,38.91,93.46,APC
Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,38.91,93.46,APC
Sperm isolation simple,89260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,38.91,93.46,APC
Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.35,,,,,,,fee schedule,38.91,93.46,
Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,72.78,,,,,,,fee schedule,38.91,93.46,
Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.58,,,,,,,fee schedule,38.91,93.46,
Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.91,,,,,,,fee schedule,38.91,93.46,
Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.25,,,,,,,fee schedule,38.91,93.46,
Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,38.91,93.46,APC
Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,38.91,93.46,APC
Sperm isolation complex,89261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,38.91,93.46,APC
Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,51.92,239.87,
Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,239.87,,,,,,,fee schedule,51.92,239.87,
Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,51.92,239.87,
Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,51.92,239.87,
Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,51.92,239.87,
Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,239.87,APC
Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,239.87,APC
Identify sperm tissue,89264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,239.87,APC
Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,305.56,
Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,295.55,,,,,,,fee schedule,101.85,305.56,
Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,305.56,
Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,305.56,
Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,305.56,
Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,305.56,APC
Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,305.56,APC
Insemination of oocytes,89268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,305.56,APC
Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.22,,,,,,,fee schedule,415.64,1445.01,
Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,415.64,,,,,,,fee schedule,415.64,1445.01,
Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,555.94,,,,,,,fee schedule,415.64,1445.01,
Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.3,,,,,,,fee schedule,415.64,1445.01,
Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.1,,,,,,,fee schedule,415.64,1445.01,
Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,415.64,1445.01,APC
Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,415.64,1445.01,APC
Extended culture of oocytes,89272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,415.64,1445.01,APC
Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.22,,,,,,,fee schedule,445.3,1445.01,
Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,525.71,,,,,,,fee schedule,445.3,1445.01,
Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,555.94,,,,,,,fee schedule,445.3,1445.01,
Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.3,,,,,,,fee schedule,445.3,1445.01,
Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,781.1,,,,,,,fee schedule,445.3,1445.01,
Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.92,,,,,,,fee schedule,445.3,1445.01,APC
Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,802.78,,,,,,,fee schedule,445.3,1445.01,APC
Assist oocyte fertilization,89280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.01,,,,,,,fee schedule,445.3,1445.01,APC
Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,624.77,
Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,624.77,,,,,,,fee schedule,101.85,624.77,
Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,624.77,
Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,624.77,
Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,624.77,
Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,624.77,APC
Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,624.77,APC
Assist oocyte fertilization,89281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,624.77,APC
Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,628.52,
Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,628.52,,,,,,,fee schedule,101.85,628.52,
Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,628.52,
Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,628.52,
Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,628.52,
Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,628.52,APC
Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,628.52,APC
Biopsy oocyte polar body,89290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,628.52,APC
Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,790.61,
Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,790.61,,,,,,,fee schedule,101.85,790.61,
Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,790.61,
Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,790.61,
Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,790.61,
Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,790.61,APC
Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,790.61,APC
Biopsy oocyte polar body,89291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,790.61,APC
Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,9.35,30.48,
Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.35,,,,,,,fee schedule,9.35,30.48,
Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,9.35,30.48,
Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,9.35,30.48,
Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,9.35,30.48,
Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.33,,,,,,,fee schedule,9.35,30.48,APC
Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.84,,,,,,,fee schedule,9.35,30.48,APC
Semen analysis w/huhner,89300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.71,,,,,,,fee schedule,9.35,30.48,APC
Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.23,,,,,,,fee schedule,8.18,37.06,
Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.18,,,,,,,fee schedule,8.18,37.06,
Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.38,,,,,,,fee schedule,8.18,37.06,
Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.13,,,,,,,fee schedule,8.18,37.06,
Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.06,,,,,,,fee schedule,8.18,37.06,
Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.04,,,,,,,fee schedule,8.18,37.06,APC
Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.61,,,,,,,fee schedule,8.18,37.06,APC
Semen analysis w/count,89310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.5,,,,,,,fee schedule,8.18,37.06,APC
Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.13,,,,,,,fee schedule,11.69,51.9,
Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.69,,,,,,,fee schedule,11.69,51.9,
Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.94,,,,,,,fee schedule,11.69,51.9,
Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.59,,,,,,,fee schedule,11.69,51.9,
Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.9,,,,,,,fee schedule,11.69,51.9,
Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.93,,,,,,,fee schedule,11.69,51.9,APC
Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.31,,,,,,,fee schedule,11.69,51.9,APC
Semen anal vol/count/mot,89320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.16,,,,,,,fee schedule,11.69,51.9,APC
Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.13,,,,,,,fee schedule,11.45,51.9,
Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,11.45,,,,,,,fee schedule,11.45,51.9,
Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.94,,,,,,,fee schedule,11.45,51.9,
Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.59,,,,,,,fee schedule,11.45,51.9,
Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.9,,,,,,,fee schedule,11.45,51.9,
Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,11.45,51.9,APC
Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,11.45,51.9,APC
Semen anal sperm detection,89321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,11.45,51.9,APC
Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.03,,,,,,,fee schedule,14.73,66.73,
Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,14.73,,,,,,,fee schedule,14.73,66.73,
Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.5,,,,,,,fee schedule,14.73,66.73,
Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.04,,,,,,,fee schedule,14.73,66.73,
Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.73,,,,,,,fee schedule,14.73,66.73,
Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.28,,,,,,,fee schedule,14.73,66.73,APC
Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.5,,,,,,,fee schedule,14.73,66.73,APC
Semen anal strict criteria,89322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.9,,,,,,,fee schedule,14.73,66.73,APC
Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.98,,,,,,,fee schedule,10.14,45.98,
Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.14,,,,,,,fee schedule,10.14,45.98,
Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.72,,,,,,,fee schedule,10.14,45.98,
Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.21,,,,,,,fee schedule,10.14,45.98,
Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.98,,,,,,,fee schedule,10.14,45.98,
Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.2,,,,,,,fee schedule,10.14,45.98,APC
Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.67,,,,,,,fee schedule,10.14,45.98,APC
Sperm antibody test,89325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.21,,,,,,,fee schedule,10.14,45.98,APC
Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.5,,,,,,,fee schedule,18.61,90.28,
Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.61,,,,,,,fee schedule,18.61,90.28,
Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.25,,,,,,,fee schedule,18.61,90.28,
Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.46,,,,,,,fee schedule,18.61,90.28,
Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.28,,,,,,,fee schedule,18.61,90.28,
Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.57,,,,,,,fee schedule,18.61,90.28,APC
Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.59,,,,,,,fee schedule,18.61,90.28,APC
Sperm evaluation test,89329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.26,,,,,,,fee schedule,18.61,90.28,APC
Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.06,,,,,,,fee schedule,9.86,42.62,
Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,9.86,,,,,,,fee schedule,9.86,42.62,
Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.33,,,,,,,fee schedule,9.86,42.62,
Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.3,,,,,,,fee schedule,9.86,42.62,
Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.62,,,,,,,fee schedule,9.86,42.62,
Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.9,,,,,,,fee schedule,9.86,42.62,APC
Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.38,,,,,,,fee schedule,9.86,42.62,APC
Evaluation cervical mucus,89330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.68,,,,,,,fee schedule,9.86,42.62,APC
Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.12,,,,,,,fee schedule,18.61,80.64,
Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,18.61,,,,,,,fee schedule,18.61,80.64,
Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.39,,,,,,,fee schedule,18.61,80.64,
Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.97,,,,,,,fee schedule,18.61,80.64,
Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.64,,,,,,,fee schedule,18.61,80.64,
Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.57,,,,,,,fee schedule,18.61,80.64,APC
Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.59,,,,,,,fee schedule,18.61,80.64,APC
Retrograde ejaculation anal,89331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.26,,,,,,,fee schedule,18.61,80.64,APC
Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.35,,,,,,,fee schedule,38.91,106.3,
Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,106.3,,,,,,,fee schedule,38.91,106.3,
Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.58,,,,,,,fee schedule,38.91,106.3,
Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.91,,,,,,,fee schedule,38.91,106.3,
Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.25,,,,,,,fee schedule,38.91,106.3,
Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,38.91,106.3,APC
Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,38.91,106.3,APC
Cryopreserve testicular tiss,89335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,38.91,106.3,APC
Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,413.84,
Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,413.84,,,,,,,fee schedule,101.85,413.84,
Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,413.84,
Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,413.84,
Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,413.84,
Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,413.84,APC
Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,413.84,APC
Cryopreservation oocyte(s),89337,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,413.84,APC
Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,305.56,
Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,156.14,,,,,,,fee schedule,101.85,305.56,
Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,305.56,
Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,305.56,
Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,305.56,
Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,305.56,APC
Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,305.56,APC
Storage/year embryo(s),89342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,305.56,APC
Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,101.85,305.56,
Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,173.97,,,,,,,fee schedule,101.85,305.56,
Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,101.85,305.56,
Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,101.85,305.56,
Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,101.85,305.56,
Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,101.85,305.56,APC
Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,101.85,305.56,APC
Storage/year sperm/semen,89343,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,101.85,305.56,APC
Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,94.96,305.56,
Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,94.96,,,,,,,fee schedule,94.96,305.56,
Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,94.96,305.56,
Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,94.96,305.56,
Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,94.96,305.56,
Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,94.96,305.56,APC
Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,94.96,305.56,APC
Storage/year reprod tissue,89344,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,94.96,305.56,APC
Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,275.17,,,,,,,fee schedule,169.76,316.45,
Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,218.76,,,,,,,fee schedule,169.76,316.45,
Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,225.23,,,,,,,fee schedule,169.76,316.45,
Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,180.4,,,,,,,fee schedule,169.76,316.45,
Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,316.45,,,,,,,fee schedule,169.76,316.45,
Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,169.76,316.45,APC
Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,169.76,316.45,APC
Storage/year oocyte(s),89346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,169.76,316.45,APC
Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,8.46,305.56,
Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.46,,,,,,,fee schedule,8.46,305.56,
Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,8.46,305.56,
Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,8.46,305.56,
Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,8.46,305.56,
Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,8.46,305.56,APC
Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,8.46,305.56,APC
Thawing cryopresrved embryo,89352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,8.46,305.56,APC
Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.35,,,,,,,fee schedule,8.46,93.46,
Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.46,,,,,,,fee schedule,8.46,93.46,
Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.58,,,,,,,fee schedule,8.46,93.46,
Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.91,,,,,,,fee schedule,8.46,93.46,
Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.25,,,,,,,fee schedule,8.46,93.46,
Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,8.46,93.46,APC
Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,8.46,93.46,APC
Thawing cryopresrved sperm,89353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,8.46,93.46,APC
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,8.46,305.56,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.46,,,,,,,fee schedule,8.46,305.56,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,8.46,305.56,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,8.46,305.56,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,8.46,305.56,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,8.46,305.56,APC
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,8.46,305.56,APC
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,8.46,305.56,APC
Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.35,,,,,,,fee schedule,6.03,305.56,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,6.03,,,,,,,fee schedule,6.03,305.56,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.15,,,,,,,fee schedule,6.03,305.56,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.85,,,,,,,fee schedule,6.03,305.56,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.65,,,,,,,fee schedule,6.03,305.56,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.25,,,,,,,fee schedule,6.03,305.56,APC
Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,169.76,,,,,,,fee schedule,6.03,305.56,APC
Thawing cryopresrved oocyte,89356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,305.56,,,,,,,fee schedule,6.03,305.56,APC
Unlisted reprod med lab proc,89398,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.52,,,,,,,fee schedule,51.92,93.46,APC
Unlisted reprod med lab proc,89398,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.92,,,,,,,fee schedule,51.92,93.46,APC
Unlisted reprod med lab proc,89398,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.46,,,,,,,fee schedule,51.92,93.46,APC
Human ig im,90281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.98,,,,,,,fee schedule,96.98,111.53,
Human ig im,90281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.98,,,,,,,fee schedule,96.98,111.53,
Human ig im,90281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.98,,,,,,,fee schedule,96.98,111.53,
Human ig im,90281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.53,,,,,,,fee schedule,96.98,111.53,
Human ig iv,90283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.85,,,,,,,fee schedule,75.85,87.23,
Human ig iv,90283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.85,,,,,,,fee schedule,75.85,87.23,
Human ig iv,90283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.85,,,,,,,fee schedule,75.85,87.23,
Human ig iv,90283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.23,,,,,,,fee schedule,75.85,87.23,
Human ig sc,90284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.17,,,,,,,fee schedule,15.17,17.45,
Human ig sc,90284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.17,,,,,,,fee schedule,15.17,17.45,
Human ig sc,90284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.17,,,,,,,fee schedule,15.17,17.45,
Human ig sc,90284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.45,,,,,,,fee schedule,15.17,17.45,
Botulinum antitoxin,90287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,532,,,,,,,fee schedule,532,611.8,
Botulinum antitoxin,90287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,532,,,,,,,fee schedule,532,611.8,
Botulinum antitoxin,90287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,532,,,,,,,fee schedule,532,611.8,
Botulinum antitoxin,90287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,611.8,,,,,,,fee schedule,532,611.8,
Botulism ig iv,90288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48705,,,,,,,fee schedule,48705,56010.75,
Botulism ig iv,90288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48705,,,,,,,fee schedule,48705,56010.75,
Botulism ig iv,90288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48705,,,,,,,fee schedule,48705,56010.75,
Botulism ig iv,90288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56010.75,,,,,,,fee schedule,48705,56010.75,
Cmv ig iv,90291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1791.99,,,,,,,fee schedule,1791.99,2060.79,
Cmv ig iv,90291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1791.99,,,,,,,fee schedule,1791.99,2060.79,
Cmv ig iv,90291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1791.99,,,,,,,fee schedule,1791.99,2060.79,
Cmv ig iv,90291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2060.79,,,,,,,fee schedule,1791.99,2060.79,
Diphtheria antitoxin,90296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,341.19,,,,,,,fee schedule,341.19,392.37,
Diphtheria antitoxin,90296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,341.19,,,,,,,fee schedule,341.19,392.37,
Diphtheria antitoxin,90296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,341.19,,,,,,,fee schedule,341.19,392.37,
Diphtheria antitoxin,90296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.37,,,,,,,fee schedule,341.19,392.37,
Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,135.59,,,,,,,fee schedule,135.59,246.51,
Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.59,,,,,,,fee schedule,135.59,246.51,
Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.59,,,,,,,fee schedule,135.59,246.51,
Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.93,,,,,,,fee schedule,135.59,246.51,
Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.8,,,,,,,fee schedule,135.59,246.51,APC
Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,136.95,,,,,,,fee schedule,135.59,246.51,APC
Hep b ig im,90371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.51,,,,,,,fee schedule,135.59,246.51,APC
Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,276.49,,,,,,,fee schedule,276.49,506.13,
Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,276.49,,,,,,,fee schedule,276.49,506.13,
Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,276.49,,,,,,,fee schedule,276.49,506.13,
Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,317.96,,,,,,,fee schedule,276.49,506.13,
Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,295.24,,,,,,,fee schedule,276.49,506.13,APC
Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,281.18,,,,,,,fee schedule,276.49,506.13,APC
Rabies ig im/sc,90375,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,506.13,,,,,,,fee schedule,276.49,506.13,APC
Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,461.62,,,,,,,fee schedule,352.44,634.39,
Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,461.62,,,,,,,fee schedule,352.44,634.39,
Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,461.62,,,,,,,fee schedule,352.44,634.39,
Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,530.86,,,,,,,fee schedule,352.44,634.39,
Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,370.06,,,,,,,fee schedule,352.44,634.39,APC
Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,352.44,,,,,,,fee schedule,352.44,634.39,APC
Rabies ig heat treated,90376,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,634.39,,,,,,,fee schedule,352.44,634.39,APC
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,406.49,,,,,,,fee schedule,243.2,467.46,
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,406.49,,,,,,,fee schedule,243.2,467.46,
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,406.49,,,,,,,fee schedule,243.2,467.46,
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,467.46,,,,,,,fee schedule,243.2,467.46,
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,255.36,,,,,,,fee schedule,243.2,467.46,APC
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,243.2,,,,,,,fee schedule,243.2,467.46,APC
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,437.76,,,,,,,fee schedule,243.2,467.46,APC
Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1857.07,,,,,,,fee schedule,436.75,2135.63,
Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1857.07,,,,,,,fee schedule,436.75,2135.63,
Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1857.07,,,,,,,fee schedule,436.75,2135.63,
Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2135.63,,,,,,,fee schedule,436.75,2135.63,
Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,2135.63,APC
Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,436.75,,,,,,,fee schedule,436.75,2135.63,APC
Rsv mab im 50mg,90378,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,786.15,,,,,,,fee schedule,436.75,2135.63,APC
Rsv monoc antb seasn .5ml im,90380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,633.99,,,,,,,fee schedule,633.99,729.09,
Rsv monoc antb seasn .5ml im,90380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,633.99,,,,,,,fee schedule,633.99,729.09,
Rsv monoc antb seasn .5ml im,90380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,633.99,,,,,,,fee schedule,633.99,729.09,
Rsv monoc antb seasn .5ml im,90380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,729.09,,,,,,,fee schedule,633.99,729.09,
Rsv monoc antb seasnl 1ml im,90381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,633.99,,,,,,,fee schedule,633.99,729.09,
Rsv monoc antb seasnl 1ml im,90381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,633.99,,,,,,,fee schedule,633.99,729.09,
Rsv monoc antb seasnl 1ml im,90381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,633.99,,,,,,,fee schedule,633.99,729.09,
Rsv monoc antb seasnl 1ml im,90381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,729.09,,,,,,,fee schedule,633.99,729.09,
Rsv monoc antb seasn .7ml im,90382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,567.12,,,,,,,fee schedule,567.12,652.19,
Rsv monoc antb seasn .7ml im,90382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.12,,,,,,,fee schedule,567.12,652.19,
Rsv monoc antb seasn .7ml im,90382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,567.12,,,,,,,fee schedule,567.12,652.19,
Rsv monoc antb seasn .7ml im,90382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,652.19,,,,,,,fee schedule,567.12,652.19,
Rh ig full-dose im,90384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.49,,,,,,,fee schedule,84.49,97.16,
Rh ig full-dose im,90384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.49,,,,,,,fee schedule,84.49,97.16,
Rh ig full-dose im,90384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.49,,,,,,,fee schedule,84.49,97.16,
Rh ig full-dose im,90384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.16,,,,,,,fee schedule,84.49,97.16,
Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.44,,,,,,,fee schedule,30.44,144,
Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.44,,,,,,,fee schedule,30.44,144,
Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.44,,,,,,,fee schedule,30.44,144,
Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.01,,,,,,,fee schedule,30.44,144,
Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84,,,,,,,fee schedule,30.44,144,APC
Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,80,,,,,,,fee schedule,30.44,144,APC
Rh ig minidose im,90385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,144,,,,,,,fee schedule,30.44,144,APC
Rh ig iv,90386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.14,,,,,,,fee schedule,173.14,199.11,
Rh ig iv,90386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.14,,,,,,,fee schedule,173.14,199.11,
Rh ig iv,90386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.14,,,,,,,fee schedule,173.14,199.11,
Rh ig iv,90386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.11,,,,,,,fee schedule,173.14,199.11,
Tetanus ig im,90389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,662.15,,,,,,,fee schedule,662.15,761.47,
Tetanus ig im,90389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,662.15,,,,,,,fee schedule,662.15,761.47,
Tetanus ig im,90389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,662.15,,,,,,,fee schedule,662.15,761.47,
Tetanus ig im,90389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,761.47,,,,,,,fee schedule,662.15,761.47,
Vaccina ig im,90393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51,,,,,,,fee schedule,51,58.65,
Vaccina ig im,90393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51,,,,,,,fee schedule,51,58.65,
Vaccina ig im,90393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51,,,,,,,fee schedule,51,58.65,
Vaccina ig im,90393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.65,,,,,,,fee schedule,51,58.65,
Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2326.37,,,,,,,fee schedule,2326.37,4495.92,
Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2326.37,,,,,,,fee schedule,2326.37,4495.92,
Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2326.37,,,,,,,fee schedule,2326.37,4495.92,
Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2675.33,,,,,,,fee schedule,2326.37,4495.92,
Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2622.62,,,,,,,fee schedule,2326.37,4495.92,APC
Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2497.73,,,,,,,fee schedule,2326.37,4495.92,APC
Varicella-zoster ig im,90396,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4495.92,,,,,,,fee schedule,2326.37,4495.92,APC
Im admin 1st/only component,90460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.07,,,,,,,fee schedule,34.14,59.88,
Im admin 1st/only component,90460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.62,,,,,,,fee schedule,34.14,59.88,
Im admin 1st/only component,90460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.14,,,,,,,fee schedule,34.14,59.88,
Im admin 1st/only component,90460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.88,,,,,,,fee schedule,34.14,59.88,
Im admin each addl component,90461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.44,,,,,,,fee schedule,19.3,33.86,
Im admin each addl component,90461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.1,,,,,,,fee schedule,19.3,33.86,
Im admin each addl component,90461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.3,,,,,,,fee schedule,19.3,33.86,
Im admin each addl component,90461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.86,,,,,,,fee schedule,19.3,33.86,
Immunization admin,90471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.04,,,,,,,fee schedule,36.74,129.13,
Immunization admin,90471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.87,,,,,,,fee schedule,36.74,129.13,
Immunization admin,90471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.74,,,,,,,fee schedule,36.74,129.13,
Immunization admin,90471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.45,,,,,,,fee schedule,36.74,129.13,
Immunization admin,90471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,36.74,129.13,APC
Immunization admin,90471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,36.74,129.13,APC
Immunization admin,90471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,36.74,129.13,APC
Immunization admin each add,90472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.81,,,,,,,fee schedule,14.95,26.23,
Immunization admin each add,90472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.67,,,,,,,fee schedule,14.95,26.23,
Immunization admin each add,90472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.95,,,,,,,fee schedule,14.95,26.23,
Immunization admin each add,90472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.23,,,,,,,fee schedule,14.95,26.23,
Immune admin oral/nasal,90473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.76,,,,,,,fee schedule,14.92,129.13,
Immune admin oral/nasal,90473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.63,,,,,,,fee schedule,14.92,129.13,
Immune admin oral/nasal,90473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.92,,,,,,,fee schedule,14.92,129.13,
Immune admin oral/nasal,90473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.17,,,,,,,fee schedule,14.92,129.13,
Immune admin oral/nasal,90473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,14.92,129.13,APC
Immune admin oral/nasal,90473,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,14.92,129.13,APC
Immune admin oral/nasal,90473,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,14.92,129.13,APC
Immune admin oral/nasal addl,90474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,12.85,22.54,
Immune admin oral/nasal addl,90474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,12.85,22.54,
Immune admin oral/nasal addl,90474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,12.85,22.54,
Immune admin oral/nasal addl,90474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,12.85,22.54,
Adenovirus vaccine type 4,90476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29,,,,,,,fee schedule,29,33.35,
Adenovirus vaccine type 4,90476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29,,,,,,,fee schedule,29,33.35,
Adenovirus vaccine type 4,90476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29,,,,,,,fee schedule,29,33.35,
Adenovirus vaccine type 4,90476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.35,,,,,,,fee schedule,29,33.35,
Adenovirus vaccine type 7,90477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29,,,,,,,fee schedule,29,33.35,
Adenovirus vaccine type 7,90477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29,,,,,,,fee schedule,29,33.35,
Adenovirus vaccine type 7,90477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29,,,,,,,fee schedule,29,33.35,
Adenovirus vaccine type 7,90477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.35,,,,,,,fee schedule,29,33.35,
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.52,,,,,,,fee schedule,40.49,72.89,APC
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40.49,,,,,,,fee schedule,40.49,72.89,APC
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,72.89,,,,,,,fee schedule,40.49,72.89,APC
Anthrax vaccine sc or im,90581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.86,,,,,,,fee schedule,112.86,129.79,
Anthrax vaccine sc or im,90581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112.86,,,,,,,fee schedule,112.86,129.79,
Anthrax vaccine sc or im,90581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.86,,,,,,,fee schedule,112.86,129.79,
Anthrax vaccine sc or im,90581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.79,,,,,,,fee schedule,112.86,129.79,
Bcg vaccine percut,90585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.4,,,,,,,fee schedule,201.4,231.61,
Bcg vaccine percut,90585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.4,,,,,,,fee schedule,201.4,231.61,
Bcg vaccine percut,90585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.4,,,,,,,fee schedule,201.4,231.61,
Bcg vaccine percut,90585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.61,,,,,,,fee schedule,201.4,231.61,
Bcg vaccine intravesical,90586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.4,,,,,,,fee schedule,201.4,231.61,
Bcg vaccine intravesical,90586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.4,,,,,,,fee schedule,201.4,231.61,
Bcg vaccine intravesical,90586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.4,,,,,,,fee schedule,201.4,231.61,
Bcg vaccine intravesical,90586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.61,,,,,,,fee schedule,201.4,231.61,
Dengue vacc quad 3 dose subq,90587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.24,,,,,,,fee schedule,75.24,86.53,
Dengue vacc quad 3 dose subq,90587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.24,,,,,,,fee schedule,75.24,86.53,
Dengue vacc quad 3 dose subq,90587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.24,,,,,,,fee schedule,75.24,86.53,
Dengue vacc quad 3 dose subq,90587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.53,,,,,,,fee schedule,75.24,86.53,
Chikungunya vaccine live im,90589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,313.5,,,,,,,fee schedule,313.5,360.53,
Chikungunya vaccine live im,90589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,313.5,,,,,,,fee schedule,313.5,360.53,
Chikungunya vaccine live im,90589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,313.5,,,,,,,fee schedule,313.5,360.53,
Chikungunya vaccine live im,90589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,360.53,,,,,,,fee schedule,313.5,360.53,
Chikungunya vacc recomb im,90593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,313.5,,,,,,,fee schedule,313.5,360.53,
Chikungunya vacc recomb im,90593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,313.5,,,,,,,fee schedule,313.5,360.53,
Chikungunya vacc recomb im,90593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,313.5,,,,,,,fee schedule,313.5,360.53,
Chikungunya vacc recomb im,90593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,360.53,,,,,,,fee schedule,313.5,360.53,
Menacwy-tt vaccine im,90619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.9,,,,,,,fee schedule,195.9,225.29,
Menacwy-tt vaccine im,90619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.9,,,,,,,fee schedule,195.9,225.29,
Menacwy-tt vaccine im,90619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.9,,,,,,,fee schedule,195.9,225.29,
Menacwy-tt vaccine im,90619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.29,,,,,,,fee schedule,195.9,225.29,
Menb rp w/omv vaccine im,90620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,270.18,,,,,,,fee schedule,270.18,310.71,
Menb rp w/omv vaccine im,90620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.18,,,,,,,fee schedule,270.18,310.71,
Menb rp w/omv vaccine im,90620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,270.18,,,,,,,fee schedule,270.18,310.71,
Menb rp w/omv vaccine im,90620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,310.71,,,,,,,fee schedule,270.18,310.71,
Menb rlp vaccine im,90621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.2,,,,,,,fee schedule,236.2,271.63,
Menb rlp vaccine im,90621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,236.2,,,,,,,fee schedule,236.2,271.63,
Menb rlp vaccine im,90621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,236.2,,,,,,,fee schedule,236.2,271.63,
Menb rlp vaccine im,90621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,271.63,,,,,,,fee schedule,236.2,271.63,
Menacwy-tt menb-fhbp vacc im,90623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,270.07,,,,,,,fee schedule,270.07,310.58,
Menacwy-tt menb-fhbp vacc im,90623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.07,,,,,,,fee schedule,270.07,310.58,
Menacwy-tt menb-fhbp vacc im,90623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,270.07,,,,,,,fee schedule,270.07,310.58,
Menacwy-tt menb-fhbp vacc im,90623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,310.58,,,,,,,fee schedule,270.07,310.58,
Cholera vaccine live oral,90625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.31,,,,,,,fee schedule,332.31,382.16,
Cholera vaccine live oral,90625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.31,,,,,,,fee schedule,332.31,382.16,
Cholera vaccine live oral,90625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.31,,,,,,,fee schedule,332.31,382.16,
Cholera vaccine live oral,90625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,382.16,,,,,,,fee schedule,332.31,382.16,
Hepa vaccine adult im,90632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.56,,,,,,,fee schedule,92.56,106.44,
Hepa vaccine adult im,90632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.56,,,,,,,fee schedule,92.56,106.44,
Hepa vaccine adult im,90632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.56,,,,,,,fee schedule,92.56,106.44,
Hepa vaccine adult im,90632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.44,,,,,,,fee schedule,92.56,106.44,
Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.14,,,,,,,fee schedule,44.14,50.76,
Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.14,,,,,,,fee schedule,44.14,50.76,
Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.14,,,,,,,fee schedule,44.14,50.76,
Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.76,,,,,,,fee schedule,44.14,50.76,
Hepa vacc ped/adol 3 dose,90634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.8,,,,,,,fee schedule,29.8,34.27,
Hepa vacc ped/adol 3 dose,90634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.8,,,,,,,fee schedule,29.8,34.27,
Hepa vacc ped/adol 3 dose,90634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.8,,,,,,,fee schedule,29.8,34.27,
Hepa vacc ped/adol 3 dose,90634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.27,,,,,,,fee schedule,29.8,34.27,
Hep a/hep b vacc adult im,90636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.69,,,,,,,fee schedule,150.69,173.29,
Hep a/hep b vacc adult im,90636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.69,,,,,,,fee schedule,150.69,173.29,
Hep a/hep b vacc adult im,90636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.69,,,,,,,fee schedule,150.69,173.29,
Hep a/hep b vacc adult im,90636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.29,,,,,,,fee schedule,150.69,173.29,
Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.88,,,,,,,fee schedule,27.88,32.06,
Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.88,,,,,,,fee schedule,27.88,32.06,
Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.88,,,,,,,fee schedule,27.88,32.06,
Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.06,,,,,,,fee schedule,27.88,32.06,
Hib prp-omp vacc 3 dose im,90647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.71,,,,,,,fee schedule,34.71,39.92,
Hib prp-omp vacc 3 dose im,90647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.71,,,,,,,fee schedule,34.71,39.92,
Hib prp-omp vacc 3 dose im,90647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.71,,,,,,,fee schedule,34.71,39.92,
Hib prp-omp vacc 3 dose im,90647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.92,,,,,,,fee schedule,34.71,39.92,
Hib prp-t vaccine 4 dose im,90648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.87,,,,,,,fee schedule,14.87,17.1,
Hib prp-t vaccine 4 dose im,90648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.87,,,,,,,fee schedule,14.87,17.1,
Hib prp-t vaccine 4 dose im,90648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.87,,,,,,,fee schedule,14.87,17.1,
Hib prp-t vaccine 4 dose im,90648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.1,,,,,,,fee schedule,14.87,17.1,
4vhpv vaccine 3 dose im,90649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.45,,,,,,,fee schedule,182.45,209.82,
4vhpv vaccine 3 dose im,90649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.45,,,,,,,fee schedule,182.45,209.82,
4vhpv vaccine 3 dose im,90649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.45,,,,,,,fee schedule,182.45,209.82,
4vhpv vaccine 3 dose im,90649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.82,,,,,,,fee schedule,182.45,209.82,
2vhpv vaccine 3 dose im,90650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.01,,,,,,,fee schedule,151.01,173.66,
2vhpv vaccine 3 dose im,90650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.01,,,,,,,fee schedule,151.01,173.66,
2vhpv vaccine 3 dose im,90650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.01,,,,,,,fee schedule,151.01,173.66,
2vhpv vaccine 3 dose im,90650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.66,,,,,,,fee schedule,151.01,173.66,
9vhpv vaccine 3 dose im,90651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,350.53,,,,,,,fee schedule,350.53,403.11,
9vhpv vaccine 3 dose im,90651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,350.53,,,,,,,fee schedule,350.53,403.11,
9vhpv vaccine 3 dose im,90651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.53,,,,,,,fee schedule,350.53,403.11,
9vhpv vaccine 3 dose im,90651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,403.11,,,,,,,fee schedule,350.53,403.11,
Iiv adjuvant vaccine im,90653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.49,,,,,,,fee schedule,83.49,96.01,
Iiv adjuvant vaccine im,90653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.49,,,,,,,fee schedule,83.49,96.01,
Iiv adjuvant vaccine im,90653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.49,,,,,,,fee schedule,83.49,96.01,
Iiv adjuvant vaccine im,90653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.01,,,,,,,fee schedule,83.49,96.01,
Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.1,,,,,,,fee schedule,14.1,16.22,
Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.1,,,,,,,fee schedule,14.1,16.22,
Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.1,,,,,,,fee schedule,14.1,16.22,
Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.22,,,,,,,fee schedule,14.1,16.22,
Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.35,,,,,,,fee schedule,22.35,25.7,
Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.35,,,,,,,fee schedule,22.35,25.7,
Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.35,,,,,,,fee schedule,22.35,25.7,
Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.7,,,,,,,fee schedule,22.35,25.7,
Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.93,,,,,,,fee schedule,10.93,12.57,
Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.93,,,,,,,fee schedule,10.93,12.57,
Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.93,,,,,,,fee schedule,10.93,12.57,
Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.57,,,,,,,fee schedule,10.93,12.57,
Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.86,,,,,,,fee schedule,21.86,25.14,
Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.86,,,,,,,fee schedule,21.86,25.14,
Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.86,,,,,,,fee schedule,21.86,25.14,
Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.14,,,,,,,fee schedule,21.86,25.14,
Laiv3 vaccine intranasal,90660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.87,,,,,,,fee schedule,28.87,33.2,
Laiv3 vaccine intranasal,90660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.87,,,,,,,fee schedule,28.87,33.2,
Laiv3 vaccine intranasal,90660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.87,,,,,,,fee schedule,28.87,33.2,
Laiv3 vaccine intranasal,90660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.2,,,,,,,fee schedule,28.87,33.2,
Cciiv3 vac no prsv 0.5 ml im,90661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.85,,,,,,,fee schedule,36.85,42.38,
Cciiv3 vac no prsv 0.5 ml im,90661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.85,,,,,,,fee schedule,36.85,42.38,
Cciiv3 vac no prsv 0.5 ml im,90661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.85,,,,,,,fee schedule,36.85,42.38,
Cciiv3 vac no prsv 0.5 ml im,90661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.38,,,,,,,fee schedule,36.85,42.38,
Iiv no prsv increased ag im,90662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.5,,,,,,,fee schedule,83.5,96.03,
Iiv no prsv increased ag im,90662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.5,,,,,,,fee schedule,83.5,96.03,
Iiv no prsv increased ag im,90662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.5,,,,,,,fee schedule,83.5,96.03,
Iiv no prsv increased ag im,90662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.03,,,,,,,fee schedule,83.5,96.03,
Pcv13 vaccine im,90670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,257.99,,,,,,,fee schedule,257.99,296.69,
Pcv13 vaccine im,90670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,257.99,,,,,,,fee schedule,257.99,296.69,
Pcv13 vaccine im,90670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,257.99,,,,,,,fee schedule,257.99,296.69,
Pcv13 vaccine im,90670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,296.69,,,,,,,fee schedule,257.99,296.69,
Pcv15 vaccine im,90671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.15,,,,,,,fee schedule,261.15,300.32,
Pcv15 vaccine im,90671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.15,,,,,,,fee schedule,261.15,300.32,
Pcv15 vaccine im,90671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,261.15,,,,,,,fee schedule,261.15,300.32,
Pcv15 vaccine im,90671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.32,,,,,,,fee schedule,261.15,300.32,
Laiv4 vaccine intranasal,90672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.79,,,,,,,fee schedule,27.79,31.96,
Laiv4 vaccine intranasal,90672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.79,,,,,,,fee schedule,27.79,31.96,
Laiv4 vaccine intranasal,90672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.79,,,,,,,fee schedule,27.79,31.96,
Laiv4 vaccine intranasal,90672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.96,,,,,,,fee schedule,27.79,31.96,
Riv3 vaccine no preserv im,90673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.5,,,,,,,fee schedule,83.5,96.03,
Riv3 vaccine no preserv im,90673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.5,,,,,,,fee schedule,83.5,96.03,
Riv3 vaccine no preserv im,90673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.5,,,,,,,fee schedule,83.5,96.03,
Riv3 vaccine no preserv im,90673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.03,,,,,,,fee schedule,83.5,96.03,
Cciiv4 vac no prsv 0.5 ml im,90674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.17,,,,,,,fee schedule,34.17,39.3,
Cciiv4 vac no prsv 0.5 ml im,90674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.17,,,,,,,fee schedule,34.17,39.3,
Cciiv4 vac no prsv 0.5 ml im,90674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.17,,,,,,,fee schedule,34.17,39.3,
Cciiv4 vac no prsv 0.5 ml im,90674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.3,,,,,,,fee schedule,34.17,39.3,
Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,495.45,,,,,,,fee schedule,331.98,597.56,
Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,495.45,,,,,,,fee schedule,331.98,597.56,
Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,495.45,,,,,,,fee schedule,331.98,597.56,
Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,569.77,,,,,,,fee schedule,331.98,597.56,
Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,348.58,,,,,,,fee schedule,331.98,597.56,APC
Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,331.98,,,,,,,fee schedule,331.98,597.56,APC
Rabies vaccine im,90675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,597.56,,,,,,,fee schedule,331.98,597.56,APC
Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.1,,,,,,,fee schedule,86.1,426.35,
Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.1,,,,,,,fee schedule,86.1,426.35,
Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.1,,,,,,,fee schedule,86.1,426.35,
Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.02,,,,,,,fee schedule,86.1,426.35,
Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.7,,,,,,,fee schedule,86.1,426.35,APC
Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236.86,,,,,,,fee schedule,86.1,426.35,APC
Rabies vaccine id,90676,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,426.35,,,,,,,fee schedule,86.1,426.35,APC
Pcv20 vaccine im,90677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,312.9,,,,,,,fee schedule,312.9,359.84,
Pcv20 vaccine im,90677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312.9,,,,,,,fee schedule,312.9,359.84,
Pcv20 vaccine im,90677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,312.9,,,,,,,fee schedule,312.9,359.84,
Pcv20 vaccine im,90677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,359.84,,,,,,,fee schedule,312.9,359.84,
Rsv vacc pref bivalent im,90678,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,349.75,,,,,,,fee schedule,349.75,402.21,
Rsv vacc pref bivalent im,90678,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,349.75,,,,,,,fee schedule,349.75,402.21,
Rsv vacc pref bivalent im,90678,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,349.75,,,,,,,fee schedule,349.75,402.21,
Rsv vacc pref bivalent im,90678,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,402.21,,,,,,,fee schedule,349.75,402.21,
Rsv vacc pref recomb adjt im,90679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,349.24,,,,,,,fee schedule,349.24,401.63,
Rsv vacc pref recomb adjt im,90679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,349.24,,,,,,,fee schedule,349.24,401.63,
Rsv vacc pref recomb adjt im,90679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,349.24,,,,,,,fee schedule,349.24,401.63,
Rsv vacc pref recomb adjt im,90679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,401.63,,,,,,,fee schedule,349.24,401.63,
Rv5 vacc 3 dose live oral,90680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.51,,,,,,,fee schedule,112.51,129.39,
Rv5 vacc 3 dose live oral,90680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112.51,,,,,,,fee schedule,112.51,129.39,
Rv5 vacc 3 dose live oral,90680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.51,,,,,,,fee schedule,112.51,129.39,
Rv5 vacc 3 dose live oral,90680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.39,,,,,,,fee schedule,112.51,129.39,
Rv1 vacc 2 dose live oral,90681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,167.46,,,,,,,fee schedule,167.46,192.58,
Rv1 vacc 2 dose live oral,90681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.46,,,,,,,fee schedule,167.46,192.58,
Rv1 vacc 2 dose live oral,90681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.46,,,,,,,fee schedule,167.46,192.58,
Rv1 vacc 2 dose live oral,90681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,192.58,,,,,,,fee schedule,167.46,192.58,
Riv4 vacc recombinant dna im,90682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.4,,,,,,,fee schedule,73.4,84.41,
Riv4 vacc recombinant dna im,90682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.4,,,,,,,fee schedule,73.4,84.41,
Riv4 vacc recombinant dna im,90682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.4,,,,,,,fee schedule,73.4,84.41,
Riv4 vacc recombinant dna im,90682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.41,,,,,,,fee schedule,73.4,84.41,
Rsv vacc mrna lipid nano im,90683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.6,,,,,,,fee schedule,330.6,380.19,
Rsv vacc mrna lipid nano im,90683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,330.6,,,,,,,fee schedule,330.6,380.19,
Rsv vacc mrna lipid nano im,90683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,330.6,,,,,,,fee schedule,330.6,380.19,
Rsv vacc mrna lipid nano im,90683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.19,,,,,,,fee schedule,330.6,380.19,
Pcv21 vaccine im,90684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,327.89,,,,,,,fee schedule,327.89,377.07,
Pcv21 vaccine im,90684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,327.89,,,,,,,fee schedule,327.89,377.07,
Pcv21 vaccine im,90684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,327.89,,,,,,,fee schedule,327.89,377.07,
Pcv21 vaccine im,90684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,377.07,,,,,,,fee schedule,327.89,377.07,
Iiv4 vacc no prsv 0.25 ml im,90685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.64,,,,,,,fee schedule,21.64,24.89,
Iiv4 vacc no prsv 0.25 ml im,90685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.64,,,,,,,fee schedule,21.64,24.89,
Iiv4 vacc no prsv 0.25 ml im,90685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.64,,,,,,,fee schedule,21.64,24.89,
Iiv4 vacc no prsv 0.25 ml im,90685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.89,,,,,,,fee schedule,21.64,24.89,
Iiv4 vacc no prsv 0.5 ml im,90686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.35,,,,,,,fee schedule,22.35,25.7,
Iiv4 vacc no prsv 0.5 ml im,90686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.35,,,,,,,fee schedule,22.35,25.7,
Iiv4 vacc no prsv 0.5 ml im,90686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.35,,,,,,,fee schedule,22.35,25.7,
Iiv4 vacc no prsv 0.5 ml im,90686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.7,,,,,,,fee schedule,22.35,25.7,
Iiv4 vaccine splt 0.25 ml im,90687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.44,,,,,,,fee schedule,10.44,12.01,
Iiv4 vaccine splt 0.25 ml im,90687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.44,,,,,,,fee schedule,10.44,12.01,
Iiv4 vaccine splt 0.25 ml im,90687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.44,,,,,,,fee schedule,10.44,12.01,
Iiv4 vaccine splt 0.25 ml im,90687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.01,,,,,,,fee schedule,10.44,12.01,
Iiv4 vaccine splt 0.5 ml im,90688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.88,,,,,,,fee schedule,20.88,24.01,
Iiv4 vaccine splt 0.5 ml im,90688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.88,,,,,,,fee schedule,20.88,24.01,
Iiv4 vaccine splt 0.5 ml im,90688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.88,,,,,,,fee schedule,20.88,24.01,
Iiv4 vaccine splt 0.5 ml im,90688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.01,,,,,,,fee schedule,20.88,24.01,
Typhoid vaccine oral,90690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.68,,,,,,,fee schedule,133.68,153.73,
Typhoid vaccine oral,90690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.68,,,,,,,fee schedule,133.68,153.73,
Typhoid vaccine oral,90690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.68,,,,,,,fee schedule,133.68,153.73,
Typhoid vaccine oral,90690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.73,,,,,,,fee schedule,133.68,153.73,
Typhoid vaccine im,90691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,175.45,,,,,,,fee schedule,175.45,201.77,
Typhoid vaccine im,90691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.45,,,,,,,fee schedule,175.45,201.77,
Typhoid vaccine im,90691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.45,,,,,,,fee schedule,175.45,201.77,
Typhoid vaccine im,90691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,201.77,,,,,,,fee schedule,175.45,201.77,
Vacc aiiv4 no prsrv 0.5ml im,90694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.36,,,,,,,fee schedule,77.36,88.96,
Vacc aiiv4 no prsrv 0.5ml im,90694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.36,,,,,,,fee schedule,77.36,88.96,
Vacc aiiv4 no prsrv 0.5ml im,90694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.36,,,,,,,fee schedule,77.36,88.96,
Vacc aiiv4 no prsrv 0.5ml im,90694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.96,,,,,,,fee schedule,77.36,88.96,
Dtap-ipv vaccine 4-6 yrs im,90696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.05,,,,,,,fee schedule,71.05,81.71,
Dtap-ipv vaccine 4-6 yrs im,90696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.05,,,,,,,fee schedule,71.05,81.71,
Dtap-ipv vaccine 4-6 yrs im,90696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.05,,,,,,,fee schedule,71.05,81.71,
Dtap-ipv vaccine 4-6 yrs im,90696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.71,,,,,,,fee schedule,71.05,81.71,
Dtap-ipv-hib-hepb vaccine im,90697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.69,,,,,,,fee schedule,177.69,204.34,
Dtap-ipv-hib-hepb vaccine im,90697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.69,,,,,,,fee schedule,177.69,204.34,
Dtap-ipv-hib-hepb vaccine im,90697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.69,,,,,,,fee schedule,177.69,204.34,
Dtap-ipv-hib-hepb vaccine im,90697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,204.34,,,,,,,fee schedule,177.69,204.34,
Dtap-ipv/hib vaccine im,90698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.15,,,,,,,fee schedule,136.15,156.57,
Dtap-ipv/hib vaccine im,90698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.15,,,,,,,fee schedule,136.15,156.57,
Dtap-ipv/hib vaccine im,90698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.15,,,,,,,fee schedule,136.15,156.57,
Dtap-ipv/hib vaccine im,90698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,156.57,,,,,,,fee schedule,136.15,156.57,
Dtap vaccine < 7 yrs im,90700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.31,,,,,,,fee schedule,33.31,38.31,
Dtap vaccine < 7 yrs im,90700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.31,,,,,,,fee schedule,33.31,38.31,
Dtap vaccine < 7 yrs im,90700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.31,,,,,,,fee schedule,33.31,38.31,
Dtap vaccine < 7 yrs im,90700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.31,,,,,,,fee schedule,33.31,38.31,
Dt vaccine under 7 yrs im,90702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.06,,,,,,,fee schedule,75.06,86.32,
Dt vaccine under 7 yrs im,90702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.06,,,,,,,fee schedule,75.06,86.32,
Dt vaccine under 7 yrs im,90702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.06,,,,,,,fee schedule,75.06,86.32,
Dt vaccine under 7 yrs im,90702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.32,,,,,,,fee schedule,75.06,86.32,
Mmr vaccine sc,90707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.1,,,,,,,fee schedule,108.1,124.32,
Mmr vaccine sc,90707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.1,,,,,,,fee schedule,108.1,124.32,
Mmr vaccine sc,90707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.1,,,,,,,fee schedule,108.1,124.32,
Mmr vaccine sc,90707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.32,,,,,,,fee schedule,108.1,124.32,
Mmrv vaccine sc,90710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,316.53,,,,,,,fee schedule,316.53,364.01,
Mmrv vaccine sc,90710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,316.53,,,,,,,fee schedule,316.53,364.01,
Mmrv vaccine sc,90710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.53,,,,,,,fee schedule,316.53,364.01,
Mmrv vaccine sc,90710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,364.01,,,,,,,fee schedule,316.53,364.01,
Poliovirus ipv sc/im,90713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.85,,,,,,,fee schedule,50.85,58.48,
Poliovirus ipv sc/im,90713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.85,,,,,,,fee schedule,50.85,58.48,
Poliovirus ipv sc/im,90713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.85,,,,,,,fee schedule,50.85,58.48,
Poliovirus ipv sc/im,90713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.48,,,,,,,fee schedule,50.85,58.48,
Td vacc no presv 7 yrs+ im,90714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.88,,,,,,,fee schedule,47.88,55.06,
Td vacc no presv 7 yrs+ im,90714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.88,,,,,,,fee schedule,47.88,55.06,
Td vacc no presv 7 yrs+ im,90714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.88,,,,,,,fee schedule,47.88,55.06,
Td vacc no presv 7 yrs+ im,90714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.06,,,,,,,fee schedule,47.88,55.06,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.15,,,,,,,fee schedule,55.15,63.42,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.15,,,,,,,fee schedule,55.15,63.42,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.15,,,,,,,fee schedule,55.15,63.42,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.42,,,,,,,fee schedule,55.15,63.42,
Var vaccine live subq,90716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,208.48,,,,,,,fee schedule,208.48,239.75,
Var vaccine live subq,90716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.48,,,,,,,fee schedule,208.48,239.75,
Var vaccine live subq,90716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,208.48,,,,,,,fee schedule,208.48,239.75,
Var vaccine live subq,90716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,239.75,,,,,,,fee schedule,208.48,239.75,
Yellow fever vaccine subq,90717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.08,,,,,,,fee schedule,268.08,308.29,
Yellow fever vaccine subq,90717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.08,,,,,,,fee schedule,268.08,308.29,
Yellow fever vaccine subq,90717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,268.08,,,,,,,fee schedule,268.08,308.29,
Yellow fever vaccine subq,90717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.29,,,,,,,fee schedule,268.08,308.29,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.41,,,,,,,fee schedule,117.41,135.02,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.41,,,,,,,fee schedule,117.41,135.02,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.41,,,,,,,fee schedule,117.41,135.02,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.02,,,,,,,fee schedule,117.41,135.02,
Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.48,,,,,,,fee schedule,133.48,153.5,
Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.48,,,,,,,fee schedule,133.48,153.5,
Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.48,,,,,,,fee schedule,133.48,153.5,
Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.5,,,,,,,fee schedule,133.48,153.5,
Mpsv4 vaccine subq,90733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.27,,,,,,,fee schedule,140.27,161.31,
Mpsv4 vaccine subq,90733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.27,,,,,,,fee schedule,140.27,161.31,
Mpsv4 vaccine subq,90733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.27,,,,,,,fee schedule,140.27,161.31,
Mpsv4 vaccine subq,90733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.31,,,,,,,fee schedule,140.27,161.31,
Mcv4 menacwy vaccine im,90734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.95,,,,,,,fee schedule,189.95,218.44,
Mcv4 menacwy vaccine im,90734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.95,,,,,,,fee schedule,189.95,218.44,
Mcv4 menacwy vaccine im,90734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,189.95,,,,,,,fee schedule,189.95,218.44,
Mcv4 menacwy vaccine im,90734,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.44,,,,,,,fee schedule,189.95,218.44,
Hzv vaccine live subq,90736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.44,,,,,,,fee schedule,242.44,278.81,
Hzv vaccine live subq,90736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.44,,,,,,,fee schedule,242.44,278.81,
Hzv vaccine live subq,90736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,242.44,,,,,,,fee schedule,242.44,278.81,
Hzv vaccine live subq,90736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.81,,,,,,,fee schedule,242.44,278.81,
Inactivated je vacc im,90738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,336.4,,,,,,,fee schedule,336.4,386.86,
Inactivated je vacc im,90738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,336.4,,,,,,,fee schedule,336.4,386.86,
Inactivated je vacc im,90738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,336.4,,,,,,,fee schedule,336.4,386.86,
Inactivated je vacc im,90738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,386.86,,,,,,,fee schedule,336.4,386.86,
Hepb vacc 2 dose adult im,90739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.56,,,,,,,fee schedule,177.56,204.19,
Hepb vacc 2 dose adult im,90739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.56,,,,,,,fee schedule,177.56,204.19,
Hepb vacc 2 dose adult im,90739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.56,,,,,,,fee schedule,177.56,204.19,
Hepb vacc 2 dose adult im,90739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,204.19,,,,,,,fee schedule,177.56,204.19,
Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.8,,,,,,,fee schedule,212.8,244.72,
Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.8,,,,,,,fee schedule,212.8,244.72,
Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.8,,,,,,,fee schedule,212.8,244.72,
Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.72,,,,,,,fee schedule,212.8,244.72,
Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.3,,,,,,,fee schedule,78.3,90.05,
Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.3,,,,,,,fee schedule,78.3,90.05,
Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.3,,,,,,,fee schedule,78.3,90.05,
Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.05,,,,,,,fee schedule,78.3,90.05,
Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.67,,,,,,,fee schedule,31.67,36.42,
Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.67,,,,,,,fee schedule,31.67,36.42,
Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.67,,,,,,,fee schedule,31.67,36.42,
Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.42,,,,,,,fee schedule,31.67,36.42,
Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.3,,,,,,,fee schedule,78.3,90.05,
Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.3,,,,,,,fee schedule,78.3,90.05,
Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.3,,,,,,,fee schedule,78.3,90.05,
Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.05,,,,,,,fee schedule,78.3,90.05,
Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.43,,,,,,,fee schedule,164.43,189.09,
Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.43,,,,,,,fee schedule,164.43,189.09,
Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.43,,,,,,,fee schedule,164.43,189.09,
Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.09,,,,,,,fee schedule,164.43,189.09,
Hib-hepb vaccine im,90748,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.95,,,,,,,fee schedule,47.95,55.14,
Hib-hepb vaccine im,90748,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.95,,,,,,,fee schedule,47.95,55.14,
Hib-hepb vaccine im,90748,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.95,,,,,,,fee schedule,47.95,55.14,
Hib-hepb vaccine im,90748,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.14,,,,,,,fee schedule,47.95,55.14,
Hzv vacc recombinant im njx,90750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,245.68,,,,,,,fee schedule,245.68,282.53,
Hzv vacc recombinant im njx,90750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,245.68,,,,,,,fee schedule,245.68,282.53,
Hzv vacc recombinant im njx,90750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,245.68,,,,,,,fee schedule,245.68,282.53,
Hzv vacc recombinant im njx,90750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,282.53,,,,,,,fee schedule,245.68,282.53,
Cciiv4 vacc abx free im,90756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.38,,,,,,,fee schedule,32.38,37.24,
Cciiv4 vacc abx free im,90756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.38,,,,,,,fee schedule,32.38,37.24,
Cciiv4 vacc abx free im,90756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.38,,,,,,,fee schedule,32.38,37.24,
Cciiv4 vacc abx free im,90756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.24,,,,,,,fee schedule,32.38,37.24,
Psytx complex interactive,90785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.88,,,,,,,fee schedule,3.2,5.61,
Psytx complex interactive,90785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.99,,,,,,,fee schedule,3.2,5.61,
Psytx complex interactive,90785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.2,,,,,,,fee schedule,3.2,5.61,
Psytx complex interactive,90785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.61,,,,,,,fee schedule,3.2,5.61,
Psych diagnostic evaluation,90791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Psych diagnostic evaluation,90791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Psych diagnostic evaluation,90791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Psych diagnostic evaluation,90791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Psych diagnostic evaluation,90791,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Psych diagnostic evaluation,90791,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Psych diagnostic evaluation,90791,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Psych diag eval w/med srvcs,90792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Psych diag eval w/med srvcs,90792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Psych diag eval w/med srvcs,90792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Psych diag eval w/med srvcs,90792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Psych diag eval w/med srvcs,90792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Psych diag eval w/med srvcs,90792,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Psych diag eval w/med srvcs,90792,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Psytx w pt 30 minutes,90832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,318.34,
Psytx w pt 30 minutes,90832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,318.34,
Psytx w pt 30 minutes,90832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,318.34,
Psytx w pt 30 minutes,90832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,318.34,
Psytx w pt 30 minutes,90832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,68.9,318.34,APC
Psytx w pt 30 minutes,90832,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,68.9,318.34,APC
Psytx w pt 30 minutes,90832,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,68.9,318.34,APC
Psytx w pt w e/m 30 min,90833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.43,,,,,,,fee schedule,18.64,32.69,
Psytx w pt w e/m 30 min,90833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.27,,,,,,,fee schedule,18.64,32.69,
Psytx w pt w e/m 30 min,90833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.64,,,,,,,fee schedule,18.64,32.69,
Psytx w pt w e/m 30 min,90833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.69,,,,,,,fee schedule,18.64,32.69,
Psytx w pt 45 minutes,90834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Psytx w pt 45 minutes,90834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Psytx w pt 45 minutes,90834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Psytx w pt 45 minutes,90834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Psytx w pt 45 minutes,90834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Psytx w pt 45 minutes,90834,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Psytx w pt 45 minutes,90834,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Psytx w pt w e/m 45 min,90836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Psytx w pt w e/m 45 min,90836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Psytx w pt w e/m 45 min,90836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Psytx w pt w e/m 45 min,90836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Psytx w pt 60 minutes,90837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Psytx w pt 60 minutes,90837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Psytx w pt 60 minutes,90837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Psytx w pt 60 minutes,90837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Psytx w pt 60 minutes,90837,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Psytx w pt 60 minutes,90837,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Psytx w pt 60 minutes,90837,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Psytx w pt w e/m 60 min,90838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.03,,,,,,,fee schedule,31.49,55.23,
Psytx w pt w e/m 60 min,90838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.31,,,,,,,fee schedule,31.49,55.23,
Psytx w pt w e/m 60 min,90838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.49,,,,,,,fee schedule,31.49,55.23,
Psytx w pt w e/m 60 min,90838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.23,,,,,,,fee schedule,31.49,55.23,
Psytx crisis initial 60 min,90839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Psytx crisis initial 60 min,90839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Psytx crisis initial 60 min,90839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Psytx crisis initial 60 min,90839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Psytx crisis initial 60 min,90839,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Psytx crisis initial 60 min,90839,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Psytx crisis initial 60 min,90839,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Psytx crisis ea addl 30 min,90840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.53,,,,,,,fee schedule,14.77,25.91,
Psytx crisis ea addl 30 min,90840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.44,,,,,,,fee schedule,14.77,25.91,
Psytx crisis ea addl 30 min,90840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.77,,,,,,,fee schedule,14.77,25.91,
Psytx crisis ea addl 30 min,90840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.91,,,,,,,fee schedule,14.77,25.91,
Psychoanalysis,90845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Psychoanalysis,90845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Psychoanalysis,90845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Psychoanalysis,90845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Psychoanalysis,90845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Psychoanalysis,90845,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Psychoanalysis,90845,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Family psytx w/o pt 50 min,90846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Family psytx w/o pt 50 min,90846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Family psytx w/o pt 50 min,90846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Family psytx w/o pt 50 min,90846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Family psytx w/o pt 50 min,90846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Family psytx w/o pt 50 min,90846,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Family psytx w/o pt 50 min,90846,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Family psytx w/pt 50 min,90847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Family psytx w/pt 50 min,90847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Family psytx w/pt 50 min,90847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Family psytx w/pt 50 min,90847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Family psytx w/pt 50 min,90847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Family psytx w/pt 50 min,90847,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Family psytx w/pt 50 min,90847,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Multiple family group psytx,90849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Multiple family group psytx,90849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Multiple family group psytx,90849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Multiple family group psytx,90849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Multiple family group psytx,90849,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Multiple family group psytx,90849,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Multiple family group psytx,90849,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Group psychotherapy,90853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
Group psychotherapy,90853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
Group psychotherapy,90853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
Group psychotherapy,90853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
Group psychotherapy,90853,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
Group psychotherapy,90853,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
Group psychotherapy,90853,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
Narcosynthesis,90865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Narcosynthesis,90865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Narcosynthesis,90865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Narcosynthesis,90865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Narcosynthesis,90865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Narcosynthesis,90865,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Narcosynthesis,90865,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Tcranial magn stim tx plan,90867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Tcranial magn stim tx plan,90867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Tcranial magn stim tx plan,90867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Tcranial magn stim tx plan,90867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Tcranial magn stim tx plan,90867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Tcranial magn stim tx plan,90867,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Tcranial magn stim tx plan,90867,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Tcranial magn stim tx deli,90868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Tcranial magn stim tx deli,90868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Tcranial magn stim tx deli,90868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Tcranial magn stim tx deli,90868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Tcranial magn stim tx deli,90868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Tcranial magn stim tx deli,90868,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Tcranial magn stim tx deli,90868,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Tcran magn stim redetemine,90869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,387.26,
Tcran magn stim redetemine,90869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,387.26,
Tcran magn stim redetemine,90869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,387.26,
Tcran magn stim redetemine,90869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,387.26,
Tcran magn stim redetemine,90869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,124.61,387.26,APC
Tcran magn stim redetemine,90869,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,124.61,387.26,APC
Tcran magn stim redetemine,90869,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,124.61,387.26,APC
Electroconvulsive therapy,90870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,621.94,,,,,,,fee schedule,407.74,1540.17,
Electroconvulsive therapy,90870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,509.06,,,,,,,fee schedule,407.74,1540.17,
Electroconvulsive therapy,90870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,407.74,,,,,,,fee schedule,407.74,1540.17,
Electroconvulsive therapy,90870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,715.23,,,,,,,fee schedule,407.74,1540.17,
Electroconvulsive therapy,90870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,407.74,1540.17,APC
Electroconvulsive therapy,90870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,407.74,1540.17,APC
Electroconvulsive therapy,90870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,407.74,1540.17,APC
Psychophysiological therapy,90875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,52.96,
Psychophysiological therapy,90875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,52.96,
Psychophysiological therapy,90875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,52.96,
Psychophysiological therapy,90875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,52.96,
Psychophysiological therapy,90876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.88,,,,,,,fee schedule,66.79,117.16,
Psychophysiological therapy,90876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.39,,,,,,,fee schedule,66.79,117.16,
Psychophysiological therapy,90876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.79,,,,,,,fee schedule,66.79,117.16,
Psychophysiological therapy,90876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.16,,,,,,,fee schedule,66.79,117.16,
Hypnotherapy,90880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,101.22,216.74,
Hypnotherapy,90880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,101.22,216.74,
Hypnotherapy,90880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,101.22,216.74,
Hypnotherapy,90880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,101.22,216.74,
Hypnotherapy,90880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,101.22,216.74,APC
Hypnotherapy,90880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,101.22,216.74,APC
Hypnotherapy,90880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,101.22,216.74,APC
Environmental manipulation,90882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.1,,,,,,,fee schedule,92.51,162.27,
Environmental manipulation,90882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.49,,,,,,,fee schedule,92.51,162.27,
Environmental manipulation,90882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.51,,,,,,,fee schedule,92.51,162.27,
Environmental manipulation,90882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.27,,,,,,,fee schedule,92.51,162.27,
Psy evaluation of records,90885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Psy evaluation of records,90885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Psy evaluation of records,90885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Psy evaluation of records,90885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Consultation with family,90887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.13,,,,,,,fee schedule,59.09,103.65,
Consultation with family,90887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.77,,,,,,,fee schedule,59.09,103.65,
Consultation with family,90887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.09,,,,,,,fee schedule,59.09,103.65,
Consultation with family,90887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.65,,,,,,,fee schedule,59.09,103.65,
Preparation of report,90889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,118.56,,,,,,,fee schedule,77.73,136.34,
Preparation of report,90889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.04,,,,,,,fee schedule,77.73,136.34,
Preparation of report,90889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.73,,,,,,,fee schedule,77.73,136.34,
Preparation of report,90889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.34,,,,,,,fee schedule,77.73,136.34,
Psychiatric service/therapy,90899,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,67.2,APC
Psychiatric service/therapy,90899,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,67.2,APC
Psychiatric service/therapy,90899,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,67.2,APC
Biofeedback train any meth,90901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.76,,,,,,,fee schedule,16.21,68.72,
Biofeedback train any meth,90901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.91,,,,,,,fee schedule,16.21,68.72,
Biofeedback train any meth,90901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.18,,,,,,,fee schedule,16.21,68.72,
Biofeedback train any meth,90901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.72,,,,,,,fee schedule,16.21,68.72,
Biofeedback train any meth,90901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.02,,,,,,,fee schedule,16.21,68.72,APC
Biofeedback train any meth,90901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.21,,,,,,,fee schedule,16.21,68.72,APC
Biofeedback train any meth,90901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.18,,,,,,,fee schedule,16.21,68.72,APC
Bfb training 1st 15 min,90912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.33,,,,,,,fee schedule,37.13,101.58,
Bfb training 1st 15 min,90912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.3,,,,,,,fee schedule,37.13,101.58,
Bfb training 1st 15 min,90912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.91,,,,,,,fee schedule,37.13,101.58,
Bfb training 1st 15 min,90912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.58,,,,,,,fee schedule,37.13,101.58,
Bfb training 1st 15 min,90912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.99,,,,,,,fee schedule,37.13,101.58,APC
Bfb training 1st 15 min,90912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.13,,,,,,,fee schedule,37.13,101.58,APC
Bfb training 1st 15 min,90912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.83,,,,,,,fee schedule,37.13,101.58,APC
Bfb training ea addl 15 min,90913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.07,,,,,,,fee schedule,21.61,56.43,
Bfb training ea addl 15 min,90913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.16,,,,,,,fee schedule,21.61,56.43,
Bfb training ea addl 15 min,90913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.17,,,,,,,fee schedule,21.61,56.43,
Bfb training ea addl 15 min,90913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.43,,,,,,,fee schedule,21.61,56.43,
Bfb training ea addl 15 min,90913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.69,,,,,,,fee schedule,21.61,56.43,APC
Bfb training ea addl 15 min,90913,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.61,,,,,,,fee schedule,21.61,56.43,APC
Bfb training ea addl 15 min,90913,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.9,,,,,,,fee schedule,21.61,56.43,APC
Hemodialysis one evaluation,90935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,826.41,,,,,,,fee schedule,541.79,1230.92,
Hemodialysis one evaluation,90935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,676.42,,,,,,,fee schedule,541.79,1230.92,
Hemodialysis one evaluation,90935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,541.79,,,,,,,fee schedule,541.79,1230.92,
Hemodialysis one evaluation,90935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,950.37,,,,,,,fee schedule,541.79,1230.92,
Hemodialysis one evaluation,90935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,718.04,,,,,,,fee schedule,541.79,1230.92,APC
Hemodialysis one evaluation,90935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,683.85,,,,,,,fee schedule,541.79,1230.92,APC
Hemodialysis one evaluation,90935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1230.92,,,,,,,fee schedule,541.79,1230.92,APC
Hemodialysis repeated eval,90937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,45.6,79.99,
Hemodialysis repeated eval,90937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,45.6,79.99,
Hemodialysis repeated eval,90937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,45.6,79.99,
Hemodialysis repeated eval,90937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,45.6,79.99,
Hemodialysis Access Study,90940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97,,,,,,,fee schedule,63.59,111.55,
Hemodialysis Access Study,90940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.39,,,,,,,fee schedule,63.59,111.55,
Hemodialysis Access Study,90940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.59,,,,,,,fee schedule,63.59,111.55,
Hemodialysis Access Study,90940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.55,,,,,,,fee schedule,63.59,111.55,
Dialysis one evaluation,90945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,971.66,,,,,,,fee schedule,415.76,1117.41,
Dialysis one evaluation,90945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,795.3,,,,,,,fee schedule,415.76,1117.41,
Dialysis one evaluation,90945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,637.02,,,,,,,fee schedule,415.76,1117.41,
Dialysis one evaluation,90945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1117.41,,,,,,,fee schedule,415.76,1117.41,
Dialysis one evaluation,90945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,436.55,,,,,,,fee schedule,415.76,1117.41,APC
Dialysis one evaluation,90945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,415.76,,,,,,,fee schedule,415.76,1117.41,APC
Dialysis one evaluation,90945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,748.37,,,,,,,fee schedule,415.76,1117.41,APC
Dialysis repeated eval,90947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.32,,,,,,,fee schedule,53.31,93.52,
Dialysis repeated eval,90947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.56,,,,,,,fee schedule,53.31,93.52,
Dialysis repeated eval,90947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.31,,,,,,,fee schedule,53.31,93.52,
Dialysis repeated eval,90947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.52,,,,,,,fee schedule,53.31,93.52,
Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,686.87,,,,,,,fee schedule,450.31,789.9,
Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,562.2,,,,,,,fee schedule,450.31,789.9,
Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,450.31,,,,,,,fee schedule,450.31,789.9,
Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,789.9,,,,,,,fee schedule,450.31,789.9,
Esrd serv 2-3 vsts p mo <2yr,90952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1292.42,,,,,,,fee schedule,847.31,1486.28,
Esrd serv 2-3 vsts p mo <2yr,90952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1057.85,,,,,,,fee schedule,847.31,1486.28,
Esrd serv 2-3 vsts p mo <2yr,90952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,847.31,,,,,,,fee schedule,847.31,1486.28,
Esrd serv 2-3 vsts p mo <2yr,90952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1486.28,,,,,,,fee schedule,847.31,1486.28,
Esrd serv 1 visit p mo <2yrs,90953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,861.29,,,,,,,fee schedule,564.66,990.48,
Esrd serv 1 visit p mo <2yrs,90953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,704.97,,,,,,,fee schedule,564.66,990.48,
Esrd serv 1 visit p mo <2yrs,90953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,564.66,,,,,,,fee schedule,564.66,990.48,
Esrd serv 1 visit p mo <2yrs,90953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,990.48,,,,,,,fee schedule,564.66,990.48,
Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,592.82,,,,,,,fee schedule,388.65,681.74,
Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,485.22,,,,,,,fee schedule,388.65,681.74,
Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,388.65,,,,,,,fee schedule,388.65,681.74,
Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,681.74,,,,,,,fee schedule,388.65,681.74,
Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,351.75,,,,,,,fee schedule,230.61,404.51,
Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,287.91,,,,,,,fee schedule,230.61,404.51,
Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,230.61,,,,,,,fee schedule,230.61,404.51,
Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,404.51,,,,,,,fee schedule,230.61,404.51,
Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,260.63,,,,,,,fee schedule,170.87,299.72,
Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.33,,,,,,,fee schedule,170.87,299.72,
Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.87,,,,,,,fee schedule,170.87,299.72,
Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,299.72,,,,,,,fee schedule,170.87,299.72,
Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,481.09,,,,,,,fee schedule,315.4,553.25,
Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,393.77,,,,,,,fee schedule,315.4,553.25,
Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.4,,,,,,,fee schedule,315.4,553.25,
Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,553.25,,,,,,,fee schedule,315.4,553.25,
Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,339.99,,,,,,,fee schedule,222.9,390.99,
Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,278.28,,,,,,,fee schedule,222.9,390.99,
Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.9,,,,,,,fee schedule,222.9,390.99,
Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,390.99,,,,,,,fee schedule,222.9,390.99,
Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,248.87,,,,,,,fee schedule,163.16,286.2,
Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,203.7,,,,,,,fee schedule,163.16,286.2,
Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.16,,,,,,,fee schedule,163.16,286.2,
Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,286.2,,,,,,,fee schedule,163.16,286.2,
Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.92,,,,,,,fee schedule,161.88,283.96,
Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.1,,,,,,,fee schedule,161.88,283.96,
Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.88,,,,,,,fee schedule,161.88,283.96,
Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.96,,,,,,,fee schedule,161.88,283.96,
Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,216.52,,,,,,,fee schedule,141.95,249,
Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.22,,,,,,,fee schedule,141.95,249,
Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.95,,,,,,,fee schedule,141.95,249,
Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,249,,,,,,,fee schedule,141.95,249,
Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,208.45,
Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,208.45,
Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,208.45,
Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,208.45,
Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,410.56,,,,,,,fee schedule,269.16,472.14,
Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,336.04,,,,,,,fee schedule,269.16,472.14,
Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,269.16,,,,,,,fee schedule,269.16,472.14,
Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,472.14,,,,,,,fee schedule,269.16,472.14,
Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,367.42,,,,,,,fee schedule,240.88,422.53,
Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,300.73,,,,,,,fee schedule,240.88,422.53,
Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,240.88,,,,,,,fee schedule,240.88,422.53,
Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,422.53,,,,,,,fee schedule,240.88,422.53,
Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,971.66,,,,,,,fee schedule,637.02,1117.41,
Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,795.3,,,,,,,fee schedule,637.02,1117.41,
Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,637.02,,,,,,,fee schedule,637.02,1117.41,
Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1117.41,,,,,,,fee schedule,637.02,1117.41,
Esrd home pt serv p mo 20+,90966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,215.57,,,,,,,fee schedule,141.33,247.91,
Esrd home pt serv p mo 20+,90966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,176.44,,,,,,,fee schedule,141.33,247.91,
Esrd home pt serv p mo 20+,90966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.33,,,,,,,fee schedule,141.33,247.91,
Esrd home pt serv p mo 20+,90966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,247.91,,,,,,,fee schedule,141.33,247.91,
Esrd home pt serv p day <2,90967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.69,,,,,,,fee schedule,8.98,15.74,
Esrd home pt serv p day <2,90967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.21,,,,,,,fee schedule,8.98,15.74,
Esrd home pt serv p day <2,90967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.98,,,,,,,fee schedule,8.98,15.74,
Esrd home pt serv p day <2,90967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.74,,,,,,,fee schedule,8.98,15.74,
Esrd home pt srv p day 2-11,90968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.75,,,,,,,fee schedule,7.7,13.51,
Esrd home pt srv p day 2-11,90968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.62,,,,,,,fee schedule,7.7,13.51,
Esrd home pt srv p day 2-11,90968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.7,,,,,,,fee schedule,7.7,13.51,
Esrd home pt srv p day 2-11,90968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.51,,,,,,,fee schedule,7.7,13.51,
Esrd home pt srv p day 12-19,90969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.75,,,,,,,fee schedule,7.7,13.51,
Esrd home pt srv p day 12-19,90969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.62,,,,,,,fee schedule,7.7,13.51,
Esrd home pt srv p day 12-19,90969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.7,,,,,,,fee schedule,7.7,13.51,
Esrd home pt srv p day 12-19,90969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.51,,,,,,,fee schedule,7.7,13.51,
Esrd home pt serv p day 20+,90970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.87,,,,,,,fee schedule,4.5,7.9,
Esrd home pt serv p day 20+,90970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.62,,,,,,,fee schedule,4.5,7.9,
Esrd home pt serv p day 20+,90970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.5,,,,,,,fee schedule,4.5,7.9,
Esrd home pt serv p day 20+,90970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.9,,,,,,,fee schedule,4.5,7.9,
Dialysis training complete,90989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.71,,,,,,,fee schedule,423.98,743.72,
Dialysis training complete,90989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,529.33,,,,,,,fee schedule,423.98,743.72,
Dialysis training complete,90989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,423.98,,,,,,,fee schedule,423.98,743.72,
Dialysis training complete,90989,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.72,,,,,,,fee schedule,423.98,743.72,
Dialysis training incompl,90993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.12,,,,,,,fee schedule,91.86,161.14,
Dialysis training incompl,90993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.69,,,,,,,fee schedule,91.86,161.14,
Dialysis training incompl,90993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.86,,,,,,,fee schedule,91.86,161.14,
Dialysis training incompl,90993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.14,,,,,,,fee schedule,91.86,161.14,
Hemoperfusion,90997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.83,,,,,,,fee schedule,37.26,65.35,
Hemoperfusion,90997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.52,,,,,,,fee schedule,37.26,65.35,
Hemoperfusion,90997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.26,,,,,,,fee schedule,37.26,65.35,
Hemoperfusion,90997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.35,,,,,,,fee schedule,37.26,65.35,
Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.85,,,,,,,fee schedule,196.58,669.27,
Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,245.43,,,,,,,fee schedule,196.58,669.27,
Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,196.58,,,,,,,fee schedule,196.58,669.27,
Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.83,,,,,,,fee schedule,196.58,669.27,
Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,196.58,669.27,APC
Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,196.58,669.27,APC
Esophagus motility study,91010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,196.58,669.27,APC
Esophgl motil w/stim/perfus,91013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.22,,,,,,,fee schedule,25.06,43.95,
Esophgl motil w/stim/perfus,91013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.28,,,,,,,fee schedule,25.06,43.95,
Esophgl motil w/stim/perfus,91013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.06,,,,,,,fee schedule,25.06,43.95,
Esophgl motil w/stim/perfus,91013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.95,,,,,,,fee schedule,25.06,43.95,
Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,436.02,,,,,,,fee schedule,285.85,669.27,
Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.88,,,,,,,fee schedule,285.85,669.27,
Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,285.85,,,,,,,fee schedule,285.85,669.27,
Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.42,,,,,,,fee schedule,285.85,669.27,
Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,285.85,669.27,APC
Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,285.85,669.27,APC
Gastric motility studies,91020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,285.85,669.27,APC
Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.77,,,,,,,fee schedule,167.03,669.27,
Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.53,,,,,,,fee schedule,167.03,669.27,
Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.03,,,,,,,fee schedule,167.03,669.27,
Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.99,,,,,,,fee schedule,167.03,669.27,
Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,167.03,669.27,APC
Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,167.03,669.27,APC
Duodenal motility study,91022,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,167.03,669.27,APC
Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,241.03,,,,,,,fee schedule,158.02,669.27,
Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,197.28,,,,,,,fee schedule,158.02,669.27,
Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.02,,,,,,,fee schedule,158.02,669.27,
Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,277.18,,,,,,,fee schedule,158.02,669.27,
Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,158.02,669.27,APC
Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,158.02,669.27,APC
Acid perfusion of esophagus,91030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,158.02,669.27,APC
Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,446.65,,,,,,,fee schedule,292.82,669.27,
Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,365.58,,,,,,,fee schedule,292.82,669.27,
Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,292.82,,,,,,,fee schedule,292.82,669.27,
Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,513.65,,,,,,,fee schedule,292.82,669.27,
Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,292.82,669.27,APC
Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,292.82,669.27,APC
Gastroesophageal reflux test,91034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,292.82,669.27,APC
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1093.51,,,,,,,fee schedule,716.91,1540.17,
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,895.04,,,,,,,fee schedule,716.91,1540.17,
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,716.91,,,,,,,fee schedule,716.91,1540.17,
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1257.54,,,,,,,fee schedule,716.91,1540.17,
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,716.91,1540.17,APC
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,716.91,1540.17,APC
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,716.91,1540.17,APC
Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,301.78,,,,,,,fee schedule,197.85,387.26,
Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,247.01,,,,,,,fee schedule,197.85,387.26,
Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.85,,,,,,,fee schedule,197.85,387.26,
Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,347.05,,,,,,,fee schedule,197.85,387.26,
Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,197.85,387.26,APC
Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,197.85,387.26,APC
Esoph imped function test,91037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,197.85,387.26,APC
Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1078.79,,,,,,,fee schedule,371.82,1240.61,
Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,882.99,,,,,,,fee schedule,371.82,1240.61,
Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,707.25,,,,,,,fee schedule,371.82,1240.61,
Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1240.61,,,,,,,fee schedule,371.82,1240.61,
Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1240.61,APC
Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1240.61,APC
Esoph imped funct test > 1hr,91038,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1240.61,APC
Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1039.62,,,,,,,fee schedule,371.82,1195.56,
Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,850.93,,,,,,,fee schedule,371.82,1195.56,
Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,681.57,,,,,,,fee schedule,371.82,1195.56,
Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1195.56,,,,,,,fee schedule,371.82,1195.56,
Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1195.56,APC
Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1195.56,APC
Esoph balloon distension tst,91040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1195.56,APC
Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,340.56,,,,,,,fee schedule,215.15,391.64,
Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,278.75,,,,,,,fee schedule,215.15,391.64,
Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.27,,,,,,,fee schedule,215.15,391.64,
Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,391.64,,,,,,,fee schedule,215.15,391.64,
Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,391.64,APC
Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,391.64,APC
Breath hydrogen/methane test,91065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,391.64,APC
Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2815.27,,,,,,,fee schedule,903.72,3237.56,
Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2304.3,,,,,,,fee schedule,903.72,3237.56,
Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1845.69,,,,,,,fee schedule,903.72,3237.56,
Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3237.56,,,,,,,fee schedule,903.72,3237.56,
Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,3237.56,APC
Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,3237.56,APC
Gi tract capsule endoscopy,91110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,3237.56,APC
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1916.59,,,,,,,fee schedule,903.72,2204.08,
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1568.73,,,,,,,fee schedule,903.72,2204.08,
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1256.52,,,,,,,fee schedule,903.72,2204.08,
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2204.08,,,,,,,fee schedule,903.72,2204.08,
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,2204.08,APC
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,2204.08,APC
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,2204.08,APC
Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2668.15,,,,,,,fee schedule,903.72,3068.37,
Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2183.88,,,,,,,fee schedule,903.72,3068.37,
Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1749.24,,,,,,,fee schedule,903.72,3068.37,
Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3068.37,,,,,,,fee schedule,903.72,3068.37,
Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,948.91,,,,,,,fee schedule,903.72,3068.37,APC
Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,903.72,,,,,,,fee schedule,903.72,3068.37,APC
Gi wireless capsule measure,91112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1626.7,,,,,,,fee schedule,903.72,3068.37,APC
Gi trc img intral colon i&r,91113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1574.53,,,,,,,fee schedule,926.61,1810.71,
Gi trc img intral colon i&r,91113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1288.75,,,,,,,fee schedule,926.61,1810.71,
Gi trc img intral colon i&r,91113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1032.26,,,,,,,fee schedule,926.61,1810.71,
Gi trc img intral colon i&r,91113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1810.71,,,,,,,fee schedule,926.61,1810.71,
Gi trc img intral colon i&r,91113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,926.61,1810.71,APC
Gi trc img intral colon i&r,91113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,926.61,1810.71,APC
Gi trc img intral colon i&r,91113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,926.61,1810.71,APC
Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,323.1,,,,,,,fee schedule,211.82,387.26,
Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,264.46,,,,,,,fee schedule,211.82,387.26,
Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.82,,,,,,,fee schedule,211.82,387.26,
Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,371.57,,,,,,,fee schedule,211.82,387.26,
Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,211.82,387.26,APC
Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,211.82,387.26,APC
Colon motility 6 hr study,91117,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,211.82,387.26,APC
Rectal sensation test,91120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1036.68,,,,,,,fee schedule,679.65,1192.18,
Rectal sensation test,91120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,848.52,,,,,,,fee schedule,679.65,1192.18,
Rectal sensation test,91120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,679.65,,,,,,,fee schedule,679.65,1192.18,
Rectal sensation test,91120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1192.18,,,,,,,fee schedule,679.65,1192.18,
Anal pressure record,91122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,380.18,,,,,,,fee schedule,249.25,437.21,
Anal pressure record,91122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,311.18,,,,,,,fee schedule,249.25,437.21,
Anal pressure record,91122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.25,,,,,,,fee schedule,249.25,437.21,
Anal pressure record,91122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,437.21,,,,,,,fee schedule,249.25,437.21,
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,387.26,APC
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,387.26,APC
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,387.26,APC
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,669.27,APC
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,669.27,APC
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,669.27,APC
Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.16,,,,,,,fee schedule,215.15,387.26,
Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,271.87,,,,,,,fee schedule,215.15,387.26,
Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.76,,,,,,,fee schedule,215.15,387.26,
Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,381.98,,,,,,,fee schedule,215.15,387.26,
Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,387.26,APC
Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,387.26,APC
Electrogastrography,91132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,387.26,APC
Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,378.21,,,,,,,fee schedule,132.57,434.94,
Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,309.56,,,,,,,fee schedule,132.57,434.94,
Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,247.95,,,,,,,fee schedule,132.57,434.94,
Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,434.94,,,,,,,fee schedule,132.57,434.94,
Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,434.94,APC
Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,434.94,APC
Electrogastrography W/Test,91133,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,434.94,APC
Liver elastography,91200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.58,,,,,,,fee schedule,44.96,230.78,
Liver elastography,91200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.13,,,,,,,fee schedule,44.96,230.78,
Liver elastography,91200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.96,,,,,,,fee schedule,44.96,230.78,
Liver elastography,91200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.87,,,,,,,fee schedule,44.96,230.78,
Liver elastography,91200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,44.96,230.78,APC
Liver elastography,91200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,44.96,230.78,APC
Liver elastography,91200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,44.96,230.78,APC
Gastroenterology procedure,91299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Gastroenterology procedure,91299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Gastroenterology procedure,91299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Coronavirus vaccine 5,91304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.54,,,,,,,fee schedule,161.54,185.77,
Coronavirus vaccine 5,91304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.54,,,,,,,fee schedule,161.54,185.77,
Coronavirus vaccine 5,91304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.54,,,,,,,fee schedule,161.54,185.77,
Coronavirus vaccine 5,91304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.77,,,,,,,fee schedule,161.54,185.77,
Sarscov2 vac 3mcg trs-suc im,91318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.55,,,,,,,fee schedule,65.55,75.38,
Sarscov2 vac 3mcg trs-suc im,91318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.55,,,,,,,fee schedule,65.55,75.38,
Sarscov2 vac 3mcg trs-suc im,91318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.55,,,,,,,fee schedule,65.55,75.38,
Sarscov2 vac 3mcg trs-suc im,91318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.38,,,,,,,fee schedule,65.55,75.38,
Sarscv2 vac 10mcg trs-suc im,91319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.78,,,,,,,fee schedule,87.78,100.95,
Sarscv2 vac 10mcg trs-suc im,91319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.78,,,,,,,fee schedule,87.78,100.95,
Sarscv2 vac 10mcg trs-suc im,91319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.78,,,,,,,fee schedule,87.78,100.95,
Sarscv2 vac 10mcg trs-suc im,91319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.95,,,,,,,fee schedule,87.78,100.95,
Sarscv2 vac 30mcg trs-suc im,91320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.9,,,,,,,fee schedule,155.9,179.29,
Sarscv2 vac 30mcg trs-suc im,91320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.9,,,,,,,fee schedule,155.9,179.29,
Sarscv2 vac 30mcg trs-suc im,91320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,155.9,,,,,,,fee schedule,155.9,179.29,
Sarscv2 vac 30mcg trs-suc im,91320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.29,,,,,,,fee schedule,155.9,179.29,
Sarscov2 vac 25 mcg/.25ml im,91321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.06,,,,,,,fee schedule,147.06,169.12,
Sarscov2 vac 25 mcg/.25ml im,91321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.06,,,,,,,fee schedule,147.06,169.12,
Sarscov2 vac 25 mcg/.25ml im,91321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.06,,,,,,,fee schedule,147.06,169.12,
Sarscov2 vac 25 mcg/.25ml im,91321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.12,,,,,,,fee schedule,147.06,169.12,
Sarscov2 vac 50 mcg/0.5ml im,91322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.65,,,,,,,fee schedule,161.65,185.9,
Sarscov2 vac 50 mcg/0.5ml im,91322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.65,,,,,,,fee schedule,161.65,185.9,
Sarscov2 vac 50 mcg/0.5ml im,91322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.65,,,,,,,fee schedule,161.65,185.9,
Sarscov2 vac 50 mcg/0.5ml im,91322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.9,,,,,,,fee schedule,161.65,185.9,
Eye exam new patient,92002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Eye exam new patient,92002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Eye exam new patient,92002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Eye exam new patient,92002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Eye exam new patient,92002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Eye exam new patient,92002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Eye exam new patient,92002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Eye exam new patient,92004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Eye exam new patient,92004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Eye exam new patient,92004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Eye exam new patient,92004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Eye exam new patient,92004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Eye exam new patient,92004,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Eye exam new patient,92004,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Eye exam establish patient,92012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Eye exam establish patient,92012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Eye exam establish patient,92012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Eye exam establish patient,92012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Eye exam establish patient,92012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Eye exam establish patient,92012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Eye exam establish patient,92012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Determine refractive state,92015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,10.27,18.02,
Determine refractive state,92015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,10.27,18.02,
Determine refractive state,92015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,18.02,
Determine refractive state,92015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,10.27,18.02,
New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7563.84,,,,,,,fee schedule,2368.94,8698.42,
New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6191,,,,,,,fee schedule,2368.94,8698.42,
New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4958.85,,,,,,,fee schedule,2368.94,8698.42,
New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8698.42,,,,,,,fee schedule,2368.94,8698.42,
New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,2368.94,8698.42,APC
New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,2368.94,8698.42,APC
New eye exam & treatment,92018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,2368.94,8698.42,APC
Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4885.25,,,,,,,fee schedule,2368.94,5618.04,
Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3998.58,,,,,,,fee schedule,2368.94,5618.04,
Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3202.77,,,,,,,fee schedule,2368.94,5618.04,
Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5618.04,,,,,,,fee schedule,2368.94,5618.04,
Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2487.38,,,,,,,fee schedule,2368.94,5618.04,APC
Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2368.94,,,,,,,fee schedule,2368.94,5618.04,APC
Eye exam & treatment,92019,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4264.08,,,,,,,fee schedule,2368.94,5618.04,APC
Special eye evaluation,92020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Special eye evaluation,92020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Special eye evaluation,92020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Special eye evaluation,92020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Special eye evaluation,92020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Special eye evaluation,92020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Special eye evaluation,92020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Corneal Topography,92025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.98,,,,,,,fee schedule,32.11,105.8,
Corneal Topography,92025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.09,,,,,,,fee schedule,32.11,105.8,
Corneal Topography,92025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.11,,,,,,,fee schedule,32.11,105.8,
Corneal Topography,92025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.33,,,,,,,fee schedule,32.11,105.8,
Corneal Topography,92025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,32.11,105.8,APC
Corneal Topography,92025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,32.11,105.8,APC
Corneal Topography,92025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,32.11,105.8,APC
Special eye evaluation,92060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.49,,,,,,,fee schedule,48.18,105.8,
Special eye evaluation,92060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.15,,,,,,,fee schedule,48.18,105.8,
Special eye evaluation,92060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.18,,,,,,,fee schedule,48.18,105.8,
Special eye evaluation,92060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.51,,,,,,,fee schedule,48.18,105.8,
Special eye evaluation,92060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,48.18,105.8,APC
Special eye evaluation,92060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,48.18,105.8,APC
Special eye evaluation,92060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,48.18,105.8,APC
Orthoptic/pleoptic training,92065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.96,,,,,,,fee schedule,65.53,114.95,
Orthoptic/pleoptic training,92065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.82,,,,,,,fee schedule,65.53,114.95,
Orthoptic/pleoptic training,92065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.53,,,,,,,fee schedule,65.53,114.95,
Orthoptic/pleoptic training,92065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.95,,,,,,,fee schedule,65.53,114.95,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.86,,,,,,,fee schedule,58.78,126.34,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.92,,,,,,,fee schedule,58.78,126.34,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.02,,,,,,,fee schedule,58.78,126.34,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.34,,,,,,,fee schedule,58.78,126.34,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,126.34,APC
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,126.34,APC
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,126.34,APC
Contact lens fitting for tx,92071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.11,,,,,,,fee schedule,28.26,49.58,
Contact lens fitting for tx,92071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.29,,,,,,,fee schedule,28.26,49.58,
Contact lens fitting for tx,92071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.26,,,,,,,fee schedule,28.26,49.58,
Contact lens fitting for tx,92071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.58,,,,,,,fee schedule,28.26,49.58,
Fit contac lens for managmnt,92072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.47,,,,,,,fee schedule,112.42,197.19,
Fit contac lens for managmnt,92072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.35,,,,,,,fee schedule,112.42,197.19,
Fit contac lens for managmnt,92072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.42,,,,,,,fee schedule,112.42,197.19,
Fit contac lens for managmnt,92072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.19,,,,,,,fee schedule,112.42,197.19,
Visual field examination(s),92081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.98,,,,,,,fee schedule,32.11,105.8,
Visual field examination(s),92081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.09,,,,,,,fee schedule,32.11,105.8,
Visual field examination(s),92081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.11,,,,,,,fee schedule,32.11,105.8,
Visual field examination(s),92081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.33,,,,,,,fee schedule,32.11,105.8,
Visual field examination(s),92081,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,32.11,105.8,APC
Visual field examination(s),92081,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,32.11,105.8,APC
Visual field examination(s),92081,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,32.11,105.8,APC
Visual field examination(s),92082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.49,,,,,,,fee schedule,48.18,105.8,
Visual field examination(s),92082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.15,,,,,,,fee schedule,48.18,105.8,
Visual field examination(s),92082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.18,,,,,,,fee schedule,48.18,105.8,
Visual field examination(s),92082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.51,,,,,,,fee schedule,48.18,105.8,
Visual field examination(s),92082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,48.18,105.8,APC
Visual field examination(s),92082,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,48.18,105.8,APC
Visual field examination(s),92082,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,48.18,105.8,APC
Visual field examination(s),92083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.92,,,,,,,fee schedule,66.16,238.63,
Visual field examination(s),92083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.6,,,,,,,fee schedule,66.16,238.63,
Visual field examination(s),92083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.16,,,,,,,fee schedule,66.16,238.63,
Visual field examination(s),92083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.06,,,,,,,fee schedule,66.16,238.63,
Visual field examination(s),92083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,66.16,238.63,APC
Visual field examination(s),92083,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,66.16,238.63,APC
Visual field examination(s),92083,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,66.16,238.63,APC
Serial tonometry exam(s),92100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.72,,,,,,,fee schedule,104.71,183.68,
Serial tonometry exam(s),92100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.73,,,,,,,fee schedule,104.71,183.68,
Serial tonometry exam(s),92100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.71,,,,,,,fee schedule,104.71,183.68,
Serial tonometry exam(s),92100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.68,,,,,,,fee schedule,104.71,183.68,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.17,,,,,,,fee schedule,26.34,105.8,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.88,,,,,,,fee schedule,26.34,105.8,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.34,,,,,,,fee schedule,26.34,105.8,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.2,,,,,,,fee schedule,26.34,105.8,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,26.34,105.8,APC
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,26.34,105.8,APC
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,26.34,105.8,APC
Cmptr ophth img optic nerve,92133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,105.8,
Cmptr ophth img optic nerve,92133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,105.8,
Cmptr ophth img optic nerve,92133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,105.8,
Cmptr ophth img optic nerve,92133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,105.8,
Cmptr ophth img optic nerve,92133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,26.98,105.8,APC
Cmptr ophth img optic nerve,92133,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,26.98,105.8,APC
Cmptr ophth img optic nerve,92133,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,26.98,105.8,APC
Cptr ophth dx img post segmt,92134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.12,,,,,,,fee schedule,27.61,105.8,
Cptr ophth dx img post segmt,92134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.48,,,,,,,fee schedule,27.61,105.8,
Cptr ophth dx img post segmt,92134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.61,,,,,,,fee schedule,27.61,105.8,
Cptr ophth dx img post segmt,92134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.44,,,,,,,fee schedule,27.61,105.8,
Cptr ophth dx img post segmt,92134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,27.61,105.8,APC
Cptr ophth dx img post segmt,92134,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,27.61,105.8,APC
Cptr ophth dx img post segmt,92134,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,27.61,105.8,APC
Ophthalmic biometry,92136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.69,,,,,,,fee schedule,106,238.63,
Ophthalmic biometry,92136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.34,,,,,,,fee schedule,106,238.63,
Ophthalmic biometry,92136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106,,,,,,,fee schedule,106,238.63,
Ophthalmic biometry,92136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.94,,,,,,,fee schedule,106,238.63,
Ophthalmic biometry,92136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,106,238.63,APC
Ophthalmic biometry,92136,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,106,238.63,APC
Ophthalmic biometry,92136,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,106,238.63,APC
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,509.14,,,,,,,fee schedule,215.15,585.51,
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.73,,,,,,,fee schedule,215.15,585.51,
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,333.79,,,,,,,fee schedule,215.15,585.51,
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,585.51,,,,,,,fee schedule,215.15,585.51,
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,585.51,APC
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,585.51,APC
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,585.51,APC
Corneal hysteresis deter,92145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.53,,,,,,,fee schedule,14.77,105.8,
Corneal hysteresis deter,92145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.44,,,,,,,fee schedule,14.77,105.8,
Corneal hysteresis deter,92145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.77,,,,,,,fee schedule,14.77,105.8,
Corneal hysteresis deter,92145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.91,,,,,,,fee schedule,14.77,105.8,
Corneal hysteresis deter,92145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,14.77,105.8,APC
Corneal hysteresis deter,92145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,14.77,105.8,APC
Corneal hysteresis deter,92145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,14.77,105.8,APC
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.86,,,,,,,fee schedule,58.78,122.89,
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.46,,,,,,,fee schedule,58.78,122.89,
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.06,,,,,,,fee schedule,58.78,122.89,
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.89,,,,,,,fee schedule,58.78,122.89,
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,122.89,APC
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,122.89,APC
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,122.89,APC
Opscpy extnd on/mac draw,92202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.86,,,,,,,fee schedule,58.78,122.89,
Opscpy extnd on/mac draw,92202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.46,,,,,,,fee schedule,58.78,122.89,
Opscpy extnd on/mac draw,92202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.06,,,,,,,fee schedule,58.78,122.89,
Opscpy extnd on/mac draw,92202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.89,,,,,,,fee schedule,58.78,122.89,
Opscpy extnd on/mac draw,92202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,122.89,APC
Opscpy extnd on/mac draw,92202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,122.89,APC
Opscpy extnd on/mac draw,92202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,122.89,APC
Remote dx retinal imaging,92227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.17,,,,,,,fee schedule,26.34,105.8,
Remote dx retinal imaging,92227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.88,,,,,,,fee schedule,26.34,105.8,
Remote dx retinal imaging,92227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.34,,,,,,,fee schedule,26.34,105.8,
Remote dx retinal imaging,92227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.2,,,,,,,fee schedule,26.34,105.8,
Remote dx retinal imaging,92227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,26.34,105.8,APC
Remote dx retinal imaging,92227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,26.34,105.8,APC
Remote dx retinal imaging,92227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,26.34,105.8,APC
Remote retinal imaging mgmt,92228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,24.4,66.99,
Remote retinal imaging mgmt,92228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,24.4,66.99,
Remote retinal imaging mgmt,92228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,24.4,66.99,
Remote retinal imaging mgmt,92228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,24.4,66.99,
Remote retinal imaging mgmt,92228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,24.4,66.99,APC
Remote retinal imaging mgmt,92228,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,24.4,66.99,APC
Remote retinal imaging mgmt,92228,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,24.4,66.99,APC
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.14,,,,,,,fee schedule,58.78,124.36,
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.51,,,,,,,fee schedule,58.78,124.36,
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.9,,,,,,,fee schedule,58.78,124.36,
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.36,,,,,,,fee schedule,58.78,124.36,
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,124.36,APC
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,124.36,APC
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,124.36,APC
Eye exam with photos,92230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,669.27,
Eye exam with photos,92230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,669.27,
Eye exam with photos,92230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,669.27,
Eye exam with photos,92230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,669.27,
Eye exam with photos,92230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,258.44,669.27,APC
Eye exam with photos,92230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,258.44,669.27,APC
Eye exam with photos,92230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,258.44,669.27,APC
Fluorescein angrph uni/bi,92235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,116.61,,,,,,,fee schedule,76.45,387.26,
Fluorescein angrph uni/bi,92235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95.45,,,,,,,fee schedule,76.45,387.26,
Fluorescein angrph uni/bi,92235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.45,,,,,,,fee schedule,76.45,387.26,
Fluorescein angrph uni/bi,92235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,134.1,,,,,,,fee schedule,76.45,387.26,
Fluorescein angrph uni/bi,92235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,76.45,387.26,APC
Fluorescein angrph uni/bi,92235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,76.45,387.26,APC
Fluorescein angrph uni/bi,92235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,76.45,387.26,APC
Icg angiography uni/bi,92240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,445.82,,,,,,,fee schedule,215.15,512.69,
Icg angiography uni/bi,92240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,364.9,,,,,,,fee schedule,215.15,512.69,
Icg angiography uni/bi,92240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,292.28,,,,,,,fee schedule,215.15,512.69,
Icg angiography uni/bi,92240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,512.69,,,,,,,fee schedule,215.15,512.69,
Icg angiography uni/bi,92240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,512.69,APC
Icg angiography uni/bi,92240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,512.69,APC
Icg angiography uni/bi,92240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,512.69,APC
Fluorescein icg angiography,92242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,473.26,,,,,,,fee schedule,215.15,544.25,
Fluorescein icg angiography,92242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,387.36,,,,,,,fee schedule,215.15,544.25,
Fluorescein icg angiography,92242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.27,,,,,,,fee schedule,215.15,544.25,
Fluorescein icg angiography,92242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,544.25,,,,,,,fee schedule,215.15,544.25,
Fluorescein icg angiography,92242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,544.25,APC
Fluorescein icg angiography,92242,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,544.25,APC
Fluorescein icg angiography,92242,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,544.25,APC
Eye exam with photos,92250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.5,,,,,,,fee schedule,79.66,238.63,
Eye exam with photos,92250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.45,,,,,,,fee schedule,79.66,238.63,
Eye exam with photos,92250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.66,,,,,,,fee schedule,79.66,238.63,
Eye exam with photos,92250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.73,,,,,,,fee schedule,79.66,238.63,
Eye exam with photos,92250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,79.66,238.63,APC
Eye exam with photos,92250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,79.66,238.63,APC
Eye exam with photos,92250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,79.66,238.63,APC
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Eye muscle evaluation,92265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.79,,,,,,,fee schedule,58.78,122.81,
Eye muscle evaluation,92265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.41,,,,,,,fee schedule,58.78,122.81,
Eye muscle evaluation,92265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.01,,,,,,,fee schedule,58.78,122.81,
Eye muscle evaluation,92265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.81,,,,,,,fee schedule,58.78,122.81,
Eye muscle evaluation,92265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,122.81,APC
Eye muscle evaluation,92265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,122.81,APC
Eye muscle evaluation,92265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,122.81,APC
Electro-oculography,92270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.12,,,,,,,fee schedule,91.86,238.63,
Electro-oculography,92270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.69,,,,,,,fee schedule,91.86,238.63,
Electro-oculography,92270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.86,,,,,,,fee schedule,91.86,238.63,
Electro-oculography,92270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.14,,,,,,,fee schedule,91.86,238.63,
Electro-oculography,92270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,91.86,238.63,APC
Electro-oculography,92270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,91.86,238.63,APC
Electro-oculography,92270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,91.86,238.63,APC
Full field erg w/i&r,92273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,662.37,,,,,,,fee schedule,215.15,761.73,
Full field erg w/i&r,92273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,542.15,,,,,,,fee schedule,215.15,761.73,
Full field erg w/i&r,92273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,434.25,,,,,,,fee schedule,215.15,761.73,
Full field erg w/i&r,92273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,761.73,,,,,,,fee schedule,215.15,761.73,
Full field erg w/i&r,92273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,761.73,APC
Full field erg w/i&r,92273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,761.73,APC
Full field erg w/i&r,92273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,761.73,APC
Multifocal erg w/i&r,92274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,356.91,,,,,,,fee schedule,128.21,410.45,
Multifocal erg w/i&r,92274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,292.13,,,,,,,fee schedule,128.21,410.45,
Multifocal erg w/i&r,92274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.99,,,,,,,fee schedule,128.21,410.45,
Multifocal erg w/i&r,92274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.45,,,,,,,fee schedule,128.21,410.45,
Multifocal erg w/i&r,92274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,410.45,APC
Multifocal erg w/i&r,92274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,410.45,APC
Multifocal erg w/i&r,92274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,410.45,APC
Color vision examination,92283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.35,,,,,,,fee schedule,58.78,147.6,
Color vision examination,92283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.05,,,,,,,fee schedule,58.78,147.6,
Color vision examination,92283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.15,,,,,,,fee schedule,58.78,147.6,
Color vision examination,92283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.6,,,,,,,fee schedule,58.78,147.6,
Color vision examination,92283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,147.6,APC
Color vision examination,92283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,147.6,APC
Color vision examination,92283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,147.6,APC
Dark adaptation eye exam,92284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,138.16,,,,,,,fee schedule,90.58,801.21,
Dark adaptation eye exam,92284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.08,,,,,,,fee schedule,90.58,801.21,
Dark adaptation eye exam,92284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.58,,,,,,,fee schedule,90.58,801.21,
Dark adaptation eye exam,92284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,158.88,,,,,,,fee schedule,90.58,801.21,
Dark adaptation eye exam,92284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,90.58,801.21,APC
Dark adaptation eye exam,92284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,90.58,801.21,APC
Dark adaptation eye exam,92284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,90.58,801.21,APC
Eye photography,92285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.98,,,,,,,fee schedule,32.11,66.99,
Eye photography,92285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.09,,,,,,,fee schedule,32.11,66.99,
Eye photography,92285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.11,,,,,,,fee schedule,32.11,66.99,
Eye photography,92285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.33,,,,,,,fee schedule,32.11,66.99,
Eye photography,92285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,32.11,66.99,APC
Eye photography,92285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,32.11,66.99,APC
Eye photography,92285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,32.11,66.99,APC
Internal eye photography,92286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,29.55,238.63,
Internal eye photography,92286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,29.55,238.63,
Internal eye photography,92286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,29.55,238.63,
Internal eye photography,92286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,29.55,238.63,
Internal eye photography,92286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,29.55,238.63,APC
Internal eye photography,92286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,29.55,238.63,APC
Internal eye photography,92286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,29.55,238.63,APC
Internal eye photography,92287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,250.84,,,,,,,fee schedule,132.57,288.47,
Internal eye photography,92287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,205.31,,,,,,,fee schedule,132.57,288.47,
Internal eye photography,92287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.45,,,,,,,fee schedule,132.57,288.47,
Internal eye photography,92287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,288.47,,,,,,,fee schedule,132.57,288.47,
Internal eye photography,92287,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,288.47,APC
Internal eye photography,92287,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,288.47,APC
Internal eye photography,92287,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,288.47,APC
Contact lens fitting,92310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,165.65,
Contact lens fitting,92310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,165.65,
Contact lens fitting,92310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,165.65,
Contact lens fitting,92310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,165.65,
Contact lens fitting,92311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Contact lens fitting,92311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Contact lens fitting,92311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Contact lens fitting,92311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Contact lens fitting,92311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Contact lens fitting,92311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Contact lens fitting,92311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Contact lens fitting,92312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Contact lens fitting,92312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Contact lens fitting,92312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Contact lens fitting,92312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Contact lens fitting,92312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Contact lens fitting,92312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Contact lens fitting,92312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Contact lens fitting,92313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Contact lens fitting,92313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Contact lens fitting,92313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Contact lens fitting,92313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Contact lens fitting,92313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Contact lens fitting,92313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Contact lens fitting,92313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Prescription of contact lens,92314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.94,,,,,,,fee schedule,97.65,171.28,
Prescription of contact lens,92314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.91,,,,,,,fee schedule,97.65,171.28,
Prescription of contact lens,92314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.65,,,,,,,fee schedule,97.65,171.28,
Prescription of contact lens,92314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.28,,,,,,,fee schedule,97.65,171.28,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Rx corneoscleral cntact lens,92317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Rx corneoscleral cntact lens,92317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Rx corneoscleral cntact lens,92317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Rx corneoscleral cntact lens,92317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Rx corneoscleral cntact lens,92317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Rx corneoscleral cntact lens,92317,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Rx corneoscleral cntact lens,92317,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Modification of contact lens,92325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Modification of contact lens,92325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Modification of contact lens,92325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Modification of contact lens,92325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Modification of contact lens,92325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Modification of contact lens,92325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Modification of contact lens,92325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Replacement of contact lens,92326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Replacement of contact lens,92326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Replacement of contact lens,92326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Replacement of contact lens,92326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Replacement of contact lens,92326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Replacement of contact lens,92326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Replacement of contact lens,92326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Fit spectacles monofocal,92340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.76,,,,,,,fee schedule,39.18,68.72,
Fit spectacles monofocal,92340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.91,,,,,,,fee schedule,39.18,68.72,
Fit spectacles monofocal,92340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.18,,,,,,,fee schedule,39.18,68.72,
Fit spectacles monofocal,92340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.72,,,,,,,fee schedule,39.18,68.72,
Fit spectacles bifocal,92341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.7,,,,,,,fee schedule,41.11,72.11,
Fit spectacles bifocal,92341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.32,,,,,,,fee schedule,41.11,72.11,
Fit spectacles bifocal,92341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.11,,,,,,,fee schedule,41.11,72.11,
Fit spectacles bifocal,92341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.11,,,,,,,fee schedule,41.11,72.11,
Fit spectacles multifocal,92342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.65,,,,,,,fee schedule,43.04,75.5,
Fit spectacles multifocal,92342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.73,,,,,,,fee schedule,43.04,75.5,
Fit spectacles multifocal,92342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.04,,,,,,,fee schedule,43.04,75.5,
Fit spectacles multifocal,92342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.5,,,,,,,fee schedule,43.04,75.5,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Fit spectacles single system,92354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Fit spectacles single system,92354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Fit spectacles single system,92354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Fit spectacles single system,92354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Fit spectacles single system,92354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Fit spectacles single system,92354,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Fit spectacles single system,92354,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Fit spectacles compound lens,92355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Fit spectacles compound lens,92355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Fit spectacles compound lens,92355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Fit spectacles compound lens,92355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Fit spectacles compound lens,92355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Fit spectacles compound lens,92355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Fit spectacles compound lens,92355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Aphakia prosth service temp,92358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Aphakia prosth service temp,92358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Aphakia prosth service temp,92358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Aphakia prosth service temp,92358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Aphakia prosth service temp,92358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Aphakia prosth service temp,92358,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Aphakia prosth service temp,92358,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Repair & adjust spectacles,92370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.93,,,,,,,fee schedule,34.05,59.72,
Repair & adjust spectacles,92370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.5,,,,,,,fee schedule,34.05,59.72,
Repair & adjust spectacles,92370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.05,,,,,,,fee schedule,34.05,59.72,
Repair & adjust spectacles,92370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.72,,,,,,,fee schedule,34.05,59.72,
Repair & adjust spectacles,92371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Repair & adjust spectacles,92371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Repair & adjust spectacles,92371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Repair & adjust spectacles,92371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Repair & adjust spectacles,92371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Repair & adjust spectacles,92371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Repair & adjust spectacles,92371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Eye service or procedure,92499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Eye service or procedure,92499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Eye service or procedure,92499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8392.68,,,,,,,fee schedule,537.39,9651.58,
Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6869.41,,,,,,,fee schedule,537.39,9651.58,
Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5502.24,,,,,,,fee schedule,537.39,9651.58,
Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9651.58,,,,,,,fee schedule,537.39,9651.58,
Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.26,,,,,,,fee schedule,537.39,9651.58,APC
Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.39,,,,,,,fee schedule,537.39,9651.58,APC
Ear and throat examination,92502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,967.3,,,,,,,fee schedule,537.39,9651.58,APC
Ear microscopy examination,92504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.7,,,,,,,fee schedule,41.76,73.26,
Ear microscopy examination,92504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.14,,,,,,,fee schedule,41.76,73.26,
Ear microscopy examination,92504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.76,,,,,,,fee schedule,41.76,73.26,
Ear microscopy examination,92504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.26,,,,,,,fee schedule,41.76,73.26,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.08,,,,,,,fee schedule,72.17,135.45,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,72.17,135.45,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,72.17,135.45,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.1,,,,,,,fee schedule,72.17,135.45,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.17,,,,,,,fee schedule,72.17,135.45,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,72.17,135.45,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.59,,,,,,,fee schedule,72.17,135.45,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,72.17,135.45,
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.01,,,,,,,fee schedule,72.17,135.45,APC
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,75.25,,,,,,,fee schedule,72.17,135.45,APC
Speech/hearing therapy,92507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,135.45,,,,,,,fee schedule,72.17,135.45,APC
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.39,,,,,,,fee schedule,19.92,123.63,
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,19.92,123.63,
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,19.92,123.63,
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.87,,,,,,,fee schedule,19.92,123.63,
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.92,,,,,,,fee schedule,19.92,123.63,
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,19.92,123.63,
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.95,,,,,,,fee schedule,19.92,123.63,
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,19.92,123.63,
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.02,,,,,,,fee schedule,19.92,123.63,APC
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.83,,,,,,,fee schedule,19.92,123.63,APC
Speech/hearing therapy,92508,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42.89,,,,,,,fee schedule,19.92,123.63,APC
Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,218.63,,,,,,,fee schedule,143.33,358,
Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.95,,,,,,,fee schedule,143.33,358,
Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.33,,,,,,,fee schedule,143.33,358,
Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,251.42,,,,,,,fee schedule,143.33,358,
Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.83,,,,,,,fee schedule,143.33,358,APC
Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.89,,,,,,,fee schedule,143.33,358,APC
Nasopharyngoscopy,92511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,358,,,,,,,fee schedule,143.33,358,APC
Nasal function studies,92512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Nasal function studies,92512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Nasal function studies,92512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Nasal function studies,92512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Nasal function studies,92512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Nasal function studies,92512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Nasal function studies,92512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Facial nerve function test,92516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,387.26,
Facial nerve function test,92516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,387.26,
Facial nerve function test,92516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,387.26,
Facial nerve function test,92516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,387.26,
Facial nerve function test,92516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,124.61,387.26,APC
Facial nerve function test,92516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,124.61,387.26,APC
Facial nerve function test,92516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,124.61,387.26,APC
Vemp test i&r cervical,92517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.1,,,,,,,fee schedule,128.21,311.77,
Vemp test i&r cervical,92517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,221.9,,,,,,,fee schedule,128.21,311.77,
Vemp test i&r cervical,92517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.73,,,,,,,fee schedule,128.21,311.77,
Vemp test i&r cervical,92517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,311.77,,,,,,,fee schedule,128.21,311.77,
Vemp test i&r cervical,92517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,311.77,APC
Vemp test i&r cervical,92517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,311.77,APC
Vemp test i&r cervical,92517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,311.77,APC
Vemp test i&r ocular,92518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.1,,,,,,,fee schedule,128.21,311.77,
Vemp test i&r ocular,92518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,221.9,,,,,,,fee schedule,128.21,311.77,
Vemp test i&r ocular,92518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.73,,,,,,,fee schedule,128.21,311.77,
Vemp test i&r ocular,92518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,311.77,,,,,,,fee schedule,128.21,311.77,
Vemp test i&r ocular,92518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,311.77,APC
Vemp test i&r ocular,92518,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,311.77,APC
Vemp test i&r ocular,92518,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,311.77,APC
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,513.76,,,,,,,fee schedule,215.15,590.82,
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,420.51,,,,,,,fee schedule,215.15,590.82,
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,336.82,,,,,,,fee schedule,215.15,590.82,
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,590.82,,,,,,,fee schedule,215.15,590.82,
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,590.82,APC
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,590.82,APC
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,590.82,APC
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,98.06,238.63,
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,98.06,238.63,
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,98.06,238.63,
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,98.06,238.63,
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Laryngeal function studies,92520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.35,,,,,,,fee schedule,84.15,230.87,
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,84.15,230.87,
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,84.15,230.87,
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.05,,,,,,,fee schedule,84.15,230.87,
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.15,,,,,,,fee schedule,84.15,230.87,
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,84.15,230.87,
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.6,,,,,,,fee schedule,84.15,230.87,
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,84.15,230.87,
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.67,,,,,,,fee schedule,84.15,230.87,APC
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.26,,,,,,,fee schedule,84.15,230.87,APC
Evaluation of speech fluency,92521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.87,,,,,,,fee schedule,84.15,230.87,APC
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.92,,,,,,,fee schedule,66.16,194.45,
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,66.16,194.45,
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,66.16,194.45,
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.6,,,,,,,fee schedule,66.16,194.45,
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.16,,,,,,,fee schedule,66.16,194.45,
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,66.16,194.45,
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.06,,,,,,,fee schedule,66.16,194.45,
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,66.16,194.45,
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.43,,,,,,,fee schedule,66.16,194.45,APC
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,108.03,,,,,,,fee schedule,66.16,194.45,APC
Evaluate speech production,92522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,194.45,,,,,,,fee schedule,66.16,194.45,APC
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,238.09,,,,,,,fee schedule,126.93,392.38,
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,126.93,392.38,
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,126.93,392.38,
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.88,,,,,,,fee schedule,126.93,392.38,
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.09,,,,,,,fee schedule,126.93,392.38,
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,126.93,392.38,
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,273.8,,,,,,,fee schedule,126.93,392.38,
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,126.93,392.38,
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,228.89,,,,,,,fee schedule,126.93,392.38,APC
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,217.99,,,,,,,fee schedule,126.93,392.38,APC
Speech sound lang comprehen,92523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.38,,,,,,,fee schedule,126.93,392.38,APC
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.13,,,,,,,fee schedule,60.4,190.48,
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,60.4,190.48,
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,60.4,190.48,
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.41,,,,,,,fee schedule,60.4,190.48,
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.4,,,,,,,fee schedule,60.4,190.48,
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,60.4,190.48,
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.95,,,,,,,fee schedule,60.4,190.48,
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,60.4,190.48,
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,111.11,,,,,,,fee schedule,60.4,190.48,APC
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,105.82,,,,,,,fee schedule,60.4,190.48,APC
Behavral qualit analys voice,92524,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,190.48,,,,,,,fee schedule,60.4,190.48,APC
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.88,,,,,,,fee schedule,66.79,145.46,
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,66.79,145.46,
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,66.79,145.46,
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.39,,,,,,,fee schedule,66.79,145.46,
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.79,,,,,,,fee schedule,66.79,145.46,
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,66.79,145.46,
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.16,,,,,,,fee schedule,66.79,145.46,
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,66.79,145.46,
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.85,,,,,,,fee schedule,66.79,145.46,APC
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,80.81,,,,,,,fee schedule,66.79,145.46,APC
Oral function therapy,92526,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,145.46,,,,,,,fee schedule,66.79,145.46,APC
Spontaneous nystagmus study,92531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.43,,,,,,,fee schedule,18.64,32.69,
Spontaneous nystagmus study,92531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.27,,,,,,,fee schedule,18.64,32.69,
Spontaneous nystagmus study,92531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.64,,,,,,,fee schedule,18.64,32.69,
Spontaneous nystagmus study,92531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.69,,,,,,,fee schedule,18.64,32.69,
Positional nystagmus test,92532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,37.19,
Positional nystagmus test,92532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,37.19,
Positional nystagmus test,92532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,37.19,
Positional nystagmus test,92532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,37.19,
Caloric vestibular test,92533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,52.96,
Caloric vestibular test,92533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,52.96,
Caloric vestibular test,92533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,52.96,
Caloric vestibular test,92533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,52.96,
Optokinetic nystagmus test,92534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.26,,,,,,,fee schedule,23.12,40.55,
Optokinetic nystagmus test,92534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.86,,,,,,,fee schedule,23.12,40.55,
Optokinetic nystagmus test,92534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.12,,,,,,,fee schedule,23.12,40.55,
Optokinetic nystagmus test,92534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.55,,,,,,,fee schedule,23.12,40.55,
Caloric vstblr test w/rec,92537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.51,,,,,,,fee schedule,15.41,230.78,
Caloric vstblr test w/rec,92537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.24,,,,,,,fee schedule,15.41,230.78,
Caloric vstblr test w/rec,92537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.41,,,,,,,fee schedule,15.41,230.78,
Caloric vstblr test w/rec,92537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.04,,,,,,,fee schedule,15.41,230.78,
Caloric vstblr test w/rec,92537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,15.41,230.78,APC
Caloric vstblr test w/rec,92537,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,15.41,230.78,APC
Caloric vstblr test w/rec,92537,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,15.41,230.78,APC
Caloric vstblr test w/rec,92538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,680.93,,,,,,,fee schedule,215.15,783.07,
Caloric vstblr test w/rec,92538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,557.34,,,,,,,fee schedule,215.15,783.07,
Caloric vstblr test w/rec,92538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,446.42,,,,,,,fee schedule,215.15,783.07,
Caloric vstblr test w/rec,92538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,783.07,,,,,,,fee schedule,215.15,783.07,
Caloric vstblr test w/rec,92538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,783.07,APC
Caloric vstblr test w/rec,92538,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,783.07,APC
Caloric vstblr test w/rec,92538,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,783.07,APC
Basic vestibular evaluation,92540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,578.74,,,,,,,fee schedule,215.15,665.55,
Basic vestibular evaluation,92540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,473.7,,,,,,,fee schedule,215.15,665.55,
Basic vestibular evaluation,92540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,379.42,,,,,,,fee schedule,215.15,665.55,
Basic vestibular evaluation,92540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,665.55,,,,,,,fee schedule,215.15,665.55,
Basic vestibular evaluation,92540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,665.55,APC
Basic vestibular evaluation,92540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,665.55,APC
Basic vestibular evaluation,92540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,665.55,APC
Spontaneous nystagmus test,92541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.8,,,,,,,fee schedule,6.42,238.63,
Spontaneous nystagmus test,92541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.02,,,,,,,fee schedule,6.42,238.63,
Spontaneous nystagmus test,92541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.42,,,,,,,fee schedule,6.42,238.63,
Spontaneous nystagmus test,92541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.27,,,,,,,fee schedule,6.42,238.63,
Spontaneous nystagmus test,92541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,6.42,238.63,APC
Spontaneous nystagmus test,92541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,6.42,238.63,APC
Spontaneous nystagmus test,92541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,6.42,238.63,APC
Positional nystagmus test,92542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.84,,,,,,,fee schedule,5.14,238.63,
Positional nystagmus test,92542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.42,,,,,,,fee schedule,5.14,238.63,
Positional nystagmus test,92542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.14,,,,,,,fee schedule,5.14,238.63,
Positional nystagmus test,92542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.02,,,,,,,fee schedule,5.14,238.63,
Positional nystagmus test,92542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,5.14,238.63,APC
Positional nystagmus test,92542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,5.14,238.63,APC
Positional nystagmus test,92542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,5.14,238.63,APC
Optokinetic nystagmus test,92544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.87,,,,,,,fee schedule,4.5,230.78,
Optokinetic nystagmus test,92544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.62,,,,,,,fee schedule,4.5,230.78,
Optokinetic nystagmus test,92544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.5,,,,,,,fee schedule,4.5,230.78,
Optokinetic nystagmus test,92544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.9,,,,,,,fee schedule,4.5,230.78,
Optokinetic nystagmus test,92544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,4.5,230.78,APC
Optokinetic nystagmus test,92544,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,4.5,230.78,APC
Optokinetic nystagmus test,92544,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,4.5,230.78,APC
Oscillating tracking test,92545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.86,,,,,,,fee schedule,3.84,387.26,
Oscillating tracking test,92545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.8,,,,,,,fee schedule,3.84,387.26,
Oscillating tracking test,92545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.84,,,,,,,fee schedule,3.84,387.26,
Oscillating tracking test,92545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.74,,,,,,,fee schedule,3.84,387.26,
Oscillating tracking test,92545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,3.84,387.26,APC
Oscillating tracking test,92545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,3.84,387.26,APC
Oscillating tracking test,92545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,3.84,387.26,APC
Sinusoidal rotational test,92546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.98,,,,,,,fee schedule,128.21,279.43,
Sinusoidal rotational test,92546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.88,,,,,,,fee schedule,128.21,279.43,
Sinusoidal rotational test,92546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.3,,,,,,,fee schedule,128.21,279.43,
Sinusoidal rotational test,92546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,279.43,,,,,,,fee schedule,128.21,279.43,
Sinusoidal rotational test,92546,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,279.43,APC
Sinusoidal rotational test,92546,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,279.43,APC
Sinusoidal rotational test,92546,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,279.43,APC
Supplemental electrical test,92547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.69,,,,,,,fee schedule,8.98,15.74,
Supplemental electrical test,92547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.21,,,,,,,fee schedule,8.98,15.74,
Supplemental electrical test,92547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.98,,,,,,,fee schedule,8.98,15.74,
Supplemental electrical test,92547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.74,,,,,,,fee schedule,8.98,15.74,
Posturography,92548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,202.82,,,,,,,fee schedule,132.57,238.63,
Posturography,92548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.01,,,,,,,fee schedule,132.57,238.63,
Posturography,92548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.97,,,,,,,fee schedule,132.57,238.63,
Posturography,92548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.24,,,,,,,fee schedule,132.57,238.63,
Posturography,92548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,238.63,APC
Posturography,92548,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,238.63,APC
Posturography,92548,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,238.63,APC
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.8,,,,,,,fee schedule,132.57,243.57,
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.36,,,,,,,fee schedule,132.57,243.57,
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.86,,,,,,,fee schedule,132.57,243.57,
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.57,,,,,,,fee schedule,132.57,243.57,
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,243.57,APC
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,243.57,APC
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,243.57,APC
Tympanometry & reflex thresh,92550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,387.26,
Tympanometry & reflex thresh,92550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,387.26,
Tympanometry & reflex thresh,92550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,387.26,
Tympanometry & reflex thresh,92550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,387.26,
Tympanometry & reflex thresh,92550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,124.61,387.26,APC
Tympanometry & reflex thresh,92550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,124.61,387.26,APC
Tympanometry & reflex thresh,92550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,124.61,387.26,APC
Pure tone hearing test air,92551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.06,,,,,,,fee schedule,56.42,98.97,
Pure tone hearing test air,92551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.44,,,,,,,fee schedule,56.42,98.97,
Pure tone hearing test air,92551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.42,,,,,,,fee schedule,56.42,98.97,
Pure tone hearing test air,92551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.97,,,,,,,fee schedule,56.42,98.97,
Pure tone audiometry air,92552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.49,,,,,,,fee schedule,81.62,238.63,
Pure tone audiometry air,92552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.9,,,,,,,fee schedule,81.62,238.63,
Pure tone audiometry air,92552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.62,,,,,,,fee schedule,81.62,238.63,
Pure tone audiometry air,92552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.16,,,,,,,fee schedule,81.62,238.63,
Pure tone audiometry air,92552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,81.62,238.63,APC
Pure tone audiometry air,92552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,81.62,238.63,APC
Pure tone audiometry air,92552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,81.62,238.63,APC
Audiometry air & bone,92553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,296.01,,,,,,,fee schedule,128.21,340.41,
Audiometry air & bone,92553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.28,,,,,,,fee schedule,128.21,340.41,
Audiometry air & bone,92553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,194.06,,,,,,,fee schedule,128.21,340.41,
Audiometry air & bone,92553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.41,,,,,,,fee schedule,128.21,340.41,
Audiometry air & bone,92553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,340.41,APC
Audiometry air & bone,92553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,340.41,APC
Audiometry air & bone,92553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,340.41,APC
Speech threshold audiometry,92555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.73,,,,,,,fee schedule,58.78,129.64,
Speech threshold audiometry,92555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.27,,,,,,,fee schedule,58.78,129.64,
Speech threshold audiometry,92555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.91,,,,,,,fee schedule,58.78,129.64,
Speech threshold audiometry,92555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.64,,,,,,,fee schedule,58.78,129.64,
Speech threshold audiometry,92555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,129.64,APC
Speech threshold audiometry,92555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,129.64,APC
Speech threshold audiometry,92555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,129.64,APC
Speech audiometry complete,92556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,176.58,,,,,,,fee schedule,58.78,203.07,
Speech audiometry complete,92556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,144.53,,,,,,,fee schedule,58.78,203.07,
Speech audiometry complete,92556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,115.77,,,,,,,fee schedule,58.78,203.07,
Speech audiometry complete,92556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,203.07,,,,,,,fee schedule,58.78,203.07,
Speech audiometry complete,92556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,203.07,APC
Speech audiometry complete,92556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,203.07,APC
Speech audiometry complete,92556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,203.07,APC
Comprehensive hearing test,92557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.88,,,,,,,fee schedule,128.21,380.51,
Comprehensive hearing test,92557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.83,,,,,,,fee schedule,128.21,380.51,
Comprehensive hearing test,92557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,216.92,,,,,,,fee schedule,128.21,380.51,
Comprehensive hearing test,92557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.51,,,,,,,fee schedule,128.21,380.51,
Comprehensive hearing test,92557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,380.51,APC
Comprehensive hearing test,92557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,380.51,APC
Comprehensive hearing test,92557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,380.51,APC
Evoked auditory test qual,92558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,17.99,31.56,
Evoked auditory test qual,92558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,17.99,31.56,
Evoked auditory test qual,92558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,17.99,31.56,
Evoked auditory test qual,92558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,17.99,31.56,
Loudness balance test,92562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.35,,,,,,,fee schedule,84.15,387.26,
Loudness balance test,92562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.05,,,,,,,fee schedule,84.15,387.26,
Loudness balance test,92562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.15,,,,,,,fee schedule,84.15,387.26,
Loudness balance test,92562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.6,,,,,,,fee schedule,84.15,387.26,
Loudness balance test,92562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,84.15,387.26,APC
Loudness balance test,92562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,84.15,387.26,APC
Loudness balance test,92562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,84.15,387.26,APC
Tone decay hearing test,92563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.24,,,,,,,fee schedule,37.22,98.03,
Tone decay hearing test,92563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.77,,,,,,,fee schedule,37.22,98.03,
Tone decay hearing test,92563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.88,,,,,,,fee schedule,37.22,98.03,
Tone decay hearing test,92563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.03,,,,,,,fee schedule,37.22,98.03,
Tone decay hearing test,92563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,98.03,APC
Tone decay hearing test,92563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,98.03,APC
Tone decay hearing test,92563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,98.03,APC
Stenger test pure tone,92565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.11,,,,,,,fee schedule,28.26,105.8,
Stenger test pure tone,92565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.29,,,,,,,fee schedule,28.26,105.8,
Stenger test pure tone,92565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.26,,,,,,,fee schedule,28.26,105.8,
Stenger test pure tone,92565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.58,,,,,,,fee schedule,28.26,105.8,
Stenger test pure tone,92565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,28.26,105.8,APC
Stenger test pure tone,92565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,28.26,105.8,APC
Stenger test pure tone,92565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,28.26,105.8,APC
Tympanometry,92567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.49,,,,,,,fee schedule,37.22,143.16,
Tympanometry,92567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.9,,,,,,,fee schedule,37.22,143.16,
Tympanometry,92567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.62,,,,,,,fee schedule,37.22,143.16,
Tympanometry,92567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.16,,,,,,,fee schedule,37.22,143.16,
Tympanometry,92567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,143.16,APC
Tympanometry,92567,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,143.16,APC
Tympanometry,92567,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,143.16,APC
Acoustic refl threshold tst,92568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Acoustic refl threshold tst,92568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Acoustic refl threshold tst,92568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Acoustic refl threshold tst,92568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Acoustic refl threshold tst,92568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Acoustic refl threshold tst,92568,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Acoustic refl threshold tst,92568,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Acoustic immitance testing,92570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Acoustic immitance testing,92570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Acoustic immitance testing,92570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Acoustic immitance testing,92570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Acoustic immitance testing,92570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Acoustic immitance testing,92570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Acoustic immitance testing,92570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Filtered speech hearing test,92571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.44,,,,,,,fee schedule,37.22,86.76,
Filtered speech hearing test,92571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.75,,,,,,,fee schedule,37.22,86.76,
Filtered speech hearing test,92571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.46,,,,,,,fee schedule,37.22,86.76,
Filtered speech hearing test,92571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.76,,,,,,,fee schedule,37.22,86.76,
Filtered speech hearing test,92571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,86.76,APC
Filtered speech hearing test,92571,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,86.76,APC
Filtered speech hearing test,92571,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,86.76,APC
Staggered spondaic word test,92572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.2,,,,,,,fee schedule,57.17,230.78,
Staggered spondaic word test,92572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.37,,,,,,,fee schedule,57.17,230.78,
Staggered spondaic word test,92572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.17,,,,,,,fee schedule,57.17,230.78,
Staggered spondaic word test,92572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.28,,,,,,,fee schedule,57.17,230.78,
Staggered spondaic word test,92572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,57.17,230.78,APC
Staggered spondaic word test,92572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,57.17,230.78,APC
Staggered spondaic word test,92572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,57.17,230.78,APC
Sensorineural acuity test,92575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.69,,,,,,,fee schedule,37.22,185.94,
Sensorineural acuity test,92575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.34,,,,,,,fee schedule,37.22,185.94,
Sensorineural acuity test,92575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106,,,,,,,fee schedule,37.22,185.94,
Sensorineural acuity test,92575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.94,,,,,,,fee schedule,37.22,185.94,
Sensorineural acuity test,92575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,185.94,APC
Sensorineural acuity test,92575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,185.94,APC
Sensorineural acuity test,92575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,185.94,APC
Synthetic sentence test,92576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.92,,,,,,,fee schedule,37.22,116.06,
Synthetic sentence test,92576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.6,,,,,,,fee schedule,37.22,116.06,
Synthetic sentence test,92576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.16,,,,,,,fee schedule,37.22,116.06,
Synthetic sentence test,92576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.06,,,,,,,fee schedule,37.22,116.06,
Synthetic sentence test,92576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,116.06,APC
Synthetic sentence test,92576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,116.06,APC
Synthetic sentence test,92576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,116.06,APC
Stenger test speech,92577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.12,,,,,,,fee schedule,27.61,669.27,
Stenger test speech,92577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.48,,,,,,,fee schedule,27.61,669.27,
Stenger test speech,92577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.61,,,,,,,fee schedule,27.61,669.27,
Stenger test speech,92577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.44,,,,,,,fee schedule,27.61,669.27,
Stenger test speech,92577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,27.61,669.27,APC
Stenger test speech,92577,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,27.61,669.27,APC
Stenger test speech,92577,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,27.61,669.27,APC
Visual audiometry (vra),92579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.88,,,,,,,fee schedule,215.15,387.26,
Visual audiometry (vra),92579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.83,,,,,,,fee schedule,215.15,387.26,
Visual audiometry (vra),92579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,216.92,,,,,,,fee schedule,215.15,387.26,
Visual audiometry (vra),92579,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.51,,,,,,,fee schedule,215.15,387.26,
Visual audiometry (vra),92579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,387.26,APC
Visual audiometry (vra),92579,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,387.26,APC
Visual audiometry (vra),92579,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,387.26,APC
Conditioning play audiometry,92582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.88,,,,,,,fee schedule,128.21,380.51,
Conditioning play audiometry,92582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.83,,,,,,,fee schedule,128.21,380.51,
Conditioning play audiometry,92582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,216.92,,,,,,,fee schedule,128.21,380.51,
Conditioning play audiometry,92582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.51,,,,,,,fee schedule,128.21,380.51,
Conditioning play audiometry,92582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,380.51,APC
Conditioning play audiometry,92582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,380.51,APC
Conditioning play audiometry,92582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,380.51,APC
Select picture audiometry,92583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.14,,,,,,,fee schedule,58.78,160.01,
Select picture audiometry,92583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.89,,,,,,,fee schedule,58.78,160.01,
Select picture audiometry,92583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.22,,,,,,,fee schedule,58.78,160.01,
Select picture audiometry,92583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.01,,,,,,,fee schedule,58.78,160.01,
Select picture audiometry,92583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,160.01,APC
Select picture audiometry,92583,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,160.01,APC
Select picture audiometry,92583,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,160.01,APC
Electrocochleography,92584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,439.82,,,,,,,fee schedule,128.21,505.79,
Electrocochleography,92584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,359.99,,,,,,,fee schedule,128.21,505.79,
Electrocochleography,92584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,288.35,,,,,,,fee schedule,128.21,505.79,
Electrocochleography,92584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,505.79,,,,,,,fee schedule,128.21,505.79,
Electrocochleography,92584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,505.79,APC
Electrocochleography,92584,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,505.79,APC
Electrocochleography,92584,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,505.79,APC
Evoked auditory test limited,92587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,223.07,,,,,,,fee schedule,146.24,387.26,
Evoked auditory test limited,92587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.58,,,,,,,fee schedule,146.24,387.26,
Evoked auditory test limited,92587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.24,,,,,,,fee schedule,146.24,387.26,
Evoked auditory test limited,92587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,256.53,,,,,,,fee schedule,146.24,387.26,
Evoked auditory test limited,92587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,146.24,387.26,APC
Evoked auditory test limited,92587,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,146.24,387.26,APC
Evoked auditory test limited,92587,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,146.24,387.26,APC
Evoked auditory tst complete,92588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.8,,,,,,,fee schedule,7.08,669.27,
Evoked auditory tst complete,92588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.84,,,,,,,fee schedule,7.08,669.27,
Evoked auditory tst complete,92588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.08,,,,,,,fee schedule,7.08,669.27,
Evoked auditory tst complete,92588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.42,,,,,,,fee schedule,7.08,669.27,
Evoked auditory tst complete,92588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,7.08,669.27,APC
Evoked auditory tst complete,92588,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,7.08,669.27,APC
Evoked auditory tst complete,92588,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,7.08,669.27,APC
Hearing aid exam one ear,92590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.03,,,,,,,fee schedule,62.3,109.28,
Hearing aid exam one ear,92590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.78,,,,,,,fee schedule,62.3,109.28,
Hearing aid exam one ear,92590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.3,,,,,,,fee schedule,62.3,109.28,
Hearing aid exam one ear,92590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.28,,,,,,,fee schedule,62.3,109.28,
Hearing aid exam both ears,92591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,138.59,
Hearing aid exam both ears,92591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,138.59,
Hearing aid exam both ears,92591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,138.59,
Hearing aid exam both ears,92591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,138.59,
Hearing aid check one ear,92592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.22,,,,,,,fee schedule,25.06,43.95,
Hearing aid check one ear,92592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.28,,,,,,,fee schedule,25.06,43.95,
Hearing aid check one ear,92592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.06,,,,,,,fee schedule,25.06,43.95,
Hearing aid check one ear,92592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.95,,,,,,,fee schedule,25.06,43.95,
Hearing aid check both ears,92593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.73,,,,,,,fee schedule,40.47,70.99,
Hearing aid check both ears,92593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.53,,,,,,,fee schedule,40.47,70.99,
Hearing aid check both ears,92593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.47,,,,,,,fee schedule,40.47,70.99,
Hearing aid check both ears,92593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.99,,,,,,,fee schedule,40.47,70.99,
Electro hearng aid test one,92594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Electro hearng aid test one,92594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Electro hearng aid test one,92594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Electro hearng aid test one,92594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Electro hearng aid tst both,92595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.39,,,,,,,fee schedule,50.74,89,
Electro hearng aid tst both,92595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.34,,,,,,,fee schedule,50.74,89,
Electro hearng aid tst both,92595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.74,,,,,,,fee schedule,50.74,89,
Electro hearng aid tst both,92595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89,,,,,,,fee schedule,50.74,89,
Ear protector evaluation,92596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.64,,,,,,,fee schedule,37.22,131.84,
Ear protector evaluation,92596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.83,,,,,,,fee schedule,37.22,131.84,
Ear protector evaluation,92596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.16,,,,,,,fee schedule,37.22,131.84,
Ear protector evaluation,92596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.84,,,,,,,fee schedule,37.22,131.84,
Ear protector evaluation,92596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,131.84,APC
Ear protector evaluation,92596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,131.84,APC
Ear protector evaluation,92596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,131.84,APC
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.54,,,,,,,fee schedule,46.25,127.03,
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,46.25,127.03,
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,46.25,127.03,
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.74,,,,,,,fee schedule,46.25,127.03,
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.25,,,,,,,fee schedule,46.25,127.03,
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,46.25,127.03,
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.12,,,,,,,fee schedule,46.25,127.03,
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,46.25,127.03,
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.1,,,,,,,fee schedule,46.25,127.03,APC
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.57,,,,,,,fee schedule,46.25,127.03,APC
Oral speech device eval,92597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,127.03,,,,,,,fee schedule,46.25,127.03,APC
Cochlear implt f/up exam <7,92601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,875.99,,,,,,,fee schedule,128.21,1007.39,
Cochlear implt f/up exam <7,92601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,717,,,,,,,fee schedule,128.21,1007.39,
Cochlear implt f/up exam <7,92601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,574.3,,,,,,,fee schedule,128.21,1007.39,
Cochlear implt f/up exam <7,92601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1007.39,,,,,,,fee schedule,128.21,1007.39,
Cochlear implt f/up exam <7,92601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,1007.39,APC
Cochlear implt f/up exam <7,92601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,1007.39,APC
Cochlear implt f/up exam <7,92601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,1007.39,APC
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,617.3,,,,,,,fee schedule,128.21,709.9,
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,505.26,,,,,,,fee schedule,128.21,709.9,
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,404.7,,,,,,,fee schedule,128.21,709.9,
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,709.9,,,,,,,fee schedule,128.21,709.9,
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,709.9,APC
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,709.9,APC
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,709.9,APC
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,556.83,,,,,,,fee schedule,128.21,640.35,
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,455.77,,,,,,,fee schedule,128.21,640.35,
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,365.06,,,,,,,fee schedule,128.21,640.35,
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,640.35,,,,,,,fee schedule,128.21,640.35,
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,640.35,APC
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,640.35,APC
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,640.35,APC
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,611.17,,,,,,,fee schedule,128.21,702.85,
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,500.24,,,,,,,fee schedule,128.21,702.85,
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,400.68,,,,,,,fee schedule,128.21,702.85,
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,702.85,,,,,,,fee schedule,128.21,702.85,
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,702.85,APC
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,702.85,APC
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,702.85,APC
Ex for nonspeech device rx,92605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.39,,,,,,,fee schedule,50.74,123.63,
Ex for nonspeech device rx,92605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,50.74,123.63,
Ex for nonspeech device rx,92605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,50.74,123.63,
Ex for nonspeech device rx,92605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.34,,,,,,,fee schedule,50.74,123.63,
Ex for nonspeech device rx,92605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.74,,,,,,,fee schedule,50.74,123.63,
Ex for nonspeech device rx,92605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,50.74,123.63,
Ex for nonspeech device rx,92605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89,,,,,,,fee schedule,50.74,123.63,
Ex for nonspeech device rx,92605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,50.74,123.63,
Non-speech device service,92606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.24,,,,,,,fee schedule,55.88,123.63,
Non-speech device service,92606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,55.88,123.63,
Non-speech device service,92606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,55.88,123.63,
Non-speech device service,92606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.77,,,,,,,fee schedule,55.88,123.63,
Non-speech device service,92606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.88,,,,,,,fee schedule,55.88,123.63,
Non-speech device service,92606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,55.88,123.63,
Non-speech device service,92606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.03,,,,,,,fee schedule,55.88,123.63,
Non-speech device service,92606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,55.88,123.63,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.6,,,,,,,fee schedule,107.5,210.71,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,210.71,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,210.71,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.73,,,,,,,fee schedule,107.5,210.71,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.91,,,,,,,fee schedule,107.5,210.71,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,210.71,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.29,,,,,,,fee schedule,107.5,210.71,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,210.71,
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.91,,,,,,,fee schedule,107.5,210.71,APC
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,117.06,,,,,,,fee schedule,107.5,210.71,APC
Ex for speech device rx 1hr,92607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,210.71,,,,,,,fee schedule,107.5,210.71,APC
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.44,,,,,,,fee schedule,46.91,123.63,
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,46.91,123.63,
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,46.91,123.63,
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.75,,,,,,,fee schedule,46.91,123.63,
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.46,,,,,,,fee schedule,46.91,123.63,
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,46.91,123.63,
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.76,,,,,,,fee schedule,46.91,123.63,
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,46.91,123.63,
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.26,,,,,,,fee schedule,46.91,123.63,APC
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.91,,,,,,,fee schedule,46.91,123.63,APC
Ex for speech device rx addl,92608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84.44,,,,,,,fee schedule,46.91,123.63,APC
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.84,,,,,,,fee schedule,98.05,176.92,
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,98.05,176.92,
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,98.05,176.92,
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.92,,,,,,,fee schedule,98.05,176.92,
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.86,,,,,,,fee schedule,98.05,176.92,
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,98.05,176.92,
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.92,,,,,,,fee schedule,98.05,176.92,
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,98.05,176.92,
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.95,,,,,,,fee schedule,98.05,176.92,APC
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,98.05,,,,,,,fee schedule,98.05,176.92,APC
Use of speech device service,92609,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,176.49,,,,,,,fee schedule,98.05,176.92,APC
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.83,,,,,,,fee schedule,56.61,123.63,
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,56.61,123.63,
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,56.61,123.63,
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.8,,,,,,,fee schedule,56.61,123.63,
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.73,,,,,,,fee schedule,56.61,123.63,
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,56.61,123.63,
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.55,,,,,,,fee schedule,56.61,123.63,
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,56.61,123.63,
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.44,,,,,,,fee schedule,56.61,123.63,APC
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,56.61,,,,,,,fee schedule,56.61,123.63,APC
Evaluate swallowing function,92610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,101.9,,,,,,,fee schedule,56.61,123.63,APC
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.88,,,,,,,fee schedule,66.79,163.89,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,66.79,163.89,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,66.79,163.89,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.39,,,,,,,fee schedule,66.79,163.89,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.79,,,,,,,fee schedule,66.79,163.89,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,66.79,163.89,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.16,,,,,,,fee schedule,66.79,163.89,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,66.79,163.89,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.6,,,,,,,fee schedule,66.79,163.89,APC
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,91.05,,,,,,,fee schedule,66.79,163.89,APC
Motion fluoroscopy/swallow,92611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,163.89,,,,,,,fee schedule,66.79,163.89,APC
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,388.03,,,,,,,fee schedule,53.37,446.23,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,53.37,446.23,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,53.37,446.23,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,317.6,,,,,,,fee schedule,53.37,446.23,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,254.39,,,,,,,fee schedule,53.37,446.23,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,53.37,446.23,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,446.23,,,,,,,fee schedule,53.37,446.23,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,53.37,446.23,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.04,,,,,,,fee schedule,53.37,446.23,APC
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.37,,,,,,,fee schedule,53.37,446.23,APC
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,96.07,,,,,,,fee schedule,53.37,446.23,APC
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.35,,,,,,,fee schedule,20.55,123.63,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,20.55,123.63,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,20.55,123.63,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.66,,,,,,,fee schedule,20.55,123.63,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.55,,,,,,,fee schedule,20.55,123.63,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,20.55,123.63,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.05,,,,,,,fee schedule,20.55,123.63,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,20.55,123.63,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.49,,,,,,,fee schedule,53.44,308.76,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,53.44,308.76,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,53.44,308.76,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,219.76,,,,,,,fee schedule,53.44,308.76,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.02,,,,,,,fee schedule,53.44,308.76,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,53.44,308.76,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.76,,,,,,,fee schedule,53.44,308.76,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,53.44,308.76,
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.11,,,,,,,fee schedule,53.44,308.76,APC
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.44,,,,,,,fee schedule,53.44,308.76,APC
Laryngoscopic sensory vid,92614,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,96.19,,,,,,,fee schedule,53.44,308.76,APC
Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,17.99,123.63,
Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,17.99,123.63,
Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,17.99,123.63,
Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,17.99,123.63,
Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,17.99,123.63,
Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,17.99,123.63,
Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,17.99,123.63,
Laryngoscopic sensory i&r,92615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,17.99,123.63,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,378.21,,,,,,,fee schedule,80.86,434.94,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,80.86,434.94,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,80.86,434.94,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,309.56,,,,,,,fee schedule,80.86,434.94,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,247.95,,,,,,,fee schedule,80.86,434.94,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,80.86,434.94,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,434.94,,,,,,,fee schedule,80.86,434.94,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,80.86,434.94,
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.9,,,,,,,fee schedule,80.86,434.94,APC
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,80.86,,,,,,,fee schedule,80.86,434.94,APC
Fees w/laryngeal sense test,92616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,145.55,,,,,,,fee schedule,80.86,434.94,APC
Fees w/laryngeal sense i&r,92617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,22.47,39.42,
Fees w/laryngeal sense i&r,92617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,22.47,39.42,
Fees w/laryngeal sense i&r,92617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,22.47,39.42,
Fees w/laryngeal sense i&r,92617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,22.47,39.42,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,123.63,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,17.36,123.63,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,17.36,123.63,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,123.63,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,123.63,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,17.36,123.63,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,123.63,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,17.36,123.63,
Auditory function 60 min,92620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Auditory function 60 min,92620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Auditory function 60 min,92620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Auditory function 60 min,92620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Auditory function 60 min,92620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Auditory function 60 min,92620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Auditory function 60 min,92620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Auditory function + 15 min,92621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,30.45,
Auditory function + 15 min,92621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,30.45,
Auditory function + 15 min,92621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,30.45,
Auditory function + 15 min,92621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,30.45,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.89,,,,,,,fee schedule,128.21,309.22,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.09,,,,,,,fee schedule,128.21,309.22,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.28,,,,,,,fee schedule,128.21,309.22,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.22,,,,,,,fee schedule,128.21,309.22,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,309.22,APC
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,309.22,APC
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,309.22,APC
Dx aly aud oi snd prcsr each,92623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.96,,,,,,,fee schedule,10.46,18.35,
Dx aly aud oi snd prcsr each,92623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.06,,,,,,,fee schedule,10.46,18.35,
Dx aly aud oi snd prcsr each,92623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.46,,,,,,,fee schedule,10.46,18.35,
Dx aly aud oi snd prcsr each,92623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.35,,,,,,,fee schedule,10.46,18.35,
Tinnitus assessment,92625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Tinnitus assessment,92625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Tinnitus assessment,92625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Tinnitus assessment,92625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Tinnitus assessment,92625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Tinnitus assessment,92625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Tinnitus assessment,92625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.68,,,,,,,fee schedule,107.5,298.63,
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,298.63,
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,298.63,
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.55,,,,,,,fee schedule,107.5,298.63,
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.25,,,,,,,fee schedule,107.5,298.63,
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,298.63,
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.63,,,,,,,fee schedule,107.5,298.63,
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,298.63,
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,107.5,298.63,APC
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,107.5,298.63,APC
Eval aud rehab status,92626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,107.5,298.63,APC
Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.43,,,,,,,fee schedule,18.64,123.63,
Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,18.64,123.63,
Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,18.64,123.63,
Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.27,,,,,,,fee schedule,18.64,123.63,
Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.64,,,,,,,fee schedule,18.64,123.63,
Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,18.64,123.63,
Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.69,,,,,,,fee schedule,18.64,123.63,
Eval aud status rehab add-on,92627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,18.64,123.63,
Aud rehab pre-ling hear loss,92630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Aud rehab pre-ling hear loss,92630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Aud rehab pre-ling hear loss,92630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Aud rehab pre-ling hear loss,92630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Aud rehab postling hear loss,92633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Aud rehab postling hear loss,92633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Aud rehab postling hear loss,92633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Aud rehab postling hear loss,92633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Aud brainstem implt programg,92640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Aud brainstem implt programg,92640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Aud brainstem implt programg,92640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Aud brainstem implt programg,92640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Aud brainstem implt programg,92640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Aud brainstem implt programg,92640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Aud brainstem implt programg,92640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Aep scr auditory potential,92650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.96,,,,,,,fee schedule,24.89,43.65,
Aep scr auditory potential,92650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.07,,,,,,,fee schedule,24.89,43.65,
Aep scr auditory potential,92650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.89,,,,,,,fee schedule,24.89,43.65,
Aep scr auditory potential,92650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.65,,,,,,,fee schedule,24.89,43.65,
Aep hearing status deter i&r,92651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.1,,,,,,,fee schedule,177.73,387.26,
Aep hearing status deter i&r,92651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,221.9,,,,,,,fee schedule,177.73,387.26,
Aep hearing status deter i&r,92651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.73,,,,,,,fee schedule,177.73,387.26,
Aep hearing status deter i&r,92651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,311.77,,,,,,,fee schedule,177.73,387.26,
Aep hearing status deter i&r,92651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,177.73,387.26,APC
Aep hearing status deter i&r,92651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,177.73,387.26,APC
Aep hearing status deter i&r,92651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,177.73,387.26,APC
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,513.76,,,,,,,fee schedule,215.15,590.82,
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,420.51,,,,,,,fee schedule,215.15,590.82,
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,336.82,,,,,,,fee schedule,215.15,590.82,
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,590.82,,,,,,,fee schedule,215.15,590.82,
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,590.82,APC
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,590.82,APC
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,590.82,APC
Aep neurodiagnostic i&r,92653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,513.76,,,,,,,fee schedule,215.15,590.82,
Aep neurodiagnostic i&r,92653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,420.51,,,,,,,fee schedule,215.15,590.82,
Aep neurodiagnostic i&r,92653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,336.82,,,,,,,fee schedule,215.15,590.82,
Aep neurodiagnostic i&r,92653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,590.82,,,,,,,fee schedule,215.15,590.82,
Aep neurodiagnostic i&r,92653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,590.82,APC
Aep neurodiagnostic i&r,92653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,590.82,APC
Aep neurodiagnostic i&r,92653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,590.82,APC
Ent procedure/service,92700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Ent procedure/service,92700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Ent procedure/service,92700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7860.93,,,,,,,fee schedule,5153.63,10207.97,
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6434.17,,,,,,,fee schedule,5153.63,10207.97,
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5153.63,,,,,,,fee schedule,5153.63,10207.97,
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9040.07,,,,,,,fee schedule,5153.63,10207.97,
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,5153.63,10207.97,APC
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,5153.63,10207.97,APC
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,5153.63,10207.97,APC
Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9147.83,,,,,,,fee schedule,5997.32,20704.82,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7487.5,,,,,,,fee schedule,5997.32,20704.82,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5997.32,,,,,,,fee schedule,5997.32,20704.82,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10520,,,,,,,fee schedule,5997.32,20704.82,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,5997.32,20704.82,APC
Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,5997.32,20704.82,APC
Prq card angio/athrect 1 art,92924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,5997.32,20704.82,APC
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14339.28,,,,,,,fee schedule,9400.83,20704.82,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11736.7,,,,,,,fee schedule,9400.83,20704.82,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9400.83,,,,,,,fee schedule,9400.83,20704.82,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16490.17,,,,,,,fee schedule,9400.83,20704.82,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9400.83,20704.82,APC
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9400.83,20704.82,APC
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9400.83,20704.82,APC
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14339.28,,,,,,,fee schedule,9400.83,32878.29,
Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11736.7,,,,,,,fee schedule,9400.83,32878.29,
Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9400.83,,,,,,,fee schedule,9400.83,32878.29,
Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16490.17,,,,,,,fee schedule,9400.83,32878.29,
Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,9400.83,32878.29,APC
Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,9400.83,32878.29,APC
Prq card stent/ath/angio,92933,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,9400.83,32878.29,APC
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14339.27,,,,,,,fee schedule,9400.83,20704.82,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11736.69,,,,,,,fee schedule,9400.83,20704.82,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9400.83,,,,,,,fee schedule,9400.83,20704.82,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16490.16,,,,,,,fee schedule,9400.83,20704.82,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9400.83,20704.82,APC
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9400.83,20704.82,APC
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9400.83,20704.82,APC
Prq card revasc mi 1 vsl,92941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,16773,
Prq card revasc mi 1 vsl,92941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,16773,
Prq card revasc mi 1 vsl,92941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,16773,
Prq card revasc mi 1 vsl,92941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,16773,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14752.5,,,,,,,fee schedule,9671.74,20704.82,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12074.92,,,,,,,fee schedule,9671.74,20704.82,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9671.74,,,,,,,fee schedule,9671.74,20704.82,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16965.38,,,,,,,fee schedule,9671.74,20704.82,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9671.74,20704.82,APC
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9671.74,20704.82,APC
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9671.74,20704.82,APC
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Heart/lung resuscitation cpr,92950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,719.86,,,,,,,fee schedule,471.94,1185.42,
Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,589.21,,,,,,,fee schedule,471.94,1185.42,
Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,471.94,,,,,,,fee schedule,471.94,1185.42,
Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,827.84,,,,,,,fee schedule,471.94,1185.42,
Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,691.5,,,,,,,fee schedule,471.94,1185.42,APC
Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,658.57,,,,,,,fee schedule,471.94,1185.42,APC
Temporary external pacing,92953,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1185.42,,,,,,,fee schedule,471.94,1185.42,APC
Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,840.34,,,,,,,fee schedule,550.93,1185.42,
Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,687.82,,,,,,,fee schedule,550.93,1185.42,
Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,550.93,,,,,,,fee schedule,550.93,1185.42,
Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,966.39,,,,,,,fee schedule,550.93,1185.42,
Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,691.5,,,,,,,fee schedule,550.93,1185.42,APC
Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,658.57,,,,,,,fee schedule,550.93,1185.42,APC
Cardioversion electric ext,92960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1185.42,,,,,,,fee schedule,550.93,1185.42,APC
Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,719.86,,,,,,,fee schedule,471.94,1185.42,
Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,589.21,,,,,,,fee schedule,471.94,1185.42,
Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,471.94,,,,,,,fee schedule,471.94,1185.42,
Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,827.84,,,,,,,fee schedule,471.94,1185.42,
Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,691.5,,,,,,,fee schedule,471.94,1185.42,APC
Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,658.57,,,,,,,fee schedule,471.94,1185.42,APC
Cardioversion electric int,92961,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1185.42,,,,,,,fee schedule,471.94,1185.42,APC
Perq trluml coronry lithotrp,92972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.65,,,,,,,fee schedule,41.07,72.05,
Perq trluml coronry lithotrp,92972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.28,,,,,,,fee schedule,41.07,72.05,
Perq trluml coronry lithotrp,92972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.07,,,,,,,fee schedule,41.07,72.05,
Perq trluml coronry lithotrp,92972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.05,,,,,,,fee schedule,41.07,72.05,
Prq coronary mech thrombect,92973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.7,,,,,,,fee schedule,72.57,127.31,
Prq coronary mech thrombect,92973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.61,,,,,,,fee schedule,72.57,127.31,
Prq coronary mech thrombect,92973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.57,,,,,,,fee schedule,72.57,127.31,
Prq coronary mech thrombect,92973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.31,,,,,,,fee schedule,72.57,127.31,
Cath place cardio brachytx,92974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.96,,,,,,,fee schedule,65.53,114.95,
Cath place cardio brachytx,92974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.82,,,,,,,fee schedule,65.53,114.95,
Cath place cardio brachytx,92974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.53,,,,,,,fee schedule,65.53,114.95,
Cath place cardio brachytx,92974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.95,,,,,,,fee schedule,65.53,114.95,
Dissolve clot heart vessel,92977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,273.99,480.61,
Dissolve clot heart vessel,92977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,273.99,480.61,
Dissolve clot heart vessel,92977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,273.99,480.61,
Dissolve clot heart vessel,92977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,273.99,480.61,
Endoluminl ivus oct c 1st,92978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3792.43,,,,,,,fee schedule,2486.32,4361.29,
Endoluminl ivus oct c 1st,92978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3104.1,,,,,,,fee schedule,2486.32,4361.29,
Endoluminl ivus oct c 1st,92978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2486.32,,,,,,,fee schedule,2486.32,4361.29,
Endoluminl ivus oct c 1st,92978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4361.29,,,,,,,fee schedule,2486.32,4361.29,
Endoluminl ivus oct c ea,92979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.72,,,,,,,fee schedule,168.31,295.23,
Endoluminl ivus oct c ea,92979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.13,,,,,,,fee schedule,168.31,295.23,
Endoluminl ivus oct c ea,92979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.31,,,,,,,fee schedule,168.31,295.23,
Endoluminl ivus oct c ea,92979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,295.23,,,,,,,fee schedule,168.31,295.23,
Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7216.3,,,,,,,fee schedule,4731.01,10207.97,
Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5906.54,,,,,,,fee schedule,4731.01,10207.97,
Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4731.01,,,,,,,fee schedule,4731.01,10207.97,
Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8298.75,,,,,,,fee schedule,4731.01,10207.97,
Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5954.65,,,,,,,fee schedule,4731.01,10207.97,APC
Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5671.1,,,,,,,fee schedule,4731.01,10207.97,APC
Revision of aortic valve,92986,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10207.97,,,,,,,fee schedule,4731.01,10207.97,APC
Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Revision of mitral valve,92987,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4673.21,,,,,,,fee schedule,3063.76,20704.82,
Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3825.02,,,,,,,fee schedule,3063.76,20704.82,
Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3063.76,,,,,,,fee schedule,3063.76,20704.82,
Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5374.19,,,,,,,fee schedule,3063.76,20704.82,
Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,3063.76,20704.82,APC
Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,3063.76,20704.82,APC
Revision of pulmonary valve,92990,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,3063.76,20704.82,APC
Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2082.13,,,,,,,fee schedule,1365.04,20704.82,
Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1704.22,,,,,,,fee schedule,1365.04,20704.82,
Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1365.04,,,,,,,fee schedule,1365.04,20704.82,
Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2394.45,,,,,,,fee schedule,1365.04,20704.82,
Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,1365.04,20704.82,APC
Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,1365.04,20704.82,APC
Pul art balloon repr percut,92997,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,1365.04,20704.82,APC
Pul art balloon repr percut,92998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1017.9,,,,,,,fee schedule,667.34,1170.59,
Pul art balloon repr percut,92998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,833.15,,,,,,,fee schedule,667.34,1170.59,
Pul art balloon repr percut,92998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,667.34,,,,,,,fee schedule,667.34,1170.59,
Pul art balloon repr percut,92998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1170.59,,,,,,,fee schedule,667.34,1170.59,
Electrocardiogram complete,93000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.05,,,,,,,fee schedule,18.39,32.26,
Electrocardiogram complete,93000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.96,,,,,,,fee schedule,18.39,32.26,
Electrocardiogram complete,93000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.39,,,,,,,fee schedule,18.39,32.26,
Electrocardiogram complete,93000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.26,,,,,,,fee schedule,18.39,32.26,
Electrocardiogram tracing,93005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.01,,,,,,,fee schedule,31.48,105.8,
Electrocardiogram tracing,93005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.3,,,,,,,fee schedule,31.48,105.8,
Electrocardiogram tracing,93005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.48,,,,,,,fee schedule,31.48,105.8,
Electrocardiogram tracing,93005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.21,,,,,,,fee schedule,31.48,105.8,
Electrocardiogram tracing,93005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,31.48,105.8,APC
Electrocardiogram tracing,93005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,31.48,105.8,APC
Electrocardiogram tracing,93005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,31.48,105.8,APC
Electrocardiogram report,93010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.86,,,,,,,fee schedule,3.84,6.74,
Electrocardiogram report,93010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.8,,,,,,,fee schedule,3.84,6.74,
Electrocardiogram report,93010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.84,,,,,,,fee schedule,3.84,6.74,
Electrocardiogram report,93010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.74,,,,,,,fee schedule,3.84,6.74,
Cardiovascular stress test,93015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.63,,,,,,,fee schedule,138.74,243.37,
Cardiovascular stress test,93015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.22,,,,,,,fee schedule,138.74,243.37,
Cardiovascular stress test,93015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.74,,,,,,,fee schedule,138.74,243.37,
Cardiovascular stress test,93015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.37,,,,,,,fee schedule,138.74,243.37,
Cardiovascular stress test,93016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,10.27,18.02,
Cardiovascular stress test,93016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,10.27,18.02,
Cardiovascular stress test,93016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,18.02,
Cardiovascular stress test,93016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,10.27,18.02,
Cardiovascular stress test,93017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,387.26,APC
Cardiovascular stress test,93017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,387.26,APC
Cardiovascular stress test,93017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,387.26,APC
Cardiovascular stress test,93018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.8,,,,,,,fee schedule,7.08,12.42,
Cardiovascular stress test,93018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.84,,,,,,,fee schedule,7.08,12.42,
Cardiovascular stress test,93018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.08,,,,,,,fee schedule,7.08,12.42,
Cardiovascular stress test,93018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.42,,,,,,,fee schedule,7.08,12.42,
Cardiac drug stress test,93024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.9,,,,,,,fee schedule,98.93,801.21,
Cardiac drug stress test,93024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.51,,,,,,,fee schedule,98.93,801.21,
Cardiac drug stress test,93024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.93,,,,,,,fee schedule,98.93,801.21,
Cardiac drug stress test,93024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.54,,,,,,,fee schedule,98.93,801.21,
Cardiac drug stress test,93024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,98.93,801.21,APC
Cardiac drug stress test,93024,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,98.93,801.21,APC
Cardiac drug stress test,93024,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,98.93,801.21,APC
Microvolt t-wave assess,93025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.81,,,,,,,fee schedule,128.21,399.98,
Microvolt t-wave assess,93025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.68,,,,,,,fee schedule,128.21,399.98,
Microvolt t-wave assess,93025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,228.02,,,,,,,fee schedule,128.21,399.98,
Microvolt t-wave assess,93025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.98,,,,,,,fee schedule,128.21,399.98,
Microvolt t-wave assess,93025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,399.98,APC
Microvolt t-wave assess,93025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,399.98,APC
Microvolt t-wave assess,93025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,399.98,APC
Rhythm ECG with report,93040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.26,,,,,,,fee schedule,23.12,40.55,
Rhythm ECG with report,93040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.86,,,,,,,fee schedule,23.12,40.55,
Rhythm ECG with report,93040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.12,,,,,,,fee schedule,23.12,40.55,
Rhythm ECG with report,93040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.55,,,,,,,fee schedule,23.12,40.55,
Rhythm ecg tracing,93041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,10.27,105.8,
Rhythm ecg tracing,93041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,10.27,105.8,
Rhythm ecg tracing,93041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,105.8,
Rhythm ecg tracing,93041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,10.27,105.8,
Rhythm ecg tracing,93041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,10.27,105.8,APC
Rhythm ecg tracing,93041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,10.27,105.8,APC
Rhythm ecg tracing,93041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,10.27,105.8,APC
Rhythm ecg report,93042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.93,,,,,,,fee schedule,2.58,4.52,
Rhythm ecg report,93042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.22,,,,,,,fee schedule,2.58,4.52,
Rhythm ecg report,93042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.58,,,,,,,fee schedule,2.58,4.52,
Rhythm ecg report,93042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.52,,,,,,,fee schedule,2.58,4.52,
Art pressure waveform analys,93050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.49,,,,,,,fee schedule,16.06,51.88,
Art pressure waveform analys,93050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.05,,,,,,,fee schedule,16.06,51.88,
Art pressure waveform analys,93050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.06,,,,,,,fee schedule,16.06,51.88,
Art pressure waveform analys,93050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.16,,,,,,,fee schedule,16.06,51.88,
Art pressure waveform analys,93050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,16.06,51.88,APC
Art pressure waveform analys,93050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,16.06,51.88,APC
Art pressure waveform analys,93050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,16.06,51.88,APC
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Therapy activation ipnss,93150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.65,,,,,,,fee schedule,94.73,191.65,
Therapy activation ipnss,93150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.4,,,,,,,fee schedule,94.73,191.65,
Therapy activation ipnss,93150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.26,,,,,,,fee schedule,94.73,191.65,
Therapy activation ipnss,93150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,191.65,,,,,,,fee schedule,94.73,191.65,
Therapy activation ipnss,93150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,191.65,APC
Therapy activation ipnss,93150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,191.65,APC
Therapy activation ipnss,93150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,191.65,APC
Interrog&prgrmg ipnss,93151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.65,,,,,,,fee schedule,94.73,191.65,
Interrog&prgrmg ipnss,93151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.4,,,,,,,fee schedule,94.73,191.65,
Interrog&prgrmg ipnss,93151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.26,,,,,,,fee schedule,94.73,191.65,
Interrog&prgrmg ipnss,93151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,191.65,,,,,,,fee schedule,94.73,191.65,
Interrog&prgrmg ipnss,93151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,191.65,APC
Interrog&prgrmg ipnss,93151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,191.65,APC
Interrog&prgrmg ipnss,93151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,191.65,APC
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,514.17,,,,,,,fee schedule,306.03,591.3,
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,420.85,,,,,,,fee schedule,306.03,591.3,
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,337.09,,,,,,,fee schedule,306.03,591.3,
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,591.3,,,,,,,fee schedule,306.03,591.3,
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,306.03,591.3,APC
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,306.03,591.3,APC
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,306.03,591.3,APC
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.65,,,,,,,fee schedule,94.73,191.65,
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.4,,,,,,,fee schedule,94.73,191.65,
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.26,,,,,,,fee schedule,94.73,191.65,
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,191.65,,,,,,,fee schedule,94.73,191.65,
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,191.65,APC
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,191.65,APC
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,191.65,APC
Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.78,,,,,,,fee schedule,165.72,290.7,
Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.9,,,,,,,fee schedule,165.72,290.7,
Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.72,,,,,,,fee schedule,165.72,290.7,
Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.7,,,,,,,fee schedule,165.72,290.7,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.03,,,,,,,fee schedule,106.88,238.63,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.44,,,,,,,fee schedule,106.88,238.63,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.88,,,,,,,fee schedule,106.88,238.63,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.48,,,,,,,fee schedule,106.88,238.63,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,106.88,238.63,APC
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,106.88,238.63,APC
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,106.88,238.63,APC
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.69,,,,,,,fee schedule,58.78,188.24,
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.98,,,,,,,fee schedule,58.78,188.24,
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.32,,,,,,,fee schedule,58.78,188.24,
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.24,,,,,,,fee schedule,58.78,188.24,
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,188.24,APC
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,188.24,APC
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,188.24,APC
Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.56,,,,,,,fee schedule,14.13,24.79,
Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.65,,,,,,,fee schedule,14.13,24.79,
Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.13,,,,,,,fee schedule,14.13,24.79,
Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.79,,,,,,,fee schedule,14.13,24.79,
Remote 30 day ecg rev/report,93228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.63,,,,,,,fee schedule,12.21,21.42,
Remote 30 day ecg rev/report,93228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.25,,,,,,,fee schedule,12.21,21.42,
Remote 30 day ecg rev/report,93228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.21,,,,,,,fee schedule,12.21,21.42,
Remote 30 day ecg rev/report,93228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.42,,,,,,,fee schedule,12.21,21.42,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1990.06,,,,,,,fee schedule,371.82,2288.57,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1628.86,,,,,,,fee schedule,371.82,2288.57,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1304.68,,,,,,,fee schedule,371.82,2288.57,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2288.57,,,,,,,fee schedule,371.82,2288.57,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,2288.57,APC
Remote 30 day ecg tech supp,93229,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,2288.57,APC
Remote 30 day ecg tech supp,93229,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,2288.57,APC
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.73,,,,,,,fee schedule,37.22,75.59,
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.8,,,,,,,fee schedule,37.22,75.59,
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.09,,,,,,,fee schedule,37.22,75.59,
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.59,,,,,,,fee schedule,37.22,75.59,
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,75.59,APC
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,75.59,APC
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,75.59,APC
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.14,,,,,,,fee schedule,70.9,238.63,
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.51,,,,,,,fee schedule,70.9,238.63,
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.9,,,,,,,fee schedule,70.9,238.63,
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.36,,,,,,,fee schedule,70.9,238.63,
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,70.9,238.63,APC
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,70.9,238.63,APC
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,70.9,238.63,APC
Ext ecg>48hr<7d rev&interpj,93244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.88,,,,,,,fee schedule,8.44,14.81,
Ext ecg>48hr<7d rev&interpj,93244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.54,,,,,,,fee schedule,8.44,14.81,
Ext ecg>48hr<7d rev&interpj,93244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.44,,,,,,,fee schedule,8.44,14.81,
Ext ecg>48hr<7d rev&interpj,93244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.81,,,,,,,fee schedule,8.44,14.81,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.14,,,,,,,fee schedule,37.22,124.36,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.51,,,,,,,fee schedule,37.22,124.36,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.9,,,,,,,fee schedule,37.22,124.36,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.36,,,,,,,fee schedule,37.22,124.36,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,124.36,APC
Ext ecg>7d<15d recording,93246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,124.36,APC
Ext ecg>7d<15d recording,93246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,124.36,APC
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.49,,,,,,,fee schedule,132.57,250.11,
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.02,,,,,,,fee schedule,132.57,250.11,
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.59,,,,,,,fee schedule,132.57,250.11,
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.11,,,,,,,fee schedule,132.57,250.11,
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,250.11,APC
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,250.11,APC
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,250.11,APC
Ext ecg>7d<15d rev&interpj,93248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.25,,,,,,,fee schedule,9.34,16.39,
Ext ecg>7d<15d rev&interpj,93248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.66,,,,,,,fee schedule,9.34,16.39,
Ext ecg>7d<15d rev&interpj,93248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.34,,,,,,,fee schedule,9.34,16.39,
Ext ecg>7d<15d rev&interpj,93248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.39,,,,,,,fee schedule,9.34,16.39,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.76,,,,,,,fee schedule,37.19,67.57,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.1,,,,,,,fee schedule,37.19,67.57,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.52,,,,,,,fee schedule,37.19,67.57,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.57,,,,,,,fee schedule,37.19,67.57,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,67.57,APC
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,67.57,APC
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,67.57,APC
Interrogate subq defib,93261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.76,,,,,,,fee schedule,37.19,67.57,
Interrogate subq defib,93261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.1,,,,,,,fee schedule,37.19,67.57,
Interrogate subq defib,93261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.52,,,,,,,fee schedule,37.19,67.57,
Interrogate subq defib,93261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.57,,,,,,,fee schedule,37.19,67.57,
Interrogate subq defib,93261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,67.57,APC
Interrogate subq defib,93261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,67.57,APC
Interrogate subq defib,93261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,67.57,APC
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.29,,,,,,,fee schedule,37.19,75.08,
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.44,,,,,,,fee schedule,37.19,75.08,
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.8,,,,,,,fee schedule,37.19,75.08,
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.08,,,,,,,fee schedule,37.19,75.08,
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,75.08,APC
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,75.08,APC
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,75.08,APC
ECG record/review,93268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,564.4,,,,,,,fee schedule,370.02,649.06,
ECG record/review,93268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,461.96,,,,,,,fee schedule,370.02,649.06,
ECG record/review,93268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,370.02,,,,,,,fee schedule,370.02,649.06,
ECG record/review,93268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,649.06,,,,,,,fee schedule,370.02,649.06,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.31,,,,,,,fee schedule,37.19,75.11,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.46,,,,,,,fee schedule,37.19,75.11,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.82,,,,,,,fee schedule,37.19,75.11,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.11,,,,,,,fee schedule,37.19,75.11,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,75.11,APC
Remote 30 day ecg rev/report,93270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,75.11,APC
Remote 30 day ecg rev/report,93270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,75.11,APC
Ecg/monitoring and analysis,93271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,468.36,,,,,,,fee schedule,94.73,538.61,
Ecg/monitoring and analysis,93271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,383.35,,,,,,,fee schedule,94.73,538.61,
Ecg/monitoring and analysis,93271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,307.06,,,,,,,fee schedule,94.73,538.61,
Ecg/monitoring and analysis,93271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,538.61,,,,,,,fee schedule,94.73,538.61,
Ecg/monitoring and analysis,93271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,538.61,APC
Ecg/monitoring and analysis,93271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,538.61,APC
Ecg/monitoring and analysis,93271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,538.61,APC
Ecg/review interpret only,93272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.64,,,,,,,fee schedule,11.56,20.29,
Ecg/review interpret only,93272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.44,,,,,,,fee schedule,11.56,20.29,
Ecg/review interpret only,93272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.56,,,,,,,fee schedule,11.56,20.29,
Ecg/review interpret only,93272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.29,,,,,,,fee schedule,11.56,20.29,
ECG/signal-averaged,93278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.95,,,,,,,fee schedule,32.75,105.8,
ECG/signal-averaged,93278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.88,,,,,,,fee schedule,32.75,105.8,
ECG/signal-averaged,93278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.75,,,,,,,fee schedule,32.75,105.8,
ECG/signal-averaged,93278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.44,,,,,,,fee schedule,32.75,105.8,
ECG/signal-averaged,93278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,32.75,105.8,APC
ECG/signal-averaged,93278,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,32.75,105.8,APC
ECG/signal-averaged,93278,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,32.75,105.8,APC
Pm device progr eval sngl,93279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.31,,,,,,,fee schedule,37.19,75.11,
Pm device progr eval sngl,93279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.46,,,,,,,fee schedule,37.19,75.11,
Pm device progr eval sngl,93279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.82,,,,,,,fee schedule,37.19,75.11,
Pm device progr eval sngl,93279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.11,,,,,,,fee schedule,37.19,75.11,
Pm device progr eval sngl,93279,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,75.11,APC
Pm device progr eval sngl,93279,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,75.11,APC
Pm device progr eval sngl,93279,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,75.11,APC
Pm device progr eval dual,93280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.31,,,,,,,fee schedule,37.19,75.11,
Pm device progr eval dual,93280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.46,,,,,,,fee schedule,37.19,75.11,
Pm device progr eval dual,93280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.82,,,,,,,fee schedule,37.19,75.11,
Pm device progr eval dual,93280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.11,,,,,,,fee schedule,37.19,75.11,
Pm device progr eval dual,93280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,75.11,APC
Pm device progr eval dual,93280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,75.11,APC
Pm device progr eval dual,93280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,75.11,APC
Pm device progr eval multi,93281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.67,,,,,,,fee schedule,37.19,74.37,
Pm device progr eval multi,93281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.93,,,,,,,fee schedule,37.19,74.37,
Pm device progr eval multi,93281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.4,,,,,,,fee schedule,37.19,74.37,
Pm device progr eval multi,93281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.37,,,,,,,fee schedule,37.19,74.37,
Pm device progr eval multi,93281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,74.37,APC
Pm device progr eval multi,93281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,74.37,APC
Pm device progr eval multi,93281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,74.37,APC
Prgrmg eval implantable dfb,93282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.31,,,,,,,fee schedule,37.19,75.11,
Prgrmg eval implantable dfb,93282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.46,,,,,,,fee schedule,37.19,75.11,
Prgrmg eval implantable dfb,93282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.82,,,,,,,fee schedule,37.19,75.11,
Prgrmg eval implantable dfb,93282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.11,,,,,,,fee schedule,37.19,75.11,
Prgrmg eval implantable dfb,93282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,75.11,APC
Prgrmg eval implantable dfb,93282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,75.11,APC
Prgrmg eval implantable dfb,93282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,75.11,APC
Prgrmg eval implantable dfb,93283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.31,,,,,,,fee schedule,37.19,75.11,
Prgrmg eval implantable dfb,93283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.46,,,,,,,fee schedule,37.19,75.11,
Prgrmg eval implantable dfb,93283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.82,,,,,,,fee schedule,37.19,75.11,
Prgrmg eval implantable dfb,93283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.11,,,,,,,fee schedule,37.19,75.11,
Prgrmg eval implantable dfb,93283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,75.11,APC
Prgrmg eval implantable dfb,93283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,75.11,APC
Prgrmg eval implantable dfb,93283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,75.11,APC
Prgrmg eval implantable dfb,93284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.44,,,,,,,fee schedule,37.19,86.76,
Prgrmg eval implantable dfb,93284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.75,,,,,,,fee schedule,37.19,86.76,
Prgrmg eval implantable dfb,93284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.46,,,,,,,fee schedule,37.19,86.76,
Prgrmg eval implantable dfb,93284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.76,,,,,,,fee schedule,37.19,86.76,
Prgrmg eval implantable dfb,93284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,86.76,APC
Prgrmg eval implantable dfb,93284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,86.76,APC
Prgrmg eval implantable dfb,93284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,86.76,APC
Ilr device eval progr,93285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.09,,,,,,,fee schedule,28.91,66.94,
Ilr device eval progr,93285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,28.91,66.94,
Ilr device eval progr,93285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,28.91,66.94,
Ilr device eval progr,93285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.7,,,,,,,fee schedule,28.91,66.94,
Ilr device eval progr,93285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,28.91,66.94,APC
Ilr device eval progr,93285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,28.91,66.94,APC
Ilr device eval progr,93285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,28.91,66.94,APC
Peri-px pacemaker device evl,93286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.3,,,,,,,fee schedule,21.83,38.3,
Peri-px pacemaker device evl,93286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.26,,,,,,,fee schedule,21.83,38.3,
Peri-px pacemaker device evl,93286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.83,,,,,,,fee schedule,21.83,38.3,
Peri-px pacemaker device evl,93286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.3,,,,,,,fee schedule,21.83,38.3,
Peri-px device eval & prgr,93287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,24.4,42.8,
Peri-px device eval & prgr,93287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,24.4,42.8,
Peri-px device eval & prgr,93287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,24.4,42.8,
Peri-px device eval & prgr,93287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,24.4,42.8,
Pm device eval in person,93288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.31,,,,,,,fee schedule,37.19,75.11,
Pm device eval in person,93288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.46,,,,,,,fee schedule,37.19,75.11,
Pm device eval in person,93288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.82,,,,,,,fee schedule,37.19,75.11,
Pm device eval in person,93288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.11,,,,,,,fee schedule,37.19,75.11,
Pm device eval in person,93288,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,75.11,APC
Pm device eval in person,93288,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,75.11,APC
Pm device eval in person,93288,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,75.11,APC
Interrog device eval heart,93289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.87,,,,,,,fee schedule,35.97,66.94,
Interrog device eval heart,93289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.91,,,,,,,fee schedule,35.97,66.94,
Interrog device eval heart,93289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.97,,,,,,,fee schedule,35.97,66.94,
Interrog device eval heart,93289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.1,,,,,,,fee schedule,35.97,66.94,
Interrog device eval heart,93289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,35.97,66.94,APC
Interrog device eval heart,93289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,35.97,66.94,APC
Interrog device eval heart,93289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,35.97,66.94,APC
Icm device eval,93290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,66.94,
Icm device eval,93290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,66.94,
Icm device eval,93290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,66.94,
Icm device eval,93290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,66.94,
Icm device eval,93290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,17.36,66.94,APC
Icm device eval,93290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,17.36,66.94,APC
Icm device eval,93290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,17.36,66.94,APC
Ilr device interrogate,93291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,51.88,
Ilr device interrogate,93291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,51.88,
Ilr device interrogate,93291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,51.88,
Ilr device interrogate,93291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,51.88,
Ilr device interrogate,93291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,26.98,51.88,APC
Ilr device interrogate,93291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,26.98,51.88,APC
Ilr device interrogate,93291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,26.98,51.88,APC
Wcd device interrogate,93292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.39,,,,,,,fee schedule,19.92,66.94,
Wcd device interrogate,93292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.87,,,,,,,fee schedule,19.92,66.94,
Wcd device interrogate,93292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.92,,,,,,,fee schedule,19.92,66.94,
Wcd device interrogate,93292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.95,,,,,,,fee schedule,19.92,66.94,
Wcd device interrogate,93292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,19.92,66.94,APC
Wcd device interrogate,93292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,19.92,66.94,APC
Wcd device interrogate,93292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,19.92,66.94,APC
Pm phone r-strip device eval,93293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.83,,,,,,,fee schedule,37.19,120.55,
Pm phone r-strip device eval,93293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.8,,,,,,,fee schedule,37.19,120.55,
Pm phone r-strip device eval,93293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.73,,,,,,,fee schedule,37.19,120.55,
Pm phone r-strip device eval,93293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.55,,,,,,,fee schedule,37.19,120.55,
Pm phone r-strip device eval,93293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,120.55,APC
Pm phone r-strip device eval,93293,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,120.55,APC
Pm phone r-strip device eval,93293,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,120.55,APC
Pm device interrogate remote,93294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,30.45,
Pm device interrogate remote,93294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,30.45,
Pm device interrogate remote,93294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,30.45,
Pm device interrogate remote,93294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,30.45,
Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.91,,,,,,,fee schedule,34.69,60.85,
Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.31,,,,,,,fee schedule,34.69,60.85,
Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.69,,,,,,,fee schedule,34.69,60.85,
Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.85,,,,,,,fee schedule,34.69,60.85,
Pm/icd remote tech serv,93296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.51,,,,,,,fee schedule,37.19,83.39,
Pm/icd remote tech serv,93296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.35,,,,,,,fee schedule,37.19,83.39,
Pm/icd remote tech serv,93296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.54,,,,,,,fee schedule,37.19,83.39,
Pm/icd remote tech serv,93296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.39,,,,,,,fee schedule,37.19,83.39,
Pm/icd remote tech serv,93296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,83.39,APC
Pm/icd remote tech serv,93296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,83.39,APC
Pm/icd remote tech serv,93296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,83.39,APC
Icm device interrogat remote,93297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,12.85,66.94,
Icm device interrogat remote,93297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,12.85,66.94,
Icm device interrogat remote,93297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,12.85,66.94,
Icm device interrogat remote,93297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,12.85,66.94,
Icm device interrogat remote,93297,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,12.85,66.94,APC
Icm device interrogat remote,93297,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,12.85,66.94,APC
Icm device interrogat remote,93297,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,12.85,66.94,APC
Ilr device interrogat remote,93298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,13.49,66.94,
Ilr device interrogat remote,93298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,13.49,66.94,
Ilr device interrogat remote,93298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,13.49,66.94,
Ilr device interrogat remote,93298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,13.49,66.94,
Ilr device interrogat remote,93298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,13.49,66.94,APC
Ilr device interrogat remote,93298,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,13.49,66.94,APC
Ilr device interrogat remote,93298,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,13.49,66.94,APC
Echo transthoracic,93303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1410.3,,,,,,,fee schedule,544.45,1621.85,
Echo transthoracic,93303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1154.33,,,,,,,fee schedule,544.45,1621.85,
Echo transthoracic,93303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,924.59,,,,,,,fee schedule,544.45,1621.85,
Echo transthoracic,93303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1621.85,,,,,,,fee schedule,544.45,1621.85,
Echo transthoracic,93303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,1621.85,APC
Echo transthoracic,93303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,1621.85,APC
Echo transthoracic,93303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,1621.85,APC
Echo transthoracic,93304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,532.68,,,,,,,fee schedule,349.23,980.01,
Echo transthoracic,93304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,436,,,,,,,fee schedule,349.23,980.01,
Echo transthoracic,93304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,349.23,,,,,,,fee schedule,349.23,980.01,
Echo transthoracic,93304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,612.58,,,,,,,fee schedule,349.23,980.01,
Echo transthoracic,93304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,349.23,980.01,APC
Echo transthoracic,93304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,349.23,980.01,APC
Echo transthoracic,93304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,349.23,980.01,APC
Tte w/doppler complete,93306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,980.01,APC
Tte w/doppler complete,93306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,980.01,APC
Tte w/doppler complete,93306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,980.01,APC
Tte w/o doppler complete,93307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,234.16,,,,,,,fee schedule,153.52,427.94,
Tte w/o doppler complete,93307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.66,,,,,,,fee schedule,153.52,427.94,
Tte w/o doppler complete,93307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,153.52,,,,,,,fee schedule,153.52,427.94,
Tte w/o doppler complete,93307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,269.28,,,,,,,fee schedule,153.52,427.94,
Tte w/o doppler complete,93307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,153.52,427.94,APC
Tte w/o doppler complete,93307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,153.52,427.94,APC
Tte w/o doppler complete,93307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,153.52,427.94,APC
Tte f-up or lmtd,93308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.65,,,,,,,fee schedule,237.74,743.65,
Tte f-up or lmtd,93308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,529.28,,,,,,,fee schedule,237.74,743.65,
Tte f-up or lmtd,93308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,423.94,,,,,,,fee schedule,237.74,743.65,
Tte f-up or lmtd,93308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.65,,,,,,,fee schedule,237.74,743.65,
Tte f-up or lmtd,93308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,743.65,APC
Tte f-up or lmtd,93308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,743.65,APC
Tte f-up or lmtd,93308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,743.65,APC
Echo transesophageal,93312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1270.34,,,,,,,fee schedule,544.45,1460.89,
Echo transesophageal,93312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1039.77,,,,,,,fee schedule,544.45,1460.89,
Echo transesophageal,93312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,832.83,,,,,,,fee schedule,544.45,1460.89,
Echo transesophageal,93312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1460.89,,,,,,,fee schedule,544.45,1460.89,
Echo transesophageal,93312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,1460.89,APC
Echo transesophageal,93312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,1460.89,APC
Echo transesophageal,93312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,1460.89,APC
Echo transesophageal,93313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,838.86,,,,,,,fee schedule,544.45,980.01,
Echo transesophageal,93313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,686.61,,,,,,,fee schedule,544.45,980.01,
Echo transesophageal,93313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,549.96,,,,,,,fee schedule,544.45,980.01,
Echo transesophageal,93313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,964.69,,,,,,,fee schedule,544.45,980.01,
Echo transesophageal,93313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,980.01,APC
Echo transesophageal,93313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,980.01,APC
Echo transesophageal,93313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,980.01,APC
Echo transesophageal,93314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,400.73,,,,,,,fee schedule,262.72,460.84,
Echo transesophageal,93314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,328,,,,,,,fee schedule,262.72,460.84,
Echo transesophageal,93314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.72,,,,,,,fee schedule,262.72,460.84,
Echo transesophageal,93314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,460.84,,,,,,,fee schedule,262.72,460.84,
Echo transesophageal,93315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1410.3,,,,,,,fee schedule,544.45,1621.85,
Echo transesophageal,93315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1154.33,,,,,,,fee schedule,544.45,1621.85,
Echo transesophageal,93315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,924.59,,,,,,,fee schedule,544.45,1621.85,
Echo transesophageal,93315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1621.85,,,,,,,fee schedule,544.45,1621.85,
Echo transesophageal,93315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,1621.85,APC
Echo transesophageal,93315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,1621.85,APC
Echo transesophageal,93315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,1621.85,APC
Echo transesophageal,93316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,838.86,,,,,,,fee schedule,544.45,980.01,
Echo transesophageal,93316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,686.61,,,,,,,fee schedule,544.45,980.01,
Echo transesophageal,93316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,549.96,,,,,,,fee schedule,544.45,980.01,
Echo transesophageal,93316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,964.69,,,,,,,fee schedule,544.45,980.01,
Echo transesophageal,93316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,980.01,APC
Echo transesophageal,93316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,980.01,APC
Echo transesophageal,93316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,980.01,APC
Echo transesophageal,93317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,260.63,,,,,,,fee schedule,170.87,299.72,
Echo transesophageal,93317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.33,,,,,,,fee schedule,170.87,299.72,
Echo transesophageal,93317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.87,,,,,,,fee schedule,170.87,299.72,
Echo transesophageal,93317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,299.72,,,,,,,fee schedule,170.87,299.72,
Echo Transesophageal Intraop,93318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.98,,,,,,,fee schedule,192.08,980.01,
Echo Transesophageal Intraop,93318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.8,,,,,,,fee schedule,192.08,980.01,
Echo Transesophageal Intraop,93318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.08,,,,,,,fee schedule,192.08,980.01,
Echo Transesophageal Intraop,93318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,336.93,,,,,,,fee schedule,192.08,980.01,
Echo Transesophageal Intraop,93318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,192.08,980.01,APC
Echo Transesophageal Intraop,93318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,192.08,980.01,APC
Echo Transesophageal Intraop,93318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,192.08,980.01,APC
3d echo img cgen car anomal,93319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.36,,,,,,,fee schedule,54.65,95.86,
3d echo img cgen car anomal,93319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.23,,,,,,,fee schedule,54.65,95.86,
3d echo img cgen car anomal,93319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.65,,,,,,,fee schedule,54.65,95.86,
3d echo img cgen car anomal,93319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.86,,,,,,,fee schedule,54.65,95.86,
Doppler echo exam heart,93321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.53,,,,,,,fee schedule,37.72,66.16,
Doppler echo exam heart,93321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.09,,,,,,,fee schedule,37.72,66.16,
Doppler echo exam heart,93321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.72,,,,,,,fee schedule,37.72,66.16,
Doppler echo exam heart,93321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.16,,,,,,,fee schedule,37.72,66.16,
Doppler color flow add-on,93325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.94,,,,,,,fee schedule,45.2,79.28,
Doppler color flow add-on,93325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.43,,,,,,,fee schedule,45.2,79.28,
Doppler color flow add-on,93325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.2,,,,,,,fee schedule,45.2,79.28,
Doppler color flow add-on,93325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.28,,,,,,,fee schedule,45.2,79.28,
Stress tte only,93350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,710.72,,,,,,,fee schedule,465.95,980.01,
Stress tte only,93350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,581.72,,,,,,,fee schedule,465.95,980.01,
Stress tte only,93350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,465.95,,,,,,,fee schedule,465.95,980.01,
Stress tte only,93350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,817.33,,,,,,,fee schedule,465.95,980.01,
Stress tte only,93350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,465.95,980.01,APC
Stress tte only,93350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,465.95,980.01,APC
Stress tte only,93350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,465.95,980.01,APC
Stress tte complete,93351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,980.01,APC
Stress tte complete,93351,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,980.01,APC
Stress tte complete,93351,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,980.01,APC
Admin ecg contrast agent,93352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.85,,,,,,,fee schedule,81.2,142.43,
Admin ecg contrast agent,93352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.37,,,,,,,fee schedule,81.2,142.43,
Admin ecg contrast agent,93352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.2,,,,,,,fee schedule,81.2,142.43,
Admin ecg contrast agent,93352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.43,,,,,,,fee schedule,81.2,142.43,
Echo transesophageal (tee),93355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.98,,,,,,,fee schedule,95.7,167.88,
Echo transesophageal (tee),93355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.48,,,,,,,fee schedule,95.7,167.88,
Echo transesophageal (tee),93355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.7,,,,,,,fee schedule,95.7,167.88,
Echo transesophageal (tee),93355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.88,,,,,,,fee schedule,95.7,167.88,
Myocrd strain img spckl trck,93356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.84,,,,,,,fee schedule,15.63,27.42,
Myocrd strain img spckl trck,93356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.51,,,,,,,fee schedule,15.63,27.42,
Myocrd strain img spckl trck,93356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.63,,,,,,,fee schedule,15.63,27.42,
Myocrd strain img spckl trck,93356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.42,,,,,,,fee schedule,15.63,27.42,
Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6112.46,,,,,,,fee schedule,3230.27,7029.33,
Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5003.05,,,,,,,fee schedule,3230.27,7029.33,
Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4007.33,,,,,,,fee schedule,3230.27,7029.33,
Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7029.33,,,,,,,fee schedule,3230.27,7029.33,
Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,7029.33,APC
Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,7029.33,APC
Right heart cath,93451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,7029.33,APC
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1611.85,,,,,,,fee schedule,1056.73,5814.49,
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1319.3,,,,,,,fee schedule,1056.73,5814.49,
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1056.73,,,,,,,fee schedule,1056.73,5814.49,
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1853.63,,,,,,,fee schedule,1056.73,5814.49,
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,1056.73,5814.49,APC
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,1056.73,5814.49,APC
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,1056.73,5814.49,APC
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2065.52,,,,,,,fee schedule,1354.15,5814.49,
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1690.63,,,,,,,fee schedule,1354.15,5814.49,
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1354.15,,,,,,,fee schedule,1354.15,5814.49,
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2375.35,,,,,,,fee schedule,1354.15,5814.49,
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,1354.15,5814.49,APC
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,1354.15,5814.49,APC
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,1354.15,5814.49,APC
Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6172.94,,,,,,,fee schedule,3230.27,7098.88,
Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5052.55,,,,,,,fee schedule,3230.27,7098.88,
Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4046.98,,,,,,,fee schedule,3230.27,7098.88,
Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7098.88,,,,,,,fee schedule,3230.27,7098.88,
Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,7098.88,APC
Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,7098.88,APC
Coronary artery angio s&i,93454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,7098.88,APC
Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7100.91,,,,,,,fee schedule,3230.27,8166.05,
Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5812.09,,,,,,,fee schedule,3230.27,8166.05,
Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4655.36,,,,,,,fee schedule,3230.27,8166.05,
Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8166.05,,,,,,,fee schedule,3230.27,8166.05,
Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,8166.05,APC
Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,8166.05,APC
Coronary art/grft angio s&i,93455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,8166.05,APC
R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12100.89,,,,,,,fee schedule,3230.27,13916.02,
R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9904.58,,,,,,,fee schedule,3230.27,13916.02,
R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7933.34,,,,,,,fee schedule,3230.27,13916.02,
R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13916.02,,,,,,,fee schedule,3230.27,13916.02,
R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,13916.02,APC
R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,13916.02,APC
R hrt coronary artery angio,93456,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,13916.02,APC
R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2324.21,,,,,,,fee schedule,1523.75,5814.49,
R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1902.37,,,,,,,fee schedule,1523.75,5814.49,
R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1523.75,,,,,,,fee schedule,1523.75,5814.49,
R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2672.84,,,,,,,fee schedule,1523.75,5814.49,
R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,1523.75,5814.49,APC
R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,1523.75,5814.49,APC
R hrt art/grft angio,93457,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,1523.75,5814.49,APC
L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11780.28,,,,,,,fee schedule,3230.27,13547.32,
L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9642.16,,,,,,,fee schedule,3230.27,13547.32,
L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7723.15,,,,,,,fee schedule,3230.27,13547.32,
L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13547.32,,,,,,,fee schedule,3230.27,13547.32,
L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,13547.32,APC
L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,13547.32,APC
L hrt artery/ventricle angio,93458,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,13547.32,APC
L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12708.28,,,,,,,fee schedule,3230.27,14614.52,
L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10401.73,,,,,,,fee schedule,3230.27,14614.52,
L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8331.55,,,,,,,fee schedule,3230.27,14614.52,
L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14614.52,,,,,,,fee schedule,3230.27,14614.52,
L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,14614.52,APC
L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,14614.52,APC
L hrt art/grft angio,93459,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,14614.52,APC
R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13023.23,,,,,,,fee schedule,3230.27,14976.71,
R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10659.51,,,,,,,fee schedule,3230.27,14976.71,
R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8538.03,,,,,,,fee schedule,3230.27,14976.71,
R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14976.71,,,,,,,fee schedule,3230.27,14976.71,
R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,14976.71,APC
R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,14976.71,APC
R&l hrt art/ventricle angio,93460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,14976.71,APC
R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13951.17,,,,,,,fee schedule,3230.27,16043.85,
R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11419.03,,,,,,,fee schedule,3230.27,16043.85,
R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9146.39,,,,,,,fee schedule,3230.27,16043.85,
R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16043.85,,,,,,,fee schedule,3230.27,16043.85,
R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,16043.85,APC
R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,16043.85,APC
R&l hrt art/ventricle angio,93461,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,16043.85,APC
L hrt cath trnsptl puncture,93462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6112.46,,,,,,,fee schedule,4007.33,7029.33,
L hrt cath trnsptl puncture,93462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5003.05,,,,,,,fee schedule,4007.33,7029.33,
L hrt cath trnsptl puncture,93462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4007.33,,,,,,,fee schedule,4007.33,7029.33,
L hrt cath trnsptl puncture,93462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7029.33,,,,,,,fee schedule,4007.33,7029.33,
Drug admin & hemodynmic meas,93463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,422.4,,,,,,,fee schedule,276.93,485.76,
Drug admin & hemodynmic meas,93463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,345.73,,,,,,,fee schedule,276.93,485.76,
Drug admin & hemodynmic meas,93463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,276.93,,,,,,,fee schedule,276.93,485.76,
Drug admin & hemodynmic meas,93463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,485.76,,,,,,,fee schedule,276.93,485.76,
Exercise w/hemodynamic meas,93464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,581.01,,,,,,,fee schedule,380.91,668.16,
Exercise w/hemodynamic meas,93464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,475.56,,,,,,,fee schedule,380.91,668.16,
Exercise w/hemodynamic meas,93464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,380.91,,,,,,,fee schedule,380.91,668.16,
Exercise w/hemodynamic meas,93464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,668.16,,,,,,,fee schedule,380.91,668.16,
Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1023.13,,,,,,,fee schedule,670.76,2823.29,
Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.43,,,,,,,fee schedule,670.76,2823.29,
Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.76,,,,,,,fee schedule,670.76,2823.29,
Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.6,,,,,,,fee schedule,670.76,2823.29,
Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1646.92,,,,,,,fee schedule,670.76,2823.29,APC
Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1568.49,,,,,,,fee schedule,670.76,2823.29,APC
Insert/place heart catheter,93503,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2823.29,,,,,,,fee schedule,670.76,2823.29,APC
Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2810.23,,,,,,,fee schedule,1842.39,5663.03,
Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2300.17,,,,,,,fee schedule,1842.39,5663.03,
Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1842.39,,,,,,,fee schedule,1842.39,5663.03,
Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3231.76,,,,,,,fee schedule,1842.39,5663.03,
Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3303.43,,,,,,,fee schedule,1842.39,5663.03,APC
Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3146.13,,,,,,,fee schedule,1842.39,5663.03,APC
Biopsy of heart lining,93505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5663.03,,,,,,,fee schedule,1842.39,5663.03,APC
Inject congenital card cath,93563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,909.21,,,,,,,fee schedule,596.08,1045.59,
Inject congenital card cath,93563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,744.19,,,,,,,fee schedule,596.08,1045.59,
Inject congenital card cath,93563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,596.08,,,,,,,fee schedule,596.08,1045.59,
Inject congenital card cath,93563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1045.59,,,,,,,fee schedule,596.08,1045.59,
Inject hrt congntl art/grft,93564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.21,,,,,,,fee schedule,25.71,45.09,
Inject hrt congntl art/grft,93564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.09,,,,,,,fee schedule,25.71,45.09,
Inject hrt congntl art/grft,93564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.71,,,,,,,fee schedule,25.71,45.09,
Inject hrt congntl art/grft,93564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.09,,,,,,,fee schedule,25.71,45.09,
Inject l ventr/atrial angio,93565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,686.81,,,,,,,fee schedule,450.27,789.83,
Inject l ventr/atrial angio,93565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,562.15,,,,,,,fee schedule,450.27,789.83,
Inject l ventr/atrial angio,93565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,450.27,,,,,,,fee schedule,450.27,789.83,
Inject l ventr/atrial angio,93565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,789.83,,,,,,,fee schedule,450.27,789.83,
Inject r ventr/atrial angio,93566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,911.34,,,,,,,fee schedule,597.47,1048.04,
Inject r ventr/atrial angio,93566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,745.93,,,,,,,fee schedule,597.47,1048.04,
Inject r ventr/atrial angio,93566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,597.47,,,,,,,fee schedule,597.47,1048.04,
Inject r ventr/atrial angio,93566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1048.04,,,,,,,fee schedule,597.47,1048.04,
Inject suprvlv aortography,93567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,487.43,,,,,,,fee schedule,319.56,560.54,
Inject suprvlv aortography,93567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,398.96,,,,,,,fee schedule,319.56,560.54,
Inject suprvlv aortography,93567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,319.56,,,,,,,fee schedule,319.56,560.54,
Inject suprvlv aortography,93567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,560.54,,,,,,,fee schedule,319.56,560.54,
Inject pulm art hrt cath,93568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,933.48,,,,,,,fee schedule,611.99,1073.5,
Inject pulm art hrt cath,93568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,764.05,,,,,,,fee schedule,611.99,1073.5,
Inject pulm art hrt cath,93568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,611.99,,,,,,,fee schedule,611.99,1073.5,
Inject pulm art hrt cath,93568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1073.5,,,,,,,fee schedule,611.99,1073.5,
Heart flow reserve measure,93571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6830.38,,,,,,,fee schedule,4478,7854.94,
Heart flow reserve measure,93571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5590.67,,,,,,,fee schedule,4478,7854.94,
Heart flow reserve measure,93571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4478,,,,,,,fee schedule,4478,7854.94,
Heart flow reserve measure,93571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7854.94,,,,,,,fee schedule,4478,7854.94,
Heart flow reserve measure,93572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5089.46,,,,,,,fee schedule,3336.65,5852.88,
Heart flow reserve measure,93572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4165.72,,,,,,,fee schedule,3336.65,5852.88,
Heart flow reserve measure,93572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3336.65,,,,,,,fee schedule,3336.65,5852.88,
Heart flow reserve measure,93572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5852.88,,,,,,,fee schedule,3336.65,5852.88,
Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13114.01,,,,,,,fee schedule,8597.54,32878.29,
Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10733.82,,,,,,,fee schedule,8597.54,32878.29,
Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8597.54,,,,,,,fee schedule,8597.54,32878.29,
Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15081.11,,,,,,,fee schedule,8597.54,32878.29,
Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,8597.54,32878.29,APC
Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,8597.54,32878.29,APC
Transcath closure of asd,93580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,8597.54,32878.29,APC
Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22107.39,,,,,,,fee schedule,14493.6,32878.29,
Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18094.9,,,,,,,fee schedule,14493.6,32878.29,
Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14493.6,,,,,,,fee schedule,14493.6,32878.29,
Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25423.5,,,,,,,fee schedule,14493.6,32878.29,
Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,14493.6,32878.29,APC
Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,14493.6,32878.29,APC
Transcath closure of vsd,93581,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,14493.6,32878.29,APC
Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5351.85,,,,,,,fee schedule,3508.67,32878.29,
Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4380.49,,,,,,,fee schedule,3508.67,32878.29,
Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3508.67,,,,,,,fee schedule,3508.67,32878.29,
Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6154.63,,,,,,,fee schedule,3508.67,32878.29,
Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,3508.67,32878.29,APC
Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,3508.67,32878.29,APC
Perq transcath closure pda,93582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,3508.67,32878.29,APC
Vngrph chd anom/persist svc,93584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.42,,,,,,,fee schedule,16.67,29.23,
Vngrph chd anom/persist svc,93584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.81,,,,,,,fee schedule,16.67,29.23,
Vngrph chd anom/persist svc,93584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.67,,,,,,,fee schedule,16.67,29.23,
Vngrph chd anom/persist svc,93584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.23,,,,,,,fee schedule,16.67,29.23,
Vngrph chd azygs/hemiazygs,93585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.64,,,,,,,fee schedule,15.5,27.19,
Vngrph chd azygs/hemiazygs,93585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.35,,,,,,,fee schedule,15.5,27.19,
Vngrph chd azygs/hemiazygs,93585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.5,,,,,,,fee schedule,15.5,27.19,
Vngrph chd azygs/hemiazygs,93585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.19,,,,,,,fee schedule,15.5,27.19,
Vngrph chd coronary sinus,93586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.14,,,,,,,fee schedule,19.76,34.66,
Vngrph chd coronary sinus,93586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.67,,,,,,,fee schedule,19.76,34.66,
Vngrph chd coronary sinus,93586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.76,,,,,,,fee schedule,19.76,34.66,
Vngrph chd coronary sinus,93586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.66,,,,,,,fee schedule,19.76,34.66,
Vngrph chd vnvn cltrl at/abv,93587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.33,,,,,,,fee schedule,29.06,50.98,
Vngrph chd vnvn cltrl at/abv,93587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.28,,,,,,,fee schedule,29.06,50.98,
Vngrph chd vnvn cltrl at/abv,93587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.06,,,,,,,fee schedule,29.06,50.98,
Vngrph chd vnvn cltrl at/abv,93587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.98,,,,,,,fee schedule,29.06,50.98,
Vngrph chd vnvn cltrl below,93588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.93,,,,,,,fee schedule,29.46,51.67,
Vngrph chd vnvn cltrl below,93588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.78,,,,,,,fee schedule,29.46,51.67,
Vngrph chd vnvn cltrl below,93588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.46,,,,,,,fee schedule,29.46,51.67,
Vngrph chd vnvn cltrl below,93588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.67,,,,,,,fee schedule,29.46,51.67,
Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24163.47,,,,,,,fee schedule,15841.57,32878.29,
Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19777.8,,,,,,,fee schedule,15841.57,32878.29,
Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15841.57,,,,,,,fee schedule,15841.57,32878.29,
Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27787.99,,,,,,,fee schedule,15841.57,32878.29,
Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,15841.57,32878.29,APC
Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,15841.57,32878.29,APC
Perq transcath cls mitral,93590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,15841.57,32878.29,APC
Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24163.47,,,,,,,fee schedule,15841.57,32878.29,
Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19777.8,,,,,,,fee schedule,15841.57,32878.29,
Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15841.57,,,,,,,fee schedule,15841.57,32878.29,
Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27787.99,,,,,,,fee schedule,15841.57,32878.29,
Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,15841.57,32878.29,APC
Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,15841.57,32878.29,APC
Perq transcath cls aortic,93591,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,15841.57,32878.29,APC
Perq transcath closure each,93592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,276.33,,,,,,,fee schedule,181.16,317.78,
Perq transcath closure each,93592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,226.18,,,,,,,fee schedule,181.16,317.78,
Perq transcath closure each,93592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,181.16,,,,,,,fee schedule,181.16,317.78,
Perq transcath closure each,93592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,317.78,,,,,,,fee schedule,181.16,317.78,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5753.36,,,,,,,fee schedule,3230.27,6616.36,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4709.13,,,,,,,fee schedule,3230.27,6616.36,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.9,,,,,,,fee schedule,3230.27,6616.36,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6616.36,,,,,,,fee schedule,3230.27,6616.36,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,6616.36,APC
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,6616.36,APC
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,6616.36,APC
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5753.36,,,,,,,fee schedule,3230.27,6616.36,
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4709.13,,,,,,,fee schedule,3230.27,6616.36,
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.9,,,,,,,fee schedule,3230.27,6616.36,
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6616.36,,,,,,,fee schedule,3230.27,6616.36,
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,6616.36,APC
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,6616.36,APC
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,6616.36,APC
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5753.36,,,,,,,fee schedule,3230.27,6616.36,
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4709.13,,,,,,,fee schedule,3230.27,6616.36,
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.9,,,,,,,fee schedule,3230.27,6616.36,
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6616.36,,,,,,,fee schedule,3230.27,6616.36,
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,6616.36,APC
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,6616.36,APC
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,6616.36,APC
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5753.36,,,,,,,fee schedule,3230.27,6616.36,
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4709.13,,,,,,,fee schedule,3230.27,6616.36,
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.9,,,,,,,fee schedule,3230.27,6616.36,
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6616.36,,,,,,,fee schedule,3230.27,6616.36,
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,6616.36,APC
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,6616.36,APC
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,6616.36,APC
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5753.36,,,,,,,fee schedule,3230.27,6616.36,
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4709.13,,,,,,,fee schedule,3230.27,6616.36,
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3771.9,,,,,,,fee schedule,3230.27,6616.36,
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6616.36,,,,,,,fee schedule,3230.27,6616.36,
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3391.79,,,,,,,fee schedule,3230.27,6616.36,APC
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3230.27,,,,,,,fee schedule,3230.27,6616.36,APC
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5814.49,,,,,,,fee schedule,3230.27,6616.36,APC
Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.34,,,,,,,fee schedule,148.39,13988.91,
Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.26,,,,,,,fee schedule,148.39,13988.91,
Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.39,,,,,,,fee schedule,148.39,13988.91,
Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.29,,,,,,,fee schedule,148.39,13988.91,
Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8160.2,,,,,,,fee schedule,148.39,13988.91,APC
Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7771.62,,,,,,,fee schedule,148.39,13988.91,APC
Bundle of His recording,93600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13988.91,,,,,,,fee schedule,148.39,13988.91,APC
Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.35,,,,,,,fee schedule,84.15,13988.91,
Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.05,,,,,,,fee schedule,84.15,13988.91,
Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.15,,,,,,,fee schedule,84.15,13988.91,
Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.6,,,,,,,fee schedule,84.15,13988.91,
Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8160.2,,,,,,,fee schedule,84.15,13988.91,APC
Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7771.62,,,,,,,fee schedule,84.15,13988.91,APC
Intra-atrial recording,93602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13988.91,,,,,,,fee schedule,84.15,13988.91,APC
Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194,,,,,,,fee schedule,127.19,2183.69,
Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.79,,,,,,,fee schedule,127.19,2183.69,
Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.19,,,,,,,fee schedule,127.19,2183.69,
Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,223.1,,,,,,,fee schedule,127.19,2183.69,
Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1273.82,,,,,,,fee schedule,127.19,2183.69,APC
Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1213.16,,,,,,,fee schedule,127.19,2183.69,APC
Right ventricular recording,93603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2183.69,,,,,,,fee schedule,127.19,2183.69,APC
Map tachycardia add-on,93609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3084.11,,,,,,,fee schedule,2021.94,3546.73,
Map tachycardia add-on,93609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2524.34,,,,,,,fee schedule,2021.94,3546.73,
Map tachycardia add-on,93609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2021.94,,,,,,,fee schedule,2021.94,3546.73,
Map tachycardia add-on,93609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3546.73,,,,,,,fee schedule,2021.94,3546.73,
Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.77,,,,,,,fee schedule,102.12,13988.91,
Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.5,,,,,,,fee schedule,102.12,13988.91,
Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.12,,,,,,,fee schedule,102.12,13988.91,
Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.14,,,,,,,fee schedule,102.12,13988.91,
Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8160.2,,,,,,,fee schedule,102.12,13988.91,APC
Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7771.62,,,,,,,fee schedule,102.12,13988.91,APC
Intra-atrial pacing,93610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13988.91,,,,,,,fee schedule,102.12,13988.91,APC
Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,180.3,,,,,,,fee schedule,118.2,13988.91,
Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.58,,,,,,,fee schedule,118.2,13988.91,
Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.2,,,,,,,fee schedule,118.2,13988.91,
Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,207.35,,,,,,,fee schedule,118.2,13988.91,
Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8160.2,,,,,,,fee schedule,118.2,13988.91,APC
Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7771.62,,,,,,,fee schedule,118.2,13988.91,APC
Intraventricular pacing,93612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13988.91,,,,,,,fee schedule,118.2,13988.91,APC
Electrophys map 3d add-on,93613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6545.24,,,,,,,fee schedule,4291.06,7527.03,
Electrophys map 3d add-on,93613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5357.28,,,,,,,fee schedule,4291.06,7527.03,
Electrophys map 3d add-on,93613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4291.06,,,,,,,fee schedule,4291.06,7527.03,
Electrophys map 3d add-on,93613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7527.03,,,,,,,fee schedule,4291.06,7527.03,
Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.43,,,,,,,fee schedule,18.64,2183.69,
Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.27,,,,,,,fee schedule,18.64,2183.69,
Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.64,,,,,,,fee schedule,18.64,2183.69,
Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.69,,,,,,,fee schedule,18.64,2183.69,
Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1273.82,,,,,,,fee schedule,18.64,2183.69,APC
Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1213.16,,,,,,,fee schedule,18.64,2183.69,APC
Esophageal recording,93615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2183.69,,,,,,,fee schedule,18.64,2183.69,APC
Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.95,,,,,,,fee schedule,32.75,2183.69,
Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.88,,,,,,,fee schedule,32.75,2183.69,
Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.75,,,,,,,fee schedule,32.75,2183.69,
Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.44,,,,,,,fee schedule,32.75,2183.69,
Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1273.82,,,,,,,fee schedule,32.75,2183.69,APC
Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1213.16,,,,,,,fee schedule,32.75,2183.69,APC
Esophageal recording,93616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2183.69,,,,,,,fee schedule,32.75,2183.69,APC
Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,420.35,,,,,,,fee schedule,275.58,2183.69,
Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,344.06,,,,,,,fee schedule,275.58,2183.69,
Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,275.58,,,,,,,fee schedule,275.58,2183.69,
Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,483.4,,,,,,,fee schedule,275.58,2183.69,
Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1273.82,,,,,,,fee schedule,275.58,2183.69,APC
Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1213.16,,,,,,,fee schedule,275.58,2183.69,APC
Heart rhythm pacing,93618,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2183.69,,,,,,,fee schedule,275.58,2183.69,APC
Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,839.74,,,,,,,fee schedule,550.53,13988.91,
Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,687.33,,,,,,,fee schedule,550.53,13988.91,
Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,550.53,,,,,,,fee schedule,550.53,13988.91,
Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,965.7,,,,,,,fee schedule,550.53,13988.91,
Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8160.2,,,,,,,fee schedule,550.53,13988.91,APC
Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7771.62,,,,,,,fee schedule,550.53,13988.91,APC
Electrophysiology evaluation,93619,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13988.91,,,,,,,fee schedule,550.53,13988.91,APC
Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9169.4,,,,,,,fee schedule,6011.46,13988.91,
Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7505.15,,,,,,,fee schedule,6011.46,13988.91,
Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6011.46,,,,,,,fee schedule,6011.46,13988.91,
Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10544.81,,,,,,,fee schedule,6011.46,13988.91,
Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8160.2,,,,,,,fee schedule,6011.46,13988.91,APC
Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7771.62,,,,,,,fee schedule,6011.46,13988.91,APC
Electrophysiology evaluation,93620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13988.91,,,,,,,fee schedule,6011.46,13988.91,APC
Electrophysiology evaluation,93621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7962.91,,,,,,,fee schedule,5220.48,9157.35,
Electrophysiology evaluation,93621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6517.64,,,,,,,fee schedule,5220.48,9157.35,
Electrophysiology evaluation,93621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5220.48,,,,,,,fee schedule,5220.48,9157.35,
Electrophysiology evaluation,93621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9157.35,,,,,,,fee schedule,5220.48,9157.35,
Electrophysiology evaluation,93622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.62,,,,,,,fee schedule,107.27,188.16,
Electrophysiology evaluation,93622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.92,,,,,,,fee schedule,107.27,188.16,
Electrophysiology evaluation,93622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.27,,,,,,,fee schedule,107.27,188.16,
Electrophysiology evaluation,93622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.16,,,,,,,fee schedule,107.27,188.16,
Stimulation pacing heart,93623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4368.32,,,,,,,fee schedule,2863.87,5023.57,
Stimulation pacing heart,93623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3575.47,,,,,,,fee schedule,2863.87,5023.57,
Stimulation pacing heart,93623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2863.87,,,,,,,fee schedule,2863.87,5023.57,
Stimulation pacing heart,93623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5023.57,,,,,,,fee schedule,2863.87,5023.57,
Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194,,,,,,,fee schedule,127.19,13988.91,
Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.79,,,,,,,fee schedule,127.19,13988.91,
Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.19,,,,,,,fee schedule,127.19,13988.91,
Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,223.1,,,,,,,fee schedule,127.19,13988.91,
Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8160.2,,,,,,,fee schedule,127.19,13988.91,APC
Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7771.62,,,,,,,fee schedule,127.19,13988.91,APC
Electrophysiologic study,93624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13988.91,,,,,,,fee schedule,127.19,13988.91,APC
Heart pacing mapping,93631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,376.24,,,,,,,fee schedule,246.66,432.68,
Heart pacing mapping,93631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.95,,,,,,,fee schedule,246.66,432.68,
Heart pacing mapping,93631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.66,,,,,,,fee schedule,246.66,432.68,
Heart pacing mapping,93631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,432.68,,,,,,,fee schedule,246.66,432.68,
Evaluation heart device,93640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,766.25,,,,,,,fee schedule,502.35,881.19,
Evaluation heart device,93640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,627.18,,,,,,,fee schedule,502.35,881.19,
Evaluation heart device,93640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,502.35,,,,,,,fee schedule,502.35,881.19,
Evaluation heart device,93640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,881.19,,,,,,,fee schedule,502.35,881.19,
Electrophysiology evaluation,93641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,789.75,,,,,,,fee schedule,517.76,908.21,
Electrophysiology evaluation,93641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,646.41,,,,,,,fee schedule,517.76,908.21,
Electrophysiology evaluation,93641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,517.76,,,,,,,fee schedule,517.76,908.21,
Electrophysiology evaluation,93641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,908.21,,,,,,,fee schedule,517.76,908.21,
Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1754.81,,,,,,,fee schedule,1150.45,2183.69,
Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1436.31,,,,,,,fee schedule,1150.45,2183.69,
Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1150.45,,,,,,,fee schedule,1150.45,2183.69,
Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2018.03,,,,,,,fee schedule,1150.45,2183.69,
Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1273.82,,,,,,,fee schedule,1150.45,2183.69,APC
Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1213.16,,,,,,,fee schedule,1150.45,2183.69,APC
Electrophysiology evaluation,93642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2183.69,,,,,,,fee schedule,1150.45,2183.69,APC
Electrophysiology evaluation,93644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.7,,,,,,,fee schedule,105.35,184.81,
Electrophysiology evaluation,93644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.53,,,,,,,fee schedule,105.35,184.81,
Electrophysiology evaluation,93644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.35,,,,,,,fee schedule,105.35,184.81,
Electrophysiology evaluation,93644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.81,,,,,,,fee schedule,105.35,184.81,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6498.92,,,,,,,fee schedule,4260.69,13988.91,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5319.37,,,,,,,fee schedule,4260.69,13988.91,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4260.69,,,,,,,fee schedule,4260.69,13988.91,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7473.76,,,,,,,fee schedule,4260.69,13988.91,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8160.2,,,,,,,fee schedule,4260.69,13988.91,APC
Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7771.62,,,,,,,fee schedule,4260.69,13988.91,APC
Ablate heart dysrhythm focus,93650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13988.91,,,,,,,fee schedule,4260.69,13988.91,APC
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19304,,,,,,,fee schedule,12655.7,46878.96,
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15800.32,,,,,,,fee schedule,12655.7,46878.96,
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12655.7,,,,,,,fee schedule,12655.7,46878.96,
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22199.6,,,,,,,fee schedule,12655.7,46878.96,
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27346.06,,,,,,,fee schedule,12655.7,46878.96,APC
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26043.87,,,,,,,fee schedule,12655.7,46878.96,APC
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46878.96,,,,,,,fee schedule,12655.7,46878.96,APC
Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24958.42,,,,,,,fee schedule,16362.74,46878.96,
Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20428.47,,,,,,,fee schedule,16362.74,46878.96,
Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16362.74,,,,,,,fee schedule,16362.74,46878.96,
Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28702.18,,,,,,,fee schedule,16362.74,46878.96,
Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27346.06,,,,,,,fee schedule,16362.74,46878.96,APC
Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26043.87,,,,,,,fee schedule,16362.74,46878.96,APC
Ep & ablate ventric tachy,93654,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46878.96,,,,,,,fee schedule,16362.74,46878.96,APC
Ablate arrhythmia add on,93655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5067.32,,,,,,,fee schedule,3322.13,5827.42,
Ablate arrhythmia add on,93655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4147.6,,,,,,,fee schedule,3322.13,5827.42,
Ablate arrhythmia add on,93655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3322.13,,,,,,,fee schedule,3322.13,5827.42,
Ablate arrhythmia add on,93655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5827.42,,,,,,,fee schedule,3322.13,5827.42,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21414.5,,,,,,,fee schedule,14039.35,46878.96,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17527.77,,,,,,,fee schedule,14039.35,46878.96,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14039.35,,,,,,,fee schedule,14039.35,46878.96,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24626.68,,,,,,,fee schedule,14039.35,46878.96,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27346.06,,,,,,,fee schedule,14039.35,46878.96,APC
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26043.87,,,,,,,fee schedule,14039.35,46878.96,APC
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46878.96,,,,,,,fee schedule,14039.35,46878.96,APC
Tx l/r atrial fib addl,93657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,307.69,,,,,,,fee schedule,201.72,353.84,
Tx l/r atrial fib addl,93657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.84,,,,,,,fee schedule,201.72,353.84,
Tx l/r atrial fib addl,93657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.72,,,,,,,fee schedule,201.72,353.84,
Tx l/r atrial fib addl,93657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,353.84,,,,,,,fee schedule,201.72,353.84,
Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,358.88,,,,,,,fee schedule,235.28,669.27,
Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,293.74,,,,,,,fee schedule,235.28,669.27,
Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.28,,,,,,,fee schedule,235.28,669.27,
Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,412.71,,,,,,,fee schedule,235.28,669.27,
Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,235.28,669.27,APC
Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,235.28,669.27,APC
Tilt table evaluation,93660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,235.28,669.27,APC
Intracardiac Ecg (Ice),93662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2850.73,,,,,,,fee schedule,1868.94,3278.34,
Intracardiac Ecg (Ice),93662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2333.32,,,,,,,fee schedule,1868.94,3278.34,
Intracardiac Ecg (Ice),93662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1868.94,,,,,,,fee schedule,1868.94,3278.34,
Intracardiac Ecg (Ice),93662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3278.34,,,,,,,fee schedule,1868.94,3278.34,
Peripheral Vascular Rehab,93668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.91,,,,,,,fee schedule,34.69,105.8,
Peripheral Vascular Rehab,93668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.31,,,,,,,fee schedule,34.69,105.8,
Peripheral Vascular Rehab,93668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.69,,,,,,,fee schedule,34.69,105.8,
Peripheral Vascular Rehab,93668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.85,,,,,,,fee schedule,34.69,105.8,
Peripheral Vascular Rehab,93668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,34.69,105.8,APC
Peripheral Vascular Rehab,93668,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,34.69,105.8,APC
Peripheral Vascular Rehab,93668,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,34.69,105.8,APC
Bioimpedance cv analysis,93701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.98,,,,,,,fee schedule,32.11,238.63,
Bioimpedance cv analysis,93701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.09,,,,,,,fee schedule,32.11,238.63,
Bioimpedance cv analysis,93701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.11,,,,,,,fee schedule,32.11,238.63,
Bioimpedance cv analysis,93701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.33,,,,,,,fee schedule,32.11,238.63,
Bioimpedance cv analysis,93701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,32.11,238.63,APC
Bioimpedance cv analysis,93701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,32.11,238.63,APC
Bioimpedance cv analysis,93701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,32.11,238.63,APC
Bis xtracell fluid analysis,93702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,341.95,,,,,,,fee schedule,128.21,393.24,
Bis xtracell fluid analysis,93702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.89,,,,,,,fee schedule,128.21,393.24,
Bis xtracell fluid analysis,93702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.18,,,,,,,fee schedule,128.21,393.24,
Bis xtracell fluid analysis,93702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,393.24,,,,,,,fee schedule,128.21,393.24,
Bis xtracell fluid analysis,93702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,393.24,APC
Bis xtracell fluid analysis,93702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,393.24,APC
Bis xtracell fluid analysis,93702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,393.24,APC
Analyze pacemaker system,93724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.39,,,,,,,fee schedule,50.74,550.86,
Analyze pacemaker system,93724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.34,,,,,,,fee schedule,50.74,550.86,
Analyze pacemaker system,93724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.74,,,,,,,fee schedule,50.74,550.86,
Analyze pacemaker system,93724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89,,,,,,,fee schedule,50.74,550.86,
Analyze pacemaker system,93724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,50.74,550.86,APC
Analyze pacemaker system,93724,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,50.74,550.86,APC
Analyze pacemaker system,93724,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,50.74,550.86,APC
Temperature gradient studies,93740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.93,,,,,,,fee schedule,2.58,230.78,
Temperature gradient studies,93740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.22,,,,,,,fee schedule,2.58,230.78,
Temperature gradient studies,93740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.58,,,,,,,fee schedule,2.58,230.78,
Temperature gradient studies,93740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.52,,,,,,,fee schedule,2.58,230.78,
Temperature gradient studies,93740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,2.58,230.78,APC
Temperature gradient studies,93740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,2.58,230.78,APC
Temperature gradient studies,93740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,2.58,230.78,APC
Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,377.83,,,,,,,fee schedule,247.71,550.86,
Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,309.25,,,,,,,fee schedule,247.71,550.86,
Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,247.71,,,,,,,fee schedule,247.71,550.86,
Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,434.5,,,,,,,fee schedule,247.71,550.86,
Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.33,,,,,,,fee schedule,247.71,550.86,APC
Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.03,,,,,,,fee schedule,247.71,550.86,APC
Set-up cardiovert-defibrill,93745,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.86,,,,,,,fee schedule,247.71,550.86,APC
Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.36,,,,,,,fee schedule,94.73,187.86,
Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.71,,,,,,,fee schedule,94.73,187.86,
Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.1,,,,,,,fee schedule,94.73,187.86,
Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.86,,,,,,,fee schedule,94.73,187.86,
Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,187.86,APC
Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,187.86,APC
Interrogation vad in person,93750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,187.86,APC
Measure venous pressure,93770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.96,,,,,,,fee schedule,1.28,2.25,
Measure venous pressure,93770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.28,2.25,
Measure venous pressure,93770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.28,,,,,,,fee schedule,1.28,2.25,
Measure venous pressure,93770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.25,,,,,,,fee schedule,1.28,2.25,
Ambulatory BP monitoring,93784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.94,,,,,,,fee schedule,97.65,171.28,
Ambulatory BP monitoring,93784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.91,,,,,,,fee schedule,97.65,171.28,
Ambulatory BP monitoring,93784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.65,,,,,,,fee schedule,97.65,171.28,
Ambulatory BP monitoring,93784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.28,,,,,,,fee schedule,97.65,171.28,
Ambulatory BP recording,93786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.3,,,,,,,fee schedule,53.96,238.63,
Ambulatory BP recording,93786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.36,,,,,,,fee schedule,53.96,238.63,
Ambulatory BP recording,93786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.96,,,,,,,fee schedule,53.96,238.63,
Ambulatory BP recording,93786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.65,,,,,,,fee schedule,53.96,238.63,
Ambulatory BP recording,93786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.96,238.63,APC
Ambulatory BP recording,93786,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.96,238.63,APC
Ambulatory BP recording,93786,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.96,238.63,APC
Ambulatory BP analysis,93788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.69,,,,,,,fee schedule,9.63,238.63,
Ambulatory BP analysis,93788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.02,,,,,,,fee schedule,9.63,238.63,
Ambulatory BP analysis,93788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.63,,,,,,,fee schedule,9.63,238.63,
Ambulatory BP analysis,93788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.89,,,,,,,fee schedule,9.63,238.63,
Ambulatory BP analysis,93788,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,9.63,238.63,APC
Ambulatory BP analysis,93788,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,9.63,238.63,APC
Ambulatory BP analysis,93788,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,9.63,238.63,APC
Review/report BP recording,93790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.69,,,,,,,fee schedule,8.98,15.74,
Review/report BP recording,93790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.21,,,,,,,fee schedule,8.98,15.74,
Review/report BP recording,93790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.98,,,,,,,fee schedule,8.98,15.74,
Review/report BP recording,93790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.74,,,,,,,fee schedule,8.98,15.74,
Pt/caregiver trainj home inr,93792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.41,,,,,,,fee schedule,97.3,170.67,
Pt/caregiver trainj home inr,93792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.47,,,,,,,fee schedule,97.3,170.67,
Pt/caregiver trainj home inr,93792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.3,,,,,,,fee schedule,97.3,170.67,
Pt/caregiver trainj home inr,93792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.67,,,,,,,fee schedule,97.3,170.67,
Anticoag mgmt pt warfarin,93793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.74,,,,,,,fee schedule,9.66,16.95,
Anticoag mgmt pt warfarin,93793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.06,,,,,,,fee schedule,9.66,16.95,
Anticoag mgmt pt warfarin,93793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.66,,,,,,,fee schedule,9.66,16.95,
Anticoag mgmt pt warfarin,93793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.95,,,,,,,fee schedule,9.66,16.95,
Cardiac rehab,93797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.84,,,,,,,fee schedule,108.07,231.2,
Cardiac rehab,93797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.92,,,,,,,fee schedule,108.07,231.2,
Cardiac rehab,93797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.07,,,,,,,fee schedule,108.07,231.2,
Cardiac rehab,93797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.57,,,,,,,fee schedule,108.07,231.2,
Cardiac rehab,93797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.87,,,,,,,fee schedule,108.07,231.2,APC
Cardiac rehab,93797,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.44,,,,,,,fee schedule,108.07,231.2,APC
Cardiac rehab,93797,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.2,,,,,,,fee schedule,108.07,231.2,APC
Cardiac rehab/monitor,93798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.84,,,,,,,fee schedule,108.07,231.2,
Cardiac rehab/monitor,93798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.92,,,,,,,fee schedule,108.07,231.2,
Cardiac rehab/monitor,93798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.07,,,,,,,fee schedule,108.07,231.2,
Cardiac rehab/monitor,93798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.57,,,,,,,fee schedule,108.07,231.2,
Cardiac rehab/monitor,93798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.87,,,,,,,fee schedule,108.07,231.2,APC
Cardiac rehab/monitor,93798,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.44,,,,,,,fee schedule,108.07,231.2,APC
Cardiac rehab/monitor,93798,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.2,,,,,,,fee schedule,108.07,231.2,APC
Cardiovascular procedure,93799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Cardiovascular procedure,93799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Cardiovascular procedure,93799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Extracranial bilat study,93880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Extracranial bilat study,93880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Extracranial bilat study,93880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Extracranial uni/ltd study,93882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,287.08,,,,,,,fee schedule,104.17,330.14,
Extracranial uni/ltd study,93882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.97,,,,,,,fee schedule,104.17,330.14,
Extracranial uni/ltd study,93882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,188.21,,,,,,,fee schedule,104.17,330.14,
Extracranial uni/ltd study,93882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,330.14,,,,,,,fee schedule,104.17,330.14,
Extracranial uni/ltd study,93882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,330.14,APC
Extracranial uni/ltd study,93882,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,330.14,APC
Extracranial uni/ltd study,93882,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,330.14,APC
Intracranial complete study,93886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,424.57,,,,,,,fee schedule,237.74,488.26,
Intracranial complete study,93886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,347.51,,,,,,,fee schedule,237.74,488.26,
Intracranial complete study,93886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,278.35,,,,,,,fee schedule,237.74,488.26,
Intracranial complete study,93886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,488.26,,,,,,,fee schedule,237.74,488.26,
Intracranial complete study,93886,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,488.26,APC
Intracranial complete study,93886,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,488.26,APC
Intracranial complete study,93886,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,488.26,APC
Intracranial limited study,93888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.6,,,,,,,fee schedule,104.17,431.94,
Intracranial limited study,93888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.43,,,,,,,fee schedule,104.17,431.94,
Intracranial limited study,93888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.24,,,,,,,fee schedule,104.17,431.94,
Intracranial limited study,93888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.94,,,,,,,fee schedule,104.17,431.94,
Intracranial limited study,93888,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,431.94,APC
Intracranial limited study,93888,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,431.94,APC
Intracranial limited study,93888,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,431.94,APC
Tcd emboli detect w/o inj,93892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,744.67,,,,,,,fee schedule,104.17,856.37,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,609.51,,,,,,,fee schedule,104.17,856.37,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,488.21,,,,,,,fee schedule,104.17,856.37,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,856.37,,,,,,,fee schedule,104.17,856.37,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,856.37,APC
Tcd emboli detect w/o inj,93892,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,856.37,APC
Tcd emboli detect w/o inj,93892,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,856.37,APC
Tcd emboli detect w/inj,93893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,793.68,,,,,,,fee schedule,104.17,912.73,
Tcd emboli detect w/inj,93893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,649.63,,,,,,,fee schedule,104.17,912.73,
Tcd emboli detect w/inj,93893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,520.34,,,,,,,fee schedule,104.17,912.73,
Tcd emboli detect w/inj,93893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,912.73,,,,,,,fee schedule,104.17,912.73,
Tcd emboli detect w/inj,93893,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,912.73,APC
Tcd emboli detect w/inj,93893,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,912.73,APC
Tcd emboli detect w/inj,93893,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,912.73,APC
Vsrctv std tcd icr art compl,93896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.93,,,,,,,fee schedule,155.33,272.47,
Vsrctv std tcd icr art compl,93896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.93,,,,,,,fee schedule,155.33,272.47,
Vsrctv std tcd icr art compl,93896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,155.33,,,,,,,fee schedule,155.33,272.47,
Vsrctv std tcd icr art compl,93896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,272.47,,,,,,,fee schedule,155.33,272.47,
Emboli detcj wo iv mbubb njx,93897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,313.61,,,,,,,fee schedule,205.6,360.65,
Emboli detcj wo iv mbubb njx,93897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,256.69,,,,,,,fee schedule,205.6,360.65,
Emboli detcj wo iv mbubb njx,93897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,205.6,,,,,,,fee schedule,205.6,360.65,
Emboli detcj wo iv mbubb njx,93897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,360.65,,,,,,,fee schedule,205.6,360.65,
Ven-artl shunt det mbubb njx,93898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.19,,,,,,,fee schedule,212.54,372.82,
Ven-artl shunt det mbubb njx,93898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.35,,,,,,,fee schedule,212.54,372.82,
Ven-artl shunt det mbubb njx,93898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.54,,,,,,,fee schedule,212.54,372.82,
Ven-artl shunt det mbubb njx,93898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,372.82,,,,,,,fee schedule,212.54,372.82,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.41,,,,,,,fee schedule,132.57,254.62,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.22,,,,,,,fee schedule,132.57,254.62,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.16,,,,,,,fee schedule,132.57,254.62,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,254.62,,,,,,,fee schedule,132.57,254.62,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,254.62,APC
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,254.62,APC
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,254.62,APC
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,265.09,,,,,,,fee schedule,173.79,387.26,
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,216.98,,,,,,,fee schedule,173.79,387.26,
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.79,,,,,,,fee schedule,173.79,387.26,
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,304.85,,,,,,,fee schedule,173.79,387.26,
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,173.79,387.26,APC
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,173.79,387.26,APC
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,173.79,387.26,APC
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.69,,,,,,,fee schedule,159.11,387.26,
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.64,,,,,,,fee schedule,159.11,387.26,
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.11,,,,,,,fee schedule,159.11,387.26,
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,279.09,,,,,,,fee schedule,159.11,387.26,
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,159.11,387.26,APC
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,159.11,387.26,APC
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,159.11,387.26,APC
Lower extremity study,93925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,371.17,,,,,,,fee schedule,237.74,427.94,
Lower extremity study,93925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,303.8,,,,,,,fee schedule,237.74,427.94,
Lower extremity study,93925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,243.34,,,,,,,fee schedule,237.74,427.94,
Lower extremity study,93925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,426.85,,,,,,,fee schedule,237.74,427.94,
Lower extremity study,93925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Lower extremity study,93925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Lower extremity study,93925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Lower extremity study,93926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.95,,,,,,,fee schedule,104.17,456.49,
Lower extremity study,93926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.9,,,,,,,fee schedule,104.17,456.49,
Lower extremity study,93926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.24,,,,,,,fee schedule,104.17,456.49,
Lower extremity study,93926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,456.49,,,,,,,fee schedule,104.17,456.49,
Lower extremity study,93926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,456.49,APC
Lower extremity study,93926,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,456.49,APC
Lower extremity study,93926,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,456.49,APC
Upper extremity study,93930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,320.39,,,,,,,fee schedule,210.05,427.94,
Upper extremity study,93930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.24,,,,,,,fee schedule,210.05,427.94,
Upper extremity study,93930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,210.05,,,,,,,fee schedule,210.05,427.94,
Upper extremity study,93930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,368.45,,,,,,,fee schedule,210.05,427.94,
Upper extremity study,93930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,210.05,427.94,APC
Upper extremity study,93930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,210.05,427.94,APC
Upper extremity study,93930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,210.05,427.94,APC
Upper extremity study,93931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,278.95,,,,,,,fee schedule,104.17,320.79,
Upper extremity study,93931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,228.32,,,,,,,fee schedule,104.17,320.79,
Upper extremity study,93931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.88,,,,,,,fee schedule,104.17,320.79,
Upper extremity study,93931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,320.79,,,,,,,fee schedule,104.17,320.79,
Upper extremity study,93931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,320.79,APC
Upper extremity study,93931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,320.79,APC
Upper extremity study,93931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,320.79,APC
Extremity study,93970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Extremity study,93970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Extremity study,93970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Extremity study,93971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Extremity study,93971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Extremity study,93971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Vascular study,93975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Vascular study,93975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Vascular study,93975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Vascular study,93976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,431.98,,,,,,,fee schedule,104.17,496.78,
Vascular study,93976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.58,,,,,,,fee schedule,104.17,496.78,
Vascular study,93976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.21,,,,,,,fee schedule,104.17,496.78,
Vascular study,93976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.78,,,,,,,fee schedule,104.17,496.78,
Vascular study,93976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,496.78,APC
Vascular study,93976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,496.78,APC
Vascular study,93976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,496.78,APC
Vascular study,93978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,427.94,APC
Vascular study,93978,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,427.94,APC
Vascular study,93978,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,427.94,APC
Vascular study,93979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,313.46,,,,,,,fee schedule,104.17,360.48,
Vascular study,93979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,256.57,,,,,,,fee schedule,104.17,360.48,
Vascular study,93979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,205.5,,,,,,,fee schedule,104.17,360.48,
Vascular study,93979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,360.48,,,,,,,fee schedule,104.17,360.48,
Vascular study,93979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,360.48,APC
Vascular study,93979,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,360.48,APC
Vascular study,93979,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,360.48,APC
Penile vascular study,93980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.18,,,,,,,fee schedule,104.17,308.41,
Penile vascular study,93980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,219.51,,,,,,,fee schedule,104.17,308.41,
Penile vascular study,93980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.82,,,,,,,fee schedule,104.17,308.41,
Penile vascular study,93980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.41,,,,,,,fee schedule,104.17,308.41,
Penile vascular study,93980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,308.41,APC
Penile vascular study,93980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,308.41,APC
Penile vascular study,93980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,308.41,APC
Penile vascular study,93981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.06,,,,,,,fee schedule,93.79,187.51,
Penile vascular study,93981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.09,,,,,,,fee schedule,93.79,187.51,
Penile vascular study,93981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.79,,,,,,,fee schedule,93.79,187.51,
Penile vascular study,93981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.52,,,,,,,fee schedule,93.79,187.51,
Penile vascular study,93981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,93.79,187.51,APC
Penile vascular study,93981,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,93.79,187.51,APC
Penile vascular study,93981,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,93.79,187.51,APC
Dup-scan hemo compl bi std,93985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,452.68,,,,,,,fee schedule,237.74,520.58,
Dup-scan hemo compl bi std,93985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,370.52,,,,,,,fee schedule,237.74,520.58,
Dup-scan hemo compl bi std,93985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,296.78,,,,,,,fee schedule,237.74,520.58,
Dup-scan hemo compl bi std,93985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,520.58,,,,,,,fee schedule,237.74,520.58,
Dup-scan hemo compl bi std,93985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,520.58,APC
Dup-scan hemo compl bi std,93985,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,520.58,APC
Dup-scan hemo compl bi std,93985,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,520.58,APC
Dup-scan hemo compl uni std,93986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.73,,,,,,,fee schedule,104.17,250.39,
Dup-scan hemo compl uni std,93986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.21,,,,,,,fee schedule,104.17,250.39,
Dup-scan hemo compl uni std,93986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.74,,,,,,,fee schedule,104.17,250.39,
Dup-scan hemo compl uni std,93986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.39,,,,,,,fee schedule,104.17,250.39,
Dup-scan hemo compl uni std,93986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,250.39,APC
Dup-scan hemo compl uni std,93986,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,250.39,APC
Dup-scan hemo compl uni std,93986,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,250.39,APC
Doppler flow testing,93990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,420.05,,,,,,,fee schedule,104.17,483.06,
Doppler flow testing,93990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,343.81,,,,,,,fee schedule,104.17,483.06,
Doppler flow testing,93990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,275.38,,,,,,,fee schedule,104.17,483.06,
Doppler flow testing,93990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,483.06,,,,,,,fee schedule,104.17,483.06,
Doppler flow testing,93990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,483.06,APC
Doppler flow testing,93990,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,483.06,APC
Doppler flow testing,93990,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,483.06,APC
Noninvas vasc dx study proc,93998,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Noninvas vasc dx study proc,93998,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Noninvas vasc dx study proc,93998,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Vent mgmt inpat init day,94002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,634.05,,,,,,,fee schedule,415.68,1108.02,
Vent mgmt inpat init day,94002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,518.97,,,,,,,fee schedule,415.68,1108.02,
Vent mgmt inpat init day,94002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,415.68,,,,,,,fee schedule,415.68,1108.02,
Vent mgmt inpat init day,94002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,729.16,,,,,,,fee schedule,415.68,1108.02,
Vent mgmt inpat init day,94002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,646.35,,,,,,,fee schedule,415.68,1108.02,APC
Vent mgmt inpat init day,94002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,615.57,,,,,,,fee schedule,415.68,1108.02,APC
Vent mgmt inpat init day,94002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1108.02,,,,,,,fee schedule,415.68,1108.02,APC
Vent mgmt inpat subq day,94003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,634.05,,,,,,,fee schedule,415.68,1108.02,
Vent mgmt inpat subq day,94003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,518.97,,,,,,,fee schedule,415.68,1108.02,
Vent mgmt inpat subq day,94003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,415.68,,,,,,,fee schedule,415.68,1108.02,
Vent mgmt inpat subq day,94003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,729.16,,,,,,,fee schedule,415.68,1108.02,
Vent mgmt inpat subq day,94003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,646.35,,,,,,,fee schedule,415.68,1108.02,APC
Vent mgmt inpat subq day,94003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,615.57,,,,,,,fee schedule,415.68,1108.02,APC
Vent mgmt inpat subq day,94003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1108.02,,,,,,,fee schedule,415.68,1108.02,APC
Vent Mgmt NF per day,94004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.35,,,,,,,fee schedule,20.55,36.05,
Vent Mgmt NF per day,94004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.66,,,,,,,fee schedule,20.55,36.05,
Vent Mgmt NF per day,94004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.55,,,,,,,fee schedule,20.55,36.05,
Vent Mgmt NF per day,94004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.05,,,,,,,fee schedule,20.55,36.05,
Home Vent mgmt Supervision,94005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.88,,,,,,,fee schedule,66.79,117.16,
Home Vent mgmt Supervision,94005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.39,,,,,,,fee schedule,66.79,117.16,
Home Vent mgmt Supervision,94005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.79,,,,,,,fee schedule,66.79,117.16,
Home Vent mgmt Supervision,94005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.16,,,,,,,fee schedule,66.79,117.16,
Breathing capacity test,94010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.29,,,,,,,fee schedule,67.72,387.26,
Breathing capacity test,94010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.54,,,,,,,fee schedule,67.72,387.26,
Breathing capacity test,94010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.72,,,,,,,fee schedule,67.72,387.26,
Breathing capacity test,94010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.78,,,,,,,fee schedule,67.72,387.26,
Breathing capacity test,94010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,67.72,387.26,APC
Breathing capacity test,94010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,67.72,387.26,APC
Breathing capacity test,94010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,67.72,387.26,APC
Spirometry up to 2 yrs old,94011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Spirometry up to 2 yrs old,94011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Spirometry up to 2 yrs old,94011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Spirometry up to 2 yrs old,94011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Spirometry up to 2 yrs old,94011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Spirometry up to 2 yrs old,94011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Spirometry up to 2 yrs old,94011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,621.94,,,,,,,fee schedule,371.82,715.23,
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,509.06,,,,,,,fee schedule,371.82,715.23,
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,407.74,,,,,,,fee schedule,371.82,715.23,
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,715.23,,,,,,,fee schedule,371.82,715.23,
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,715.23,APC
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,715.23,APC
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,715.23,APC
Patient recorded spirometry,94014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.05,,,,,,,fee schedule,61.66,801.21,
Patient recorded spirometry,94014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.98,,,,,,,fee schedule,61.66,801.21,
Patient recorded spirometry,94014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.66,,,,,,,fee schedule,61.66,801.21,
Patient recorded spirometry,94014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.16,,,,,,,fee schedule,61.66,801.21,
Patient recorded spirometry,94014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,61.66,801.21,APC
Patient recorded spirometry,94014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,61.66,801.21,APC
Patient recorded spirometry,94014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,61.66,801.21,APC
Patient recorded spirometry,94015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.21,,,,,,,fee schedule,56.52,387.26,
Patient recorded spirometry,94015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.56,,,,,,,fee schedule,56.52,387.26,
Patient recorded spirometry,94015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.52,,,,,,,fee schedule,56.52,387.26,
Patient recorded spirometry,94015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.14,,,,,,,fee schedule,56.52,387.26,
Patient recorded spirometry,94015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,56.52,387.26,APC
Patient recorded spirometry,94015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,56.52,387.26,APC
Patient recorded spirometry,94015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,56.52,387.26,APC
Review patient spirometry,94016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.64,,,,,,,fee schedule,11.56,43.54,
Review patient spirometry,94016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.44,,,,,,,fee schedule,11.56,43.54,
Review patient spirometry,94016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.56,,,,,,,fee schedule,11.56,43.54,
Review patient spirometry,94016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.29,,,,,,,fee schedule,11.56,43.54,
Review patient spirometry,94016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.4,,,,,,,fee schedule,11.56,43.54,APC
Review patient spirometry,94016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.19,,,,,,,fee schedule,11.56,43.54,APC
Review patient spirometry,94016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.54,,,,,,,fee schedule,11.56,43.54,APC
Evaluation of wheezing,94060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.67,,,,,,,fee schedule,149.92,669.27,
Evaluation of wheezing,94060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.17,,,,,,,fee schedule,149.92,669.27,
Evaluation of wheezing,94060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.92,,,,,,,fee schedule,149.92,669.27,
Evaluation of wheezing,94060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,262.97,,,,,,,fee schedule,149.92,669.27,
Evaluation of wheezing,94060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,149.92,669.27,APC
Evaluation of wheezing,94060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,149.92,669.27,APC
Evaluation of wheezing,94060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,149.92,669.27,APC
Evaluation of wheezing,94070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.21,,,,,,,fee schedule,56.52,669.27,
Evaluation of wheezing,94070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.56,,,,,,,fee schedule,56.52,669.27,
Evaluation of wheezing,94070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.52,,,,,,,fee schedule,56.52,669.27,
Evaluation of wheezing,94070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.14,,,,,,,fee schedule,56.52,669.27,
Evaluation of wheezing,94070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,56.52,669.27,APC
Evaluation of wheezing,94070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,56.52,669.27,APC
Evaluation of wheezing,94070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,56.52,669.27,APC
Vital capacity test,94150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.16,,,,,,,fee schedule,12.56,230.78,
Vital capacity test,94150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.68,,,,,,,fee schedule,12.56,230.78,
Vital capacity test,94150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.56,,,,,,,fee schedule,12.56,230.78,
Vital capacity test,94150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.03,,,,,,,fee schedule,12.56,230.78,
Vital capacity test,94150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,12.56,230.78,APC
Vital capacity test,94150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,12.56,230.78,APC
Vital capacity test,94150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,12.56,230.78,APC
Lung function test (MBC/MVV),94200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.87,,,,,,,fee schedule,36.63,105.8,
Lung function test (MBC/MVV),94200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.73,,,,,,,fee schedule,36.63,105.8,
Lung function test (MBC/MVV),94200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.63,,,,,,,fee schedule,36.63,105.8,
Lung function test (MBC/MVV),94200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.25,,,,,,,fee schedule,36.63,105.8,
Lung function test (MBC/MVV),94200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,36.63,105.8,APC
Lung function test (MBC/MVV),94200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,36.63,105.8,APC
Lung function test (MBC/MVV),94200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,36.63,105.8,APC
Respiratory flow volume loop,94375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.58,,,,,,,fee schedule,44.96,387.26,
Respiratory flow volume loop,94375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.13,,,,,,,fee schedule,44.96,387.26,
Respiratory flow volume loop,94375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.96,,,,,,,fee schedule,44.96,387.26,
Respiratory flow volume loop,94375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.87,,,,,,,fee schedule,44.96,387.26,
Respiratory flow volume loop,94375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,44.96,387.26,APC
Respiratory flow volume loop,94375,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,44.96,387.26,APC
Respiratory flow volume loop,94375,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,44.96,387.26,APC
Hypoxia response curve,94450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.21,,,,,,,fee schedule,89.3,230.78,
Hypoxia response curve,94450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,111.49,,,,,,,fee schedule,89.3,230.78,
Hypoxia response curve,94450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.3,,,,,,,fee schedule,89.3,230.78,
Hypoxia response curve,94450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,156.64,,,,,,,fee schedule,89.3,230.78,
Hypoxia response curve,94450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,89.3,230.78,APC
Hypoxia response curve,94450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,89.3,230.78,APC
Hypoxia response curve,94450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,89.3,230.78,APC
Hast w/report,94452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.51,,,,,,,fee schedule,78.35,238.63,
Hast w/report,94452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.82,,,,,,,fee schedule,78.35,238.63,
Hast w/report,94452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.35,,,,,,,fee schedule,78.35,238.63,
Hast w/report,94452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.44,,,,,,,fee schedule,78.35,238.63,
Hast w/report,94452,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,78.35,238.63,APC
Hast w/report,94452,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,78.35,238.63,APC
Hast w/report,94452,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,78.35,238.63,APC
Hast w/oxygen titrate,94453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,168.52,,,,,,,fee schedule,110.48,238.63,
Hast w/oxygen titrate,94453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.93,,,,,,,fee schedule,110.48,238.63,
Hast w/oxygen titrate,94453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.48,,,,,,,fee schedule,110.48,238.63,
Hast w/oxygen titrate,94453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,193.8,,,,,,,fee schedule,110.48,238.63,
Hast w/oxygen titrate,94453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,110.48,238.63,APC
Hast w/oxygen titrate,94453,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,110.48,238.63,APC
Hast w/oxygen titrate,94453,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,110.48,238.63,APC
Surfactant Admin Thru Tube,94610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.41,,,,,,,fee schedule,158.92,392.74,
Surfactant Admin Thru Tube,94610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.41,,,,,,,fee schedule,158.92,392.74,
Surfactant Admin Thru Tube,94610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.92,,,,,,,fee schedule,158.92,392.74,
Surfactant Admin Thru Tube,94610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.77,,,,,,,fee schedule,158.92,392.74,
Surfactant Admin Thru Tube,94610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,229.1,,,,,,,fee schedule,158.92,392.74,APC
Surfactant Admin Thru Tube,94610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.19,,,,,,,fee schedule,158.92,392.74,APC
Surfactant Admin Thru Tube,94610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.74,,,,,,,fee schedule,158.92,392.74,APC
Exercise tst brncspsm,94617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,286.75,,,,,,,fee schedule,132.57,329.76,
Exercise tst brncspsm,94617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.7,,,,,,,fee schedule,132.57,329.76,
Exercise tst brncspsm,94617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,187.99,,,,,,,fee schedule,132.57,329.76,
Exercise tst brncspsm,94617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,329.76,,,,,,,fee schedule,132.57,329.76,
Exercise tst brncspsm,94617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,329.76,APC
Exercise tst brncspsm,94617,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,329.76,APC
Exercise tst brncspsm,94617,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,329.76,APC
Pulmonary stress testing,94618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,286.75,,,,,,,fee schedule,132.57,329.76,
Pulmonary stress testing,94618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.7,,,,,,,fee schedule,132.57,329.76,
Pulmonary stress testing,94618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,187.99,,,,,,,fee schedule,132.57,329.76,
Pulmonary stress testing,94618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,329.76,,,,,,,fee schedule,132.57,329.76,
Pulmonary stress testing,94618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,329.76,APC
Pulmonary stress testing,94618,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,329.76,APC
Pulmonary stress testing,94618,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,329.76,APC
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.14,,,,,,,fee schedule,58.78,124.36,
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.51,,,,,,,fee schedule,58.78,124.36,
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.9,,,,,,,fee schedule,58.78,124.36,
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.36,,,,,,,fee schedule,58.78,124.36,
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,124.36,APC
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,124.36,APC
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,124.36,APC
Pulm stress test/complex,94621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,436.55,,,,,,,fee schedule,286.2,669.27,
Pulm stress test/complex,94621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,357.32,,,,,,,fee schedule,286.2,669.27,
Pulm stress test/complex,94621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.2,,,,,,,fee schedule,286.2,669.27,
Pulm stress test/complex,94621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,502.03,,,,,,,fee schedule,286.2,669.27,
Pulm stress test/complex,94621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,286.2,669.27,APC
Pulm stress test/complex,94621,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,286.2,669.27,APC
Pulm stress test/complex,94621,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,286.2,669.27,APC
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.45,,,,,,,fee schedule,58.78,127.02,
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.4,,,,,,,fee schedule,58.78,127.02,
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.41,,,,,,,fee schedule,58.78,127.02,
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.02,,,,,,,fee schedule,58.78,127.02,
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,127.02,APC
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,127.02,APC
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,127.02,APC
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.45,,,,,,,fee schedule,58.78,127.02,
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.4,,,,,,,fee schedule,58.78,127.02,
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.41,,,,,,,fee schedule,58.78,127.02,
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.02,,,,,,,fee schedule,58.78,127.02,
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,127.02,APC
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,127.02,APC
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,127.02,APC
Airway inhalation treatment,94640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.27,,,,,,,fee schedule,34.92,392.74,
Airway inhalation treatment,94640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.6,,,,,,,fee schedule,34.92,392.74,
Airway inhalation treatment,94640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.92,,,,,,,fee schedule,34.92,392.74,
Airway inhalation treatment,94640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.26,,,,,,,fee schedule,34.92,392.74,
Airway inhalation treatment,94640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,229.1,,,,,,,fee schedule,34.92,392.74,APC
Airway inhalation treatment,94640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.19,,,,,,,fee schedule,34.92,392.74,APC
Airway inhalation treatment,94640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.74,,,,,,,fee schedule,34.92,392.74,APC
Aerosol inhalation treatment,94642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.74,,,,,,,fee schedule,59.49,392.74,
Aerosol inhalation treatment,94642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.27,,,,,,,fee schedule,59.49,392.74,
Aerosol inhalation treatment,94642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.49,,,,,,,fee schedule,59.49,392.74,
Aerosol inhalation treatment,94642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,104.35,,,,,,,fee schedule,59.49,392.74,
Aerosol inhalation treatment,94642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,229.1,,,,,,,fee schedule,59.49,392.74,APC
Aerosol inhalation treatment,94642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.19,,,,,,,fee schedule,59.49,392.74,APC
Aerosol inhalation treatment,94642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.74,,,,,,,fee schedule,59.49,392.74,APC
Cbt 1st hour,94644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.63,,,,,,,fee schedule,80.4,238.63,
Cbt 1st hour,94644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.37,,,,,,,fee schedule,80.4,238.63,
Cbt 1st hour,94644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.4,,,,,,,fee schedule,80.4,238.63,
Cbt 1st hour,94644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.02,,,,,,,fee schedule,80.4,238.63,
Cbt 1st hour,94644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,80.4,238.63,APC
Cbt 1st hour,94644,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,80.4,238.63,APC
Cbt 1st hour,94644,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,80.4,238.63,APC
Cbt each addl hour,94645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.69,,,,,,,fee schedule,83.71,146.84,
Cbt each addl hour,94645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.51,,,,,,,fee schedule,83.71,146.84,
Cbt each addl hour,94645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.71,,,,,,,fee schedule,83.71,146.84,
Cbt each addl hour,94645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.84,,,,,,,fee schedule,83.71,146.84,
Pos airway pressure cpap,94660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,244.55,,,,,,,fee schedule,160.33,392.74,
Pos airway pressure cpap,94660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,200.16,,,,,,,fee schedule,160.33,392.74,
Pos airway pressure cpap,94660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,160.33,,,,,,,fee schedule,160.33,392.74,
Pos airway pressure cpap,94660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,281.23,,,,,,,fee schedule,160.33,392.74,
Pos airway pressure cpap,94660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,229.1,,,,,,,fee schedule,160.33,392.74,APC
Pos airway pressure cpap,94660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.19,,,,,,,fee schedule,160.33,392.74,APC
Pos airway pressure cpap,94660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.74,,,,,,,fee schedule,160.33,392.74,APC
Neg press ventilation cnp,94662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,634.05,,,,,,,fee schedule,415.68,729.16,
Neg press ventilation cnp,94662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,518.97,,,,,,,fee schedule,415.68,729.16,
Neg press ventilation cnp,94662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,415.68,,,,,,,fee schedule,415.68,729.16,
Neg press ventilation cnp,94662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,729.16,,,,,,,fee schedule,415.68,729.16,
Evaluate pt use of inhaler,94664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.41,,,,,,,fee schedule,158.92,392.74,
Evaluate pt use of inhaler,94664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.41,,,,,,,fee schedule,158.92,392.74,
Evaluate pt use of inhaler,94664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.92,,,,,,,fee schedule,158.92,392.74,
Evaluate pt use of inhaler,94664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.77,,,,,,,fee schedule,158.92,392.74,
Evaluate pt use of inhaler,94664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,229.1,,,,,,,fee schedule,158.92,392.74,APC
Evaluate pt use of inhaler,94664,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.19,,,,,,,fee schedule,158.92,392.74,APC
Evaluate pt use of inhaler,94664,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.74,,,,,,,fee schedule,158.92,392.74,APC
Chest wall manipulation,94667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Chest wall manipulation,94667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Chest wall manipulation,94667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Chest wall manipulation,94667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Chest wall manipulation,94667,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Chest wall manipulation,94667,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Chest wall manipulation,94667,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Chest wall manipulation,94668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.17,,,,,,,fee schedule,26.34,238.63,
Chest wall manipulation,94668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.88,,,,,,,fee schedule,26.34,238.63,
Chest wall manipulation,94668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.34,,,,,,,fee schedule,26.34,238.63,
Chest wall manipulation,94668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.2,,,,,,,fee schedule,26.34,238.63,
Chest wall manipulation,94668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,26.34,238.63,APC
Chest wall manipulation,94668,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,26.34,238.63,APC
Chest wall manipulation,94668,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,26.34,238.63,APC
Mechanical chest wall oscill,94669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.41,,,,,,,fee schedule,158.92,392.74,
Mechanical chest wall oscill,94669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.41,,,,,,,fee schedule,158.92,392.74,
Mechanical chest wall oscill,94669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.92,,,,,,,fee schedule,158.92,392.74,
Mechanical chest wall oscill,94669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.77,,,,,,,fee schedule,158.92,392.74,
Mechanical chest wall oscill,94669,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,229.1,,,,,,,fee schedule,158.92,392.74,APC
Mechanical chest wall oscill,94669,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,218.19,,,,,,,fee schedule,158.92,392.74,APC
Mechanical chest wall oscill,94669,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,392.74,,,,,,,fee schedule,158.92,392.74,APC
Exhaled air analysis o2,94680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.46,,,,,,,fee schedule,80.28,230.78,
Exhaled air analysis o2,94680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.23,,,,,,,fee schedule,80.28,230.78,
Exhaled air analysis o2,94680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.28,,,,,,,fee schedule,80.28,230.78,
Exhaled air analysis o2,94680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,140.83,,,,,,,fee schedule,80.28,230.78,
Exhaled air analysis o2,94680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,80.28,230.78,APC
Exhaled air analysis o2,94680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,80.28,230.78,APC
Exhaled air analysis o2,94680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,80.28,230.78,APC
Exhaled air analysis o2/co2,94681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.5,,,,,,,fee schedule,79.66,669.27,
Exhaled air analysis o2/co2,94681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.45,,,,,,,fee schedule,79.66,669.27,
Exhaled air analysis o2/co2,94681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.66,,,,,,,fee schedule,79.66,669.27,
Exhaled air analysis o2/co2,94681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.73,,,,,,,fee schedule,79.66,669.27,
Exhaled air analysis o2/co2,94681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,79.66,669.27,APC
Exhaled air analysis o2/co2,94681,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,79.66,669.27,APC
Exhaled air analysis o2/co2,94681,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,79.66,669.27,APC
Exhaled air analysis,94690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.3,,,,,,,fee schedule,58.78,151,
Exhaled air analysis,94690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.47,,,,,,,fee schedule,58.78,151,
Exhaled air analysis,94690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.08,,,,,,,fee schedule,58.78,151,
Exhaled air analysis,94690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151,,,,,,,fee schedule,58.78,151,
Exhaled air analysis,94690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,151,APC
Exhaled air analysis,94690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,151,APC
Exhaled air analysis,94690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,151,APC
Pulm funct tst plethysmograp,94726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,249.75,,,,,,,fee schedule,163.74,669.27,
Pulm funct tst plethysmograp,94726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,204.42,,,,,,,fee schedule,163.74,669.27,
Pulm funct tst plethysmograp,94726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.74,,,,,,,fee schedule,163.74,669.27,
Pulm funct tst plethysmograp,94726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,287.21,,,,,,,fee schedule,163.74,669.27,
Pulm funct tst plethysmograp,94726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,163.74,669.27,APC
Pulm funct tst plethysmograp,94726,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,163.74,669.27,APC
Pulm funct tst plethysmograp,94726,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,163.74,669.27,APC
Pulm function test by gas,94727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.3,,,,,,,fee schedule,53.96,387.26,
Pulm function test by gas,94727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.36,,,,,,,fee schedule,53.96,387.26,
Pulm function test by gas,94727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.96,,,,,,,fee schedule,53.96,387.26,
Pulm function test by gas,94727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.65,,,,,,,fee schedule,53.96,387.26,
Pulm function test by gas,94727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,53.96,387.26,APC
Pulm function test by gas,94727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,53.96,387.26,APC
Pulm function test by gas,94727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,53.96,387.26,APC
Pulm funct test oscillometry,94728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.47,,,,,,,fee schedule,48.82,230.78,
Pulm funct test oscillometry,94728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.95,,,,,,,fee schedule,48.82,230.78,
Pulm funct test oscillometry,94728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.82,,,,,,,fee schedule,48.82,230.78,
Pulm funct test oscillometry,94728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.64,,,,,,,fee schedule,48.82,230.78,
Pulm funct test oscillometry,94728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,48.82,230.78,APC
Pulm funct test oscillometry,94728,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,48.82,230.78,APC
Pulm funct test oscillometry,94728,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,48.82,230.78,APC
Co/membane diffuse capacity,94729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.47,,,,,,,fee schedule,52.1,91.39,
Co/membane diffuse capacity,94729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.05,,,,,,,fee schedule,52.1,91.39,
Co/membane diffuse capacity,94729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.1,,,,,,,fee schedule,52.1,91.39,
Co/membane diffuse capacity,94729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.39,,,,,,,fee schedule,52.1,91.39,
Measure blood oxygen level,94760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.83,,,,,,,fee schedule,5.79,10.15,
Measure blood oxygen level,94760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.23,,,,,,,fee schedule,5.79,10.15,
Measure blood oxygen level,94760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.79,,,,,,,fee schedule,5.79,10.15,
Measure blood oxygen level,94760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.15,,,,,,,fee schedule,5.79,10.15,
Measure blood oxygen level,94761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.27,,,,,,,fee schedule,53.94,94.61,
Measure blood oxygen level,94761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.34,,,,,,,fee schedule,53.94,94.61,
Measure blood oxygen level,94761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.94,,,,,,,fee schedule,53.94,94.61,
Measure blood oxygen level,94761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.61,,,,,,,fee schedule,53.94,94.61,
Measure blood oxygen level,94762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.82,,,,,,,fee schedule,84.45,230.78,
Measure blood oxygen level,94762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.44,,,,,,,fee schedule,84.45,230.78,
Measure blood oxygen level,94762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.45,,,,,,,fee schedule,84.45,230.78,
Measure blood oxygen level,94762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.14,,,,,,,fee schedule,84.45,230.78,
Measure blood oxygen level,94762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,84.45,230.78,APC
Measure blood oxygen level,94762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,84.45,230.78,APC
Measure blood oxygen level,94762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,84.45,230.78,APC
Breath recording infant,94772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,621.94,,,,,,,fee schedule,371.82,715.23,
Breath recording infant,94772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,509.06,,,,,,,fee schedule,371.82,715.23,
Breath recording infant,94772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,407.74,,,,,,,fee schedule,371.82,715.23,
Breath recording infant,94772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,715.23,,,,,,,fee schedule,371.82,715.23,
Breath recording infant,94772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,715.23,APC
Breath recording infant,94772,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,715.23,APC
Breath recording infant,94772,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,715.23,APC
Ped home apnea rec hk-up,94775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,230.78,
Ped home apnea rec hk-up,94775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,230.78,
Ped home apnea rec hk-up,94775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,230.78,
Ped home apnea rec hk-up,94775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,230.78,
Ped home apnea rec hk-up,94775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,124.61,230.78,APC
Ped home apnea rec hk-up,94775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,124.61,230.78,APC
Ped home apnea rec hk-up,94775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,124.61,230.78,APC
Ped home apnea rec downld,94776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.92,,,,,,,fee schedule,68.79,230.78,
Ped home apnea rec downld,94776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.88,,,,,,,fee schedule,68.79,230.78,
Ped home apnea rec downld,94776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.79,,,,,,,fee schedule,68.79,230.78,
Ped home apnea rec downld,94776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.66,,,,,,,fee schedule,68.79,230.78,
Ped home apnea rec downld,94776,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,68.79,230.78,APC
Ped home apnea rec downld,94776,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,68.79,230.78,APC
Ped home apnea rec downld,94776,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,68.79,230.78,APC
Car seat/bed test 60 min,94780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Car seat/bed test 60 min,94780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Car seat/bed test 60 min,94780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Car seat/bed test 60 min,94780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Car seat/bed test 60 min,94780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Car seat/bed test 60 min,94780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Car seat/bed test 60 min,94780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Car seat/bed test + 30 min,94781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,52.96,
Car seat/bed test + 30 min,94781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,52.96,
Car seat/bed test + 30 min,94781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,52.96,
Car seat/bed test + 30 min,94781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,52.96,
Pulmonary service/procedure,94799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Pulmonary service/procedure,94799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Pulmonary service/procedure,94799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Percut allergy skin tests,95004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,1540.17,
Percut allergy skin tests,95004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,1540.17,
Percut allergy skin tests,95004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,1540.17,
Percut allergy skin tests,95004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,1540.17,
Percut allergy skin tests,95004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,258.44,1540.17,APC
Percut allergy skin tests,95004,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,258.44,1540.17,APC
Percut allergy skin tests,95004,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,258.44,1540.17,APC
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Perq & icut allg test venoms,95017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,51.88,
Perq & icut allg test venoms,95017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,51.88,
Perq & icut allg test venoms,95017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,51.88,
Perq & icut allg test venoms,95017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,51.88,
Perq & icut allg test venoms,95017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,27.82,51.88,APC
Perq & icut allg test venoms,95017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,27.82,51.88,APC
Perq & icut allg test venoms,95017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,27.82,51.88,APC
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Icut allergy test drug/bug,95024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Icut allergy test drug/bug,95024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Icut allergy test drug/bug,95024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Icut allergy test drug/bug,95024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Icut allergy test drug/bug,95024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Icut allergy test drug/bug,95024,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Icut allergy test drug/bug,95024,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Icut allergy titrate-airborn,95027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,51.88,
Icut allergy titrate-airborn,95027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,51.88,
Icut allergy titrate-airborn,95027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,51.88,
Icut allergy titrate-airborn,95027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,51.88,
Icut allergy titrate-airborn,95027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,27.82,51.88,APC
Icut allergy titrate-airborn,95027,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,27.82,51.88,APC
Icut allergy titrate-airborn,95027,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,27.82,51.88,APC
Icut allergy test-delayed,95028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,24.4,66.99,
Icut allergy test-delayed,95028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,24.4,66.99,
Icut allergy test-delayed,95028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,24.4,66.99,
Icut allergy test-delayed,95028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,24.4,66.99,
Icut allergy test-delayed,95028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,24.4,66.99,APC
Icut allergy test-delayed,95028,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,24.4,66.99,APC
Icut allergy test-delayed,95028,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,24.4,66.99,APC
Allergy patch tests,95044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,1540.17,
Allergy patch tests,95044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,1540.17,
Allergy patch tests,95044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,1540.17,
Allergy patch tests,95044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,1540.17,
Allergy patch tests,95044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,258.44,1540.17,APC
Allergy patch tests,95044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,258.44,1540.17,APC
Allergy patch tests,95044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,258.44,1540.17,APC
Photo patch test,95052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,105.8,
Photo patch test,95052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,105.8,
Photo patch test,95052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,105.8,
Photo patch test,95052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,105.8,
Photo patch test,95052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,27.82,105.8,APC
Photo patch test,95052,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,27.82,105.8,APC
Photo patch test,95052,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,27.82,105.8,APC
Photosensitivity tests,95056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,238.63,
Photosensitivity tests,95056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,238.63,
Photosensitivity tests,95056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,238.63,
Photosensitivity tests,95056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,238.63,
Photosensitivity tests,95056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,53.47,238.63,APC
Photosensitivity tests,95056,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,53.47,238.63,APC
Photosensitivity tests,95056,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,53.47,238.63,APC
Eye allergy tests,95060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.98,,,,,,,fee schedule,64.24,238.63,
Eye allergy tests,95060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.2,,,,,,,fee schedule,64.24,238.63,
Eye allergy tests,95060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.24,,,,,,,fee schedule,64.24,238.63,
Eye allergy tests,95060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.68,,,,,,,fee schedule,64.24,238.63,
Eye allergy tests,95060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,64.24,238.63,APC
Eye allergy tests,95060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,64.24,238.63,APC
Eye allergy tests,95060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,64.24,238.63,APC
Nose allergy test,95065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,37.22,79.99,
Nose allergy test,95065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,37.22,79.99,
Nose allergy test,95065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,37.22,79.99,
Nose allergy test,95065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,37.22,79.99,
Nose allergy test,95065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,79.99,APC
Nose allergy test,95065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,79.99,APC
Nose allergy test,95065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,79.99,APC
Bronchial allergy tests,95070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.24,,,,,,,fee schedule,55.88,669.27,
Bronchial allergy tests,95070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.77,,,,,,,fee schedule,55.88,669.27,
Bronchial allergy tests,95070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.88,,,,,,,fee schedule,55.88,669.27,
Bronchial allergy tests,95070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.03,,,,,,,fee schedule,55.88,669.27,
Bronchial allergy tests,95070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,55.88,669.27,APC
Bronchial allergy tests,95070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,55.88,669.27,APC
Bronchial allergy tests,95070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,55.88,669.27,APC
Ingest challenge ini 120 min,95076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,621.94,,,,,,,fee schedule,371.82,715.23,
Ingest challenge ini 120 min,95076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,509.06,,,,,,,fee schedule,371.82,715.23,
Ingest challenge ini 120 min,95076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,407.74,,,,,,,fee schedule,371.82,715.23,
Ingest challenge ini 120 min,95076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,715.23,,,,,,,fee schedule,371.82,715.23,
Ingest challenge ini 120 min,95076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,715.23,APC
Ingest challenge ini 120 min,95076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,715.23,APC
Ingest challenge ini 120 min,95076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,715.23,APC
Ingest challenge addl 60 min,95079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.16,,,,,,,fee schedule,58.45,102.53,
Ingest challenge addl 60 min,95079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.98,,,,,,,fee schedule,58.45,102.53,
Ingest challenge addl 60 min,95079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.45,,,,,,,fee schedule,58.45,102.53,
Ingest challenge addl 60 min,95079,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.53,,,,,,,fee schedule,58.45,102.53,
Immunotherapy one injection,95115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Immunotherapy one injection,95115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Immunotherapy one injection,95115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Immunotherapy one injection,95115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Immunotherapy one injection,95115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Immunotherapy one injection,95115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Immunotherapy one injection,95115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Immunotherapy injections,95117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Immunotherapy injections,95117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Immunotherapy injections,95117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Immunotherapy injections,95117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Immunotherapy injections,95117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Immunotherapy injections,95117,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Immunotherapy injections,95117,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Immunotherapy one injection,95120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.63,,,,,,,fee schedule,12.21,21.42,
Immunotherapy one injection,95120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.25,,,,,,,fee schedule,12.21,21.42,
Immunotherapy one injection,95120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.21,,,,,,,fee schedule,12.21,21.42,
Immunotherapy one injection,95120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.42,,,,,,,fee schedule,12.21,21.42,
Immunotherapy 2/> injections,95125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.53,,,,,,,fee schedule,14.77,25.91,
Immunotherapy 2/> injections,95125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.44,,,,,,,fee schedule,14.77,25.91,
Immunotherapy 2/> injections,95125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.77,,,,,,,fee schedule,14.77,25.91,
Immunotherapy 2/> injections,95125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.91,,,,,,,fee schedule,14.77,25.91,
Immntx 1 sting insect,95130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,37.19,
Immntx 1 sting insect,95130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,37.19,
Immntx 1 sting insect,95130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,37.19,
Immntx 1 sting insect,95130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,37.19,
Immntx 2 sting insects,95131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,47.32,
Immntx 2 sting insects,95131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,47.32,
Immntx 2 sting insects,95131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,47.32,
Immntx 2 sting insects,95131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,47.32,
Immntx 3 sting insects,95132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.98,,,,,,,fee schedule,32.11,56.33,
Immntx 3 sting insects,95132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.09,,,,,,,fee schedule,32.11,56.33,
Immntx 3 sting insects,95132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.11,,,,,,,fee schedule,32.11,56.33,
Immntx 3 sting insects,95132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.33,,,,,,,fee schedule,32.11,56.33,
Immntx 4 sting insects,95133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.76,,,,,,,fee schedule,39.18,68.72,
Immntx 4 sting insects,95133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.91,,,,,,,fee schedule,39.18,68.72,
Immntx 4 sting insects,95133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.18,,,,,,,fee schedule,39.18,68.72,
Immntx 4 sting insects,95133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.72,,,,,,,fee schedule,39.18,68.72,
Immntx 5 sting insects,95134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.54,,,,,,,fee schedule,46.25,81.12,
Immntx 5 sting insects,95134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.74,,,,,,,fee schedule,46.25,81.12,
Immntx 5 sting insects,95134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.25,,,,,,,fee schedule,46.25,81.12,
Immntx 5 sting insects,95134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.12,,,,,,,fee schedule,46.25,81.12,
Antigen therapy services,95144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95144,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95144,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.53,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.1,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.14,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.46,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.53,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.1,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.14,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.46,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95148,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95148,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.53,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.1,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.14,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.46,,,,,,,fee schedule,52.14,129.13,
Antigen therapy services,95149,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95149,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95149,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,52.14,129.13,APC
Antigen therapy services,95165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Antigen therapy services,95170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Antigen therapy services,95170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Rapid desensitization,95180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,801.21,
Rapid desensitization,95180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,801.21,
Rapid desensitization,95180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,801.21,
Rapid desensitization,95180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,801.21,
Rapid desensitization,95180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,258.44,801.21,APC
Rapid desensitization,95180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,258.44,801.21,APC
Rapid desensitization,95180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,258.44,801.21,APC
Allergy immunology services,95199,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Allergy immunology services,95199,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Allergy immunology services,95199,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.77,,,,,,,fee schedule,58.78,175.69,
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.04,,,,,,,fee schedule,58.78,175.69,
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.16,,,,,,,fee schedule,58.78,175.69,
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.69,,,,,,,fee schedule,58.78,175.69,
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,175.69,APC
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,175.69,APC
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,175.69,APC
Glucose monitoring cont,95250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,436.02,,,,,,,fee schedule,132.66,501.42,
Glucose monitoring cont,95250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,356.88,,,,,,,fee schedule,132.66,501.42,
Glucose monitoring cont,95250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,285.85,,,,,,,fee schedule,132.66,501.42,
Glucose monitoring cont,95250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,501.42,,,,,,,fee schedule,132.66,501.42,
Glucose monitoring cont,95250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,501.42,APC
Glucose monitoring cont,95250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,501.42,APC
Glucose monitoring cont,95250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,501.42,APC
Gluc monitor cont phys i&r,95251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.3,,,,,,,fee schedule,21.83,38.3,
Gluc monitor cont phys i&r,95251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.26,,,,,,,fee schedule,21.83,38.3,
Gluc monitor cont phys i&r,95251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.83,,,,,,,fee schedule,21.83,38.3,
Gluc monitor cont phys i&r,95251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.3,,,,,,,fee schedule,21.83,38.3,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,491.64,,,,,,,fee schedule,215.15,565.39,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,402.41,,,,,,,fee schedule,215.15,565.39,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,322.32,,,,,,,fee schedule,215.15,565.39,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,565.39,,,,,,,fee schedule,215.15,565.39,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,565.39,APC
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,565.39,APC
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,565.39,APC
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,491.64,,,,,,,fee schedule,215.15,565.39,
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,402.41,,,,,,,fee schedule,215.15,565.39,
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,322.32,,,,,,,fee schedule,215.15,565.39,
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,565.39,,,,,,,fee schedule,215.15,565.39,
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,565.39,APC
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,565.39,APC
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,565.39,APC
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,491.64,,,,,,,fee schedule,215.15,565.39,
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,402.41,,,,,,,fee schedule,215.15,565.39,
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,322.32,,,,,,,fee schedule,215.15,565.39,
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,565.39,,,,,,,fee schedule,215.15,565.39,
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,565.39,APC
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,565.39,APC
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,565.39,APC
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,491.64,,,,,,,fee schedule,215.15,565.39,
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,402.41,,,,,,,fee schedule,215.15,565.39,
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,322.32,,,,,,,fee schedule,215.15,565.39,
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,565.39,,,,,,,fee schedule,215.15,565.39,
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,565.39,APC
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,565.39,APC
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,565.39,APC
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.3,,,,,,,fee schedule,371.82,1084.8,
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772.09,,,,,,,fee schedule,371.82,1084.8,
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.43,,,,,,,fee schedule,371.82,1084.8,
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.8,,,,,,,fee schedule,371.82,1084.8,
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1084.8,APC
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1084.8,APC
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1084.8,APC
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.3,,,,,,,fee schedule,371.82,1084.8,
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772.09,,,,,,,fee schedule,371.82,1084.8,
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.43,,,,,,,fee schedule,371.82,1084.8,
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.8,,,,,,,fee schedule,371.82,1084.8,
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1084.8,APC
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1084.8,APC
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1084.8,APC
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.3,,,,,,,fee schedule,371.82,1084.8,
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772.09,,,,,,,fee schedule,371.82,1084.8,
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.43,,,,,,,fee schedule,371.82,1084.8,
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.8,,,,,,,fee schedule,371.82,1084.8,
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1084.8,APC
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1084.8,APC
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1084.8,APC
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,491.64,,,,,,,fee schedule,215.15,565.39,
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,402.41,,,,,,,fee schedule,215.15,565.39,
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,322.32,,,,,,,fee schedule,215.15,565.39,
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,565.39,,,,,,,fee schedule,215.15,565.39,
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,565.39,APC
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,565.39,APC
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,565.39,APC
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,491.64,,,,,,,fee schedule,322.32,669.27,
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,402.41,,,,,,,fee schedule,322.32,669.27,
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,322.32,,,,,,,fee schedule,322.32,669.27,
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,565.39,,,,,,,fee schedule,322.32,669.27,
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,322.32,669.27,APC
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,322.32,669.27,APC
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,322.32,669.27,APC
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.3,,,,,,,fee schedule,371.82,1084.8,
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772.09,,,,,,,fee schedule,371.82,1084.8,
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.43,,,,,,,fee schedule,371.82,1084.8,
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.8,,,,,,,fee schedule,371.82,1084.8,
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1084.8,APC
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1084.8,APC
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1084.8,APC
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.3,,,,,,,fee schedule,371.82,1084.8,
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772.09,,,,,,,fee schedule,371.82,1084.8,
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.43,,,,,,,fee schedule,371.82,1084.8,
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.8,,,,,,,fee schedule,371.82,1084.8,
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1084.8,APC
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1084.8,APC
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1084.8,APC
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,943.3,,,,,,,fee schedule,371.82,1084.8,
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,772.09,,,,,,,fee schedule,371.82,1084.8,
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,618.43,,,,,,,fee schedule,371.82,1084.8,
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1084.8,,,,,,,fee schedule,371.82,1084.8,
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1084.8,APC
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1084.8,APC
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1084.8,APC
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1765.6,,,,,,,fee schedule,855.65,2030.44,
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1445.14,,,,,,,fee schedule,855.65,2030.44,
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1157.53,,,,,,,fee schedule,855.65,2030.44,
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2030.44,,,,,,,fee schedule,855.65,2030.44,
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,2030.44,APC
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,2030.44,APC
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,2030.44,APC
Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.49,,,,,,,fee schedule,37.69,66.11,
Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.06,,,,,,,fee schedule,37.69,66.11,
Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.69,,,,,,,fee schedule,37.69,66.11,
Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.11,,,,,,,fee schedule,37.69,66.11,
Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.45,,,,,,,fee schedule,54.71,95.97,
Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.3,,,,,,,fee schedule,54.71,95.97,
Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.71,,,,,,,fee schedule,54.71,95.97,
Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.97,,,,,,,fee schedule,54.71,95.97,
Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,93.95,,,,,,,fee schedule,61.59,108.04,
Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.9,,,,,,,fee schedule,61.59,108.04,
Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.59,,,,,,,fee schedule,61.59,108.04,
Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.04,,,,,,,fee schedule,61.59,108.04,
Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.72,,,,,,,fee schedule,85.04,149.18,
Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.18,,,,,,,fee schedule,85.04,149.18,
Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.04,,,,,,,fee schedule,85.04,149.18,
Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.18,,,,,,,fee schedule,85.04,149.18,
Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.22,,,,,,,fee schedule,87.34,153.2,
Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.04,,,,,,,fee schedule,87.34,153.2,
Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.34,,,,,,,fee schedule,87.34,153.2,
Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.2,,,,,,,fee schedule,87.34,153.2,
Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.84,,,,,,,fee schedule,104.79,183.82,
Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.83,,,,,,,fee schedule,104.79,183.82,
Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.79,,,,,,,fee schedule,104.79,183.82,
Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.82,,,,,,,fee schedule,104.79,183.82,
Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.15,,,,,,,fee schedule,108.93,191.07,
Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.99,,,,,,,fee schedule,108.93,191.07,
Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.93,,,,,,,fee schedule,108.93,191.07,
Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,191.07,,,,,,,fee schedule,108.93,191.07,
Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.72,,,,,,,fee schedule,134.21,235.43,
Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.56,,,,,,,fee schedule,134.21,235.43,
Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.21,,,,,,,fee schedule,134.21,235.43,
Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.43,,,,,,,fee schedule,134.21,235.43,
Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.38,,,,,,,fee schedule,125.47,220.09,
Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.64,,,,,,,fee schedule,125.47,220.09,
Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.47,,,,,,,fee schedule,125.47,220.09,
Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.09,,,,,,,fee schedule,125.47,220.09,
Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,258.73,,,,,,,fee schedule,169.62,297.54,
Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.77,,,,,,,fee schedule,169.62,297.54,
Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.62,,,,,,,fee schedule,169.62,297.54,
Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,297.54,,,,,,,fee schedule,169.62,297.54,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3771.47,,,,,,,fee schedule,855.65,4337.19,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3086.95,,,,,,,fee schedule,855.65,4337.19,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2472.58,,,,,,,fee schedule,855.65,4337.19,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4337.19,,,,,,,fee schedule,855.65,4337.19,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,4337.19,APC
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,4337.19,APC
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,4337.19,APC
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2813.14,,,,,,,fee schedule,855.65,3235.11,
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2302.56,,,,,,,fee schedule,855.65,3235.11,
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1844.29,,,,,,,fee schedule,855.65,3235.11,
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3235.11,,,,,,,fee schedule,855.65,3235.11,
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,3235.11,APC
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,3235.11,APC
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,3235.11,APC
Slp stdy unattended,95800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,348.81,,,,,,,fee schedule,215.15,401.13,
Slp stdy unattended,95800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,285.5,,,,,,,fee schedule,215.15,401.13,
Slp stdy unattended,95800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,228.68,,,,,,,fee schedule,215.15,401.13,
Slp stdy unattended,95800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,401.13,,,,,,,fee schedule,215.15,401.13,
Slp stdy unattended,95800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,401.13,APC
Slp stdy unattended,95800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,401.13,APC
Slp stdy unattended,95800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,401.13,APC
Slp stdy unatnd w/anal,95801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.64,,,,,,,fee schedule,58.78,131.84,
Slp stdy unatnd w/anal,95801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.83,,,,,,,fee schedule,58.78,131.84,
Slp stdy unatnd w/anal,95801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.16,,,,,,,fee schedule,58.78,131.84,
Slp stdy unatnd w/anal,95801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.84,,,,,,,fee schedule,58.78,131.84,
Slp stdy unatnd w/anal,95801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,131.84,APC
Slp stdy unatnd w/anal,95801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,131.84,APC
Slp stdy unatnd w/anal,95801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,131.84,APC
Actigraphy testing,95803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.49,,,,,,,fee schedule,58.78,308.76,
Actigraphy testing,95803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,219.76,,,,,,,fee schedule,58.78,308.76,
Actigraphy testing,95803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.02,,,,,,,fee schedule,58.78,308.76,
Actigraphy testing,95803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.76,,,,,,,fee schedule,58.78,308.76,
Actigraphy testing,95803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,308.76,APC
Actigraphy testing,95803,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,308.76,APC
Actigraphy testing,95803,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,308.76,APC
Multiple sleep latency test,95805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2280,,,,,,,fee schedule,855.65,2622,
Multiple sleep latency test,95805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1866.18,,,,,,,fee schedule,855.65,2622,
Multiple sleep latency test,95805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1494.77,,,,,,,fee schedule,855.65,2622,
Multiple sleep latency test,95805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2622,,,,,,,fee schedule,855.65,2622,
Multiple sleep latency test,95805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,2622,APC
Multiple sleep latency test,95805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,2622,APC
Multiple sleep latency test,95805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,2622,APC
Sleep study unatt&resp efft,95806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,298.86,,,,,,,fee schedule,195.93,387.26,
Sleep study unatt&resp efft,95806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,244.62,,,,,,,fee schedule,195.93,387.26,
Sleep study unatt&resp efft,95806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.93,,,,,,,fee schedule,195.93,387.26,
Sleep study unatt&resp efft,95806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,343.69,,,,,,,fee schedule,195.93,387.26,
Sleep study unatt&resp efft,95806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,195.93,387.26,APC
Sleep study unatt&resp efft,95806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,195.93,387.26,APC
Sleep study unatt&resp efft,95806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,195.93,387.26,APC
Sleep study attended,95807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,713.95,,,,,,,fee schedule,371.82,821.04,
Sleep study attended,95807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,584.37,,,,,,,fee schedule,371.82,821.04,
Sleep study attended,95807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,468.07,,,,,,,fee schedule,371.82,821.04,
Sleep study attended,95807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,821.04,,,,,,,fee schedule,371.82,821.04,
Sleep study attended,95807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,821.04,APC
Sleep study attended,95807,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,821.04,APC
Sleep study attended,95807,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,821.04,APC
Polysom any age 1-3> param,95808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1525.63,,,,,,,fee schedule,855.65,1754.47,
Polysom any age 1-3> param,95808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1248.73,,,,,,,fee schedule,855.65,1754.47,
Polysom any age 1-3> param,95808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1000.2,,,,,,,fee schedule,855.65,1754.47,
Polysom any age 1-3> param,95808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1754.47,,,,,,,fee schedule,855.65,1754.47,
Polysom any age 1-3> param,95808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,1754.47,APC
Polysom any age 1-3> param,95808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,1754.47,APC
Polysom any age 1-3> param,95808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,1754.47,APC
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,1540.17,APC
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,1540.17,APC
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,1540.17,APC
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1860.02,,,,,,,fee schedule,855.65,2139.02,
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1522.43,,,,,,,fee schedule,855.65,2139.02,
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1219.43,,,,,,,fee schedule,855.65,2139.02,
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2139.02,,,,,,,fee schedule,855.65,2139.02,
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,2139.02,APC
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,2139.02,APC
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,2139.02,APC
Eeg 41-60 minutes,95812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,507.69,,,,,,,fee schedule,215.15,583.84,
Eeg 41-60 minutes,95812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,415.54,,,,,,,fee schedule,215.15,583.84,
Eeg 41-60 minutes,95812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.84,,,,,,,fee schedule,215.15,583.84,
Eeg 41-60 minutes,95812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,583.84,,,,,,,fee schedule,215.15,583.84,
Eeg 41-60 minutes,95812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,583.84,APC
Eeg 41-60 minutes,95812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,583.84,APC
Eeg 41-60 minutes,95812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,583.84,APC
Eeg over 1 hour,95813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,507.69,,,,,,,fee schedule,215.15,583.84,
Eeg over 1 hour,95813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,415.54,,,,,,,fee schedule,215.15,583.84,
Eeg over 1 hour,95813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.84,,,,,,,fee schedule,215.15,583.84,
Eeg over 1 hour,95813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,583.84,,,,,,,fee schedule,215.15,583.84,
Eeg over 1 hour,95813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,583.84,APC
Eeg over 1 hour,95813,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,583.84,APC
Eeg over 1 hour,95813,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,583.84,APC
Eeg awake and drowsy,95816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,678.56,,,,,,,fee schedule,215.15,780.34,
Eeg awake and drowsy,95816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,555.4,,,,,,,fee schedule,215.15,780.34,
Eeg awake and drowsy,95816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,444.86,,,,,,,fee schedule,215.15,780.34,
Eeg awake and drowsy,95816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,780.34,,,,,,,fee schedule,215.15,780.34,
Eeg awake and drowsy,95816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,780.34,APC
Eeg awake and drowsy,95816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,780.34,APC
Eeg awake and drowsy,95816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,780.34,APC
Eeg awake and asleep,95819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,641.53,,,,,,,fee schedule,215.15,737.76,
Eeg awake and asleep,95819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,525.09,,,,,,,fee schedule,215.15,737.76,
Eeg awake and asleep,95819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,420.59,,,,,,,fee schedule,215.15,737.76,
Eeg awake and asleep,95819,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,737.76,,,,,,,fee schedule,215.15,737.76,
Eeg awake and asleep,95819,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,737.76,APC
Eeg awake and asleep,95819,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,737.76,APC
Eeg awake and asleep,95819,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,737.76,APC
Eeg coma or sleep only,95822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,876.94,,,,,,,fee schedule,215.15,1008.48,
Eeg coma or sleep only,95822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,717.78,,,,,,,fee schedule,215.15,1008.48,
Eeg coma or sleep only,95822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,574.92,,,,,,,fee schedule,215.15,1008.48,
Eeg coma or sleep only,95822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1008.48,,,,,,,fee schedule,215.15,1008.48,
Eeg coma or sleep only,95822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,1008.48,APC
Eeg coma or sleep only,95822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,1008.48,APC
Eeg coma or sleep only,95822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,1008.48,APC
Eeg cerebral death only,95824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.47,,,,,,,fee schedule,112.42,669.27,
Eeg cerebral death only,95824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.35,,,,,,,fee schedule,112.42,669.27,
Eeg cerebral death only,95824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.42,,,,,,,fee schedule,112.42,669.27,
Eeg cerebral death only,95824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.19,,,,,,,fee schedule,112.42,669.27,
Eeg cerebral death only,95824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,112.42,669.27,APC
Eeg cerebral death only,95824,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,112.42,669.27,APC
Eeg cerebral death only,95824,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,112.42,669.27,APC
Surgery electrocorticogram,95829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4363.27,,,,,,,fee schedule,2860.56,5017.76,
Surgery electrocorticogram,95829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3571.34,,,,,,,fee schedule,2860.56,5017.76,
Surgery electrocorticogram,95829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2860.56,,,,,,,fee schedule,2860.56,5017.76,
Surgery electrocorticogram,95829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5017.76,,,,,,,fee schedule,2860.56,5017.76,
Insert electrodes for EEG,95830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,428.2,,,,,,,fee schedule,280.73,492.43,
Insert electrodes for EEG,95830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,350.48,,,,,,,fee schedule,280.73,492.43,
Insert electrodes for EEG,95830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,280.73,,,,,,,fee schedule,280.73,492.43,
Insert electrodes for EEG,95830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,492.43,,,,,,,fee schedule,280.73,492.43,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.56,,,,,,,fee schedule,37.19,112.19,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.85,,,,,,,fee schedule,37.19,112.19,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.96,,,,,,,fee schedule,37.19,112.19,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.19,,,,,,,fee schedule,37.19,112.19,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,112.19,APC
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,112.19,APC
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,112.19,APC
Range of motion measurements,95851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.3,,,,,,,fee schedule,6.87,38.3,
Range of motion measurements,95851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.26,,,,,,,fee schedule,6.87,38.3,
Range of motion measurements,95851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.83,,,,,,,fee schedule,6.87,38.3,
Range of motion measurements,95851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.3,,,,,,,fee schedule,6.87,38.3,
Range of motion measurements,95851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.21,,,,,,,fee schedule,6.87,38.3,APC
Range of motion measurements,95851,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.87,,,,,,,fee schedule,6.87,38.3,APC
Range of motion measurements,95851,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.37,,,,,,,fee schedule,6.87,38.3,APC
Range of motion measurements,95852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.35,,,,,,,fee schedule,5.2,36.05,
Range of motion measurements,95852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.66,,,,,,,fee schedule,5.2,36.05,
Range of motion measurements,95852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.55,,,,,,,fee schedule,5.2,36.05,
Range of motion measurements,95852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.05,,,,,,,fee schedule,5.2,36.05,
Range of motion measurements,95852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.46,,,,,,,fee schedule,5.2,36.05,APC
Range of motion measurements,95852,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.2,,,,,,,fee schedule,5.2,36.05,APC
Range of motion measurements,95852,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.36,,,,,,,fee schedule,5.2,36.05,APC
Cholinesterase challenge,95857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Cholinesterase challenge,95857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Cholinesterase challenge,95857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Cholinesterase challenge,95857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Cholinesterase challenge,95857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Cholinesterase challenge,95857,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Cholinesterase challenge,95857,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Muscle test one limb,95860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194.98,,,,,,,fee schedule,127.83,238.63,
Muscle test one limb,95860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,159.59,,,,,,,fee schedule,127.83,238.63,
Muscle test one limb,95860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.83,,,,,,,fee schedule,127.83,238.63,
Muscle test one limb,95860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,224.23,,,,,,,fee schedule,127.83,238.63,
Muscle test one limb,95860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,127.83,238.63,APC
Muscle test one limb,95860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,127.83,238.63,APC
Muscle test one limb,95860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,127.83,238.63,APC
Muscle test 2 limbs,95861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,250.84,,,,,,,fee schedule,132.57,288.47,
Muscle test 2 limbs,95861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,205.31,,,,,,,fee schedule,132.57,288.47,
Muscle test 2 limbs,95861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.45,,,,,,,fee schedule,132.57,288.47,
Muscle test 2 limbs,95861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,288.47,,,,,,,fee schedule,132.57,288.47,
Muscle test 2 limbs,95861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,288.47,APC
Muscle test 2 limbs,95861,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,288.47,APC
Muscle test 2 limbs,95861,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,288.47,APC
Muscle test 3 limbs,95863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,326.28,,,,,,,fee schedule,128.21,375.22,
Muscle test 3 limbs,95863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,267.06,,,,,,,fee schedule,128.21,375.22,
Muscle test 3 limbs,95863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.91,,,,,,,fee schedule,128.21,375.22,
Muscle test 3 limbs,95863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,375.22,,,,,,,fee schedule,128.21,375.22,
Muscle test 3 limbs,95863,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,375.22,APC
Muscle test 3 limbs,95863,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,375.22,APC
Muscle test 3 limbs,95863,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,375.22,APC
Muscle test 4 limbs,95864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,381.18,,,,,,,fee schedule,128.21,438.36,
Muscle test 4 limbs,95864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312,,,,,,,fee schedule,128.21,438.36,
Muscle test 4 limbs,95864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.9,,,,,,,fee schedule,128.21,438.36,
Muscle test 4 limbs,95864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.36,,,,,,,fee schedule,128.21,438.36,
Muscle test 4 limbs,95864,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,438.36,APC
Muscle test 4 limbs,95864,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,438.36,APC
Muscle test 4 limbs,95864,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,438.36,APC
Muscle test larynx,95865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,170.5,,,,,,,fee schedule,111.78,238.63,
Muscle test larynx,95865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.55,,,,,,,fee schedule,111.78,238.63,
Muscle test larynx,95865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.78,,,,,,,fee schedule,111.78,238.63,
Muscle test larynx,95865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.08,,,,,,,fee schedule,111.78,238.63,
Muscle test larynx,95865,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,111.78,238.63,APC
Muscle test larynx,95865,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,111.78,238.63,APC
Muscle test larynx,95865,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,111.78,238.63,APC
Muscle test hemidiaphragm,95866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,187.15,,,,,,,fee schedule,122.7,230.78,
Muscle test hemidiaphragm,95866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.18,,,,,,,fee schedule,122.7,230.78,
Muscle test hemidiaphragm,95866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.7,,,,,,,fee schedule,122.7,230.78,
Muscle test hemidiaphragm,95866,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,215.22,,,,,,,fee schedule,122.7,230.78,
Muscle test hemidiaphragm,95866,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,122.7,230.78,APC
Muscle test hemidiaphragm,95866,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,122.7,230.78,APC
Muscle test hemidiaphragm,95866,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,122.7,230.78,APC
Muscle test cran nerv unilat,95867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.87,,,,,,,fee schedule,99.57,387.26,
Muscle test cran nerv unilat,95867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.31,,,,,,,fee schedule,99.57,387.26,
Muscle test cran nerv unilat,95867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.57,,,,,,,fee schedule,99.57,387.26,
Muscle test cran nerv unilat,95867,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.65,,,,,,,fee schedule,99.57,387.26,
Muscle test cran nerv unilat,95867,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,99.57,387.26,APC
Muscle test cran nerv unilat,95867,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,99.57,387.26,APC
Muscle test cran nerv unilat,95867,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,99.57,387.26,APC
Muscle test cran nerve bilat,95868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.96,,,,,,,fee schedule,128.47,387.26,
Muscle test cran nerve bilat,95868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.39,,,,,,,fee schedule,128.47,387.26,
Muscle test cran nerve bilat,95868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.47,,,,,,,fee schedule,128.47,387.26,
Muscle test cran nerve bilat,95868,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.35,,,,,,,fee schedule,128.47,387.26,
Muscle test cran nerve bilat,95868,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,128.47,387.26,APC
Muscle test cran nerve bilat,95868,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,128.47,387.26,APC
Muscle test cran nerve bilat,95868,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,128.47,387.26,APC
Muscle test thor paraspinal,95869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,197.94,,,,,,,fee schedule,129.77,387.26,
Muscle test thor paraspinal,95869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.01,,,,,,,fee schedule,129.77,387.26,
Muscle test thor paraspinal,95869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.77,,,,,,,fee schedule,129.77,387.26,
Muscle test thor paraspinal,95869,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227.63,,,,,,,fee schedule,129.77,387.26,
Muscle test thor paraspinal,95869,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,129.77,387.26,APC
Muscle test thor paraspinal,95869,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,129.77,387.26,APC
Muscle test thor paraspinal,95869,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,129.77,387.26,APC
Muscle test nonparaspinal,95870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.26,,,,,,,fee schedule,74.25,238.63,
Muscle test nonparaspinal,95870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.7,,,,,,,fee schedule,74.25,238.63,
Muscle test nonparaspinal,95870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.25,,,,,,,fee schedule,74.25,238.63,
Muscle test nonparaspinal,95870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.25,,,,,,,fee schedule,74.25,238.63,
Muscle test nonparaspinal,95870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,74.25,238.63,APC
Muscle test nonparaspinal,95870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,74.25,238.63,APC
Muscle test nonparaspinal,95870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,74.25,238.63,APC
Muscle test one fiber,95872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,116.61,,,,,,,fee schedule,76.45,387.26,
Muscle test one fiber,95872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95.45,,,,,,,fee schedule,76.45,387.26,
Muscle test one fiber,95872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.45,,,,,,,fee schedule,76.45,387.26,
Muscle test one fiber,95872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,134.1,,,,,,,fee schedule,76.45,387.26,
Muscle test one fiber,95872,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,76.45,387.26,APC
Muscle test one fiber,95872,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,76.45,387.26,APC
Muscle test one fiber,95872,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,76.45,387.26,APC
Guide nerv destr elec stim,95873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.98,,,,,,,fee schedule,96.36,169.03,
Guide nerv destr elec stim,95873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.3,,,,,,,fee schedule,96.36,169.03,
Guide nerv destr elec stim,95873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.36,,,,,,,fee schedule,96.36,169.03,
Guide nerv destr elec stim,95873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.03,,,,,,,fee schedule,96.36,169.03,
Guide nerv destr needle emg,95874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.94,,,,,,,fee schedule,97.65,171.28,
Guide nerv destr needle emg,95874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.91,,,,,,,fee schedule,97.65,171.28,
Guide nerv destr needle emg,95874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.65,,,,,,,fee schedule,97.65,171.28,
Guide nerv destr needle emg,95874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.28,,,,,,,fee schedule,97.65,171.28,
Limb exercise test,95875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.7,,,,,,,fee schedule,105.35,230.78,
Limb exercise test,95875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.53,,,,,,,fee schedule,105.35,230.78,
Limb exercise test,95875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.35,,,,,,,fee schedule,105.35,230.78,
Limb exercise test,95875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.81,,,,,,,fee schedule,105.35,230.78,
Limb exercise test,95875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,105.35,230.78,APC
Limb exercise test,95875,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,105.35,230.78,APC
Limb exercise test,95875,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,105.35,230.78,APC
Musc tst done w/nerv tst lim,95885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.75,,,,,,,fee schedule,71.95,126.21,
Musc tst done w/nerv tst lim,95885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.83,,,,,,,fee schedule,71.95,126.21,
Musc tst done w/nerv tst lim,95885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.95,,,,,,,fee schedule,71.95,126.21,
Musc tst done w/nerv tst lim,95885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.21,,,,,,,fee schedule,71.95,126.21,
Musc test done w/n test comp,95886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.45,,,,,,,fee schedule,80.93,141.97,
Musc test done w/n test comp,95886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.04,,,,,,,fee schedule,80.93,141.97,
Musc test done w/n test comp,95886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.93,,,,,,,fee schedule,80.93,141.97,
Musc test done w/n test comp,95886,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.97,,,,,,,fee schedule,80.93,141.97,
Musc tst done w/n tst nonext,95887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.59,,,,,,,fee schedule,77.09,135.23,
Musc tst done w/n tst nonext,95887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.25,,,,,,,fee schedule,77.09,135.23,
Musc tst done w/n tst nonext,95887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.09,,,,,,,fee schedule,77.09,135.23,
Musc tst done w/n tst nonext,95887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.23,,,,,,,fee schedule,77.09,135.23,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,322.92,,,,,,,fee schedule,211.71,801.21,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,264.31,,,,,,,fee schedule,211.71,801.21,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.71,,,,,,,fee schedule,211.71,801.21,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,371.36,,,,,,,fee schedule,211.71,801.21,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,211.71,801.21,APC
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,211.71,801.21,APC
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,211.71,801.21,APC
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,387.26,
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,387.26,
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,387.26,
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,387.26,
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,79.01,387.26,APC
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,79.01,387.26,APC
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,79.01,387.26,APC
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.72,,,,,,,fee schedule,104.71,387.26,
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.73,,,,,,,fee schedule,104.71,387.26,
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.71,,,,,,,fee schedule,104.71,387.26,
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.68,,,,,,,fee schedule,104.71,387.26,
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,104.71,387.26,APC
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,104.71,387.26,APC
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,104.71,387.26,APC
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.1,,,,,,,fee schedule,123.97,387.26,
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.78,,,,,,,fee schedule,123.97,387.26,
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.97,,,,,,,fee schedule,123.97,387.26,
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.47,,,,,,,fee schedule,123.97,387.26,
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,123.97,387.26,APC
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,123.97,387.26,APC
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,123.97,387.26,APC
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.92,,,,,,,fee schedule,161.88,669.27,
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.1,,,,,,,fee schedule,161.88,669.27,
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.88,,,,,,,fee schedule,161.88,669.27,
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.96,,,,,,,fee schedule,161.88,669.27,
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,161.88,669.27,APC
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,161.88,669.27,APC
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,161.88,669.27,APC
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,277.32,,,,,,,fee schedule,181.81,669.27,
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,226.99,,,,,,,fee schedule,181.81,669.27,
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,181.81,,,,,,,fee schedule,181.81,669.27,
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,318.92,,,,,,,fee schedule,181.81,669.27,
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,181.81,669.27,APC
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,181.81,669.27,APC
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,181.81,669.27,APC
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,276.33,,,,,,,fee schedule,181.16,669.27,
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,226.18,,,,,,,fee schedule,181.16,669.27,
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,181.16,,,,,,,fee schedule,181.16,669.27,
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,317.78,,,,,,,fee schedule,181.16,669.27,
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,181.16,669.27,APC
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,181.16,669.27,APC
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,181.16,669.27,APC
Nrv cndj test 13/> studies,95913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,301.78,,,,,,,fee schedule,197.85,669.27,
Nrv cndj test 13/> studies,95913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,247.01,,,,,,,fee schedule,197.85,669.27,
Nrv cndj test 13/> studies,95913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.85,,,,,,,fee schedule,197.85,669.27,
Nrv cndj test 13/> studies,95913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,347.05,,,,,,,fee schedule,197.85,669.27,
Nrv cndj test 13/> studies,95913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,197.85,669.27,APC
Nrv cndj test 13/> studies,95913,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,197.85,669.27,APC
Nrv cndj test 13/> studies,95913,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,197.85,669.27,APC
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.95,,,,,,,fee schedule,132.57,255.24,
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.67,,,,,,,fee schedule,132.57,255.24,
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.51,,,,,,,fee schedule,132.57,255.24,
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.24,,,,,,,fee schedule,132.57,255.24,
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,255.24,APC
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,255.24,APC
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,255.24,APC
Autonomic nrv parasym inervj,95921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.75,,,,,,,fee schedule,71.95,230.78,
Autonomic nrv parasym inervj,95921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.83,,,,,,,fee schedule,71.95,230.78,
Autonomic nrv parasym inervj,95921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.95,,,,,,,fee schedule,71.95,230.78,
Autonomic nrv parasym inervj,95921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.21,,,,,,,fee schedule,71.95,230.78,
Autonomic nrv parasym inervj,95921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,71.95,230.78,APC
Autonomic nrv parasym inervj,95921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,71.95,230.78,APC
Autonomic nrv parasym inervj,95921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,71.95,230.78,APC
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.08,,,,,,,fee schedule,93.15,238.63,
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,116.29,,,,,,,fee schedule,93.15,238.63,
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.15,,,,,,,fee schedule,93.15,238.63,
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,163.39,,,,,,,fee schedule,93.15,238.63,
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,93.15,238.63,APC
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,93.15,238.63,APC
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,93.15,238.63,APC
Autonomic nrv syst funj test,95923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,262.59,,,,,,,fee schedule,132.57,301.98,
Autonomic nrv syst funj test,95923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.93,,,,,,,fee schedule,132.57,301.98,
Autonomic nrv syst funj test,95923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.15,,,,,,,fee schedule,132.57,301.98,
Autonomic nrv syst funj test,95923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,301.98,,,,,,,fee schedule,132.57,301.98,
Autonomic nrv syst funj test,95923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,301.98,APC
Autonomic nrv syst funj test,95923,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,301.98,APC
Autonomic nrv syst funj test,95923,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,301.98,APC
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.43,,,,,,,fee schedule,113.05,387.26,
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.13,,,,,,,fee schedule,113.05,387.26,
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.05,,,,,,,fee schedule,113.05,387.26,
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.29,,,,,,,fee schedule,113.05,387.26,
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,113.05,387.26,APC
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,113.05,387.26,APC
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,113.05,387.26,APC
Somatosensory testing,95925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,306.68,,,,,,,fee schedule,201.06,387.26,
Somatosensory testing,95925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.02,,,,,,,fee schedule,201.06,387.26,
Somatosensory testing,95925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.06,,,,,,,fee schedule,201.06,387.26,
Somatosensory testing,95925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,352.68,,,,,,,fee schedule,201.06,387.26,
Somatosensory testing,95925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,201.06,387.26,APC
Somatosensory testing,95925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,201.06,387.26,APC
Somatosensory testing,95925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,201.06,387.26,APC
Somatosensory testing,95926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,295.9,,,,,,,fee schedule,193.99,387.26,
Somatosensory testing,95926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,242.19,,,,,,,fee schedule,193.99,387.26,
Somatosensory testing,95926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.99,,,,,,,fee schedule,193.99,387.26,
Somatosensory testing,95926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.29,,,,,,,fee schedule,193.99,387.26,
Somatosensory testing,95926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,193.99,387.26,APC
Somatosensory testing,95926,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,193.99,387.26,APC
Somatosensory testing,95926,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,193.99,387.26,APC
Somatosensory testing,95927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,305.69,,,,,,,fee schedule,200.41,387.26,
Somatosensory testing,95927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,250.21,,,,,,,fee schedule,200.41,387.26,
Somatosensory testing,95927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,200.41,,,,,,,fee schedule,200.41,387.26,
Somatosensory testing,95927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,351.54,,,,,,,fee schedule,200.41,387.26,
Somatosensory testing,95927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,200.41,387.26,APC
Somatosensory testing,95927,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,200.41,387.26,APC
Somatosensory testing,95927,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,200.41,387.26,APC
C motor evoked uppr limbs,95928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,367.42,,,,,,,fee schedule,240.88,1540.17,
C motor evoked uppr limbs,95928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,300.73,,,,,,,fee schedule,240.88,1540.17,
C motor evoked uppr limbs,95928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,240.88,,,,,,,fee schedule,240.88,1540.17,
C motor evoked uppr limbs,95928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,422.53,,,,,,,fee schedule,240.88,1540.17,
C motor evoked uppr limbs,95928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,240.88,1540.17,APC
C motor evoked uppr limbs,95928,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,240.88,1540.17,APC
C motor evoked uppr limbs,95928,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,240.88,1540.17,APC
C motor evoked lwr limbs,95929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.08,,,,,,,fee schedule,251.8,669.27,
C motor evoked lwr limbs,95929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.37,,,,,,,fee schedule,251.8,669.27,
C motor evoked lwr limbs,95929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.8,,,,,,,fee schedule,251.8,669.27,
C motor evoked lwr limbs,95929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,441.69,,,,,,,fee schedule,251.8,669.27,
C motor evoked lwr limbs,95929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,251.8,669.27,APC
C motor evoked lwr limbs,95929,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,251.8,669.27,APC
C motor evoked lwr limbs,95929,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,251.8,669.27,APC
Visual evoked potential test,95930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,456.63,,,,,,,fee schedule,215.15,525.12,
Visual evoked potential test,95930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,373.75,,,,,,,fee schedule,215.15,525.12,
Visual evoked potential test,95930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.37,,,,,,,fee schedule,215.15,525.12,
Visual evoked potential test,95930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,525.12,,,,,,,fee schedule,215.15,525.12,
Visual evoked potential test,95930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,525.12,APC
Visual evoked potential test,95930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,525.12,APC
Visual evoked potential test,95930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,525.12,APC
Blink reflex test,95933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.43,,,,,,,fee schedule,58.78,143.09,
Blink reflex test,95933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.85,,,,,,,fee schedule,58.78,143.09,
Blink reflex test,95933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.58,,,,,,,fee schedule,58.78,143.09,
Blink reflex test,95933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.09,,,,,,,fee schedule,58.78,143.09,
Blink reflex test,95933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,58.78,143.09,APC
Blink reflex test,95933,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,58.78,143.09,APC
Blink reflex test,95933,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,58.78,143.09,APC
Neuromuscular junction test,95937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.3,,,,,,,fee schedule,86.08,230.78,
Neuromuscular junction test,95937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.47,,,,,,,fee schedule,86.08,230.78,
Neuromuscular junction test,95937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.08,,,,,,,fee schedule,86.08,230.78,
Neuromuscular junction test,95937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151,,,,,,,fee schedule,86.08,230.78,
Neuromuscular junction test,95937,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,86.08,230.78,APC
Neuromuscular junction test,95937,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,86.08,230.78,APC
Neuromuscular junction test,95937,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,86.08,230.78,APC
Somatosensory testing,95938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1002.27,,,,,,,fee schedule,657.09,1540.17,
Somatosensory testing,95938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,820.36,,,,,,,fee schedule,657.09,1540.17,
Somatosensory testing,95938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,657.09,,,,,,,fee schedule,657.09,1540.17,
Somatosensory testing,95938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1152.61,,,,,,,fee schedule,657.09,1540.17,
Somatosensory testing,95938,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,657.09,1540.17,APC
Somatosensory testing,95938,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,657.09,1540.17,APC
Somatosensory testing,95938,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,657.09,1540.17,APC
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,176.78,,,,,,,fee schedule,115.9,1540.17,
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,144.69,,,,,,,fee schedule,115.9,1540.17,
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,115.9,,,,,,,fee schedule,115.9,1540.17,
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,203.3,,,,,,,fee schedule,115.9,1540.17,
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,115.9,1540.17,APC
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,115.9,1540.17,APC
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,115.9,1540.17,APC
Ionm in operatng room 15 min,95940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,17.99,31.56,
Ionm in operatng room 15 min,95940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,17.99,31.56,
Ionm in operatng room 15 min,95940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,17.99,31.56,
Ionm in operatng room 15 min,95940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,17.99,31.56,
EEG monitoring/giving drugs,95954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,904.39,,,,,,,fee schedule,371.82,1040.05,
EEG monitoring/giving drugs,95954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,740.24,,,,,,,fee schedule,371.82,1040.05,
EEG monitoring/giving drugs,95954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,592.92,,,,,,,fee schedule,371.82,1040.05,
EEG monitoring/giving drugs,95954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1040.05,,,,,,,fee schedule,371.82,1040.05,
EEG monitoring/giving drugs,95954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1040.05,APC
EEG monitoring/giving drugs,95954,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1040.05,APC
EEG monitoring/giving drugs,95954,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1040.05,APC
EEG during surgery,95955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,442.9,,,,,,,fee schedule,290.37,509.34,
EEG during surgery,95955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,362.51,,,,,,,fee schedule,290.37,509.34,
EEG during surgery,95955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,290.37,,,,,,,fee schedule,290.37,509.34,
EEG during surgery,95955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,509.34,,,,,,,fee schedule,290.37,509.34,
EEG digital analysis,95957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,553.6,,,,,,,fee schedule,362.94,636.64,
EEG digital analysis,95957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,453.12,,,,,,,fee schedule,362.94,636.64,
EEG digital analysis,95957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,362.94,,,,,,,fee schedule,362.94,636.64,
EEG digital analysis,95957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,636.64,,,,,,,fee schedule,362.94,636.64,
EEG monitoring/function test,95958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,977.88,,,,,,,fee schedule,641.1,1540.17,
EEG monitoring/function test,95958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,800.39,,,,,,,fee schedule,641.1,1540.17,
EEG monitoring/function test,95958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,641.1,,,,,,,fee schedule,641.1,1540.17,
EEG monitoring/function test,95958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1124.56,,,,,,,fee schedule,641.1,1540.17,
EEG monitoring/function test,95958,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,641.1,1540.17,APC
EEG monitoring/function test,95958,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,641.1,1540.17,APC
EEG monitoring/function test,95958,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,641.1,1540.17,APC
Electrode stimulation brain,95961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.86,,,,,,,fee schedule,259.53,1540.17,
Electrode stimulation brain,95961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.01,,,,,,,fee schedule,259.53,1540.17,
Electrode stimulation brain,95961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.53,,,,,,,fee schedule,259.53,1540.17,
Electrode stimulation brain,95961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.24,,,,,,,fee schedule,259.53,1540.17,
Electrode stimulation brain,95961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,259.53,1540.17,APC
Electrode stimulation brain,95961,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,259.53,1540.17,APC
Electrode stimulation brain,95961,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,259.53,1540.17,APC
Electrode stim brain add-on,95962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.98,,,,,,,fee schedule,159.3,279.43,
Electrode stim brain add-on,95962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.88,,,,,,,fee schedule,159.3,279.43,
Electrode stim brain add-on,95962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.3,,,,,,,fee schedule,159.3,279.43,
Electrode stim brain add-on,95962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,279.43,,,,,,,fee schedule,159.3,279.43,
Meg spontaneous,95965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4707.21,,,,,,,fee schedule,855.65,5413.29,
Meg spontaneous,95965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3852.85,,,,,,,fee schedule,855.65,5413.29,
Meg spontaneous,95965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3086.05,,,,,,,fee schedule,855.65,5413.29,
Meg spontaneous,95965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5413.29,,,,,,,fee schedule,855.65,5413.29,
Meg spontaneous,95965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,5413.29,APC
Meg spontaneous,95965,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,5413.29,APC
Meg spontaneous,95965,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,5413.29,APC
Meg evoked single,95966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2359.49,,,,,,,fee schedule,855.65,2713.41,
Meg evoked single,95966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1931.24,,,,,,,fee schedule,855.65,2713.41,
Meg evoked single,95966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1546.88,,,,,,,fee schedule,855.65,2713.41,
Meg evoked single,95966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2713.41,,,,,,,fee schedule,855.65,2713.41,
Meg evoked single,95966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,2713.41,APC
Meg evoked single,95966,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,2713.41,APC
Meg evoked single,95966,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,2713.41,APC
Meg evoked each addl,95967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2069.44,,,,,,,fee schedule,1356.72,2379.86,
Meg evoked each addl,95967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1693.84,,,,,,,fee schedule,1356.72,2379.86,
Meg evoked each addl,95967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1356.72,,,,,,,fee schedule,1356.72,2379.86,
Meg evoked each addl,95967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2379.86,,,,,,,fee schedule,1356.72,2379.86,
Analyze neurostim no prog,95970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,238.63,
Analyze neurostim no prog,95970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,238.63,
Analyze neurostim no prog,95970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,238.63,
Analyze neurostim no prog,95970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,238.63,
Analyze neurostim no prog,95970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,98.06,238.63,APC
Analyze neurostim no prog,95970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,98.06,238.63,APC
Analyze neurostim no prog,95970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,98.06,238.63,APC
Analyze neurostim simple,95971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.36,,,,,,,fee schedule,94.73,187.86,
Analyze neurostim simple,95971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.71,,,,,,,fee schedule,94.73,187.86,
Analyze neurostim simple,95971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.1,,,,,,,fee schedule,94.73,187.86,
Analyze neurostim simple,95971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.86,,,,,,,fee schedule,94.73,187.86,
Analyze neurostim simple,95971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,187.86,APC
Analyze neurostim simple,95971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,187.86,APC
Analyze neurostim simple,95971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,187.86,APC
Analyze neurostim complex,95972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.36,,,,,,,fee schedule,94.73,187.86,
Analyze neurostim complex,95972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.71,,,,,,,fee schedule,94.73,187.86,
Analyze neurostim complex,95972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.1,,,,,,,fee schedule,94.73,187.86,
Analyze neurostim complex,95972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.86,,,,,,,fee schedule,94.73,187.86,
Analyze neurostim complex,95972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,187.86,APC
Analyze neurostim complex,95972,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,187.86,APC
Analyze neurostim complex,95972,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,187.86,APC
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.56,,,,,,,fee schedule,37.19,112.19,
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.85,,,,,,,fee schedule,37.19,112.19,
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.96,,,,,,,fee schedule,37.19,112.19,
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.19,,,,,,,fee schedule,37.19,112.19,
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,112.19,APC
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,112.19,APC
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,112.19,APC
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,308.58,,,,,,,fee schedule,94.73,354.87,
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,252.57,,,,,,,fee schedule,94.73,354.87,
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.31,,,,,,,fee schedule,94.73,354.87,
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,354.87,,,,,,,fee schedule,94.73,354.87,
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,94.73,354.87,APC
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,94.73,354.87,APC
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,94.73,354.87,APC
Io anal gast n-stim init,95980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,22.47,39.42,
Io anal gast n-stim init,95980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,22.47,39.42,
Io anal gast n-stim init,95980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,22.47,39.42,
Io anal gast n-stim init,95980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,22.47,39.42,
Io anal gast n-stim subsq,95981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Io anal gast n-stim subsq,95981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Io anal gast n-stim subsq,95981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Io anal gast n-stim subsq,95981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Io anal gast n-stim subsq,95981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Io anal gast n-stim subsq,95981,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Io anal gast n-stim subsq,95981,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.56,,,,,,,fee schedule,34.46,66.94,
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.02,,,,,,,fee schedule,34.46,66.94,
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.46,,,,,,,fee schedule,34.46,66.94,
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.44,,,,,,,fee schedule,34.46,66.94,
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,34.46,66.94,APC
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,34.46,66.94,APC
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,34.46,66.94,APC
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.56,,,,,,,fee schedule,63.96,170.51,
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.85,,,,,,,fee schedule,63.96,170.51,
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.96,,,,,,,fee schedule,63.96,170.51,
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.19,,,,,,,fee schedule,63.96,170.51,
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.47,,,,,,,fee schedule,63.96,170.51,APC
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.73,,,,,,,fee schedule,63.96,170.51,APC
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.51,,,,,,,fee schedule,63.96,170.51,APC
Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.9,,,,,,,fee schedule,24.19,42.44,
Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.2,,,,,,,fee schedule,24.19,42.44,
Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.19,,,,,,,fee schedule,24.19,42.44,
Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.44,,,,,,,fee schedule,24.19,42.44,
Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,273.99,592.41,
Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,273.99,592.41,
Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,273.99,592.41,
Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,273.99,592.41,
Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,273.99,592.41,APC
Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,273.99,592.41,APC
Spin/brain pump refil & main,95990,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,273.99,592.41,APC
Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,345.48,,,,,,,fee schedule,226.5,550.53,
Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,282.78,,,,,,,fee schedule,226.5,550.53,
Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,226.5,,,,,,,fee schedule,226.5,550.53,
Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,397.3,,,,,,,fee schedule,226.5,550.53,
Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.14,,,,,,,fee schedule,226.5,550.53,APC
Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,305.85,,,,,,,fee schedule,226.5,550.53,APC
Spin/brain pump refil & main,95991,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,550.53,,,,,,,fee schedule,226.5,550.53,APC
Canalith repositioning proc,95992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.12,,,,,,,fee schedule,27.61,54.04,
Canalith repositioning proc,95992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.48,,,,,,,fee schedule,27.61,54.04,
Canalith repositioning proc,95992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.61,,,,,,,fee schedule,27.61,54.04,
Canalith repositioning proc,95992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.44,,,,,,,fee schedule,27.61,54.04,
Canalith repositioning proc,95992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.52,,,,,,,fee schedule,27.61,54.04,APC
Canalith repositioning proc,95992,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.02,,,,,,,fee schedule,27.61,54.04,APC
Canalith repositioning proc,95992,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54.04,,,,,,,fee schedule,27.61,54.04,APC
Neurological procedure,95999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
Neurological procedure,95999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
Neurological procedure,95999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Motion analysis video/3d,96000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,265.55,,,,,,,fee schedule,174.09,669.27,
Motion analysis video/3d,96000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,217.35,,,,,,,fee schedule,174.09,669.27,
Motion analysis video/3d,96000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.09,,,,,,,fee schedule,174.09,669.27,
Motion analysis video/3d,96000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,305.38,,,,,,,fee schedule,174.09,669.27,
Motion analysis video/3d,96000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,174.09,669.27,APC
Motion analysis video/3d,96000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,174.09,669.27,APC
Motion analysis video/3d,96000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,174.09,669.27,APC
Motion test w/ft press meas,96001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,339.99,,,,,,,fee schedule,222.9,1540.17,
Motion test w/ft press meas,96001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,278.28,,,,,,,fee schedule,222.9,1540.17,
Motion test w/ft press meas,96001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.9,,,,,,,fee schedule,222.9,1540.17,
Motion test w/ft press meas,96001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,390.99,,,,,,,fee schedule,222.9,1540.17,
Motion test w/ft press meas,96001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,222.9,1540.17,APC
Motion test w/ft press meas,96001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,222.9,1540.17,APC
Motion test w/ft press meas,96001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,222.9,1540.17,APC
Dynamic surface emg,96002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.73,,,,,,,fee schedule,39.81,387.26,
Dynamic surface emg,96002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.71,,,,,,,fee schedule,39.81,387.26,
Dynamic surface emg,96002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.81,,,,,,,fee schedule,39.81,387.26,
Dynamic surface emg,96002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.84,,,,,,,fee schedule,39.81,387.26,
Dynamic surface emg,96002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,39.81,387.26,APC
Dynamic surface emg,96002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,39.81,387.26,APC
Dynamic surface emg,96002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,39.81,387.26,APC
Phys review of motion tests,96004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.96,,,,,,,fee schedule,65.53,114.95,
Phys review of motion tests,96004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.82,,,,,,,fee schedule,65.53,114.95,
Phys review of motion tests,96004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.53,,,,,,,fee schedule,65.53,114.95,
Phys review of motion tests,96004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.95,,,,,,,fee schedule,65.53,114.95,
Genetic counseling svc ea 30,96041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.85,,,,,,,fee schedule,52.35,91.83,
Genetic counseling svc ea 30,96041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.36,,,,,,,fee schedule,52.35,91.83,
Genetic counseling svc ea 30,96041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.35,,,,,,,fee schedule,52.35,91.83,
Genetic counseling svc ea 30,96041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.83,,,,,,,fee schedule,52.35,91.83,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.51,,,,,,,fee schedule,78.35,169.54,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,78.35,169.54,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,78.35,169.54,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.82,,,,,,,fee schedule,78.35,169.54,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.35,,,,,,,fee schedule,78.35,169.54,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,78.35,169.54,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.44,,,,,,,fee schedule,78.35,169.54,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,78.35,169.54,
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.9,,,,,,,fee schedule,78.35,169.54,APC
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.19,,,,,,,fee schedule,78.35,169.54,APC
Assessment of aphasia,96105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,169.54,,,,,,,fee schedule,78.35,169.54,APC
Developmental screen w/score,96110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.47,,,,,,,fee schedule,16.7,123.63,
Developmental screen w/score,96110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,16.7,123.63,
Developmental screen w/score,96110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,16.7,123.63,
Developmental screen w/score,96110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.85,,,,,,,fee schedule,16.7,123.63,
Developmental screen w/score,96110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.7,,,,,,,fee schedule,16.7,123.63,
Developmental screen w/score,96110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,16.7,123.63,
Developmental screen w/score,96110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.29,,,,,,,fee schedule,16.7,123.63,
Developmental screen w/score,96110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,16.7,123.63,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,356.91,,,,,,,fee schedule,107.5,410.45,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,410.45,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,410.45,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,292.13,,,,,,,fee schedule,107.5,410.45,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.99,,,,,,,fee schedule,107.5,410.45,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,410.45,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.45,,,,,,,fee schedule,107.5,410.45,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,410.45,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,107.5,410.45,APC
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,107.5,410.45,APC
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,107.5,410.45,APC
Devel tst phys/qhp ea addl,96113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Devel tst phys/qhp ea addl,96113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Devel tst phys/qhp ea addl,96113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Devel tst phys/qhp ea addl,96113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Neurobehavioral status exam,96116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.43,,,,,,,fee schedule,215.15,399.54,
Neurobehavioral status exam,96116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.37,,,,,,,fee schedule,215.15,399.54,
Neurobehavioral status exam,96116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.78,,,,,,,fee schedule,215.15,399.54,
Neurobehavioral status exam,96116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.54,,,,,,,fee schedule,215.15,399.54,
Neurobehavioral status exam,96116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,399.54,APC
Neurobehavioral status exam,96116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,399.54,APC
Neurobehavioral status exam,96116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,399.54,APC
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.95,,,,,,,fee schedule,97,178.47,
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,97,178.47,
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,97,178.47,
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.1,,,,,,,fee schedule,97,178.47,
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97,,,,,,,fee schedule,97,178.47,
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,97,178.47,
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.14,,,,,,,fee schedule,97,178.47,
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,97,178.47,
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.11,,,,,,,fee schedule,97,178.47,APC
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,99.15,,,,,,,fee schedule,97,178.47,APC
Cognitive test by hc pro,96125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,178.47,,,,,,,fee schedule,97,178.47,APC
Brief emotional/behav assmt,96127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,10.27,66.99,
Brief emotional/behav assmt,96127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,10.27,66.99,
Brief emotional/behav assmt,96127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,66.99,
Brief emotional/behav assmt,96127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,10.27,66.99,
Brief emotional/behav assmt,96127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,10.27,66.99,APC
Brief emotional/behav assmt,96127,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,10.27,66.99,APC
Brief emotional/behav assmt,96127,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,10.27,66.99,APC
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,356.91,,,,,,,fee schedule,215.15,410.45,
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,292.13,,,,,,,fee schedule,215.15,410.45,
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.99,,,,,,,fee schedule,215.15,410.45,
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.45,,,,,,,fee schedule,215.15,410.45,
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,410.45,APC
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,410.45,APC
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,410.45,APC
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,356.91,,,,,,,fee schedule,233.99,669.27,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,292.13,,,,,,,fee schedule,233.99,669.27,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.99,,,,,,,fee schedule,233.99,669.27,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.45,,,,,,,fee schedule,233.99,669.27,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,233.99,669.27,APC
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,233.99,669.27,APC
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,233.99,669.27,APC
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,29.55,238.63,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,29.55,238.63,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,29.55,238.63,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,29.55,238.63,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,29.55,238.63,APC
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,29.55,238.63,APC
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,29.55,238.63,APC
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,29.55,801.21,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,29.55,801.21,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,29.55,801.21,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,29.55,801.21,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,29.55,801.21,APC
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,29.55,801.21,APC
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,29.55,801.21,APC
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,28.82,51.88,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,28.82,51.88,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,28.82,51.88,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,28.82,51.88,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.56,,,,,,,fee schedule,100.02,182.2,
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.87,,,,,,,fee schedule,100.02,182.2,
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.02,,,,,,,fee schedule,100.02,182.2,
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.44,,,,,,,fee schedule,100.02,182.2,
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,100.02,182.2,APC
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,100.02,182.2,APC
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,100.02,182.2,APC
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.56,,,,,,,fee schedule,100.02,318.34,
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.87,,,,,,,fee schedule,100.02,318.34,
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.02,,,,,,,fee schedule,100.02,318.34,
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.44,,,,,,,fee schedule,100.02,318.34,
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,100.02,318.34,APC
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,100.02,318.34,APC
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,100.02,318.34,APC
Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.37,,,,,,,fee schedule,27.12,47.58,
Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.86,,,,,,,fee schedule,27.12,47.58,
Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.12,,,,,,,fee schedule,27.12,47.58,
Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.58,,,,,,,fee schedule,27.12,47.58,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,24.74,67.2,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.89,,,,,,,fee schedule,24.74,67.2,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.74,,,,,,,fee schedule,24.74,67.2,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,24.74,67.2,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,24.74,67.2,APC
Pt-focused hlth risk assmt,96160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,24.74,67.2,APC
Pt-focused hlth risk assmt,96160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,24.74,67.2,APC
Caregiver health risk assmt,96161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,24.74,67.2,
Caregiver health risk assmt,96161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.89,,,,,,,fee schedule,24.74,67.2,
Caregiver health risk assmt,96161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.74,,,,,,,fee schedule,24.74,67.2,
Caregiver health risk assmt,96161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,24.74,67.2,
Caregiver health risk assmt,96161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,24.74,67.2,APC
Caregiver health risk assmt,96161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,24.74,67.2,APC
Caregiver health risk assmt,96161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,24.74,67.2,APC
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.07,,,,,,,fee schedule,34.79,67.2,
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.44,,,,,,,fee schedule,34.79,67.2,
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.79,,,,,,,fee schedule,34.79,67.2,
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.03,,,,,,,fee schedule,34.79,67.2,
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,34.79,67.2,APC
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,34.79,67.2,APC
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,34.79,67.2,APC
Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.71,,,,,,,fee schedule,5.05,8.87,
Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.31,,,,,,,fee schedule,5.05,8.87,
Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.05,,,,,,,fee schedule,5.05,8.87,
Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.87,,,,,,,fee schedule,5.05,8.87,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.07,,,,,,,fee schedule,34.79,67.2,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.44,,,,,,,fee schedule,34.79,67.2,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.79,,,,,,,fee schedule,34.79,67.2,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.03,,,,,,,fee schedule,34.79,67.2,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,34.79,67.2,APC
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,34.79,67.2,APC
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,34.79,67.2,APC
Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.57,,,,,,,fee schedule,29.88,52.41,
Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.3,,,,,,,fee schedule,29.88,52.41,
Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.88,,,,,,,fee schedule,29.88,52.41,
Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.41,,,,,,,fee schedule,29.88,52.41,
Hlth bhv ivntj fam wo pt 1st,96170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.54,,,,,,,fee schedule,100.66,176.57,
Hlth bhv ivntj fam wo pt 1st,96170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.67,,,,,,,fee schedule,100.66,176.57,
Hlth bhv ivntj fam wo pt 1st,96170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.66,,,,,,,fee schedule,100.66,176.57,
Hlth bhv ivntj fam wo pt 1st,96170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.57,,,,,,,fee schedule,100.66,176.57,
Hlth bhv ivntj fam w/o pt ea,96171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.09,,,,,,,fee schedule,36.77,64.5,
Hlth bhv ivntj fam w/o pt ea,96171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.91,,,,,,,fee schedule,36.77,64.5,
Hlth bhv ivntj fam w/o pt ea,96171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.77,,,,,,,fee schedule,36.77,64.5,
Hlth bhv ivntj fam w/o pt ea,96171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.5,,,,,,,fee schedule,36.77,64.5,
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.53,,,,,,,fee schedule,9.53,30.92,
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.89,,,,,,,fee schedule,9.53,30.92,
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.53,,,,,,,fee schedule,9.53,30.92,
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.71,,,,,,,fee schedule,9.53,30.92,
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.04,,,,,,,fee schedule,9.53,30.92,APC
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.18,,,,,,,fee schedule,9.53,30.92,APC
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.92,,,,,,,fee schedule,9.53,30.92,APC
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.17,,,,,,,fee schedule,2.08,9.4,
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.59,,,,,,,fee schedule,2.08,9.4,
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.08,,,,,,,fee schedule,2.08,9.4,
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.65,,,,,,,fee schedule,2.08,9.4,
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.48,,,,,,,fee schedule,2.08,9.4,APC
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.22,,,,,,,fee schedule,2.08,9.4,APC
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.4,,,,,,,fee schedule,2.08,9.4,APC
Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.07,,,,,,,fee schedule,144.28,381.49,
Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.13,,,,,,,fee schedule,144.28,381.49,
Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,144.28,,,,,,,fee schedule,144.28,381.49,
Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,253.08,,,,,,,fee schedule,144.28,381.49,
Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,144.28,381.49,APC
Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,144.28,381.49,APC
Hydration iv infusion init,96360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,144.28,381.49,APC
Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.33,,,,,,,fee schedule,46.66,145.28,
Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.4,,,,,,,fee schedule,46.66,145.28,
Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.82,,,,,,,fee schedule,46.66,145.28,
Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.28,,,,,,,fee schedule,46.66,145.28,
Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,46.66,145.28,APC
Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,46.66,145.28,APC
Hydrate iv infusion add-on,96361,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,46.66,145.28,APC
Ther/proph/diag iv inf init,96365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.7,,,,,,,fee schedule,150.59,381.49,
Ther/proph/diag iv inf init,96365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,188.01,,,,,,,fee schedule,150.59,381.49,
Ther/proph/diag iv inf init,96365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.59,,,,,,,fee schedule,150.59,381.49,
Ther/proph/diag iv inf init,96365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,264.16,,,,,,,fee schedule,150.59,381.49,
Ther/proph/diag iv inf init,96365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,150.59,381.49,APC
Ther/proph/diag iv inf init,96365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,150.59,381.49,APC
Ther/proph/diag iv inf init,96365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,150.59,381.49,APC
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.01,,,,,,,fee schedule,46.66,169.06,
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.33,,,,,,,fee schedule,46.66,169.06,
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.38,,,,,,,fee schedule,46.66,169.06,
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.06,,,,,,,fee schedule,46.66,169.06,
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,46.66,169.06,APC
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,46.66,169.06,APC
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,46.66,169.06,APC
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,213.05,,,,,,,fee schedule,71.74,245.01,
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.38,,,,,,,fee schedule,71.74,245.01,
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.68,,,,,,,fee schedule,71.74,245.01,
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,245.01,,,,,,,fee schedule,71.74,245.01,
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,71.74,245.01,APC
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,71.74,245.01,APC
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,71.74,245.01,APC
Ther/diag concurrent inf,96368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,207.08,,,,,,,fee schedule,135.76,238.14,
Ther/diag concurrent inf,96368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.49,,,,,,,fee schedule,135.76,238.14,
Ther/diag concurrent inf,96368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.76,,,,,,,fee schedule,135.76,238.14,
Ther/diag concurrent inf,96368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,238.14,,,,,,,fee schedule,135.76,238.14,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.84,,,,,,,fee schedule,176.25,381.49,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.05,,,,,,,fee schedule,176.25,381.49,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.25,,,,,,,fee schedule,176.25,381.49,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.17,,,,,,,fee schedule,176.25,381.49,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,176.25,381.49,APC
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,176.25,381.49,APC
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,176.25,381.49,APC
Sc ther infusion addl hr,96370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Sc ther infusion addl hr,96370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Sc ther infusion addl hr,96370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Sc ther infusion addl hr,96370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Sc ther infusion addl hr,96370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Sc ther infusion addl hr,96370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Sc ther infusion addl hr,96370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Sc ther infusion reset pump,96371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.53,,,,,,,fee schedule,52.14,129.13,
Sc ther infusion reset pump,96371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.1,,,,,,,fee schedule,52.14,129.13,
Sc ther infusion reset pump,96371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.14,,,,,,,fee schedule,52.14,129.13,
Sc ther infusion reset pump,96371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.46,,,,,,,fee schedule,52.14,129.13,
Sc ther infusion reset pump,96371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,52.14,129.13,APC
Sc ther infusion reset pump,96371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,52.14,129.13,APC
Sc ther infusion reset pump,96371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,52.14,129.13,APC
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.91,,,,,,,fee schedule,71.74,129.13,
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.6,,,,,,,fee schedule,71.74,129.13,
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.37,,,,,,,fee schedule,71.74,129.13,
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.7,,,,,,,fee schedule,71.74,129.13,
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,71.74,129.13,APC
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,71.74,129.13,APC
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,71.74,129.13,APC
Ther/proph/diag inj ia,96373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.84,,,,,,,fee schedule,176.25,381.49,
Ther/proph/diag inj ia,96373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.05,,,,,,,fee schedule,176.25,381.49,
Ther/proph/diag inj ia,96373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.25,,,,,,,fee schedule,176.25,381.49,
Ther/proph/diag inj ia,96373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.17,,,,,,,fee schedule,176.25,381.49,
Ther/proph/diag inj ia,96373,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,176.25,381.49,APC
Ther/proph/diag inj ia,96373,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,176.25,381.49,APC
Ther/proph/diag inj ia,96373,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,176.25,381.49,APC
Ther/proph/diag inj iv push,96374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.57,,,,,,,fee schedule,117.07,381.49,
Ther/proph/diag inj iv push,96374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.16,,,,,,,fee schedule,117.07,381.49,
Ther/proph/diag inj iv push,96374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.07,,,,,,,fee schedule,117.07,381.49,
Ther/proph/diag inj iv push,96374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.36,,,,,,,fee schedule,117.07,381.49,
Ther/proph/diag inj iv push,96374,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,117.07,381.49,APC
Ther/proph/diag inj iv push,96374,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,117.07,381.49,APC
Ther/proph/diag inj iv push,96374,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,117.07,381.49,APC
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191,,,,,,,fee schedule,46.66,219.65,
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.33,,,,,,,fee schedule,46.66,219.65,
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.22,,,,,,,fee schedule,46.66,219.65,
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,219.65,,,,,,,fee schedule,46.66,219.65,
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,46.66,219.65,APC
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,46.66,219.65,APC
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,46.66,219.65,APC
Tx/pro/dx inj same drug adon,96376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,174.17,,,,,,,fee schedule,114.19,200.3,
Tx/pro/dx inj same drug adon,96376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.56,,,,,,,fee schedule,114.19,200.3,
Tx/pro/dx inj same drug adon,96376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.19,,,,,,,fee schedule,114.19,200.3,
Tx/pro/dx inj same drug adon,96376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,200.3,,,,,,,fee schedule,114.19,200.3,
Applicaton on-body injector,96377,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,46.66,83.98,APC
Applicaton on-body injector,96377,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,46.66,83.98,APC
Applicaton on-body injector,96377,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,46.66,83.98,APC
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,46.66,83.98,APC
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,46.66,83.98,APC
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,46.66,83.98,APC
Admn rsv monoc antb im cnsl,96380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.55,,,,,,,fee schedule,22.65,39.73,
Admn rsv monoc antb im cnsl,96380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.28,,,,,,,fee schedule,22.65,39.73,
Admn rsv monoc antb im cnsl,96380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.65,,,,,,,fee schedule,22.65,39.73,
Admn rsv monoc antb im cnsl,96380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.73,,,,,,,fee schedule,22.65,39.73,
1 admn rsv monoc antb im njx,96381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.82,,,,,,,fee schedule,19.55,34.29,
1 admn rsv monoc antb im njx,96381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.41,,,,,,,fee schedule,19.55,34.29,
1 admn rsv monoc antb im njx,96381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.55,,,,,,,fee schedule,19.55,34.29,
1 admn rsv monoc antb im njx,96381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.29,,,,,,,fee schedule,19.55,34.29,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,264.39,,,,,,,fee schedule,71.74,304.05,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,216.4,,,,,,,fee schedule,71.74,304.05,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.33,,,,,,,fee schedule,71.74,304.05,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,304.05,,,,,,,fee schedule,71.74,304.05,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,71.74,304.05,APC
Chemo anti-neopl sq/im,96401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,71.74,304.05,APC
Chemo anti-neopl sq/im,96401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,71.74,304.05,APC
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.14,,,,,,,fee schedule,71.74,293.41,
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.83,,,,,,,fee schedule,71.74,293.41,
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.27,,,,,,,fee schedule,71.74,293.41,
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,293.41,,,,,,,fee schedule,71.74,293.41,
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,71.74,293.41,APC
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,71.74,293.41,APC
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,71.74,293.41,APC
Chemo intralesional up to 7,96405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.53,,,,,,,fee schedule,52.14,129.13,
Chemo intralesional up to 7,96405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.1,,,,,,,fee schedule,52.14,129.13,
Chemo intralesional up to 7,96405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.14,,,,,,,fee schedule,52.14,129.13,
Chemo intralesional up to 7,96405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.46,,,,,,,fee schedule,52.14,129.13,
Chemo intralesional up to 7,96405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,52.14,129.13,APC
Chemo intralesional up to 7,96405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,52.14,129.13,APC
Chemo intralesional up to 7,96405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,52.14,129.13,APC
Chemo intralesional over 7,96406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.84,,,,,,,fee schedule,176.25,381.49,
Chemo intralesional over 7,96406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.05,,,,,,,fee schedule,176.25,381.49,
Chemo intralesional over 7,96406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.25,,,,,,,fee schedule,176.25,381.49,
Chemo intralesional over 7,96406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.17,,,,,,,fee schedule,176.25,381.49,
Chemo intralesional over 7,96406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,176.25,381.49,APC
Chemo intralesional over 7,96406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,176.25,381.49,APC
Chemo intralesional over 7,96406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,176.25,381.49,APC
Chemo iv push sngl drug,96409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.46,,,,,,,fee schedule,191.74,592.41,
Chemo iv push sngl drug,96409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.38,,,,,,,fee schedule,191.74,592.41,
Chemo iv push sngl drug,96409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.74,,,,,,,fee schedule,191.74,592.41,
Chemo iv push sngl drug,96409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,336.33,,,,,,,fee schedule,191.74,592.41,
Chemo iv push sngl drug,96409,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,191.74,592.41,APC
Chemo iv push sngl drug,96409,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,191.74,592.41,APC
Chemo iv push sngl drug,96409,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,191.74,592.41,APC
Chemo iv push addl drug,96411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,265.87,,,,,,,fee schedule,71.74,305.75,
Chemo iv push addl drug,96411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,217.61,,,,,,,fee schedule,71.74,305.75,
Chemo iv push addl drug,96411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.3,,,,,,,fee schedule,71.74,305.75,
Chemo iv push addl drug,96411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,305.75,,,,,,,fee schedule,71.74,305.75,
Chemo iv push addl drug,96411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,71.74,305.75,APC
Chemo iv push addl drug,96411,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,71.74,305.75,APC
Chemo iv push addl drug,96411,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,71.74,305.75,APC
Chemo iv infusion 1 hr,96413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,306.33,,,,,,,fee schedule,200.83,592.41,
Chemo iv infusion 1 hr,96413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,250.73,,,,,,,fee schedule,200.83,592.41,
Chemo iv infusion 1 hr,96413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,200.83,,,,,,,fee schedule,200.83,592.41,
Chemo iv infusion 1 hr,96413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,352.28,,,,,,,fee schedule,200.83,592.41,
Chemo iv infusion 1 hr,96413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,200.83,592.41,APC
Chemo iv infusion 1 hr,96413,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,200.83,592.41,APC
Chemo iv infusion 1 hr,96413,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,200.83,592.41,APC
Chemo iv infusion addl hr,96415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,176.58,,,,,,,fee schedule,71.74,203.07,
Chemo iv infusion addl hr,96415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,144.53,,,,,,,fee schedule,71.74,203.07,
Chemo iv infusion addl hr,96415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,115.77,,,,,,,fee schedule,71.74,203.07,
Chemo iv infusion addl hr,96415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,203.07,,,,,,,fee schedule,71.74,203.07,
Chemo iv infusion addl hr,96415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,71.74,203.07,APC
Chemo iv infusion addl hr,96415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,71.74,203.07,APC
Chemo iv infusion addl hr,96415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,71.74,203.07,APC
Chemo prolong infuse w/pump,96416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,273.99,592.41,
Chemo prolong infuse w/pump,96416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,273.99,592.41,
Chemo prolong infuse w/pump,96416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,273.99,592.41,
Chemo prolong infuse w/pump,96416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,273.99,592.41,
Chemo prolong infuse w/pump,96416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,273.99,592.41,APC
Chemo prolong infuse w/pump,96416,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,273.99,592.41,APC
Chemo prolong infuse w/pump,96416,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,273.99,592.41,APC
Chemo iv infus each addl seq,96417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,337.57,,,,,,,fee schedule,71.74,388.21,
Chemo iv infus each addl seq,96417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,276.3,,,,,,,fee schedule,71.74,388.21,
Chemo iv infus each addl seq,96417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,221.31,,,,,,,fee schedule,71.74,388.21,
Chemo iv infus each addl seq,96417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,388.21,,,,,,,fee schedule,71.74,388.21,
Chemo iv infus each addl seq,96417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,71.74,388.21,APC
Chemo iv infus each addl seq,96417,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,71.74,388.21,APC
Chemo iv infus each addl seq,96417,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,71.74,388.21,APC
Chemo ia push tecnique,96420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,273.99,592.41,
Chemo ia push tecnique,96420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,273.99,592.41,
Chemo ia push tecnique,96420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,273.99,592.41,
Chemo ia push tecnique,96420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,273.99,592.41,
Chemo ia push tecnique,96420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,273.99,592.41,APC
Chemo ia push tecnique,96420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,273.99,592.41,APC
Chemo ia push tecnique,96420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,273.99,592.41,APC
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.84,,,,,,,fee schedule,176.25,592.41,
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.05,,,,,,,fee schedule,176.25,592.41,
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.25,,,,,,,fee schedule,176.25,592.41,
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.17,,,,,,,fee schedule,176.25,592.41,
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,176.25,592.41,APC
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,176.25,592.41,APC
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,176.25,592.41,APC
Chemo ia infuse each addl hr,96423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Chemo ia infuse each addl hr,96423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Chemo ia infuse each addl hr,96423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Chemo ia infuse each addl hr,96423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Chemo ia infuse each addl hr,96423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Chemo ia infuse each addl hr,96423,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Chemo ia infuse each addl hr,96423,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Chemotherapy infusion method,96425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,273.99,592.41,
Chemotherapy infusion method,96425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,273.99,592.41,
Chemotherapy infusion method,96425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,273.99,592.41,
Chemotherapy infusion method,96425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,273.99,592.41,
Chemotherapy infusion method,96425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,273.99,592.41,APC
Chemotherapy infusion method,96425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,273.99,592.41,APC
Chemotherapy infusion method,96425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,273.99,592.41,APC
Chemotherapy intracavitary,96440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,273.99,592.41,
Chemotherapy intracavitary,96440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,273.99,592.41,
Chemotherapy intracavitary,96440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,273.99,592.41,
Chemotherapy intracavitary,96440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,273.99,592.41,
Chemotherapy intracavitary,96440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,273.99,592.41,APC
Chemotherapy intracavitary,96440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,273.99,592.41,APC
Chemotherapy intracavitary,96440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,273.99,592.41,APC
Chemotx admn prtl cavity,96446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,525.83,,,,,,,fee schedule,329.12,604.7,
Chemotx admn prtl cavity,96446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,430.39,,,,,,,fee schedule,329.12,604.7,
Chemotx admn prtl cavity,96446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,344.73,,,,,,,fee schedule,329.12,604.7,
Chemotx admn prtl cavity,96446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,604.7,,,,,,,fee schedule,329.12,604.7,
Chemotx admn prtl cavity,96446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,329.12,604.7,APC
Chemotx admn prtl cavity,96446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,329.12,604.7,APC
Chemotx admn prtl cavity,96446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,329.12,604.7,APC
Chemotherapy into cns,96450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.59,,,,,,,fee schedule,133.47,592.41,
Chemotherapy into cns,96450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.64,,,,,,,fee schedule,133.47,592.41,
Chemotherapy into cns,96450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.47,,,,,,,fee schedule,133.47,592.41,
Chemotherapy into cns,96450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,234.13,,,,,,,fee schedule,133.47,592.41,
Chemotherapy into cns,96450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,133.47,592.41,APC
Chemotherapy into cns,96450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,133.47,592.41,APC
Chemotherapy into cns,96450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,133.47,592.41,APC
Refill/maint portable pump,96521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.84,,,,,,,fee schedule,176.25,381.49,
Refill/maint portable pump,96521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.05,,,,,,,fee schedule,176.25,381.49,
Refill/maint portable pump,96521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.25,,,,,,,fee schedule,176.25,381.49,
Refill/maint portable pump,96521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.17,,,,,,,fee schedule,176.25,381.49,
Refill/maint portable pump,96521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,176.25,381.49,APC
Refill/maint portable pump,96521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,176.25,381.49,APC
Refill/maint portable pump,96521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,176.25,381.49,APC
Refill/maint pump/resvr syst,96522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.84,,,,,,,fee schedule,176.25,381.49,
Refill/maint pump/resvr syst,96522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.05,,,,,,,fee schedule,176.25,381.49,
Refill/maint pump/resvr syst,96522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.25,,,,,,,fee schedule,176.25,381.49,
Refill/maint pump/resvr syst,96522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.17,,,,,,,fee schedule,176.25,381.49,
Refill/maint pump/resvr syst,96522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,176.25,381.49,APC
Refill/maint pump/resvr syst,96522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,176.25,381.49,APC
Refill/maint pump/resvr syst,96522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,176.25,381.49,APC
Irrig drug delivery device,96523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Irrig drug delivery device,96523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Irrig drug delivery device,96523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Irrig drug delivery device,96523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Irrig drug delivery device,96523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Irrig drug delivery device,96523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Irrig drug delivery device,96523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Chemotherapy injection,96542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.84,,,,,,,fee schedule,176.25,592.41,
Chemotherapy injection,96542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.05,,,,,,,fee schedule,176.25,592.41,
Chemotherapy injection,96542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.25,,,,,,,fee schedule,176.25,592.41,
Chemotherapy injection,96542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.17,,,,,,,fee schedule,176.25,592.41,
Chemotherapy injection,96542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,176.25,592.41,APC
Chemotherapy injection,96542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,176.25,592.41,APC
Chemotherapy injection,96542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,176.25,592.41,APC
Chemotherapy unspecified,96549,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,46.66,83.98,APC
Chemotherapy unspecified,96549,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,46.66,83.98,APC
Chemotherapy unspecified,96549,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,46.66,83.98,APC
Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Photodynamic tx skin,96567,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Photodynmc tx 30 min add-on,96570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.3,,,,,,,fee schedule,21.83,38.3,
Photodynmc tx 30 min add-on,96570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.26,,,,,,,fee schedule,21.83,38.3,
Photodynmc tx 30 min add-on,96570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.83,,,,,,,fee schedule,21.83,38.3,
Photodynmc tx 30 min add-on,96570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.3,,,,,,,fee schedule,21.83,38.3,
Photodynamic tx addl 15 min,96571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,10.27,18.02,
Photodynamic tx addl 15 min,96571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,10.27,18.02,
Photodynamic tx addl 15 min,96571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,18.02,
Photodynamic tx addl 15 min,96571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,10.27,18.02,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,461.21,,,,,,,fee schedule,199.91,530.39,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,377.5,,,,,,,fee schedule,199.91,530.39,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,302.37,,,,,,,fee schedule,199.91,530.39,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,530.39,,,,,,,fee schedule,199.91,530.39,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,530.39,APC
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,530.39,APC
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,530.39,APC
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,461.21,,,,,,,fee schedule,199.91,530.39,
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,377.5,,,,,,,fee schedule,199.91,530.39,
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,302.37,,,,,,,fee schedule,199.91,530.39,
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,530.39,,,,,,,fee schedule,199.91,530.39,
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,530.39,APC
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,530.39,APC
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,530.39,APC
Ultraviolet light therapy,96900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Ultraviolet light therapy,96900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Ultraviolet light therapy,96900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Ultraviolet light therapy,96900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Ultraviolet light therapy,96900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Ultraviolet light therapy,96900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Ultraviolet light therapy,96900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Trichogram,96902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.64,,,,,,,fee schedule,11.56,20.29,
Trichogram,96902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.44,,,,,,,fee schedule,11.56,20.29,
Trichogram,96902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.56,,,,,,,fee schedule,11.56,20.29,
Trichogram,96902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.29,,,,,,,fee schedule,11.56,20.29,
Whole Body Photography,96904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.47,,,,,,,fee schedule,112.42,197.19,
Whole Body Photography,96904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.35,,,,,,,fee schedule,112.42,197.19,
Whole Body Photography,96904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.42,,,,,,,fee schedule,112.42,197.19,
Whole Body Photography,96904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.19,,,,,,,fee schedule,112.42,197.19,
Photochemotherapy with UV-B,96910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Photochemotherapy with UV-B,96910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Photochemotherapy with UV-B,96910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Photochemotherapy with UV-B,96910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Photochemotherapy with UV-B,96910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Photochemotherapy with UV-B,96910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Photochemotherapy with UV-B,96910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Photochemotherapy with UV-A,96912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Photochemotherapy with UV-A,96912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Photochemotherapy with UV-A,96912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Photochemotherapy with UV-A,96912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Photochemotherapy with UV-A,96912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Photochemotherapy with UV-A,96912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Photochemotherapy with UV-A,96912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
Photochemotherapy uv-a or b,96913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,286.88,729.1,
Photochemotherapy uv-a or b,96913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,286.88,729.1,
Photochemotherapy uv-a or b,96913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,286.88,729.1,
Photochemotherapy uv-a or b,96913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,286.88,729.1,
Photochemotherapy uv-a or b,96913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,286.88,729.1,APC
Photochemotherapy uv-a or b,96913,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,286.88,729.1,APC
Photochemotherapy uv-a or b,96913,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,286.88,729.1,APC
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,729.1,
Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,729.1,
Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,729.1,
Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,729.1,
Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,150.12,729.1,APC
Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,150.12,729.1,APC
Laser tx skin >500 sq cm,96922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,150.12,729.1,APC
Rcm celulr subcelulr img skn,96931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,441.92,,,,,,,fee schedule,289.72,508.21,
Rcm celulr subcelulr img skn,96931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,361.71,,,,,,,fee schedule,289.72,508.21,
Rcm celulr subcelulr img skn,96931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,289.72,,,,,,,fee schedule,289.72,508.21,
Rcm celulr subcelulr img skn,96931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,508.21,,,,,,,fee schedule,289.72,508.21,
Rcm celulr subcelulr img skn,96932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,286.11,,,,,,,fee schedule,187.57,329.03,
Rcm celulr subcelulr img skn,96932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.18,,,,,,,fee schedule,187.57,329.03,
Rcm celulr subcelulr img skn,96932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,187.57,,,,,,,fee schedule,187.57,329.03,
Rcm celulr subcelulr img skn,96932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,329.03,,,,,,,fee schedule,187.57,329.03,
Rcm celulr subcelulr img skn,96933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.26,,,,,,,fee schedule,23.12,40.55,
Rcm celulr subcelulr img skn,96933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.86,,,,,,,fee schedule,23.12,40.55,
Rcm celulr subcelulr img skn,96933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.12,,,,,,,fee schedule,23.12,40.55,
Rcm celulr subcelulr img skn,96933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.55,,,,,,,fee schedule,23.12,40.55,
Rcm celulr subcelulr img skn,96934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.32,,,,,,,fee schedule,149.03,261.42,
Rcm celulr subcelulr img skn,96934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.06,,,,,,,fee schedule,149.03,261.42,
Rcm celulr subcelulr img skn,96934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.03,,,,,,,fee schedule,149.03,261.42,
Rcm celulr subcelulr img skn,96934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.42,,,,,,,fee schedule,149.03,261.42,
Rcm celulr subcelulr img skn,96935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.02,,,,,,,fee schedule,62.95,110.42,
Rcm celulr subcelulr img skn,96935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.59,,,,,,,fee schedule,62.95,110.42,
Rcm celulr subcelulr img skn,96935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.95,,,,,,,fee schedule,62.95,110.42,
Rcm celulr subcelulr img skn,96935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,110.42,,,,,,,fee schedule,62.95,110.42,
Rcm celulr subcelulr img skn,96936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.3,,,,,,,fee schedule,21.83,38.3,
Rcm celulr subcelulr img skn,96936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.26,,,,,,,fee schedule,21.83,38.3,
Rcm celulr subcelulr img skn,96936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.83,,,,,,,fee schedule,21.83,38.3,
Rcm celulr subcelulr img skn,96936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.3,,,,,,,fee schedule,21.83,38.3,
Dermatological procedure,96999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,199.91,359.84,APC
Dermatological procedure,96999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,199.91,359.84,APC
Dermatological procedure,96999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,199.91,359.84,APC
Hot or cold packs therapy,97010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.8,,,,,,,fee schedule,6.42,123.63,
Hot or cold packs therapy,97010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,6.42,123.63,
Hot or cold packs therapy,97010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,6.42,123.63,
Hot or cold packs therapy,97010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.02,,,,,,,fee schedule,6.42,123.63,
Hot or cold packs therapy,97010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.42,,,,,,,fee schedule,6.42,123.63,
Hot or cold packs therapy,97010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,6.42,123.63,
Hot or cold packs therapy,97010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.27,,,,,,,fee schedule,6.42,123.63,
Hot or cold packs therapy,97010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,6.42,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,12.85,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,12.85,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,12.85,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,12.85,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,12.85,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,12.85,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,12.85,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,12.85,123.63,
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.1,,,,,,,fee schedule,12.85,123.63,APC
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.38,,,,,,,fee schedule,12.85,123.63,APC
Mechanical traction therapy,97012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.88,,,,,,,fee schedule,12.85,123.63,APC
Electric stimulation therapy,97014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.47,,,,,,,fee schedule,16.7,123.63,
Electric stimulation therapy,97014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,16.7,123.63,
Electric stimulation therapy,97014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,16.7,123.63,
Electric stimulation therapy,97014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.85,,,,,,,fee schedule,16.7,123.63,
Electric stimulation therapy,97014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.7,,,,,,,fee schedule,16.7,123.63,
Electric stimulation therapy,97014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,16.7,123.63,
Electric stimulation therapy,97014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.29,,,,,,,fee schedule,16.7,123.63,
Electric stimulation therapy,97014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,16.7,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.26,,,,,,,fee schedule,12.05,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,12.05,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,12.05,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.86,,,,,,,fee schedule,12.05,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.12,,,,,,,fee schedule,12.05,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,12.05,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.55,,,,,,,fee schedule,12.05,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,12.05,123.63,
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,12.05,123.63,APC
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.05,,,,,,,fee schedule,12.05,123.63,APC
Vasopneumatic device therapy,97016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.69,,,,,,,fee schedule,12.05,123.63,APC
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.51,,,,,,,fee schedule,6.11,123.63,
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,6.11,123.63,
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,6.11,123.63,
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.24,,,,,,,fee schedule,6.11,123.63,
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.41,,,,,,,fee schedule,6.11,123.63,
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,6.11,123.63,
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.04,,,,,,,fee schedule,6.11,123.63,
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,6.11,123.63,
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.42,,,,,,,fee schedule,6.11,123.63,APC
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.11,,,,,,,fee schedule,6.11,123.63,APC
Paraffin bath therapy,97018,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11,,,,,,,fee schedule,6.11,123.63,APC
Microwave therapy,97020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Microwave therapy,97020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Microwave therapy,97020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Microwave therapy,97020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.03,,,,,,,fee schedule,14.9,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,14.9,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,14.9,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.31,,,,,,,fee schedule,14.9,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.49,,,,,,,fee schedule,14.9,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,14.9,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.23,,,,,,,fee schedule,14.9,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,14.9,123.63,
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.64,,,,,,,fee schedule,14.9,123.63,APC
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.9,,,,,,,fee schedule,14.9,123.63,APC
Whirlpool therapy,97022,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.82,,,,,,,fee schedule,14.9,123.63,APC
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.75,,,,,,,fee schedule,6.96,123.63,
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,6.96,123.63,
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,6.96,123.63,
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.62,,,,,,,fee schedule,6.96,123.63,
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.7,,,,,,,fee schedule,6.96,123.63,
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,6.96,123.63,
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.51,,,,,,,fee schedule,6.96,123.63,
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,6.96,123.63,
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.31,,,,,,,fee schedule,6.96,123.63,APC
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.96,,,,,,,fee schedule,6.96,123.63,APC
Diathermy eg microwave,97024,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.53,,,,,,,fee schedule,6.96,123.63,APC
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.8,,,,,,,fee schedule,6.35,123.63,
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,6.35,123.63,
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,6.35,123.63,
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.02,,,,,,,fee schedule,6.35,123.63,
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.42,,,,,,,fee schedule,6.35,123.63,
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,6.35,123.63,
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.27,,,,,,,fee schedule,6.35,123.63,
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,6.35,123.63,
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.67,,,,,,,fee schedule,6.35,123.63,APC
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.35,,,,,,,fee schedule,6.35,123.63,APC
Infrared therapy,97026,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.43,,,,,,,fee schedule,6.35,123.63,APC
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.75,,,,,,,fee schedule,7.7,123.63,
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,7.7,123.63,
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,7.7,123.63,
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.62,,,,,,,fee schedule,7.7,123.63,
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.7,,,,,,,fee schedule,7.7,123.63,
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,7.7,123.63,
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.51,,,,,,,fee schedule,7.7,123.63,
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,7.7,123.63,
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.33,,,,,,,fee schedule,7.7,123.63,APC
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.93,,,,,,,fee schedule,7.7,123.63,APC
Ultraviolet therapy,97028,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.27,,,,,,,fee schedule,7.7,123.63,APC
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,14.22,123.63,
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,14.22,123.63,
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,14.22,123.63,
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,14.22,123.63,
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,14.22,123.63,
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,14.22,123.63,
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,14.22,123.63,
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,14.22,123.63,
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.93,,,,,,,fee schedule,14.22,123.63,APC
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.22,,,,,,,fee schedule,14.22,123.63,APC
Electrical stimulation,97032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.6,,,,,,,fee schedule,14.22,123.63,APC
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,18.21,123.63,
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,18.21,123.63,
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,18.21,123.63,
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,18.21,123.63,
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,18.21,123.63,
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,18.21,123.63,
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,18.21,123.63,
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,18.21,123.63,
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.12,,,,,,,fee schedule,18.21,123.63,APC
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.21,,,,,,,fee schedule,18.21,123.63,APC
Electric current therapy,97033,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.78,,,,,,,fee schedule,18.21,123.63,APC
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.43,,,,,,,fee schedule,13.49,123.63,
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,13.49,123.63,
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,13.49,123.63,
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.27,,,,,,,fee schedule,13.49,123.63,
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.64,,,,,,,fee schedule,13.49,123.63,
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,13.49,123.63,
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.69,,,,,,,fee schedule,13.49,123.63,
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,13.49,123.63,
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.16,,,,,,,fee schedule,13.49,123.63,APC
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.49,,,,,,,fee schedule,13.49,123.63,APC
Contrast bath therapy,97034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.28,,,,,,,fee schedule,13.49,123.63,APC
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.69,,,,,,,fee schedule,8.98,123.63,
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,8.98,123.63,
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,8.98,123.63,
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.21,,,,,,,fee schedule,8.98,123.63,
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.98,,,,,,,fee schedule,8.98,123.63,
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,8.98,123.63,
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.74,,,,,,,fee schedule,8.98,123.63,
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,8.98,123.63,
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.49,,,,,,,fee schedule,8.98,123.63,APC
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.8,,,,,,,fee schedule,8.98,123.63,APC
Ultrasound therapy,97035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24.84,,,,,,,fee schedule,8.98,123.63,APC
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.7,,,,,,,fee schedule,34.09,123.63,
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,34.09,123.63,
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,34.09,123.63,
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.32,,,,,,,fee schedule,34.09,123.63,
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.11,,,,,,,fee schedule,34.09,123.63,
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,34.09,123.63,
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.11,,,,,,,fee schedule,34.09,123.63,
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,34.09,123.63,
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.79,,,,,,,fee schedule,34.09,123.63,APC
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.09,,,,,,,fee schedule,34.09,123.63,APC
Hydrotherapy,97036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.36,,,,,,,fee schedule,34.09,123.63,APC
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.05,,,,,,,fee schedule,37.22,123.63,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,37.22,123.63,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,37.22,123.63,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.52,,,,,,,fee schedule,37.22,123.63,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.27,,,,,,,fee schedule,37.22,123.63,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,37.22,123.63,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.41,,,,,,,fee schedule,37.22,123.63,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,37.22,123.63,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,37.22,123.63,APC
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,37.22,123.63,APC
Appl modality 1+lllt po pain,97037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,37.22,123.63,APC
Physical therapy treatment,97039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Physical therapy treatment,97039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Physical therapy treatment,97039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Physical therapy treatment,97039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.09,,,,,,,fee schedule,27.91,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,27.91,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,27.91,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,27.91,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,27.91,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,27.91,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.7,,,,,,,fee schedule,27.91,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,27.91,123.63,
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.31,,,,,,,fee schedule,27.91,123.63,APC
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.91,,,,,,,fee schedule,27.91,123.63,APC
Therapeutic exercises,97110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.24,,,,,,,fee schedule,27.91,123.63,APC
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.03,,,,,,,fee schedule,31.41,123.63,
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,31.41,123.63,
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,31.41,123.63,
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.31,,,,,,,fee schedule,31.41,123.63,
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.49,,,,,,,fee schedule,31.41,123.63,
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,31.41,123.63,
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.23,,,,,,,fee schedule,31.41,123.63,
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,31.41,123.63,
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.98,,,,,,,fee schedule,31.41,123.63,APC
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.41,,,,,,,fee schedule,31.41,123.63,APC
Neuromuscular reeducation,97112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56.54,,,,,,,fee schedule,31.41,123.63,APC
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.44,,,,,,,fee schedule,36.58,123.63,
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,36.58,123.63,
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,36.58,123.63,
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.75,,,,,,,fee schedule,36.58,123.63,
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.46,,,,,,,fee schedule,36.58,123.63,
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,36.58,123.63,
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.76,,,,,,,fee schedule,36.58,123.63,
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,36.58,123.63,
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.41,,,,,,,fee schedule,36.58,123.63,APC
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.58,,,,,,,fee schedule,36.58,123.63,APC
Aquatic therapy/exercises,97113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.84,,,,,,,fee schedule,36.58,123.63,APC
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.22,,,,,,,fee schedule,25.06,123.63,
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,25.06,123.63,
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,25.06,123.63,
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.28,,,,,,,fee schedule,25.06,123.63,
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.06,,,,,,,fee schedule,25.06,123.63,
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,25.06,123.63,
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.95,,,,,,,fee schedule,25.06,123.63,
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,25.06,123.63,
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.25,,,,,,,fee schedule,25.06,123.63,APC
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.81,,,,,,,fee schedule,25.06,123.63,APC
Gait training therapy,97116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.86,,,,,,,fee schedule,25.06,123.63,APC
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,24.4,123.63,
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,24.4,123.63,
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,24.4,123.63,
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,24.4,123.63,
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,24.4,123.63,
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,24.4,123.63,
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,24.4,123.63,
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,24.4,123.63,
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.81,,,,,,,fee schedule,24.4,123.63,APC
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.34,,,,,,,fee schedule,24.4,123.63,APC
Massage therapy,97124,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.81,,,,,,,fee schedule,24.4,123.63,APC
Ther ivntj w/focus cog funcj,97127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Ther ivntj w/focus cog funcj,97127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Ther ivntj w/focus cog funcj,97127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Ther ivntj w/focus cog funcj,97127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.97,,,,,,,fee schedule,19.52,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,19.52,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,19.52,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.44,,,,,,,fee schedule,19.52,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.79,,,,,,,fee schedule,19.52,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,19.52,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.02,,,,,,,fee schedule,19.52,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,19.52,123.63,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.5,,,,,,,fee schedule,19.52,123.63,APC
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.52,,,,,,,fee schedule,19.52,123.63,APC
Ther ivntj 1st 15 min,97129,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.14,,,,,,,fee schedule,19.52,123.63,APC
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.57,,,,,,,fee schedule,18.29,123.63,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,18.29,123.63,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,18.29,123.63,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.3,,,,,,,fee schedule,18.29,123.63,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.88,,,,,,,fee schedule,18.29,123.63,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,18.29,123.63,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.41,,,,,,,fee schedule,18.29,123.63,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,18.29,123.63,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.2,,,,,,,fee schedule,18.29,123.63,APC
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.29,,,,,,,fee schedule,18.29,123.63,APC
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.92,,,,,,,fee schedule,18.29,123.63,APC
Physical medicine procedure,97139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Physical medicine procedure,97139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Physical medicine procedure,97139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Physical medicine procedure,97139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.17,,,,,,,fee schedule,26.34,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,26.34,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,26.34,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.88,,,,,,,fee schedule,26.34,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.34,,,,,,,fee schedule,26.34,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,26.34,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.2,,,,,,,fee schedule,26.34,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,26.34,123.63,
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.96,,,,,,,fee schedule,26.34,123.63,APC
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.63,,,,,,,fee schedule,26.34,123.63,APC
Manual therapy 1/> regions,97140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.93,,,,,,,fee schedule,26.34,123.63,APC
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.63,,,,,,,fee schedule,12.21,123.63,
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,12.21,123.63,
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,12.21,123.63,
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.25,,,,,,,fee schedule,12.21,123.63,
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.21,,,,,,,fee schedule,12.21,123.63,
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,12.21,123.63,
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.42,,,,,,,fee schedule,12.21,123.63,
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,12.21,123.63,
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.89,,,,,,,fee schedule,12.21,123.63,APC
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.99,,,,,,,fee schedule,12.21,123.63,APC
Group therapeutic procedures,97150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.38,,,,,,,fee schedule,12.21,123.63,APC
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.63,,,,,,,fee schedule,57.45,182.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,57.45,182.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,57.45,182.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.73,,,,,,,fee schedule,57.45,182.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.45,,,,,,,fee schedule,57.45,182.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,57.45,182.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.77,,,,,,,fee schedule,57.45,182.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,57.45,182.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,57.45,182.2,APC
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,57.45,182.2,APC
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,57.45,182.2,APC
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.63,,,,,,,fee schedule,57.45,182.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,57.45,182.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,57.45,182.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.73,,,,,,,fee schedule,57.45,182.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.45,,,,,,,fee schedule,57.45,182.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,57.45,182.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.77,,,,,,,fee schedule,57.45,182.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,57.45,182.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,57.45,182.2,APC
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,57.45,182.2,APC
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,57.45,182.2,APC
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.63,,,,,,,fee schedule,57.45,182.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,57.45,182.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,57.45,182.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.73,,,,,,,fee schedule,57.45,182.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.45,,,,,,,fee schedule,57.45,182.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,57.45,182.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.77,,,,,,,fee schedule,57.45,182.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,57.45,182.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,57.45,182.2,APC
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,57.45,182.2,APC
Adaptive behavior tx by tech,97153,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,57.45,182.2,APC
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.63,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.73,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.45,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.77,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,123.63,APC
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,123.63,APC
Grp adapt bhv tx by tech,97154,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,123.63,APC
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.63,,,,,,,fee schedule,57.45,318.34,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,57.45,318.34,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,57.45,318.34,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.73,,,,,,,fee schedule,57.45,318.34,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.45,,,,,,,fee schedule,57.45,318.34,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,57.45,318.34,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.77,,,,,,,fee schedule,57.45,318.34,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,57.45,318.34,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,57.45,318.34,APC
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,57.45,318.34,APC
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,57.45,318.34,APC
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.63,,,,,,,fee schedule,37.33,123.63,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,37.33,123.63,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,37.33,123.63,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.73,,,,,,,fee schedule,37.33,123.63,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.45,,,,,,,fee schedule,37.33,123.63,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,37.33,123.63,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.77,,,,,,,fee schedule,37.33,123.63,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,37.33,123.63,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,123.63,APC
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,123.63,APC
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,123.63,APC
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.63,,,,,,,fee schedule,37.33,123.63,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,37.33,123.63,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,37.33,123.63,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.73,,,,,,,fee schedule,37.33,123.63,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.45,,,,,,,fee schedule,37.33,123.63,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,37.33,123.63,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.77,,,,,,,fee schedule,37.33,123.63,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,37.33,123.63,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,123.63,APC
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,123.63,APC
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,123.63,APC
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.63,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.73,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.45,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.77,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,37.33,123.63,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,123.63,APC
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,123.63,APC
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,123.63,APC
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.02,,,,,,,fee schedule,62.95,173.66,
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,62.95,173.66,
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,62.95,173.66,
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.59,,,,,,,fee schedule,62.95,173.66,
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.95,,,,,,,fee schedule,62.95,173.66,
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,62.95,173.66,
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,110.42,,,,,,,fee schedule,62.95,173.66,
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,62.95,173.66,
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.3,,,,,,,fee schedule,62.95,173.66,APC
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.48,,,,,,,fee schedule,62.95,173.66,APC
Pt eval low complex 20 min,97161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.66,,,,,,,fee schedule,62.95,173.66,APC
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.02,,,,,,,fee schedule,62.95,173.66,
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,62.95,173.66,
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,62.95,173.66,
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.59,,,,,,,fee schedule,62.95,173.66,
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.95,,,,,,,fee schedule,62.95,173.66,
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,62.95,173.66,
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,110.42,,,,,,,fee schedule,62.95,173.66,
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,62.95,173.66,
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.3,,,,,,,fee schedule,62.95,173.66,APC
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.48,,,,,,,fee schedule,62.95,173.66,APC
Pt eval mod complex 30 min,97162,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.66,,,,,,,fee schedule,62.95,173.66,APC
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.02,,,,,,,fee schedule,62.95,169.02,
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,62.95,169.02,
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,62.95,169.02,
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.59,,,,,,,fee schedule,62.95,169.02,
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.95,,,,,,,fee schedule,62.95,169.02,
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,62.95,169.02,
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,110.42,,,,,,,fee schedule,62.95,169.02,
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,62.95,169.02,
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.6,,,,,,,fee schedule,62.95,169.02,APC
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,93.9,,,,,,,fee schedule,62.95,169.02,APC
Pt eval high complex 45 min,97163,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,169.02,,,,,,,fee schedule,62.95,169.02,APC
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.54,,,,,,,fee schedule,46.9,119.65,
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.46,,,,,,,fee schedule,46.9,119.65,
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.46,,,,,,,fee schedule,46.9,119.65,
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.56,,,,,,,fee schedule,46.9,119.65,
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.9,,,,,,,fee schedule,46.9,119.65,
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.98,,,,,,,fee schedule,46.9,119.65,
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.27,,,,,,,fee schedule,46.9,119.65,
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.46,,,,,,,fee schedule,46.9,119.65,
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.79,,,,,,,fee schedule,46.9,119.65,APC
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,66.47,,,,,,,fee schedule,46.9,119.65,APC
Pt re-eval est plan care,97164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,119.65,,,,,,,fee schedule,46.9,119.65,APC
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.16,,,,,,,fee schedule,58.45,173.41,
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,58.45,173.41,
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,58.45,173.41,
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.98,,,,,,,fee schedule,58.45,173.41,
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.45,,,,,,,fee schedule,58.45,173.41,
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,58.45,173.41,
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.53,,,,,,,fee schedule,58.45,173.41,
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,58.45,173.41,
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.16,,,,,,,fee schedule,58.45,173.41,APC
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.34,,,,,,,fee schedule,58.45,173.41,APC
Ot eval low complex 30 min,97165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.41,,,,,,,fee schedule,58.45,173.41,APC
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.16,,,,,,,fee schedule,58.45,173.41,
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,58.45,173.41,
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,58.45,173.41,
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.98,,,,,,,fee schedule,58.45,173.41,
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.45,,,,,,,fee schedule,58.45,173.41,
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,58.45,173.41,
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.53,,,,,,,fee schedule,58.45,173.41,
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,58.45,173.41,
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.16,,,,,,,fee schedule,58.45,173.41,APC
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.34,,,,,,,fee schedule,58.45,173.41,APC
Ot eval mod complex 45 min,97166,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.41,,,,,,,fee schedule,58.45,173.41,APC
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.16,,,,,,,fee schedule,58.45,178.31,
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.93,,,,,,,fee schedule,58.45,178.31,
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.93,,,,,,,fee schedule,58.45,178.31,
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.98,,,,,,,fee schedule,58.45,178.31,
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.45,,,,,,,fee schedule,58.45,178.31,
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.97,,,,,,,fee schedule,58.45,178.31,
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.53,,,,,,,fee schedule,58.45,178.31,
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.93,,,,,,,fee schedule,58.45,178.31,
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.01,,,,,,,fee schedule,58.45,178.31,APC
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,99.06,,,,,,,fee schedule,58.45,178.31,APC
Ot eval high complex 60 min,97167,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,178.31,,,,,,,fee schedule,58.45,178.31,APC
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.7,,,,,,,fee schedule,41.76,117.68,
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.46,,,,,,,fee schedule,41.76,117.68,
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.46,,,,,,,fee schedule,41.76,117.68,
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.14,,,,,,,fee schedule,41.76,117.68,
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.76,,,,,,,fee schedule,41.76,117.68,
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.98,,,,,,,fee schedule,41.76,117.68,
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.26,,,,,,,fee schedule,41.76,117.68,
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.46,,,,,,,fee schedule,41.76,117.68,
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.65,,,,,,,fee schedule,41.76,117.68,APC
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.38,,,,,,,fee schedule,41.76,117.68,APC
Ot re-eval est plan care,97168,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,117.68,,,,,,,fee schedule,41.76,117.68,APC
Athletic trn eval low cmplx,97169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval low cmplx,97169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval low cmplx,97169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval low cmplx,97169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.39,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval low cmplx,97169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.59,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval low cmplx,97169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval low cmplx,97169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.55,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval low cmplx,97169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.39,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.59,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.55,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval high cmplx,97171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval high cmplx,97171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval high cmplx,97171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval high cmplx,97171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.39,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval high cmplx,97171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.59,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval high cmplx,97171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval high cmplx,97171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.55,,,,,,,fee schedule,63.59,123.63,
Athletic trn eval high cmplx,97171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,63.59,123.63,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.03,,,,,,,fee schedule,31.49,123.63,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,31.49,123.63,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,31.49,123.63,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.31,,,,,,,fee schedule,31.49,123.63,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.49,,,,,,,fee schedule,31.49,123.63,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,31.49,123.63,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.23,,,,,,,fee schedule,31.49,123.63,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,31.49,123.63,
Orthotic training,97504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Orthotic training,97504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Orthotic training,97504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Orthotic training,97504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Prosthetic training,97520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Prosthetic training,97520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Prosthetic training,97520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Prosthetic training,97520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.91,,,,,,,fee schedule,33.37,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,33.37,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,33.37,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.31,,,,,,,fee schedule,33.37,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.69,,,,,,,fee schedule,33.37,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,33.37,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.85,,,,,,,fee schedule,33.37,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,33.37,123.63,
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.04,,,,,,,fee schedule,33.37,123.63,APC
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.37,,,,,,,fee schedule,33.37,123.63,APC
Therapeutic activities,97530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,60.07,,,,,,,fee schedule,33.37,123.63,APC
Cognitive Skills Development,97532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Cognitive Skills Development,97532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Cognitive Skills Development,97532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Cognitive Skills Development,97532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,24.4,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,24.4,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,24.4,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,24.4,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,24.4,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,24.4,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,24.4,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,24.4,123.63,
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,62.43,,,,,,,fee schedule,24.4,123.63,APC
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,59.46,,,,,,,fee schedule,24.4,123.63,APC
Sensory Integration,97533,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,107.03,,,,,,,fee schedule,24.4,123.63,APC
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.95,,,,,,,fee schedule,30.96,123.63,
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,30.96,123.63,
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,30.96,123.63,
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.7,,,,,,,fee schedule,30.96,123.63,
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.4,,,,,,,fee schedule,30.96,123.63,
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,30.96,123.63,
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.59,,,,,,,fee schedule,30.96,123.63,
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,30.96,123.63,
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.51,,,,,,,fee schedule,30.96,123.63,APC
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.96,,,,,,,fee schedule,30.96,123.63,APC
Self care mngment training,97535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55.73,,,,,,,fee schedule,30.96,123.63,APC
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.22,,,,,,,fee schedule,25.06,123.63,
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,25.06,123.63,
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,25.06,123.63,
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.28,,,,,,,fee schedule,25.06,123.63,
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.06,,,,,,,fee schedule,25.06,123.63,
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,25.06,123.63,
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.95,,,,,,,fee schedule,25.06,123.63,
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,25.06,123.63,
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.33,,,,,,,fee schedule,25.06,123.63,APC
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.74,,,,,,,fee schedule,25.06,123.63,APC
Community/work reintegration,97537,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57.13,,,,,,,fee schedule,25.06,123.63,APC
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.21,,,,,,,fee schedule,25.71,123.63,
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,25.71,123.63,
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,25.71,123.63,
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.09,,,,,,,fee schedule,25.71,123.63,
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.71,,,,,,,fee schedule,25.71,123.63,
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,25.71,123.63,
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.09,,,,,,,fee schedule,25.71,123.63,
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,25.71,123.63,
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.32,,,,,,,fee schedule,25.71,123.63,APC
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.78,,,,,,,fee schedule,25.71,123.63,APC
Wheelchair mngment training,97542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55.4,,,,,,,fee schedule,25.71,123.63,APC
Work hardening,97545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,238.09,,,,,,,fee schedule,107.5,273.8,
Work hardening,97545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,273.8,
Work hardening,97545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,273.8,
Work hardening,97545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.88,,,,,,,fee schedule,107.5,273.8,
Work hardening,97545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.09,,,,,,,fee schedule,107.5,273.8,
Work hardening,97545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,273.8,
Work hardening,97545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,273.8,,,,,,,fee schedule,107.5,273.8,
Work hardening,97545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,273.8,
Work hardening add-on,97546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.03,,,,,,,fee schedule,62.3,123.63,
Work hardening add-on,97546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,62.3,123.63,
Work hardening add-on,97546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,62.3,123.63,
Work hardening add-on,97546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.78,,,,,,,fee schedule,62.3,123.63,
Work hardening add-on,97546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.3,,,,,,,fee schedule,62.3,123.63,
Work hardening add-on,97546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,62.3,123.63,
Work hardening add-on,97546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.28,,,,,,,fee schedule,62.3,123.63,
Work hardening add-on,97546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,62.3,123.63,
Caregiver traing 1st 30 min,97550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.1,,,,,,,fee schedule,21.7,71.59,
Caregiver traing 1st 30 min,97550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.09,,,,,,,fee schedule,21.7,71.59,
Caregiver traing 1st 30 min,97550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.7,,,,,,,fee schedule,21.7,71.59,
Caregiver traing 1st 30 min,97550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.07,,,,,,,fee schedule,21.7,71.59,
Caregiver traing 1st 30 min,97550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.76,,,,,,,fee schedule,21.7,71.59,APC
Caregiver traing 1st 30 min,97550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.77,,,,,,,fee schedule,21.7,71.59,APC
Caregiver traing 1st 30 min,97550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,71.59,,,,,,,fee schedule,21.7,71.59,APC
Caregiver traing ea addl 15,97551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.19,,,,,,,fee schedule,9.3,37.69,
Caregiver traing ea addl 15,97551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.61,,,,,,,fee schedule,9.3,37.69,
Caregiver traing ea addl 15,97551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.3,,,,,,,fee schedule,9.3,37.69,
Caregiver traing ea addl 15,97551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.32,,,,,,,fee schedule,9.3,37.69,
Caregiver traing ea addl 15,97551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.99,,,,,,,fee schedule,9.3,37.69,APC
Caregiver traing ea addl 15,97551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.94,,,,,,,fee schedule,9.3,37.69,APC
Caregiver traing ea addl 15,97551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.69,,,,,,,fee schedule,9.3,37.69,APC
Group caregiver training,97552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.42,,,,,,,fee schedule,9.53,29.23,
Group caregiver training,97552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.81,,,,,,,fee schedule,9.53,29.23,
Group caregiver training,97552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.67,,,,,,,fee schedule,9.53,29.23,
Group caregiver training,97552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.23,,,,,,,fee schedule,9.53,29.23,
Group caregiver training,97552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.01,,,,,,,fee schedule,9.53,29.23,APC
Group caregiver training,97552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.53,,,,,,,fee schedule,9.53,29.23,APC
Group caregiver training,97552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.15,,,,,,,fee schedule,9.53,29.23,APC
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.61,,,,,,,fee schedule,112.51,359.84,
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.46,,,,,,,fee schedule,112.51,359.84,
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.51,,,,,,,fee schedule,112.51,359.84,
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.35,,,,,,,fee schedule,112.51,359.84,
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,112.51,359.84,APC
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,112.51,359.84,APC
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,112.51,359.84,APC
Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,183.17,,,,,,,fee schedule,120.09,210.65,
Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.92,,,,,,,fee schedule,120.09,210.65,
Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,120.09,,,,,,,fee schedule,120.09,210.65,
Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,210.65,,,,,,,fee schedule,120.09,210.65,
Wound(s) care non-selective,97602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Wound(s) care non-selective,97602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Wound(s) care non-selective,97602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Wound(s) care non-selective,97602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Wound(s) care non-selective,97602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Wound(s) care non-selective,97602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Wound(s) care non-selective,97602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Neg press wound tx <=50 cm,97605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,289.47,,,,,,,fee schedule,189.78,359.84,
Neg press wound tx <=50 cm,97605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,236.93,,,,,,,fee schedule,189.78,359.84,
Neg press wound tx <=50 cm,97605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,189.78,,,,,,,fee schedule,189.78,359.84,
Neg press wound tx <=50 cm,97605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,332.89,,,,,,,fee schedule,189.78,359.84,
Neg press wound tx <=50 cm,97605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,189.78,359.84,APC
Neg press wound tx <=50 cm,97605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,189.78,359.84,APC
Neg press wound tx <=50 cm,97605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,189.78,359.84,APC
Neg press wound tx >50 cm,97606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,286.88,729.1,
Neg press wound tx >50 cm,97606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,286.88,729.1,
Neg press wound tx >50 cm,97606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,286.88,729.1,
Neg press wound tx >50 cm,97606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,286.88,729.1,
Neg press wound tx >50 cm,97606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,286.88,729.1,APC
Neg press wound tx >50 cm,97606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,286.88,729.1,APC
Neg press wound tx >50 cm,97606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,286.88,729.1,APC
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,281.69,,,,,,,fee schedule,184.68,729.1,
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,230.56,,,,,,,fee schedule,184.68,729.1,
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,184.68,,,,,,,fee schedule,184.68,729.1,
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,323.94,,,,,,,fee schedule,184.68,729.1,
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,184.68,729.1,APC
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,184.68,729.1,APC
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,184.68,729.1,APC
Neg press wound tx >50 cm,97608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.59,,,,,,,fee schedule,286.88,729.1,
Neg press wound tx >50 cm,97608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.17,,,,,,,fee schedule,286.88,729.1,
Neg press wound tx >50 cm,97608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.88,,,,,,,fee schedule,286.88,729.1,
Neg press wound tx >50 cm,97608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.23,,,,,,,fee schedule,286.88,729.1,
Neg press wound tx >50 cm,97608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.31,,,,,,,fee schedule,286.88,729.1,APC
Neg press wound tx >50 cm,97608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,405.05,,,,,,,fee schedule,286.88,729.1,APC
Neg press wound tx >50 cm,97608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,729.1,,,,,,,fee schedule,286.88,729.1,APC
Low frequency non-thermal us,97610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Low frequency non-thermal us,97610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Low frequency non-thermal us,97610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Low frequency non-thermal us,97610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Low frequency non-thermal us,97610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Low frequency non-thermal us,97610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Low frequency non-thermal us,97610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,29.55,123.63,
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,29.55,123.63,
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,29.55,123.63,
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,29.55,123.63,
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,29.55,123.63,
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,29.55,123.63,
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,29.55,123.63,
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,29.55,123.63,
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.99,,,,,,,fee schedule,29.55,123.63,APC
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.32,,,,,,,fee schedule,29.55,123.63,APC
Physical performance test,97750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59.98,,,,,,,fee schedule,29.55,123.63,APC
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,123.63,
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,23.77,123.63,
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,23.77,123.63,
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,123.63,
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,123.63,
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,23.77,123.63,
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,123.63,
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,23.77,123.63,
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.15,,,,,,,fee schedule,23.77,123.63,APC
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.33,,,,,,,fee schedule,23.77,123.63,APC
Assistive technology assess,97755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.39,,,,,,,fee schedule,23.77,123.63,APC
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.76,,,,,,,fee schedule,39.18,123.63,
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,39.18,123.63,
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,39.18,123.63,
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.91,,,,,,,fee schedule,39.18,123.63,
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.18,,,,,,,fee schedule,39.18,123.63,
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,39.18,123.63,
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.72,,,,,,,fee schedule,39.18,123.63,
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,39.18,123.63,
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.79,,,,,,,fee schedule,39.18,123.63,APC
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.61,,,,,,,fee schedule,39.18,123.63,APC
Orthotic mgmt and training,97760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78.5,,,,,,,fee schedule,39.18,123.63,APC
Prosthetic training,97761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,69.16,
Prosthetic training,97761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,69.16,
Prosthetic training,97761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,69.16,
Prosthetic training,97761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,69.16,
Prosthetic training,97761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.34,,,,,,,fee schedule,30.19,69.16,APC
Prosthetic training,97761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.42,,,,,,,fee schedule,30.19,69.16,APC
Prosthetic training,97761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.16,,,,,,,fee schedule,30.19,69.16,APC
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.5,,,,,,,fee schedule,49.15,98.33,
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.98,,,,,,,fee schedule,49.15,98.33,
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.05,,,,,,,fee schedule,49.15,98.33,
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.33,,,,,,,fee schedule,49.15,98.33,
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.61,,,,,,,fee schedule,49.15,98.33,APC
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.15,,,,,,,fee schedule,49.15,98.33,APC
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88.47,,,,,,,fee schedule,49.15,98.33,APC
Physical medicine procedure,97799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Physical medicine procedure,97799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
Physical medicine procedure,97799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
Physical medicine procedure,97799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
Medical nutrition indiv in,97802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.04,,,,,,,fee schedule,26.32,51.8,
Medical nutrition indiv in,97802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.87,,,,,,,fee schedule,26.32,51.8,
Medical nutrition indiv in,97802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.53,,,,,,,fee schedule,26.32,51.8,
Medical nutrition indiv in,97802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.8,,,,,,,fee schedule,26.32,51.8,
Medical nutrition indiv in,97802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.64,,,,,,,fee schedule,26.32,51.8,APC
Medical nutrition indiv in,97802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.32,,,,,,,fee schedule,26.32,51.8,APC
Medical nutrition indiv in,97802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.38,,,,,,,fee schedule,26.32,51.8,APC
Med nutrition indiv subseq,97803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.35,,,,,,,fee schedule,21.51,51,
Med nutrition indiv subseq,97803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.3,,,,,,,fee schedule,21.51,51,
Med nutrition indiv subseq,97803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.08,,,,,,,fee schedule,21.51,51,
Med nutrition indiv subseq,97803,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51,,,,,,,fee schedule,21.51,51,
Med nutrition indiv subseq,97803,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,51,APC
Med nutrition indiv subseq,97803,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,51,APC
Med nutrition indiv subseq,97803,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.72,,,,,,,fee schedule,21.51,51,APC
Medical nutrition group,97804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.63,,,,,,,fee schedule,12.08,21.74,
Medical nutrition group,97804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.25,,,,,,,fee schedule,12.08,21.74,
Medical nutrition group,97804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.21,,,,,,,fee schedule,12.08,21.74,
Medical nutrition group,97804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.42,,,,,,,fee schedule,12.08,21.74,
Medical nutrition group,97804,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.68,,,,,,,fee schedule,12.08,21.74,APC
Medical nutrition group,97804,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.08,,,,,,,fee schedule,12.08,21.74,APC
Medical nutrition group,97804,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.74,,,,,,,fee schedule,12.08,21.74,APC
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.72,,,,,,,fee schedule,19.48,51.88,
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.33,,,,,,,fee schedule,19.48,51.88,
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.48,,,,,,,fee schedule,19.48,51.88,
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.18,,,,,,,fee schedule,19.48,51.88,
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,19.48,51.88,APC
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,19.48,51.88,APC
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,19.48,51.88,APC
Acupunct w/o stimul addl 15m,97811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.53,,,,,,,fee schedule,14.12,24.76,
Acupunct w/o stimul addl 15m,97811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.62,,,,,,,fee schedule,14.12,24.76,
Acupunct w/o stimul addl 15m,97811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.12,,,,,,,fee schedule,14.12,24.76,
Acupunct w/o stimul addl 15m,97811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.76,,,,,,,fee schedule,14.12,24.76,
Acupunct w/stimul 15 min,97813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.69,,,,,,,fee schedule,18.81,51.88,
Acupunct w/stimul 15 min,97813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.48,,,,,,,fee schedule,18.81,51.88,
Acupunct w/stimul 15 min,97813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.81,,,,,,,fee schedule,18.81,51.88,
Acupunct w/stimul 15 min,97813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.99,,,,,,,fee schedule,18.81,51.88,
Acupunct w/stimul 15 min,97813,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,18.81,51.88,APC
Acupunct w/stimul 15 min,97813,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,18.81,51.88,APC
Acupunct w/stimul 15 min,97813,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,18.81,51.88,APC
Acupunct w/stimul addl 15m,97814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.54,,,,,,,fee schedule,14.78,25.92,
Acupunct w/stimul addl 15m,97814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.45,,,,,,,fee schedule,14.78,25.92,
Acupunct w/stimul addl 15m,97814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.78,,,,,,,fee schedule,14.78,25.92,
Acupunct w/stimul addl 15m,97814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.92,,,,,,,fee schedule,14.78,25.92,
Synch audio-video new sf 15,98000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.62,,,,,,,fee schedule,19.42,34.06,
Synch audio-video new sf 15,98000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.24,,,,,,,fee schedule,19.42,34.06,
Synch audio-video new sf 15,98000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.42,,,,,,,fee schedule,19.42,34.06,
Synch audio-video new sf 15,98000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.06,,,,,,,fee schedule,19.42,34.06,
Synch audio-video new low 30,98001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.43,,,,,,,fee schedule,29.13,51.09,
Synch audio-video new low 30,98001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.37,,,,,,,fee schedule,29.13,51.09,
Synch audio-video new low 30,98001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.13,,,,,,,fee schedule,29.13,51.09,
Synch audio-video new low 30,98001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.09,,,,,,,fee schedule,29.13,51.09,
Synch audio-video new mod 45,98002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.23,,,,,,,fee schedule,44.73,78.46,
Synch audio-video new mod 45,98002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.85,,,,,,,fee schedule,44.73,78.46,
Synch audio-video new mod 45,98002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.73,,,,,,,fee schedule,44.73,78.46,
Synch audio-video new mod 45,98002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.46,,,,,,,fee schedule,44.73,78.46,
Synch audio-video new hi 60,98003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.8,,,,,,,fee schedule,57.56,100.97,
Synch audio-video new hi 60,98003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.86,,,,,,,fee schedule,57.56,100.97,
Synch audio-video new hi 60,98003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.56,,,,,,,fee schedule,57.56,100.97,
Synch audio-video new hi 60,98003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.97,,,,,,,fee schedule,57.56,100.97,
Synch audio-video est sf 10,98004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.81,,,,,,,fee schedule,15.61,27.38,
Synch audio-video est sf 10,98004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.49,,,,,,,fee schedule,15.61,27.38,
Synch audio-video est sf 10,98004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.61,,,,,,,fee schedule,15.61,27.38,
Synch audio-video est sf 10,98004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.38,,,,,,,fee schedule,15.61,27.38,
Synch audio-video est low 20,98005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.56,,,,,,,fee schedule,24.62,43.19,
Synch audio-video est low 20,98005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.74,,,,,,,fee schedule,24.62,43.19,
Synch audio-video est low 20,98005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.62,,,,,,,fee schedule,24.62,43.19,
Synch audio-video est low 20,98005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.19,,,,,,,fee schedule,24.62,43.19,
Synch audio-video est mod 30,98006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.94,,,,,,,fee schedule,35.36,62.03,
Synch audio-video est mod 30,98006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.15,,,,,,,fee schedule,35.36,62.03,
Synch audio-video est mod 30,98006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.36,,,,,,,fee schedule,35.36,62.03,
Synch audio-video est mod 30,98006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.03,,,,,,,fee schedule,35.36,62.03,
Synch audio-video est hi 40,98007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.28,,,,,,,fee schedule,45.42,79.67,
Synch audio-video est hi 40,98007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.71,,,,,,,fee schedule,45.42,79.67,
Synch audio-video est hi 40,98007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.42,,,,,,,fee schedule,45.42,79.67,
Synch audio-video est hi 40,98007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.67,,,,,,,fee schedule,45.42,79.67,
Synch audio-only new sf 15,98008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.5,,,,,,,fee schedule,18.03,31.63,
Synch audio-only new sf 15,98008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.51,,,,,,,fee schedule,18.03,31.63,
Synch audio-only new sf 15,98008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.03,,,,,,,fee schedule,18.03,31.63,
Synch audio-only new sf 15,98008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.63,,,,,,,fee schedule,18.03,31.63,
Synch audio-only new low 30,98009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.78,,,,,,,fee schedule,27.39,48.05,
Synch audio-only new low 30,98009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.2,,,,,,,fee schedule,27.39,48.05,
Synch audio-only new low 30,98009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.39,,,,,,,fee schedule,27.39,48.05,
Synch audio-only new low 30,98009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.05,,,,,,,fee schedule,27.39,48.05,
Synch audio-only new mod 45,98010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.94,,,,,,,fee schedule,41.26,72.38,
Synch audio-only new mod 45,98010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.52,,,,,,,fee schedule,41.26,72.38,
Synch audio-only new mod 45,98010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.26,,,,,,,fee schedule,41.26,72.38,
Synch audio-only new mod 45,98010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.38,,,,,,,fee schedule,41.26,72.38,
Synch audio-only new high 60,98011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.4,,,,,,,fee schedule,52.71,92.46,
Synch audio-only new high 60,98011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.81,,,,,,,fee schedule,52.71,92.46,
Synch audio-only new high 60,98011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.71,,,,,,,fee schedule,52.71,92.46,
Synch audio-only new high 60,98011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.46,,,,,,,fee schedule,52.71,92.46,
Synch audio-only est sf 10,98012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.16,,,,,,,fee schedule,13.87,24.33,
Synch audio-only est sf 10,98012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.32,,,,,,,fee schedule,13.87,24.33,
Synch audio-only est sf 10,98012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.87,,,,,,,fee schedule,13.87,24.33,
Synch audio-only est sf 10,98012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.33,,,,,,,fee schedule,13.87,24.33,
Synch audio-only est low 20,98013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.84,,,,,,,fee schedule,22.19,38.92,
Synch audio-only est low 20,98013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.7,,,,,,,fee schedule,22.19,38.92,
Synch audio-only est low 20,98013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.19,,,,,,,fee schedule,22.19,38.92,
Synch audio-only est low 20,98013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.92,,,,,,,fee schedule,22.19,38.92,
Synch audio-only est mod 30,98014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.13,,,,,,,fee schedule,31.55,55.35,
Synch audio-only est mod 30,98014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.39,,,,,,,fee schedule,31.55,55.35,
Synch audio-only est mod 30,98014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.55,,,,,,,fee schedule,31.55,55.35,
Synch audio-only est mod 30,98014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.35,,,,,,,fee schedule,31.55,55.35,
Synch audio-only est high 40,98015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.69,,,,,,,fee schedule,44.38,77.84,
Synch audio-only est high 40,98015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.4,,,,,,,fee schedule,44.38,77.84,
Synch audio-only est high 40,98015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.38,,,,,,,fee schedule,44.38,77.84,
Synch audio-only est high 40,98015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.84,,,,,,,fee schedule,44.38,77.84,
Brief comunicaj tech-bsd svc,98016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.99,,,,,,,fee schedule,5.89,10.34,
Brief comunicaj tech-bsd svc,98016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.36,,,,,,,fee schedule,5.89,10.34,
Brief comunicaj tech-bsd svc,98016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.89,,,,,,,fee schedule,5.89,10.34,
Brief comunicaj tech-bsd svc,98016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.34,,,,,,,fee schedule,5.89,10.34,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.83,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.35,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 1-2 regions,98925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 1-2 regions,98925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.73,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 3-4 regions,98926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.83,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 3-4 regions,98926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 3-4 regions,98926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 3-4 regions,98926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.35,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 3-4 regions,98926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 3-4 regions,98926,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 3-4 regions,98926,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.73,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 5-6 regions,98927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.83,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 5-6 regions,98927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 5-6 regions,98927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 5-6 regions,98927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.35,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 5-6 regions,98927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 5-6 regions,98927,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 5-6 regions,98927,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.73,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 7-8 regions,98928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.83,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 7-8 regions,98928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 7-8 regions,98928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 7-8 regions,98928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.35,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 7-8 regions,98928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 7-8 regions,98928,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 7-8 regions,98928,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.73,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 9-10 regions,98929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.83,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 9-10 regions,98929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 9-10 regions,98929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.15,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 9-10 regions,98929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.35,,,,,,,fee schedule,21.51,42.35,
Osteopath manj 9-10 regions,98929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 9-10 regions,98929,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,42.35,APC
Osteopath manj 9-10 regions,98929,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.73,,,,,,,fee schedule,21.51,42.35,APC
Chiropract manj 1-2 regions,98940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.83,,,,,,,fee schedule,21.51,42.35,
Chiropract manj 1-2 regions,98940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.15,,,,,,,fee schedule,21.51,42.35,
Chiropract manj 1-2 regions,98940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.15,,,,,,,fee schedule,21.51,42.35,
Chiropract manj 1-2 regions,98940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.35,,,,,,,fee schedule,21.51,42.35,
Chiropract manj 1-2 regions,98940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,42.35,APC
Chiropract manj 1-2 regions,98940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,42.35,APC
Chiropract manj 1-2 regions,98940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.73,,,,,,,fee schedule,21.51,42.35,APC
Chiropract manj 3-4 regions,98941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.83,,,,,,,fee schedule,21.51,42.35,
Chiropract manj 3-4 regions,98941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.15,,,,,,,fee schedule,21.51,42.35,
Chiropract manj 3-4 regions,98941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.15,,,,,,,fee schedule,21.51,42.35,
Chiropract manj 3-4 regions,98941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.35,,,,,,,fee schedule,21.51,42.35,
Chiropract manj 3-4 regions,98941,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,42.35,APC
Chiropract manj 3-4 regions,98941,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,42.35,APC
Chiropract manj 3-4 regions,98941,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.73,,,,,,,fee schedule,21.51,42.35,APC
Chiropractic manj 5 regions,98942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.83,,,,,,,fee schedule,21.51,42.35,
Chiropractic manj 5 regions,98942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.15,,,,,,,fee schedule,21.51,42.35,
Chiropractic manj 5 regions,98942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.15,,,,,,,fee schedule,21.51,42.35,
Chiropractic manj 5 regions,98942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.35,,,,,,,fee schedule,21.51,42.35,
Chiropractic manj 5 regions,98942,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.59,,,,,,,fee schedule,21.51,42.35,APC
Chiropractic manj 5 regions,98942,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.51,,,,,,,fee schedule,21.51,42.35,APC
Chiropractic manj 5 regions,98942,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.73,,,,,,,fee schedule,21.51,42.35,APC
Chiropract manj xtrspinl 1/>,98943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,17.99,31.56,
Chiropract manj xtrspinl 1/>,98943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,17.99,31.56,
Chiropract manj xtrspinl 1/>,98943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,17.99,31.56,
Chiropract manj xtrspinl 1/>,98943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,17.99,31.56,
Self-mgmt educ & train 1 pt,98960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.44,,,,,,,fee schedule,49.46,86.76,
Self-mgmt educ & train 1 pt,98960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.75,,,,,,,fee schedule,49.46,86.76,
Self-mgmt educ & train 1 pt,98960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.46,,,,,,,fee schedule,49.46,86.76,
Self-mgmt educ & train 1 pt,98960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.76,,,,,,,fee schedule,49.46,86.76,
Self-mgmt educ/train 2-4 pt,98961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Self-mgmt educ/train 2-4 pt,98961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Self-mgmt educ/train 2-4 pt,98961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Self-mgmt educ/train 2-4 pt,98961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Self-mgmt educ/train 5-8 pt,98962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,30.45,
Self-mgmt educ/train 5-8 pt,98962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,30.45,
Self-mgmt educ/train 5-8 pt,98962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,30.45,
Self-mgmt educ/train 5-8 pt,98962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,30.45,
Hc pro phone call 5-10 min,98966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.74,,,,,,,fee schedule,8.35,18.94,
Hc pro phone call 5-10 min,98966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.43,,,,,,,fee schedule,8.35,18.94,
Hc pro phone call 5-10 min,98966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.35,,,,,,,fee schedule,8.35,18.94,
Hc pro phone call 5-10 min,98966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.65,,,,,,,fee schedule,8.35,18.94,
Hc pro phone call 5-10 min,98966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.05,,,,,,,fee schedule,8.35,18.94,APC
Hc pro phone call 5-10 min,98966,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.52,,,,,,,fee schedule,8.35,18.94,APC
Hc pro phone call 5-10 min,98966,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.94,,,,,,,fee schedule,8.35,18.94,APC
Hc pro phone call 11-20 min,98967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.53,,,,,,,fee schedule,14.77,35.8,
Hc pro phone call 11-20 min,98967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.44,,,,,,,fee schedule,14.77,35.8,
Hc pro phone call 11-20 min,98967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.77,,,,,,,fee schedule,14.77,35.8,
Hc pro phone call 11-20 min,98967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.91,,,,,,,fee schedule,14.77,35.8,
Hc pro phone call 11-20 min,98967,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.88,,,,,,,fee schedule,14.77,35.8,APC
Hc pro phone call 11-20 min,98967,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.89,,,,,,,fee schedule,14.77,35.8,APC
Hc pro phone call 11-20 min,98967,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.8,,,,,,,fee schedule,14.77,35.8,APC
Hc pro phone call 21-30 min,98968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,52.92,
Hc pro phone call 21-30 min,98968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,52.92,
Hc pro phone call 21-30 min,98968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,52.92,
Hc pro phone call 21-30 min,98968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,52.92,
Hc pro phone call 21-30 min,98968,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.87,,,,,,,fee schedule,21.2,52.92,APC
Hc pro phone call 21-30 min,98968,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.4,,,,,,,fee schedule,21.2,52.92,APC
Hc pro phone call 21-30 min,98968,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.92,,,,,,,fee schedule,21.2,52.92,APC
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.24,,,,,,,fee schedule,10.25,29.03,
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.66,,,,,,,fee schedule,10.25,29.03,
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.55,,,,,,,fee schedule,10.25,29.03,
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.03,,,,,,,fee schedule,10.25,29.03,
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.76,,,,,,,fee schedule,10.25,29.03,APC
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.25,,,,,,,fee schedule,10.25,29.03,APC
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.45,,,,,,,fee schedule,10.25,29.03,APC
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.49,,,,,,,fee schedule,19.37,58.06,
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.33,,,,,,,fee schedule,19.37,58.06,
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.1,,,,,,,fee schedule,19.37,58.06,
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.06,,,,,,,fee schedule,19.37,58.06,
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.34,,,,,,,fee schedule,19.37,58.06,APC
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.37,,,,,,,fee schedule,19.37,58.06,APC
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.87,,,,,,,fee schedule,19.37,58.06,APC
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.72,,,,,,,fee schedule,28.75,87.08,
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.98,,,,,,,fee schedule,28.75,87.08,
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.64,,,,,,,fee schedule,28.75,87.08,
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.08,,,,,,,fee schedule,28.75,87.08,
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.19,,,,,,,fee schedule,28.75,87.08,APC
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.75,,,,,,,fee schedule,28.75,87.08,APC
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.75,,,,,,,fee schedule,28.75,87.08,APC
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,235.77,,,,,,,fee schedule,132.66,271.14,
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,192.98,,,,,,,fee schedule,132.66,271.14,
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.57,,,,,,,fee schedule,132.66,271.14,
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,271.14,,,,,,,fee schedule,132.66,271.14,
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,271.14,APC
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,271.14,APC
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,271.14,APC
Rem ther mntr dev sply resp,98976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.89,,,,,,,fee schedule,37.19,84.97,
Rem ther mntr dev sply resp,98976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.48,,,,,,,fee schedule,37.19,84.97,
Rem ther mntr dev sply resp,98976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.44,,,,,,,fee schedule,37.19,84.97,
Rem ther mntr dev sply resp,98976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.97,,,,,,,fee schedule,37.19,84.97,
Rem ther mntr dev sply resp,98976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,84.97,APC
Rem ther mntr dev sply resp,98976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,84.97,APC
Rem ther mntr dev sply resp,98976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,84.97,APC
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.89,,,,,,,fee schedule,37.19,84.97,
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.48,,,,,,,fee schedule,37.19,84.97,
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.44,,,,,,,fee schedule,37.19,84.97,
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.97,,,,,,,fee schedule,37.19,84.97,
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,84.97,APC
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,84.97,APC
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,84.97,APC
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.9,,,,,,,fee schedule,37.19,76.94,
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.76,,,,,,,fee schedule,37.19,76.94,
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.86,,,,,,,fee schedule,37.19,76.94,
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.94,,,,,,,fee schedule,37.19,76.94,
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,76.94,APC
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,76.94,APC
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,76.94,APC
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.91,,,,,,,fee schedule,11.34,20.41,APC
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.34,,,,,,,fee schedule,11.34,20.41,APC
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.41,,,,,,,fee schedule,11.34,20.41,APC
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.1,,,,,,,fee schedule,25.5,61.07,
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.46,,,,,,,fee schedule,25.5,61.07,
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.81,,,,,,,fee schedule,25.5,61.07,
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.07,,,,,,,fee schedule,25.5,61.07,
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.78,,,,,,,fee schedule,25.5,61.07,APC
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.5,,,,,,,fee schedule,25.5,61.07,APC
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.9,,,,,,,fee schedule,25.5,61.07,APC
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.96,,,,,,,fee schedule,22.92,46.67,
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.61,,,,,,,fee schedule,22.92,46.67,
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.92,,,,,,,fee schedule,22.92,46.67,
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.2,,,,,,,fee schedule,22.92,46.67,
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.23,,,,,,,fee schedule,22.92,46.67,APC
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.93,,,,,,,fee schedule,22.92,46.67,APC
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.67,,,,,,,fee schedule,22.92,46.67,APC
Rtm dev sply resp sys 2-15 d,98984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Rtm dev sply resp sys 2-15 d,98984,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Rtm dev sply resp sys 2-15 d,98984,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Rtm dev sply mscsk sys 2-15d,98985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Rtm dev sply mscsk sys 2-15d,98985,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Rtm dev sply mscsk sys 2-15d,98985,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Rtm dev sply cbt 2-15 d,98986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Rtm dev sply cbt 2-15 d,98986,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Rtm dev sply cbt 2-15 d,98986,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Specimen handling office-lab,99000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.8,,,,,,,fee schedule,6.42,11.27,
Specimen handling office-lab,99000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.02,,,,,,,fee schedule,6.42,11.27,
Specimen handling office-lab,99000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.42,,,,,,,fee schedule,6.42,11.27,
Specimen handling office-lab,99000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.27,,,,,,,fee schedule,6.42,11.27,
Specimen handling pt-lab,99001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.55,,,,,,,fee schedule,14.78,25.93,
Specimen handling pt-lab,99001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.46,,,,,,,fee schedule,14.78,25.93,
Specimen handling pt-lab,99001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.78,,,,,,,fee schedule,14.78,25.93,
Specimen handling pt-lab,99001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.93,,,,,,,fee schedule,14.78,25.93,
Device handling phys/qhp,99002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.74,,,,,,,fee schedule,8.35,14.65,
Device handling phys/qhp,99002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.43,,,,,,,fee schedule,8.35,14.65,
Device handling phys/qhp,99002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.35,,,,,,,fee schedule,8.35,14.65,
Device handling phys/qhp,99002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.65,,,,,,,fee schedule,8.35,14.65,
Medical services after hrs,99050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,37.19,
Medical services after hrs,99050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,37.19,
Medical services after hrs,99050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,37.19,
Medical services after hrs,99050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,37.19,
Med service out of office,99056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.39,,,,,,,fee schedule,19.92,34.95,
Med service out of office,99056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.87,,,,,,,fee schedule,19.92,34.95,
Med service out of office,99056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.92,,,,,,,fee schedule,19.92,34.95,
Med service out of office,99056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.95,,,,,,,fee schedule,19.92,34.95,
Office emergency care,99058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.21,,,,,,,fee schedule,25.71,45.09,
Office emergency care,99058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.09,,,,,,,fee schedule,25.71,45.09,
Office emergency care,99058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.71,,,,,,,fee schedule,25.71,45.09,
Office emergency care,99058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.09,,,,,,,fee schedule,25.71,45.09,
Out of office emerg med serv,99060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.11,,,,,,,fee schedule,28.26,49.58,
Out of office emerg med serv,99060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.29,,,,,,,fee schedule,28.26,49.58,
Out of office emerg med serv,99060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.26,,,,,,,fee schedule,28.26,49.58,
Out of office emerg med serv,99060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.58,,,,,,,fee schedule,28.26,49.58,
Collect/review data from pt,99091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,47.32,
Collect/review data from pt,99091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,47.32,
Collect/review data from pt,99091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,47.32,
Collect/review data from pt,99091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,47.32,
Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.72,,,,,,,fee schedule,104.71,183.68,
Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.73,,,,,,,fee schedule,104.71,183.68,
Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.71,,,,,,,fee schedule,104.71,183.68,
Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.68,,,,,,,fee schedule,104.71,183.68,
Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.62,,,,,,,fee schedule,75.8,132.96,
Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.63,,,,,,,fee schedule,75.8,132.96,
Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.8,,,,,,,fee schedule,75.8,132.96,
Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.96,,,,,,,fee schedule,75.8,132.96,
Mod sed same phys/qhp ea,99153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.39,,,,,,,fee schedule,19.92,34.95,
Mod sed same phys/qhp ea,99153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.87,,,,,,,fee schedule,19.92,34.95,
Mod sed same phys/qhp ea,99153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.92,,,,,,,fee schedule,19.92,34.95,
Mod sed same phys/qhp ea,99153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.95,,,,,,,fee schedule,19.92,34.95,
Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.87,,,,,,,fee schedule,35.97,63.1,
Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.91,,,,,,,fee schedule,35.97,63.1,
Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.97,,,,,,,fee schedule,35.97,63.1,
Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.1,,,,,,,fee schedule,35.97,63.1,
Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,22.47,39.42,
Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,22.47,39.42,
Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,22.47,39.42,
Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,22.47,39.42,
Mod sed other phys/qhp ea,99157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,30.45,
Mod sed other phys/qhp ea,99157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,30.45,
Mod sed other phys/qhp ea,99157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,30.45,
Mod sed other phys/qhp ea,99157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,30.45,
Anogenital exam child w imag,99170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.65,,,,,,,fee schedule,149.25,362.6,
Anogenital exam child w imag,99170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.33,,,,,,,fee schedule,149.25,362.6,
Anogenital exam child w imag,99170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.25,,,,,,,fee schedule,149.25,362.6,
Anogenital exam child w imag,99170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.8,,,,,,,fee schedule,149.25,362.6,
Anogenital exam child w imag,99170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.52,,,,,,,fee schedule,149.25,362.6,APC
Anogenital exam child w imag,99170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,201.44,,,,,,,fee schedule,149.25,362.6,APC
Anogenital exam child w imag,99170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,362.6,,,,,,,fee schedule,149.25,362.6,APC
Ocular Function Screen,99172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.21,,,,,,,fee schedule,25.71,45.09,
Ocular Function Screen,99172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.09,,,,,,,fee schedule,25.71,45.09,
Ocular Function Screen,99172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.71,,,,,,,fee schedule,25.71,45.09,
Ocular Function Screen,99172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.09,,,,,,,fee schedule,25.71,45.09,
Visual acuity screen,99173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.84,,,,,,,fee schedule,5.14,9.02,
Visual acuity screen,99173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.42,,,,,,,fee schedule,5.14,9.02,
Visual acuity screen,99173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.14,,,,,,,fee schedule,5.14,9.02,
Visual acuity screen,99173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.02,,,,,,,fee schedule,5.14,9.02,
Ocular instrumnt screen bil,99174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.51,,,,,,,fee schedule,15.41,27.04,
Ocular instrumnt screen bil,99174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.24,,,,,,,fee schedule,15.41,27.04,
Ocular instrumnt screen bil,99174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.41,,,,,,,fee schedule,15.41,27.04,
Ocular instrumnt screen bil,99174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.04,,,,,,,fee schedule,15.41,27.04,
Induction of vomiting,99175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.11,,,,,,,fee schedule,28.26,49.58,
Induction of vomiting,99175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.29,,,,,,,fee schedule,28.26,49.58,
Induction of vomiting,99175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.26,,,,,,,fee schedule,28.26,49.58,
Induction of vomiting,99175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.58,,,,,,,fee schedule,28.26,49.58,
Hyperbaric oxygen therapy,99183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.42,,,,,,,fee schedule,50.1,87.88,
Hyperbaric oxygen therapy,99183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.55,,,,,,,fee schedule,50.1,87.88,
Hyperbaric oxygen therapy,99183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.1,,,,,,,fee schedule,50.1,87.88,
Hyperbaric oxygen therapy,99183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.88,,,,,,,fee schedule,50.1,87.88,
Phlebotomy,99195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,327.82,,,,,,,fee schedule,132.57,376.99,
Phlebotomy,99195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.32,,,,,,,fee schedule,132.57,376.99,
Phlebotomy,99195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.92,,,,,,,fee schedule,132.57,376.99,
Phlebotomy,99195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,376.99,,,,,,,fee schedule,132.57,376.99,
Phlebotomy,99195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,376.99,APC
Phlebotomy,99195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,376.99,APC
Phlebotomy,99195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,376.99,APC
Office/outpatient visit new,99202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.77,,,,,,,fee schedule,70.65,123.94,
Office/outpatient visit new,99202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.21,,,,,,,fee schedule,70.65,123.94,
Office/outpatient visit new,99202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.65,,,,,,,fee schedule,70.65,123.94,
Office/outpatient visit new,99202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.94,,,,,,,fee schedule,70.65,123.94,
Office/outpatient visit new,99203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.01,,,,,,,fee schedule,78.02,136.86,
Office/outpatient visit new,99203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.41,,,,,,,fee schedule,78.02,136.86,
Office/outpatient visit new,99203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.02,,,,,,,fee schedule,78.02,136.86,
Office/outpatient visit new,99203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.86,,,,,,,fee schedule,78.02,136.86,
Office/outpatient visit new,99204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.01,,,,,,,fee schedule,78.02,136.86,
Office/outpatient visit new,99204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.41,,,,,,,fee schedule,78.02,136.86,
Office/outpatient visit new,99204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.02,,,,,,,fee schedule,78.02,136.86,
Office/outpatient visit new,99204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.86,,,,,,,fee schedule,78.02,136.86,
Office/outpatient visit new,99205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,232.22,,,,,,,fee schedule,152.24,267.05,
Office/outpatient visit new,99205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.07,,,,,,,fee schedule,152.24,267.05,
Office/outpatient visit new,99205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.24,,,,,,,fee schedule,152.24,267.05,
Office/outpatient visit new,99205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,267.05,,,,,,,fee schedule,152.24,267.05,
Office/outpatient visit est,99211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.22,,,,,,,fee schedule,59.15,103.75,
Office/outpatient visit est,99211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.85,,,,,,,fee schedule,59.15,103.75,
Office/outpatient visit est,99211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.15,,,,,,,fee schedule,59.15,103.75,
Office/outpatient visit est,99211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.75,,,,,,,fee schedule,59.15,103.75,
Office/outpatient visit est,99212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.24,,,,,,,fee schedule,59.16,103.78,
Office/outpatient visit est,99212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.86,,,,,,,fee schedule,59.16,103.78,
Office/outpatient visit est,99212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.16,,,,,,,fee schedule,59.16,103.78,
Office/outpatient visit est,99212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.78,,,,,,,fee schedule,59.16,103.78,
Office/outpatient visit est,99213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.63,,,,,,,fee schedule,64.66,113.42,
Office/outpatient visit est,99213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.73,,,,,,,fee schedule,64.66,113.42,
Office/outpatient visit est,99213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.66,,,,,,,fee schedule,64.66,113.42,
Office/outpatient visit est,99213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.42,,,,,,,fee schedule,64.66,113.42,
Office/outpatient visit est,99214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.44,,,,,,,fee schedule,92.73,162.66,
Office/outpatient visit est,99214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.77,,,,,,,fee schedule,92.73,162.66,
Office/outpatient visit est,99214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.73,,,,,,,fee schedule,92.73,162.66,
Office/outpatient visit est,99214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.66,,,,,,,fee schedule,92.73,162.66,
Office/outpatient visit est,99215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.76,,,,,,,fee schedule,91.63,160.72,
Office/outpatient visit est,99215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.39,,,,,,,fee schedule,91.63,160.72,
Office/outpatient visit est,99215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.63,,,,,,,fee schedule,91.63,160.72,
Office/outpatient visit est,99215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.72,,,,,,,fee schedule,91.63,160.72,
Initial hospital care,99221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.47,,,,,,,fee schedule,48.82,85.64,
Initial hospital care,99221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.95,,,,,,,fee schedule,48.82,85.64,
Initial hospital care,99221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.82,,,,,,,fee schedule,48.82,85.64,
Initial hospital care,99221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.64,,,,,,,fee schedule,48.82,85.64,
Initial hospital care,99222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.85,,,,,,,fee schedule,67.43,118.28,
Initial hospital care,99222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.18,,,,,,,fee schedule,67.43,118.28,
Initial hospital care,99222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.43,,,,,,,fee schedule,67.43,118.28,
Initial hospital care,99222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.28,,,,,,,fee schedule,67.43,118.28,
Initial hospital care,99223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.81,,,,,,,fee schedule,101.49,178.03,
Initial hospital care,99223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.71,,,,,,,fee schedule,101.49,178.03,
Initial hospital care,99223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.49,,,,,,,fee schedule,101.49,178.03,
Initial hospital care,99223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.03,,,,,,,fee schedule,101.49,178.03,
Subsequent hospital care,99231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.43,,,,,,,fee schedule,18.64,32.69,
Subsequent hospital care,99231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.27,,,,,,,fee schedule,18.64,32.69,
Subsequent hospital care,99231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.64,,,,,,,fee schedule,18.64,32.69,
Subsequent hospital care,99231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.69,,,,,,,fee schedule,18.64,32.69,
Subsequent hospital care,99232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.87,,,,,,,fee schedule,35.97,63.1,
Subsequent hospital care,99232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.91,,,,,,,fee schedule,35.97,63.1,
Subsequent hospital care,99232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.97,,,,,,,fee schedule,35.97,63.1,
Subsequent hospital care,99232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.1,,,,,,,fee schedule,35.97,63.1,
Subsequent hospital care,99233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.35,,,,,,,fee schedule,52.02,91.25,
Subsequent hospital care,99233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.95,,,,,,,fee schedule,52.02,91.25,
Subsequent hospital care,99233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.02,,,,,,,fee schedule,52.02,91.25,
Subsequent hospital care,99233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.25,,,,,,,fee schedule,52.02,91.25,
Observ/hosp same date,99234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.96,,,,,,,fee schedule,64.88,113.8,
Observ/hosp same date,99234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81,,,,,,,fee schedule,64.88,113.8,
Observ/hosp same date,99234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.88,,,,,,,fee schedule,64.88,113.8,
Observ/hosp same date,99234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.8,,,,,,,fee schedule,64.88,113.8,
Observ/hosp same date,99235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.35,,,,,,,fee schedule,84.15,147.6,
Observ/hosp same date,99235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.05,,,,,,,fee schedule,84.15,147.6,
Observ/hosp same date,99235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.15,,,,,,,fee schedule,84.15,147.6,
Observ/hosp same date,99235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.6,,,,,,,fee schedule,84.15,147.6,
Observ/hosp same date,99236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.62,,,,,,,fee schedule,107.27,188.16,
Observ/hosp same date,99236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.92,,,,,,,fee schedule,107.27,188.16,
Observ/hosp same date,99236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.27,,,,,,,fee schedule,107.27,188.16,
Observ/hosp same date,99236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.16,,,,,,,fee schedule,107.27,188.16,
Hospital discharge day,99238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,44.32,77.74,
Hospital discharge day,99238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,44.32,77.74,
Hospital discharge day,99238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,44.32,77.74,
Hospital discharge day,99238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,44.32,77.74,
Hospital discharge day,99239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.96,,,,,,,fee schedule,65.53,114.95,
Hospital discharge day,99239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.82,,,,,,,fee schedule,65.53,114.95,
Hospital discharge day,99239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.53,,,,,,,fee schedule,65.53,114.95,
Hospital discharge day,99239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.95,,,,,,,fee schedule,65.53,114.95,
Office consultation,99242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.91,,,,,,,fee schedule,65.5,114.9,
Office consultation,99242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.78,,,,,,,fee schedule,65.5,114.9,
Office consultation,99242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.5,,,,,,,fee schedule,65.5,114.9,
Office consultation,99242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.9,,,,,,,fee schedule,65.5,114.9,
Office consultation,99243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.06,,,,,,,fee schedule,93.79,164.52,
Office consultation,99243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.09,,,,,,,fee schedule,93.79,164.52,
Office consultation,99243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.79,,,,,,,fee schedule,93.79,164.52,
Office consultation,99243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.52,,,,,,,fee schedule,93.79,164.52,
Office consultation,99244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.04,,,,,,,fee schedule,125.9,220.85,
Office consultation,99244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.18,,,,,,,fee schedule,125.9,220.85,
Office consultation,99244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.9,,,,,,,fee schedule,125.9,220.85,
Office consultation,99244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.85,,,,,,,fee schedule,125.9,220.85,
Office consultation,99245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,225.34,,,,,,,fee schedule,147.73,259.14,
Office consultation,99245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,184.44,,,,,,,fee schedule,147.73,259.14,
Office consultation,99245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.73,,,,,,,fee schedule,147.73,259.14,
Office consultation,99245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.14,,,,,,,fee schedule,147.73,259.14,
Inpatient consultation,99252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.95,,,,,,,fee schedule,33.4,58.59,
Inpatient consultation,99252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.7,,,,,,,fee schedule,33.4,58.59,
Inpatient consultation,99252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.4,,,,,,,fee schedule,33.4,58.59,
Inpatient consultation,99252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.59,,,,,,,fee schedule,33.4,58.59,
Inpatient consultation,99253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.3,,,,,,,fee schedule,53.96,94.65,
Inpatient consultation,99253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.36,,,,,,,fee schedule,53.96,94.65,
Inpatient consultation,99253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.96,,,,,,,fee schedule,53.96,94.65,
Inpatient consultation,99253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.65,,,,,,,fee schedule,53.96,94.65,
Inpatient consultation,99254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,138.59,
Inpatient consultation,99254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,138.59,
Inpatient consultation,99254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,138.59,
Inpatient consultation,99254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,138.59,
Inpatient consultation,99255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.1,,,,,,,fee schedule,92.51,162.27,
Inpatient consultation,99255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.49,,,,,,,fee schedule,92.51,162.27,
Inpatient consultation,99255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.51,,,,,,,fee schedule,92.51,162.27,
Inpatient consultation,99255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.27,,,,,,,fee schedule,92.51,162.27,
Emergency dept visit,99281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.77,,,,,,,fee schedule,60.16,151.24,
Emergency dept visit,99281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.11,,,,,,,fee schedule,60.16,151.24,
Emergency dept visit,99281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.16,,,,,,,fee schedule,60.16,151.24,
Emergency dept visit,99281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.54,,,,,,,fee schedule,60.16,151.24,
Emergency dept visit,99281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,88.22,,,,,,,fee schedule,60.16,151.24,APC
Emergency dept visit,99281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,84.02,,,,,,,fee schedule,60.16,151.24,APC
Emergency dept visit,99281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,151.24,,,,,,,fee schedule,60.16,151.24,APC
Emergency dept visit,99282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,166.7,,,,,,,fee schedule,109.29,275.39,
Emergency dept visit,99282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.44,,,,,,,fee schedule,109.29,275.39,
Emergency dept visit,99282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.29,,,,,,,fee schedule,109.29,275.39,
Emergency dept visit,99282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,191.71,,,,,,,fee schedule,109.29,275.39,
Emergency dept visit,99282,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,160.64,,,,,,,fee schedule,109.29,275.39,APC
Emergency dept visit,99282,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,152.99,,,,,,,fee schedule,109.29,275.39,APC
Emergency dept visit,99282,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,275.39,,,,,,,fee schedule,109.29,275.39,APC
Emergency dept visit,99283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,300.98,,,,,,,fee schedule,197.32,489.59,
Emergency dept visit,99283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,246.35,,,,,,,fee schedule,197.32,489.59,
Emergency dept visit,99283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.32,,,,,,,fee schedule,197.32,489.59,
Emergency dept visit,99283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,346.13,,,,,,,fee schedule,197.32,489.59,
Emergency dept visit,99283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,285.6,,,,,,,fee schedule,197.32,489.59,APC
Emergency dept visit,99283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,272,,,,,,,fee schedule,197.32,489.59,APC
Emergency dept visit,99283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,489.59,,,,,,,fee schedule,197.32,489.59,APC
Emergency dept visit,99284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,497.13,,,,,,,fee schedule,325.92,748.37,
Emergency dept visit,99284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,406.9,,,,,,,fee schedule,325.92,748.37,
Emergency dept visit,99284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.92,,,,,,,fee schedule,325.92,748.37,
Emergency dept visit,99284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,571.7,,,,,,,fee schedule,325.92,748.37,
Emergency dept visit,99284,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,436.55,,,,,,,fee schedule,325.92,748.37,APC
Emergency dept visit,99284,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,415.76,,,,,,,fee schedule,325.92,748.37,APC
Emergency dept visit,99284,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,748.37,,,,,,,fee schedule,325.92,748.37,APC
Emergency dept visit,99285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,730.91,,,,,,,fee schedule,479.18,1068.1,
Emergency dept visit,99285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,598.25,,,,,,,fee schedule,479.18,1068.1,
Emergency dept visit,99285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,479.18,,,,,,,fee schedule,479.18,1068.1,
Emergency dept visit,99285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,840.55,,,,,,,fee schedule,479.18,1068.1,
Emergency dept visit,99285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,623.06,,,,,,,fee schedule,479.18,1068.1,APC
Emergency dept visit,99285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,593.39,,,,,,,fee schedule,479.18,1068.1,APC
Emergency dept visit,99285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1068.1,,,,,,,fee schedule,479.18,1068.1,APC
Critical care first hour,99291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1027.64,,,,,,,fee schedule,673.72,1481.5,
Critical care first hour,99291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,841.12,,,,,,,fee schedule,673.72,1481.5,
Critical care first hour,99291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,673.72,,,,,,,fee schedule,673.72,1481.5,
Critical care first hour,99291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1181.79,,,,,,,fee schedule,673.72,1481.5,
Critical care first hour,99291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,864.21,,,,,,,fee schedule,673.72,1481.5,APC
Critical care first hour,99291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,823.06,,,,,,,fee schedule,673.72,1481.5,APC
Critical care first hour,99291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1481.5,,,,,,,fee schedule,673.72,1481.5,APC
Critical care addl 30 min,99292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.96,,,,,,,fee schedule,65.53,114.95,
Critical care addl 30 min,99292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.82,,,,,,,fee schedule,65.53,114.95,
Critical care addl 30 min,99292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.53,,,,,,,fee schedule,65.53,114.95,
Critical care addl 30 min,99292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.95,,,,,,,fee schedule,65.53,114.95,
Nursing facility care init,99304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.32,,,,,,,fee schedule,53.31,93.52,
Nursing facility care init,99304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.56,,,,,,,fee schedule,53.31,93.52,
Nursing facility care init,99304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.31,,,,,,,fee schedule,53.31,93.52,
Nursing facility care init,99304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.52,,,,,,,fee schedule,53.31,93.52,
Nursing facility care init,99305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.62,,,,,,,fee schedule,75.8,132.96,
Nursing facility care init,99305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.63,,,,,,,fee schedule,75.8,132.96,
Nursing facility care init,99305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.8,,,,,,,fee schedule,75.8,132.96,
Nursing facility care init,99305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.96,,,,,,,fee schedule,75.8,132.96,
Nursing facility care init,99306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.06,,,,,,,fee schedule,93.79,164.52,
Nursing facility care init,99306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.09,,,,,,,fee schedule,93.79,164.52,
Nursing facility care init,99306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.79,,,,,,,fee schedule,93.79,164.52,
Nursing facility care init,99306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.52,,,,,,,fee schedule,93.79,164.52,
Nursing fac care subseq,99307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.09,,,,,,,fee schedule,28.91,50.7,
Nursing fac care subseq,99307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,28.91,50.7,
Nursing fac care subseq,99307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,28.91,50.7,
Nursing fac care subseq,99307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.7,,,,,,,fee schedule,28.91,50.7,
Nursing fac care subseq,99308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,45.6,79.99,
Nursing fac care subseq,99308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,45.6,79.99,
Nursing fac care subseq,99308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,45.6,79.99,
Nursing fac care subseq,99308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,45.6,79.99,
Nursing fac care subseq,99309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.12,,,,,,,fee schedule,59.74,104.79,
Nursing fac care subseq,99309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.58,,,,,,,fee schedule,59.74,104.79,
Nursing fac care subseq,99309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.74,,,,,,,fee schedule,59.74,104.79,
Nursing fac care subseq,99309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,104.79,,,,,,,fee schedule,59.74,104.79,
Nursing fac care subseq,99310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.31,,,,,,,fee schedule,85.43,149.86,
Nursing fac care subseq,99310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.66,,,,,,,fee schedule,85.43,149.86,
Nursing fac care subseq,99310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.43,,,,,,,fee schedule,85.43,149.86,
Nursing fac care subseq,99310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.86,,,,,,,fee schedule,85.43,149.86,
Nursing fac discharge day,99315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,45.6,79.99,
Nursing fac discharge day,99315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,45.6,79.99,
Nursing fac discharge day,99315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,45.6,79.99,
Nursing fac discharge day,99315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,45.6,79.99,
Nursing fac discharge day,99316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.05,,,,,,,fee schedule,61.66,108.16,
Nursing fac discharge day,99316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.98,,,,,,,fee schedule,61.66,108.16,
Nursing fac discharge day,99316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.66,,,,,,,fee schedule,61.66,108.16,
Nursing fac discharge day,99316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.16,,,,,,,fee schedule,61.66,108.16,
Home visit new patient,99341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,52.96,
Home visit new patient,99341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,52.96,
Home visit new patient,99341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,52.96,
Home visit new patient,99341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,52.96,
Home visit new patient,99342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.73,,,,,,,fee schedule,39.81,69.84,
Home visit new patient,99342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.71,,,,,,,fee schedule,39.81,69.84,
Home visit new patient,99342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.81,,,,,,,fee schedule,39.81,69.84,
Home visit new patient,99342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.84,,,,,,,fee schedule,39.81,69.84,
Home visit new patient,99344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.87,,,,,,,fee schedule,99.57,174.65,
Home visit new patient,99344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.31,,,,,,,fee schedule,99.57,174.65,
Home visit new patient,99344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.57,,,,,,,fee schedule,99.57,174.65,
Home visit new patient,99344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.65,,,,,,,fee schedule,99.57,174.65,
Home visit new patient,99345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,183.22,,,,,,,fee schedule,120.12,210.7,
Home visit new patient,99345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.97,,,,,,,fee schedule,120.12,210.7,
Home visit new patient,99345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,120.12,,,,,,,fee schedule,120.12,210.7,
Home visit new patient,99345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,210.7,,,,,,,fee schedule,120.12,210.7,
Home visit est patient,99347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.03,,,,,,,fee schedule,31.49,55.23,
Home visit est patient,99347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.31,,,,,,,fee schedule,31.49,55.23,
Home visit est patient,99347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.49,,,,,,,fee schedule,31.49,55.23,
Home visit est patient,99347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.23,,,,,,,fee schedule,31.49,55.23,
Home visit est patient,99348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,45.6,79.99,
Home visit est patient,99348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,45.6,79.99,
Home visit est patient,99348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,45.6,79.99,
Home visit est patient,99348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,45.6,79.99,
Home visit est patient,99349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.67,,,,,,,fee schedule,73.21,128.42,
Home visit est patient,99349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.4,,,,,,,fee schedule,73.21,128.42,
Home visit est patient,99349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.21,,,,,,,fee schedule,73.21,128.42,
Home visit est patient,99349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.42,,,,,,,fee schedule,73.21,128.42,
Home visit est patient,99350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.94,,,,,,,fee schedule,97.65,171.28,
Home visit est patient,99350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.91,,,,,,,fee schedule,97.65,171.28,
Home visit est patient,99350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.65,,,,,,,fee schedule,97.65,171.28,
Home visit est patient,99350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.28,,,,,,,fee schedule,97.65,171.28,
Prolong service w/o contact,99358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.16,,,,,,,fee schedule,58.45,102.53,
Prolong service w/o contact,99358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.98,,,,,,,fee schedule,58.45,102.53,
Prolong service w/o contact,99358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.45,,,,,,,fee schedule,58.45,102.53,
Prolong service w/o contact,99358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.53,,,,,,,fee schedule,58.45,102.53,
Prolong serv w/o contact add,99359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.09,,,,,,,fee schedule,28.91,50.7,
Prolong serv w/o contact add,99359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,28.91,50.7,
Prolong serv w/o contact add,99359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,28.91,50.7,
Prolong serv w/o contact add,99359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.7,,,,,,,fee schedule,28.91,50.7,
Physician standby services,99360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,29.55,51.83,
Physician standby services,99360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,29.55,51.83,
Physician standby services,99360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,29.55,51.83,
Physician standby services,99360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,29.55,51.83,
Team conf w/pat by hc prof,99366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.3,,,,,,,fee schedule,21.83,38.3,
Team conf w/pat by hc prof,99366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.26,,,,,,,fee schedule,21.83,38.3,
Team conf w/pat by hc prof,99366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.83,,,,,,,fee schedule,21.83,38.3,
Team conf w/pat by hc prof,99366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.3,,,,,,,fee schedule,21.83,38.3,
Team conf w/o pat by phys,99367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,47.32,
Team conf w/o pat by phys,99367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,47.32,
Team conf w/o pat by phys,99367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,47.32,
Team conf w/o pat by phys,99367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,47.32,
Team conf w/o pat by hc pro,99368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,17.99,31.56,
Team conf w/o pat by hc pro,99368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,17.99,31.56,
Team conf w/o pat by hc pro,99368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,17.99,31.56,
Team conf w/o pat by hc pro,99368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,17.99,31.56,
Home health care supervision,99374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.35,,,,,,,fee schedule,52.02,91.25,
Home health care supervision,99374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.95,,,,,,,fee schedule,52.02,91.25,
Home health care supervision,99374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.02,,,,,,,fee schedule,52.02,91.25,
Home health care supervision,99374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.25,,,,,,,fee schedule,52.02,91.25,
Home health care supervision,99375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.75,,,,,,,fee schedule,71.95,126.21,
Home health care supervision,99375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.83,,,,,,,fee schedule,71.95,126.21,
Home health care supervision,99375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.95,,,,,,,fee schedule,71.95,126.21,
Home health care supervision,99375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.21,,,,,,,fee schedule,71.95,126.21,
Hospice care supervision,99377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.35,,,,,,,fee schedule,52.02,91.25,
Hospice care supervision,99377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.95,,,,,,,fee schedule,52.02,91.25,
Hospice care supervision,99377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.02,,,,,,,fee schedule,52.02,91.25,
Hospice care supervision,99377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.25,,,,,,,fee schedule,52.02,91.25,
Hospice care supervision,99378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.75,,,,,,,fee schedule,71.95,126.21,
Hospice care supervision,99378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.83,,,,,,,fee schedule,71.95,126.21,
Hospice care supervision,99378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.95,,,,,,,fee schedule,71.95,126.21,
Hospice care supervision,99378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.21,,,,,,,fee schedule,71.95,126.21,
Nursing fac care supervision,99379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.35,,,,,,,fee schedule,52.02,91.25,
Nursing fac care supervision,99379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.95,,,,,,,fee schedule,52.02,91.25,
Nursing fac care supervision,99379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.02,,,,,,,fee schedule,52.02,91.25,
Nursing fac care supervision,99379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.25,,,,,,,fee schedule,52.02,91.25,
Nursing fac care supervision,99380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.75,,,,,,,fee schedule,71.95,126.21,
Nursing fac care supervision,99380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.83,,,,,,,fee schedule,71.95,126.21,
Nursing fac care supervision,99380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.95,,,,,,,fee schedule,71.95,126.21,
Nursing fac care supervision,99380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.21,,,,,,,fee schedule,71.95,126.21,
Init pm e/m new pat infant,99381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.61,,,,,,,fee schedule,91.53,160.55,
Init pm e/m new pat infant,99381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.27,,,,,,,fee schedule,91.53,160.55,
Init pm e/m new pat infant,99381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.53,,,,,,,fee schedule,91.53,160.55,
Init pm e/m new pat infant,99381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.55,,,,,,,fee schedule,91.53,160.55,
Init pm e/m new pat 1-4 yrs,99382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.63,,,,,,,fee schedule,91.54,160.57,
Init pm e/m new pat 1-4 yrs,99382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.29,,,,,,,fee schedule,91.54,160.57,
Init pm e/m new pat 1-4 yrs,99382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.54,,,,,,,fee schedule,91.54,160.57,
Init pm e/m new pat 1-4 yrs,99382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.57,,,,,,,fee schedule,91.54,160.57,
Prev visit new age 5-11,99383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.12,,,,,,,fee schedule,73.51,128.94,
Prev visit new age 5-11,99383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.77,,,,,,,fee schedule,73.51,128.94,
Prev visit new age 5-11,99383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.51,,,,,,,fee schedule,73.51,128.94,
Prev visit new age 5-11,99383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.94,,,,,,,fee schedule,73.51,128.94,
Prev visit new age 12-17,99384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.33,,,,,,,fee schedule,84.79,148.73,
Prev visit new age 12-17,99384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.86,,,,,,,fee schedule,84.79,148.73,
Prev visit new age 12-17,99384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.79,,,,,,,fee schedule,84.79,148.73,
Prev visit new age 12-17,99384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.73,,,,,,,fee schedule,84.79,148.73,
Prev visit new age 18-39,99385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.15,,,,,,,fee schedule,66.31,116.32,
Prev visit new age 18-39,99385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.79,,,,,,,fee schedule,66.31,116.32,
Prev visit new age 18-39,99385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.31,,,,,,,fee schedule,66.31,116.32,
Prev visit new age 18-39,99385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.32,,,,,,,fee schedule,66.31,116.32,
Prev visit new age 40-64,99386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.41,,,,,,,fee schedule,71.73,125.82,
Prev visit new age 40-64,99386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.55,,,,,,,fee schedule,71.73,125.82,
Prev visit new age 40-64,99386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.73,,,,,,,fee schedule,71.73,125.82,
Prev visit new age 40-64,99386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.82,,,,,,,fee schedule,71.73,125.82,
Init pm e/m new pat 65+ yrs,99387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.96,,,,,,,fee schedule,128.47,225.35,
Init pm e/m new pat 65+ yrs,99387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.39,,,,,,,fee schedule,128.47,225.35,
Init pm e/m new pat 65+ yrs,99387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.47,,,,,,,fee schedule,128.47,225.35,
Init pm e/m new pat 65+ yrs,99387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.35,,,,,,,fee schedule,128.47,225.35,
Per pm reeval est pat infant,99391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.01,,,,,,,fee schedule,78.02,136.86,
Per pm reeval est pat infant,99391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.41,,,,,,,fee schedule,78.02,136.86,
Per pm reeval est pat infant,99391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.02,,,,,,,fee schedule,78.02,136.86,
Per pm reeval est pat infant,99391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.86,,,,,,,fee schedule,78.02,136.86,
Prev visit est age 1-4,99392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.83,,,,,,,fee schedule,73.97,129.75,
Prev visit est age 1-4,99392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.35,,,,,,,fee schedule,73.97,129.75,
Prev visit est age 1-4,99392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.97,,,,,,,fee schedule,73.97,129.75,
Prev visit est age 1-4,99392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.75,,,,,,,fee schedule,73.97,129.75,
Prev visit est age 5-11,99393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.09,,,,,,,fee schedule,67.59,118.55,
Prev visit est age 5-11,99393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.38,,,,,,,fee schedule,67.59,118.55,
Prev visit est age 5-11,99393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.59,,,,,,,fee schedule,67.59,118.55,
Prev visit est age 5-11,99393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.55,,,,,,,fee schedule,67.59,118.55,
Prev visit est age 12-17,99394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.12,,,,,,,fee schedule,73.51,128.94,
Prev visit est age 12-17,99394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.77,,,,,,,fee schedule,73.51,128.94,
Prev visit est age 12-17,99394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.51,,,,,,,fee schedule,73.51,128.94,
Prev visit est age 12-17,99394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.94,,,,,,,fee schedule,73.51,128.94,
Prev visit est age 18-39,99395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.43,,,,,,,fee schedule,64.53,113.19,
Prev visit est age 18-39,99395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.56,,,,,,,fee schedule,64.53,113.19,
Prev visit est age 18-39,99395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.53,,,,,,,fee schedule,64.53,113.19,
Prev visit est age 18-39,99395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.19,,,,,,,fee schedule,64.53,113.19,
Prev visit est age 40-64,99396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.91,,,,,,,fee schedule,64.19,112.6,
Prev visit est age 40-64,99396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.14,,,,,,,fee schedule,64.19,112.6,
Prev visit est age 40-64,99396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.19,,,,,,,fee schedule,64.19,112.6,
Prev visit est age 40-64,99396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.6,,,,,,,fee schedule,64.19,112.6,
Per pm reeval est pat 65+ yr,99397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.63,,,,,,,fee schedule,69.91,122.62,
Per pm reeval est pat 65+ yr,99397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.28,,,,,,,fee schedule,69.91,122.62,
Per pm reeval est pat 65+ yr,99397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.91,,,,,,,fee schedule,69.91,122.62,
Per pm reeval est pat 65+ yr,99397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.62,,,,,,,fee schedule,69.91,122.62,
Preventive counseling indiv,99401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,138.64,,,,,,,fee schedule,90.89,159.44,
Preventive counseling indiv,99401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.48,,,,,,,fee schedule,90.89,159.44,
Preventive counseling indiv,99401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.89,,,,,,,fee schedule,90.89,159.44,
Preventive counseling indiv,99401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,159.44,,,,,,,fee schedule,90.89,159.44,
Preventive counseling indiv,99402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.07,,,,,,,fee schedule,101.01,177.18,
Preventive counseling indiv,99402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.11,,,,,,,fee schedule,101.01,177.18,
Preventive counseling indiv,99402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.01,,,,,,,fee schedule,101.01,177.18,
Preventive counseling indiv,99402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,177.18,,,,,,,fee schedule,101.01,177.18,
Preventive counseling indiv,99403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.46,,,,,,,fee schedule,111.1,194.88,
Preventive counseling indiv,99403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.7,,,,,,,fee schedule,111.1,194.88,
Preventive counseling indiv,99403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.1,,,,,,,fee schedule,111.1,194.88,
Preventive counseling indiv,99403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.88,,,,,,,fee schedule,111.1,194.88,
Preventive counseling indiv,99404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,184.86,,,,,,,fee schedule,121.19,212.59,
Preventive counseling indiv,99404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.31,,,,,,,fee schedule,121.19,212.59,
Preventive counseling indiv,99404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.19,,,,,,,fee schedule,121.19,212.59,
Preventive counseling indiv,99404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,212.59,,,,,,,fee schedule,121.19,212.59,
Behav chng smoking 3-10 min,99406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,24.74,67.2,
Behav chng smoking 3-10 min,99406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.89,,,,,,,fee schedule,24.74,67.2,
Behav chng smoking 3-10 min,99406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.74,,,,,,,fee schedule,24.74,67.2,
Behav chng smoking 3-10 min,99406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,24.74,67.2,
Behav chng smoking 3-10 min,99406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,24.74,67.2,APC
Behav chng smoking 3-10 min,99406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,24.74,67.2,APC
Behav chng smoking 3-10 min,99406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,24.74,67.2,APC
Behav chng smoking > 10 min,99407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,24.74,67.2,
Behav chng smoking > 10 min,99407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.89,,,,,,,fee schedule,24.74,67.2,
Behav chng smoking > 10 min,99407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.74,,,,,,,fee schedule,24.74,67.2,
Behav chng smoking > 10 min,99407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,24.74,67.2,
Behav chng smoking > 10 min,99407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,24.74,67.2,APC
Behav chng smoking > 10 min,99407,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,24.74,67.2,APC
Behav chng smoking > 10 min,99407,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,24.74,67.2,APC
Audit/dast 15-30 min,99408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.4,,,,,,,fee schedule,19.27,33.81,
Audit/dast 15-30 min,99408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.06,,,,,,,fee schedule,19.27,33.81,
Audit/dast 15-30 min,99408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.27,,,,,,,fee schedule,19.27,33.81,
Audit/dast 15-30 min,99408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.81,,,,,,,fee schedule,19.27,33.81,
Audit/dast over 30 min,99409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.9,,,,,,,fee schedule,35.34,61.99,
Audit/dast over 30 min,99409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.12,,,,,,,fee schedule,35.34,61.99,
Audit/dast over 30 min,99409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.34,,,,,,,fee schedule,35.34,61.99,
Audit/dast over 30 min,99409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.99,,,,,,,fee schedule,35.34,61.99,
Preventive counseling group,99411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.4,,,,,,,fee schedule,19.27,33.81,
Preventive counseling group,99411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.06,,,,,,,fee schedule,19.27,33.81,
Preventive counseling group,99411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.27,,,,,,,fee schedule,19.27,33.81,
Preventive counseling group,99411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.81,,,,,,,fee schedule,19.27,33.81,
Preventive counseling group,99412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.3,,,,,,,fee schedule,21.83,38.3,
Preventive counseling group,99412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.26,,,,,,,fee schedule,21.83,38.3,
Preventive counseling group,99412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.83,,,,,,,fee schedule,21.83,38.3,
Preventive counseling group,99412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.3,,,,,,,fee schedule,21.83,38.3,
Prolong clincl staff svc,99415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.49,,,,,,,fee schedule,16.06,28.16,
Prolong clincl staff svc,99415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.05,,,,,,,fee schedule,16.06,28.16,
Prolong clincl staff svc,99415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.06,,,,,,,fee schedule,16.06,28.16,
Prolong clincl staff svc,99415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.16,,,,,,,fee schedule,16.06,28.16,
Prolong clincl staff svc add,99416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.74,,,,,,,fee schedule,8.35,14.65,
Prolong clincl staff svc add,99416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.43,,,,,,,fee schedule,8.35,14.65,
Prolong clincl staff svc add,99416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.35,,,,,,,fee schedule,8.35,14.65,
Prolong clincl staff svc add,99416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.65,,,,,,,fee schedule,8.35,14.65,
Prolng ip/obs e/m ea 15 min,99418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,12.85,22.54,
Prolng ip/obs e/m ea 15 min,99418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,12.85,22.54,
Prolng ip/obs e/m ea 15 min,99418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,12.85,22.54,
Prolng ip/obs e/m ea 15 min,99418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,12.85,22.54,
Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.94,,,,,,,fee schedule,17.01,29.83,
Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.23,,,,,,,fee schedule,17.01,29.83,
Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.01,,,,,,,fee schedule,17.01,29.83,
Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.83,,,,,,,fee schedule,17.01,29.83,
Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.28,,,,,,,fee schedule,34.93,61.27,
Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.61,,,,,,,fee schedule,34.93,61.27,
Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.93,,,,,,,fee schedule,34.93,61.27,
Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.27,,,,,,,fee schedule,34.93,61.27,
Ol dig e/m svc 21+ min,99423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.83,,,,,,,fee schedule,55.61,97.55,
Ol dig e/m svc 21+ min,99423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.43,,,,,,,fee schedule,55.61,97.55,
Ol dig e/m svc 21+ min,99423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.61,,,,,,,fee schedule,55.61,97.55,
Ol dig e/m svc 21+ min,99423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.55,,,,,,,fee schedule,55.61,97.55,
Prin care mgmt phys 1st 30,99424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.81,,,,,,,fee schedule,37.9,66.48,
Prin care mgmt phys 1st 30,99424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.32,,,,,,,fee schedule,37.9,66.48,
Prin care mgmt phys 1st 30,99424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.9,,,,,,,fee schedule,37.9,66.48,
Prin care mgmt phys 1st 30,99424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.48,,,,,,,fee schedule,37.9,66.48,
Prin care mgmt phys ea addl,99425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.36,,,,,,,fee schedule,29.08,51.01,
Prin care mgmt phys ea addl,99425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.31,,,,,,,fee schedule,29.08,51.01,
Prin care mgmt phys ea addl,99425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.08,,,,,,,fee schedule,29.08,51.01,
Prin care mgmt phys ea addl,99425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.01,,,,,,,fee schedule,29.08,51.01,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.46,,,,,,,fee schedule,97.33,182.2,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.51,,,,,,,fee schedule,97.33,182.2,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.33,,,,,,,fee schedule,97.33,182.2,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.73,,,,,,,fee schedule,97.33,182.2,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,97.33,182.2,APC
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,97.33,182.2,APC
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,97.33,182.2,APC
Prin care mgmt staff ea addl,99427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.03,,,,,,,fee schedule,28.21,49.48,
Prin care mgmt staff ea addl,99427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.22,,,,,,,fee schedule,28.21,49.48,
Prin care mgmt staff ea addl,99427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.21,,,,,,,fee schedule,28.21,49.48,
Prin care mgmt staff ea addl,99427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.48,,,,,,,fee schedule,28.21,49.48,
Chrnc care mgmt phys ea addl,99437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.4,,,,,,,fee schedule,30.42,53.36,
Chrnc care mgmt phys ea addl,99437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.98,,,,,,,fee schedule,30.42,53.36,
Chrnc care mgmt phys ea addl,99437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.42,,,,,,,fee schedule,30.42,53.36,
Chrnc care mgmt phys ea addl,99437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.36,,,,,,,fee schedule,30.42,53.36,
Chrnc care mgmt svc ea addl,99439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.9,,,,,,,fee schedule,22.22,38.99,
Chrnc care mgmt svc ea addl,99439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.75,,,,,,,fee schedule,22.22,38.99,
Chrnc care mgmt svc ea addl,99439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.22,,,,,,,fee schedule,22.22,38.99,
Chrnc care mgmt svc ea addl,99439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.99,,,,,,,fee schedule,22.22,38.99,
Rem mntr physiol param 2-15,99445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,66.94,APC
Rem mntr physiol param 2-15,99445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,66.94,APC
Rem mntr physiol param 2-15,99445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,66.94,APC
Rem mntr physiol param setup,99453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,304.12,,,,,,,fee schedule,132.66,349.74,
Rem mntr physiol param setup,99453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,248.92,,,,,,,fee schedule,132.66,349.74,
Rem mntr physiol param setup,99453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.38,,,,,,,fee schedule,132.66,349.74,
Rem mntr physiol param setup,99453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,349.74,,,,,,,fee schedule,132.66,349.74,
Rem mntr physiol param setup,99453,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,349.74,APC
Rem mntr physiol param setup,99453,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,349.74,APC
Rem mntr physiol param setup,99453,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,349.74,APC
Rem mntr physiol param dev,99454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.56,,,,,,,fee schedule,37.19,112.19,
Rem mntr physiol param dev,99454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.85,,,,,,,fee schedule,37.19,112.19,
Rem mntr physiol param dev,99454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.96,,,,,,,fee schedule,37.19,112.19,
Rem mntr physiol param dev,99454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.19,,,,,,,fee schedule,37.19,112.19,
Rem mntr physiol param dev,99454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.05,,,,,,,fee schedule,37.19,112.19,APC
Rem mntr physiol param dev,99454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.19,,,,,,,fee schedule,37.19,112.19,APC
Rem mntr physiol param dev,99454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.94,,,,,,,fee schedule,37.19,112.19,APC
Rem physiol mntr ea addl 20,99458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.79,,,,,,,fee schedule,41.82,73.36,
Rem physiol mntr ea addl 20,99458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.21,,,,,,,fee schedule,41.82,73.36,
Rem physiol mntr ea addl 20,99458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.82,,,,,,,fee schedule,41.82,73.36,
Rem physiol mntr ea addl 20,99458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.36,,,,,,,fee schedule,41.82,73.36,
Pelvic examination,99459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.2,,,,,,,fee schedule,26.36,46.23,
Pelvic examination,99459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.9,,,,,,,fee schedule,26.36,46.23,
Pelvic examination,99459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.36,,,,,,,fee schedule,26.36,46.23,
Pelvic examination,99459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.23,,,,,,,fee schedule,26.36,46.23,
Init nb em per day hosp,99460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Init nb em per day hosp,99460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Init nb em per day hosp,99460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Init nb em per day hosp,99460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Init nb em per day hosp,99460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Init nb em per day hosp,99460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Init nb em per day hosp,99460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Init nb em per day non-fac,99461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.4,,,,,,,fee schedule,82.87,145.36,
Init nb em per day non-fac,99461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.46,,,,,,,fee schedule,82.87,145.36,
Init nb em per day non-fac,99461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.87,,,,,,,fee schedule,82.87,145.36,
Init nb em per day non-fac,99461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.36,,,,,,,fee schedule,82.87,145.36,
Same day nb discharge,99463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Same day nb discharge,99463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Same day nb discharge,99463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Same day nb discharge,99463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Same day nb discharge,99463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Same day nb discharge,99463,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Same day nb discharge,99463,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Attendance at delivery,99464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.79,,,,,,,fee schedule,37.89,66.46,
Attendance at delivery,99464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.3,,,,,,,fee schedule,37.89,66.46,
Attendance at delivery,99464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.89,,,,,,,fee schedule,37.89,66.46,
Attendance at delivery,99464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.46,,,,,,,fee schedule,37.89,66.46,
Nb resuscitation,99465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,719.86,,,,,,,fee schedule,471.94,1185.42,
Nb resuscitation,99465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,589.21,,,,,,,fee schedule,471.94,1185.42,
Nb resuscitation,99465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,471.94,,,,,,,fee schedule,471.94,1185.42,
Nb resuscitation,99465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,827.84,,,,,,,fee schedule,471.94,1185.42,
Nb resuscitation,99465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,691.5,,,,,,,fee schedule,471.94,1185.42,APC
Nb resuscitation,99465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,658.57,,,,,,,fee schedule,471.94,1185.42,APC
Nb resuscitation,99465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1185.42,,,,,,,fee schedule,471.94,1185.42,APC
Ped crit care transport,99466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,175.38,,,,,,,fee schedule,114.98,201.69,
Ped crit care transport,99466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,143.55,,,,,,,fee schedule,114.98,201.69,
Ped crit care transport,99466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.98,,,,,,,fee schedule,114.98,201.69,
Ped crit care transport,99466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,201.69,,,,,,,fee schedule,114.98,201.69,
Ped crit care transport addl,99467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.13,,,,,,,fee schedule,59.09,103.65,
Ped crit care transport addl,99467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.77,,,,,,,fee schedule,59.09,103.65,
Ped crit care transport addl,99467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.09,,,,,,,fee schedule,59.09,103.65,
Ped crit care transport addl,99467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.65,,,,,,,fee schedule,59.09,103.65,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.66,,,,,,,fee schedule,28.82,51.88,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.55,,,,,,,fee schedule,28.82,51.88,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.28,,,,,,,fee schedule,28.82,51.88,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.36,,,,,,,fee schedule,28.82,51.88,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Self-meas bp pt educaj/train,99473,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Self-meas bp pt educaj/train,99473,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.52,,,,,,,fee schedule,11.49,20.15,
Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.34,,,,,,,fee schedule,11.49,20.15,
Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.49,,,,,,,fee schedule,11.49,20.15,
Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.15,,,,,,,fee schedule,11.49,20.15,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.43,,,,,,,fee schedule,101.22,225.89,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.78,,,,,,,fee schedule,101.22,225.89,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.78,,,,,,,fee schedule,101.22,225.89,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.89,,,,,,,fee schedule,101.22,225.89,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,101.22,225.89,APC
Assmt & care pln pt cog imp,99483,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,101.22,225.89,APC
Assmt & care pln pt cog imp,99483,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,101.22,225.89,APC
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83,,,,,,,fee schedule,37.33,95.45,
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.94,,,,,,,fee schedule,37.33,95.45,
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.41,,,,,,,fee schedule,37.33,95.45,
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.45,,,,,,,fee schedule,37.33,95.45,
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,95.45,APC
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,95.45,APC
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,95.45,APC
Suprv interfacilty transport,99485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.83,,,,,,,fee schedule,37.26,65.35,
Suprv interfacilty transport,99485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.52,,,,,,,fee schedule,37.26,65.35,
Suprv interfacilty transport,99485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.26,,,,,,,fee schedule,37.26,65.35,
Suprv interfacilty transport,99485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.35,,,,,,,fee schedule,37.26,65.35,
Suprv interfac trnsport addl,99486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.98,,,,,,,fee schedule,32.11,56.33,
Suprv interfac trnsport addl,99486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.09,,,,,,,fee schedule,32.11,56.33,
Suprv interfac trnsport addl,99486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.11,,,,,,,fee schedule,32.11,56.33,
Suprv interfac trnsport addl,99486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.33,,,,,,,fee schedule,32.11,56.33,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,318.34,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,318.34,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,318.34,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,318.34,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,68.9,318.34,APC
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,68.9,318.34,APC
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,68.9,318.34,APC
Cmplx chron care addl 30 min,99489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.42,,,,,,,fee schedule,50.1,87.88,
Cmplx chron care addl 30 min,99489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.55,,,,,,,fee schedule,50.1,87.88,
Cmplx chron care addl 30 min,99489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.1,,,,,,,fee schedule,50.1,87.88,
Cmplx chron care addl 30 min,99489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.88,,,,,,,fee schedule,50.1,87.88,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
1st psyc collab care mgmt,99492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.43,,,,,,,fee schedule,101.22,225.89,
1st psyc collab care mgmt,99492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.78,,,,,,,fee schedule,101.22,225.89,
1st psyc collab care mgmt,99492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.78,,,,,,,fee schedule,101.22,225.89,
1st psyc collab care mgmt,99492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.89,,,,,,,fee schedule,101.22,225.89,
1st psyc collab care mgmt,99492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,101.22,225.89,APC
1st psyc collab care mgmt,99492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,101.22,225.89,APC
1st psyc collab care mgmt,99492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,101.22,225.89,APC
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.43,,,,,,,fee schedule,101.22,225.89,
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.78,,,,,,,fee schedule,101.22,225.89,
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.78,,,,,,,fee schedule,101.22,225.89,
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.89,,,,,,,fee schedule,101.22,225.89,
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,101.22,225.89,APC
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,101.22,225.89,APC
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,101.22,225.89,APC
Trans care mgmt 14 day disch,99495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Trans care mgmt 14 day disch,99495,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Trans care mgmt 14 day disch,99495,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Trans care mgmt 7 day disch,99496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Trans care mgmt 7 day disch,99496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Trans care mgmt 7 day disch,99496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Trans care mgmt 7 day disch,99496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Trans care mgmt 7 day disch,99496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Trans care mgmt 7 day disch,99496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Trans care mgmt 7 day disch,99496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Advncd care plan 30 min,99497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
Advncd care plan 30 min,99497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
Advncd care plan 30 min,99497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
Advncd care plan 30 min,99497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
Advncd care plan 30 min,99497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
Advncd care plan 30 min,99497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
Advncd care plan 30 min,99497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
Advncd care plan addl 30 min,99498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.91,,,,,,,fee schedule,34.69,60.85,
Advncd care plan addl 30 min,99498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.31,,,,,,,fee schedule,34.69,60.85,
Advncd care plan addl 30 min,99498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.69,,,,,,,fee schedule,34.69,60.85,
Advncd care plan addl 30 min,99498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.85,,,,,,,fee schedule,34.69,60.85,
Outside state ambulance serv,A0021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.63,,,,,,,fee schedule,12.21,21.42,
Outside state ambulance serv,A0021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.25,,,,,,,fee schedule,12.21,21.42,
Outside state ambulance serv,A0021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.21,,,,,,,fee schedule,12.21,21.42,
Outside state ambulance serv,A0021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.42,,,,,,,fee schedule,12.21,21.42,
Noner transport case worker,A0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.65,1.14,
Noner transport case worker,A0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.65,1.14,
Noner transport case worker,A0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,1.14,
Noner transport case worker,A0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.65,1.14,
Neonatal emergency transport,A0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1060.21,,,,,,,fee schedule,695.07,1219.24,
Neonatal emergency transport,A0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,867.78,,,,,,,fee schedule,695.07,1219.24,
Neonatal emergency transport,A0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,695.07,,,,,,,fee schedule,695.07,1219.24,
Neonatal emergency transport,A0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1219.24,,,,,,,fee schedule,695.07,1219.24,
Basic life support mileage,A0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,10.27,18.02,
Basic life support mileage,A0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,10.27,18.02,
Basic life support mileage,A0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,18.02,
Basic life support mileage,A0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,10.27,18.02,
Basic support routine suppls,A0382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.56,,,,,,,fee schedule,14.13,24.79,
Basic support routine suppls,A0382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.65,,,,,,,fee schedule,14.13,24.79,
Basic support routine suppls,A0382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.13,,,,,,,fee schedule,14.13,24.79,
Basic support routine suppls,A0382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.79,,,,,,,fee schedule,14.13,24.79,
Bls defibrillation supplies,A0384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.77,,,,,,,fee schedule,71.31,125.09,
Bls defibrillation supplies,A0384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.03,,,,,,,fee schedule,71.31,125.09,
Bls defibrillation supplies,A0384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.31,,,,,,,fee schedule,71.31,125.09,
Bls defibrillation supplies,A0384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.09,,,,,,,fee schedule,71.31,125.09,
Advanced life support mileag,A0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,10.27,18.02,
Advanced life support mileag,A0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,10.27,18.02,
Advanced life support mileag,A0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,18.02,
Advanced life support mileag,A0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,10.27,18.02,
Als defibrillation supplies,A0392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.77,,,,,,,fee schedule,71.31,125.09,
Als defibrillation supplies,A0392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.03,,,,,,,fee schedule,71.31,125.09,
Als defibrillation supplies,A0392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.31,,,,,,,fee schedule,71.31,125.09,
Als defibrillation supplies,A0392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.09,,,,,,,fee schedule,71.31,125.09,
Als IV drug therapy supplies,A0394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.93,,,,,,,fee schedule,34.05,59.72,
Als IV drug therapy supplies,A0394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.5,,,,,,,fee schedule,34.05,59.72,
Als IV drug therapy supplies,A0394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.05,,,,,,,fee schedule,34.05,59.72,
Als IV drug therapy supplies,A0394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.72,,,,,,,fee schedule,34.05,59.72,
Als esophageal intub suppls,A0396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.21,,,,,,,fee schedule,56.52,99.14,
Als esophageal intub suppls,A0396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.56,,,,,,,fee schedule,56.52,99.14,
Als esophageal intub suppls,A0396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.52,,,,,,,fee schedule,56.52,99.14,
Als esophageal intub suppls,A0396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.14,,,,,,,fee schedule,56.52,99.14,
Als routine disposble suppls,A0398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.56,,,,,,,fee schedule,14.13,24.79,
Als routine disposble suppls,A0398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.65,,,,,,,fee schedule,14.13,24.79,
Als routine disposble suppls,A0398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.13,,,,,,,fee schedule,14.13,24.79,
Als routine disposble suppls,A0398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.79,,,,,,,fee schedule,14.13,24.79,
Ambulance 02 life sustaining,A0422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.33,,,,,,,fee schedule,52.66,92.38,
Ambulance 02 life sustaining,A0422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.75,,,,,,,fee schedule,52.66,92.38,
Ambulance 02 life sustaining,A0422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.66,,,,,,,fee schedule,52.66,92.38,
Ambulance 02 life sustaining,A0422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.38,,,,,,,fee schedule,52.66,92.38,
Ground mileage,A0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,9.33,18.02,
Ground mileage,A0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,9.33,18.02,
Ground mileage,A0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,9.33,18.02,
Ground mileage,A0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,9.33,18.02,
Ground mileage,A0425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.8,,,,,,,fee schedule,9.33,18.02,APC
Ground mileage,A0425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.33,,,,,,,fee schedule,9.33,18.02,APC
Ground mileage,A0425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.79,,,,,,,fee schedule,9.33,18.02,APC
Als 1,A0426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,804.47,,,,,,,fee schedule,327.09,925.14,
Als 1,A0426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,658.46,,,,,,,fee schedule,327.09,925.14,
Als 1,A0426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,527.41,,,,,,,fee schedule,327.09,925.14,
Als 1,A0426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,925.14,,,,,,,fee schedule,327.09,925.14,
Als 1,A0426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.44,,,,,,,fee schedule,327.09,925.14,APC
Als 1,A0426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,327.09,,,,,,,fee schedule,327.09,925.14,APC
Als 1,A0426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,588.76,,,,,,,fee schedule,327.09,925.14,APC
ALS1-emergency,A0427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,845.61,,,,,,,fee schedule,517.89,972.45,
ALS1-emergency,A0427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,692.13,,,,,,,fee schedule,517.89,972.45,
ALS1-emergency,A0427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,554.38,,,,,,,fee schedule,517.89,972.45,
ALS1-emergency,A0427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,972.45,,,,,,,fee schedule,517.89,972.45,
ALS1-emergency,A0427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,543.78,,,,,,,fee schedule,517.89,972.45,APC
ALS1-emergency,A0427,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,517.89,,,,,,,fee schedule,517.89,972.45,APC
ALS1-emergency,A0427,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,932.2,,,,,,,fee schedule,517.89,972.45,APC
bls,A0428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,707.46,,,,,,,fee schedule,272.57,813.58,
bls,A0428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,579.06,,,,,,,fee schedule,272.57,813.58,
bls,A0428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,463.81,,,,,,,fee schedule,272.57,813.58,
bls,A0428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,813.58,,,,,,,fee schedule,272.57,813.58,
bls,A0428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,286.2,,,,,,,fee schedule,272.57,813.58,APC
bls,A0428,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,272.57,,,,,,,fee schedule,272.57,813.58,APC
bls,A0428,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,490.63,,,,,,,fee schedule,272.57,813.58,APC
BLS-emergency,A0429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,733.9,,,,,,,fee schedule,436.12,843.99,
BLS-emergency,A0429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,600.7,,,,,,,fee schedule,436.12,843.99,
BLS-emergency,A0429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.14,,,,,,,fee schedule,436.12,843.99,
BLS-emergency,A0429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,843.99,,,,,,,fee schedule,436.12,843.99,
BLS-emergency,A0429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,457.93,,,,,,,fee schedule,436.12,843.99,APC
BLS-emergency,A0429,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,436.12,,,,,,,fee schedule,436.12,843.99,APC
BLS-emergency,A0429,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,785.02,,,,,,,fee schedule,436.12,843.99,APC
Miscellaneous M <46.50 and A >=77.50,A2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.26,,,,,,,fee schedule,13.26,15.25,
Miscellaneous M <46.50 and A >=77.50,A2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.26,,,,,,,fee schedule,13.26,15.25,
Miscellaneous M <46.50 and A >=77.50,A2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.26,,,,,,,fee schedule,13.26,15.25,
Miscellaneous M <46.50 and A >=77.50,A2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.25,,,,,,,fee schedule,13.26,15.25,
1 CC sterile syringe&needle,A4206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.01,,,,,,,fee schedule,0.66,1.16,
1 CC sterile syringe&needle,A4206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.83,,,,,,,fee schedule,0.66,1.16,
1 CC sterile syringe&needle,A4206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.66,,,,,,,fee schedule,0.66,1.16,
1 CC sterile syringe&needle,A4206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.16,,,,,,,fee schedule,0.66,1.16,
3 CC sterile syringe&needle,A4208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.81,,,,,,,fee schedule,0.53,0.93,
3 CC sterile syringe&needle,A4208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.66,,,,,,,fee schedule,0.53,0.93,
3 CC sterile syringe&needle,A4208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.53,,,,,,,fee schedule,0.53,0.93,
3 CC sterile syringe&needle,A4208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.93,,,,,,,fee schedule,0.53,0.93,
5+ CC sterile syringe&needle,A4209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.81,,,,,,,fee schedule,0.53,0.93,
5+ CC sterile syringe&needle,A4209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.66,,,,,,,fee schedule,0.53,0.93,
5+ CC sterile syringe&needle,A4209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.53,,,,,,,fee schedule,0.53,0.93,
5+ CC sterile syringe&needle,A4209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.93,,,,,,,fee schedule,0.53,0.93,
Nonneedle injection device,A4210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,914.62,,,,,,,fee schedule,599.62,1051.81,
Nonneedle injection device,A4210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,748.62,,,,,,,fee schedule,599.62,1051.81,
Nonneedle injection device,A4210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,599.62,,,,,,,fee schedule,599.62,1051.81,
Nonneedle injection device,A4210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1051.81,,,,,,,fee schedule,599.62,1051.81,
Non coring needle or stylet,A4212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.66,,,,,,,fee schedule,10.92,19.16,
Non coring needle or stylet,A4212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.64,,,,,,,fee schedule,10.92,19.16,
Non coring needle or stylet,A4212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.92,,,,,,,fee schedule,10.92,19.16,
Non coring needle or stylet,A4212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.16,,,,,,,fee schedule,10.92,19.16,
20+ CC syringe only,A4213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.64,,,,,,,fee schedule,1.08,1.89,
20+ CC syringe only,A4213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.34,,,,,,,fee schedule,1.08,1.89,
20+ CC syringe only,A4213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.08,,,,,,,fee schedule,1.08,1.89,
20+ CC syringe only,A4213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.89,,,,,,,fee schedule,1.08,1.89,
"Sterile water/saline, 10 ml",A4216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.3,,,,,,,fee schedule,2.16,3.8,
"Sterile water/saline, 10 ml",A4216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.7,,,,,,,fee schedule,2.16,3.8,
"Sterile water/saline, 10 ml",A4216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.16,,,,,,,fee schedule,2.16,3.8,
"Sterile water/saline, 10 ml",A4216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.8,,,,,,,fee schedule,2.16,3.8,
"Sterile water/saline, 500 ml",A4217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.22,,,,,,,fee schedule,6.7,11.75,
"Sterile water/saline, 500 ml",A4217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.37,,,,,,,fee schedule,6.7,11.75,
"Sterile water/saline, 500 ml",A4217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.7,,,,,,,fee schedule,6.7,11.75,
"Sterile water/saline, 500 ml",A4217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.75,,,,,,,fee schedule,6.7,11.75,
Supp non-insulin inf cath/wk,A4221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.96,,,,,,,fee schedule,34.72,60.9,
Supp non-insulin inf cath/wk,A4221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.35,,,,,,,fee schedule,34.72,60.9,
Supp non-insulin inf cath/wk,A4221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.72,,,,,,,fee schedule,34.72,60.9,
Supp non-insulin inf cath/wk,A4221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.9,,,,,,,fee schedule,34.72,60.9,
Infusion supplies with pump,A4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.43,,,,,,,fee schedule,65.84,115.49,
Infusion supplies with pump,A4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.2,,,,,,,fee schedule,65.84,115.49,
Infusion supplies with pump,A4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.84,,,,,,,fee schedule,65.84,115.49,
Infusion supplies with pump,A4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.49,,,,,,,fee schedule,65.84,115.49,
Supply insulin inf cath/wk,A4224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.96,,,,,,,fee schedule,34.72,60.9,
Supply insulin inf cath/wk,A4224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.35,,,,,,,fee schedule,34.72,60.9,
Supply insulin inf cath/wk,A4224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.72,,,,,,,fee schedule,34.72,60.9,
Supply insulin inf cath/wk,A4224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.9,,,,,,,fee schedule,34.72,60.9,
Sup/ext insulin inf pump syr,A4225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.1,,,,,,,fee schedule,4.65,8.17,
Sup/ext insulin inf pump syr,A4225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.81,,,,,,,fee schedule,4.65,8.17,
Sup/ext insulin inf pump syr,A4225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.65,,,,,,,fee schedule,4.65,8.17,
Sup/ext insulin inf pump syr,A4225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.17,,,,,,,fee schedule,4.65,8.17,
Alkalin batt for glucose mon,A4233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.38,,,,,,,fee schedule,0.9,1.59,
Alkalin batt for glucose mon,A4233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.13,,,,,,,fee schedule,0.9,1.59,
Alkalin batt for glucose mon,A4233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.9,,,,,,,fee schedule,0.9,1.59,
Alkalin batt for glucose mon,A4233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.59,,,,,,,fee schedule,0.9,1.59,
J-cell batt for glucose mon,A4234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.43,,,,,,,fee schedule,4.22,7.39,
J-cell batt for glucose mon,A4234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.26,,,,,,,fee schedule,4.22,7.39,
J-cell batt for glucose mon,A4234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.22,,,,,,,fee schedule,4.22,7.39,
J-cell batt for glucose mon,A4234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.39,,,,,,,fee schedule,4.22,7.39,
Lithium batt for glucose mon,A4235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.71,,,,,,,fee schedule,1.78,3.12,
Lithium batt for glucose mon,A4235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.22,,,,,,,fee schedule,1.78,3.12,
Lithium batt for glucose mon,A4235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.78,,,,,,,fee schedule,1.78,3.12,
Lithium batt for glucose mon,A4235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.12,,,,,,,fee schedule,1.78,3.12,
Silvr oxide batt glucose mon,A4236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.17,,,,,,,fee schedule,2.08,3.65,
Silvr oxide batt glucose mon,A4236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.59,,,,,,,fee schedule,2.08,3.65,
Silvr oxide batt glucose mon,A4236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.08,,,,,,,fee schedule,2.08,3.65,
Silvr oxide batt glucose mon,A4236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.65,,,,,,,fee schedule,2.08,3.65,
Alcohol or peroxide per pint,A4244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.96,,,,,,,fee schedule,1.28,2.25,
Alcohol or peroxide per pint,A4244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.28,2.25,
Alcohol or peroxide per pint,A4244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.28,,,,,,,fee schedule,1.28,2.25,
Alcohol or peroxide per pint,A4244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.25,,,,,,,fee schedule,1.28,2.25,
Alcohol wipes per box,A4245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.61,,,,,,,fee schedule,4.99,8.75,
Alcohol wipes per box,A4245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.23,,,,,,,fee schedule,4.99,8.75,
Alcohol wipes per box,A4245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.99,,,,,,,fee schedule,4.99,8.75,
Alcohol wipes per box,A4245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.75,,,,,,,fee schedule,4.99,8.75,
Betadine/phisohex solution,A4246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.86,,,,,,,fee schedule,3.84,6.74,
Betadine/phisohex solution,A4246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.8,,,,,,,fee schedule,3.84,6.74,
Betadine/phisohex solution,A4246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.84,,,,,,,fee schedule,3.84,6.74,
Betadine/phisohex solution,A4246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.74,,,,,,,fee schedule,3.84,6.74,
Betadine/iodine swabs/wipes,A4247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.7,,,,,,,fee schedule,0.46,0.81,
Betadine/iodine swabs/wipes,A4247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.57,,,,,,,fee schedule,0.46,0.81,
Betadine/iodine swabs/wipes,A4247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.46,,,,,,,fee schedule,0.46,0.81,
Betadine/iodine swabs/wipes,A4247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.81,,,,,,,fee schedule,0.46,0.81,
Urine reagent strips/tablets,A4250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,180.41,,,,,,,fee schedule,118.28,207.47,
Urine reagent strips/tablets,A4250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.67,,,,,,,fee schedule,118.28,207.47,
Urine reagent strips/tablets,A4250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.28,,,,,,,fee schedule,118.28,207.47,
Urine reagent strips/tablets,A4250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,207.47,,,,,,,fee schedule,118.28,207.47,
Blood glucose/reagent strips,A4253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.86,,,,,,,fee schedule,80.55,141.29,
Blood glucose/reagent strips,A4253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.56,,,,,,,fee schedule,80.55,141.29,
Blood glucose/reagent strips,A4253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.55,,,,,,,fee schedule,80.55,141.29,
Blood glucose/reagent strips,A4253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.29,,,,,,,fee schedule,80.55,141.29,
Glucose monitor platforms,A4255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.28,,,,,,,fee schedule,8.05,14.12,
Glucose monitor platforms,A4255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.05,,,,,,,fee schedule,8.05,14.12,
Glucose monitor platforms,A4255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.05,,,,,,,fee schedule,8.05,14.12,
Glucose monitor platforms,A4255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.12,,,,,,,fee schedule,8.05,14.12,
Calibrator solution/chips,A4256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.84,,,,,,,fee schedule,18.25,32.02,
Calibrator solution/chips,A4256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.79,,,,,,,fee schedule,18.25,32.02,
Calibrator solution/chips,A4256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.25,,,,,,,fee schedule,18.25,32.02,
Calibrator solution/chips,A4256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.02,,,,,,,fee schedule,18.25,32.02,
Replace lensshield cartridge,A4257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.76,,,,,,,fee schedule,25.41,44.57,
Replace lensshield cartridge,A4257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.73,,,,,,,fee schedule,25.41,44.57,
Replace lensshield cartridge,A4257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.41,,,,,,,fee schedule,25.41,44.57,
Replace lensshield cartridge,A4257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.57,,,,,,,fee schedule,25.41,44.57,
Lancet device each,A4258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.77,,,,,,,fee schedule,3.78,6.64,
Lancet device each,A4258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.72,,,,,,,fee schedule,3.78,6.64,
Lancet device each,A4258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.78,,,,,,,fee schedule,3.78,6.64,
Lancet device each,A4258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.64,,,,,,,fee schedule,3.78,6.64,
Lancets per box,A4259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.75,,,,,,,fee schedule,11.64,20.41,
Lancets per box,A4259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.53,,,,,,,fee schedule,11.64,20.41,
Lancets per box,A4259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.64,,,,,,,fee schedule,11.64,20.41,
Lancets per box,A4259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.41,,,,,,,fee schedule,11.64,20.41,
Temporary tear duct plug,A4262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.65,1.14,
Temporary tear duct plug,A4262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.65,1.14,
Temporary tear duct plug,A4262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,1.14,
Temporary tear duct plug,A4262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.65,1.14,
Permanent tear duct plug,A4263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,90.13,
Permanent tear duct plug,A4263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,90.13,
Permanent tear duct plug,A4263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,90.13,
Permanent tear duct plug,A4263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,90.13,
Paraffin,A4265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.33,,,,,,,fee schedule,6.77,11.88,
Paraffin,A4265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.46,,,,,,,fee schedule,6.77,11.88,
Paraffin,A4265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.77,,,,,,,fee schedule,6.77,11.88,
Paraffin,A4265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.88,,,,,,,fee schedule,6.77,11.88,
Male condom,A4267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.65,1.14,
Male condom,A4267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.65,1.14,
Male condom,A4267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,1.14,
Male condom,A4267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.65,1.14,
Spermicide,A4269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.96,,,,,,,fee schedule,1.28,2.25,
Spermicide,A4269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.28,2.25,
Spermicide,A4269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.28,,,,,,,fee schedule,1.28,2.25,
Spermicide,A4269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.25,,,,,,,fee schedule,1.28,2.25,
Brst prsths adhsv attchmnt,A4280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.15,,,,,,,fee schedule,10.59,18.57,
Brst prsths adhsv attchmnt,A4280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.22,,,,,,,fee schedule,10.59,18.57,
Brst prsths adhsv attchmnt,A4280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.59,,,,,,,fee schedule,10.59,18.57,
Brst prsths adhsv attchmnt,A4280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.57,,,,,,,fee schedule,10.59,18.57,
Replcmnt breast pump shield,A4284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,22.47,39.42,
Replcmnt breast pump shield,A4284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,22.47,39.42,
Replcmnt breast pump shield,A4284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,22.47,39.42,
Replcmnt breast pump shield,A4284,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,22.47,39.42,
Drug delivery system >=50 ML,A4305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.47,,,,,,,fee schedule,16.7,29.29,
Drug delivery system >=50 ML,A4305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.85,,,,,,,fee schedule,16.7,29.29,
Drug delivery system >=50 ML,A4305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.7,,,,,,,fee schedule,16.7,29.29,
Drug delivery system >=50 ML,A4305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.29,,,,,,,fee schedule,16.7,29.29,
Drug delivery system <=50 ml,A4306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.26,,,,,,,fee schedule,23.12,40.55,
Drug delivery system <=50 ml,A4306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.86,,,,,,,fee schedule,23.12,40.55,
Drug delivery system <=50 ml,A4306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.12,,,,,,,fee schedule,23.12,40.55,
Drug delivery system <=50 ml,A4306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.55,,,,,,,fee schedule,23.12,40.55,
Insert tray w/o bag/cath,A4310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.49,,,,,,,fee schedule,15.4,27.01,
Insert tray w/o bag/cath,A4310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.23,,,,,,,fee schedule,15.4,27.01,
Insert tray w/o bag/cath,A4310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.4,,,,,,,fee schedule,15.4,27.01,
Insert tray w/o bag/cath,A4310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.01,,,,,,,fee schedule,15.4,27.01,
Catheter w/o bag 2-way latex,A4311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.05,,,,,,,fee schedule,29.53,51.81,
Catheter w/o bag 2-way latex,A4311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.87,,,,,,,fee schedule,29.53,51.81,
Catheter w/o bag 2-way latex,A4311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.53,,,,,,,fee schedule,29.53,51.81,
Catheter w/o bag 2-way latex,A4311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.81,,,,,,,fee schedule,29.53,51.81,
Cath w/o bag 2-way silicone,A4312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.82,,,,,,,fee schedule,35.94,63.04,
Cath w/o bag 2-way silicone,A4312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.87,,,,,,,fee schedule,35.94,63.04,
Cath w/o bag 2-way silicone,A4312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.94,,,,,,,fee schedule,35.94,63.04,
Cath w/o bag 2-way silicone,A4312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.04,,,,,,,fee schedule,35.94,63.04,
Catheter w/bag 3-way,A4313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.86,,,,,,,fee schedule,31.38,55.04,
Catheter w/bag 3-way,A4313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.17,,,,,,,fee schedule,31.38,55.04,
Catheter w/bag 3-way,A4313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.38,,,,,,,fee schedule,31.38,55.04,
Catheter w/bag 3-way,A4313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.04,,,,,,,fee schedule,31.38,55.04,
Cath w/drainage 2-way latex,A4314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.86,,,,,,,fee schedule,50.39,88.39,
Cath w/drainage 2-way latex,A4314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.91,,,,,,,fee schedule,50.39,88.39,
Cath w/drainage 2-way latex,A4314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.39,,,,,,,fee schedule,50.39,88.39,
Cath w/drainage 2-way latex,A4314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.39,,,,,,,fee schedule,50.39,88.39,
Cath w/drainage 2-way silcne,A4315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.18,,,,,,,fee schedule,52.57,92.21,
Cath w/drainage 2-way silcne,A4315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.63,,,,,,,fee schedule,52.57,92.21,
Cath w/drainage 2-way silcne,A4315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.57,,,,,,,fee schedule,52.57,92.21,
Cath w/drainage 2-way silcne,A4315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.21,,,,,,,fee schedule,52.57,92.21,
Cath w/drainage 3-way,A4316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.3,,,,,,,fee schedule,56.58,99.25,
Cath w/drainage 3-way,A4316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.64,,,,,,,fee schedule,56.58,99.25,
Cath w/drainage 3-way,A4316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.58,,,,,,,fee schedule,56.58,99.25,
Cath w/drainage 3-way,A4316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.25,,,,,,,fee schedule,56.58,99.25,
Irrigation tray,A4320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.95,,,,,,,fee schedule,9.8,17.19,
Irrigation tray,A4320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.24,,,,,,,fee schedule,9.8,17.19,
Irrigation tray,A4320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.8,,,,,,,fee schedule,9.8,17.19,
Irrigation tray,A4320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.19,,,,,,,fee schedule,9.8,17.19,
Irrigation syringe,A4322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.25,,,,,,,fee schedule,6.06,10.64,
Irrigation syringe,A4322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.57,,,,,,,fee schedule,6.06,10.64,
Irrigation syringe,A4322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.06,,,,,,,fee schedule,6.06,10.64,
Irrigation syringe,A4322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.64,,,,,,,fee schedule,6.06,10.64,
Male external catheter,A4326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.45,,,,,,,fee schedule,18.65,32.72,
Male external catheter,A4326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.29,,,,,,,fee schedule,18.65,32.72,
Male external catheter,A4326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.65,,,,,,,fee schedule,18.65,32.72,
Male external catheter,A4326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.72,,,,,,,fee schedule,18.65,32.72,
Fem urinary collect dev cup,A4327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,135.59,,,,,,,fee schedule,88.89,155.93,
Fem urinary collect dev cup,A4327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.98,,,,,,,fee schedule,88.89,155.93,
Fem urinary collect dev cup,A4327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.89,,,,,,,fee schedule,88.89,155.93,
Fem urinary collect dev cup,A4327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.93,,,,,,,fee schedule,88.89,155.93,
Fem urinary collect pouch,A4328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.61,,,,,,,fee schedule,20.72,36.35,
Fem urinary collect pouch,A4328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.87,,,,,,,fee schedule,20.72,36.35,
Fem urinary collect pouch,A4328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.72,,,,,,,fee schedule,20.72,36.35,
Fem urinary collect pouch,A4328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.35,,,,,,,fee schedule,20.72,36.35,
Stool collection pouch,A4330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.85,,,,,,,fee schedule,14.98,26.28,
Stool collection pouch,A4330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.7,,,,,,,fee schedule,14.98,26.28,
Stool collection pouch,A4330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.98,,,,,,,fee schedule,14.98,26.28,
Stool collection pouch,A4330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.28,,,,,,,fee schedule,14.98,26.28,
Extension drainage tubing,A4331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.05,,,,,,,fee schedule,9.21,16.16,
Extension drainage tubing,A4331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.5,,,,,,,fee schedule,9.21,16.16,
Extension drainage tubing,A4331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.21,,,,,,,fee schedule,9.21,16.16,
Extension drainage tubing,A4331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.16,,,,,,,fee schedule,9.21,16.16,
Lube sterile packet,A4332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.35,,,,,,,fee schedule,0.23,0.4,
Lube sterile packet,A4332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.29,,,,,,,fee schedule,0.23,0.4,
Lube sterile packet,A4332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.23,0.4,
Lube sterile packet,A4332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.4,,,,,,,fee schedule,0.23,0.4,
Urinary cath anchor device,A4333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.7,,,,,,,fee schedule,4.39,7.71,
Urinary cath anchor device,A4333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.48,,,,,,,fee schedule,4.39,7.71,
Urinary cath anchor device,A4333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.39,,,,,,,fee schedule,4.39,7.71,
Urinary cath anchor device,A4333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.71,,,,,,,fee schedule,4.39,7.71,
Urinary cath leg strap,A4334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.95,,,,,,,fee schedule,9.8,17.19,
Urinary cath leg strap,A4334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.24,,,,,,,fee schedule,9.8,17.19,
Urinary cath leg strap,A4334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.8,,,,,,,fee schedule,9.8,17.19,
Urinary cath leg strap,A4334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.19,,,,,,,fee schedule,9.8,17.19,
Urethral insert,A4336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.37,,,,,,,fee schedule,2.86,5.03,
Urethral insert,A4336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.58,,,,,,,fee schedule,2.86,5.03,
Urethral insert,A4336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.86,,,,,,,fee schedule,2.86,5.03,
Urethral insert,A4336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.03,,,,,,,fee schedule,2.86,5.03,
Indwelling catheter latex,A4338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.54,,,,,,,fee schedule,35.1,61.57,
Indwelling catheter latex,A4338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.82,,,,,,,fee schedule,35.1,61.57,
Indwelling catheter latex,A4338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.1,,,,,,,fee schedule,35.1,61.57,
Indwelling catheter latex,A4338,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.57,,,,,,,fee schedule,35.1,61.57,
Indwelling catheter special,A4340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.03,,,,,,,fee schedule,53.78,94.33,
Indwelling catheter special,A4340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.14,,,,,,,fee schedule,53.78,94.33,
Indwelling catheter special,A4340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.78,,,,,,,fee schedule,53.78,94.33,
Indwelling catheter special,A4340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.33,,,,,,,fee schedule,53.78,94.33,
Cath indw foley 2 way silicn,A4344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.66,,,,,,,fee schedule,31.9,55.96,
Cath indw foley 2 way silicn,A4344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.83,,,,,,,fee schedule,31.9,55.96,
Cath indw foley 2 way silicn,A4344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.9,,,,,,,fee schedule,31.9,55.96,
Cath indw foley 2 way silicn,A4344,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.96,,,,,,,fee schedule,31.9,55.96,
Cath indw foley 3 way,A4346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.51,,,,,,,fee schedule,39.01,68.44,
Cath indw foley 3 way,A4346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.71,,,,,,,fee schedule,39.01,68.44,
Cath indw foley 3 way,A4346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.01,,,,,,,fee schedule,39.01,68.44,
Cath indw foley 3 way,A4346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.44,,,,,,,fee schedule,39.01,68.44,
Disposable male external cat,A4349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.93,,,,,,,fee schedule,2.58,4.52,
Disposable male external cat,A4349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.22,,,,,,,fee schedule,2.58,4.52,
Disposable male external cat,A4349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.58,,,,,,,fee schedule,2.58,4.52,
Disposable male external cat,A4349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.52,,,,,,,fee schedule,2.58,4.52,
Straight tip urine catheter,A4351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.99,,,,,,,fee schedule,1.3,2.29,
Straight tip urine catheter,A4351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.63,,,,,,,fee schedule,1.3,2.29,
Straight tip urine catheter,A4351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.3,,,,,,,fee schedule,1.3,2.29,
Straight tip urine catheter,A4351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.29,,,,,,,fee schedule,1.3,2.29,
Coude tip urinary catheter,A4352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.13,,,,,,,fee schedule,1.4,2.45,
Coude tip urinary catheter,A4352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.74,,,,,,,fee schedule,1.4,2.45,
Coude tip urinary catheter,A4352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.4,,,,,,,fee schedule,1.4,2.45,
Coude tip urinary catheter,A4352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.45,,,,,,,fee schedule,1.4,2.45,
Intermittent urinary cath,A4353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.83,,,,,,,fee schedule,10.38,18.2,
Intermittent urinary cath,A4353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.96,,,,,,,fee schedule,10.38,18.2,
Intermittent urinary cath,A4353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.38,,,,,,,fee schedule,10.38,18.2,
Intermittent urinary cath,A4353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.2,,,,,,,fee schedule,10.38,18.2,
Cath insertion tray w/bag,A4354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.97,,,,,,,fee schedule,20.3,35.62,
Cath insertion tray w/bag,A4354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.35,,,,,,,fee schedule,20.3,35.62,
Cath insertion tray w/bag,A4354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.3,,,,,,,fee schedule,20.3,35.62,
Cath insertion tray w/bag,A4354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.62,,,,,,,fee schedule,20.3,35.62,
Bladder irrigation tubing,A4355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.09,,,,,,,fee schedule,17.76,31.15,
Bladder irrigation tubing,A4355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.17,,,,,,,fee schedule,17.76,31.15,
Bladder irrigation tubing,A4355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.76,,,,,,,fee schedule,17.76,31.15,
Bladder irrigation tubing,A4355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.15,,,,,,,fee schedule,17.76,31.15,
Ext ureth clmp or compr dvc,A4356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,138.66,,,,,,,fee schedule,90.91,159.46,
Ext ureth clmp or compr dvc,A4356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.49,,,,,,,fee schedule,90.91,159.46,
Ext ureth clmp or compr dvc,A4356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.91,,,,,,,fee schedule,90.91,159.46,
Ext ureth clmp or compr dvc,A4356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,159.46,,,,,,,fee schedule,90.91,159.46,
Bedside drainage bag,A4357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.4,,,,,,,fee schedule,8.13,14.26,
Bedside drainage bag,A4357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.15,,,,,,,fee schedule,8.13,14.26,
Bedside drainage bag,A4357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.13,,,,,,,fee schedule,8.13,14.26,
Bedside drainage bag,A4357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.26,,,,,,,fee schedule,8.13,14.26,
Urinary leg or abdomen bag,A4358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.85,,,,,,,fee schedule,11.7,20.53,
Urinary leg or abdomen bag,A4358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.61,,,,,,,fee schedule,11.7,20.53,
Urinary leg or abdomen bag,A4358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.7,,,,,,,fee schedule,11.7,20.53,
Urinary leg or abdomen bag,A4358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.53,,,,,,,fee schedule,11.7,20.53,
Disposable ext urethral dev,A4360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.46,,,,,,,fee schedule,0.96,1.68,
Disposable ext urethral dev,A4360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.2,,,,,,,fee schedule,0.96,1.68,
Disposable ext urethral dev,A4360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.96,,,,,,,fee schedule,0.96,1.68,
Disposable ext urethral dev,A4360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.68,,,,,,,fee schedule,0.96,1.68,
Ostomy face plate,A4361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.7,,,,,,,fee schedule,20.78,36.46,
Ostomy face plate,A4361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.95,,,,,,,fee schedule,20.78,36.46,
Ostomy face plate,A4361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.78,,,,,,,fee schedule,20.78,36.46,
Ostomy face plate,A4361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.46,,,,,,,fee schedule,20.78,36.46,
Solid skin barrier,A4362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.22,,,,,,,fee schedule,7.36,12.9,
Solid skin barrier,A4362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.18,,,,,,,fee schedule,7.36,12.9,
Solid skin barrier,A4362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.36,,,,,,,fee schedule,7.36,12.9,
Solid skin barrier,A4362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.9,,,,,,,fee schedule,7.36,12.9,
"Ostomy clamp, replacement",A4363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.13,,,,,,,fee schedule,4.02,7.05,
"Ostomy clamp, replacement",A4363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.02,,,,,,,fee schedule,4.02,7.05,
"Ostomy clamp, replacement",A4363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.02,,,,,,,fee schedule,4.02,7.05,
"Ostomy clamp, replacement",A4363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.05,,,,,,,fee schedule,4.02,7.05,
"Adhesive, liquid or equal",A4364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.63,,,,,,,fee schedule,13.53,23.72,
"Adhesive, liquid or equal",A4364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.89,,,,,,,fee schedule,13.53,23.72,
"Adhesive, liquid or equal",A4364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.53,,,,,,,fee schedule,13.53,23.72,
"Adhesive, liquid or equal",A4364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.72,,,,,,,fee schedule,13.53,23.72,
Ostomy vent,A4366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.93,,,,,,,fee schedule,2.58,4.52,
Ostomy vent,A4366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.22,,,,,,,fee schedule,2.58,4.52,
Ostomy vent,A4366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.58,,,,,,,fee schedule,2.58,4.52,
Ostomy vent,A4366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.52,,,,,,,fee schedule,2.58,4.52,
Ostomy belt,A4367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.94,,,,,,,fee schedule,14.38,25.23,
Ostomy belt,A4367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.96,,,,,,,fee schedule,14.38,25.23,
Ostomy belt,A4367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.38,,,,,,,fee schedule,14.38,25.23,
Ostomy belt,A4367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.23,,,,,,,fee schedule,14.38,25.23,
Ostomy filter,A4368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.29,,,,,,,fee schedule,0.85,1.48,
Ostomy filter,A4368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.06,,,,,,,fee schedule,0.85,1.48,
Ostomy filter,A4368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.85,,,,,,,fee schedule,0.85,1.48,
Ostomy filter,A4368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.48,,,,,,,fee schedule,0.85,1.48,
Skin barrier liquid per oz,A4369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.58,,,,,,,fee schedule,15.46,27.12,
Skin barrier liquid per oz,A4369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.3,,,,,,,fee schedule,15.46,27.12,
Skin barrier liquid per oz,A4369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.46,,,,,,,fee schedule,15.46,27.12,
Skin barrier liquid per oz,A4369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.12,,,,,,,fee schedule,15.46,27.12,
Skin barrier powder per oz,A4371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.69,,,,,,,fee schedule,14.22,24.94,
Skin barrier powder per oz,A4371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.75,,,,,,,fee schedule,14.22,24.94,
Skin barrier powder per oz,A4371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.22,,,,,,,fee schedule,14.22,24.94,
Skin barrier powder per oz,A4371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.94,,,,,,,fee schedule,14.22,24.94,
Skin barrier solid 4x4 equiv,A4372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.74,,,,,,,fee schedule,8.35,14.65,
Skin barrier solid 4x4 equiv,A4372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.43,,,,,,,fee schedule,8.35,14.65,
Skin barrier solid 4x4 equiv,A4372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.35,,,,,,,fee schedule,8.35,14.65,
Skin barrier solid 4x4 equiv,A4372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.65,,,,,,,fee schedule,8.35,14.65,
Skin barrier with flange,A4373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.52,,,,,,,fee schedule,14.11,24.75,
Skin barrier with flange,A4373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.61,,,,,,,fee schedule,14.11,24.75,
Skin barrier with flange,A4373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.11,,,,,,,fee schedule,14.11,24.75,
Skin barrier with flange,A4373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.75,,,,,,,fee schedule,14.11,24.75,
Drainable plastic pch w fcpl,A4375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.19,,,,,,,fee schedule,34.22,60.02,
Drainable plastic pch w fcpl,A4375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.72,,,,,,,fee schedule,34.22,60.02,
Drainable plastic pch w fcpl,A4375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.22,,,,,,,fee schedule,34.22,60.02,
Drainable plastic pch w fcpl,A4375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.02,,,,,,,fee schedule,34.22,60.02,
Drainable rubber pch w fcplt,A4376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.64,,,,,,,fee schedule,94.83,166.34,
Drainable rubber pch w fcplt,A4376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.39,,,,,,,fee schedule,94.83,166.34,
Drainable rubber pch w fcplt,A4376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.83,,,,,,,fee schedule,94.83,166.34,
Drainable rubber pch w fcplt,A4376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,166.34,,,,,,,fee schedule,94.83,166.34,
Drainable plstic pch w/o fp,A4377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.04,,,,,,,fee schedule,8.55,15,
Drainable plstic pch w/o fp,A4377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.67,,,,,,,fee schedule,8.55,15,
Drainable plstic pch w/o fp,A4377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.55,,,,,,,fee schedule,8.55,15,
Drainable plstic pch w/o fp,A4377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15,,,,,,,fee schedule,8.55,15,
Drainable rubber pch w/o fp,A4378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,93.43,,,,,,,fee schedule,61.25,107.44,
Drainable rubber pch w/o fp,A4378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.47,,,,,,,fee schedule,61.25,107.44,
Drainable rubber pch w/o fp,A4378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.25,,,,,,,fee schedule,61.25,107.44,
Drainable rubber pch w/o fp,A4378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,107.44,,,,,,,fee schedule,61.25,107.44,
Urinary plastic pouch w fcpl,A4379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.64,,,,,,,fee schedule,29.92,52.49,
Urinary plastic pouch w fcpl,A4379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.36,,,,,,,fee schedule,29.92,52.49,
Urinary plastic pouch w fcpl,A4379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.92,,,,,,,fee schedule,29.92,52.49,
Urinary plastic pouch w fcpl,A4379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.49,,,,,,,fee schedule,29.92,52.49,
Urinary rubber pouch w fcplt,A4380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.43,,,,,,,fee schedule,74.36,130.44,
Urinary rubber pouch w fcplt,A4380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.84,,,,,,,fee schedule,74.36,130.44,
Urinary rubber pouch w fcplt,A4380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.36,,,,,,,fee schedule,74.36,130.44,
Urinary rubber pouch w fcplt,A4380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.44,,,,,,,fee schedule,74.36,130.44,
Urinary plastic pouch w/o fp,A4381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.05,,,,,,,fee schedule,9.21,16.16,
Urinary plastic pouch w/o fp,A4381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.5,,,,,,,fee schedule,9.21,16.16,
Urinary plastic pouch w/o fp,A4381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.21,,,,,,,fee schedule,9.21,16.16,
Urinary plastic pouch w/o fp,A4381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.16,,,,,,,fee schedule,9.21,16.16,
Urinary hvy plstc pch w/o fp,A4382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.8,,,,,,,fee schedule,49.04,86.02,
Urinary hvy plstc pch w/o fp,A4382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.22,,,,,,,fee schedule,49.04,86.02,
Urinary hvy plstc pch w/o fp,A4382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.04,,,,,,,fee schedule,49.04,86.02,
Urinary hvy plstc pch w/o fp,A4382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.02,,,,,,,fee schedule,49.04,86.02,
Urinary rubber pouch w/o fp,A4383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.66,,,,,,,fee schedule,56.16,98.51,
Urinary rubber pouch w/o fp,A4383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.11,,,,,,,fee schedule,56.16,98.51,
Urinary rubber pouch w/o fp,A4383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.16,,,,,,,fee schedule,56.16,98.51,
Urinary rubber pouch w/o fp,A4383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.51,,,,,,,fee schedule,56.16,98.51,
Ostomy faceplt/silicone ring,A4384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.21,,,,,,,fee schedule,19.15,33.59,
Ostomy faceplt/silicone ring,A4384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.91,,,,,,,fee schedule,19.15,33.59,
Ostomy faceplt/silicone ring,A4384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.15,,,,,,,fee schedule,19.15,33.59,
Ostomy faceplt/silicone ring,A4384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.59,,,,,,,fee schedule,19.15,33.59,
Ost skn barrier sld ext wear,A4385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.67,,,,,,,fee schedule,8.96,15.72,
Ost skn barrier sld ext wear,A4385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.19,,,,,,,fee schedule,8.96,15.72,
Ost skn barrier sld ext wear,A4385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.96,,,,,,,fee schedule,8.96,15.72,
Ost skn barrier sld ext wear,A4385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.72,,,,,,,fee schedule,8.96,15.72,
Ost clsd pouch w att st barr,A4387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.83,,,,,,,fee schedule,4.48,7.85,
Ost clsd pouch w att st barr,A4387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.59,,,,,,,fee schedule,4.48,7.85,
Ost clsd pouch w att st barr,A4387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.48,,,,,,,fee schedule,4.48,7.85,
Ost clsd pouch w att st barr,A4387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.85,,,,,,,fee schedule,4.48,7.85,
Drainable pch w ex wear barr,A4388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.92,,,,,,,fee schedule,8.47,14.86,
Drainable pch w ex wear barr,A4388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.58,,,,,,,fee schedule,8.47,14.86,
Drainable pch w ex wear barr,A4388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.47,,,,,,,fee schedule,8.47,14.86,
Drainable pch w ex wear barr,A4388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.86,,,,,,,fee schedule,8.47,14.86,
Drainable pch w st wear barr,A4389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.41,,,,,,,fee schedule,14.04,24.62,
Drainable pch w st wear barr,A4389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.52,,,,,,,fee schedule,14.04,24.62,
Drainable pch w st wear barr,A4389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.04,,,,,,,fee schedule,14.04,24.62,
Drainable pch w st wear barr,A4389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.62,,,,,,,fee schedule,14.04,24.62,
Drainable pch ex wear convex,A4390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.57,,,,,,,fee schedule,16.76,29.41,
Drainable pch ex wear convex,A4390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.93,,,,,,,fee schedule,16.76,29.41,
Drainable pch ex wear convex,A4390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.76,,,,,,,fee schedule,16.76,29.41,
Drainable pch ex wear convex,A4390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.41,,,,,,,fee schedule,16.76,29.41,
Urinary pouch w ex wear barr,A4391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.02,,,,,,,fee schedule,15.75,27.62,
Urinary pouch w ex wear barr,A4391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.66,,,,,,,fee schedule,15.75,27.62,
Urinary pouch w ex wear barr,A4391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.75,,,,,,,fee schedule,15.75,27.62,
Urinary pouch w ex wear barr,A4391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.62,,,,,,,fee schedule,15.75,27.62,
Urinary pouch w st wear barr,A4392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.22,,,,,,,fee schedule,16.53,29,
Urinary pouch w st wear barr,A4392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.64,,,,,,,fee schedule,16.53,29,
Urinary pouch w st wear barr,A4392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.53,,,,,,,fee schedule,16.53,29,
Urinary pouch w st wear barr,A4392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29,,,,,,,fee schedule,16.53,29,
Urine pch w ex wear bar conv,A4393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.38,,,,,,,fee schedule,15.98,28.04,
Urine pch w ex wear bar conv,A4393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.96,,,,,,,fee schedule,15.98,28.04,
Urine pch w ex wear bar conv,A4393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.98,,,,,,,fee schedule,15.98,28.04,
Urine pch w ex wear bar conv,A4393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.04,,,,,,,fee schedule,15.98,28.04,
Ostomy pouch liq deodorant,A4394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.22,,,,,,,fee schedule,4.08,7.15,
Ostomy pouch liq deodorant,A4394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.09,,,,,,,fee schedule,4.08,7.15,
Ostomy pouch liq deodorant,A4394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.08,,,,,,,fee schedule,4.08,7.15,
Ostomy pouch liq deodorant,A4394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.15,,,,,,,fee schedule,4.08,7.15,
Ostomy pouch solid deodorant,A4395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.13,,,,,,,fee schedule,0.09,0.15,
Ostomy pouch solid deodorant,A4395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.11,,,,,,,fee schedule,0.09,0.15,
Ostomy pouch solid deodorant,A4395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.15,
Ostomy pouch solid deodorant,A4395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.15,,,,,,,fee schedule,0.09,0.15,
Peristomal hernia supprt blt,A4396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.02,,,,,,,fee schedule,80.65,141.47,
Peristomal hernia supprt blt,A4396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.69,,,,,,,fee schedule,80.65,141.47,
Peristomal hernia supprt blt,A4396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.65,,,,,,,fee schedule,80.65,141.47,
Peristomal hernia supprt blt,A4396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.47,,,,,,,fee schedule,80.65,141.47,
Ostomy irrigation bag,A4398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.06,,,,,,,fee schedule,53.14,93.22,
Ostomy irrigation bag,A4398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.35,,,,,,,fee schedule,53.14,93.22,
Ostomy irrigation bag,A4398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.14,,,,,,,fee schedule,53.14,93.22,
Ostomy irrigation bag,A4398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.22,,,,,,,fee schedule,53.14,93.22,
Ostomy irrig cone/cath w brs,A4399,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.05,,,,,,,fee schedule,19.7,34.56,
Ostomy irrig cone/cath w brs,A4399,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.6,,,,,,,fee schedule,19.7,34.56,
Ostomy irrig cone/cath w brs,A4399,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.7,,,,,,,fee schedule,19.7,34.56,
Ostomy irrig cone/cath w brs,A4399,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.56,,,,,,,fee schedule,19.7,34.56,
Ostomy irrigation set,A4400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.23,,,,,,,fee schedule,93.9,164.71,
Ostomy irrigation set,A4400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.23,,,,,,,fee schedule,93.9,164.71,
Ostomy irrigation set,A4400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.9,,,,,,,fee schedule,93.9,164.71,
Ostomy irrigation set,A4400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.71,,,,,,,fee schedule,93.9,164.71,
Lubricant per ounce,A4402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.65,,,,,,,fee schedule,3.7,6.5,
Lubricant per ounce,A4402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.62,,,,,,,fee schedule,3.7,6.5,
Lubricant per ounce,A4402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.7,,,,,,,fee schedule,3.7,6.5,
Lubricant per ounce,A4402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.5,,,,,,,fee schedule,3.7,6.5,
Ostomy ring each,A4404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.45,,,,,,,fee schedule,4.23,7.42,
Ostomy ring each,A4404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.28,,,,,,,fee schedule,4.23,7.42,
Ostomy ring each,A4404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.23,,,,,,,fee schedule,4.23,7.42,
Ostomy ring each,A4404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.42,,,,,,,fee schedule,4.23,7.42,
Nonpectin based ostomy paste,A4405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.49,,,,,,,fee schedule,5.57,9.76,
Nonpectin based ostomy paste,A4405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.95,,,,,,,fee schedule,5.57,9.76,
Nonpectin based ostomy paste,A4405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.57,,,,,,,fee schedule,5.57,9.76,
Nonpectin based ostomy paste,A4405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.76,,,,,,,fee schedule,5.57,9.76,
Pectin based ostomy paste,A4406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.03,,,,,,,fee schedule,10.51,18.43,
Pectin based ostomy paste,A4406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.12,,,,,,,fee schedule,10.51,18.43,
Pectin based ostomy paste,A4406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.51,,,,,,,fee schedule,10.51,18.43,
Pectin based ostomy paste,A4406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.43,,,,,,,fee schedule,10.51,18.43,
"Ext wear ost skn barr <=4sq""",A4407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.17,,,,,,,fee schedule,16.5,28.95,
"Ext wear ost skn barr <=4sq""",A4407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.6,,,,,,,fee schedule,16.5,28.95,
"Ext wear ost skn barr <=4sq""",A4407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.5,,,,,,,fee schedule,16.5,28.95,
"Ext wear ost skn barr <=4sq""",A4407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.95,,,,,,,fee schedule,16.5,28.95,
"Ext wear ost skn barr >4sq""",A4408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.6,,,,,,,fee schedule,16.78,29.44,
"Ext wear ost skn barr >4sq""",A4408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.95,,,,,,,fee schedule,16.78,29.44,
"Ext wear ost skn barr >4sq""",A4408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.78,,,,,,,fee schedule,16.78,29.44,
"Ext wear ost skn barr >4sq""",A4408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.44,,,,,,,fee schedule,16.78,29.44,
Ost skn barr convex <=4 sq i,A4409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.88,,,,,,,fee schedule,11.72,20.56,
Ost skn barr convex <=4 sq i,A4409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.63,,,,,,,fee schedule,11.72,20.56,
Ost skn barr convex <=4 sq i,A4409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.72,,,,,,,fee schedule,11.72,20.56,
Ost skn barr convex <=4 sq i,A4409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.56,,,,,,,fee schedule,11.72,20.56,
Ost skn barr extnd >4 sq,A4410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.93,,,,,,,fee schedule,17.66,30.97,
Ost skn barr extnd >4 sq,A4410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.04,,,,,,,fee schedule,17.66,30.97,
Ost skn barr extnd >4 sq,A4410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.66,,,,,,,fee schedule,17.66,30.97,
Ost skn barr extnd >4 sq,A4410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.97,,,,,,,fee schedule,17.66,30.97,
Ost skn barr extnd =4sq,A4411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.5,,,,,,,fee schedule,10.16,17.83,
Ost skn barr extnd =4sq,A4411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.69,,,,,,,fee schedule,10.16,17.83,
Ost skn barr extnd =4sq,A4411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.16,,,,,,,fee schedule,10.16,17.83,
Ost skn barr extnd =4sq,A4411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.83,,,,,,,fee schedule,10.16,17.83,
Ost pouch drain high output,A4412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.79,,,,,,,fee schedule,11.01,19.31,
Ost pouch drain high output,A4412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.74,,,,,,,fee schedule,11.01,19.31,
Ost pouch drain high output,A4412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.01,,,,,,,fee schedule,11.01,19.31,
Ost pouch drain high output,A4412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.31,,,,,,,fee schedule,11.01,19.31,
2 pc drainable ost pouch,A4413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.79,,,,,,,fee schedule,12.32,21.61,
2 pc drainable ost pouch,A4413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.38,,,,,,,fee schedule,12.32,21.61,
2 pc drainable ost pouch,A4413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.32,,,,,,,fee schedule,12.32,21.61,
2 pc drainable ost pouch,A4413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.61,,,,,,,fee schedule,12.32,21.61,
Ost sknbar w/o conv<=4 sq in,A4414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.81,,,,,,,fee schedule,9.05,15.88,
Ost sknbar w/o conv<=4 sq in,A4414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.3,,,,,,,fee schedule,9.05,15.88,
Ost sknbar w/o conv<=4 sq in,A4414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.05,,,,,,,fee schedule,9.05,15.88,
Ost sknbar w/o conv<=4 sq in,A4414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.88,,,,,,,fee schedule,9.05,15.88,
Ost skn barr w/o conv >4 sqi,A4415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.94,,,,,,,fee schedule,11.11,19.48,
Ost skn barr w/o conv >4 sqi,A4415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.87,,,,,,,fee schedule,11.11,19.48,
Ost skn barr w/o conv >4 sqi,A4415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.11,,,,,,,fee schedule,11.11,19.48,
Ost skn barr w/o conv >4 sqi,A4415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.48,,,,,,,fee schedule,11.11,19.48,
Ost pch clsd w barrier/filtr,A4416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.59,,,,,,,fee schedule,4.98,8.73,
Ost pch clsd w barrier/filtr,A4416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.21,,,,,,,fee schedule,4.98,8.73,
Ost pch clsd w barrier/filtr,A4416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.98,,,,,,,fee schedule,4.98,8.73,
Ost pch clsd w barrier/filtr,A4416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.73,,,,,,,fee schedule,4.98,8.73,
Ost pch w bar/bltinconv/fltr,A4417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.28,,,,,,,fee schedule,7.4,12.97,
Ost pch w bar/bltinconv/fltr,A4417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.23,,,,,,,fee schedule,7.4,12.97,
Ost pch w bar/bltinconv/fltr,A4417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.4,,,,,,,fee schedule,7.4,12.97,
Ost pch w bar/bltinconv/fltr,A4417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.97,,,,,,,fee schedule,7.4,12.97,
Ost pch clsd w/o bar w filtr,A4418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.17,,,,,,,fee schedule,3.39,5.95,
Ost pch clsd w/o bar w filtr,A4418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.23,,,,,,,fee schedule,3.39,5.95,
Ost pch clsd w/o bar w filtr,A4418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.39,,,,,,,fee schedule,3.39,5.95,
Ost pch clsd w/o bar w filtr,A4418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.95,,,,,,,fee schedule,3.39,5.95,
Ost pch for bar w flange/flt,A4419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.56,,,,,,,fee schedule,2.99,5.24,
Ost pch for bar w flange/flt,A4419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.73,,,,,,,fee schedule,2.99,5.24,
Ost pch for bar w flange/flt,A4419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.99,,,,,,,fee schedule,2.99,5.24,
Ost pch for bar w flange/flt,A4419,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.24,,,,,,,fee schedule,2.99,5.24,
Ost pouch absorbent material,A4422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.35,,,,,,,fee schedule,0.23,0.4,
Ost pouch absorbent material,A4422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.29,,,,,,,fee schedule,0.23,0.4,
Ost pouch absorbent material,A4422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.23,0.4,
Ost pouch absorbent material,A4422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.4,,,,,,,fee schedule,0.23,0.4,
Ost pch for bar w lk fl/fltr,A4423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.56,,,,,,,fee schedule,2.99,5.24,
Ost pch for bar w lk fl/fltr,A4423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.73,,,,,,,fee schedule,2.99,5.24,
Ost pch for bar w lk fl/fltr,A4423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.99,,,,,,,fee schedule,2.99,5.24,
Ost pch for bar w lk fl/fltr,A4423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.24,,,,,,,fee schedule,2.99,5.24,
Ost pch drain w bar & filter,A4424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.96,,,,,,,fee schedule,8.5,14.9,
Ost pch drain w bar & filter,A4424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.61,,,,,,,fee schedule,8.5,14.9,
Ost pch drain w bar & filter,A4424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.5,,,,,,,fee schedule,8.5,14.9,
Ost pch drain w bar & filter,A4424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.9,,,,,,,fee schedule,8.5,14.9,
Ost pch drain for barrier fl,A4425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9,,,,,,,fee schedule,5.9,10.35,
Ost pch drain for barrier fl,A4425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.37,,,,,,,fee schedule,5.9,10.35,
Ost pch drain for barrier fl,A4425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.9,,,,,,,fee schedule,5.9,10.35,
Ost pch drain for barrier fl,A4425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.35,,,,,,,fee schedule,5.9,10.35,
Ost pch drain 2 piece system,A4426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.84,,,,,,,fee schedule,5.14,9.02,
Ost pch drain 2 piece system,A4426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.42,,,,,,,fee schedule,5.14,9.02,
Ost pch drain 2 piece system,A4426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.14,,,,,,,fee schedule,5.14,9.02,
Ost pch drain 2 piece system,A4426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.02,,,,,,,fee schedule,5.14,9.02,
Ost pch drain/barr lk flng/f,A4427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.49,,,,,,,fee schedule,5.57,9.76,
Ost pch drain/barr lk flng/f,A4427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.95,,,,,,,fee schedule,5.57,9.76,
Ost pch drain/barr lk flng/f,A4427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.57,,,,,,,fee schedule,5.57,9.76,
Ost pch drain/barr lk flng/f,A4427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.76,,,,,,,fee schedule,5.57,9.76,
Urine ost pouch w faucet/tap,A4428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.69,,,,,,,fee schedule,12.91,22.64,
Urine ost pouch w faucet/tap,A4428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.12,,,,,,,fee schedule,12.91,22.64,
Urine ost pouch w faucet/tap,A4428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.91,,,,,,,fee schedule,12.91,22.64,
Urine ost pouch w faucet/tap,A4428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.64,,,,,,,fee schedule,12.91,22.64,
Urine ost pouch w bltinconv,A4429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.06,,,,,,,fee schedule,16.43,28.82,
Urine ost pouch w bltinconv,A4429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.51,,,,,,,fee schedule,16.43,28.82,
Urine ost pouch w bltinconv,A4429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.43,,,,,,,fee schedule,16.43,28.82,
Urine ost pouch w bltinconv,A4429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.82,,,,,,,fee schedule,16.43,28.82,
Ost urine pch w b/bltin conv,A4430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.57,,,,,,,fee schedule,16.76,29.41,
Ost urine pch w b/bltin conv,A4430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.93,,,,,,,fee schedule,16.76,29.41,
Ost urine pch w b/bltin conv,A4430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.76,,,,,,,fee schedule,16.76,29.41,
Ost urine pch w b/bltin conv,A4430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.41,,,,,,,fee schedule,16.76,29.41,
Ost pch urine w barrier/tapv,A4431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.14,,,,,,,fee schedule,9.93,17.41,
Ost pch urine w barrier/tapv,A4431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.39,,,,,,,fee schedule,9.93,17.41,
Ost pch urine w barrier/tapv,A4431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.93,,,,,,,fee schedule,9.93,17.41,
Ost pch urine w barrier/tapv,A4431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.41,,,,,,,fee schedule,9.93,17.41,
Os pch urine w bar/fange/tap,A4432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.57,,,,,,,fee schedule,6.93,12.16,
Os pch urine w bar/fange/tap,A4432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.65,,,,,,,fee schedule,6.93,12.16,
Os pch urine w bar/fange/tap,A4432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.93,,,,,,,fee schedule,6.93,12.16,
Os pch urine w bar/fange/tap,A4432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.16,,,,,,,fee schedule,6.93,12.16,
Urine ost pch bar w lock fln,A4433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.22,,,,,,,fee schedule,7.36,12.9,
Urine ost pch bar w lock fln,A4433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.18,,,,,,,fee schedule,7.36,12.9,
Urine ost pch bar w lock fln,A4433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.36,,,,,,,fee schedule,7.36,12.9,
Urine ost pch bar w lock fln,A4433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.9,,,,,,,fee schedule,7.36,12.9,
Ost pch urine w lock flng/ft,A4434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.09,,,,,,,fee schedule,17.1,30,
Ost pch urine w lock flng/ft,A4434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.35,,,,,,,fee schedule,17.1,30,
Ost pch urine w lock flng/ft,A4434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.1,,,,,,,fee schedule,17.1,30,
Ost pch urine w lock flng/ft,A4434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30,,,,,,,fee schedule,17.1,30,
1pc ost pch drain hgh output,A4435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.52,,,,,,,fee schedule,11.49,20.15,
1pc ost pch drain hgh output,A4435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.34,,,,,,,fee schedule,11.49,20.15,
1pc ost pch drain hgh output,A4435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.49,,,,,,,fee schedule,11.49,20.15,
1pc ost pch drain hgh output,A4435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.15,,,,,,,fee schedule,11.49,20.15,
Non-waterproof tape,A4450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.24,,,,,,,fee schedule,0.16,0.28,
Non-waterproof tape,A4450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.2,,,,,,,fee schedule,0.16,0.28,
Non-waterproof tape,A4450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.16,,,,,,,fee schedule,0.16,0.28,
Non-waterproof tape,A4450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.28,,,,,,,fee schedule,0.16,0.28,
Waterproof tape,A4452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.08,,,,,,,fee schedule,0.71,1.24,
Waterproof tape,A4452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.88,,,,,,,fee schedule,0.71,1.24,
Waterproof tape,A4452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.71,,,,,,,fee schedule,0.71,1.24,
Waterproof tape,A4452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.24,,,,,,,fee schedule,0.71,1.24,
Adhesive remover per ounce,A4455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.37,,,,,,,fee schedule,3.52,6.18,
Adhesive remover per ounce,A4455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.4,,,,,,,fee schedule,3.52,6.18,
Adhesive remover per ounce,A4455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.52,,,,,,,fee schedule,3.52,6.18,
Adhesive remover per ounce,A4455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.18,,,,,,,fee schedule,3.52,6.18,
"Adhesive remover, wipes",A4456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.65,,,,,,,fee schedule,0.43,0.75,
"Adhesive remover, wipes",A4456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.53,,,,,,,fee schedule,0.43,0.75,
"Adhesive remover, wipes",A4456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.43,,,,,,,fee schedule,0.43,0.75,
"Adhesive remover, wipes",A4456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.75,,,,,,,fee schedule,0.43,0.75,
Surgicl dress hold non-reuse,A4461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.01,,,,,,,fee schedule,6.56,11.51,
Surgicl dress hold non-reuse,A4461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.19,,,,,,,fee schedule,6.56,11.51,
Surgicl dress hold non-reuse,A4461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.56,,,,,,,fee schedule,6.56,11.51,
Surgicl dress hold non-reuse,A4461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.51,,,,,,,fee schedule,6.56,11.51,
Surgical dress holder reuse,A4463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.45,,,,,,,fee schedule,26.52,46.52,
Surgical dress holder reuse,A4463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.11,,,,,,,fee schedule,26.52,46.52,
Surgical dress holder reuse,A4463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.52,,,,,,,fee schedule,26.52,46.52,
Surgical dress holder reuse,A4463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.52,,,,,,,fee schedule,26.52,46.52,
Non-elastic extremity binder,A4465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.64,,,,,,,fee schedule,11.56,20.29,
Non-elastic extremity binder,A4465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.44,,,,,,,fee schedule,11.56,20.29,
Non-elastic extremity binder,A4465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.56,,,,,,,fee schedule,11.56,20.29,
Non-elastic extremity binder,A4465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.29,,,,,,,fee schedule,11.56,20.29,
Gravlee jet washer,A4470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.74,,,,,,,fee schedule,8.35,14.65,
Gravlee jet washer,A4470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.43,,,,,,,fee schedule,8.35,14.65,
Gravlee jet washer,A4470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.35,,,,,,,fee schedule,8.35,14.65,
Gravlee jet washer,A4470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.65,,,,,,,fee schedule,8.35,14.65,
Vabra aspirator,A4480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.8,,,,,,,fee schedule,6.42,11.27,
Vabra aspirator,A4480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.02,,,,,,,fee schedule,6.42,11.27,
Vabra aspirator,A4480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.42,,,,,,,fee schedule,6.42,11.27,
Vabra aspirator,A4480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.27,,,,,,,fee schedule,6.42,11.27,
Tracheostoma filter,A4481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.12,,,,,,,fee schedule,0.73,1.29,
Tracheostoma filter,A4481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.92,,,,,,,fee schedule,0.73,1.29,
Tracheostoma filter,A4481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.73,,,,,,,fee schedule,0.73,1.29,
Tracheostoma filter,A4481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.29,,,,,,,fee schedule,0.73,1.29,
Above knee surgical stocking,A4490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.74,,,,,,,fee schedule,8.35,14.65,
Above knee surgical stocking,A4490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.43,,,,,,,fee schedule,8.35,14.65,
Above knee surgical stocking,A4490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.35,,,,,,,fee schedule,8.35,14.65,
Above knee surgical stocking,A4490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.65,,,,,,,fee schedule,8.35,14.65,
Thigh length surg stocking,A4495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.74,,,,,,,fee schedule,8.35,14.65,
Thigh length surg stocking,A4495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.43,,,,,,,fee schedule,8.35,14.65,
Thigh length surg stocking,A4495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.35,,,,,,,fee schedule,8.35,14.65,
Thigh length surg stocking,A4495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.65,,,,,,,fee schedule,8.35,14.65,
Below knee surgical stocking,A4500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.8,,,,,,,fee schedule,6.42,11.27,
Below knee surgical stocking,A4500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.02,,,,,,,fee schedule,6.42,11.27,
Below knee surgical stocking,A4500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.42,,,,,,,fee schedule,6.42,11.27,
Below knee surgical stocking,A4500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.27,,,,,,,fee schedule,6.42,11.27,
Full length surg stocking,A4510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.51,,,,,,,fee schedule,15.41,27.04,
Full length surg stocking,A4510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.24,,,,,,,fee schedule,15.41,27.04,
Full length surg stocking,A4510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.41,,,,,,,fee schedule,15.41,27.04,
Full length surg stocking,A4510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.04,,,,,,,fee schedule,15.41,27.04,
Surgical trays,A4550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.79,,,,,,,fee schedule,37.89,66.46,
Surgical trays,A4550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.3,,,,,,,fee schedule,37.89,66.46,
Surgical trays,A4550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.89,,,,,,,fee schedule,37.89,66.46,
Surgical trays,A4550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.46,,,,,,,fee schedule,37.89,66.46,
Disposable underpads,A4554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.86,,,,,,,fee schedule,3.84,6.74,
Disposable underpads,A4554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.8,,,,,,,fee schedule,3.84,6.74,
Disposable underpads,A4554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.84,,,,,,,fee schedule,3.84,6.74,
Disposable underpads,A4554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.74,,,,,,,fee schedule,3.84,6.74,
"Electrodes, pair",A4556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.9,,,,,,,fee schedule,24.19,42.44,
"Electrodes, pair",A4556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.2,,,,,,,fee schedule,24.19,42.44,
"Electrodes, pair",A4556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.19,,,,,,,fee schedule,24.19,42.44,
"Electrodes, pair",A4556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.44,,,,,,,fee schedule,24.19,42.44,
"Lead wires, pair",A4557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.13,,,,,,,fee schedule,18.44,32.35,
"Lead wires, pair",A4557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.02,,,,,,,fee schedule,18.44,32.35,
"Lead wires, pair",A4557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.44,,,,,,,fee schedule,18.44,32.35,
"Lead wires, pair",A4557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.35,,,,,,,fee schedule,18.44,32.35,
Conductive gel or paste,A4558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.58,,,,,,,fee schedule,10.87,19.07,
Conductive gel or paste,A4558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.57,,,,,,,fee schedule,10.87,19.07,
Conductive gel or paste,A4558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.87,,,,,,,fee schedule,10.87,19.07,
Conductive gel or paste,A4558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.07,,,,,,,fee schedule,10.87,19.07,
Coupling gel or paste,A4559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.29,,,,,,,fee schedule,0.19,0.33,
Coupling gel or paste,A4559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.24,,,,,,,fee schedule,0.19,0.33,
Coupling gel or paste,A4559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.19,,,,,,,fee schedule,0.19,0.33,
Coupling gel or paste,A4559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.33,,,,,,,fee schedule,0.19,0.33,
"Pessary rubber, any type",A4561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.32,,,,,,,fee schedule,40.86,71.67,
"Pessary rubber, any type",A4561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.01,,,,,,,fee schedule,40.86,71.67,
"Pessary rubber, any type",A4561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.86,,,,,,,fee schedule,40.86,71.67,
"Pessary rubber, any type",A4561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.67,,,,,,,fee schedule,40.86,71.67,
"Pessary, non rubber,any type",A4562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.79,,,,,,,fee schedule,101.48,178.01,
"Pessary, non rubber,any type",A4562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.7,,,,,,,fee schedule,101.48,178.01,
"Pessary, non rubber,any type",A4562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.48,,,,,,,fee schedule,101.48,178.01,
"Pessary, non rubber,any type",A4562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.01,,,,,,,fee schedule,101.48,178.01,
Vag inser rectal control sys,A4563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1764.61,,,,,,,fee schedule,1680.58,3025.04,APC
Vag inser rectal control sys,A4563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1680.58,,,,,,,fee schedule,1680.58,3025.04,APC
Vag inser rectal control sys,A4563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3025.04,,,,,,,fee schedule,1680.58,3025.04,APC
Slings,A4565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.4,,,,,,,fee schedule,15.34,26.91,
Slings,A4565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.15,,,,,,,fee schedule,15.34,26.91,
Slings,A4565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.34,,,,,,,fee schedule,15.34,26.91,
Slings,A4565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.91,,,,,,,fee schedule,15.34,26.91,
Splint,A4570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.28,,,,,,,fee schedule,22.47,39.42,
Splint,A4570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.06,,,,,,,fee schedule,22.47,39.42,
Splint,A4570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.47,,,,,,,fee schedule,22.47,39.42,
Splint,A4570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.42,,,,,,,fee schedule,22.47,39.42,
Special casting material,A4590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.42,,,,,,,fee schedule,50.1,87.88,
Special casting material,A4590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.55,,,,,,,fee schedule,50.1,87.88,
Special casting material,A4590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.1,,,,,,,fee schedule,50.1,87.88,
Special casting material,A4590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.88,,,,,,,fee schedule,50.1,87.88,
Neuromod sti sys adj rehab,A4593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.45,,,,,,,fee schedule,52.81,95.06,APC
Neuromod sti sys adj rehab,A4593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52.81,,,,,,,fee schedule,52.81,95.06,APC
Neuromod sti sys adj rehab,A4593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95.06,,,,,,,fee schedule,52.81,95.06,APC
TENS suppl 2 lead per month,A4595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.13,,,,,,,fee schedule,17.79,31.2,
TENS suppl 2 lead per month,A4595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.21,,,,,,,fee schedule,17.79,31.2,
TENS suppl 2 lead per month,A4595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.79,,,,,,,fee schedule,17.79,31.2,
TENS suppl 2 lead per month,A4595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.2,,,,,,,fee schedule,17.79,31.2,
Replace lithium battery 1.5v,A4602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.28,,,,,,,fee schedule,7.4,12.97,
Replace lithium battery 1.5v,A4602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.23,,,,,,,fee schedule,7.4,12.97,
Replace lithium battery 1.5v,A4602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.4,,,,,,,fee schedule,7.4,12.97,
Replace lithium battery 1.5v,A4602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.97,,,,,,,fee schedule,7.4,12.97,
Tubing with heating element,A4604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.18,,,,,,,fee schedule,69.61,122.11,
Tubing with heating element,A4604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.91,,,,,,,fee schedule,69.61,122.11,
Tubing with heating element,A4604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.61,,,,,,,fee schedule,69.61,122.11,
Tubing with heating element,A4604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.11,,,,,,,fee schedule,69.61,122.11,
Trach suction cath close sys,A4605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.85,,,,,,,fee schedule,32.68,57.33,
Trach suction cath close sys,A4605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.8,,,,,,,fee schedule,32.68,57.33,
Trach suction cath close sys,A4605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.68,,,,,,,fee schedule,32.68,57.33,
Trach suction cath close sys,A4605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.33,,,,,,,fee schedule,32.68,57.33,
Transtracheal oxygen cath,A4608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.34,,,,,,,fee schedule,99.87,175.19,
Transtracheal oxygen cath,A4608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.69,,,,,,,fee schedule,99.87,175.19,
Transtracheal oxygen cath,A4608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.87,,,,,,,fee schedule,99.87,175.19,
Transtracheal oxygen cath,A4608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.19,,,,,,,fee schedule,99.87,175.19,
Hand-held PEFR meter,A4614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.23,,,,,,,fee schedule,36.86,64.66,
Hand-held PEFR meter,A4614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.02,,,,,,,fee schedule,36.86,64.66,
Hand-held PEFR meter,A4614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.86,,,,,,,fee schedule,36.86,64.66,
Hand-held PEFR meter,A4614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.66,,,,,,,fee schedule,36.86,64.66,
Cannula nasal,A4615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.2,,,,,,,fee schedule,1.44,2.53,
Cannula nasal,A4615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.8,,,,,,,fee schedule,1.44,2.53,
Cannula nasal,A4615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.44,,,,,,,fee schedule,1.44,2.53,
Cannula nasal,A4615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.53,,,,,,,fee schedule,1.44,2.53,
Tubing (oxygen) per foot,A4616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.2,,,,,,,fee schedule,0.13,0.23,
Tubing (oxygen) per foot,A4616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.16,,,,,,,fee schedule,0.13,0.23,
Tubing (oxygen) per foot,A4616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.13,,,,,,,fee schedule,0.13,0.23,
Tubing (oxygen) per foot,A4616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.23,,,,,,,fee schedule,0.13,0.23,
Mouth piece,A4617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.68,,,,,,,fee schedule,0.45,0.78,
Mouth piece,A4617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.56,,,,,,,fee schedule,0.45,0.78,
Mouth piece,A4617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.45,,,,,,,fee schedule,0.45,0.78,
Mouth piece,A4617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.78,,,,,,,fee schedule,0.45,0.78,
Breathing circuits,A4618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.01,,,,,,,fee schedule,17.71,31.06,
Breathing circuits,A4618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.11,,,,,,,fee schedule,17.71,31.06,
Breathing circuits,A4618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.71,,,,,,,fee schedule,17.71,31.06,
Breathing circuits,A4618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.06,,,,,,,fee schedule,17.71,31.06,
Face tent,A4619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.4,,,,,,,fee schedule,3.54,6.21,
Face tent,A4619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.42,,,,,,,fee schedule,3.54,6.21,
Face tent,A4619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.54,,,,,,,fee schedule,3.54,6.21,
Face tent,A4619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.21,,,,,,,fee schedule,3.54,6.21,
Variable concentration mask,A4620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.91,,,,,,,fee schedule,1.25,2.2,
Variable concentration mask,A4620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.56,,,,,,,fee schedule,1.25,2.2,
Variable concentration mask,A4620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.25,,,,,,,fee schedule,1.25,2.2,
Variable concentration mask,A4620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.2,,,,,,,fee schedule,1.25,2.2,
Tracheostomy inner cannula,A4623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.89,,,,,,,fee schedule,13.04,22.87,
Tracheostomy inner cannula,A4623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.28,,,,,,,fee schedule,13.04,22.87,
Tracheostomy inner cannula,A4623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.04,,,,,,,fee schedule,13.04,22.87,
Tracheostomy inner cannula,A4623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.87,,,,,,,fee schedule,13.04,22.87,
Tracheal suction tube,A4624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.78,,,,,,,fee schedule,4.44,7.8,
Tracheal suction tube,A4624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.55,,,,,,,fee schedule,4.44,7.8,
Tracheal suction tube,A4624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.44,,,,,,,fee schedule,4.44,7.8,
Tracheal suction tube,A4624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.8,,,,,,,fee schedule,4.44,7.8,
Trach care kit for new trach,A4625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.04,,,,,,,fee schedule,13.79,24.2,
Trach care kit for new trach,A4625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.22,,,,,,,fee schedule,13.79,24.2,
Trach care kit for new trach,A4625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.79,,,,,,,fee schedule,13.79,24.2,
Trach care kit for new trach,A4625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.2,,,,,,,fee schedule,13.79,24.2,
Tracheostomy cleaning brush,A4626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.23,,,,,,,fee schedule,5.4,9.46,
Tracheostomy cleaning brush,A4626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.74,,,,,,,fee schedule,5.4,9.46,
Tracheostomy cleaning brush,A4626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.4,,,,,,,fee schedule,5.4,9.46,
Tracheostomy cleaning brush,A4626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.46,,,,,,,fee schedule,5.4,9.46,
Spacer bag/reservoir,A4627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.61,,,,,,,fee schedule,35.8,62.8,
Spacer bag/reservoir,A4627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.7,,,,,,,fee schedule,35.8,62.8,
Spacer bag/reservoir,A4627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.8,,,,,,,fee schedule,35.8,62.8,
Spacer bag/reservoir,A4627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.8,,,,,,,fee schedule,35.8,62.8,
Oropharyngeal suction cath,A4628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.35,,,,,,,fee schedule,7.44,13.05,
Oropharyngeal suction cath,A4628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.29,,,,,,,fee schedule,7.44,13.05,
Oropharyngeal suction cath,A4628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.44,,,,,,,fee schedule,7.44,13.05,
Oropharyngeal suction cath,A4628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.05,,,,,,,fee schedule,7.44,13.05,
Tracheostomy care kit,A4629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.1,,,,,,,fee schedule,9.24,16.22,
Tracheostomy care kit,A4629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.54,,,,,,,fee schedule,9.24,16.22,
Tracheostomy care kit,A4629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.24,,,,,,,fee schedule,9.24,16.22,
Tracheostomy care kit,A4629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.22,,,,,,,fee schedule,9.24,16.22,
Repl bat t.e.n.s. own by pt,A4630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.13,,,,,,,fee schedule,10.57,18.55,
Repl bat t.e.n.s. own by pt,A4630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.2,,,,,,,fee schedule,10.57,18.55,
Repl bat t.e.n.s. own by pt,A4630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.57,,,,,,,fee schedule,10.57,18.55,
Repl bat t.e.n.s. own by pt,A4630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.55,,,,,,,fee schedule,10.57,18.55,
Uvl replacement bulb,A4633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.71,,,,,,,fee schedule,81.76,143.42,
Uvl replacement bulb,A4633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.08,,,,,,,fee schedule,81.76,143.42,
Uvl replacement bulb,A4633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.76,,,,,,,fee schedule,81.76,143.42,
Uvl replacement bulb,A4633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.42,,,,,,,fee schedule,81.76,143.42,
Underarm crutch pad,A4635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.23,,,,,,,fee schedule,8.67,15.21,
Underarm crutch pad,A4635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.83,,,,,,,fee schedule,8.67,15.21,
Underarm crutch pad,A4635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.67,,,,,,,fee schedule,8.67,15.21,
Underarm crutch pad,A4635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.21,,,,,,,fee schedule,8.67,15.21,
Handgrip for cane etc,A4636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.07,,,,,,,fee schedule,5.29,9.28,
Handgrip for cane etc,A4636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.61,,,,,,,fee schedule,5.29,9.28,
Handgrip for cane etc,A4636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.29,,,,,,,fee schedule,5.29,9.28,
Handgrip for cane etc,A4636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.28,,,,,,,fee schedule,5.29,9.28,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.5,,,,,,,fee schedule,2.95,5.18,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.68,,,,,,,fee schedule,2.95,5.18,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.95,,,,,,,fee schedule,2.95,5.18,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.18,,,,,,,fee schedule,2.95,5.18,
Infrared ht sys replcmnt pad,A4639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.31,,,,,,,fee schedule,57.24,100.41,
Infrared ht sys replcmnt pad,A4639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.46,,,,,,,fee schedule,57.24,100.41,
Infrared ht sys replcmnt pad,A4639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.24,,,,,,,fee schedule,57.24,100.41,
Infrared ht sys replcmnt pad,A4639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.41,,,,,,,fee schedule,57.24,100.41,
Alternating pressure pad,A4640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.47,,,,,,,fee schedule,97.99,171.89,
Alternating pressure pad,A4640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.34,,,,,,,fee schedule,97.99,171.89,
Alternating pressure pad,A4640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.99,,,,,,,fee schedule,97.99,171.89,
Alternating pressure pad,A4640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.89,,,,,,,fee schedule,97.99,171.89,
In111 satumomab,A4642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1423.75,,,,,,,fee schedule,1423.75,1637.31,
In111 satumomab,A4642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1423.75,,,,,,,fee schedule,1423.75,1637.31,
In111 satumomab,A4642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1423.75,,,,,,,fee schedule,1423.75,1637.31,
In111 satumomab,A4642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1637.31,,,,,,,fee schedule,1423.75,1637.31,
Sphyg/bp app w cuff and stet,A4660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.47,,,,,,,fee schedule,16.7,29.29,
Sphyg/bp app w cuff and stet,A4660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.85,,,,,,,fee schedule,16.7,29.29,
Sphyg/bp app w cuff and stet,A4660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.7,,,,,,,fee schedule,16.7,29.29,
Sphyg/bp app w cuff and stet,A4660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.29,,,,,,,fee schedule,16.7,29.29,
Dialysis blood pressure cuff,A4663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.95,,,,,,,fee schedule,32.75,57.44,
Dialysis blood pressure cuff,A4663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.88,,,,,,,fee schedule,32.75,57.44,
Dialysis blood pressure cuff,A4663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.75,,,,,,,fee schedule,32.75,57.44,
Dialysis blood pressure cuff,A4663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.44,,,,,,,fee schedule,32.75,57.44,
"Automatic bp monitor, dial",A4670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.39,,,,,,,fee schedule,83.52,146.5,
"Automatic bp monitor, dial",A4670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.27,,,,,,,fee schedule,83.52,146.5,
"Automatic bp monitor, dial",A4670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.52,,,,,,,fee schedule,83.52,146.5,
"Automatic bp monitor, dial",A4670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.5,,,,,,,fee schedule,83.52,146.5,
"Activated carbon filter, ea",A4680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.34,,,,,,,fee schedule,84.8,148.74,
"Activated carbon filter, ea",A4680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.86,,,,,,,fee schedule,84.8,148.74,
"Activated carbon filter, ea",A4680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.8,,,,,,,fee schedule,84.8,148.74,
"Activated carbon filter, ea",A4680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.74,,,,,,,fee schedule,84.8,148.74,
"Dialyzer, each",A4690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1281.62,,,,,,,fee schedule,840.23,1473.86,
"Dialyzer, each",A4690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1049.01,,,,,,,fee schedule,840.23,1473.86,
"Dialyzer, each",A4690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,840.23,,,,,,,fee schedule,840.23,1473.86,
"Dialyzer, each",A4690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1473.86,,,,,,,fee schedule,840.23,1473.86,
Art or venous blood tubing,A4750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.49,,,,,,,fee schedule,16.06,28.16,
Art or venous blood tubing,A4750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.05,,,,,,,fee schedule,16.06,28.16,
Art or venous blood tubing,A4750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.06,,,,,,,fee schedule,16.06,28.16,
Art or venous blood tubing,A4750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.16,,,,,,,fee schedule,16.06,28.16,
Blood glucose test strips,A4772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.93,,,,,,,fee schedule,34.05,59.72,
Blood glucose test strips,A4772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.5,,,,,,,fee schedule,34.05,59.72,
Blood glucose test strips,A4772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.05,,,,,,,fee schedule,34.05,59.72,
Blood glucose test strips,A4772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.72,,,,,,,fee schedule,34.05,59.72,
Occult blood test strips,A4773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,37.19,
Occult blood test strips,A4773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,37.19,
Occult blood test strips,A4773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,37.19,
Occult blood test strips,A4773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,37.19,
Protamine sulfate per 50 mg,A4802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.56,,,,,,,fee schedule,18.07,31.69,
Protamine sulfate per 50 mg,A4802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.56,,,,,,,fee schedule,18.07,31.69,
Protamine sulfate per 50 mg,A4802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.07,,,,,,,fee schedule,18.07,31.69,
Protamine sulfate per 50 mg,A4802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.69,,,,,,,fee schedule,18.07,31.69,
Non-sterile gloves,A4927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.84,,,,,,,fee schedule,5.14,9.02,
Non-sterile gloves,A4927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.42,,,,,,,fee schedule,5.14,9.02,
Non-sterile gloves,A4927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.14,,,,,,,fee schedule,5.14,9.02,
Non-sterile gloves,A4927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.02,,,,,,,fee schedule,5.14,9.02,
"Tourniquet for dialysis, ea",A4929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.65,1.14,
"Tourniquet for dialysis, ea",A4929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.65,1.14,
"Tourniquet for dialysis, ea",A4929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,1.14,
"Tourniquet for dialysis, ea",A4929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.65,1.14,
"Sterile, gloves per pair",A4930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.96,,,,,,,fee schedule,1.28,2.25,
"Sterile, gloves per pair",A4930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.28,2.25,
"Sterile, gloves per pair",A4930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.28,,,,,,,fee schedule,1.28,2.25,
"Sterile, gloves per pair",A4930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.25,,,,,,,fee schedule,1.28,2.25,
Pouch clsd w barr attached,A5051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.35,,,,,,,fee schedule,4.16,7.3,
Pouch clsd w barr attached,A5051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.2,,,,,,,fee schedule,4.16,7.3,
Pouch clsd w barr attached,A5051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.16,,,,,,,fee schedule,4.16,7.3,
Pouch clsd w barr attached,A5051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.3,,,,,,,fee schedule,4.16,7.3,
Clsd ostomy pouch w/o barr,A5052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.35,,,,,,,fee schedule,6.13,10.75,
Clsd ostomy pouch w/o barr,A5052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.65,,,,,,,fee schedule,6.13,10.75,
Clsd ostomy pouch w/o barr,A5052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.13,,,,,,,fee schedule,6.13,10.75,
Clsd ostomy pouch w/o barr,A5052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.75,,,,,,,fee schedule,6.13,10.75,
Clsd ostomy pouch faceplate,A5053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.26,,,,,,,fee schedule,3.45,6.05,
Clsd ostomy pouch faceplate,A5053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.31,,,,,,,fee schedule,3.45,6.05,
Clsd ostomy pouch faceplate,A5053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.45,,,,,,,fee schedule,3.45,6.05,
Clsd ostomy pouch faceplate,A5053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.05,,,,,,,fee schedule,3.45,6.05,
Clsd ostomy pouch w/flange,A5054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.13,,,,,,,fee schedule,2.71,4.75,
Clsd ostomy pouch w/flange,A5054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.38,,,,,,,fee schedule,2.71,4.75,
Clsd ostomy pouch w/flange,A5054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.71,,,,,,,fee schedule,2.71,4.75,
Clsd ostomy pouch w/flange,A5054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.75,,,,,,,fee schedule,2.71,4.75,
Stoma cap,A5055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.2,,,,,,,fee schedule,4.06,7.13,
Stoma cap,A5055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.07,,,,,,,fee schedule,4.06,7.13,
Stoma cap,A5055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.06,,,,,,,fee schedule,4.06,7.13,
Stoma cap,A5055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.13,,,,,,,fee schedule,4.06,7.13,
1 pc ost pouch w filter,A5056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.91,,,,,,,fee schedule,10.43,18.3,
1 pc ost pouch w filter,A5056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.02,,,,,,,fee schedule,10.43,18.3,
1 pc ost pouch w filter,A5056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.43,,,,,,,fee schedule,10.43,18.3,
1 pc ost pouch w filter,A5056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.3,,,,,,,fee schedule,10.43,18.3,
1 pc ost pou w built-in conv,A5057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.19,,,,,,,fee schedule,19.14,33.57,
1 pc ost pou w built-in conv,A5057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.89,,,,,,,fee schedule,19.14,33.57,
1 pc ost pou w built-in conv,A5057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.14,,,,,,,fee schedule,19.14,33.57,
1 pc ost pou w built-in conv,A5057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.57,,,,,,,fee schedule,19.14,33.57,
Pouch drainable w barrier at,A5061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.2,,,,,,,fee schedule,6.69,11.73,
Pouch drainable w barrier at,A5061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.35,,,,,,,fee schedule,6.69,11.73,
Pouch drainable w barrier at,A5061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.69,,,,,,,fee schedule,6.69,11.73,
Pouch drainable w barrier at,A5061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.73,,,,,,,fee schedule,6.69,11.73,
Drnble ostomy pouch w/o barr,A5062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.58,,,,,,,fee schedule,8.25,14.47,
Drnble ostomy pouch w/o barr,A5062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.3,,,,,,,fee schedule,8.25,14.47,
Drnble ostomy pouch w/o barr,A5062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.25,,,,,,,fee schedule,8.25,14.47,
Drnble ostomy pouch w/o barr,A5062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.47,,,,,,,fee schedule,8.25,14.47,
Drain ostomy pouch w/flange,A5063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.87,,,,,,,fee schedule,4.5,7.9,
Drain ostomy pouch w/flange,A5063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.62,,,,,,,fee schedule,4.5,7.9,
Drain ostomy pouch w/flange,A5063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.5,,,,,,,fee schedule,4.5,7.9,
Drain ostomy pouch w/flange,A5063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.9,,,,,,,fee schedule,4.5,7.9,
Urinary pouch w/barrier,A5071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.64,,,,,,,fee schedule,11.56,20.29,
Urinary pouch w/barrier,A5071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.44,,,,,,,fee schedule,11.56,20.29,
Urinary pouch w/barrier,A5071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.56,,,,,,,fee schedule,11.56,20.29,
Urinary pouch w/barrier,A5071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.29,,,,,,,fee schedule,11.56,20.29,
Urinary pouch w/o barrier,A5072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.26,,,,,,,fee schedule,4.76,8.35,
Urinary pouch w/o barrier,A5072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.94,,,,,,,fee schedule,4.76,8.35,
Urinary pouch w/o barrier,A5072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.76,,,,,,,fee schedule,4.76,8.35,
Urinary pouch w/o barrier,A5072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.35,,,,,,,fee schedule,4.76,8.35,
Urinary pouch on barr w/flng,A5073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.32,,,,,,,fee schedule,6.11,10.72,
Urinary pouch on barr w/flng,A5073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.63,,,,,,,fee schedule,6.11,10.72,
Urinary pouch on barr w/flng,A5073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.11,,,,,,,fee schedule,6.11,10.72,
Urinary pouch on barr w/flng,A5073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.72,,,,,,,fee schedule,6.11,10.72,
"Stoma plug or seal, any type",A5081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.57,,,,,,,fee schedule,5.62,9.86,
"Stoma plug or seal, any type",A5081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.01,,,,,,,fee schedule,5.62,9.86,
"Stoma plug or seal, any type",A5081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.62,,,,,,,fee schedule,5.62,9.86,
"Stoma plug or seal, any type",A5081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.86,,,,,,,fee schedule,5.62,9.86,
Continent stoma catheter,A5082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.14,,,,,,,fee schedule,23.69,41.56,
Continent stoma catheter,A5082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.58,,,,,,,fee schedule,23.69,41.56,
Continent stoma catheter,A5082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.69,,,,,,,fee schedule,23.69,41.56,
Continent stoma catheter,A5082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.56,,,,,,,fee schedule,23.69,41.56,
Stoma absorptive cover,A5083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.93,,,,,,,fee schedule,1.27,2.22,
Stoma absorptive cover,A5083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.58,,,,,,,fee schedule,1.27,2.22,
Stoma absorptive cover,A5083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.27,,,,,,,fee schedule,1.27,2.22,
Stoma absorptive cover,A5083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.22,,,,,,,fee schedule,1.27,2.22,
Ostomy accessory convex inse,A5093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.45,,,,,,,fee schedule,2.92,5.12,
Ostomy accessory convex inse,A5093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.64,,,,,,,fee schedule,2.92,5.12,
Ostomy accessory convex inse,A5093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.92,,,,,,,fee schedule,2.92,5.12,
Ostomy accessory convex inse,A5093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.12,,,,,,,fee schedule,2.92,5.12,
"Expired, orthopedic, length of stay is 14 days or more",A5102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.6,,,,,,,fee schedule,54.15,94.99,
"Expired, orthopedic, length of stay is 14 days or more",A5102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.61,,,,,,,fee schedule,54.15,94.99,
"Expired, orthopedic, length of stay is 14 days or more",A5102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.15,,,,,,,fee schedule,54.15,94.99,
"Expired, orthopedic, length of stay is 14 days or more",A5102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.99,,,,,,,fee schedule,54.15,94.99,
Urinary suspensory,A5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.92,,,,,,,fee schedule,81.24,142.51,
Urinary suspensory,A5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.43,,,,,,,fee schedule,81.24,142.51,
Urinary suspensory,A5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.24,,,,,,,fee schedule,81.24,142.51,
Urinary suspensory,A5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.51,,,,,,,fee schedule,81.24,142.51,
Urinary leg bag,A5112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.21,,,,,,,fee schedule,68.98,120.99,
Urinary leg bag,A5112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.11,,,,,,,fee schedule,68.98,120.99,
Urinary leg bag,A5112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.98,,,,,,,fee schedule,68.98,120.99,
Urinary leg bag,A5112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.99,,,,,,,fee schedule,68.98,120.99,
Latex leg strap,A5113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.31,,,,,,,fee schedule,9.38,16.46,
Latex leg strap,A5113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.71,,,,,,,fee schedule,9.38,16.46,
Latex leg strap,A5113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.38,,,,,,,fee schedule,9.38,16.46,
Latex leg strap,A5113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.46,,,,,,,fee schedule,9.38,16.46,
Foam/fabric leg strap,A5114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.12,,,,,,,fee schedule,15.16,26.59,
Foam/fabric leg strap,A5114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.92,,,,,,,fee schedule,15.16,26.59,
Foam/fabric leg strap,A5114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.16,,,,,,,fee schedule,15.16,26.59,
Foam/fabric leg strap,A5114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.59,,,,,,,fee schedule,15.16,26.59,
"Skin barrier, wipe or swab",A5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.58,,,,,,,fee schedule,0.38,0.67,
"Skin barrier, wipe or swab",A5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.47,,,,,,,fee schedule,0.38,0.67,
"Skin barrier, wipe or swab",A5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.38,,,,,,,fee schedule,0.38,0.67,
"Skin barrier, wipe or swab",A5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.67,,,,,,,fee schedule,0.38,0.67,
Solid skin barrier 6x6,A5121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.77,,,,,,,fee schedule,18.86,33.09,
Solid skin barrier 6x6,A5121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.55,,,,,,,fee schedule,18.86,33.09,
Solid skin barrier 6x6,A5121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.86,,,,,,,fee schedule,18.86,33.09,
Solid skin barrier 6x6,A5121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.09,,,,,,,fee schedule,18.86,33.09,
Solid skin barrier 8x8,A5122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.36,,,,,,,fee schedule,31.05,54.46,
Solid skin barrier 8x8,A5122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.76,,,,,,,fee schedule,31.05,54.46,
Solid skin barrier 8x8,A5122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.05,,,,,,,fee schedule,31.05,54.46,
Solid skin barrier 8x8,A5122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.46,,,,,,,fee schedule,31.05,54.46,
Disk/foam pad +or- adhesive,A5126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.38,,,,,,,fee schedule,2.22,3.89,
Disk/foam pad +or- adhesive,A5126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.77,,,,,,,fee schedule,2.22,3.89,
Disk/foam pad +or- adhesive,A5126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.22,,,,,,,fee schedule,2.22,3.89,
Disk/foam pad +or- adhesive,A5126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.89,,,,,,,fee schedule,2.22,3.89,
Appliance cleaner,A5131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.63,,,,,,,fee schedule,16.15,28.32,
Appliance cleaner,A5131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.16,,,,,,,fee schedule,16.15,28.32,
Appliance cleaner,A5131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.15,,,,,,,fee schedule,16.15,28.32,
Appliance cleaner,A5131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.32,,,,,,,fee schedule,16.15,28.32,
Percutaneous catheter anchor,A5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.38,,,,,,,fee schedule,22.54,39.54,
Percutaneous catheter anchor,A5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.14,,,,,,,fee schedule,22.54,39.54,
Percutaneous catheter anchor,A5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.54,,,,,,,fee schedule,22.54,39.54,
Percutaneous catheter anchor,A5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.54,,,,,,,fee schedule,22.54,39.54,
Diab shoe for density insert,A5500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.25,,,,,,,fee schedule,126.69,222.24,
Diab shoe for density insert,A5500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.18,,,,,,,fee schedule,126.69,222.24,
Diab shoe for density insert,A5500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.69,,,,,,,fee schedule,126.69,222.24,
Diab shoe for density insert,A5500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.24,,,,,,,fee schedule,126.69,222.24,
Diabetic custom molded shoe,A5501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,579.66,,,,,,,fee schedule,380.03,666.61,
Diabetic custom molded shoe,A5501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,474.45,,,,,,,fee schedule,380.03,666.61,
Diabetic custom molded shoe,A5501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,380.03,,,,,,,fee schedule,380.03,666.61,
Diabetic custom molded shoe,A5501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,666.61,,,,,,,fee schedule,380.03,666.61,
Diabetic shoe w/roller/rockr,A5503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.31,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe w/roller/rockr,A5503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.01,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe w/roller/rockr,A5503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.49,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe w/roller/rockr,A5503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.61,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe with wedge,A5504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.31,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe with wedge,A5504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.01,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe with wedge,A5504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.49,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe with wedge,A5504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.61,,,,,,,fee schedule,62.49,109.61,
Diab shoe w/metatarsal bar,A5505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.31,,,,,,,fee schedule,62.49,109.61,
Diab shoe w/metatarsal bar,A5505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.01,,,,,,,fee schedule,62.49,109.61,
Diab shoe w/metatarsal bar,A5505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.49,,,,,,,fee schedule,62.49,109.61,
Diab shoe w/metatarsal bar,A5505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.61,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe w/off set heel,A5506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.31,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe w/off set heel,A5506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.01,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe w/off set heel,A5506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.49,,,,,,,fee schedule,62.49,109.61,
Diabetic shoe w/off set heel,A5506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.61,,,,,,,fee schedule,62.49,109.61,
Multi den insert direct form,A5512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.83,,,,,,,fee schedule,51.68,90.65,
Multi den insert direct form,A5512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.52,,,,,,,fee schedule,51.68,90.65,
Multi den insert direct form,A5512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.68,,,,,,,fee schedule,51.68,90.65,
Multi den insert direct form,A5512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.65,,,,,,,fee schedule,51.68,90.65,
Multi den insert custom mold,A5513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.65,,,,,,,fee schedule,77.13,135.3,
Multi den insert custom mold,A5513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.3,,,,,,,fee schedule,77.13,135.3,
Multi den insert custom mold,A5513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.13,,,,,,,fee schedule,77.13,135.3,
Multi den insert custom mold,A5513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.3,,,,,,,fee schedule,77.13,135.3,
Collagen based wound filler,A6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.5,,,,,,,fee schedule,38.35,67.28,
Collagen based wound filler,A6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.88,,,,,,,fee schedule,38.35,67.28,
Collagen based wound filler,A6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.35,,,,,,,fee schedule,38.35,67.28,
Collagen based wound filler,A6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.28,,,,,,,fee schedule,38.35,67.28,
Collagen gel/paste wound fil,A6011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.31,,,,,,,fee schedule,3.48,6.11,
Collagen gel/paste wound fil,A6011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.35,,,,,,,fee schedule,3.48,6.11,
Collagen gel/paste wound fil,A6011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.48,,,,,,,fee schedule,3.48,6.11,
Collagen gel/paste wound fil,A6011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.11,,,,,,,fee schedule,3.48,6.11,
Collagen dressing <=16 sq in,A6021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.88,,,,,,,fee schedule,41.88,73.46,
Collagen dressing <=16 sq in,A6021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.29,,,,,,,fee schedule,41.88,73.46,
Collagen dressing <=16 sq in,A6021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.88,,,,,,,fee schedule,41.88,73.46,
Collagen dressing <=16 sq in,A6021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.46,,,,,,,fee schedule,41.88,73.46,
Collagen drsg>16<=48 sq in,A6022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.88,,,,,,,fee schedule,41.88,73.46,
Collagen drsg>16<=48 sq in,A6022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.29,,,,,,,fee schedule,41.88,73.46,
Collagen drsg>16<=48 sq in,A6022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.88,,,,,,,fee schedule,41.88,73.46,
Collagen drsg>16<=48 sq in,A6022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.46,,,,,,,fee schedule,41.88,73.46,
Collagen dressing >48 sq in,A6023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,578.42,,,,,,,fee schedule,379.21,665.18,
Collagen dressing >48 sq in,A6023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,473.44,,,,,,,fee schedule,379.21,665.18,
Collagen dressing >48 sq in,A6023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,379.21,,,,,,,fee schedule,379.21,665.18,
Collagen dressing >48 sq in,A6023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,665.18,,,,,,,fee schedule,379.21,665.18,
Collagen dsg wound filler,A6024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.81,,,,,,,fee schedule,12.33,21.63,
Collagen dsg wound filler,A6024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.4,,,,,,,fee schedule,12.33,21.63,
Collagen dsg wound filler,A6024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.33,,,,,,,fee schedule,12.33,21.63,
Collagen dsg wound filler,A6024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.63,,,,,,,fee schedule,12.33,21.63,
"Silicone gel sheet, each",A6025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.58,,,,,,,fee schedule,50.86,89.22,
"Silicone gel sheet, each",A6025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.5,,,,,,,fee schedule,50.86,89.22,
"Silicone gel sheet, each",A6025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.86,,,,,,,fee schedule,50.86,89.22,
"Silicone gel sheet, each",A6025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.22,,,,,,,fee schedule,50.86,89.22,
Wound pouch each,A6154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.84,,,,,,,fee schedule,28.09,49.27,
Wound pouch each,A6154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.06,,,,,,,fee schedule,28.09,49.27,
Wound pouch each,A6154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.09,,,,,,,fee schedule,28.09,49.27,
Wound pouch each,A6154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.27,,,,,,,fee schedule,28.09,49.27,
Alginate dressing <=16 sq in,A6196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.97,,,,,,,fee schedule,10.47,18.37,
Alginate dressing <=16 sq in,A6196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.07,,,,,,,fee schedule,10.47,18.37,
Alginate dressing <=16 sq in,A6196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.47,,,,,,,fee schedule,10.47,18.37,
Alginate dressing <=16 sq in,A6196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.37,,,,,,,fee schedule,10.47,18.37,
Alginate drsg >16 <=48 sq in,A6197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.95,,,,,,,fee schedule,32.75,57.44,
Alginate drsg >16 <=48 sq in,A6197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.88,,,,,,,fee schedule,32.75,57.44,
Alginate drsg >16 <=48 sq in,A6197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.75,,,,,,,fee schedule,32.75,57.44,
Alginate drsg >16 <=48 sq in,A6197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.44,,,,,,,fee schedule,32.75,57.44,
Alginate drsg wound filler,A6199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.06,,,,,,,fee schedule,10.53,18.47,
Alginate drsg wound filler,A6199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.15,,,,,,,fee schedule,10.53,18.47,
Alginate drsg wound filler,A6199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.53,,,,,,,fee schedule,10.53,18.47,
Alginate drsg wound filler,A6199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.47,,,,,,,fee schedule,10.53,18.47,
Composite drsg <= 16 sq in,A6203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.16,,,,,,,fee schedule,5.35,9.38,
Composite drsg <= 16 sq in,A6203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.68,,,,,,,fee schedule,5.35,9.38,
Composite drsg <= 16 sq in,A6203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.35,,,,,,,fee schedule,5.35,9.38,
Composite drsg <= 16 sq in,A6203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.38,,,,,,,fee schedule,5.35,9.38,
Composite drsg >16<=48 sq in,A6204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.91,,,,,,,fee schedule,12.4,21.75,
Composite drsg >16<=48 sq in,A6204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.48,,,,,,,fee schedule,12.4,21.75,
Composite drsg >16<=48 sq in,A6204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.4,,,,,,,fee schedule,12.4,21.75,
Composite drsg >16<=48 sq in,A6204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.75,,,,,,,fee schedule,12.4,21.75,
Contact layer <= 16 sq in,A6206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.83,,,,,,,fee schedule,5.79,10.15,
Contact layer <= 16 sq in,A6206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.23,,,,,,,fee schedule,5.79,10.15,
Contact layer <= 16 sq in,A6206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.79,,,,,,,fee schedule,5.79,10.15,
Contact layer <= 16 sq in,A6206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.15,,,,,,,fee schedule,5.79,10.15,
Contact layer >16<= 48 sq in,A6207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.28,,,,,,,fee schedule,14.61,25.62,
Contact layer >16<= 48 sq in,A6207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.24,,,,,,,fee schedule,14.61,25.62,
Contact layer >16<= 48 sq in,A6207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.61,,,,,,,fee schedule,14.61,25.62,
Contact layer >16<= 48 sq in,A6207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.62,,,,,,,fee schedule,14.61,25.62,
Foam drsg <=16 sq in w/o bdr,A6209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.73,,,,,,,fee schedule,14.9,26.14,
Foam drsg <=16 sq in w/o bdr,A6209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.6,,,,,,,fee schedule,14.9,26.14,
Foam drsg <=16 sq in w/o bdr,A6209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.9,,,,,,,fee schedule,14.9,26.14,
Foam drsg <=16 sq in w/o bdr,A6209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.14,,,,,,,fee schedule,14.9,26.14,
Foam drg >16<=48 sq in w/o b,A6210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.55,,,,,,,fee schedule,39.7,69.63,
Foam drg >16<=48 sq in w/o b,A6210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.56,,,,,,,fee schedule,39.7,69.63,
Foam drg >16<=48 sq in w/o b,A6210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.7,,,,,,,fee schedule,39.7,69.63,
Foam drg >16<=48 sq in w/o b,A6210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.63,,,,,,,fee schedule,39.7,69.63,
Foam drg > 48 sq in w/o brdr,A6211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.89,,,,,,,fee schedule,81.22,142.47,
Foam drg > 48 sq in w/o brdr,A6211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.4,,,,,,,fee schedule,81.22,142.47,
Foam drg > 48 sq in w/o brdr,A6211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.22,,,,,,,fee schedule,81.22,142.47,
Foam drg > 48 sq in w/o brdr,A6211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.47,,,,,,,fee schedule,81.22,142.47,
Foam drg <=16 sq in w/border,A6212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.51,,,,,,,fee schedule,19.35,33.94,
Foam drg <=16 sq in w/border,A6212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.15,,,,,,,fee schedule,19.35,33.94,
Foam drg <=16 sq in w/border,A6212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.35,,,,,,,fee schedule,19.35,33.94,
Foam drg <=16 sq in w/border,A6212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.94,,,,,,,fee schedule,19.35,33.94,
Foam drg >16<=48 sq in w/bdr,A6213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.12,,,,,,,fee schedule,27.61,48.44,
Foam drg >16<=48 sq in w/bdr,A6213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.48,,,,,,,fee schedule,27.61,48.44,
Foam drg >16<=48 sq in w/bdr,A6213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.61,,,,,,,fee schedule,27.61,48.44,
Foam drg >16<=48 sq in w/bdr,A6213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.44,,,,,,,fee schedule,27.61,48.44,
Foam drg > 48 sq in w/border,A6214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.27,,,,,,,fee schedule,20.5,35.96,
Foam drg > 48 sq in w/border,A6214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.59,,,,,,,fee schedule,20.5,35.96,
Foam drg > 48 sq in w/border,A6214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.5,,,,,,,fee schedule,20.5,35.96,
Foam drg > 48 sq in w/border,A6214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.96,,,,,,,fee schedule,20.5,35.96,
Non-sterile gauze<=16 sq in,A6216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.13,,,,,,,fee schedule,0.09,0.15,
Non-sterile gauze<=16 sq in,A6216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.11,,,,,,,fee schedule,0.09,0.15,
Non-sterile gauze<=16 sq in,A6216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.15,
Non-sterile gauze<=16 sq in,A6216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.15,,,,,,,fee schedule,0.09,0.15,
Non-sterile gauze > 48 sq in,A6218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.65,1.14,
Non-sterile gauze > 48 sq in,A6218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.65,1.14,
Non-sterile gauze > 48 sq in,A6218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,1.14,
Non-sterile gauze > 48 sq in,A6218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.65,1.14,
Gauze <= 16 sq in w/border,A6219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.1,,,,,,,fee schedule,2.03,3.57,
Gauze <= 16 sq in w/border,A6219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.54,,,,,,,fee schedule,2.03,3.57,
Gauze <= 16 sq in w/border,A6219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.03,,,,,,,fee schedule,2.03,3.57,
Gauze <= 16 sq in w/border,A6219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.57,,,,,,,fee schedule,2.03,3.57,
Gauze >16 <=48 sq in w/bordr,A6220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.11,,,,,,,fee schedule,2.69,4.73,
Gauze >16 <=48 sq in w/bordr,A6220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.36,,,,,,,fee schedule,2.69,4.73,
Gauze >16 <=48 sq in w/bordr,A6220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.69,,,,,,,fee schedule,2.69,4.73,
Gauze >16 <=48 sq in w/bordr,A6220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.73,,,,,,,fee schedule,2.69,4.73,
Gauze <=16 in no w/sal w/o b,A6222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.45,,,,,,,fee schedule,4.23,7.42,
Gauze <=16 in no w/sal w/o b,A6222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.28,,,,,,,fee schedule,4.23,7.42,
Gauze <=16 in no w/sal w/o b,A6222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.23,,,,,,,fee schedule,4.23,7.42,
Gauze <=16 in no w/sal w/o b,A6222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.42,,,,,,,fee schedule,4.23,7.42,
Gauze >16<=48 no w/sal w/o b,A6223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.36,,,,,,,fee schedule,4.83,8.46,
Gauze >16<=48 no w/sal w/o b,A6223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.02,,,,,,,fee schedule,4.83,8.46,
Gauze >16<=48 no w/sal w/o b,A6223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.83,,,,,,,fee schedule,4.83,8.46,
Gauze >16<=48 no w/sal w/o b,A6223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.46,,,,,,,fee schedule,4.83,8.46,
Gauze > 48 in no w/sal w/o b,A6224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.98,,,,,,,fee schedule,7.2,12.63,
Gauze > 48 in no w/sal w/o b,A6224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.99,,,,,,,fee schedule,7.2,12.63,
Gauze > 48 in no w/sal w/o b,A6224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.2,,,,,,,fee schedule,7.2,12.63,
Gauze > 48 in no w/sal w/o b,A6224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.63,,,,,,,fee schedule,7.2,12.63,
Gauze <= 16 sq in water/sal,A6228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.93,,,,,,,fee schedule,2.58,4.52,
Gauze <= 16 sq in water/sal,A6228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.22,,,,,,,fee schedule,2.58,4.52,
Gauze <= 16 sq in water/sal,A6228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.58,,,,,,,fee schedule,2.58,4.52,
Gauze <= 16 sq in water/sal,A6228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.52,,,,,,,fee schedule,2.58,4.52,
Gauze >16<=48 sq in watr/sal,A6229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.98,,,,,,,fee schedule,7.2,12.63,
Gauze >16<=48 sq in watr/sal,A6229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.99,,,,,,,fee schedule,7.2,12.63,
Gauze >16<=48 sq in watr/sal,A6229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.2,,,,,,,fee schedule,7.2,12.63,
Gauze >16<=48 sq in watr/sal,A6229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.63,,,,,,,fee schedule,7.2,12.63,
Gauze > 48 sq in water/salne,A6230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.86,,,,,,,fee schedule,3.84,6.74,
Gauze > 48 sq in water/salne,A6230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.8,,,,,,,fee schedule,3.84,6.74,
Gauze > 48 sq in water/salne,A6230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.84,,,,,,,fee schedule,3.84,6.74,
Gauze > 48 sq in water/salne,A6230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.74,,,,,,,fee schedule,3.84,6.74,
Hydrogel dsg<=16 sq in,A6231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.72,,,,,,,fee schedule,5.72,10.03,
Hydrogel dsg<=16 sq in,A6231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.14,,,,,,,fee schedule,5.72,10.03,
Hydrogel dsg<=16 sq in,A6231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.72,,,,,,,fee schedule,5.72,10.03,
Hydrogel dsg<=16 sq in,A6231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.03,,,,,,,fee schedule,5.72,10.03,
Hydrogel dsg>16<=48 sq in,A6232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.85,,,,,,,fee schedule,13.67,23.98,
Hydrogel dsg>16<=48 sq in,A6232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.07,,,,,,,fee schedule,13.67,23.98,
Hydrogel dsg>16<=48 sq in,A6232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.67,,,,,,,fee schedule,13.67,23.98,
Hydrogel dsg>16<=48 sq in,A6232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.98,,,,,,,fee schedule,13.67,23.98,
Hydrogel dressing >48 sq in,A6233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.28,,,,,,,fee schedule,38.21,67.02,
Hydrogel dressing >48 sq in,A6233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.7,,,,,,,fee schedule,38.21,67.02,
Hydrogel dressing >48 sq in,A6233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.21,,,,,,,fee schedule,38.21,67.02,
Hydrogel dressing >48 sq in,A6233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.02,,,,,,,fee schedule,38.21,67.02,
Hydrocolld drg <=16 w/o bdr,A6234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.01,,,,,,,fee schedule,10.5,18.41,
Hydrocolld drg <=16 w/o bdr,A6234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.1,,,,,,,fee schedule,10.5,18.41,
Hydrocolld drg <=16 w/o bdr,A6234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.5,,,,,,,fee schedule,10.5,18.41,
Hydrocolld drg <=16 w/o bdr,A6234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.41,,,,,,,fee schedule,10.5,18.41,
Hydrocolld drg >16<=48 w/o b,A6235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.11,,,,,,,fee schedule,33.51,58.78,
Hydrocolld drg >16<=48 w/o b,A6235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.83,,,,,,,fee schedule,33.51,58.78,
Hydrocolld drg >16<=48 w/o b,A6235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.51,,,,,,,fee schedule,33.51,58.78,
Hydrocolld drg >16<=48 w/o b,A6235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.78,,,,,,,fee schedule,33.51,58.78,
Hydrocolld drg > 48 in w/o b,A6236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.84,,,,,,,fee schedule,54.31,95.27,
Hydrocolld drg > 48 in w/o b,A6236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.8,,,,,,,fee schedule,54.31,95.27,
Hydrocolld drg > 48 in w/o b,A6236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.31,,,,,,,fee schedule,54.31,95.27,
Hydrocolld drg > 48 in w/o b,A6236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.27,,,,,,,fee schedule,54.31,95.27,
Hydrocolld drg <=16 in w/bdr,A6237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.11,,,,,,,fee schedule,11.22,19.68,
Hydrocolld drg <=16 in w/bdr,A6237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14,,,,,,,fee schedule,11.22,19.68,
Hydrocolld drg <=16 in w/bdr,A6237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.22,,,,,,,fee schedule,11.22,19.68,
Hydrocolld drg <=16 in w/bdr,A6237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.68,,,,,,,fee schedule,11.22,19.68,
Hydrocolld drg >16<=48 w/bdr,A6238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.2,,,,,,,fee schedule,20.45,35.88,
Hydrocolld drg >16<=48 w/bdr,A6238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.54,,,,,,,fee schedule,20.45,35.88,
Hydrocolld drg >16<=48 w/bdr,A6238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.45,,,,,,,fee schedule,20.45,35.88,
Hydrocolld drg >16<=48 w/bdr,A6238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.88,,,,,,,fee schedule,20.45,35.88,
Hydrocolld drg filler paste,A6240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.2,,,,,,,fee schedule,24.39,42.78,
Hydrocolld drg filler paste,A6240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.45,,,,,,,fee schedule,24.39,42.78,
Hydrocolld drg filler paste,A6240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.39,,,,,,,fee schedule,24.39,42.78,
Hydrocolld drg filler paste,A6240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.78,,,,,,,fee schedule,24.39,42.78,
Hydrocolloid drg filler dry,A6241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.82,,,,,,,fee schedule,5.13,8.99,
Hydrocolloid drg filler dry,A6241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.4,,,,,,,fee schedule,5.13,8.99,
Hydrocolloid drg filler dry,A6241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.13,,,,,,,fee schedule,5.13,8.99,
Hydrocolloid drg filler dry,A6241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.99,,,,,,,fee schedule,5.13,8.99,
Hydrogel drg <=16 in w/o bdr,A6242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.41,,,,,,,fee schedule,12.07,21.17,
Hydrogel drg <=16 in w/o bdr,A6242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.07,,,,,,,fee schedule,12.07,21.17,
Hydrogel drg <=16 in w/o bdr,A6242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.07,,,,,,,fee schedule,12.07,21.17,
Hydrogel drg <=16 in w/o bdr,A6242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.17,,,,,,,fee schedule,12.07,21.17,
Hydrogel drg >16<=48 w/o bdr,A6243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.44,,,,,,,fee schedule,24.55,43.06,
Hydrogel drg >16<=48 w/o bdr,A6243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.64,,,,,,,fee schedule,24.55,43.06,
Hydrogel drg >16<=48 w/o bdr,A6243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.55,,,,,,,fee schedule,24.55,43.06,
Hydrogel drg >16<=48 w/o bdr,A6243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.06,,,,,,,fee schedule,24.55,43.06,
Hydrogel drg >48 in w/o bdr,A6244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.39,,,,,,,fee schedule,78.27,137.3,
Hydrogel drg >48 in w/o bdr,A6244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.72,,,,,,,fee schedule,78.27,137.3,
Hydrogel drg >48 in w/o bdr,A6244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.27,,,,,,,fee schedule,78.27,137.3,
Hydrogel drg >48 in w/o bdr,A6244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.3,,,,,,,fee schedule,78.27,137.3,
Hydrogel drg <= 16 in w/bdr,A6245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.08,,,,,,,fee schedule,14.48,25.39,
Hydrogel drg <= 16 in w/bdr,A6245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.07,,,,,,,fee schedule,14.48,25.39,
Hydrogel drg <= 16 in w/bdr,A6245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.48,,,,,,,fee schedule,14.48,25.39,
Hydrogel drg <= 16 in w/bdr,A6245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.39,,,,,,,fee schedule,14.48,25.39,
Hydrogel drg >16<=48 in w/b,A6246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.19,,,,,,,fee schedule,19.79,34.72,
Hydrogel drg >16<=48 in w/b,A6246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.71,,,,,,,fee schedule,19.79,34.72,
Hydrogel drg >16<=48 in w/b,A6246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.79,,,,,,,fee schedule,19.79,34.72,
Hydrogel drg >16<=48 in w/b,A6246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.72,,,,,,,fee schedule,19.79,34.72,
Hydrogel drg > 48 sq in w/b,A6247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.28,,,,,,,fee schedule,47.39,83.12,
Hydrogel drg > 48 sq in w/b,A6247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.16,,,,,,,fee schedule,47.39,83.12,
Hydrogel drg > 48 sq in w/b,A6247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.39,,,,,,,fee schedule,47.39,83.12,
Hydrogel drg > 48 sq in w/b,A6247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.12,,,,,,,fee schedule,47.39,83.12,
Hydrogel drsg gel filler,A6248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.78,,,,,,,fee schedule,11.66,20.45,
Hydrogel drsg gel filler,A6248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.55,,,,,,,fee schedule,11.66,20.45,
Hydrogel drsg gel filler,A6248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.66,,,,,,,fee schedule,11.66,20.45,
Hydrogel drsg gel filler,A6248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.45,,,,,,,fee schedule,11.66,20.45,
Absorpt drg <=16 sq in w/o b,A6251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.06,,,,,,,fee schedule,3.97,6.97,
Absorpt drg <=16 sq in w/o b,A6251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.96,,,,,,,fee schedule,3.97,6.97,
Absorpt drg <=16 sq in w/o b,A6251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.97,,,,,,,fee schedule,3.97,6.97,
Absorpt drg <=16 sq in w/o b,A6251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.97,,,,,,,fee schedule,3.97,6.97,
Absorpt drg >16 <=48 w/o bdr,A6252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.92,,,,,,,fee schedule,6.5,11.41,
Absorpt drg >16 <=48 w/o bdr,A6252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.12,,,,,,,fee schedule,6.5,11.41,
Absorpt drg >16 <=48 w/o bdr,A6252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.5,,,,,,,fee schedule,6.5,11.41,
Absorpt drg >16 <=48 w/o bdr,A6252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.41,,,,,,,fee schedule,6.5,11.41,
Absorpt drg > 48 sq in w/o b,A6253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.23,,,,,,,fee schedule,12.61,22.11,
Absorpt drg > 48 sq in w/o b,A6253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.74,,,,,,,fee schedule,12.61,22.11,
Absorpt drg > 48 sq in w/o b,A6253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.61,,,,,,,fee schedule,12.61,22.11,
Absorpt drg > 48 sq in w/o b,A6253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.11,,,,,,,fee schedule,12.61,22.11,
Absorpt drg <=16 sq in w/bdr,A6254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.66,,,,,,,fee schedule,2.4,4.21,
Absorpt drg <=16 sq in w/bdr,A6254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3,,,,,,,fee schedule,2.4,4.21,
Absorpt drg <=16 sq in w/bdr,A6254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.4,,,,,,,fee schedule,2.4,4.21,
Absorpt drg <=16 sq in w/bdr,A6254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.21,,,,,,,fee schedule,2.4,4.21,
Absorpt drg >16<=48 in w/bdr,A6255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.23,,,,,,,fee schedule,6.05,10.61,
Absorpt drg >16<=48 in w/bdr,A6255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.55,,,,,,,fee schedule,6.05,10.61,
Absorpt drg >16<=48 in w/bdr,A6255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.05,,,,,,,fee schedule,6.05,10.61,
Absorpt drg >16<=48 in w/bdr,A6255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.61,,,,,,,fee schedule,6.05,10.61,
Transparent film <= 16 sq in,A6257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.75,,,,,,,fee schedule,1.15,2.01,
Transparent film <= 16 sq in,A6257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.43,,,,,,,fee schedule,1.15,2.01,
Transparent film <= 16 sq in,A6257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.15,,,,,,,fee schedule,1.15,2.01,
Transparent film <= 16 sq in,A6257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.01,,,,,,,fee schedule,1.15,2.01,
Transparent film >16<=48 in,A6258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.11,,,,,,,fee schedule,8.59,15.08,
Transparent film >16<=48 in,A6258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.73,,,,,,,fee schedule,8.59,15.08,
Transparent film >16<=48 in,A6258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.59,,,,,,,fee schedule,8.59,15.08,
Transparent film >16<=48 in,A6258,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.08,,,,,,,fee schedule,8.59,15.08,
Transparent film > 48 sq in,A6259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.25,,,,,,,fee schedule,21.8,38.24,
Transparent film > 48 sq in,A6259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.22,,,,,,,fee schedule,21.8,38.24,
Transparent film > 48 sq in,A6259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.8,,,,,,,fee schedule,21.8,38.24,
Transparent film > 48 sq in,A6259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.24,,,,,,,fee schedule,21.8,38.24,
Wound cleanser any type/size,A6260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.13,,,,,,,fee schedule,0.09,0.15,
Wound cleanser any type/size,A6260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.11,,,,,,,fee schedule,0.09,0.15,
Wound cleanser any type/size,A6260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.15,
Wound cleanser any type/size,A6260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.15,,,,,,,fee schedule,0.09,0.15,
Impreg gauze no h20/sal/yard,A6266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.84,,,,,,,fee schedule,3.83,6.72,
Impreg gauze no h20/sal/yard,A6266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.78,,,,,,,fee schedule,3.83,6.72,
Impreg gauze no h20/sal/yard,A6266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.83,,,,,,,fee schedule,3.83,6.72,
Impreg gauze no h20/sal/yard,A6266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.72,,,,,,,fee schedule,3.83,6.72,
Sterile gauze <= 16 sq in,A6402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.35,,,,,,,fee schedule,0.23,0.4,
Sterile gauze <= 16 sq in,A6402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.29,,,,,,,fee schedule,0.23,0.4,
Sterile gauze <= 16 sq in,A6402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.23,0.4,
Sterile gauze <= 16 sq in,A6402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.4,,,,,,,fee schedule,0.23,0.4,
Sterile gauze>16 <= 48 sq in,A6403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.29,,,,,,,fee schedule,0.85,1.48,
Sterile gauze>16 <= 48 sq in,A6403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.06,,,,,,,fee schedule,0.85,1.48,
Sterile gauze>16 <= 48 sq in,A6403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.85,,,,,,,fee schedule,0.85,1.48,
Sterile gauze>16 <= 48 sq in,A6403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.48,,,,,,,fee schedule,0.85,1.48,
Sterile gauze > 48 sq in,A6404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.65,1.14,
Sterile gauze > 48 sq in,A6404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.65,1.14,
Sterile gauze > 48 sq in,A6404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,1.14,
Sterile gauze > 48 sq in,A6404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.65,1.14,
"Packing strips, non-impreg",A6407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.69,,,,,,,fee schedule,3.73,6.54,
"Packing strips, non-impreg",A6407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.66,,,,,,,fee schedule,3.73,6.54,
"Packing strips, non-impreg",A6407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.73,,,,,,,fee schedule,3.73,6.54,
"Packing strips, non-impreg",A6407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.54,,,,,,,fee schedule,3.73,6.54,
Sterile eye pad,A6410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.14,,,,,,,fee schedule,0.75,1.31,
Sterile eye pad,A6410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.93,,,,,,,fee schedule,0.75,1.31,
Sterile eye pad,A6410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.75,,,,,,,fee schedule,0.75,1.31,
Sterile eye pad,A6410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.31,,,,,,,fee schedule,0.75,1.31,
Occlusive eye patch,A6412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.65,1.14,
Occlusive eye patch,A6412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.65,1.14,
Occlusive eye patch,A6412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,1.14,
Occlusive eye patch,A6412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.65,1.14,
"Pad band w>=3"" <5""/yd",A6441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.08,,,,,,,fee schedule,1.36,2.39,
"Pad band w>=3"" <5""/yd",A6441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.7,,,,,,,fee schedule,1.36,2.39,
"Pad band w>=3"" <5""/yd",A6441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.36,,,,,,,fee schedule,1.36,2.39,
"Pad band w>=3"" <5""/yd",A6441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.39,,,,,,,fee schedule,1.36,2.39,
"Conform band n/s w<3""/yd",A6442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.48,,,,,,,fee schedule,0.31,0.55,
"Conform band n/s w<3""/yd",A6442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.39,,,,,,,fee schedule,0.31,0.55,
"Conform band n/s w<3""/yd",A6442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.31,,,,,,,fee schedule,0.31,0.55,
"Conform band n/s w<3""/yd",A6442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.55,,,,,,,fee schedule,0.31,0.55,
"Conform band n/s w>=3""<5""/yd",A6443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.84,,,,,,,fee schedule,0.55,0.97,
"Conform band n/s w>=3""<5""/yd",A6443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.69,,,,,,,fee schedule,0.55,0.97,
"Conform band n/s w>=3""<5""/yd",A6443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.55,,,,,,,fee schedule,0.55,0.97,
"Conform band n/s w>=3""<5""/yd",A6443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.97,,,,,,,fee schedule,0.55,0.97,
"Conform band n/s w>=5""/yd",A6444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.68,,,,,,,fee schedule,1.1,1.93,
"Conform band n/s w>=5""/yd",A6444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.38,,,,,,,fee schedule,1.1,1.93,
"Conform band n/s w>=5""/yd",A6444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.1,,,,,,,fee schedule,1.1,1.93,
"Conform band n/s w>=5""/yd",A6444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.93,,,,,,,fee schedule,1.1,1.93,
"Conform band s w <3""/yd",A6445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.65,1.14,
"Conform band s w <3""/yd",A6445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.65,1.14,
"Conform band s w <3""/yd",A6445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,1.14,
"Conform band s w <3""/yd",A6445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.65,1.14,
"Conform band s w>=3"" <5""/yd",A6446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.24,,,,,,,fee schedule,0.81,1.43,
"Conform band s w>=3"" <5""/yd",A6446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.01,,,,,,,fee schedule,0.81,1.43,
"Conform band s w>=3"" <5""/yd",A6446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.81,,,,,,,fee schedule,0.81,1.43,
"Conform band s w>=3"" <5""/yd",A6446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.43,,,,,,,fee schedule,0.81,1.43,
"Conform band s w >=5""/yd",A6447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.08,,,,,,,fee schedule,1.36,2.39,
"Conform band s w >=5""/yd",A6447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.7,,,,,,,fee schedule,1.36,2.39,
"Conform band s w >=5""/yd",A6447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.36,,,,,,,fee schedule,1.36,2.39,
"Conform band s w >=5""/yd",A6447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.39,,,,,,,fee schedule,1.36,2.39,
"Lt compres band <3""/yd",A6448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.51,,,,,,,fee schedule,2.3,4.04,
"Lt compres band <3""/yd",A6448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.87,,,,,,,fee schedule,2.3,4.04,
"Lt compres band <3""/yd",A6448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.3,,,,,,,fee schedule,2.3,4.04,
"Lt compres band <3""/yd",A6448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.04,,,,,,,fee schedule,2.3,4.04,
"Lt compres band >=3"" <5""/yd",A6449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.33,,,,,,,fee schedule,3.49,6.13,
"Lt compres band >=3"" <5""/yd",A6449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.36,,,,,,,fee schedule,3.49,6.13,
"Lt compres band >=3"" <5""/yd",A6449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.49,,,,,,,fee schedule,3.49,6.13,
"Lt compres band >=3"" <5""/yd",A6449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.13,,,,,,,fee schedule,3.49,6.13,
"Lt compres band >=5""/yd",A6450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.33,,,,,,,fee schedule,3.49,6.13,
"Lt compres band >=5""/yd",A6450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.36,,,,,,,fee schedule,3.49,6.13,
"Lt compres band >=5""/yd",A6450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.49,,,,,,,fee schedule,3.49,6.13,
"Lt compres band >=5""/yd",A6450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.13,,,,,,,fee schedule,3.49,6.13,
"Mod compres band w>=3""<5""/yd",A6451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.33,,,,,,,fee schedule,3.49,6.13,
"Mod compres band w>=3""<5""/yd",A6451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.36,,,,,,,fee schedule,3.49,6.13,
"Mod compres band w>=3""<5""/yd",A6451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.49,,,,,,,fee schedule,3.49,6.13,
"Mod compres band w>=3""<5""/yd",A6451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.13,,,,,,,fee schedule,3.49,6.13,
"High compres band w>=3""<5""yd",A6452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.96,,,,,,,fee schedule,11.77,20.65,
"High compres band w>=3""<5""yd",A6452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.7,,,,,,,fee schedule,11.77,20.65,
"High compres band w>=3""<5""yd",A6452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.77,,,,,,,fee schedule,11.77,20.65,
"High compres band w>=3""<5""yd",A6452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.65,,,,,,,fee schedule,11.77,20.65,
"Self-adher band w <3""/yd",A6453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.89,,,,,,,fee schedule,1.24,2.17,
"Self-adher band w <3""/yd",A6453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.55,,,,,,,fee schedule,1.24,2.17,
"Self-adher band w <3""/yd",A6453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.24,,,,,,,fee schedule,1.24,2.17,
"Self-adher band w <3""/yd",A6453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.17,,,,,,,fee schedule,1.24,2.17,
"Self-adher band w>=3"" <5""/yd",A6454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.37,,,,,,,fee schedule,1.55,2.73,
"Self-adher band w>=3"" <5""/yd",A6454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.94,,,,,,,fee schedule,1.55,2.73,
"Self-adher band w>=3"" <5""/yd",A6454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.55,,,,,,,fee schedule,1.55,2.73,
"Self-adher band w>=3"" <5""/yd",A6454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.73,,,,,,,fee schedule,1.55,2.73,
"Self-adher band >=5""/yd",A6455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.23,,,,,,,fee schedule,2.77,4.86,
"Self-adher band >=5""/yd",A6455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.46,,,,,,,fee schedule,2.77,4.86,
"Self-adher band >=5""/yd",A6455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.77,,,,,,,fee schedule,2.77,4.86,
"Self-adher band >=5""/yd",A6455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.86,,,,,,,fee schedule,2.77,4.86,
"Zinc paste band w >=3""<5""/yd",A6456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.85,,,,,,,fee schedule,2.52,4.43,
"Zinc paste band w >=3""<5""/yd",A6456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.15,,,,,,,fee schedule,2.52,4.43,
"Zinc paste band w >=3""<5""/yd",A6456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.52,,,,,,,fee schedule,2.52,4.43,
"Zinc paste band w >=3""<5""/yd",A6456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.43,,,,,,,fee schedule,2.52,4.43,
Tubular dressing,A6457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.44,,,,,,,fee schedule,2.26,3.96,
Tubular dressing,A6457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.82,,,,,,,fee schedule,2.26,3.96,
Tubular dressing,A6457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.26,,,,,,,fee schedule,2.26,3.96,
Tubular dressing,A6457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.96,,,,,,,fee schedule,2.26,3.96,
Arg II ext com/sup/acc misc,A6460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.4,,,,,,,fee schedule,14.4,16.56,
Arg II ext com/sup/acc misc,A6460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.4,,,,,,,fee schedule,14.4,16.56,
Arg II ext com/sup/acc misc,A6460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.4,,,,,,,fee schedule,14.4,16.56,
Arg II ext com/sup/acc misc,A6460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.56,,,,,,,fee schedule,14.4,16.56,
Enzyme cartridge enteral nut,A6461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.4,,,,,,,fee schedule,14.4,16.56,
Enzyme cartridge enteral nut,A6461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.4,,,,,,,fee schedule,14.4,16.56,
Enzyme cartridge enteral nut,A6461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.4,,,,,,,fee schedule,14.4,16.56,
Enzyme cartridge enteral nut,A6461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.56,,,,,,,fee schedule,14.4,16.56,
G com garmnt glove nghttime,A6520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.77,,,,,,,fee schedule,126.45,227.61,APC
G com garmnt glove nghttime,A6520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,126.45,,,,,,,fee schedule,126.45,227.61,APC
G com garmnt glove nghttime,A6520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,227.61,,,,,,,fee schedule,126.45,227.61,APC
G com garmnt glove nght cust,A6521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,526.84,,,,,,,fee schedule,501.75,903.15,APC
G com garmnt glove nght cust,A6521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,501.75,,,,,,,fee schedule,501.75,903.15,APC
G com garmnt glove nght cust,A6521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,903.15,,,,,,,fee schedule,501.75,903.15,APC
G com garment arm nighttime,A6522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,322.62,,,,,,,fee schedule,307.26,553.07,APC
G com garment arm nighttime,A6522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,307.26,,,,,,,fee schedule,307.26,553.07,APC
G com garment arm nighttime,A6522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,553.07,,,,,,,fee schedule,307.26,553.07,APC
G com garment arm nght custm,A6523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,765.47,,,,,,,fee schedule,729.02,1312.24,APC
G com garment arm nght custm,A6523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,729.02,,,,,,,fee schedule,729.02,1312.24,APC
G com garment arm nght custm,A6523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1312.24,,,,,,,fee schedule,729.02,1312.24,APC
G com garmnt lwr leg/ft nght,A6524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,402.51,,,,,,,fee schedule,383.34,690.01,APC
G com garmnt lwr leg/ft nght,A6524,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,383.34,,,,,,,fee schedule,383.34,690.01,APC
G com garmnt lwr leg/ft nght,A6524,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,690.01,,,,,,,fee schedule,383.34,690.01,APC
G com garm lwrleg/ft ngt cus,A6525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,812.6,,,,,,,fee schedule,773.9,1393.02,APC
G com garm lwrleg/ft ngt cus,A6525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,773.9,,,,,,,fee schedule,773.9,1393.02,APC
G com garm lwrleg/ft ngt cus,A6525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1393.02,,,,,,,fee schedule,773.9,1393.02,APC
G com garmt full leg/ft nght,A6526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,727.71,,,,,,,fee schedule,693.06,1247.51,APC
G com garmt full leg/ft nght,A6526,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.06,,,,,,,fee schedule,693.06,1247.51,APC
G com garmt full leg/ft nght,A6526,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1247.51,,,,,,,fee schedule,693.06,1247.51,APC
G garmt full leg/ft nght cus,A6527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1338.17,,,,,,,fee schedule,1274.45,2294.01,APC
G garmt full leg/ft nght cus,A6527,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1274.45,,,,,,,fee schedule,1274.45,2294.01,APC
G garmt full leg/ft nght cus,A6527,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2294.01,,,,,,,fee schedule,1274.45,2294.01,APC
G com garment bra nighttime,A6528,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,699.74,,,,,,,fee schedule,666.42,1199.56,APC
G com garment bra nighttime,A6528,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,666.42,,,,,,,fee schedule,666.42,1199.56,APC
G com garment bra nighttime,A6528,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1199.56,,,,,,,fee schedule,666.42,1199.56,APC
G com garmt bra night custm,A6529,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1105.69,,,,,,,fee schedule,1053.04,1895.47,APC
G com garmt bra night custm,A6529,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1053.04,,,,,,,fee schedule,1053.04,1895.47,APC
G com garmt bra night custm,A6529,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1895.47,,,,,,,fee schedule,1053.04,1895.47,APC
Compression stocking bk18-30,A6530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.02,,,,,,,fee schedule,39.07,70.33,APC
Compression stocking bk18-30,A6530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.07,,,,,,,fee schedule,39.07,70.33,APC
Compression stocking bk18-30,A6530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.33,,,,,,,fee schedule,39.07,70.33,APC
Compression stocking bk30-40,A6531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.49,,,,,,,fee schedule,61.66,151.21,
Compression stocking bk30-40,A6531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.62,,,,,,,fee schedule,61.66,151.21,
Compression stocking bk30-40,A6531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.2,,,,,,,fee schedule,61.66,151.21,
Compression stocking bk30-40,A6531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.21,,,,,,,fee schedule,61.66,151.21,
Compression stocking bk30-40,A6531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.74,,,,,,,fee schedule,61.66,151.21,APC
Compression stocking bk30-40,A6531,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,61.66,,,,,,,fee schedule,61.66,151.21,APC
Compression stocking bk30-40,A6531,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,110.99,,,,,,,fee schedule,61.66,151.21,APC
Compression stocking bk40-50,A6532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,185.28,,,,,,,fee schedule,86.88,213.07,
Compression stocking bk40-50,A6532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.65,,,,,,,fee schedule,86.88,213.07,
Compression stocking bk40-50,A6532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.47,,,,,,,fee schedule,86.88,213.07,
Compression stocking bk40-50,A6532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,213.07,,,,,,,fee schedule,86.88,213.07,
Compression stocking bk40-50,A6532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.22,,,,,,,fee schedule,86.88,213.07,APC
Compression stocking bk40-50,A6532,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.88,,,,,,,fee schedule,86.88,213.07,APC
Compression stocking bk40-50,A6532,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.38,,,,,,,fee schedule,86.88,213.07,APC
Gc stocking thighlngth 18-30,A6533,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.6,,,,,,,fee schedule,54.86,98.75,APC
Gc stocking thighlngth 18-30,A6533,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.86,,,,,,,fee schedule,54.86,98.75,APC
Gc stocking thighlngth 18-30,A6533,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,98.75,,,,,,,fee schedule,54.86,98.75,APC
Gc stocking thighlngth 30-40,A6534,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.78,,,,,,,fee schedule,62.65,112.77,APC
Gc stocking thighlngth 30-40,A6534,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.65,,,,,,,fee schedule,62.65,112.77,APC
Gc stocking thighlngth 30-40,A6534,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,112.77,,,,,,,fee schedule,62.65,112.77,APC
Gc stocking thighlngth 40-50,A6535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.74,,,,,,,fee schedule,72.13,129.83,APC
Gc stocking thighlngth 40-50,A6535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,72.13,,,,,,,fee schedule,72.13,129.83,APC
Gc stocking thighlngth 40-50,A6535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.83,,,,,,,fee schedule,72.13,129.83,APC
Gc stocking full lngth 18-30,A6536,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.65,,,,,,,fee schedule,73.95,133.11,APC
Gc stocking full lngth 18-30,A6536,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.95,,,,,,,fee schedule,73.95,133.11,APC
Gc stocking full lngth 18-30,A6536,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,133.11,,,,,,,fee schedule,73.95,133.11,APC
Gc stocking full lngth 30-40,A6537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.05,,,,,,,fee schedule,87.67,157.81,APC
Gc stocking full lngth 30-40,A6537,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,87.67,,,,,,,fee schedule,87.67,157.81,APC
Gc stocking full lngth 30-40,A6537,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,157.81,,,,,,,fee schedule,87.67,157.81,APC
Gc stocking full lngth 40-50,A6538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.78,,,,,,,fee schedule,102.65,184.77,APC
Gc stocking full lngth 40-50,A6538,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,102.65,,,,,,,fee schedule,102.65,184.77,APC
Gc stocking full lngth 40-50,A6538,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,184.77,,,,,,,fee schedule,102.65,184.77,APC
Gc stocking waistlngth 18-30,A6539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.75,,,,,,,fee schedule,97.86,176.15,APC
Gc stocking waistlngth 18-30,A6539,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,97.86,,,,,,,fee schedule,97.86,176.15,APC
Gc stocking waistlngth 18-30,A6539,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,176.15,,,,,,,fee schedule,97.86,176.15,APC
Gc stocking waistlngth 30-40,A6540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.51,,,,,,,fee schedule,116.68,210.02,APC
Gc stocking waistlngth 30-40,A6540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.68,,,,,,,fee schedule,116.68,210.02,APC
Gc stocking waistlngth 30-40,A6540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,210.02,,,,,,,fee schedule,116.68,210.02,APC
Gc stocking waistlngth 40-50,A6541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,145.12,,,,,,,fee schedule,138.21,248.78,APC
Gc stocking waistlngth 40-50,A6541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,138.21,,,,,,,fee schedule,138.21,248.78,APC
Gc stocking waistlngth 40-50,A6541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,248.78,,,,,,,fee schedule,138.21,248.78,APC
Gc stocking garter belt,A6544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.84,,,,,,,fee schedule,38.9,70.02,APC
Gc stocking garter belt,A6544,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.9,,,,,,,fee schedule,38.9,70.02,APC
Gc stocking garter belt,A6544,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.02,,,,,,,fee schedule,38.9,70.02,APC
Grad comp non-elastic BK,A6545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,258.92,,,,,,,fee schedule,121.41,297.76,
Grad comp non-elastic BK,A6545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.93,,,,,,,fee schedule,121.41,297.76,
Grad comp non-elastic BK,A6545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.75,,,,,,,fee schedule,121.41,297.76,
Grad comp non-elastic BK,A6545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,297.76,,,,,,,fee schedule,121.41,297.76,
Grad comp non-elastic BK,A6545,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,127.48,,,,,,,fee schedule,121.41,297.76,APC
Grad comp non-elastic BK,A6545,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,121.41,,,,,,,fee schedule,121.41,297.76,APC
Grad comp non-elastic BK,A6545,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,218.54,,,,,,,fee schedule,121.41,297.76,APC
Acces cust grad silic band,A6548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.9,,,,,,,fee schedule,20.86,37.55,APC
Acces cust grad silic band,A6548,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.86,,,,,,,fee schedule,20.86,37.55,APC
Acces cust grad silic band,A6548,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.55,,,,,,,fee schedule,20.86,37.55,APC
Neg pres wound ther drsg set,A6550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.02,,,,,,,fee schedule,44.59,78.22,
Neg pres wound ther drsg set,A6550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.67,,,,,,,fee schedule,44.59,78.22,
Neg pres wound ther drsg set,A6550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.59,,,,,,,fee schedule,44.59,78.22,
Neg pres wound ther drsg set,A6550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.22,,,,,,,fee schedule,44.59,78.22,
Grad com stocking bk 30-40,A6552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.87,,,,,,,fee schedule,57.97,104.35,APC
Grad com stocking bk 30-40,A6552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57.97,,,,,,,fee schedule,57.97,104.35,APC
Grad com stocking bk 30-40,A6552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.35,,,,,,,fee schedule,57.97,104.35,APC
G com stcking bk 30-40 custm,A6553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,237.7,,,,,,,fee schedule,226.38,407.48,APC
G com stcking bk 30-40 custm,A6553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,226.38,,,,,,,fee schedule,226.38,407.48,APC
G com stcking bk 30-40 custm,A6553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,407.48,,,,,,,fee schedule,226.38,407.48,APC
Grad com stocking bk 40+,A6554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.71,,,,,,,fee schedule,79.72,143.5,APC
Grad com stocking bk 40+,A6554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.72,,,,,,,fee schedule,79.72,143.5,APC
Grad com stocking bk 40+,A6554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,143.5,,,,,,,fee schedule,79.72,143.5,APC
G com stcking bk 40+ custm,A6555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,237.7,,,,,,,fee schedule,226.38,407.48,APC
G com stcking bk 40+ custm,A6555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,226.38,,,,,,,fee schedule,226.38,407.48,APC
G com stcking bk 40+ custm,A6555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,407.48,,,,,,,fee schedule,226.38,407.48,APC
G com stcking thgh18-30 cust,A6556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,325.76,,,,,,,fee schedule,310.25,558.45,APC
G com stcking thgh18-30 cust,A6556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,310.25,,,,,,,fee schedule,310.25,558.45,APC
G com stcking thgh18-30 cust,A6556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,558.45,,,,,,,fee schedule,310.25,558.45,APC
G com stcking thgh30-40 cust,A6557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,325.76,,,,,,,fee schedule,310.25,558.45,APC
G com stcking thgh30-40 cust,A6557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,310.25,,,,,,,fee schedule,310.25,558.45,APC
G com stcking thgh30-40 cust,A6557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,558.45,,,,,,,fee schedule,310.25,558.45,APC
G com stcking thgh 40+ cust,A6558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,336.18,,,,,,,fee schedule,320.17,576.31,APC
G com stcking thgh 40+ cust,A6558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,320.17,,,,,,,fee schedule,320.17,576.31,APC
G com stcking thgh 40+ cust,A6558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,576.31,,,,,,,fee schedule,320.17,576.31,APC
G com stckng waist18-30 cust,A6562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1066.14,,,,,,,fee schedule,1015.37,1827.67,APC
G com stckng waist18-30 cust,A6562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1015.37,,,,,,,fee schedule,1015.37,1827.67,APC
G com stckng waist18-30 cust,A6562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1827.67,,,,,,,fee schedule,1015.37,1827.67,APC
G com stckng waist30-40 cust,A6563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1066.14,,,,,,,fee schedule,1015.37,1827.67,APC
G com stckng waist30-40 cust,A6563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1015.37,,,,,,,fee schedule,1015.37,1827.67,APC
G com stckng waist30-40 cust,A6563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1827.67,,,,,,,fee schedule,1015.37,1827.67,APC
G com stckng waist 40+ cust,A6564,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1148.47,,,,,,,fee schedule,1093.78,1968.8,APC
G com stckng waist 40+ cust,A6564,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1093.78,,,,,,,fee schedule,1093.78,1968.8,APC
G com stckng waist 40+ cust,A6564,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1968.8,,,,,,,fee schedule,1093.78,1968.8,APC
Grad comp gauntlet custom,A6565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.22,,,,,,,fee schedule,175.45,315.81,APC
Grad comp gauntlet custom,A6565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,175.45,,,,,,,fee schedule,175.45,315.81,APC
Grad comp gauntlet custom,A6565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,315.81,,,,,,,fee schedule,175.45,315.81,APC
Grad com garment neck/head,A6566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,267.49,,,,,,,fee schedule,254.75,458.55,APC
Grad com garment neck/head,A6566,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,254.75,,,,,,,fee schedule,254.75,458.55,APC
Grad com garment neck/head,A6566,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,458.55,,,,,,,fee schedule,254.75,458.55,APC
G com garment neck/head cust,A6567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,840.44,,,,,,,fee schedule,800.42,1440.76,APC
G com garment neck/head cust,A6567,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,800.42,,,,,,,fee schedule,800.42,1440.76,APC
G com garment neck/head cust,A6567,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1440.76,,,,,,,fee schedule,800.42,1440.76,APC
G com garment torso/shldr,A6568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,174.57,,,,,,,fee schedule,166.26,299.27,APC
G com garment torso/shldr,A6568,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,166.26,,,,,,,fee schedule,166.26,299.27,APC
G com garment torso/shldr,A6568,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,299.27,,,,,,,fee schedule,166.26,299.27,APC
G com garmnt torso/shdr cust,A6569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,994.08,,,,,,,fee schedule,946.74,1704.13,APC
G com garmnt torso/shdr cust,A6569,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,946.74,,,,,,,fee schedule,946.74,1704.13,APC
G com garmnt torso/shdr cust,A6569,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1704.13,,,,,,,fee schedule,946.74,1704.13,APC
Grad com garment genital,A6570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,118.94,,,,,,,fee schedule,113.28,203.9,APC
Grad com garment genital,A6570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,113.28,,,,,,,fee schedule,113.28,203.9,APC
Grad com garment genital,A6570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,203.9,,,,,,,fee schedule,113.28,203.9,APC
G com garment genital custm,A6571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,714.88,,,,,,,fee schedule,680.84,1225.51,APC
G com garment genital custm,A6571,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,680.84,,,,,,,fee schedule,680.84,1225.51,APC
G com garment genital custm,A6571,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1225.51,,,,,,,fee schedule,680.84,1225.51,APC
Grad com garment toe caps,A6572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.37,,,,,,,fee schedule,105.11,189.2,APC
Grad com garment toe caps,A6572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,105.11,,,,,,,fee schedule,105.11,189.2,APC
Grad com garment toe caps,A6572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,189.2,,,,,,,fee schedule,105.11,189.2,APC
Grad com garmnt toe cap cust,A6573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.9,,,,,,,fee schedule,249.43,448.97,APC
Grad com garmnt toe cap cust,A6573,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,249.43,,,,,,,fee schedule,249.43,448.97,APC
Grad com garmnt toe cap cust,A6573,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.97,,,,,,,fee schedule,249.43,448.97,APC
Custom gradient sleev/glov,A6574,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,333.89,,,,,,,fee schedule,317.99,572.38,APC
Custom gradient sleev/glov,A6574,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,317.99,,,,,,,fee schedule,317.99,572.38,APC
Custom gradient sleev/glov,A6574,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,572.38,,,,,,,fee schedule,317.99,572.38,APC
Gradient comp sleev/glov,A6575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.2,,,,,,,fee schedule,103.05,185.49,APC
Gradient comp sleev/glov,A6575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,103.05,,,,,,,fee schedule,103.05,185.49,APC
Gradient comp sleev/glov,A6575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,185.49,,,,,,,fee schedule,103.05,185.49,APC
Custom grad com sleeve med,A6576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,204.92,,,,,,,fee schedule,195.16,351.29,APC
Custom grad com sleeve med,A6576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,195.16,,,,,,,fee schedule,195.16,351.29,APC
Custom grad com sleeve med,A6576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,351.29,,,,,,,fee schedule,195.16,351.29,APC
Custom grad cm sleeve heavy,A6577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,169.61,,,,,,,fee schedule,161.53,290.75,APC
Custom grad cm sleeve heavy,A6577,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,161.53,,,,,,,fee schedule,161.53,290.75,APC
Custom grad cm sleeve heavy,A6577,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,290.75,,,,,,,fee schedule,161.53,290.75,APC
Gradient comp sleeve,A6578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.53,,,,,,,fee schedule,79.55,143.19,APC
Gradient comp sleeve,A6578,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.55,,,,,,,fee schedule,79.55,143.19,APC
Gradient comp sleeve,A6578,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,143.19,,,,,,,fee schedule,79.55,143.19,APC
Custom grad com glove med,A6579,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,328.92,,,,,,,fee schedule,313.26,563.87,APC
Custom grad com glove med,A6579,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,313.26,,,,,,,fee schedule,313.26,563.87,APC
Custom grad com glove med,A6579,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,563.87,,,,,,,fee schedule,313.26,563.87,APC
Custom grad com glove heavy,A6580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,326.51,,,,,,,fee schedule,310.96,559.73,APC
Custom grad com glove heavy,A6580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,310.96,,,,,,,fee schedule,310.96,559.73,APC
Custom grad com glove heavy,A6580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,559.73,,,,,,,fee schedule,310.96,559.73,APC
Gradient comp glove,A6581,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,76.64,,,,,,,fee schedule,72.99,131.38,APC
Gradient comp glove,A6581,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,72.99,,,,,,,fee schedule,72.99,131.38,APC
Gradient comp glove,A6581,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,131.38,,,,,,,fee schedule,72.99,131.38,APC
Gradient comp gauntlet,A6582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.11,,,,,,,fee schedule,48.68,87.62,APC
Gradient comp gauntlet,A6582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48.68,,,,,,,fee schedule,48.68,87.62,APC
Gradient comp gauntlet,A6582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,87.62,,,,,,,fee schedule,48.68,87.62,APC
Grad com wrap w straps bk,A6583,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.14,,,,,,,fee schedule,160.13,288.23,APC
Grad com wrap w straps bk,A6583,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,160.13,,,,,,,fee schedule,160.13,288.23,APC
Grad com wrap w straps bk,A6583,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,288.23,,,,,,,fee schedule,160.13,288.23,APC
Grad com wrap w straps ak,A6585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,199.08,,,,,,,fee schedule,189.6,341.28,APC
Grad com wrap w straps ak,A6585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,189.6,,,,,,,fee schedule,189.6,341.28,APC
Grad com wrap w straps ak,A6585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,341.28,,,,,,,fee schedule,189.6,341.28,APC
Grad com wrap w straps leg,A6586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,586.52,,,,,,,fee schedule,558.59,1005.46,APC
Grad com wrap w straps leg,A6586,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,558.59,,,,,,,fee schedule,558.59,1005.46,APC
Grad com wrap w straps leg,A6586,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1005.46,,,,,,,fee schedule,558.59,1005.46,APC
Grad com wrap w straps foot,A6587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,76.83,,,,,,,fee schedule,73.17,131.71,APC
Grad com wrap w straps foot,A6587,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.17,,,,,,,fee schedule,73.17,131.71,APC
Grad com wrap w straps foot,A6587,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,131.71,,,,,,,fee schedule,73.17,131.71,APC
Grad com wrap w straps arm,A6588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.06,,,,,,,fee schedule,243.87,438.97,APC
Grad com wrap w straps arm,A6588,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,243.87,,,,,,,fee schedule,243.87,438.97,APC
Grad com wrap w straps arm,A6588,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,438.97,,,,,,,fee schedule,243.87,438.97,APC
Grad com wrap w straps bra,A6589,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.08,,,,,,,fee schedule,96.27,173.29,APC
Grad com wrap w straps bra,A6589,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.27,,,,,,,fee schedule,96.27,173.29,APC
Grad com wrap w straps bra,A6589,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.29,,,,,,,fee schedule,96.27,173.29,APC
G comp bandge liner lwr extr,A6594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.8,,,,,,,fee schedule,35.05,63.09,APC
G comp bandge liner lwr extr,A6594,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.05,,,,,,,fee schedule,35.05,63.09,APC
G comp bandge liner lwr extr,A6594,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.09,,,,,,,fee schedule,35.05,63.09,APC
G comp bandge liner upr extr,A6595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.2,,,,,,,fee schedule,34.48,62.06,APC
G comp bandge liner upr extr,A6595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.48,,,,,,,fee schedule,34.48,62.06,APC
G comp bandge liner upr extr,A6595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,62.06,,,,,,,fee schedule,34.48,62.06,APC
G comp bandge conform gauze,A6596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.19,,,,,,,fee schedule,0.18,0.32,APC
G comp bandge conform gauze,A6596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.18,,,,,,,fee schedule,0.18,0.32,APC
G comp bandge conform gauze,A6596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.32,,,,,,,fee schedule,0.18,0.32,APC
G comp bandage long stretch,A6597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.63,,,,,,,fee schedule,1.55,2.79,APC
G comp bandage long stretch,A6597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.55,,,,,,,fee schedule,1.55,2.79,APC
G comp bandage long stretch,A6597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.79,,,,,,,fee schedule,1.55,2.79,APC
G comp bandage med stretch,A6598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.79,,,,,,,fee schedule,0.75,1.35,APC
G comp bandage med stretch,A6598,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.75,,,,,,,fee schedule,0.75,1.35,APC
G comp bandage med stretch,A6598,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.35,,,,,,,fee schedule,0.75,1.35,APC
G comp bandage short stretch,A6599,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.78,,,,,,,fee schedule,1.7,3.06,APC
G comp bandage short stretch,A6599,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.7,,,,,,,fee schedule,1.7,3.06,APC
G comp bandage short stretch,A6599,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.06,,,,,,,fee schedule,1.7,3.06,APC
G com bandge hgh dn foam sht,A6600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.22,,,,,,,fee schedule,3.07,5.53,APC
G com bandge hgh dn foam sht,A6600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.07,,,,,,,fee schedule,3.07,5.53,APC
G com bandge hgh dn foam sht,A6600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.53,,,,,,,fee schedule,3.07,5.53,APC
G com bandge hgh dn foam pad,A6601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.62,,,,,,,fee schedule,3.45,6.21,APC
G com bandge hgh dn foam pad,A6601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.45,,,,,,,fee schedule,3.45,6.21,APC
G com bandge hgh dn foam pad,A6601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.21,,,,,,,fee schedule,3.45,6.21,APC
G com bandge hgh dn foamroll,A6602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.28,,,,,,,fee schedule,5.03,9.05,APC
G com bandge hgh dn foamroll,A6602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.03,,,,,,,fee schedule,5.03,9.05,APC
G com bandge hgh dn foamroll,A6602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.05,,,,,,,fee schedule,5.03,9.05,APC
G com bandge low dn foamchnl,A6603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.48,,,,,,,fee schedule,2.36,4.25,APC
G com bandge low dn foamchnl,A6603,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.36,,,,,,,fee schedule,2.36,4.25,APC
G com bandge low dn foamchnl,A6603,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.25,,,,,,,fee schedule,2.36,4.25,APC
G com bandge low dn foam flt,A6604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.45,,,,,,,fee schedule,1.38,2.48,APC
G com bandge low dn foam flt,A6604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.38,,,,,,,fee schedule,1.38,2.48,APC
G com bandge low dn foam flt,A6604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.48,,,,,,,fee schedule,1.38,2.48,APC
G com bandage padded foam,A6605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.65,,,,,,,fee schedule,1.57,2.83,APC
G com bandage padded foam,A6605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.57,,,,,,,fee schedule,1.57,2.83,APC
G com bandage padded foam,A6605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.83,,,,,,,fee schedule,1.57,2.83,APC
G com bandage padded textile,A6606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.9,,,,,,,fee schedule,4.67,8.41,APC
G com bandage padded textile,A6606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.67,,,,,,,fee schedule,4.67,8.41,APC
G com bandage padded textile,A6606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.41,,,,,,,fee schedule,4.67,8.41,APC
G com bandage tub protct lyr,A6607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.31,,,,,,,fee schedule,1.25,2.25,APC
G com bandage tub protct lyr,A6607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.25,,,,,,,fee schedule,1.25,2.25,APC
G com bandage tub protct lyr,A6607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.25,,,,,,,fee schedule,1.25,2.25,APC
G com bandage tub protct pad,A6608,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.47,,,,,,,fee schedule,5.21,9.38,APC
G com bandage tub protct pad,A6608,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.21,,,,,,,fee schedule,5.21,9.38,APC
G com bandage tub protct pad,A6608,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.38,,,,,,,fee schedule,5.21,9.38,APC
G com stcking bk 18-30 custm,A6610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,237.7,,,,,,,fee schedule,226.38,407.48,APC
G com stcking bk 18-30 custm,A6610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,226.38,,,,,,,fee schedule,226.38,407.48,APC
G com stcking bk 18-30 custm,A6610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,407.48,,,,,,,fee schedule,226.38,407.48,APC
Disposable canister for pump,A7000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.53,,,,,,,fee schedule,14.77,25.91,
Disposable canister for pump,A7000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.44,,,,,,,fee schedule,14.77,25.91,
Disposable canister for pump,A7000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.77,,,,,,,fee schedule,14.77,25.91,
Disposable canister for pump,A7000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.91,,,,,,,fee schedule,14.77,25.91,
Nondisposable pump canister,A7001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.52,,,,,,,fee schedule,65.9,115.6,
Nondisposable pump canister,A7001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.28,,,,,,,fee schedule,65.9,115.6,
Nondisposable pump canister,A7001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.9,,,,,,,fee schedule,65.9,115.6,
Nondisposable pump canister,A7001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.6,,,,,,,fee schedule,65.9,115.6,
Tubing used w suction pump,A7002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.62,,,,,,,fee schedule,7.62,13.36,
Tubing used w suction pump,A7002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.51,,,,,,,fee schedule,7.62,13.36,
Tubing used w suction pump,A7002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.62,,,,,,,fee schedule,7.62,13.36,
Tubing used w suction pump,A7002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.36,,,,,,,fee schedule,7.62,13.36,
Nebulizer administration set,A7003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.87,,,,,,,fee schedule,91.7,160.85,
Nebulizer administration set,A7003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.48,,,,,,,fee schedule,91.7,160.85,
Nebulizer administration set,A7003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.7,,,,,,,fee schedule,91.7,160.85,
Nebulizer administration set,A7003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.85,,,,,,,fee schedule,91.7,160.85,
Disposable nebulizer sml vol,A7004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.36,,,,,,,fee schedule,2.2,3.86,
Disposable nebulizer sml vol,A7004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.75,,,,,,,fee schedule,2.2,3.86,
Disposable nebulizer sml vol,A7004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.2,,,,,,,fee schedule,2.2,3.86,
Disposable nebulizer sml vol,A7004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.86,,,,,,,fee schedule,2.2,3.86,
Nondisposable nebulizer set,A7005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.86,,,,,,,fee schedule,80.55,141.29,
Nondisposable nebulizer set,A7005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.56,,,,,,,fee schedule,80.55,141.29,
Nondisposable nebulizer set,A7005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.55,,,,,,,fee schedule,80.55,141.29,
Nondisposable nebulizer set,A7005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.29,,,,,,,fee schedule,80.55,141.29,
Filtered nebulizer admin set,A7006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.08,,,,,,,fee schedule,13.82,24.24,
Filtered nebulizer admin set,A7006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.25,,,,,,,fee schedule,13.82,24.24,
Filtered nebulizer admin set,A7006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.82,,,,,,,fee schedule,13.82,24.24,
Filtered nebulizer admin set,A7006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.24,,,,,,,fee schedule,13.82,24.24,
Lg vol nebulizer disposable,A7007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.28,,,,,,,fee schedule,6.08,10.67,
Lg vol nebulizer disposable,A7007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.6,,,,,,,fee schedule,6.08,10.67,
Lg vol nebulizer disposable,A7007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.08,,,,,,,fee schedule,6.08,10.67,
Lg vol nebulizer disposable,A7007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.67,,,,,,,fee schedule,6.08,10.67,
Disposable nebulizer prefill,A7008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.44,,,,,,,fee schedule,21.92,38.46,
Disposable nebulizer prefill,A7008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.37,,,,,,,fee schedule,21.92,38.46,
Disposable nebulizer prefill,A7008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.92,,,,,,,fee schedule,21.92,38.46,
Disposable nebulizer prefill,A7008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.46,,,,,,,fee schedule,21.92,38.46,
Nebulizer reservoir bottle,A7009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.8,,,,,,,fee schedule,83.79,146.97,
Nebulizer reservoir bottle,A7009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.6,,,,,,,fee schedule,83.79,146.97,
Nebulizer reservoir bottle,A7009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.79,,,,,,,fee schedule,83.79,146.97,
Nebulizer reservoir bottle,A7009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.97,,,,,,,fee schedule,83.79,146.97,
Disposable corrugated tubing,A7010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.79,,,,,,,fee schedule,28.05,49.21,
Disposable corrugated tubing,A7010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.02,,,,,,,fee schedule,28.05,49.21,
Disposable corrugated tubing,A7010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.05,,,,,,,fee schedule,28.05,49.21,
Disposable corrugated tubing,A7010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.21,,,,,,,fee schedule,28.05,49.21,
Nebulizer water collec devic,A7012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.41,,,,,,,fee schedule,4.86,8.52,
Nebulizer water collec devic,A7012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.07,,,,,,,fee schedule,4.86,8.52,
Nebulizer water collec devic,A7012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.86,,,,,,,fee schedule,4.86,8.52,
Nebulizer water collec devic,A7012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.52,,,,,,,fee schedule,4.86,8.52,
Disposable compressor filter,A7013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.56,,,,,,,fee schedule,1.02,1.79,
Disposable compressor filter,A7013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.28,,,,,,,fee schedule,1.02,1.79,
Disposable compressor filter,A7013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.02,,,,,,,fee schedule,1.02,1.79,
Disposable compressor filter,A7013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.79,,,,,,,fee schedule,1.02,1.79,
Compressor nondispos filter,A7014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.03,,,,,,,fee schedule,5.92,10.38,
Compressor nondispos filter,A7014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.39,,,,,,,fee schedule,5.92,10.38,
Compressor nondispos filter,A7014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.92,,,,,,,fee schedule,5.92,10.38,
Compressor nondispos filter,A7014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.38,,,,,,,fee schedule,5.92,10.38,
Aerosol mask used w nebulize,A7015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.74,,,,,,,fee schedule,9.66,16.95,
Aerosol mask used w nebulize,A7015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.06,,,,,,,fee schedule,9.66,16.95,
Aerosol mask used w nebulize,A7015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.66,,,,,,,fee schedule,9.66,16.95,
Aerosol mask used w nebulize,A7015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.95,,,,,,,fee schedule,9.66,16.95,
Nebulizer dome & mouthpiece,A7016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.03,,,,,,,fee schedule,14.44,25.33,
Nebulizer dome & mouthpiece,A7016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.03,,,,,,,fee schedule,14.44,25.33,
Nebulizer dome & mouthpiece,A7016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.44,,,,,,,fee schedule,14.44,25.33,
Nebulizer dome & mouthpiece,A7016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.33,,,,,,,fee schedule,14.44,25.33,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.03,,,,,,,fee schedule,216.37,379.53,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.13,,,,,,,fee schedule,216.37,379.53,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,216.37,,,,,,,fee schedule,216.37,379.53,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,379.53,,,,,,,fee schedule,216.37,379.53,
Water distilled w/nebulizer,A7018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.92,,,,,,,fee schedule,0.6,1.06,
Water distilled w/nebulizer,A7018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.75,,,,,,,fee schedule,0.6,1.06,
Water distilled w/nebulizer,A7018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.6,,,,,,,fee schedule,0.6,1.06,
Water distilled w/nebulizer,A7018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.06,,,,,,,fee schedule,0.6,1.06,
"Interface, cough stim device",A7020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.01,,,,,,,fee schedule,28.85,50.61,
"Interface, cough stim device",A7020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.02,,,,,,,fee schedule,28.85,50.61,
"Interface, cough stim device",A7020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.85,,,,,,,fee schedule,28.85,50.61,
"Interface, cough stim device",A7020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.61,,,,,,,fee schedule,28.85,50.61,
Replace chest compress vest,A7025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,132.21,,,,,,,fee schedule,86.68,152.04,
Replace chest compress vest,A7025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.21,,,,,,,fee schedule,86.68,152.04,
Replace chest compress vest,A7025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.68,,,,,,,fee schedule,86.68,152.04,
Replace chest compress vest,A7025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,152.04,,,,,,,fee schedule,86.68,152.04,
Replace chst cmprss sys hose,A7026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.37,,,,,,,fee schedule,57.28,100.48,
Replace chst cmprss sys hose,A7026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.51,,,,,,,fee schedule,57.28,100.48,
Replace chst cmprss sys hose,A7026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.28,,,,,,,fee schedule,57.28,100.48,
Replace chst cmprss sys hose,A7026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.48,,,,,,,fee schedule,57.28,100.48,
Combination oral/nasal mask,A7027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,326.59,,,,,,,fee schedule,214.11,375.58,
Combination oral/nasal mask,A7027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,267.31,,,,,,,fee schedule,214.11,375.58,
Combination oral/nasal mask,A7027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.11,,,,,,,fee schedule,214.11,375.58,
Combination oral/nasal mask,A7027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,375.58,,,,,,,fee schedule,214.11,375.58,
Repl oral cushion combo mask,A7028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.24,,,,,,,fee schedule,60.47,106.08,
Repl oral cushion combo mask,A7028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.5,,,,,,,fee schedule,60.47,106.08,
Repl oral cushion combo mask,A7028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.47,,,,,,,fee schedule,60.47,106.08,
Repl oral cushion combo mask,A7028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.08,,,,,,,fee schedule,60.47,106.08,
Repl nasal pillow comb mask,A7029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.17,,,,,,,fee schedule,26.99,47.35,
Repl nasal pillow comb mask,A7029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.7,,,,,,,fee schedule,26.99,47.35,
Repl nasal pillow comb mask,A7029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.99,,,,,,,fee schedule,26.99,47.35,
Repl nasal pillow comb mask,A7029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.35,,,,,,,fee schedule,26.99,47.35,
CPAP full face mask,A7030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.24,,,,,,,fee schedule,154.88,271.68,
CPAP full face mask,A7030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.36,,,,,,,fee schedule,154.88,271.68,
CPAP full face mask,A7030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.88,,,,,,,fee schedule,154.88,271.68,
CPAP full face mask,A7030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,271.68,,,,,,,fee schedule,154.88,271.68,
Replacement facemask interfa,A7031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.36,,,,,,,fee schedule,58.58,102.76,
Replacement facemask interfa,A7031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.14,,,,,,,fee schedule,58.58,102.76,
Replacement facemask interfa,A7031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.58,,,,,,,fee schedule,58.58,102.76,
Replacement facemask interfa,A7031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.76,,,,,,,fee schedule,58.58,102.76,
Replacement nasal cushion,A7032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.2,,,,,,,fee schedule,32.26,56.58,
Replacement nasal cushion,A7032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.27,,,,,,,fee schedule,32.26,56.58,
Replacement nasal cushion,A7032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.26,,,,,,,fee schedule,32.26,56.58,
Replacement nasal cushion,A7032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.58,,,,,,,fee schedule,32.26,56.58,
Replacement nasal pillows,A7033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.41,,,,,,,fee schedule,27.15,47.62,
Replacement nasal pillows,A7033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.89,,,,,,,fee schedule,27.15,47.62,
Replacement nasal pillows,A7033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.15,,,,,,,fee schedule,27.15,47.62,
Replacement nasal pillows,A7033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.62,,,,,,,fee schedule,27.15,47.62,
Nasal application device,A7034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.57,,,,,,,fee schedule,98.06,172.01,
Nasal application device,A7034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.42,,,,,,,fee schedule,98.06,172.01,
Nasal application device,A7034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.06,,,,,,,fee schedule,98.06,172.01,
Nasal application device,A7034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.01,,,,,,,fee schedule,98.06,172.01,
Pos airway press headgear,A7035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.06,,,,,,,fee schedule,32.16,56.42,
Pos airway press headgear,A7035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.16,,,,,,,fee schedule,32.16,56.42,
Pos airway press headgear,A7035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.16,,,,,,,fee schedule,32.16,56.42,
Pos airway press headgear,A7035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.42,,,,,,,fee schedule,32.16,56.42,
Pos airway press chinstrap,A7036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.96,,,,,,,fee schedule,18.99,33.3,
Pos airway press chinstrap,A7036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.7,,,,,,,fee schedule,18.99,33.3,
Pos airway press chinstrap,A7036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.99,,,,,,,fee schedule,18.99,33.3,
Pos airway press chinstrap,A7036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.3,,,,,,,fee schedule,18.99,33.3,
Pos airway pressure tubing,A7037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.76,,,,,,,fee schedule,20.82,36.52,
Pos airway pressure tubing,A7037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26,,,,,,,fee schedule,20.82,36.52,
Pos airway pressure tubing,A7037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.82,,,,,,,fee schedule,20.82,36.52,
Pos airway pressure tubing,A7037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.52,,,,,,,fee schedule,20.82,36.52,
Pos airway pressure filter,A7038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.54,,,,,,,fee schedule,3.63,6.37,
Pos airway pressure filter,A7038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.53,,,,,,,fee schedule,3.63,6.37,
Pos airway pressure filter,A7038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.63,,,,,,,fee schedule,3.63,6.37,
Pos airway pressure filter,A7038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.37,,,,,,,fee schedule,3.63,6.37,
"Filter, non disposable w pap",A7039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.76,,,,,,,fee schedule,10.99,19.27,
"Filter, non disposable w pap",A7039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.72,,,,,,,fee schedule,10.99,19.27,
"Filter, non disposable w pap",A7039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.99,,,,,,,fee schedule,10.99,19.27,
"Filter, non disposable w pap",A7039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.27,,,,,,,fee schedule,10.99,19.27,
One way chest drain valve,A7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.92,,,,,,,fee schedule,80.59,141.36,
One way chest drain valve,A7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.61,,,,,,,fee schedule,80.59,141.36,
One way chest drain valve,A7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.59,,,,,,,fee schedule,80.59,141.36,
One way chest drain valve,A7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.36,,,,,,,fee schedule,80.59,141.36,
Water seal drain container,A7041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,231.04,,,,,,,fee schedule,151.47,265.7,
Water seal drain container,A7041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.11,,,,,,,fee schedule,151.47,265.7,
Water seal drain container,A7041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.47,,,,,,,fee schedule,151.47,265.7,
Water seal drain container,A7041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.7,,,,,,,fee schedule,151.47,265.7,
PAP oral interface,A7044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,232.67,,,,,,,fee schedule,152.54,267.57,
PAP oral interface,A7044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.44,,,,,,,fee schedule,152.54,267.57,
PAP oral interface,A7044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.54,,,,,,,fee schedule,152.54,267.57,
PAP oral interface,A7044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,267.57,,,,,,,fee schedule,152.54,267.57,
Repl exhalation port for PAP,A7045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.25,,,,,,,fee schedule,22.45,39.39,
Repl exhalation port for PAP,A7045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.03,,,,,,,fee schedule,22.45,39.39,
Repl exhalation port for PAP,A7045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.45,,,,,,,fee schedule,22.45,39.39,
Repl exhalation port for PAP,A7045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.39,,,,,,,fee schedule,22.45,39.39,
"Repl water chamber, PAP dev",A7046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.66,,,,,,,fee schedule,24.03,42.16,
"Repl water chamber, PAP dev",A7046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.01,,,,,,,fee schedule,24.03,42.16,
"Repl water chamber, PAP dev",A7046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.03,,,,,,,fee schedule,24.03,42.16,
"Repl water chamber, PAP dev",A7046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.16,,,,,,,fee schedule,24.03,42.16,
Resp suction oral interface,A7047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,367.49,,,,,,,fee schedule,240.93,422.61,
Resp suction oral interface,A7047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,300.79,,,,,,,fee schedule,240.93,422.61,
Resp suction oral interface,A7047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,240.93,,,,,,,fee schedule,240.93,422.61,
Resp suction oral interface,A7047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,422.61,,,,,,,fee schedule,240.93,422.61,
Vacuum drain bottle/tube kit,A7048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.65,,,,,,,fee schedule,84.34,147.95,
Vacuum drain bottle/tube kit,A7048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.3,,,,,,,fee schedule,84.34,147.95,
Vacuum drain bottle/tube kit,A7048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.34,,,,,,,fee schedule,84.34,147.95,
Vacuum drain bottle/tube kit,A7048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.95,,,,,,,fee schedule,84.34,147.95,
Tracheostoma valve w diaphra,A7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,319.18,,,,,,,fee schedule,209.25,367.06,
Tracheostoma valve w diaphra,A7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.25,,,,,,,fee schedule,209.25,367.06,
Tracheostoma valve w diaphra,A7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,209.25,,,,,,,fee schedule,209.25,367.06,
Tracheostoma valve w diaphra,A7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,367.06,,,,,,,fee schedule,209.25,367.06,
Replacement diaphragm/fplate,A7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.76,,,,,,,fee schedule,99.49,174.52,
Replacement diaphragm/fplate,A7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.22,,,,,,,fee schedule,99.49,174.52,
Replacement diaphragm/fplate,A7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.49,,,,,,,fee schedule,99.49,174.52,
Replacement diaphragm/fplate,A7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.52,,,,,,,fee schedule,99.49,174.52,
HMES filter holder or cap,A7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.49,,,,,,,fee schedule,22.61,39.66,
HMES filter holder or cap,A7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.23,,,,,,,fee schedule,22.61,39.66,
HMES filter holder or cap,A7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.61,,,,,,,fee schedule,22.61,39.66,
HMES filter holder or cap,A7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.66,,,,,,,fee schedule,22.61,39.66,
Tracheostoma HMES filter,A7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.08,,,,,,,fee schedule,1.36,2.39,
Tracheostoma HMES filter,A7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.7,,,,,,,fee schedule,1.36,2.39,
Tracheostoma HMES filter,A7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.36,,,,,,,fee schedule,1.36,2.39,
Tracheostoma HMES filter,A7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.39,,,,,,,fee schedule,1.36,2.39,
HMES or trach valve housing,A7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.25,,,,,,,fee schedule,9.34,16.39,
HMES or trach valve housing,A7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.66,,,,,,,fee schedule,9.34,16.39,
HMES or trach valve housing,A7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.34,,,,,,,fee schedule,9.34,16.39,
HMES or trach valve housing,A7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.39,,,,,,,fee schedule,9.34,16.39,
HMES/trachvalve adhesivedisk,A7506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.01,,,,,,,fee schedule,0.66,1.16,
HMES/trachvalve adhesivedisk,A7506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.83,,,,,,,fee schedule,0.66,1.16,
HMES/trachvalve adhesivedisk,A7506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.66,,,,,,,fee schedule,0.66,1.16,
HMES/trachvalve adhesivedisk,A7506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.16,,,,,,,fee schedule,0.66,1.16,
Integrated filter & holder,A7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.55,,,,,,,fee schedule,4.95,8.68,
Integrated filter & holder,A7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.18,,,,,,,fee schedule,4.95,8.68,
Integrated filter & holder,A7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.95,,,,,,,fee schedule,4.95,8.68,
Integrated filter & holder,A7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.68,,,,,,,fee schedule,4.95,8.68,
Housing & Integrated Adhesiv,A7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.7,,,,,,,fee schedule,5.7,10.01,
Housing & Integrated Adhesiv,A7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.12,,,,,,,fee schedule,5.7,10.01,
Housing & Integrated Adhesiv,A7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.7,,,,,,,fee schedule,5.7,10.01,
Housing & Integrated Adhesiv,A7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.01,,,,,,,fee schedule,5.7,10.01,
Heat & moisture exchange sys,A7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.28,,,,,,,fee schedule,2.81,4.92,
Heat & moisture exchange sys,A7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.5,,,,,,,fee schedule,2.81,4.92,
Heat & moisture exchange sys,A7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.81,,,,,,,fee schedule,2.81,4.92,
Heat & moisture exchange sys,A7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.92,,,,,,,fee schedule,2.81,4.92,
Trach/laryn tube non-cuffed,A7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.32,,,,,,,fee schedule,94.62,165.97,
Trach/laryn tube non-cuffed,A7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.13,,,,,,,fee schedule,94.62,165.97,
Trach/laryn tube non-cuffed,A7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.62,,,,,,,fee schedule,94.62,165.97,
Trach/laryn tube non-cuffed,A7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.97,,,,,,,fee schedule,94.62,165.97,
Trach/laryn tube cuffed,A7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.95,,,,,,,fee schedule,93.72,164.39,
Trach/laryn tube cuffed,A7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117,,,,,,,fee schedule,93.72,164.39,
Trach/laryn tube cuffed,A7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.72,,,,,,,fee schedule,93.72,164.39,
Trach/laryn tube cuffed,A7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.39,,,,,,,fee schedule,93.72,164.39,
Trach/laryn tube stainless,A7522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.27,,,,,,,fee schedule,89.99,157.86,
Trach/laryn tube stainless,A7522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112.36,,,,,,,fee schedule,89.99,157.86,
Trach/laryn tube stainless,A7522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.99,,,,,,,fee schedule,89.99,157.86,
Trach/laryn tube stainless,A7522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.86,,,,,,,fee schedule,89.99,157.86,
Tracheostoma stent/stud/bttn,A7524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,235.28,,,,,,,fee schedule,154.25,270.57,
Tracheostoma stent/stud/bttn,A7524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,192.58,,,,,,,fee schedule,154.25,270.57,
Tracheostoma stent/stud/bttn,A7524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.25,,,,,,,fee schedule,154.25,270.57,
Tracheostoma stent/stud/bttn,A7524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,270.57,,,,,,,fee schedule,154.25,270.57,
Tracheostomy mask,A7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.27,,,,,,,fee schedule,4.11,7.21,
Tracheostomy mask,A7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.13,,,,,,,fee schedule,4.11,7.21,
Tracheostomy mask,A7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.11,,,,,,,fee schedule,4.11,7.21,
Tracheostomy mask,A7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.21,,,,,,,fee schedule,4.11,7.21,
Tracheostomy tube collar,A7526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.29,,,,,,,fee schedule,6.75,11.83,
Tracheostomy tube collar,A7526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.42,,,,,,,fee schedule,6.75,11.83,
Tracheostomy tube collar,A7526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.75,,,,,,,fee schedule,6.75,11.83,
Tracheostomy tube collar,A7526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.83,,,,,,,fee schedule,6.75,11.83,
Trach/laryn tube plug/stop,A7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.89,,,,,,,fee schedule,7.14,12.52,
Trach/laryn tube plug/stop,A7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.91,,,,,,,fee schedule,7.14,12.52,
Trach/laryn tube plug/stop,A7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.14,,,,,,,fee schedule,7.14,12.52,
Trach/laryn tube plug/stop,A7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.52,,,,,,,fee schedule,7.14,12.52,
Soft protect helmet prefab,A8000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,466.13,,,,,,,fee schedule,305.59,536.05,
Soft protect helmet prefab,A8000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,381.53,,,,,,,fee schedule,305.59,536.05,
Soft protect helmet prefab,A8000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,305.59,,,,,,,fee schedule,305.59,536.05,
Soft protect helmet prefab,A8000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,536.05,,,,,,,fee schedule,305.59,536.05,
Hard protect helmet prefab,A8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,466.13,,,,,,,fee schedule,305.59,536.05,
Hard protect helmet prefab,A8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,381.53,,,,,,,fee schedule,305.59,536.05,
Hard protect helmet prefab,A8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,305.59,,,,,,,fee schedule,305.59,536.05,
Hard protect helmet prefab,A8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,536.05,,,,,,,fee schedule,305.59,536.05,
"Artificial saliva, 1 ml",A9154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.37,,,,,,,fee schedule,0.37,0.43,
"Artificial saliva, 1 ml",A9154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.37,,,,,,,fee schedule,0.37,0.43,
"Artificial saliva, 1 ml",A9154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.37,,,,,,,fee schedule,0.37,0.43,
"Artificial saliva, 1 ml",A9154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.43,,,,,,,fee schedule,0.37,0.43,
Tc99m sestamibi,A9500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.89,,,,,,,fee schedule,108.89,125.22,
Tc99m sestamibi,A9500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.89,,,,,,,fee schedule,108.89,125.22,
Tc99m sestamibi,A9500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.89,,,,,,,fee schedule,108.89,125.22,
Tc99m sestamibi,A9500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.22,,,,,,,fee schedule,108.89,125.22,
Tc99m tetrofosmin,A9502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.8,,,,,,,fee schedule,136.8,157.32,
Tc99m tetrofosmin,A9502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.8,,,,,,,fee schedule,136.8,157.32,
Tc99m tetrofosmin,A9502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.8,,,,,,,fee schedule,136.8,157.32,
Tc99m tetrofosmin,A9502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.32,,,,,,,fee schedule,136.8,157.32,
Tc99m medronate,A9503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.26,,,,,,,fee schedule,13.26,15.25,
Tc99m medronate,A9503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.26,,,,,,,fee schedule,13.26,15.25,
Tc99m medronate,A9503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.26,,,,,,,fee schedule,13.26,15.25,
Tc99m medronate,A9503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.25,,,,,,,fee schedule,13.26,15.25,
Tc99m apcitide,A9504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,425,,,,,,,fee schedule,425,488.75,
Tc99m apcitide,A9504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,425,,,,,,,fee schedule,425,488.75,
Tc99m apcitide,A9504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,425,,,,,,,fee schedule,425,488.75,
Tc99m apcitide,A9504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,488.75,,,,,,,fee schedule,425,488.75,
Tl201 thallium,A9505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.31,,,,,,,fee schedule,33.31,38.31,
Tl201 thallium,A9505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.31,,,,,,,fee schedule,33.31,38.31,
Tl201 thallium,A9505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.31,,,,,,,fee schedule,33.31,38.31,
Tl201 thallium,A9505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.31,,,,,,,fee schedule,33.31,38.31,
Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,316.2,,,,,,,fee schedule,316.2,591.48,
Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,316.2,,,,,,,fee schedule,316.2,591.48,
Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.2,,,,,,,fee schedule,316.2,591.48,
Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,363.63,,,,,,,fee schedule,316.2,591.48,
Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.03,,,,,,,fee schedule,316.2,591.48,APC
Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,328.6,,,,,,,fee schedule,316.2,591.48,APC
Tc-99m graphite crucible,A9506,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,591.48,,,,,,,fee schedule,316.2,591.48,APC
In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4483.93,,,,,,,fee schedule,1730.29,5156.52,
In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4483.93,,,,,,,fee schedule,1730.29,5156.52,
In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4483.93,,,,,,,fee schedule,1730.29,5156.52,
In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5156.52,,,,,,,fee schedule,1730.29,5156.52,
In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1816.8,,,,,,,fee schedule,1730.29,5156.52,APC
In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1730.29,,,,,,,fee schedule,1730.29,5156.52,APC
In111 capromab,A9507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3114.52,,,,,,,fee schedule,1730.29,5156.52,APC
"I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,753.92,,,,,,,fee schedule,753.92,1715.42,
"I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,753.92,,,,,,,fee schedule,753.92,1715.42,
"I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,753.92,,,,,,,fee schedule,753.92,1715.42,
"I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,867.01,,,,,,,fee schedule,753.92,1715.42,
"I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1000.66,,,,,,,fee schedule,753.92,1715.42,APC
"I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,953.01,,,,,,,fee schedule,753.92,1715.42,APC
"I131 iodobenguate, dx",A9508,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1715.42,,,,,,,fee schedule,753.92,1715.42,APC
Iodine I-123 sod iodide mil,A9509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1844.67,,,,,,,fee schedule,1844.67,2121.37,
Iodine I-123 sod iodide mil,A9509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1844.67,,,,,,,fee schedule,1844.67,2121.37,
Iodine I-123 sod iodide mil,A9509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1844.67,,,,,,,fee schedule,1844.67,2121.37,
Iodine I-123 sod iodide mil,A9509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2121.37,,,,,,,fee schedule,1844.67,2121.37,
Tc99m disofenin,A9510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.4,,,,,,,fee schedule,71.4,82.11,
Tc99m disofenin,A9510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.4,,,,,,,fee schedule,71.4,82.11,
Tc99m disofenin,A9510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.4,,,,,,,fee schedule,71.4,82.11,
Tc99m disofenin,A9510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.11,,,,,,,fee schedule,71.4,82.11,
Tc99m pertechnetate,A9512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.73,,,,,,,fee schedule,1.73,1.99,
Tc99m pertechnetate,A9512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.73,,,,,,,fee schedule,1.73,1.99,
Tc99m pertechnetate,A9512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.73,,,,,,,fee schedule,1.73,1.99,
Tc99m pertechnetate,A9512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.99,,,,,,,fee schedule,1.73,1.99,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,311.13,,,,,,,fee schedule,311.13,630.37,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,311.13,,,,,,,fee schedule,311.13,630.37,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,311.13,,,,,,,fee schedule,311.13,630.37,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.8,,,,,,,fee schedule,311.13,630.37,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,367.72,,,,,,,fee schedule,311.13,630.37,APC
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,350.21,,,,,,,fee schedule,311.13,630.37,APC
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,630.37,,,,,,,fee schedule,311.13,630.37,APC
Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5100,,,,,,,fee schedule,2516.43,5865,
Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5100,,,,,,,fee schedule,2516.43,5865,
Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5100,,,,,,,fee schedule,2516.43,5865,
Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5865,,,,,,,fee schedule,2516.43,5865,
Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2642.25,,,,,,,fee schedule,2516.43,5865,APC
Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2516.43,,,,,,,fee schedule,2516.43,5865,APC
Choline c-11,A9515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4529.57,,,,,,,fee schedule,2516.43,5865,APC
Iodine I-123 sod iodide mic,A9516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.36,,,,,,,fee schedule,108.36,124.61,
Iodine I-123 sod iodide mic,A9516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.36,,,,,,,fee schedule,108.36,124.61,
Iodine I-123 sod iodide mic,A9516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.36,,,,,,,fee schedule,108.36,124.61,
Iodine I-123 sod iodide mic,A9516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.61,,,,,,,fee schedule,108.36,124.61,
"I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.41,,,,,,,fee schedule,24.07,43.33,
"I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.41,,,,,,,fee schedule,24.07,43.33,
"I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.41,,,,,,,fee schedule,24.07,43.33,
"I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.87,,,,,,,fee schedule,24.07,43.33,
"I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.27,,,,,,,fee schedule,24.07,43.33,APC
"I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.07,,,,,,,fee schedule,24.07,43.33,APC
"I131 iodide cap, rx",A9517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.33,,,,,,,fee schedule,24.07,43.33,APC
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,674.81,,,,,,,fee schedule,674.81,776.03,
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,674.81,,,,,,,fee schedule,674.81,776.03,
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,674.81,,,,,,,fee schedule,674.81,776.03,
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,776.03,,,,,,,fee schedule,674.81,776.03,
Tc99m exametazime,A9521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1748.25,,,,,,,fee schedule,1748.25,2010.49,
Tc99m exametazime,A9521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1748.25,,,,,,,fee schedule,1748.25,2010.49,
Tc99m exametazime,A9521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1748.25,,,,,,,fee schedule,1748.25,2010.49,
Tc99m exametazime,A9521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2010.49,,,,,,,fee schedule,1748.25,2010.49,
"I131 serum albumin, dx",A9524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,381.23,,,,,,,fee schedule,381.23,438.41,
"I131 serum albumin, dx",A9524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,381.23,,,,,,,fee schedule,381.23,438.41,
"I131 serum albumin, dx",A9524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,381.23,,,,,,,fee schedule,381.23,438.41,
"I131 serum albumin, dx",A9524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.41,,,,,,,fee schedule,381.23,438.41,
Nitrogen n-13 ammonia,A9526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,672.18,,,,,,,fee schedule,672.18,773.01,
Nitrogen n-13 ammonia,A9526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,672.18,,,,,,,fee schedule,672.18,773.01,
Nitrogen n-13 ammonia,A9526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,672.18,,,,,,,fee schedule,672.18,773.01,
Nitrogen n-13 ammonia,A9526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,773.01,,,,,,,fee schedule,672.18,773.01,
"Iodine i-131 iodide cap, dx",A9528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.47,,,,,,,fee schedule,199.47,229.39,
"Iodine i-131 iodide cap, dx",A9528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.47,,,,,,,fee schedule,199.47,229.39,
"Iodine i-131 iodide cap, dx",A9528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.47,,,,,,,fee schedule,199.47,229.39,
"Iodine i-131 iodide cap, dx",A9528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.39,,,,,,,fee schedule,199.47,229.39,
"I131 iodide sol, dx",A9529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.49,,,,,,,fee schedule,6.49,7.46,
"I131 iodide sol, dx",A9529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.49,,,,,,,fee schedule,6.49,7.46,
"I131 iodide sol, dx",A9529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.49,,,,,,,fee schedule,6.49,7.46,
"I131 iodide sol, dx",A9529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.46,,,,,,,fee schedule,6.49,7.46,
I131 max 100uci,A9531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.6,,,,,,,fee schedule,0.6,0.69,
I131 max 100uci,A9531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.6,,,,,,,fee schedule,0.6,0.69,
I131 max 100uci,A9531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.6,,,,,,,fee schedule,0.6,0.69,
I131 max 100uci,A9531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.69,,,,,,,fee schedule,0.6,0.69,
"I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.31,,,,,,,fee schedule,22.31,844.31,
"I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.31,,,,,,,fee schedule,22.31,844.31,
"I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.31,,,,,,,fee schedule,22.31,844.31,
"I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.66,,,,,,,fee schedule,22.31,844.31,
"I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,492.51,,,,,,,fee schedule,22.31,844.31,APC
"I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,469.06,,,,,,,fee schedule,22.31,844.31,APC
"I125 serum albumin, dx",A9532,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,844.31,,,,,,,fee schedule,22.31,844.31,APC
Tc99m depreotide,A9536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1190,,,,,,,fee schedule,1190,1368.5,
Tc99m depreotide,A9536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1190,,,,,,,fee schedule,1190,1368.5,
Tc99m depreotide,A9536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1190,,,,,,,fee schedule,1190,1368.5,
Tc99m depreotide,A9536,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1368.5,,,,,,,fee schedule,1190,1368.5,
Tc99m mebrofenin,A9537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.42,,,,,,,fee schedule,56.42,64.88,
Tc99m mebrofenin,A9537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.42,,,,,,,fee schedule,56.42,64.88,
Tc99m mebrofenin,A9537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.42,,,,,,,fee schedule,56.42,64.88,
Tc99m mebrofenin,A9537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.88,,,,,,,fee schedule,56.42,64.88,
Tc99m pyrophosphate,A9538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.33,,,,,,,fee schedule,65.33,75.13,
Tc99m pyrophosphate,A9538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.33,,,,,,,fee schedule,65.33,75.13,
Tc99m pyrophosphate,A9538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.33,,,,,,,fee schedule,65.33,75.13,
Tc99m pyrophosphate,A9538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.13,,,,,,,fee schedule,65.33,75.13,
Tc99m pentetate,A9539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.96,,,,,,,fee schedule,31.96,36.75,
Tc99m pentetate,A9539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.96,,,,,,,fee schedule,31.96,36.75,
Tc99m pentetate,A9539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.96,,,,,,,fee schedule,31.96,36.75,
Tc99m pentetate,A9539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.75,,,,,,,fee schedule,31.96,36.75,
Tc99m maa,A9540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.6,,,,,,,fee schedule,30.6,35.19,
Tc99m maa,A9540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.6,,,,,,,fee schedule,30.6,35.19,
Tc99m maa,A9540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.6,,,,,,,fee schedule,30.6,35.19,
Tc99m maa,A9540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.19,,,,,,,fee schedule,30.6,35.19,
Tc99m sulfur colloid,A9541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,272.71,,,,,,,fee schedule,272.71,313.62,
Tc99m sulfur colloid,A9541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.71,,,,,,,fee schedule,272.71,313.62,
Tc99m sulfur colloid,A9541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,272.71,,,,,,,fee schedule,272.71,313.62,
Tc99m sulfur colloid,A9541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,313.62,,,,,,,fee schedule,272.71,313.62,
"In111 ibritumomab, dx",A9542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3570,,,,,,,fee schedule,3570,4105.5,
"In111 ibritumomab, dx",A9542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3570,,,,,,,fee schedule,3570,4105.5,
"In111 ibritumomab, dx",A9542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3570,,,,,,,fee schedule,3570,4105.5,
"In111 ibritumomab, dx",A9542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4105.5,,,,,,,fee schedule,3570,4105.5,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68140.74,,,,,,,fee schedule,56824.55,102284.19,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68140.74,,,,,,,fee schedule,56824.55,102284.19,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68140.74,,,,,,,fee schedule,56824.55,102284.19,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78361.85,,,,,,,fee schedule,56824.55,102284.19,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59665.78,,,,,,,fee schedule,56824.55,102284.19,APC
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,56824.55,,,,,,,fee schedule,56824.55,102284.19,APC
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,102284.19,,,,,,,fee schedule,56824.55,102284.19,APC
In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2147.08,,,,,,,fee schedule,831.46,2469.14,
In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2147.08,,,,,,,fee schedule,831.46,2469.14,
In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2147.08,,,,,,,fee schedule,831.46,2469.14,
In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2469.14,,,,,,,fee schedule,831.46,2469.14,
In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,873.03,,,,,,,fee schedule,831.46,2469.14,APC
In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,831.46,,,,,,,fee schedule,831.46,2469.14,APC
In111 oxyquinoline,A9547,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1496.63,,,,,,,fee schedule,831.46,2469.14,APC
In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,903.21,,,,,,,fee schedule,745.62,1342.12,
In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,903.21,,,,,,,fee schedule,745.62,1342.12,
In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,903.21,,,,,,,fee schedule,745.62,1342.12,
In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1038.69,,,,,,,fee schedule,745.62,1342.12,
In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,782.9,,,,,,,fee schedule,745.62,1342.12,APC
In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,745.62,,,,,,,fee schedule,745.62,1342.12,APC
In111 pentetate,A9548,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1342.12,,,,,,,fee schedule,745.62,1342.12,APC
Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,611.41,,,,,,,fee schedule,611.41,1187.87,
Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,611.41,,,,,,,fee schedule,611.41,1187.87,
Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,611.41,,,,,,,fee schedule,611.41,1187.87,
Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,703.12,,,,,,,fee schedule,611.41,1187.87,
Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,692.93,,,,,,,fee schedule,611.41,1187.87,APC
Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,659.93,,,,,,,fee schedule,611.41,1187.87,APC
Tc99m succimer,A9551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1187.87,,,,,,,fee schedule,611.41,1187.87,APC
F18 fdg,A9552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,321.26,,,,,,,fee schedule,321.26,369.45,
F18 fdg,A9552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,321.26,,,,,,,fee schedule,321.26,369.45,
F18 fdg,A9552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,321.26,,,,,,,fee schedule,321.26,369.45,
F18 fdg,A9552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,369.45,,,,,,,fee schedule,321.26,369.45,
Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,575.28,,,,,,,fee schedule,575.28,3452.33,
Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,575.28,,,,,,,fee schedule,575.28,3452.33,
Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,575.28,,,,,,,fee schedule,575.28,3452.33,
Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,661.57,,,,,,,fee schedule,575.28,3452.33,
Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2013.86,,,,,,,fee schedule,575.28,3452.33,APC
Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1917.96,,,,,,,fee schedule,575.28,3452.33,APC
Cr51 chromate,A9553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3452.33,,,,,,,fee schedule,575.28,3452.33,APC
"I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.25,,,,,,,fee schedule,38.25,1169.35,
"I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.25,,,,,,,fee schedule,38.25,1169.35,
"I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.25,,,,,,,fee schedule,38.25,1169.35,
"I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.99,,,,,,,fee schedule,38.25,1169.35,
"I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,682.12,,,,,,,fee schedule,38.25,1169.35,APC
"I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,649.64,,,,,,,fee schedule,38.25,1169.35,APC
"I125 iothalamate, dx",A9554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1169.35,,,,,,,fee schedule,38.25,1169.35,APC
Rb82 rubidium,A9555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,521.12,,,,,,,fee schedule,521.12,599.29,
Rb82 rubidium,A9555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,521.12,,,,,,,fee schedule,521.12,599.29,
Rb82 rubidium,A9555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.12,,,,,,,fee schedule,521.12,599.29,
Rb82 rubidium,A9555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,599.29,,,,,,,fee schedule,521.12,599.29,
Ga67 gallium,A9556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.72,,,,,,,fee schedule,137.72,158.38,
Ga67 gallium,A9556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.72,,,,,,,fee schedule,137.72,158.38,
Ga67 gallium,A9556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.72,,,,,,,fee schedule,137.72,158.38,
Ga67 gallium,A9556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,158.38,,,,,,,fee schedule,137.72,158.38,
Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3739.65,,,,,,,fee schedule,775.52,4300.6,
Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3739.65,,,,,,,fee schedule,775.52,4300.6,
Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3739.65,,,,,,,fee schedule,775.52,4300.6,
Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4300.6,,,,,,,fee schedule,775.52,4300.6,
Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.3,,,,,,,fee schedule,775.52,4300.6,APC
Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,775.52,,,,,,,fee schedule,775.52,4300.6,APC
Tc99m bicisate,A9557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1395.94,,,,,,,fee schedule,775.52,4300.6,APC
Xe133 xenon 10mci,A9558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,260.2,,,,,,,fee schedule,260.2,299.23,
Xe133 xenon 10mci,A9558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,260.2,,,,,,,fee schedule,260.2,299.23,
Xe133 xenon 10mci,A9558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.2,,,,,,,fee schedule,260.2,299.23,
Xe133 xenon 10mci,A9558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,299.23,,,,,,,fee schedule,260.2,299.23,
Co57 cyano,A9559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.72,,,,,,,fee schedule,74.72,85.93,
Co57 cyano,A9559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.72,,,,,,,fee schedule,74.72,85.93,
Co57 cyano,A9559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.72,,,,,,,fee schedule,74.72,85.93,
Co57 cyano,A9559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.93,,,,,,,fee schedule,74.72,85.93,
Tc99m labeled rbc,A9560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.27,,,,,,,fee schedule,95.27,109.56,
Tc99m labeled rbc,A9560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95.27,,,,,,,fee schedule,95.27,109.56,
Tc99m labeled rbc,A9560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.27,,,,,,,fee schedule,95.27,109.56,
Tc99m labeled rbc,A9560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.56,,,,,,,fee schedule,95.27,109.56,
Tc99m oxidronate,A9561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.88,,,,,,,fee schedule,44.88,51.61,
Tc99m oxidronate,A9561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.88,,,,,,,fee schedule,44.88,51.61,
Tc99m oxidronate,A9561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.88,,,,,,,fee schedule,44.88,51.61,
Tc99m oxidronate,A9561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.61,,,,,,,fee schedule,44.88,51.61,
Tc99m mertiatide,A9562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,790.27,,,,,,,fee schedule,790.27,908.81,
Tc99m mertiatide,A9562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,790.27,,,,,,,fee schedule,790.27,908.81,
Tc99m mertiatide,A9562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,790.27,,,,,,,fee schedule,790.27,908.81,
Tc99m mertiatide,A9562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,908.81,,,,,,,fee schedule,790.27,908.81,
P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,310.97,,,,,,,fee schedule,278.24,500.83,
P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,310.97,,,,,,,fee schedule,278.24,500.83,
P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.97,,,,,,,fee schedule,278.24,500.83,
P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.62,,,,,,,fee schedule,278.24,500.83,
P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.15,,,,,,,fee schedule,278.24,500.83,APC
P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.24,,,,,,,fee schedule,278.24,500.83,APC
P32 na phosphate,A9563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,500.83,,,,,,,fee schedule,278.24,500.83,APC
P32 chromic phosphate,A9564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,296.28,,,,,,,fee schedule,296.28,340.72,
P32 chromic phosphate,A9564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,296.28,,,,,,,fee schedule,296.28,340.72,
P32 chromic phosphate,A9564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,296.28,,,,,,,fee schedule,296.28,340.72,
P32 chromic phosphate,A9564,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,340.72,,,,,,,fee schedule,296.28,340.72,
Technetium tc99m arcitumomab,A9568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1105,,,,,,,fee schedule,1105,1270.75,
Technetium tc99m arcitumomab,A9568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1105,,,,,,,fee schedule,1105,1270.75,
Technetium tc99m arcitumomab,A9568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1105,,,,,,,fee schedule,1105,1270.75,
Technetium tc99m arcitumomab,A9568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1270.75,,,,,,,fee schedule,1105,1270.75,
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1748.25,,,,,,,fee schedule,934.13,2010.49,
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1748.25,,,,,,,fee schedule,934.13,2010.49,
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1748.25,,,,,,,fee schedule,934.13,2010.49,
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2010.49,,,,,,,fee schedule,934.13,2010.49,
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,980.84,,,,,,,fee schedule,934.13,2010.49,APC
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,934.13,,,,,,,fee schedule,934.13,2010.49,APC
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1681.43,,,,,,,fee schedule,934.13,2010.49,APC
Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4294.16,,,,,,,fee schedule,1103.19,4938.28,
Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4294.16,,,,,,,fee schedule,1103.19,4938.28,
Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4294.16,,,,,,,fee schedule,1103.19,4938.28,
Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4938.28,,,,,,,fee schedule,1103.19,4938.28,
Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1158.35,,,,,,,fee schedule,1103.19,4938.28,APC
Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1103.19,,,,,,,fee schedule,1103.19,4938.28,APC
Indium In-111 auto WBC,A9570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1985.74,,,,,,,fee schedule,1103.19,4938.28,APC
Indium IN-111 auto platelet,A9571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4294.16,,,,,,,fee schedule,4294.16,4938.28,
Indium IN-111 auto platelet,A9571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4294.16,,,,,,,fee schedule,4294.16,4938.28,
Indium IN-111 auto platelet,A9571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4294.16,,,,,,,fee schedule,4294.16,4938.28,
Indium IN-111 auto platelet,A9571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4938.28,,,,,,,fee schedule,4294.16,4938.28,
Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3947.4,,,,,,,fee schedule,2000.94,4539.51,
Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3947.4,,,,,,,fee schedule,2000.94,4539.51,
Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3947.4,,,,,,,fee schedule,2000.94,4539.51,
Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4539.51,,,,,,,fee schedule,2000.94,4539.51,
Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2100.99,,,,,,,fee schedule,2000.94,4539.51,APC
Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2000.94,,,,,,,fee schedule,2000.94,4539.51,APC
Indium In-111 pentetreotide,A9572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3601.69,,,,,,,fee schedule,2000.94,4539.51,APC
"Inj, gadopiclenol, 1 ml",A9573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.54,,,,,,,fee schedule,3.54,4.07,
"Inj, gadopiclenol, 1 ml",A9573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.54,,,,,,,fee schedule,3.54,4.07,
"Inj, gadopiclenol, 1 ml",A9573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.54,,,,,,,fee schedule,3.54,4.07,
"Inj, gadopiclenol, 1 ml",A9573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.07,,,,,,,fee schedule,3.54,4.07,
Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.12,,,,,,,fee schedule,0.12,0.14,
Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.14,,,,,,,fee schedule,0.12,0.14,
Inj prohance multipack,A9576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.47,,,,,,,fee schedule,1.47,1.69,
Inj prohance multipack,A9576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.47,,,,,,,fee schedule,1.47,1.69,
Inj prohance multipack,A9576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.47,,,,,,,fee schedule,1.47,1.69,
Inj prohance multipack,A9576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.69,,,,,,,fee schedule,1.47,1.69,
Inj multihance,A9577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.81,,,,,,,fee schedule,1.81,2.08,
Inj multihance,A9577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.81,,,,,,,fee schedule,1.81,2.08,
Inj multihance,A9577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.81,,,,,,,fee schedule,1.81,2.08,
Inj multihance,A9577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.08,,,,,,,fee schedule,1.81,2.08,
Inj multihance multipack,A9578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.78,,,,,,,fee schedule,1.78,2.05,
Inj multihance multipack,A9578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.78,,,,,,,fee schedule,1.78,2.05,
Inj multihance multipack,A9578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.78,,,,,,,fee schedule,1.78,2.05,
Inj multihance multipack,A9578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.05,,,,,,,fee schedule,1.78,2.05,
Gadoxetate disodium inj,A9581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.26,,,,,,,fee schedule,15.26,17.55,
Gadoxetate disodium inj,A9581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.26,,,,,,,fee schedule,15.26,17.55,
Gadoxetate disodium inj,A9581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.26,,,,,,,fee schedule,15.26,17.55,
Gadoxetate disodium inj,A9581,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.55,,,,,,,fee schedule,15.26,17.55,
Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5210.58,,,,,,,fee schedule,2317.5,5992.17,
Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5210.58,,,,,,,fee schedule,2317.5,5992.17,
Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5210.58,,,,,,,fee schedule,2317.5,5992.17,
Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5992.17,,,,,,,fee schedule,2317.5,5992.17,
Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2433.38,,,,,,,fee schedule,2317.5,5992.17,APC
Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2317.5,,,,,,,fee schedule,2317.5,5992.17,APC
Iodine I-123 iobenguane,A9582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4171.5,,,,,,,fee schedule,2317.5,5992.17,APC
Gadofosveset trisodium inj,A9583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.86,,,,,,,fee schedule,17.86,20.54,
Gadofosveset trisodium inj,A9583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.86,,,,,,,fee schedule,17.86,20.54,
Gadofosveset trisodium inj,A9583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.86,,,,,,,fee schedule,17.86,20.54,
Gadofosveset trisodium inj,A9583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.54,,,,,,,fee schedule,17.86,20.54,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2643.84,,,,,,,fee schedule,1387.74,3040.42,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2643.84,,,,,,,fee schedule,1387.74,3040.42,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2643.84,,,,,,,fee schedule,1387.74,3040.42,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3040.42,,,,,,,fee schedule,1387.74,3040.42,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1457.13,,,,,,,fee schedule,1387.74,3040.42,APC
Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1387.74,,,,,,,fee schedule,1387.74,3040.42,APC
Iodine i-123 ioflupane,A9584,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2497.93,,,,,,,fee schedule,1387.74,3040.42,APC
Gadobutrol injection,A9585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.27,,,,,,,fee schedule,0.27,0.31,
Gadobutrol injection,A9585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.27,,,,,,,fee schedule,0.27,0.31,
Gadobutrol injection,A9585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.27,,,,,,,fee schedule,0.27,0.31,
Gadobutrol injection,A9585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.31,,,,,,,fee schedule,0.27,0.31,
Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2914.55,,,,,,,fee schedule,1825.64,3351.73,
Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2914.55,,,,,,,fee schedule,1825.64,3351.73,
Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2914.55,,,,,,,fee schedule,1825.64,3351.73,
Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3351.73,,,,,,,fee schedule,1825.64,3351.73,
Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1916.92,,,,,,,fee schedule,1825.64,3351.73,APC
Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1825.64,,,,,,,fee schedule,1825.64,3351.73,APC
Florbetapir F18,A9586,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3286.15,,,,,,,fee schedule,1825.64,3351.73,APC
Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.93,,,,,,,fee schedule,49.63,89.33,
Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.93,,,,,,,fee schedule,49.63,89.33,
Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.93,,,,,,,fee schedule,49.63,89.33,
Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.77,,,,,,,fee schedule,49.63,89.33,
Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.11,,,,,,,fee schedule,49.63,89.33,APC
Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.63,,,,,,,fee schedule,49.63,89.33,APC
Gallium ga-68,A9587,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,89.33,,,,,,,fee schedule,49.63,89.33,APC
Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,526.98,,,,,,,fee schedule,322.27,606.03,
Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,526.98,,,,,,,fee schedule,322.27,606.03,
Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,526.98,,,,,,,fee schedule,322.27,606.03,
Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,606.03,,,,,,,fee schedule,322.27,606.03,
Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,338.38,,,,,,,fee schedule,322.27,606.03,APC
Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,322.27,,,,,,,fee schedule,322.27,606.03,APC
Fluciclovine f-18,A9588,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,580.09,,,,,,,fee schedule,322.27,606.03,APC
Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1478.08,,,,,,,fee schedule,1478.08,1699.79,
Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1478.08,,,,,,,fee schedule,1478.08,1699.79,
Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1478.08,,,,,,,fee schedule,1478.08,1699.79,
Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1699.79,,,,,,,fee schedule,1478.08,1699.79,
Iodine i-131 iobenguane 1mci,A9590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,326.8,,,,,,,fee schedule,326.8,375.82,
Iodine i-131 iobenguane 1mci,A9590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,326.8,,,,,,,fee schedule,326.8,375.82,
Iodine i-131 iobenguane 1mci,A9590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.8,,,,,,,fee schedule,326.8,375.82,
Iodine i-131 iobenguane 1mci,A9590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,375.82,,,,,,,fee schedule,326.8,375.82,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,627.36,,,,,,,fee schedule,346.49,721.46,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,627.36,,,,,,,fee schedule,346.49,721.46,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,627.36,,,,,,,fee schedule,346.49,721.46,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,721.46,,,,,,,fee schedule,346.49,721.46,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,363.81,,,,,,,fee schedule,346.49,721.46,APC
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,346.49,,,,,,,fee schedule,346.49,721.46,APC
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,623.68,,,,,,,fee schedule,346.49,721.46,APC
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1053.86,,,,,,,fee schedule,478.52,1211.94,
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1053.86,,,,,,,fee schedule,478.52,1211.94,
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.86,,,,,,,fee schedule,478.52,1211.94,
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1211.94,,,,,,,fee schedule,478.52,1211.94,
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,502.45,,,,,,,fee schedule,478.52,1211.94,APC
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,478.52,,,,,,,fee schedule,478.52,1211.94,APC
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,861.34,,,,,,,fee schedule,478.52,1211.94,APC
Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3825,,,,,,,fee schedule,3825,7463.4,
Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3825,,,,,,,fee schedule,3825,7463.4,
Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3825,,,,,,,fee schedule,3825,7463.4,
Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4398.75,,,,,,,fee schedule,3825,7463.4,
Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4353.65,,,,,,,fee schedule,3825,7463.4,APC
Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4146.34,,,,,,,fee schedule,3825,7463.4,APC
Sr89 strontium,A9600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7463.4,,,,,,,fee schedule,3825,7463.4,APC
Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,357,,,,,,,fee schedule,357,667.8,
Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,357,,,,,,,fee schedule,357,667.8,
Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,357,,,,,,,fee schedule,357,667.8,
Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.55,,,,,,,fee schedule,357,667.8,
Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.55,,,,,,,fee schedule,357,667.8,APC
Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371,,,,,,,fee schedule,357,667.8,APC
Flortaucipir inj 1 millicuri,A9601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,667.8,,,,,,,fee schedule,357,667.8,APC
"Inj, pafolacianine, 0.1 mg",A9603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,135.47,,,,,,,fee schedule,135.47,155.79,
"Inj, pafolacianine, 0.1 mg",A9603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.47,,,,,,,fee schedule,135.47,155.79,
"Inj, pafolacianine, 0.1 mg",A9603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.47,,,,,,,fee schedule,135.47,155.79,
"Inj, pafolacianine, 0.1 mg",A9603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.79,,,,,,,fee schedule,135.47,155.79,
Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16608.54,,,,,,,fee schedule,3159.8,19099.82,
Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16608.54,,,,,,,fee schedule,3159.8,19099.82,
Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16608.54,,,,,,,fee schedule,3159.8,19099.82,
Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19099.82,,,,,,,fee schedule,3159.8,19099.82,
Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.79,,,,,,,fee schedule,3159.8,19099.82,APC
Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3159.8,,,,,,,fee schedule,3159.8,19099.82,APC
Sm 153 lexidronam,A9604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5687.64,,,,,,,fee schedule,3159.8,19099.82,APC
Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.4,,,,,,,fee schedule,172.4,326.79,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,172.4,,,,,,,fee schedule,172.4,326.79,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.4,,,,,,,fee schedule,172.4,326.79,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.26,,,,,,,fee schedule,172.4,326.79,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,190.63,,,,,,,fee schedule,172.4,326.79,APC
Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,181.55,,,,,,,fee schedule,172.4,326.79,APC
Radium ra223 dichloride ther,A9606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,326.79,,,,,,,fee schedule,172.4,326.79,APC
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,253.36,,,,,,,fee schedule,253.36,481.17,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,253.36,,,,,,,fee schedule,253.36,481.17,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,253.36,,,,,,,fee schedule,253.36,481.17,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,291.36,,,,,,,fee schedule,253.36,481.17,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,280.68,,,,,,,fee schedule,253.36,481.17,APC
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,267.32,,,,,,,fee schedule,253.36,481.17,APC
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,481.17,,,,,,,fee schedule,253.36,481.17,APC
"Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.69,,,,,,,fee schedule,53.69,954,
"Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.69,,,,,,,fee schedule,53.69,954,
"Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.69,,,,,,,fee schedule,53.69,954,
"Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.74,,,,,,,fee schedule,53.69,954,
"Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,556.5,,,,,,,fee schedule,53.69,954,APC
"Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,530,,,,,,,fee schedule,53.69,954,APC
"Flurpiridaz f18, diag, 1 mci",A9611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,954,,,,,,,fee schedule,53.69,954,APC
"Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.09,,,,,,,fee schedule,36.09,67.51,
"Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,36.09,67.51,
"Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.09,,,,,,,fee schedule,36.09,67.51,
"Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.5,,,,,,,fee schedule,36.09,67.51,
"Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.38,,,,,,,fee schedule,36.09,67.51,APC
"Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.51,,,,,,,fee schedule,36.09,67.51,APC
"Inj, pegulicianine, 1 mg",A9615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.51,,,,,,,fee schedule,36.09,67.51,APC
"Inj, magtrace per study dose",A9697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1316.7,,,,,,,fee schedule,1254,2257.2,APC
"Inj, magtrace per study dose",A9697,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1254,,,,,,,fee schedule,1254,2257.2,APC
"Inj, magtrace per study dose",A9697,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2257.2,,,,,,,fee schedule,1254,2257.2,APC
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,624.36,,,,,,,fee schedule,362.5,718.01,
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,624.36,,,,,,,fee schedule,362.5,718.01,
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,624.36,,,,,,,fee schedule,362.5,718.01,
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,718.01,,,,,,,fee schedule,362.5,718.01,
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,380.62,,,,,,,fee schedule,362.5,718.01,APC
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,362.5,,,,,,,fee schedule,362.5,718.01,APC
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,652.5,,,,,,,fee schedule,362.5,718.01,APC
Enter feed supkit syr by day,B4034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.19,,,,,,,fee schedule,5.37,9.42,
Enter feed supkit syr by day,B4034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.7,,,,,,,fee schedule,5.37,9.42,
Enter feed supkit syr by day,B4034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.37,,,,,,,fee schedule,5.37,9.42,
Enter feed supkit syr by day,B4034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.42,,,,,,,fee schedule,5.37,9.42,
Enteral feed supp pump per d,B4035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.48,,,,,,,fee schedule,9.49,16.65,
Enteral feed supp pump per d,B4035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.85,,,,,,,fee schedule,9.49,16.65,
Enteral feed supp pump per d,B4035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.49,,,,,,,fee schedule,9.49,16.65,
Enteral feed supp pump per d,B4035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.65,,,,,,,fee schedule,9.49,16.65,
Enteral feed sup kit grav by,B4036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.22,,,,,,,fee schedule,7.36,12.9,
Enteral feed sup kit grav by,B4036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.18,,,,,,,fee schedule,7.36,12.9,
Enteral feed sup kit grav by,B4036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.36,,,,,,,fee schedule,7.36,12.9,
Enteral feed sup kit grav by,B4036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.9,,,,,,,fee schedule,7.36,12.9,
Enteral ng tubing w/ stylet,B4081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,47.32,
Enteral ng tubing w/ stylet,B4081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,47.32,
Enteral ng tubing w/ stylet,B4081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,47.32,
Enteral ng tubing w/ stylet,B4081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,47.32,
Enteral ng tubing w/o stylet,B4082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.02,,,,,,,fee schedule,19.03,33.37,
Enteral ng tubing w/o stylet,B4082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.75,,,,,,,fee schedule,19.03,33.37,
Enteral ng tubing w/o stylet,B4082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.03,,,,,,,fee schedule,19.03,33.37,
Enteral ng tubing w/o stylet,B4082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.37,,,,,,,fee schedule,19.03,33.37,
Enteral stomach tube levine,B4083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.28,,,,,,,fee schedule,2.81,4.92,
Enteral stomach tube levine,B4083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.5,,,,,,,fee schedule,2.81,4.92,
Enteral stomach tube levine,B4083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.81,,,,,,,fee schedule,2.81,4.92,
Enteral stomach tube levine,B4083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.92,,,,,,,fee schedule,2.81,4.92,
"Gastro/jejuno tube, std",B4087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.69,,,,,,,fee schedule,47,82.44,
"Gastro/jejuno tube, std",B4087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.68,,,,,,,fee schedule,47,82.44,
"Gastro/jejuno tube, std",B4087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47,,,,,,,fee schedule,47,82.44,
"Gastro/jejuno tube, std",B4087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.44,,,,,,,fee schedule,47,82.44,
"Gastro/jejuno tube, low-pro",B4088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.75,,,,,,,fee schedule,54.25,95.16,
"Gastro/jejuno tube, low-pro",B4088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.73,,,,,,,fee schedule,54.25,95.16,
"Gastro/jejuno tube, low-pro",B4088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.25,,,,,,,fee schedule,54.25,95.16,
"Gastro/jejuno tube, low-pro",B4088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.16,,,,,,,fee schedule,54.25,95.16,
EF blenderized foods,B4149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.75,,,,,,,fee schedule,2.46,4.31,
EF blenderized foods,B4149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.07,,,,,,,fee schedule,2.46,4.31,
EF blenderized foods,B4149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.46,,,,,,,fee schedule,2.46,4.31,
EF blenderized foods,B4149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.31,,,,,,,fee schedule,2.46,4.31,
Ef complet w/intact nutrient,B4150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.64,,,,,,,fee schedule,1.08,1.89,
Ef complet w/intact nutrient,B4150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.34,,,,,,,fee schedule,1.08,1.89,
Ef complet w/intact nutrient,B4150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.08,,,,,,,fee schedule,1.08,1.89,
Ef complet w/intact nutrient,B4150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.89,,,,,,,fee schedule,1.08,1.89,
Ef calorie dense>/=1.5kcal,B4152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.38,,,,,,,fee schedule,0.9,1.59,
Ef calorie dense>/=1.5kcal,B4152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.13,,,,,,,fee schedule,0.9,1.59,
Ef calorie dense>/=1.5kcal,B4152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.9,,,,,,,fee schedule,0.9,1.59,
Ef calorie dense>/=1.5kcal,B4152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.59,,,,,,,fee schedule,0.9,1.59,
Ef hydrolyzed/amino acids,B4153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.62,,,,,,,fee schedule,4.34,7.61,
Ef hydrolyzed/amino acids,B4153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.42,,,,,,,fee schedule,4.34,7.61,
Ef hydrolyzed/amino acids,B4153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.34,,,,,,,fee schedule,4.34,7.61,
Ef hydrolyzed/amino acids,B4153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.61,,,,,,,fee schedule,4.34,7.61,
Ef spec metabolic noninherit,B4154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.62,,,,,,,fee schedule,1.72,3.01,
Ef spec metabolic noninherit,B4154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.14,,,,,,,fee schedule,1.72,3.01,
Ef spec metabolic noninherit,B4154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.72,,,,,,,fee schedule,1.72,3.01,
Ef spec metabolic noninherit,B4154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.01,,,,,,,fee schedule,1.72,3.01,
Ef incomplete/modular,B4155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.63,,,,,,,fee schedule,3.04,5.32,
Ef incomplete/modular,B4155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.79,,,,,,,fee schedule,3.04,5.32,
Ef incomplete/modular,B4155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.04,,,,,,,fee schedule,3.04,5.32,
Ef incomplete/modular,B4155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.32,,,,,,,fee schedule,3.04,5.32,
Parenteral 50% dextrose solu,B4164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.62,,,,,,,fee schedule,35.15,61.66,
Parenteral 50% dextrose solu,B4164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.89,,,,,,,fee schedule,35.15,61.66,
Parenteral 50% dextrose solu,B4164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.15,,,,,,,fee schedule,35.15,61.66,
Parenteral 50% dextrose solu,B4164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.66,,,,,,,fee schedule,35.15,61.66,
Parenteral sol amino acid 3.,B4168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.19,,,,,,,fee schedule,51.26,89.92,
Parenteral sol amino acid 3.,B4168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64,,,,,,,fee schedule,51.26,89.92,
Parenteral sol amino acid 3.,B4168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.26,,,,,,,fee schedule,51.26,89.92,
Parenteral sol amino acid 3.,B4168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.92,,,,,,,fee schedule,51.26,89.92,
Parenteral sol amino acid 5.,B4172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.4,,,,,,,fee schedule,82.87,145.36,
Parenteral sol amino acid 5.,B4172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.46,,,,,,,fee schedule,82.87,145.36,
Parenteral sol amino acid 5.,B4172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.87,,,,,,,fee schedule,82.87,145.36,
Parenteral sol amino acid 5.,B4172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.36,,,,,,,fee schedule,82.87,145.36,
Parenteral sol amino acid 7-,B4176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.3,,,,,,,fee schedule,99.19,174,
Parenteral sol amino acid 7-,B4176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.84,,,,,,,fee schedule,99.19,174,
Parenteral sol amino acid 7-,B4176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.19,,,,,,,fee schedule,99.19,174,
Parenteral sol amino acid 7-,B4176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174,,,,,,,fee schedule,99.19,174,
Parenteral sol amino acid >,B4178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.58,,,,,,,fee schedule,119.04,208.82,
Parenteral sol amino acid >,B4178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.62,,,,,,,fee schedule,119.04,208.82,
Parenteral sol amino acid >,B4178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.04,,,,,,,fee schedule,119.04,208.82,
Parenteral sol amino acid >,B4178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.82,,,,,,,fee schedule,119.04,208.82,
Parenteral sol carb > 50%,B4180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.99,,,,,,,fee schedule,50.47,88.54,
Parenteral sol carb > 50%,B4180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.02,,,,,,,fee schedule,50.47,88.54,
Parenteral sol carb > 50%,B4180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.47,,,,,,,fee schedule,50.47,88.54,
Parenteral sol carb > 50%,B4180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.54,,,,,,,fee schedule,50.47,88.54,
Parenteral sol 10 gm lipids,B4185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.86,,,,,,,fee schedule,7.78,13.64,
Parenteral sol 10 gm lipids,B4185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.71,,,,,,,fee schedule,7.78,13.64,
Parenteral sol 10 gm lipids,B4185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.78,,,,,,,fee schedule,7.78,13.64,
Parenteral sol 10 gm lipids,B4185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.64,,,,,,,fee schedule,7.78,13.64,
Parenteral sol amino acid &,B4189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,561.03,,,,,,,fee schedule,367.81,645.18,
Parenteral sol amino acid &,B4189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,459.2,,,,,,,fee schedule,367.81,645.18,
Parenteral sol amino acid &,B4189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,367.81,,,,,,,fee schedule,367.81,645.18,
Parenteral sol amino acid &,B4189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,645.18,,,,,,,fee schedule,367.81,645.18,
Parenteral sol 52-73 gm prot,B4193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,724.94,,,,,,,fee schedule,475.27,833.68,
Parenteral sol 52-73 gm prot,B4193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,593.36,,,,,,,fee schedule,475.27,833.68,
Parenteral sol 52-73 gm prot,B4193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,475.27,,,,,,,fee schedule,475.27,833.68,
Parenteral sol 52-73 gm prot,B4193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,833.68,,,,,,,fee schedule,475.27,833.68,
Parenteral sol 74-100 gm pro,B4197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,882.57,,,,,,,fee schedule,578.61,1014.96,
Parenteral sol 74-100 gm pro,B4197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,722.38,,,,,,,fee schedule,578.61,1014.96,
Parenteral sol 74-100 gm pro,B4197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,578.61,,,,,,,fee schedule,578.61,1014.96,
Parenteral sol 74-100 gm pro,B4197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1014.96,,,,,,,fee schedule,578.61,1014.96,
Parenteral sol > 100gm prote,B4199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1008.5,,,,,,,fee schedule,661.17,1159.78,
Parenteral sol > 100gm prote,B4199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,825.46,,,,,,,fee schedule,661.17,1159.78,
Parenteral sol > 100gm prote,B4199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,661.17,,,,,,,fee schedule,661.17,1159.78,
Parenteral sol > 100gm prote,B4199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1159.78,,,,,,,fee schedule,661.17,1159.78,
Parenteral nutrition additiv,B4216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.35,,,,,,,fee schedule,15.96,28,
Parenteral nutrition additiv,B4216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.93,,,,,,,fee schedule,15.96,28,
Parenteral nutrition additiv,B4216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.96,,,,,,,fee schedule,15.96,28,
Parenteral nutrition additiv,B4216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28,,,,,,,fee schedule,15.96,28,
Parenteral supply kit premix,B4220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.24,,,,,,,fee schedule,16.55,29.03,
Parenteral supply kit premix,B4220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.66,,,,,,,fee schedule,16.55,29.03,
Parenteral supply kit premix,B4220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.55,,,,,,,fee schedule,16.55,29.03,
Parenteral supply kit premix,B4220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.03,,,,,,,fee schedule,16.55,29.03,
Parenteral supply kit homemi,B4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.14,,,,,,,fee schedule,20.42,35.81,
Parenteral supply kit homemi,B4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.49,,,,,,,fee schedule,20.42,35.81,
Parenteral supply kit homemi,B4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.42,,,,,,,fee schedule,20.42,35.81,
Parenteral supply kit homemi,B4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.81,,,,,,,fee schedule,20.42,35.81,
Parenteral administration ki,B4224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.89,,,,,,,fee schedule,51.72,90.72,
Parenteral administration ki,B4224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.57,,,,,,,fee schedule,51.72,90.72,
Parenteral administration ki,B4224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.72,,,,,,,fee schedule,51.72,90.72,
Parenteral administration ki,B4224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.72,,,,,,,fee schedule,51.72,90.72,
Parenteral sol renal-amirosy,B5000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.22,,,,,,,fee schedule,0.14,0.25,
Parenteral sol renal-amirosy,B5000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.18,,,,,,,fee schedule,0.14,0.25,
Parenteral sol renal-amirosy,B5000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.14,,,,,,,fee schedule,0.14,0.25,
Parenteral sol renal-amirosy,B5000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.25,,,,,,,fee schedule,0.14,0.25,
Parenteral solution hepatic,B5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.56,,,,,,,fee schedule,0.37,0.64,
Parenteral solution hepatic,B5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.46,,,,,,,fee schedule,0.37,0.64,
Parenteral solution hepatic,B5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.37,,,,,,,fee schedule,0.37,0.64,
Parenteral solution hepatic,B5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.64,,,,,,,fee schedule,0.37,0.64,
Enter nutr inf pump any type,B9002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1687.4,,,,,,,fee schedule,1106.26,1940.51,
Enter nutr inf pump any type,B9002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1381.14,,,,,,,fee schedule,1106.26,1940.51,
Enter nutr inf pump any type,B9002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1106.26,,,,,,,fee schedule,1106.26,1940.51,
Enter nutr inf pump any type,B9002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1940.51,,,,,,,fee schedule,1106.26,1940.51,
Parenteral infus pump portab,B9004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7963.69,,,,,,,fee schedule,5221,9158.24,
Parenteral infus pump portab,B9004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6518.28,,,,,,,fee schedule,5221,9158.24,
Parenteral infus pump portab,B9004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5221,,,,,,,fee schedule,5221,9158.24,
Parenteral infus pump portab,B9004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9158.24,,,,,,,fee schedule,5221,9158.24,
Parenteral infus pump statio,B9006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7963.69,,,,,,,fee schedule,5221,9158.24,
Parenteral infus pump statio,B9006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6518.28,,,,,,,fee schedule,5221,9158.24,
Parenteral infus pump statio,B9006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5221,,,,,,,fee schedule,5221,9158.24,
Parenteral infus pump statio,B9006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9158.24,,,,,,,fee schedule,5221,9158.24,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,369.38,,,,,,,fee schedule,242.17,924.43,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,302.34,,,,,,,fee schedule,242.17,924.43,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,242.17,,,,,,,fee schedule,242.17,924.43,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,424.79,,,,,,,fee schedule,242.17,924.43,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,539.25,,,,,,,fee schedule,242.17,924.43,APC
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,513.57,,,,,,,fee schedule,242.17,924.43,APC
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,924.43,,,,,,,fee schedule,242.17,924.43,APC
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,425.51,,,,,,,fee schedule,278.96,643.48,
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,348.28,,,,,,,fee schedule,278.96,643.48,
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,278.96,,,,,,,fee schedule,278.96,643.48,
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,489.34,,,,,,,fee schedule,278.96,643.48,
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.36,,,,,,,fee schedule,278.96,643.48,APC
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.49,,,,,,,fee schedule,278.96,643.48,APC
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,643.48,,,,,,,fee schedule,278.96,643.48,APC
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.37,,,,,,,fee schedule,60.56,1635.66,
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.6,,,,,,,fee schedule,60.56,1635.66,
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.56,,,,,,,fee schedule,60.56,1635.66,
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.23,,,,,,,fee schedule,60.56,1635.66,
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,954.14,,,,,,,fee schedule,60.56,1635.66,APC
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,908.7,,,,,,,fee schedule,60.56,1635.66,APC
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1635.66,,,,,,,fee schedule,60.56,1635.66,APC
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45070.31,,,,,,,fee schedule,17771.01,51830.86,
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36890.05,,,,,,,fee schedule,17771.01,51830.86,
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29548.1,,,,,,,fee schedule,17771.01,51830.86,
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51830.86,,,,,,,fee schedule,17771.01,51830.86,
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18659.56,,,,,,,fee schedule,17771.01,51830.86,APC
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17771.01,,,,,,,fee schedule,17771.01,51830.86,APC
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31987.82,,,,,,,fee schedule,17771.01,51830.86,APC
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,329.06,,,,,,,fee schedule,174.06,378.42,
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,269.34,,,,,,,fee schedule,174.06,378.42,
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,215.73,,,,,,,fee schedule,174.06,378.42,
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,378.42,,,,,,,fee schedule,174.06,378.42,
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.76,,,,,,,fee schedule,174.06,378.42,APC
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.06,,,,,,,fee schedule,174.06,378.42,APC
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,313.31,,,,,,,fee schedule,174.06,378.42,APC
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.17,,,,,,,fee schedule,46,192.15,
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.43,,,,,,,fee schedule,46,192.15,
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46,,,,,,,fee schedule,46,192.15,
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.7,,,,,,,fee schedule,46,192.15,
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.09,,,,,,,fee schedule,46,192.15,APC
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,106.75,,,,,,,fee schedule,46,192.15,APC
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,192.15,,,,,,,fee schedule,46,192.15,APC
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.91,,,,,,,fee schedule,33.38,160.92,
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.67,,,,,,,fee schedule,33.38,160.92,
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.38,,,,,,,fee schedule,33.38,160.92,
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.55,,,,,,,fee schedule,33.38,160.92,
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,93.87,,,,,,,fee schedule,33.38,160.92,APC
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,89.4,,,,,,,fee schedule,33.38,160.92,APC
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,160.92,,,,,,,fee schedule,33.38,160.92,APC
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.13,,,,,,,fee schedule,35.26,163.45,
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,116.33,,,,,,,fee schedule,35.26,163.45,
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.18,,,,,,,fee schedule,35.26,163.45,
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,163.45,,,,,,,fee schedule,35.26,163.45,
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.02,,,,,,,fee schedule,35.26,163.45,APC
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.26,,,,,,,fee schedule,35.26,163.45,APC
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.47,,,,,,,fee schedule,35.26,163.45,APC
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.51,,,,,,,fee schedule,36.64,198.39,
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.2,,,,,,,fee schedule,36.64,198.39,
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.1,,,,,,,fee schedule,36.64,198.39,
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.39,,,,,,,fee schedule,36.64,198.39,
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.47,,,,,,,fee schedule,36.64,198.39,APC
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.64,,,,,,,fee schedule,36.64,198.39,APC
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.95,,,,,,,fee schedule,36.64,198.39,APC
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.91,,,,,,,fee schedule,88.26,229.9,
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.63,,,,,,,fee schedule,88.26,229.9,
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.06,,,,,,,fee schedule,88.26,229.9,
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.9,,,,,,,fee schedule,88.26,229.9,
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.67,,,,,,,fee schedule,88.26,229.9,APC
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,88.26,,,,,,,fee schedule,88.26,229.9,APC
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,158.87,,,,,,,fee schedule,88.26,229.9,APC
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.68,,,,,,,fee schedule,64.48,205.48,
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.25,,,,,,,fee schedule,64.48,205.48,
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.14,,,,,,,fee schedule,64.48,205.48,
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.48,,,,,,,fee schedule,64.48,205.48,
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.7,,,,,,,fee schedule,64.48,205.48,APC
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.48,,,,,,,fee schedule,64.48,205.48,APC
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,116.06,,,,,,,fee schedule,64.48,205.48,APC
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,239.21,,,,,,,fee schedule,119.11,275.09,
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.79,,,,,,,fee schedule,119.11,275.09,
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.83,,,,,,,fee schedule,119.11,275.09,
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,275.09,,,,,,,fee schedule,119.11,275.09,
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,125.07,,,,,,,fee schedule,119.11,275.09,APC
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,119.11,,,,,,,fee schedule,119.11,275.09,APC
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,214.4,,,,,,,fee schedule,119.11,275.09,APC
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.61,,,,,,,fee schedule,99.8,185.85,
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.28,,,,,,,fee schedule,99.8,185.85,
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.95,,,,,,,fee schedule,99.8,185.85,
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.85,,,,,,,fee schedule,99.8,185.85,
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.79,,,,,,,fee schedule,99.8,185.85,APC
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,99.8,,,,,,,fee schedule,99.8,185.85,APC
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,179.64,,,,,,,fee schedule,99.8,185.85,APC
"Brachytx planar, p-103",C2645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.81,,,,,,,fee schedule,4.69,14.73,
"Brachytx planar, p-103",C2645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.48,,,,,,,fee schedule,4.69,14.73,
"Brachytx planar, p-103",C2645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.4,,,,,,,fee schedule,4.69,14.73,
"Brachytx planar, p-103",C2645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.73,,,,,,,fee schedule,4.69,14.73,
"Brachytx planar, p-103",C2645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.92,,,,,,,fee schedule,4.69,14.73,APC
"Brachytx planar, p-103",C2645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.69,,,,,,,fee schedule,4.69,14.73,APC
"Brachytx planar, p-103",C2645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.44,,,,,,,fee schedule,4.69,14.73,APC
Low cost skin substitute app,C5271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.69,,,,,,,fee schedule,1381.8,2423.84,
Low cost skin substitute app,C5273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1725.14,,,,,,,fee schedule,1381.8,2423.84,
Low cost skin substitute app,C5273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.8,,,,,,,fee schedule,1381.8,2423.84,
Low cost skin substitute app,C5273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.84,,,,,,,fee schedule,1381.8,2423.84,
Low cost skin substitute app,C5275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,668.86,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,547.46,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.5,,,,,,,fee schedule,438.5,769.19,
Low cost skin substitute app,C5277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,769.19,,,,,,,fee schedule,438.5,769.19,
Deb bone 20 cm2 w/drug dev,C7500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Deb bone 20 cm2 w/drug dev,C7500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Deb bone 20 cm2 w/drug dev,C7500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1936.36,,,,,,,fee schedule,1683.79,1936.36,
Deb bone 20 cm2 w/drug dev,C7500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Perc bx breast lesions stero,C7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Perc bx breast lesions stero,C7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Perc bx breast lesions stero,C7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1936.36,,,,,,,fee schedule,1683.79,1936.36,
Perc bx breast lesions stero,C7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Perc bx breast lesions mr,C7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Perc bx breast lesions mr,C7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Perc bx breast lesions mr,C7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1936.36,,,,,,,fee schedule,1683.79,1936.36,
Perc bx breast lesions mr,C7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1683.79,,,,,,,fee schedule,1683.79,1936.36,
Open exc cerv node(s) w/ id,C7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3782.45,,,,,,,fee schedule,3782.45,4349.82,
Open exc cerv node(s) w/ id,C7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3782.45,,,,,,,fee schedule,3782.45,4349.82,
Open exc cerv node(s) w/ id,C7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4349.82,,,,,,,fee schedule,3782.45,4349.82,
Open exc cerv node(s) w/ id,C7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3782.45,,,,,,,fee schedule,3782.45,4349.82,
Perq cvt&ls inj vert bodies,C7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Perq cvt&ls inj vert bodies,C7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Perq cvt&ls inj vert bodies,C7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5665.59,,,,,,,fee schedule,4926.6,5665.59,
Perq cvt&ls inj vert bodies,C7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Perq ls&cvt inj vert bodies,C7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Perq ls&cvt inj vert bodies,C7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Perq ls&cvt inj vert bodies,C7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5665.59,,,,,,,fee schedule,4926.6,5665.59,
Perq ls&cvt inj vert bodies,C7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Fusion of finger joints,C7506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Fusion of finger joints,C7506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Fusion of finger joints,C7506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5665.59,,,,,,,fee schedule,4926.6,5665.59,
Fusion of finger joints,C7506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4926.6,,,,,,,fee schedule,4926.6,5665.59,
Perq thor&lumb vert aug,C7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10101.92,,,,,,,fee schedule,10101.92,11617.21,
Perq thor&lumb vert aug,C7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10101.92,,,,,,,fee schedule,10101.92,11617.21,
Perq thor&lumb vert aug,C7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11617.21,,,,,,,fee schedule,10101.92,11617.21,
Perq thor&lumb vert aug,C7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10101.92,,,,,,,fee schedule,10101.92,11617.21,
Perq lumb&thor vert aug,C7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10101.92,,,,,,,fee schedule,10101.92,11617.21,
Perq lumb&thor vert aug,C7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10101.92,,,,,,,fee schedule,10101.92,11617.21,
Perq lumb&thor vert aug,C7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11617.21,,,,,,,fee schedule,10101.92,11617.21,
Perq lumb&thor vert aug,C7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10101.92,,,,,,,fee schedule,10101.92,11617.21,
Dx bronch w/ navigation,C7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Dx bronch w/ navigation,C7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Dx bronch w/ navigation,C7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2551.76,,,,,,,fee schedule,2218.92,2551.76,
Dx bronch w/ navigation,C7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/lavag w/ navigation,C7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/lavag w/ navigation,C7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/lavag w/ navigation,C7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2551.76,,,,,,,fee schedule,2218.92,2551.76,
Bronch/lavag w/ navigation,C7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/bpsy(s) w/ navigation,C7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/bpsy(s) w/ navigation,C7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/bpsy(s) w/ navigation,C7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2551.76,,,,,,,fee schedule,2218.92,2551.76,
Bronch/bpsy(s) w/ navigation,C7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/bpsy(s) w/ ebus,C7512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/bpsy(s) w/ ebus,C7512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Bronch/bpsy(s) w/ ebus,C7512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2551.76,,,,,,,fee schedule,2218.92,2551.76,
Bronch/bpsy(s) w/ ebus,C7512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2218.92,,,,,,,fee schedule,2218.92,2551.76,
Cath/angio dialcir w/aplasty,C7513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dialcir w/aplasty,C7513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dialcir w/aplasty,C7513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2606.98,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dialcir w/aplasty,C7513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dial cir w/stents,C7514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dial cir w/stents,C7514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dial cir w/stents,C7514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2606.98,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dial cir w/stents,C7514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dial cir w/embol,C7515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dial cir w/embol,C7515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dial cir w/embol,C7515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2606.98,,,,,,,fee schedule,2266.94,2606.98,
Cath/angio dial cir w/embol,C7515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2266.94,,,,,,,fee schedule,2266.94,2606.98,
Cor angio w/ ivus or oct,C7516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor angio w/ ivus or oct,C7516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor angio w/ ivus or oct,C7516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
Cor angio w/ ivus or oct,C7516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor angio w/ilic/fem angio,C7517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor angio w/ilic/fem angio,C7517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor angio w/ilic/fem angio,C7517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
Cor angio w/ilic/fem angio,C7517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ ivus or oct,C7518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ ivus or oct,C7518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ ivus or oct,C7518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ ivus or oct,C7518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ flow resrv,C7519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ flow resrv,C7519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ flow resrv,C7519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ flow resrv,C7519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ilic/fem ang,C7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ilic/fem ang,C7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ilic/fem ang,C7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
Cor/gft angio w/ilic/fem ang,C7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R hrt angio w/ ivus or oct,C7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R hrt angio w/ ivus or oct,C7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R hrt angio w/ ivus or oct,C7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
R hrt angio w/ ivus or oct,C7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R hrt angio w/flow resrv,C7522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R hrt angio w/flow resrv,C7522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R hrt angio w/flow resrv,C7522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
R hrt angio w/flow resrv,C7522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt angio w/ ivus or oct,C7523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt angio w/ ivus or oct,C7523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt angio w/ ivus or oct,C7523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
L hrt angio w/ ivus or oct,C7523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt angio w/flow resrv,C7524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt angio w/flow resrv,C7524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt angio w/flow resrv,C7524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
L hrt angio w/flow resrv,C7524,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt gft ang w/ ivus or oct,C7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt gft ang w/ ivus or oct,C7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt gft ang w/ ivus or oct,C7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
L hrt gft ang w/ ivus or oct,C7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt gft ang w/flow resrv,C7526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt gft ang w/flow resrv,C7526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
L hrt gft ang w/flow resrv,C7526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
L hrt gft ang w/flow resrv,C7526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt angio w/ ivus or oct,C7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt angio w/ ivus or oct,C7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt angio w/ ivus or oct,C7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt angio w/ ivus or oct,C7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt angio w/flow resrv,C7528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt angio w/flow resrv,C7528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt angio w/flow resrv,C7528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt angio w/flow resrv,C7528,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt gft ang w/flow resrv,C7529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt gft ang w/flow resrv,C7529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt gft ang w/flow resrv,C7529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt gft ang w/flow resrv,C7529,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cath/aplasty dial cir w/stnt,C7530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7189.37,,,,,,,fee schedule,7189.37,8267.78,
Cath/aplasty dial cir w/stnt,C7530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7189.37,,,,,,,fee schedule,7189.37,8267.78,
Cath/aplasty dial cir w/stnt,C7530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8267.78,,,,,,,fee schedule,7189.37,8267.78,
Cath/aplasty dial cir w/stnt,C7530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7189.37,,,,,,,fee schedule,7189.37,8267.78,
Angio fem/pop w/ us,C7531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8606.55,,,,,,,fee schedule,8606.55,9897.53,
Angio fem/pop w/ us,C7531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8606.55,,,,,,,fee schedule,8606.55,9897.53,
Angio fem/pop w/ us,C7531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9897.53,,,,,,,fee schedule,8606.55,9897.53,
Angio fem/pop w/ us,C7531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8606.55,,,,,,,fee schedule,8606.55,9897.53,
Angio w/ us non-coronary,C7532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8303.88,,,,,,,fee schedule,8303.88,9549.46,
Angio w/ us non-coronary,C7532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8303.88,,,,,,,fee schedule,8303.88,9549.46,
Angio w/ us non-coronary,C7532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9549.46,,,,,,,fee schedule,8303.88,9549.46,
Angio w/ us non-coronary,C7532,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8303.88,,,,,,,fee schedule,8303.88,9549.46,
Ptca w/ plcmt brachytx dev,C7533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8676.16,,,,,,,fee schedule,8676.16,9977.58,
Ptca w/ plcmt brachytx dev,C7533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8676.16,,,,,,,fee schedule,8676.16,9977.58,
Ptca w/ plcmt brachytx dev,C7533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9977.58,,,,,,,fee schedule,8676.16,9977.58,
Ptca w/ plcmt brachytx dev,C7533,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8676.16,,,,,,,fee schedule,8676.16,9977.58,
Fem/pop revasc w/arthr & us,C7534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15836.38,,,,,,,fee schedule,15836.38,18211.84,
Fem/pop revasc w/arthr & us,C7534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15836.38,,,,,,,fee schedule,15836.38,18211.84,
Fem/pop revasc w/arthr & us,C7534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18211.84,,,,,,,fee schedule,15836.38,18211.84,
Fem/pop revasc w/arthr & us,C7534,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15836.38,,,,,,,fee schedule,15836.38,18211.84,
Fem/pop revasc w/stent & us,C7535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15698.7,,,,,,,fee schedule,15698.7,18053.51,
Fem/pop revasc w/stent & us,C7535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15698.7,,,,,,,fee schedule,15698.7,18053.51,
Fem/pop revasc w/stent & us,C7535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18053.51,,,,,,,fee schedule,15698.7,18053.51,
Fem/pop revasc w/stent & us,C7535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15698.7,,,,,,,fee schedule,15698.7,18053.51,
Insrt atril pm w/l vent lead,C7537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15853.1,,,,,,,fee schedule,15853.1,18231.07,
Insrt atril pm w/l vent lead,C7537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15853.1,,,,,,,fee schedule,15853.1,18231.07,
Insrt atril pm w/l vent lead,C7537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18231.07,,,,,,,fee schedule,15853.1,18231.07,
Insrt atril pm w/l vent lead,C7537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15853.1,,,,,,,fee schedule,15853.1,18231.07,
Insrt vent pm w/l vent lead,C7538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15809.4,,,,,,,fee schedule,15809.4,18180.81,
Insrt vent pm w/l vent lead,C7538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15809.4,,,,,,,fee schedule,15809.4,18180.81,
Insrt vent pm w/l vent lead,C7538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18180.81,,,,,,,fee schedule,15809.4,18180.81,
Insrt vent pm w/l vent lead,C7538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15809.4,,,,,,,fee schedule,15809.4,18180.81,
Insrt a & v pm w/l vent lead,C7539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16111.66,,,,,,,fee schedule,16111.66,18528.41,
Insrt a & v pm w/l vent lead,C7539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16111.66,,,,,,,fee schedule,16111.66,18528.41,
Insrt a & v pm w/l vent lead,C7539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18528.41,,,,,,,fee schedule,16111.66,18528.41,
Insrt a & v pm w/l vent lead,C7539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16111.66,,,,,,,fee schedule,16111.66,18528.41,
Rmv&rplc pm dul w/l vnt lead,C7540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15837.58,,,,,,,fee schedule,15837.58,18213.22,
Rmv&rplc pm dul w/l vnt lead,C7540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15837.58,,,,,,,fee schedule,15837.58,18213.22,
Rmv&rplc pm dul w/l vnt lead,C7540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18213.22,,,,,,,fee schedule,15837.58,18213.22,
Rmv&rplc pm dul w/l vnt lead,C7540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15837.58,,,,,,,fee schedule,15837.58,18213.22,
Ercp w/ pancreatoscopy,C7541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Ercp w/ pancreatoscopy,C7541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Ercp w/ pancreatoscopy,C7541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4104.51,,,,,,,fee schedule,3569.14,4104.51,
Ercp w/ pancreatoscopy,C7541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Ercp w/bx & pancreatoscopy,C7542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Ercp w/bx & pancreatoscopy,C7542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Ercp w/bx & pancreatoscopy,C7542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4104.51,,,,,,,fee schedule,3569.14,4104.51,
Ercp w/bx & pancreatoscopy,C7542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
"Ercp w/otomy, pancreatoscopy",C7543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
"Ercp w/otomy, pancreatoscopy",C7543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3569.14,,,,,,,fee schedule,3569.14,4104.51,
"Ercp w/otomy, pancreatoscopy",C7543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4104.51,,,,,,,fee schedule,3569.14,4104.51,
"Ercp w/otomy, pancreatoscopy",C7543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Ercp rmv calc pancreatoscopy,C7544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Ercp rmv calc pancreatoscopy,C7544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Ercp rmv calc pancreatoscopy,C7544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4104.51,,,,,,,fee schedule,3569.14,4104.51,
Ercp rmv calc pancreatoscopy,C7544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Exch bil cath w/ rmv calculi,C7545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Exch bil cath w/ rmv calculi,C7545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Exch bil cath w/ rmv calculi,C7545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4104.51,,,,,,,fee schedule,3569.14,4104.51,
Exch bil cath w/ rmv calculi,C7545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3569.14,,,,,,,fee schedule,3569.14,4104.51,
Rep nph/urt cath w/dil stric,C7546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Rep nph/urt cath w/dil stric,C7546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Rep nph/urt cath w/dil stric,C7546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2701.97,,,,,,,fee schedule,2349.54,2701.97,
Rep nph/urt cath w/dil stric,C7546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Cnvrt neph cath w/ dil stric,C7547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2722.84,,,,,,,fee schedule,2722.84,3131.27,
Cnvrt neph cath w/ dil stric,C7547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2722.84,,,,,,,fee schedule,2722.84,3131.27,
Cnvrt neph cath w/ dil stric,C7547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3131.27,,,,,,,fee schedule,2722.84,3131.27,
Cnvrt neph cath w/ dil stric,C7547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2722.84,,,,,,,fee schedule,2722.84,3131.27,
Exch neph cath w/ dil stric,C7548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Exch neph cath w/ dil stric,C7548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Exch neph cath w/ dil stric,C7548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2701.97,,,,,,,fee schedule,2349.54,2701.97,
Exch neph cath w/ dil stric,C7548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Chge urtr stent w/ dil stric,C7549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Chge urtr stent w/ dil stric,C7549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Chge urtr stent w/ dil stric,C7549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2701.97,,,,,,,fee schedule,2349.54,2701.97,
Chge urtr stent w/ dil stric,C7549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Cysto w/ bx(s) w/ blue light,C7550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Cysto w/ bx(s) w/ blue light,C7550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Cysto w/ bx(s) w/ blue light,C7550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2701.97,,,,,,,fee schedule,2349.54,2701.97,
Cysto w/ bx(s) w/ blue light,C7550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2349.54,,,,,,,fee schedule,2349.54,2701.97,
Exc neuroma w/ implnt nv end,C7551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4131.54,,,,,,,fee schedule,4131.54,4751.27,
Exc neuroma w/ implnt nv end,C7551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4131.54,,,,,,,fee schedule,4131.54,4751.27,
Exc neuroma w/ implnt nv end,C7551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4751.27,,,,,,,fee schedule,4131.54,4751.27,
Exc neuroma w/ implnt nv end,C7551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4131.54,,,,,,,fee schedule,4131.54,4751.27,
R hrt art/grft ang hrt flow,C7552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R hrt art/grft ang hrt flow,C7552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R hrt art/grft ang hrt flow,C7552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
R hrt art/grft ang hrt flow,C7552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt art/vent ang drg ad,C7553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt art/vent ang drg ad,C7553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3653.4,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt art/vent ang drg ad,C7553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4201.41,,,,,,,fee schedule,3653.4,4201.41,
R&l hrt art/vent ang drg ad,C7553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3653.4,,,,,,,fee schedule,3653.4,4201.41,
Cystureth blu li cyst fl img,C7554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1331.38,,,,,,,fee schedule,1331.38,1531.09,
Cystureth blu li cyst fl img,C7554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1331.38,,,,,,,fee schedule,1331.38,1531.09,
Cystureth blu li cyst fl img,C7554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1531.09,,,,,,,fee schedule,1331.38,1531.09,
Cystureth blu li cyst fl img,C7554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1331.38,,,,,,,fee schedule,1331.38,1531.09,
Rmvl thyrd w/autotran parath,C7555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6719.58,,,,,,,fee schedule,6719.58,7727.52,
Rmvl thyrd w/autotran parath,C7555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6719.58,,,,,,,fee schedule,6719.58,7727.52,
Rmvl thyrd w/autotran parath,C7555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7727.52,,,,,,,fee schedule,6719.58,7727.52,
Rmvl thyrd w/autotran parath,C7555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6719.58,,,,,,,fee schedule,6719.58,7727.52,
Bronch lavage w/ebus,C7556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2160.02,,,,,,,fee schedule,2160.02,2484.02,
Bronch lavage w/ebus,C7556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2160.02,,,,,,,fee schedule,2160.02,2484.02,
Bronch lavage w/ebus,C7556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2484.02,,,,,,,fee schedule,2160.02,2484.02,
Bronch lavage w/ebus,C7556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2160.02,,,,,,,fee schedule,2160.02,2484.02,
Cor angio/vent w/ffr,C7557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3482.88,,,,,,,fee schedule,3482.88,4005.31,
Cor angio/vent w/ffr,C7557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3482.88,,,,,,,fee schedule,3482.88,4005.31,
Cor angio/vent w/ffr,C7557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4005.31,,,,,,,fee schedule,3482.88,4005.31,
Cor angio/vent w/ffr,C7557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3482.88,,,,,,,fee schedule,3482.88,4005.31,
Ercp remove forgn body&endo,C7560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2480.53,,,,,,,fee schedule,2480.53,2852.61,
Ercp remove forgn body&endo,C7560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2480.53,,,,,,,fee schedule,2480.53,2852.61,
Ercp remove forgn body&endo,C7560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2852.61,,,,,,,fee schedule,2480.53,2852.61,
Ercp remove forgn body&endo,C7560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2480.53,,,,,,,fee schedule,2480.53,2852.61,
Dbrd bone w prep&insr rx dev,C7561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1595.44,,,,,,,fee schedule,1595.44,1834.76,
Dbrd bone w prep&insr rx dev,C7561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1595.44,,,,,,,fee schedule,1595.44,1834.76,
Dbrd bone w prep&insr rx dev,C7561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1834.76,,,,,,,fee schedule,1595.44,1834.76,
Dbrd bone w prep&insr rx dev,C7561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1595.44,,,,,,,fee schedule,1595.44,1834.76,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.73,,,,,,,fee schedule,37.19,67.2,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.43,,,,,,,fee schedule,37.19,67.2,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.19,,,,,,,fee schedule,37.19,67.2,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.24,,,,,,,fee schedule,37.19,67.2,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.19,67.2,APC
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.19,67.2,APC
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.19,67.2,APC
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.98,,,,,,,fee schedule,95.05,182.2,
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.67,,,,,,,fee schedule,95.05,182.2,
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.05,,,,,,,fee schedule,95.05,182.2,
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,166.73,,,,,,,fee schedule,95.05,182.2,
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,95.05,182.2,APC
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,95.05,182.2,APC
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,95.05,182.2,APC
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.42,,,,,,,fee schedule,32.4,67.2,
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.45,,,,,,,fee schedule,32.4,67.2,
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.4,,,,,,,fee schedule,32.4,67.2,
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.83,,,,,,,fee schedule,32.4,67.2,
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,32.4,67.2,APC
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,32.4,67.2,APC
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,32.4,67.2,APC
3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.97,,,,,,,fee schedule,94.39,230.78,
3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.84,,,,,,,fee schedule,94.39,230.78,
3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.39,,,,,,,fee schedule,94.39,230.78,
3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.57,,,,,,,fee schedule,94.39,230.78,
3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,94.39,230.78,APC
3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,94.39,230.78,APC
3d anat seg imaging preop,C8001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,94.39,230.78,APC
"Prep skin cell susp, automtd",C8002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10219.57,,,,,,,fee schedule,6699.95,12728.28,
"Prep skin cell susp, automtd",C8002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8364.72,,,,,,,fee schedule,6699.95,12728.28,
"Prep skin cell susp, automtd",C8002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6699.95,,,,,,,fee schedule,6699.95,12728.28,
"Prep skin cell susp, automtd",C8002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11752.51,,,,,,,fee schedule,6699.95,12728.28,
"Prep skin cell susp, automtd",C8002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7424.83,,,,,,,fee schedule,6699.95,12728.28,APC
"Prep skin cell susp, automtd",C8002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7071.27,,,,,,,fee schedule,6699.95,12728.28,APC
"Prep skin cell susp, automtd",C8002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12728.28,,,,,,,fee schedule,6699.95,12728.28,APC
Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30067.74,,,,,,,fee schedule,17470.77,34577.9,
Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24610.45,,,,,,,fee schedule,17470.77,34577.9,
Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19712.41,,,,,,,fee schedule,17470.77,34577.9,
Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34577.9,,,,,,,fee schedule,17470.77,34577.9,
Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18344.3,,,,,,,fee schedule,17470.77,34577.9,APC
Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17470.77,,,,,,,fee schedule,17470.77,34577.9,APC
Imp extar knee shck absrb,C8003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31447.38,,,,,,,fee schedule,17470.77,34577.9,APC
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6773.07,,,,,,,fee schedule,6450.54,11610.97,APC
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6450.54,,,,,,,fee schedule,6450.54,11610.97,APC
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11610.97,,,,,,,fee schedule,6450.54,11610.97,APC
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,30746.74,55344.12,APC
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,30746.74,55344.12,APC
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,30746.74,55344.12,APC
Rv/rpl hpgls ns inc cnt pg,C8008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,19984.73,APC
Rv/rpl hpgls ns inc cnt pg,C8008,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,19984.73,APC
Rv/rpl hpgls ns inc cnt pg,C8008,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,19984.73,APC
Rmv hpgls ns ary and pg,C8009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3403.86,6126.95,APC
Rmv hpgls ns ary and pg,C8009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3403.86,6126.95,APC
Rmv hpgls ns ary and pg,C8009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3403.86,6126.95,APC
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32284.07,,,,,,,fee schedule,30746.74,55344.12,APC
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30746.74,,,,,,,fee schedule,30746.74,55344.12,APC
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55344.12,,,,,,,fee schedule,30746.74,55344.12,APC
Rv/rpl hpgls ns ary rec,C8012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11657.76,,,,,,,fee schedule,11102.63,19984.73,APC
Rv/rpl hpgls ns ary rec,C8012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11102.63,,,,,,,fee schedule,11102.63,19984.73,APC
Rv/rpl hpgls ns ary rec,C8012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19984.73,,,,,,,fee schedule,11102.63,19984.73,APC
Rmv hpls ns ary rec,C8013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3574.06,,,,,,,fee schedule,3403.86,6126.95,APC
Rmv hpls ns ary rec,C8013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3403.86,,,,,,,fee schedule,3403.86,6126.95,APC
Rmv hpls ns ary rec,C8013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6126.95,,,,,,,fee schedule,3403.86,6126.95,APC
"Cysto, litho, w suct sheath",C8014,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,5342.52,9616.53,APC
"Cysto, litho, w suct sheath",C8014,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,5342.52,9616.53,APC
"Cysto, litho, w suct sheath",C8014,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,5342.52,9616.53,APC
"Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.2,,,,,,,fee schedule,256.47,625.71,
"Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.2,,,,,,,fee schedule,256.47,625.71,
"Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.47,,,,,,,fee schedule,256.47,625.71,
"Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.88,,,,,,,fee schedule,256.47,625.71,
"Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,256.47,625.71,APC
"Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,256.47,625.71,APC
"Mra w/cont, abd",C8900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,256.47,625.71,APC
"Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.49,,,,,,,fee schedule,218.64,427.94,
"Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.96,,,,,,,fee schedule,218.64,427.94,
"Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.64,,,,,,,fee schedule,218.64,427.94,
"Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.51,,,,,,,fee schedule,218.64,427.94,
"Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,218.64,427.94,APC
"Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,218.64,427.94,APC
"Mra w/o cont, abd",C8901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,218.64,427.94,APC
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.2,,,,,,,fee schedule,174.77,449.88,
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.2,,,,,,,fee schedule,174.77,449.88,
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.47,,,,,,,fee schedule,174.77,449.88,
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.88,,,,,,,fee schedule,174.77,449.88,
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.51,,,,,,,fee schedule,174.77,449.88,APC
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.77,,,,,,,fee schedule,174.77,449.88,APC
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.59,,,,,,,fee schedule,174.77,449.88,APC
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1297.26,,,,,,,fee schedule,347.62,1491.85,
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1061.81,,,,,,,fee schedule,347.62,1491.85,
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,850.48,,,,,,,fee schedule,347.62,1491.85,
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1491.85,,,,,,,fee schedule,347.62,1491.85,
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1491.85,APC
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1491.85,APC
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1491.85,APC
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1281.41,,,,,,,fee schedule,347.62,1473.62,
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1048.83,,,,,,,fee schedule,347.62,1473.62,
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,840.09,,,,,,,fee schedule,347.62,1473.62,
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1473.62,,,,,,,fee schedule,347.62,1473.62,
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,1473.62,APC
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,1473.62,APC
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,1473.62,APC
"MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.2,,,,,,,fee schedule,256.47,625.71,
"MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.2,,,,,,,fee schedule,256.47,625.71,
"MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.47,,,,,,,fee schedule,256.47,625.71,
"MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.88,,,,,,,fee schedule,256.47,625.71,
"MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,256.47,625.71,APC
"MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,256.47,625.71,APC
"MRA w/cont, chest",C8909,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,256.47,625.71,APC
"MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.49,,,,,,,fee schedule,218.64,427.94,
"MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.96,,,,,,,fee schedule,218.64,427.94,
"MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.64,,,,,,,fee schedule,218.64,427.94,
"MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.51,,,,,,,fee schedule,218.64,427.94,
"MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,218.64,427.94,APC
"MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,218.64,427.94,APC
"MRA w/o cont, chest",C8910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,218.64,427.94,APC
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.49,,,,,,,fee schedule,218.64,427.94,
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.96,,,,,,,fee schedule,218.64,427.94,
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.64,,,,,,,fee schedule,218.64,427.94,
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.51,,,,,,,fee schedule,218.64,427.94,
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,218.64,427.94,APC
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,218.64,427.94,APC
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,218.64,427.94,APC
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.2,,,,,,,fee schedule,256.47,625.71,
"MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.2,,,,,,,fee schedule,256.47,625.71,
"MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.47,,,,,,,fee schedule,256.47,625.71,
"MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.88,,,,,,,fee schedule,256.47,625.71,
"MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,256.47,625.71,APC
"MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,256.47,625.71,APC
"MRA w/cont, pelvis",C8918,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,256.47,625.71,APC
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.49,,,,,,,fee schedule,218.64,427.94,
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.96,,,,,,,fee schedule,218.64,427.94,
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.64,,,,,,,fee schedule,218.64,427.94,
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.51,,,,,,,fee schedule,218.64,427.94,
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,218.64,427.94,APC
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,218.64,427.94,APC
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,218.64,427.94,APC
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,637.87,,,,,,,fee schedule,347.62,733.55,
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,522.1,,,,,,,fee schedule,347.62,733.55,
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,418.19,,,,,,,fee schedule,347.62,733.55,
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,733.55,,,,,,,fee schedule,347.62,733.55,
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,733.55,APC
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,733.55,APC
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,733.55,APC
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,982.43,,,,,,,fee schedule,644.08,1405.98,
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,804.12,,,,,,,fee schedule,644.08,1405.98,
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.08,,,,,,,fee schedule,644.08,1405.98,
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1129.79,,,,,,,fee schedule,644.08,1405.98,
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.16,,,,,,,fee schedule,644.08,1405.98,APC
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.1,,,,,,,fee schedule,644.08,1405.98,APC
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1405.98,,,,,,,fee schedule,644.08,1405.98,APC
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.49,,,,,,,fee schedule,218.64,427.94,
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.96,,,,,,,fee schedule,218.64,427.94,
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.64,,,,,,,fee schedule,218.64,427.94,
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.51,,,,,,,fee schedule,218.64,427.94,
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,218.64,427.94,APC
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,218.64,427.94,APC
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,218.64,427.94,APC
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.2,,,,,,,fee schedule,256.47,625.71,
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.2,,,,,,,fee schedule,256.47,625.71,
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.47,,,,,,,fee schedule,256.47,625.71,
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.88,,,,,,,fee schedule,256.47,625.71,
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,256.47,625.71,APC
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,256.47,625.71,APC
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,256.47,625.71,APC
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.49,,,,,,,fee schedule,218.64,427.94,
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.96,,,,,,,fee schedule,218.64,427.94,
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.64,,,,,,,fee schedule,218.64,427.94,
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.51,,,,,,,fee schedule,218.64,427.94,
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,218.64,427.94,APC
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,218.64,427.94,APC
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,218.64,427.94,APC
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.63,,,,,,,fee schedule,347.62,724.07,
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.35,,,,,,,fee schedule,347.62,724.07,
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.79,,,,,,,fee schedule,347.62,724.07,
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,724.07,,,,,,,fee schedule,347.62,724.07,
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,347.62,724.07,APC
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,347.62,724.07,APC
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,347.62,724.07,APC
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,211.94,480.61,
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,211.94,480.61,
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,211.94,480.61,
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,211.94,480.61,
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.54,,,,,,,fee schedule,211.94,480.61,APC
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.94,,,,,,,fee schedule,211.94,480.61,APC
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,381.49,,,,,,,fee schedule,211.94,480.61,APC
Cocaine hcl nasal solution,C9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.72,,,,,,,fee schedule,1.72,1.98,
Cocaine hcl nasal solution,C9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.72,,,,,,,fee schedule,1.72,1.98,
Cocaine hcl nasal solution,C9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.72,,,,,,,fee schedule,1.72,1.98,
Cocaine hcl nasal solution,C9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.98,,,,,,,fee schedule,1.72,1.98,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,794.83,,,,,,,fee schedule,794.83,1510.5,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,794.83,,,,,,,fee schedule,794.83,1510.5,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,794.83,,,,,,,fee schedule,794.83,1510.5,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,914.05,,,,,,,fee schedule,794.83,1510.5,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,881.13,,,,,,,fee schedule,794.83,1510.5,APC
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,839.17,,,,,,,fee schedule,794.83,1510.5,APC
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1510.5,,,,,,,fee schedule,794.83,1510.5,APC
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.73,,,,,,,fee schedule,3.61,8.89,
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.73,,,,,,,fee schedule,3.61,8.89,
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.73,,,,,,,fee schedule,3.61,8.89,
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.89,,,,,,,fee schedule,3.61,8.89,
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.79,,,,,,,fee schedule,3.61,8.89,APC
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.61,,,,,,,fee schedule,3.61,8.89,APC
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.5,,,,,,,fee schedule,3.61,8.89,APC
"Instill, bupivac and meloxic",C9088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.77,,,,,,,fee schedule,0.77,0.89,
"Instill, bupivac and meloxic",C9088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.77,,,,,,,fee schedule,0.77,0.89,
"Instill, bupivac and meloxic",C9088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.77,,,,,,,fee schedule,0.77,0.89,
"Instill, bupivac and meloxic",C9088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.89,,,,,,,fee schedule,0.77,0.89,
"Bupivacaine implant, 1 mg",C9089,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.85,,,,,,,fee schedule,0.85,0.98,
"Bupivacaine implant, 1 mg",C9089,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.85,,,,,,,fee schedule,0.85,0.98,
"Bupivacaine implant, 1 mg",C9089,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.85,,,,,,,fee schedule,0.85,0.98,
"Bupivacaine implant, 1 mg",C9089,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.98,,,,,,,fee schedule,0.85,0.98,
"Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.32,,,,,,,fee schedule,1.32,1.52,
"Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.32,,,,,,,fee schedule,1.32,1.52,
"Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.32,,,,,,,fee schedule,1.32,1.52,
"Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.52,,,,,,,fee schedule,1.32,1.52,
"Inj, bupivacaine (posimir)",C9144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.49,,,,,,,fee schedule,0.49,0.56,
"Inj, bupivacaine (posimir)",C9144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.49,,,,,,,fee schedule,0.49,0.56,
"Inj, bupivacaine (posimir)",C9144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.49,,,,,,,fee schedule,0.49,0.56,
"Inj, bupivacaine (posimir)",C9144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.56,,,,,,,fee schedule,0.49,0.56,
"Inj, aponvie, 1 mg",C9145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.9,,,,,,,fee schedule,1.9,2.19,
"Inj, aponvie, 1 mg",C9145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.9,,,,,,,fee schedule,1.9,2.19,
"Inj, aponvie, 1 mg",C9145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.9,,,,,,,fee schedule,1.9,2.19,
"Inj, aponvie, 1 mg",C9145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.19,,,,,,,fee schedule,1.9,2.19,
"Datopotamab deruxtecan, 1 mg",C9174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.89,,,,,,,fee schedule,49.89,57.37,
"Datopotamab deruxtecan, 1 mg",C9174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.89,,,,,,,fee schedule,49.89,57.37,
"Datopotamab deruxtecan, 1 mg",C9174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.89,,,,,,,fee schedule,49.89,57.37,
"Datopotamab deruxtecan, 1 mg",C9174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.37,,,,,,,fee schedule,49.89,57.37,
"Inj, treosulfan, 50 mg",C9175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.11,,,,,,,fee schedule,31.11,35.78,
"Inj, treosulfan, 50 mg",C9175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.11,,,,,,,fee schedule,31.11,35.78,
"Inj, treosulfan, 50 mg",C9175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.11,,,,,,,fee schedule,31.11,35.78,
"Inj, treosulfan, 50 mg",C9175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.78,,,,,,,fee schedule,31.11,35.78,
"Inj, clevidipine butyrate",C9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.6,,,,,,,fee schedule,3.6,4.14,
"Inj, clevidipine butyrate",C9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.6,,,,,,,fee schedule,3.6,4.14,
"Inj, clevidipine butyrate",C9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.6,,,,,,,fee schedule,3.6,4.14,
"Inj, clevidipine butyrate",C9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.14,,,,,,,fee schedule,3.6,4.14,
Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,187.57,,,,,,,fee schedule,145.67,262.21,
Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.57,,,,,,,fee schedule,145.67,262.21,
Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,187.57,,,,,,,fee schedule,145.67,262.21,
Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,215.71,,,,,,,fee schedule,145.67,262.21,
Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,152.96,,,,,,,fee schedule,145.67,262.21,APC
Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,145.67,,,,,,,fee schedule,145.67,262.21,APC
Artiss fibrin sealant,C9250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,262.21,,,,,,,fee schedule,145.67,262.21,APC
"Injection, lacosamide",C9254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.2,,,,,,,fee schedule,0.2,0.23,
"Injection, lacosamide",C9254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.2,,,,,,,fee schedule,0.2,0.23,
"Injection, lacosamide",C9254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.2,,,,,,,fee schedule,0.2,0.23,
"Injection, lacosamide",C9254,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.23,,,,,,,fee schedule,0.2,0.23,
Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.03,,,,,,,fee schedule,1.87,3.37,
Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.03,,,,,,,fee schedule,1.87,3.37,
Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.03,,,,,,,fee schedule,1.87,3.37,
Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.33,,,,,,,fee schedule,1.87,3.37,
Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.96,,,,,,,fee schedule,1.87,3.37,APC
Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.87,,,,,,,fee schedule,1.87,3.37,APC
Bevacizumab injection,C9257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.37,,,,,,,fee schedule,1.87,3.37,APC
"Injection, glucarpidase",C9293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,419.98,,,,,,,fee schedule,419.98,808.39,
"Injection, glucarpidase",C9293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,419.98,,,,,,,fee schedule,419.98,808.39,
"Injection, glucarpidase",C9293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,419.98,,,,,,,fee schedule,419.98,808.39,
"Injection, glucarpidase",C9293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,482.98,,,,,,,fee schedule,419.98,808.39,
"Injection, glucarpidase",C9293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,471.56,,,,,,,fee schedule,419.98,808.39,APC
"Injection, glucarpidase",C9293,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,449.1,,,,,,,fee schedule,419.98,808.39,APC
"Injection, glucarpidase",C9293,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,808.39,,,,,,,fee schedule,419.98,808.39,APC
"Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.43,,,,,,,fee schedule,20.28,36.5,
"Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.43,,,,,,,fee schedule,20.28,36.5,
"Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.43,,,,,,,fee schedule,20.28,36.5,
"Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.49,,,,,,,fee schedule,20.28,36.5,
"Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.29,,,,,,,fee schedule,20.28,36.5,APC
"Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.28,,,,,,,fee schedule,20.28,36.5,APC
"Injection, cangrelor",C9460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.5,,,,,,,fee schedule,20.28,36.5,APC
"Injection, delafloxacin",C9462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.48,,,,,,,fee schedule,0.48,0.55,
"Injection, delafloxacin",C9462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.48,,,,,,,fee schedule,0.48,0.55,
"Injection, delafloxacin",C9462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.48,,,,,,,fee schedule,0.48,0.55,
"Injection, delafloxacin",C9462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.55,,,,,,,fee schedule,0.48,0.55,
Sotalol hydrochloride IV,C9482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.63,,,,,,,fee schedule,24.63,28.32,
Sotalol hydrochloride IV,C9482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.63,,,,,,,fee schedule,24.63,28.32,
Sotalol hydrochloride IV,C9482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.63,,,,,,,fee schedule,24.63,28.32,
Sotalol hydrochloride IV,C9482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.32,,,,,,,fee schedule,24.63,28.32,
Conivaptan HCL,C9488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.46,,,,,,,fee schedule,45.46,52.28,
Conivaptan HCL,C9488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.46,,,,,,,fee schedule,45.46,52.28,
Conivaptan HCL,C9488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.46,,,,,,,fee schedule,45.46,52.28,
Conivaptan HCL,C9488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.28,,,,,,,fee schedule,45.46,52.28,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Perc drug-el cor stent sing,C9600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22107.39,,,,,,,fee schedule,14493.6,32878.29,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18094.9,,,,,,,fee schedule,14493.6,32878.29,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14493.6,,,,,,,fee schedule,14493.6,32878.29,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25423.5,,,,,,,fee schedule,14493.6,32878.29,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,14493.6,32878.29,APC
Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,14493.6,32878.29,APC
Perc d-e cor stent ather s,C9602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,14493.6,32878.29,APC
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14585.22,,,,,,,fee schedule,9562.07,20704.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11938,,,,,,,fee schedule,9562.07,20704.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9562.07,,,,,,,fee schedule,9562.07,20704.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16773,,,,,,,fee schedule,9562.07,20704.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,9562.07,20704.82,APC
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,9562.07,20704.82,APC
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,9562.07,20704.82,APC
Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22107.39,,,,,,,fee schedule,14493.6,25423.5,
Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18094.9,,,,,,,fee schedule,14493.6,25423.5,
Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14493.6,,,,,,,fee schedule,14493.6,25423.5,
Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25423.5,,,,,,,fee schedule,14493.6,25423.5,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22107.39,,,,,,,fee schedule,14493.6,32878.29,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18094.9,,,,,,,fee schedule,14493.6,32878.29,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14493.6,,,,,,,fee schedule,14493.6,32878.29,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25423.5,,,,,,,fee schedule,14493.6,32878.29,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,14493.6,32878.29,APC
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,14493.6,32878.29,APC
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,14493.6,32878.29,APC
Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,985.63,,,,,,,fee schedule,646.18,1667.9,
Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,806.74,,,,,,,fee schedule,646.18,1667.9,
Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,646.18,,,,,,,fee schedule,646.18,1667.9,
Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1133.47,,,,,,,fee schedule,646.18,1667.9,
Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,646.18,1667.9,APC
Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,646.18,1667.9,APC
Place endorectal app,C9725,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,646.18,1667.9,APC
Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1533.11,,,,,,,fee schedule,1005.11,2782.81,
Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1254.85,,,,,,,fee schedule,1005.11,2782.81,
Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1005.11,,,,,,,fee schedule,1005.11,2782.81,
Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1763.08,,,,,,,fee schedule,1005.11,2782.81,
Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1005.11,2782.81,APC
Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1005.11,2782.81,APC
Insert palate implants,C9727,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1005.11,2782.81,APC
"Place device/marker, non pro",C9728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1574,,,,,,,fee schedule,1031.91,2482.48,
"Place device/marker, non pro",C9728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1288.32,,,,,,,fee schedule,1031.91,2482.48,
"Place device/marker, non pro",C9728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1031.91,,,,,,,fee schedule,1031.91,2482.48,
"Place device/marker, non pro",C9728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1810.1,,,,,,,fee schedule,1031.91,2482.48,
"Place device/marker, non pro",C9728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1448.11,,,,,,,fee schedule,1031.91,2482.48,APC
"Place device/marker, non pro",C9728,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1379.15,,,,,,,fee schedule,1031.91,2482.48,APC
"Place device/marker, non pro",C9728,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2482.48,,,,,,,fee schedule,1031.91,2482.48,APC
Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,337.83,,,,,,,fee schedule,221.48,625.71,
Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,276.51,,,,,,,fee schedule,221.48,625.71,
Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,221.48,,,,,,,fee schedule,221.48,625.71,
Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,388.5,,,,,,,fee schedule,221.48,625.71,
Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365,,,,,,,fee schedule,221.48,625.71,APC
Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.62,,,,,,,fee schedule,221.48,625.71,APC
Non-ophthalmic FVA,C9733,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.71,,,,,,,fee schedule,221.48,625.71,APC
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7196.95,,,,,,,fee schedule,4718.32,9616.53,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5890.7,,,,,,,fee schedule,4718.32,9616.53,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4718.32,,,,,,,fee schedule,4718.32,9616.53,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8276.49,,,,,,,fee schedule,4718.32,9616.53,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5609.64,,,,,,,fee schedule,4718.32,9616.53,APC
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5342.52,,,,,,,fee schedule,4718.32,9616.53,APC
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9616.53,,,,,,,fee schedule,4718.32,9616.53,APC
Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17408.71,,,,,,,fee schedule,9432.42,20020.02,
Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14249.03,,,,,,,fee schedule,9432.42,20020.02,
Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11413.15,,,,,,,fee schedule,9432.42,20020.02,
Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20020.02,,,,,,,fee schedule,9432.42,20020.02,
Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,9432.42,20020.02,APC
Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,9432.42,20020.02,APC
Cysto impl 4 or more,C9740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,9432.42,20020.02,APC
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21659.58,,,,,,,fee schedule,14200.02,24908.52,
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17728.37,,,,,,,fee schedule,14200.02,24908.52,
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14200.02,,,,,,,fee schedule,14200.02,24908.52,
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24908.52,,,,,,,fee schedule,14200.02,24908.52,
"Perc av fistula, direct",C9754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25383.6,,,,,,,fee schedule,6504.05,29191.14,
"Perc av fistula, direct",C9754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6504.05,,,,,,,fee schedule,6504.05,29191.14,
"Perc av fistula, direct",C9754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6504.05,,,,,,,fee schedule,6504.05,29191.14,
"Perc av fistula, direct",C9754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20776.48,,,,,,,fee schedule,6504.05,29191.14,
"Perc av fistula, direct",C9754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16641.49,,,,,,,fee schedule,6504.05,29191.14,
"Perc av fistula, direct",C9754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7479.66,,,,,,,fee schedule,6504.05,29191.14,
"Perc av fistula, direct",C9754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29191.14,,,,,,,fee schedule,6504.05,29191.14,
"Perc av fistula, direct",C9754,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6504.05,,,,,,,fee schedule,6504.05,29191.14,
Rf magnetic-guide av fistula,C9755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25383.6,,,,,,,fee schedule,6504.05,29191.14,
Rf magnetic-guide av fistula,C9755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6504.05,,,,,,,fee schedule,6504.05,29191.14,
Rf magnetic-guide av fistula,C9755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6504.05,,,,,,,fee schedule,6504.05,29191.14,
Rf magnetic-guide av fistula,C9755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20776.48,,,,,,,fee schedule,6504.05,29191.14,
Rf magnetic-guide av fistula,C9755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16641.49,,,,,,,fee schedule,6504.05,29191.14,
Rf magnetic-guide av fistula,C9755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7479.66,,,,,,,fee schedule,6504.05,29191.14,
Rf magnetic-guide av fistula,C9755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29191.14,,,,,,,fee schedule,6504.05,29191.14,
Rf magnetic-guide av fistula,C9755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6504.05,,,,,,,fee schedule,6504.05,29191.14,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23117.05,,,,,,,fee schedule,11925.76,26584.61,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11925.76,,,,,,,fee schedule,11925.76,26584.61,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11925.76,,,,,,,fee schedule,11925.76,26584.61,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18921.31,,,,,,,fee schedule,11925.76,26584.61,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15155.54,,,,,,,fee schedule,11925.76,26584.61,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13714.62,,,,,,,fee schedule,11925.76,26584.61,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26584.61,,,,,,,fee schedule,11925.76,26584.61,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11925.76,,,,,,,fee schedule,11925.76,26584.61,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,11925.76,26584.61,APC
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,11925.76,26584.61,APC
Spine/lumbar disk surgery,C9757,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,11925.76,26584.61,APC
Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24284.82,,,,,,,fee schedule,15921.13,30722.2,
Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19877.13,,,,,,,fee schedule,15921.13,30722.2,
Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15921.13,,,,,,,fee schedule,15921.13,30722.2,
Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27927.54,,,,,,,fee schedule,15921.13,30722.2,
Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17921.28,,,,,,,fee schedule,15921.13,30722.2,APC
Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17067.89,,,,,,,fee schedule,15921.13,30722.2,APC
Interatrial shunt IDE,C9758,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30722.2,,,,,,,fee schedule,15921.13,30722.2,APC
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.65,,,,,,,fee schedule,89.65,16978.36,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.65,,,,,,,fee schedule,89.65,16978.36,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.1,,,,,,,fee schedule,89.65,16978.36,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.65,,,,,,,fee schedule,89.65,16978.36,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9904.04,,,,,,,fee schedule,89.65,16978.36,APC
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9432.42,,,,,,,fee schedule,89.65,16978.36,APC
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16978.36,,,,,,,fee schedule,89.65,16978.36,APC
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,980.01,APC
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,980.01,APC
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,980.01,APC
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.67,,,,,,,fee schedule,544.45,980.01,APC
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,544.45,,,,,,,fee schedule,544.45,980.01,APC
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,980.01,,,,,,,fee schedule,544.45,980.01,APC
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.05,,,,,,,fee schedule,72.05,20704.82,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.05,,,,,,,fee schedule,72.05,20704.82,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.86,,,,,,,fee schedule,72.05,20704.82,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.05,,,,,,,fee schedule,72.05,20704.82,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,72.05,20704.82,APC
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,72.05,20704.82,APC
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,72.05,20704.82,APC
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.26,,,,,,,fee schedule,185.26,32878.29,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.26,,,,,,,fee schedule,185.26,32878.29,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,213.05,,,,,,,fee schedule,185.26,32878.29,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,185.26,,,,,,,fee schedule,185.26,32878.29,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,185.26,32878.29,APC
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,185.26,32878.29,APC
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,185.26,32878.29,APC
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.45,,,,,,,fee schedule,142.45,32878.29,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.45,,,,,,,fee schedule,142.45,32878.29,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,163.82,,,,,,,fee schedule,142.45,32878.29,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.45,,,,,,,fee schedule,142.45,32878.29,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,142.45,32878.29,APC
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,142.45,32878.29,APC
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,142.45,32878.29,APC
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,306.58,,,,,,,fee schedule,306.58,32878.29,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,306.58,,,,,,,fee schedule,306.58,32878.29,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,352.57,,,,,,,fee schedule,306.58,32878.29,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,306.58,,,,,,,fee schedule,306.58,32878.29,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,306.58,32878.29,APC
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,306.58,32878.29,APC
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,306.58,32878.29,APC
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19510.5,,,,,,,fee schedule,193.54,22437.08,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.54,,,,,,,fee schedule,193.54,22437.08,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.54,,,,,,,fee schedule,193.54,22437.08,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15969.34,,,,,,,fee schedule,193.54,22437.08,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12791.08,,,,,,,fee schedule,193.54,22437.08,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.57,,,,,,,fee schedule,193.54,22437.08,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22437.08,,,,,,,fee schedule,193.54,22437.08,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.54,,,,,,,fee schedule,193.54,22437.08,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,193.54,22437.08,APC
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,193.54,22437.08,APC
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,193.54,22437.08,APC
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31207.65,,,,,,,fee schedule,345.99,35888.8,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,345.99,,,,,,,fee schedule,345.99,35888.8,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,345.99,,,,,,,fee schedule,345.99,35888.8,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25543.46,,,,,,,fee schedule,345.99,35888.8,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20459.74,,,,,,,fee schedule,345.99,35888.8,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,397.89,,,,,,,fee schedule,345.99,35888.8,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35888.8,,,,,,,fee schedule,345.99,35888.8,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,345.99,,,,,,,fee schedule,345.99,35888.8,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,345.99,35888.8,APC
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,345.99,35888.8,APC
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,345.99,35888.8,APC
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31207.65,,,,,,,fee schedule,350.9,35888.8,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,350.9,,,,,,,fee schedule,350.9,35888.8,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.9,,,,,,,fee schedule,350.9,35888.8,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25543.46,,,,,,,fee schedule,350.9,35888.8,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20459.74,,,,,,,fee schedule,350.9,35888.8,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,403.54,,,,,,,fee schedule,350.9,35888.8,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35888.8,,,,,,,fee schedule,350.9,35888.8,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,350.9,,,,,,,fee schedule,350.9,35888.8,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,350.9,35888.8,APC
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,350.9,35888.8,APC
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,350.9,35888.8,APC
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31207.65,,,,,,,fee schedule,352.1,35888.8,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,352.1,,,,,,,fee schedule,352.1,35888.8,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,352.1,,,,,,,fee schedule,352.1,35888.8,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25543.46,,,,,,,fee schedule,352.1,35888.8,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20459.74,,,,,,,fee schedule,352.1,35888.8,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,404.92,,,,,,,fee schedule,352.1,35888.8,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35888.8,,,,,,,fee schedule,352.1,35888.8,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,352.1,,,,,,,fee schedule,352.1,35888.8,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,352.1,35888.8,APC
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,352.1,35888.8,APC
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,352.1,35888.8,APC
Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2921.21,,,,,,,fee schedule,2921.21,6914.9,
Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2921.21,,,,,,,fee schedule,2921.21,6914.9,
Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3359.39,,,,,,,fee schedule,2921.21,6914.9,
Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2921.21,,,,,,,fee schedule,2921.21,6914.9,
Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2921.21,6914.9,APC
Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2921.21,6914.9,APC
Esophag mucosal integ add-on,C9777,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2921.21,6914.9,APC
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3985.39,,,,,,,fee schedule,3985.39,8972.03,
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3985.39,,,,,,,fee schedule,3985.39,8972.03,
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4583.2,,,,,,,fee schedule,3985.39,8972.03,
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3985.39,,,,,,,fee schedule,3985.39,8972.03,
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5233.68,,,,,,,fee schedule,3985.39,8972.03,APC
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4984.46,,,,,,,fee schedule,3985.39,8972.03,APC
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8972.03,,,,,,,fee schedule,3985.39,8972.03,APC
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2453.16,,,,,,,fee schedule,2453.16,6914.9,
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2453.16,,,,,,,fee schedule,2453.16,6914.9,
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2821.13,,,,,,,fee schedule,2453.16,6914.9,
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2453.16,,,,,,,fee schedule,2453.16,6914.9,
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4033.69,,,,,,,fee schedule,2453.16,6914.9,APC
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3841.61,,,,,,,fee schedule,2453.16,6914.9,APC
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6914.9,,,,,,,fee schedule,2453.16,6914.9,APC
Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8727.9,,,,,,,fee schedule,8046.55,14483.79,
Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8727.9,,,,,,,fee schedule,8046.55,14483.79,
Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10037.09,,,,,,,fee schedule,8046.55,14483.79,
Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8727.9,,,,,,,fee schedule,8046.55,14483.79,
Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8448.88,,,,,,,fee schedule,8046.55,14483.79,APC
Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8046.55,,,,,,,fee schedule,8046.55,14483.79,APC
Insert cv cath inf & sup app,C9780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14483.79,,,,,,,fee schedule,8046.55,14483.79,APC
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12984.64,,,,,,,fee schedule,12792.51,23026.52,
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12984.64,,,,,,,fee schedule,12792.51,23026.52,
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14932.34,,,,,,,fee schedule,12792.51,23026.52,
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12984.64,,,,,,,fee schedule,12792.51,23026.52,
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.14,,,,,,,fee schedule,12792.51,23026.52,APC
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12792.51,,,,,,,fee schedule,12792.51,23026.52,APC
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23026.52,,,,,,,fee schedule,12792.51,23026.52,APC
Blind cor sinus reducer impl,C9783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12077.81,,,,,,,fee schedule,11502.68,20704.82,APC
Blind cor sinus reducer impl,C9783,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11502.68,,,,,,,fee schedule,11502.68,20704.82,APC
Blind cor sinus reducer impl,C9783,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20704.82,,,,,,,fee schedule,11502.68,20704.82,APC
Endo outlet restrict w/tube,C9785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Endo outlet restrict w/tube,C9785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Endo outlet restrict w/tube,C9785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1687.58,,,,,,,fee schedule,1219.59,2195.26,
Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1687.58,,,,,,,fee schedule,1219.59,2195.26,
Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1940.72,,,,,,,fee schedule,1219.59,2195.26,
Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1687.58,,,,,,,fee schedule,1219.59,2195.26,
Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1280.57,,,,,,,fee schedule,1219.59,2195.26,APC
Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1219.59,,,,,,,fee schedule,1219.59,2195.26,APC
Instill pharm renal pelvis,C9789,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2195.26,,,,,,,fee schedule,1219.59,2195.26,APC
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1799.86,,,,,,,fee schedule,855.65,2069.84,
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1473.19,,,,,,,fee schedule,855.65,2069.84,
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1179.99,,,,,,,fee schedule,855.65,2069.84,
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2069.84,,,,,,,fee schedule,855.65,2069.84,
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,2069.84,APC
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,2069.84,APC
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,2069.84,APC
Rpr intst excl anrect fist,C9796,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2903.96,,,,,,,fee schedule,2765.68,4978.22,APC
Rpr intst excl anrect fist,C9796,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2765.68,,,,,,,fee schedule,2765.68,4978.22,APC
Rpr intst excl anrect fist,C9796,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4978.22,,,,,,,fee schedule,2765.68,4978.22,APC
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19179,,,,,,,fee schedule,18265.72,32878.29,APC
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18265.72,,,,,,,fee schedule,18265.72,32878.29,APC
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32878.29,,,,,,,fee schedule,18265.72,32878.29,APC
Endo defect closure GI tract,C9901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11121.19,,,,,,,fee schedule,10591.61,19064.9,APC
Endo defect closure GI tract,C9901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10591.61,,,,,,,fee schedule,10591.61,19064.9,APC
Endo defect closure GI tract,C9901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19064.9,,,,,,,fee schedule,10591.61,19064.9,APC
Periodic oral evaluation,D0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.67,,,,,,,fee schedule,10.27,238.78,
Periodic oral evaluation,D0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.83,,,,,,,fee schedule,10.27,238.78,
Periodic oral evaluation,D0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.27,,,,,,,fee schedule,10.27,238.78,
Periodic oral evaluation,D0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.02,,,,,,,fee schedule,10.27,238.78,
Periodic oral evaluation,D0120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,10.27,238.78,APC
Periodic oral evaluation,D0120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,10.27,238.78,APC
Periodic oral evaluation,D0120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,10.27,238.78,APC
Limit oral eval problm focus,D0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,17.99,238.78,
Limit oral eval problm focus,D0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,17.99,238.78,
Limit oral eval problm focus,D0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,17.99,238.78,
Limit oral eval problm focus,D0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,17.99,238.78,
Limit oral eval problm focus,D0140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,17.99,238.78,APC
Limit oral eval problm focus,D0140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,17.99,238.78,APC
Limit oral eval problm focus,D0140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,17.99,238.78,APC
"Oral evaluation, pt < 3yrs",D0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.47,,,,,,,fee schedule,16.7,29.29,
"Oral evaluation, pt < 3yrs",D0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.85,,,,,,,fee schedule,16.7,29.29,
"Oral evaluation, pt < 3yrs",D0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.7,,,,,,,fee schedule,16.7,29.29,
"Oral evaluation, pt < 3yrs",D0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.29,,,,,,,fee schedule,16.7,29.29,
Comprehensve oral evaluation,D0150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,132.66,882.44,
Comprehensve oral evaluation,D0150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,132.66,882.44,
Comprehensve oral evaluation,D0150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,132.66,882.44,
Comprehensve oral evaluation,D0150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,132.66,882.44,
Comprehensve oral evaluation,D0150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,882.44,APC
Comprehensve oral evaluation,D0150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,882.44,APC
Comprehensve oral evaluation,D0150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,882.44,APC
Extensv oral eval prob focus,D0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.83,,,,,,,fee schedule,37.26,238.78,
Extensv oral eval prob focus,D0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.52,,,,,,,fee schedule,37.26,238.78,
Extensv oral eval prob focus,D0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.26,,,,,,,fee schedule,37.26,238.78,
Extensv oral eval prob focus,D0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.35,,,,,,,fee schedule,37.26,238.78,
Extensv oral eval prob focus,D0160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,37.26,238.78,APC
Extensv oral eval prob focus,D0160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,37.26,238.78,APC
Extensv oral eval prob focus,D0160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,37.26,238.78,APC
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.63,,,,,,,fee schedule,12.21,238.78,
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.25,,,,,,,fee schedule,12.21,238.78,
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.21,,,,,,,fee schedule,12.21,238.78,
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.42,,,,,,,fee schedule,12.21,238.78,
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,12.21,238.78,APC
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,12.21,238.78,APC
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,12.21,238.78,APC
Re-eval post-op visit,D0171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,238.78,APC
Re-eval post-op visit,D0171,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,238.78,APC
Re-eval post-op visit,D0171,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,238.78,APC
Comp periodontal evaluation,D0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.35,,,,,,,fee schedule,20.55,238.78,
Comp periodontal evaluation,D0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.66,,,,,,,fee schedule,20.55,238.78,
Comp periodontal evaluation,D0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.55,,,,,,,fee schedule,20.55,238.78,
Comp periodontal evaluation,D0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.05,,,,,,,fee schedule,20.55,238.78,
Comp periodontal evaluation,D0180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,20.55,238.78,APC
Comp periodontal evaluation,D0180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,20.55,238.78,APC
Comp periodontal evaluation,D0180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,20.55,238.78,APC
Assessment of a patient,D0191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,238.78,APC
Assessment of a patient,D0191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,238.78,APC
Assessment of a patient,D0191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,238.78,APC
Intraor complete film series,D0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.64,,,,,,,fee schedule,75.16,427.94,
Intraor complete film series,D0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.83,,,,,,,fee schedule,75.16,427.94,
Intraor complete film series,D0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.16,,,,,,,fee schedule,75.16,427.94,
Intraor complete film series,D0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.84,,,,,,,fee schedule,75.16,427.94,
Intraor complete film series,D0210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,75.16,427.94,APC
Intraor complete film series,D0210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,75.16,427.94,APC
Intraor complete film series,D0210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,75.16,427.94,APC
Intraoral periapical first,D0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.53,,,,,,,fee schedule,14.77,156.08,
Intraoral periapical first,D0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.44,,,,,,,fee schedule,14.77,156.08,
Intraoral periapical first,D0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.77,,,,,,,fee schedule,14.77,156.08,
Intraoral periapical first,D0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.91,,,,,,,fee schedule,14.77,156.08,
Intraoral periapical first,D0220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,14.77,156.08,APC
Intraoral periapical first,D0220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,14.77,156.08,APC
Intraoral periapical first,D0220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,14.77,156.08,APC
Intraoral periapical ea add,D0230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,13.49,23.67,
Intraoral periapical ea add,D0230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,13.49,23.67,
Intraoral periapical ea add,D0230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,13.49,23.67,
Intraoral periapical ea add,D0230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,13.49,23.67,
Intraoral occlusal film,D0240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,86.71,882.44,
Intraoral occlusal film,D0240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,86.71,882.44,
Intraoral occlusal film,D0240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,86.71,882.44,
Intraoral occlusal film,D0240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,86.71,882.44,
Intraoral occlusal film,D0240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,882.44,APC
Intraoral occlusal film,D0240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,882.44,APC
Intraoral occlusal film,D0240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,882.44,APC
Extraoral 2d project image,D0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,86.71,882.44,
Extraoral 2d project image,D0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,86.71,882.44,
Extraoral 2d project image,D0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,86.71,882.44,
Extraoral 2d project image,D0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,86.71,882.44,
Extraoral 2d project image,D0250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,882.44,APC
Extraoral 2d project image,D0250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,882.44,APC
Extraoral 2d project image,D0250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,882.44,APC
Extraoral posterior image,D0251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.51,,,,,,,fee schedule,58.68,156.08,
Extraoral posterior image,D0251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.26,,,,,,,fee schedule,58.68,156.08,
Extraoral posterior image,D0251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.68,,,,,,,fee schedule,58.68,156.08,
Extraoral posterior image,D0251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.94,,,,,,,fee schedule,58.68,156.08,
Extraoral posterior image,D0251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,58.68,156.08,APC
Extraoral posterior image,D0251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,58.68,156.08,APC
Extraoral posterior image,D0251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,58.68,156.08,APC
Dental bitewing single image,D0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,86.71,882.44,
Dental bitewing single image,D0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,86.71,882.44,
Dental bitewing single image,D0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,86.71,882.44,
Dental bitewing single image,D0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,86.71,882.44,
Dental bitewing single image,D0270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,882.44,APC
Dental bitewing single image,D0270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,882.44,APC
Dental bitewing single image,D0270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,882.44,APC
Dental bitewings two images,D0272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,86.71,882.44,
Dental bitewings two images,D0272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,86.71,882.44,
Dental bitewings two images,D0272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,86.71,882.44,
Dental bitewings two images,D0272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,86.71,882.44,
Dental bitewings two images,D0272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,882.44,APC
Dental bitewings two images,D0272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,882.44,APC
Dental bitewings two images,D0272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,882.44,APC
Bitewings - three images,D0273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.09,,,,,,,fee schedule,28.91,427.94,
Bitewings - three images,D0273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,28.91,427.94,
Bitewings - three images,D0273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,28.91,427.94,
Bitewings - three images,D0273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.7,,,,,,,fee schedule,28.91,427.94,
Bitewings - three images,D0273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,28.91,427.94,APC
Bitewings - three images,D0273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,28.91,427.94,APC
Bitewings - three images,D0273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,28.91,427.94,APC
Bitewings four images,D0274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,237.74,882.44,
Bitewings four images,D0274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,237.74,882.44,
Bitewings four images,D0274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,237.74,882.44,
Bitewings four images,D0274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,237.74,882.44,
Bitewings four images,D0274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,882.44,APC
Bitewings four images,D0274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,882.44,APC
Bitewings four images,D0274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,882.44,APC
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,237.74,882.44,
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,237.74,882.44,
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,237.74,882.44,
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,237.74,882.44,
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,882.44,APC
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,882.44,APC
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,882.44,APC
Dental saliography,D0310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,342.95,,,,,,,fee schedule,224.84,427.94,
Dental saliography,D0310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,280.7,,,,,,,fee schedule,224.84,427.94,
Dental saliography,D0310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.84,,,,,,,fee schedule,224.84,427.94,
Dental saliography,D0310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,394.39,,,,,,,fee schedule,224.84,427.94,
Dental saliography,D0310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,224.84,427.94,APC
Dental saliography,D0310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,224.84,427.94,APC
Dental saliography,D0310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,224.84,427.94,APC
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,606.51,,,,,,,fee schedule,237.74,697.49,
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,496.43,,,,,,,fee schedule,237.74,697.49,
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,397.63,,,,,,,fee schedule,237.74,697.49,
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,697.49,,,,,,,fee schedule,237.74,697.49,
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,237.74,697.49,APC
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,237.74,697.49,APC
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,237.74,697.49,APC
Other tmj images by report,D0321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Other tmj images by report,D0321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Other tmj images by report,D0321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Dental tomographic survey,D0322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,492.85,,,,,,,fee schedule,104.17,566.78,
Dental tomographic survey,D0322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,403.4,,,,,,,fee schedule,104.17,566.78,
Dental tomographic survey,D0322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,323.11,,,,,,,fee schedule,104.17,566.78,
Dental tomographic survey,D0322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,566.78,,,,,,,fee schedule,104.17,566.78,
Dental tomographic survey,D0322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,566.78,APC
Dental tomographic survey,D0322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,566.78,APC
Dental tomographic survey,D0322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,566.78,APC
Panoramic image,D0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.79,,,,,,,fee schedule,70.01,427.94,
Panoramic image,D0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.41,,,,,,,fee schedule,70.01,427.94,
Panoramic image,D0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.01,,,,,,,fee schedule,70.01,427.94,
Panoramic image,D0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.81,,,,,,,fee schedule,70.01,427.94,
Panoramic image,D0330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.63,,,,,,,fee schedule,70.01,427.94,APC
Panoramic image,D0330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.74,,,,,,,fee schedule,70.01,427.94,APC
Panoramic image,D0330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,427.94,,,,,,,fee schedule,70.01,427.94,APC
2d cephalometric image,D0340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,156.08,
2d cephalometric image,D0340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,156.08,
2d cephalometric image,D0340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,156.08,
2d cephalometric image,D0340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,156.08,
2d cephalometric image,D0340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,79.01,156.08,APC
2d cephalometric image,D0340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,79.01,156.08,APC
2d cephalometric image,D0340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,79.01,156.08,APC
Oral/facial photo images,D0350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.79,,,,,,,fee schedule,37.89,156.08,
Oral/facial photo images,D0350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.3,,,,,,,fee schedule,37.89,156.08,
Oral/facial photo images,D0350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.89,,,,,,,fee schedule,37.89,156.08,
Oral/facial photo images,D0350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.46,,,,,,,fee schedule,37.89,156.08,
Oral/facial photo images,D0350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,37.89,156.08,APC
Oral/facial photo images,D0350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,37.89,156.08,APC
Oral/facial photo images,D0350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,37.89,156.08,APC
Cone beam ct capt & interp,D0364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capt & interp,D0364,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capt & interp,D0364,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete man,D0365,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete man,D0365,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete man,D0365,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete max,D0366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete max,D0366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete max,D0366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interp both jaw,D0367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interp both jaw,D0367,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interp both jaw,D0367,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Max MRI capture & interprete,D0369,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Max MRI capture & interprete,D0369,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Max MRI capture & interprete,D0369,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Max ultrasound capt & interp,D0370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Max ultrasound capt & interp,D0370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Max ultrasound capt & interp,D0370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Cone beam ct capture limited,D0380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capture limited,D0380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capture limited,D0380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capt mandible,D0381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capt mandible,D0381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capt mandible,D0381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capt maxilla,D0382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capt maxilla,D0382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capt maxilla,D0382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct both jaws,D0383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct both jaws,D0383,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct both jaws,D0383,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capture TMJ,D0384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capture TMJ,D0384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Cone beam ct capture TMJ,D0384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Max MRI image capture,D0385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Max MRI image capture,D0385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Max MRI image capture,D0385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Max ultrasound image capture,D0386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,104.17,187.51,APC
Max ultrasound image capture,D0386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,104.17,187.51,APC
Max ultrasound image capture,D0386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,104.17,187.51,APC
Trtmnt simulation 3d image,D0393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Trtmnt simulation 3d image,D0393,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Trtmnt simulation 3d image,D0393,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Digital sub 2 or more images,D0394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Digital sub 2 or more images,D0394,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Digital sub 2 or more images,D0394,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Fusion 2 or more 3d images,D0395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Fusion 2 or more 3d images,D0395,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Fusion 2 or more 3d images,D0395,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Collection of microorganisms,D0415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.12,,,,,,,fee schedule,27.61,48.44,
Collection of microorganisms,D0415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.48,,,,,,,fee schedule,27.61,48.44,
Collection of microorganisms,D0415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.61,,,,,,,fee schedule,27.61,48.44,
Collection of microorganisms,D0415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.44,,,,,,,fee schedule,27.61,48.44,
Viral culture,D0416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.73,,,,,,,fee schedule,40.47,70.99,
Viral culture,D0416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.53,,,,,,,fee schedule,40.47,70.99,
Viral culture,D0416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.47,,,,,,,fee schedule,40.47,70.99,
Viral culture,D0416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.99,,,,,,,fee schedule,40.47,70.99,
Collect & prep saliva sample,D0417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.87,,,,,,,fee schedule,36.63,64.25,
Collect & prep saliva sample,D0417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.73,,,,,,,fee schedule,36.63,64.25,
Collect & prep saliva sample,D0417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.63,,,,,,,fee schedule,36.63,64.25,
Collect & prep saliva sample,D0417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.25,,,,,,,fee schedule,36.63,64.25,
Analysis of saliva sample,D0418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.79,,,,,,,fee schedule,37.89,66.46,
Analysis of saliva sample,D0418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.3,,,,,,,fee schedule,37.89,66.46,
Analysis of saliva sample,D0418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.89,,,,,,,fee schedule,37.89,66.46,
Analysis of saliva sample,D0418,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.46,,,,,,,fee schedule,37.89,66.46,
Caries susceptibility test,D0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Caries susceptibility test,D0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Caries susceptibility test,D0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Caries susceptibility test,D0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Diag tst detect mucos abnorm,D0431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.79,,,,,,,fee schedule,37.89,66.46,
Diag tst detect mucos abnorm,D0431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.3,,,,,,,fee schedule,37.89,66.46,
Diag tst detect mucos abnorm,D0431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.89,,,,,,,fee schedule,37.89,66.46,
Diag tst detect mucos abnorm,D0431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.46,,,,,,,fee schedule,37.89,66.46,
Pulp vitality test,D0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Pulp vitality test,D0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Pulp vitality test,D0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Pulp vitality test,D0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Pulp vitality test,D0460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Pulp vitality test,D0460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Pulp vitality test,D0460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Diagnostic casts,D0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.4,,,,,,,fee schedule,82.87,145.36,
Diagnostic casts,D0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.46,,,,,,,fee schedule,82.87,145.36,
Diagnostic casts,D0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.87,,,,,,,fee schedule,82.87,145.36,
Diagnostic casts,D0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.36,,,,,,,fee schedule,82.87,145.36,
"Gross exam, prep & report",D0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.35,,,,,,,fee schedule,52.02,91.25,
"Gross exam, prep & report",D0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.95,,,,,,,fee schedule,52.02,91.25,
"Gross exam, prep & report",D0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.02,,,,,,,fee schedule,52.02,91.25,
"Gross exam, prep & report",D0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.25,,,,,,,fee schedule,52.02,91.25,
"Micro exam, prep & report",D0473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,167.54,,,,,,,fee schedule,109.84,192.67,
"Micro exam, prep & report",D0473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.13,,,,,,,fee schedule,109.84,192.67,
"Micro exam, prep & report",D0473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.84,,,,,,,fee schedule,109.84,192.67,
"Micro exam, prep & report",D0473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,192.67,,,,,,,fee schedule,109.84,192.67,
Micro w exam of surg margins,D0474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.13,,,,,,,fee schedule,123.34,216.35,
Micro w exam of surg margins,D0474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.98,,,,,,,fee schedule,123.34,216.35,
Micro w exam of surg margins,D0474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.34,,,,,,,fee schedule,123.34,216.35,
Micro w exam of surg margins,D0474,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.35,,,,,,,fee schedule,123.34,216.35,
Decalcification procedure,D0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.92,,,,,,,fee schedule,66.16,116.06,
Decalcification procedure,D0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.6,,,,,,,fee schedule,66.16,116.06,
Decalcification procedure,D0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.16,,,,,,,fee schedule,66.16,116.06,
Decalcification procedure,D0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.06,,,,,,,fee schedule,66.16,116.06,
Spec stains for microorganis,D0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.98,,,,,,,fee schedule,64.24,112.68,
Spec stains for microorganis,D0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.2,,,,,,,fee schedule,64.24,112.68,
Spec stains for microorganis,D0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.24,,,,,,,fee schedule,64.24,112.68,
Spec stains for microorganis,D0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.68,,,,,,,fee schedule,64.24,112.68,
Spec stains not for microorg,D0477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.24,,,,,,,fee schedule,88.01,154.38,
Spec stains not for microorg,D0477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.88,,,,,,,fee schedule,88.01,154.38,
Spec stains not for microorg,D0477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.01,,,,,,,fee schedule,88.01,154.38,
Spec stains not for microorg,D0477,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.38,,,,,,,fee schedule,88.01,154.38,
Immunohistochemical stains,D0478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.46,,,,,,,fee schedule,80.28,140.83,
Immunohistochemical stains,D0478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.23,,,,,,,fee schedule,80.28,140.83,
Immunohistochemical stains,D0478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.28,,,,,,,fee schedule,80.28,140.83,
Immunohistochemical stains,D0478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,140.83,,,,,,,fee schedule,80.28,140.83,
Tissue in-situ hybridization,D0479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.13,,,,,,,fee schedule,123.34,216.35,
Tissue in-situ hybridization,D0479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.98,,,,,,,fee schedule,123.34,216.35,
Tissue in-situ hybridization,D0479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.34,,,,,,,fee schedule,123.34,216.35,
Tissue in-situ hybridization,D0479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.35,,,,,,,fee schedule,123.34,216.35,
Cytopath smear prep & report,D0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.62,,,,,,,fee schedule,75.8,132.96,
Cytopath smear prep & report,D0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.63,,,,,,,fee schedule,75.8,132.96,
Cytopath smear prep & report,D0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.8,,,,,,,fee schedule,75.8,132.96,
Cytopath smear prep & report,D0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.96,,,,,,,fee schedule,75.8,132.96,
Electron microscopy,D0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,433.08,,,,,,,fee schedule,283.93,498.04,
Electron microscopy,D0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,354.48,,,,,,,fee schedule,283.93,498.04,
Electron microscopy,D0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.93,,,,,,,fee schedule,283.93,498.04,
Electron microscopy,D0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,498.04,,,,,,,fee schedule,283.93,498.04,
Direct immunofluorescence,D0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,165.65,
Direct immunofluorescence,D0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,165.65,
Direct immunofluorescence,D0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,165.65,
Direct immunofluorescence,D0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,165.65,
Indirect immunofluorescence,D0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,165.65,
Indirect immunofluorescence,D0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,165.65,
Indirect immunofluorescence,D0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,165.65,
Indirect immunofluorescence,D0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,165.65,
Consult slides prep elsewher,D0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,216.52,,,,,,,fee schedule,141.95,249,
Consult slides prep elsewher,D0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.22,,,,,,,fee schedule,141.95,249,
Consult slides prep elsewher,D0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.95,,,,,,,fee schedule,141.95,249,
Consult slides prep elsewher,D0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,249,,,,,,,fee schedule,141.95,249,
Consult inc prep of slides,D0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,298.86,,,,,,,fee schedule,195.93,343.69,
Consult inc prep of slides,D0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,244.62,,,,,,,fee schedule,195.93,343.69,
Consult inc prep of slides,D0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.93,,,,,,,fee schedule,195.93,343.69,
Consult inc prep of slides,D0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,343.69,,,,,,,fee schedule,195.93,343.69,
Access of transep cytol samp,D0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.14,,,,,,,fee schedule,91.22,160.01,
Access of transep cytol samp,D0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.89,,,,,,,fee schedule,91.22,160.01,
Access of transep cytol samp,D0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.22,,,,,,,fee schedule,91.22,160.01,
Access of transep cytol samp,D0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.01,,,,,,,fee schedule,91.22,160.01,
Non-ionizing diag proc,D0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Non-ionizing diag proc,D0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Non-ionizing diag proc,D0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Non-ionizing diag proc,D0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Non-ionizing diag proc,D0600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Non-ionizing diag proc,D0600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Non-ionizing diag proc,D0600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Extra oral post radio image,D0705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Extra oral post radio image,D0705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Extra oral post radio image,D0705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Intraoral occlus radio image,D0706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Intraoral occlus radio image,D0706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Intraoral occlus radio image,D0706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Intraoral periap radio image,D0707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Intraoral periap radio image,D0707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Intraoral periap radio image,D0707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Intraoral bite radio image,D0708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Intraoral bite radio image,D0708,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Intraoral bite radio image,D0708,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Intraoral cmplt radio images,D0709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Intraoral cmplt radio images,D0709,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Intraoral cmplt radio images,D0709,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
Dental prophylaxis adult,D1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.65,,,,,,,fee schedule,43.04,238.78,
Dental prophylaxis adult,D1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.73,,,,,,,fee schedule,43.04,238.78,
Dental prophylaxis adult,D1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.04,,,,,,,fee schedule,43.04,238.78,
Dental prophylaxis adult,D1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.5,,,,,,,fee schedule,43.04,238.78,
Dental prophylaxis adult,D1110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,43.04,238.78,APC
Dental prophylaxis adult,D1110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,43.04,238.78,APC
Dental prophylaxis adult,D1110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,43.04,238.78,APC
Dental prophylaxis child,D1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,29.55,51.83,
Dental prophylaxis child,D1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,29.55,51.83,
Dental prophylaxis child,D1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,29.55,51.83,
Dental prophylaxis child,D1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,29.55,51.83,
Topical fluoride varnish,D1206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,47.32,
Topical fluoride varnish,D1206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,47.32,
Topical fluoride varnish,D1206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,47.32,
Topical fluoride varnish,D1206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,47.32,
Nutri counsel-control caries,D1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,37.19,
Nutri counsel-control caries,D1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,37.19,
Nutri counsel-control caries,D1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,37.19,
Nutri counsel-control caries,D1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,37.19,
Tobacco counseling,D1320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.26,,,,,,,fee schedule,23.12,40.55,
Tobacco counseling,D1320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.86,,,,,,,fee schedule,23.12,40.55,
Tobacco counseling,D1320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.12,,,,,,,fee schedule,23.12,40.55,
Tobacco counseling,D1320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.55,,,,,,,fee schedule,23.12,40.55,
Oral hygiene instruction,D1330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.09,,,,,,,fee schedule,28.91,50.7,
Oral hygiene instruction,D1330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,28.91,50.7,
Oral hygiene instruction,D1330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,28.91,50.7,
Oral hygiene instruction,D1330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.7,,,,,,,fee schedule,28.91,50.7,
Dental sealant per tooth,D1351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.26,,,,,,,fee schedule,23.12,40.55,
Dental sealant per tooth,D1351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.86,,,,,,,fee schedule,23.12,40.55,
Dental sealant per tooth,D1351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.12,,,,,,,fee schedule,23.12,40.55,
Dental sealant per tooth,D1351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.55,,,,,,,fee schedule,23.12,40.55,
"Prev resin rest, perm tooth",D1352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,52.96,
"Prev resin rest, perm tooth",D1352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,52.96,
"Prev resin rest, perm tooth",D1352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,52.96,
"Prev resin rest, perm tooth",D1352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,52.96,
Space maintainer fxd unilat,D1510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Space maintainer fxd unilat,D1510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Space maintainer fxd unilat,D1510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Space maintainer fxd unilat,D1510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Space maintainer fxd unilat,D1510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Space maintainer fxd unilat,D1510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Space maintainer fxd unilat,D1510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Fixed bilat space maintainer,D1515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,882.44,
Fixed bilat space maintainer,D1515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,882.44,
Fixed bilat space maintainer,D1515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,882.44,
Fixed bilat space maintainer,D1515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,882.44,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2360.56,,,,,,,fee schedule,644.16,2714.64,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1932.12,,,,,,,fee schedule,644.16,2714.64,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1547.58,,,,,,,fee schedule,644.16,2714.64,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2714.64,,,,,,,fee schedule,644.16,2714.64,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,644.16,2714.64,APC
"Fixed bilat space maint, max",D1516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,644.16,2714.64,APC
"Fixed bilat space maint, max",D1516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,644.16,2714.64,APC
"Fixed bilat space maint, man",D1517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2360.56,,,,,,,fee schedule,644.16,2714.64,
"Fixed bilat space maint, man",D1517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1932.12,,,,,,,fee schedule,644.16,2714.64,
"Fixed bilat space maint, man",D1517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1547.58,,,,,,,fee schedule,644.16,2714.64,
"Fixed bilat space maint, man",D1517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2714.64,,,,,,,fee schedule,644.16,2714.64,
"Fixed bilat space maint, man",D1517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,644.16,2714.64,APC
"Fixed bilat space maint, man",D1517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,644.16,2714.64,APC
"Fixed bilat space maint, man",D1517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,644.16,2714.64,APC
Remove unilat space maintain,D1520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Remove unilat space maintain,D1520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Remove unilat space maintain,D1520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Remove unilat space maintain,D1520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Remove unilat space maintain,D1520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Remove unilat space maintain,D1520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Remove unilat space maintain,D1520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Remove bilat space maintain,D1525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,882.44,
Remove bilat space maintain,D1525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,882.44,
Remove bilat space maintain,D1525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,882.44,
Remove bilat space maintain,D1525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,882.44,
"Remove bilat space main, max",D1526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2360.56,,,,,,,fee schedule,644.16,2714.64,
"Remove bilat space main, max",D1526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1932.12,,,,,,,fee schedule,644.16,2714.64,
"Remove bilat space main, max",D1526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1547.58,,,,,,,fee schedule,644.16,2714.64,
"Remove bilat space main, max",D1526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2714.64,,,,,,,fee schedule,644.16,2714.64,
"Remove bilat space main, max",D1526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,644.16,2714.64,APC
"Remove bilat space main, max",D1526,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,644.16,2714.64,APC
"Remove bilat space main, max",D1526,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,644.16,2714.64,APC
"Remove bilat space main, man",D1527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2360.56,,,,,,,fee schedule,644.16,2714.64,
"Remove bilat space main, man",D1527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1932.12,,,,,,,fee schedule,644.16,2714.64,
"Remove bilat space main, man",D1527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1547.58,,,,,,,fee schedule,644.16,2714.64,
"Remove bilat space main, man",D1527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2714.64,,,,,,,fee schedule,644.16,2714.64,
"Remove bilat space main, man",D1527,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,644.16,2714.64,APC
"Remove bilat space main, man",D1527,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,644.16,2714.64,APC
"Remove bilat space main, man",D1527,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,644.16,2714.64,APC
"Dist space maint, fixed unil",D1575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
"Dist space maint, fixed unil",D1575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
"Dist space maint, fixed unil",D1575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
"Dist space maint, fixed unil",D1575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
"Dist space maint, fixed unil",D1575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
"Dist space maint, fixed unil",D1575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
"Dist space maint, fixed unil",D1575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Amalgam one surface permanen,D2140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.95,,,,,,,fee schedule,33.4,1159.49,
Amalgam one surface permanen,D2140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.7,,,,,,,fee schedule,33.4,1159.49,
Amalgam one surface permanen,D2140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.4,,,,,,,fee schedule,33.4,1159.49,
Amalgam one surface permanen,D2140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.59,,,,,,,fee schedule,33.4,1159.49,
Amalgam one surface permanen,D2140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,33.4,1159.49,APC
Amalgam one surface permanen,D2140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,33.4,1159.49,APC
Amalgam one surface permanen,D2140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,33.4,1159.49,APC
Amalgam two surfaces permane,D2150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.6,,,,,,,fee schedule,43.66,1159.49,
Amalgam two surfaces permane,D2150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.51,,,,,,,fee schedule,43.66,1159.49,
Amalgam two surfaces permane,D2150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.66,,,,,,,fee schedule,43.66,1159.49,
Amalgam two surfaces permane,D2150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.59,,,,,,,fee schedule,43.66,1159.49,
Amalgam two surfaces permane,D2150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,43.66,1159.49,APC
Amalgam two surfaces permane,D2150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,43.66,1159.49,APC
Amalgam two surfaces permane,D2150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,43.66,1159.49,APC
Amalgam three surfaces perma,D2160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.33,,,,,,,fee schedule,52.66,1159.49,
Amalgam three surfaces perma,D2160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.75,,,,,,,fee schedule,52.66,1159.49,
Amalgam three surfaces perma,D2160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.66,,,,,,,fee schedule,52.66,1159.49,
Amalgam three surfaces perma,D2160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.38,,,,,,,fee schedule,52.66,1159.49,
Amalgam three surfaces perma,D2160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,52.66,1159.49,APC
Amalgam three surfaces perma,D2160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,52.66,1159.49,APC
Amalgam three surfaces perma,D2160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,52.66,1159.49,APC
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.98,,,,,,,fee schedule,64.24,1159.49,
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.2,,,,,,,fee schedule,64.24,1159.49,
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.24,,,,,,,fee schedule,64.24,1159.49,
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.68,,,,,,,fee schedule,64.24,1159.49,
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,64.24,1159.49,APC
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,64.24,1159.49,APC
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,64.24,1159.49,APC
Resin one surface-anterior,D2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.7,,,,,,,fee schedule,41.76,1159.49,
Resin one surface-anterior,D2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.14,,,,,,,fee schedule,41.76,1159.49,
Resin one surface-anterior,D2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.76,,,,,,,fee schedule,41.76,1159.49,
Resin one surface-anterior,D2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.26,,,,,,,fee schedule,41.76,1159.49,
Resin one surface-anterior,D2330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,41.76,1159.49,APC
Resin one surface-anterior,D2330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,41.76,1159.49,APC
Resin one surface-anterior,D2330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,41.76,1159.49,APC
Resin two surfaces-anterior,D2331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.32,,,,,,,fee schedule,53.31,1159.49,
Resin two surfaces-anterior,D2331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.56,,,,,,,fee schedule,53.31,1159.49,
Resin two surfaces-anterior,D2331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.31,,,,,,,fee schedule,53.31,1159.49,
Resin two surfaces-anterior,D2331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.52,,,,,,,fee schedule,53.31,1159.49,
Resin two surfaces-anterior,D2331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,53.31,1159.49,APC
Resin two surfaces-anterior,D2331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,53.31,1159.49,APC
Resin two surfaces-anterior,D2331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,53.31,1159.49,APC
Resin three surfaces-anterio,D2332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.96,,,,,,,fee schedule,64.88,1159.49,
Resin three surfaces-anterio,D2332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81,,,,,,,fee schedule,64.88,1159.49,
Resin three surfaces-anterio,D2332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.88,,,,,,,fee schedule,64.88,1159.49,
Resin three surfaces-anterio,D2332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.8,,,,,,,fee schedule,64.88,1159.49,
Resin three surfaces-anterio,D2332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,64.88,1159.49,APC
Resin three surfaces-anterio,D2332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,64.88,1159.49,APC
Resin three surfaces-anterio,D2332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,64.88,1159.49,APC
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.59,,,,,,,fee schedule,77.09,1159.49,
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.25,,,,,,,fee schedule,77.09,1159.49,
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.09,,,,,,,fee schedule,77.09,1159.49,
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.23,,,,,,,fee schedule,77.09,1159.49,
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,77.09,1159.49,APC
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,77.09,1159.49,APC
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,77.09,1159.49,APC
Ant resin-based cmpst crown,D2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.31,,,,,,,fee schedule,85.43,1159.49,
Ant resin-based cmpst crown,D2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.66,,,,,,,fee schedule,85.43,1159.49,
Ant resin-based cmpst crown,D2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.43,,,,,,,fee schedule,85.43,1159.49,
Ant resin-based cmpst crown,D2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.86,,,,,,,fee schedule,85.43,1159.49,
Ant resin-based cmpst crown,D2390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,85.43,1159.49,APC
Ant resin-based cmpst crown,D2390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,85.43,1159.49,APC
Ant resin-based cmpst crown,D2390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,85.43,1159.49,APC
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.47,,,,,,,fee schedule,48.82,1159.49,
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.95,,,,,,,fee schedule,48.82,1159.49,
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.82,,,,,,,fee schedule,48.82,1159.49,
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.64,,,,,,,fee schedule,48.82,1159.49,
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,48.82,1159.49,APC
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,48.82,1159.49,APC
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,48.82,1159.49,APC
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97,,,,,,,fee schedule,63.59,1159.49,
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.39,,,,,,,fee schedule,63.59,1159.49,
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.59,,,,,,,fee schedule,63.59,1159.49,
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.55,,,,,,,fee schedule,63.59,1159.49,
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,63.59,1159.49,APC
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,63.59,1159.49,APC
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,63.59,1159.49,APC
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,1159.49,
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,1159.49,
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,1159.49,
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,1159.49,
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,79.01,1159.49,APC
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,79.01,1159.49,APC
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,79.01,1159.49,APC
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.95,,,,,,,fee schedule,97,1159.49,
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.1,,,,,,,fee schedule,97,1159.49,
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97,,,,,,,fee schedule,97,1159.49,
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.14,,,,,,,fee schedule,97,1159.49,
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,97,1159.49,APC
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,97,1159.49,APC
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,97,1159.49,APC
Dental gold foil one surface,D2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.21,,,,,,,fee schedule,89.3,1159.49,
Dental gold foil one surface,D2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,111.49,,,,,,,fee schedule,89.3,1159.49,
Dental gold foil one surface,D2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.3,,,,,,,fee schedule,89.3,1159.49,
Dental gold foil one surface,D2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,156.64,,,,,,,fee schedule,89.3,1159.49,
Dental gold foil one surface,D2410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,89.3,1159.49,APC
Dental gold foil one surface,D2410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,89.3,1159.49,APC
Dental gold foil one surface,D2410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,89.3,1159.49,APC
Dental gold foil two surface,D2420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.34,,,,,,,fee schedule,148.39,1159.49,
Dental gold foil two surface,D2420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.26,,,,,,,fee schedule,148.39,1159.49,
Dental gold foil two surface,D2420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.39,,,,,,,fee schedule,148.39,1159.49,
Dental gold foil two surface,D2420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.29,,,,,,,fee schedule,148.39,1159.49,
Dental gold foil two surface,D2420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,148.39,1159.49,APC
Dental gold foil two surface,D2420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,148.39,1159.49,APC
Dental gold foil two surface,D2420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,148.39,1159.49,APC
Dental gold foil three surfa,D2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,392.9,,,,,,,fee schedule,257.59,1159.49,
Dental gold foil three surfa,D2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,321.59,,,,,,,fee schedule,257.59,1159.49,
Dental gold foil three surfa,D2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,257.59,,,,,,,fee schedule,257.59,1159.49,
Dental gold foil three surfa,D2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,451.84,,,,,,,fee schedule,257.59,1159.49,
Dental gold foil three surfa,D2430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,257.59,1159.49,APC
Dental gold foil three surfa,D2430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,257.59,1159.49,APC
Dental gold foil three surfa,D2430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,257.59,1159.49,APC
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.59,,,,,,,fee schedule,235.75,1159.49,
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.32,,,,,,,fee schedule,235.75,1159.49,
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.75,,,,,,,fee schedule,235.75,1159.49,
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.53,,,,,,,fee schedule,235.75,1159.49,
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,235.75,1159.49,APC
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,235.75,1159.49,APC
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,235.75,1159.49,APC
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.62,,,,,,,fee schedule,267.24,1159.49,
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.64,,,,,,,fee schedule,267.24,1159.49,
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,267.24,,,,,,,fee schedule,267.24,1159.49,
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.76,,,,,,,fee schedule,267.24,1159.49,
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,267.24,1159.49,APC
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,267.24,1159.49,APC
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,267.24,1159.49,APC
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,470.34,,,,,,,fee schedule,308.35,1159.49,
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,384.97,,,,,,,fee schedule,308.35,1159.49,
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,308.35,,,,,,,fee schedule,308.35,1159.49,
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,540.89,,,,,,,fee schedule,308.35,1159.49,
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,308.35,1159.49,APC
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,308.35,1159.49,APC
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,308.35,1159.49,APC
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,461.51,,,,,,,fee schedule,302.57,1159.49,
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,377.75,,,,,,,fee schedule,302.57,1159.49,
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,302.57,,,,,,,fee schedule,302.57,1159.49,
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,530.74,,,,,,,fee schedule,302.57,1159.49,
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,302.57,1159.49,APC
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,302.57,1159.49,APC
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,302.57,1159.49,APC
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,482.06,,,,,,,fee schedule,316.04,1159.49,
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,394.57,,,,,,,fee schedule,316.04,1159.49,
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.04,,,,,,,fee schedule,316.04,1159.49,
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,554.37,,,,,,,fee schedule,316.04,1159.49,
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,316.04,1159.49,APC
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,316.04,1159.49,APC
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,316.04,1159.49,APC
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,501.66,,,,,,,fee schedule,328.89,1159.49,
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,410.61,,,,,,,fee schedule,328.89,1159.49,
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,328.89,,,,,,,fee schedule,328.89,1159.49,
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,576.91,,,,,,,fee schedule,328.89,1159.49,
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,328.89,1159.49,APC
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,328.89,1159.49,APC
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,328.89,1159.49,APC
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.29,,,,,,,fee schedule,277.51,1159.49,
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.46,,,,,,,fee schedule,277.51,1159.49,
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.51,,,,,,,fee schedule,277.51,1159.49,
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.78,,,,,,,fee schedule,277.51,1159.49,
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,277.51,1159.49,APC
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,277.51,1159.49,APC
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,277.51,1159.49,APC
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,446.8,,,,,,,fee schedule,292.92,1159.49,
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,365.71,,,,,,,fee schedule,292.92,1159.49,
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,292.92,,,,,,,fee schedule,292.92,1159.49,
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,513.82,,,,,,,fee schedule,292.92,1159.49,
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,292.92,1159.49,APC
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,292.92,1159.49,APC
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,292.92,1159.49,APC
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,475.22,,,,,,,fee schedule,311.55,1159.49,
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,388.97,,,,,,,fee schedule,311.55,1159.49,
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,311.55,,,,,,,fee schedule,311.55,1159.49,
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,546.5,,,,,,,fee schedule,311.55,1159.49,
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,311.55,1159.49,APC
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,311.55,1159.49,APC
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,311.55,1159.49,APC
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,462.47,,,,,,,fee schedule,303.2,1159.49,
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,378.53,,,,,,,fee schedule,303.2,1159.49,
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,303.2,,,,,,,fee schedule,303.2,1159.49,
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,531.84,,,,,,,fee schedule,303.2,1159.49,
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,303.2,1159.49,APC
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,303.2,1159.49,APC
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,303.2,1159.49,APC
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.73,,,,,,,fee schedule,326.97,1159.49,
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408.21,,,,,,,fee schedule,326.97,1159.49,
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.97,,,,,,,fee schedule,326.97,1159.49,
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,573.54,,,,,,,fee schedule,326.97,1159.49,
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,326.97,1159.49,APC
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,326.97,1159.49,APC
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,326.97,1159.49,APC
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,529.12,,,,,,,fee schedule,346.89,1159.49,
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,433.08,,,,,,,fee schedule,346.89,1159.49,
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,346.89,,,,,,,fee schedule,346.89,1159.49,
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,608.49,,,,,,,fee schedule,346.89,1159.49,
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,346.89,1159.49,APC
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,346.89,1159.49,APC
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,346.89,1159.49,APC
Inlay composite/resin one su,D2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,278.24,,,,,,,fee schedule,182.41,1159.49,
Inlay composite/resin one su,D2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.74,,,,,,,fee schedule,182.41,1159.49,
Inlay composite/resin one su,D2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.41,,,,,,,fee schedule,182.41,1159.49,
Inlay composite/resin one su,D2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.98,,,,,,,fee schedule,182.41,1159.49,
Inlay composite/resin one su,D2650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,182.41,1159.49,APC
Inlay composite/resin one su,D2650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,182.41,1159.49,APC
Inlay composite/resin one su,D2650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,182.41,1159.49,APC
Inlay composite/resin two su,D2651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,331.15,,,,,,,fee schedule,217.1,1159.49,
Inlay composite/resin two su,D2651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,271.05,,,,,,,fee schedule,217.1,1159.49,
Inlay composite/resin two su,D2651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.1,,,,,,,fee schedule,217.1,1159.49,
Inlay composite/resin two su,D2651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.82,,,,,,,fee schedule,217.1,1159.49,
Inlay composite/resin two su,D2651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,217.1,1159.49,APC
Inlay composite/resin two su,D2651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,217.1,1159.49,APC
Inlay composite/resin two su,D2651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,217.1,1159.49,APC
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.81,,,,,,,fee schedule,228.02,1159.49,
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.68,,,,,,,fee schedule,228.02,1159.49,
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,228.02,,,,,,,fee schedule,228.02,1159.49,
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.98,,,,,,,fee schedule,228.02,1159.49,
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,228.02,1159.49,APC
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,228.02,1159.49,APC
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,228.02,1159.49,APC
Dental onlay resin 2 surface,D2662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,301.78,,,,,,,fee schedule,197.85,1159.49,
Dental onlay resin 2 surface,D2662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,247.01,,,,,,,fee schedule,197.85,1159.49,
Dental onlay resin 2 surface,D2662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.85,,,,,,,fee schedule,197.85,1159.49,
Dental onlay resin 2 surface,D2662,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,347.05,,,,,,,fee schedule,197.85,1159.49,
Dental onlay resin 2 surface,D2662,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,197.85,1159.49,APC
Dental onlay resin 2 surface,D2662,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,197.85,1159.49,APC
Dental onlay resin 2 surface,D2662,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,197.85,1159.49,APC
Dental onlay resin 3 surface,D2663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,355.68,,,,,,,fee schedule,233.18,1159.49,
Dental onlay resin 3 surface,D2663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.12,,,,,,,fee schedule,233.18,1159.49,
Dental onlay resin 3 surface,D2663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.18,,,,,,,fee schedule,233.18,1159.49,
Dental onlay resin 3 surface,D2663,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,409.03,,,,,,,fee schedule,233.18,1159.49,
Dental onlay resin 3 surface,D2663,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,233.18,1159.49,APC
Dental onlay resin 3 surface,D2663,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,233.18,1159.49,APC
Dental onlay resin 3 surface,D2663,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,233.18,1159.49,APC
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,381.18,,,,,,,fee schedule,249.9,1159.49,
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312,,,,,,,fee schedule,249.9,1159.49,
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.9,,,,,,,fee schedule,249.9,1159.49,
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.36,,,,,,,fee schedule,249.9,1159.49,
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,249.9,1159.49,APC
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,249.9,1159.49,APC
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,249.9,1159.49,APC
Crown resin-based indirect,D2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.6,,,,,,,fee schedule,140.69,1159.49,
Crown resin-based indirect,D2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.65,,,,,,,fee schedule,140.69,1159.49,
Crown resin-based indirect,D2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.69,,,,,,,fee schedule,140.69,1159.49,
Crown resin-based indirect,D2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.79,,,,,,,fee schedule,140.69,1159.49,
Crown resin-based indirect,D2710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,140.69,1159.49,APC
Crown resin-based indirect,D2710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,140.69,1159.49,APC
Crown resin-based indirect,D2710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,140.69,1159.49,APC
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.6,,,,,,,fee schedule,140.69,1159.49,
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.65,,,,,,,fee schedule,140.69,1159.49,
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.69,,,,,,,fee schedule,140.69,1159.49,
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.79,,,,,,,fee schedule,140.69,1159.49,
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,140.69,1159.49,APC
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,140.69,1159.49,APC
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,140.69,1159.49,APC
Crown resin w/ high noble me,D2720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,529.12,,,,,,,fee schedule,346.89,1159.49,
Crown resin w/ high noble me,D2720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,433.08,,,,,,,fee schedule,346.89,1159.49,
Crown resin w/ high noble me,D2720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,346.89,,,,,,,fee schedule,346.89,1159.49,
Crown resin w/ high noble me,D2720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,608.49,,,,,,,fee schedule,346.89,1159.49,
Crown resin w/ high noble me,D2720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,346.89,1159.49,APC
Crown resin w/ high noble me,D2720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,346.89,1159.49,APC
Crown resin w/ high noble me,D2720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,346.89,1159.49,APC
Crown resin w/ base metal,D2721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,495.82,,,,,,,fee schedule,325.06,1159.49,
Crown resin w/ base metal,D2721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,405.83,,,,,,,fee schedule,325.06,1159.49,
Crown resin w/ base metal,D2721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.06,,,,,,,fee schedule,325.06,1159.49,
Crown resin w/ base metal,D2721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,570.19,,,,,,,fee schedule,325.06,1159.49,
Crown resin w/ base metal,D2721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,325.06,1159.49,APC
Crown resin w/ base metal,D2721,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,325.06,1159.49,APC
Crown resin w/ base metal,D2721,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,325.06,1159.49,APC
Crown resin w/ noble metal,D2722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,506.54,,,,,,,fee schedule,332.09,1159.49,
Crown resin w/ noble metal,D2722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,414.6,,,,,,,fee schedule,332.09,1159.49,
Crown resin w/ noble metal,D2722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,332.09,,,,,,,fee schedule,332.09,1159.49,
Crown resin w/ noble metal,D2722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,582.52,,,,,,,fee schedule,332.09,1159.49,
Crown resin w/ noble metal,D2722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,332.09,1159.49,APC
Crown resin w/ noble metal,D2722,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,332.09,1159.49,APC
Crown resin w/ noble metal,D2722,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,332.09,1159.49,APC
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,542.83,,,,,,,fee schedule,355.88,1159.49,
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,444.31,,,,,,,fee schedule,355.88,1159.49,
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,355.88,,,,,,,fee schedule,355.88,1159.49,
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,624.25,,,,,,,fee schedule,355.88,1159.49,
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,355.88,1159.49,APC
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,355.88,1159.49,APC
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,355.88,1159.49,APC
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.99,,,,,,,fee schedule,350.74,1159.49,
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.89,,,,,,,fee schedule,350.74,1159.49,
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.74,,,,,,,fee schedule,350.74,1159.49,
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,615.24,,,,,,,fee schedule,350.74,1159.49,
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,350.74,1159.49,APC
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,350.74,1159.49,APC
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,350.74,1159.49,APC
Crown porcelain fused base m,D2751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.73,,,,,,,fee schedule,326.97,1159.49,
Crown porcelain fused base m,D2751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408.21,,,,,,,fee schedule,326.97,1159.49,
Crown porcelain fused base m,D2751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.97,,,,,,,fee schedule,326.97,1159.49,
Crown porcelain fused base m,D2751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,573.54,,,,,,,fee schedule,326.97,1159.49,
Crown porcelain fused base m,D2751,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,326.97,1159.49,APC
Crown porcelain fused base m,D2751,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,326.97,1159.49,APC
Crown porcelain fused base m,D2751,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,326.97,1159.49,APC
Crown porcelain w/ noble met,D2752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,510.5,,,,,,,fee schedule,334.68,1159.49,
Crown porcelain w/ noble met,D2752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,417.84,,,,,,,fee schedule,334.68,1159.49,
Crown porcelain w/ noble met,D2752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.68,,,,,,,fee schedule,334.68,1159.49,
Crown porcelain w/ noble met,D2752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.08,,,,,,,fee schedule,334.68,1159.49,
Crown porcelain w/ noble met,D2752,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,334.68,1159.49,APC
Crown porcelain w/ noble met,D2752,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,334.68,1159.49,APC
Crown porcelain w/ noble met,D2752,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,334.68,1159.49,APC
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,513.44,,,,,,,fee schedule,336.61,1159.49,
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,420.25,,,,,,,fee schedule,336.61,1159.49,
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,336.61,,,,,,,fee schedule,336.61,1159.49,
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,590.46,,,,,,,fee schedule,336.61,1159.49,
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,336.61,1159.49,APC
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,336.61,1159.49,APC
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,336.61,1159.49,APC
Crown 3/4 cast base metal,D2781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,483.06,,,,,,,fee schedule,316.69,1159.49,
Crown 3/4 cast base metal,D2781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.38,,,,,,,fee schedule,316.69,1159.49,
Crown 3/4 cast base metal,D2781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.69,,,,,,,fee schedule,316.69,1159.49,
Crown 3/4 cast base metal,D2781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,555.52,,,,,,,fee schedule,316.69,1159.49,
Crown 3/4 cast base metal,D2781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,316.69,1159.49,APC
Crown 3/4 cast base metal,D2781,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,316.69,1159.49,APC
Crown 3/4 cast base metal,D2781,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,316.69,1159.49,APC
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,499.7,,,,,,,fee schedule,327.6,1159.49,
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,409,,,,,,,fee schedule,327.6,1159.49,
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,327.6,,,,,,,fee schedule,327.6,1159.49,
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,574.66,,,,,,,fee schedule,327.6,1159.49,
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,327.6,1159.49,APC
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,327.6,1159.49,APC
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,327.6,1159.49,APC
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,528.14,,,,,,,fee schedule,346.25,1159.49,
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,432.28,,,,,,,fee schedule,346.25,1159.49,
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,346.25,,,,,,,fee schedule,346.25,1159.49,
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,607.36,,,,,,,fee schedule,346.25,1159.49,
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,346.25,1159.49,APC
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,346.25,1159.49,APC
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,346.25,1159.49,APC
Crown full cast high noble m,D2790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,517.36,,,,,,,fee schedule,339.18,1159.49,
Crown full cast high noble m,D2790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,423.46,,,,,,,fee schedule,339.18,1159.49,
Crown full cast high noble m,D2790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,339.18,,,,,,,fee schedule,339.18,1159.49,
Crown full cast high noble m,D2790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,594.96,,,,,,,fee schedule,339.18,1159.49,
Crown full cast high noble m,D2790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,339.18,1159.49,APC
Crown full cast high noble m,D2790,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,339.18,1159.49,APC
Crown full cast high noble m,D2790,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,339.18,1159.49,APC
Crown full cast base metal,D2791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,489.9,,,,,,,fee schedule,321.18,1159.49,
Crown full cast base metal,D2791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,400.98,,,,,,,fee schedule,321.18,1159.49,
Crown full cast base metal,D2791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,321.18,,,,,,,fee schedule,321.18,1159.49,
Crown full cast base metal,D2791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,563.39,,,,,,,fee schedule,321.18,1159.49,
Crown full cast base metal,D2791,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,321.18,1159.49,APC
Crown full cast base metal,D2791,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,321.18,1159.49,APC
Crown full cast base metal,D2791,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,321.18,1159.49,APC
Crown full cast noble metal,D2792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.73,,,,,,,fee schedule,326.97,1159.49,
Crown full cast noble metal,D2792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408.21,,,,,,,fee schedule,326.97,1159.49,
Crown full cast noble metal,D2792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.97,,,,,,,fee schedule,326.97,1159.49,
Crown full cast noble metal,D2792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,573.54,,,,,,,fee schedule,326.97,1159.49,
Crown full cast noble metal,D2792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,326.97,1159.49,APC
Crown full cast noble metal,D2792,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,326.97,1159.49,APC
Crown full cast noble metal,D2792,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,326.97,1159.49,APC
Crown-titanium,D2794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,529.12,,,,,,,fee schedule,346.89,1159.49,
Crown-titanium,D2794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,433.08,,,,,,,fee schedule,346.89,1159.49,
Crown-titanium,D2794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,346.89,,,,,,,fee schedule,346.89,1159.49,
Crown-titanium,D2794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,608.49,,,,,,,fee schedule,346.89,1159.49,
Crown-titanium,D2794,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,346.89,1159.49,APC
Crown-titanium,D2794,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,346.89,1159.49,APC
Crown-titanium,D2794,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,346.89,1159.49,APC
Provisional crown,D2799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.6,,,,,,,fee schedule,140.69,1159.49,
Provisional crown,D2799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.65,,,,,,,fee schedule,140.69,1159.49,
Provisional crown,D2799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.69,,,,,,,fee schedule,140.69,1159.49,
Provisional crown,D2799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.79,,,,,,,fee schedule,140.69,1159.49,
Provisional crown,D2799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,140.69,1159.49,APC
Provisional crown,D2799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,140.69,1159.49,APC
Provisional crown,D2799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,140.69,1159.49,APC
Recement inlay onlay or part,D2910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.11,,,,,,,fee schedule,28.26,1159.49,
Recement inlay onlay or part,D2910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.29,,,,,,,fee schedule,28.26,1159.49,
Recement inlay onlay or part,D2910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.26,,,,,,,fee schedule,28.26,1159.49,
Recement inlay onlay or part,D2910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.58,,,,,,,fee schedule,28.26,1159.49,
Recement inlay onlay or part,D2910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,28.26,1159.49,APC
Recement inlay onlay or part,D2910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,28.26,1159.49,APC
Recement inlay onlay or part,D2910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,28.26,1159.49,APC
Recement cast or prefab post,D2915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.11,,,,,,,fee schedule,28.26,1159.49,
Recement cast or prefab post,D2915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.29,,,,,,,fee schedule,28.26,1159.49,
Recement cast or prefab post,D2915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.26,,,,,,,fee schedule,28.26,1159.49,
Recement cast or prefab post,D2915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.58,,,,,,,fee schedule,28.26,1159.49,
Recement cast or prefab post,D2915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,28.26,1159.49,APC
Recement cast or prefab post,D2915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,28.26,1159.49,APC
Recement cast or prefab post,D2915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,28.26,1159.49,APC
Re-cement or re-bond crown,D2920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.09,,,,,,,fee schedule,28.91,1159.49,
Re-cement or re-bond crown,D2920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,28.91,1159.49,
Re-cement or re-bond crown,D2920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,28.91,1159.49,
Re-cement or re-bond crown,D2920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.7,,,,,,,fee schedule,28.91,1159.49,
Re-cement or re-bond crown,D2920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,28.91,1159.49,APC
Re-cement or re-bond crown,D2920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,28.91,1159.49,APC
Re-cement or re-bond crown,D2920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,28.91,1159.49,APC
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,1159.49,
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,1159.49,
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,1159.49,
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,1159.49,
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,79.01,1159.49,APC
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,79.01,1159.49,APC
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,79.01,1159.49,APC
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.21,,,,,,,fee schedule,89.3,1159.49,
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,111.49,,,,,,,fee schedule,89.3,1159.49,
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.3,,,,,,,fee schedule,89.3,1159.49,
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,156.64,,,,,,,fee schedule,89.3,1159.49,
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,89.3,1159.49,APC
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,89.3,1159.49,APC
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,89.3,1159.49,APC
Prefabricated resin crown,D2932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.05,,,,,,,fee schedule,95.09,1159.49,
Prefabricated resin crown,D2932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.72,,,,,,,fee schedule,95.09,1159.49,
Prefabricated resin crown,D2932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.09,,,,,,,fee schedule,95.09,1159.49,
Prefabricated resin crown,D2932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,166.81,,,,,,,fee schedule,95.09,1159.49,
Prefabricated resin crown,D2932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,95.09,1159.49,APC
Prefabricated resin crown,D2932,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,95.09,1159.49,APC
Prefabricated resin crown,D2932,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,95.09,1159.49,APC
Prefab stainless steel crown,D2933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.59,,,,,,,fee schedule,108.56,1159.49,
Prefab stainless steel crown,D2933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.54,,,,,,,fee schedule,108.56,1159.49,
Prefab stainless steel crown,D2933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.56,,,,,,,fee schedule,108.56,1159.49,
Prefab stainless steel crown,D2933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.43,,,,,,,fee schedule,108.56,1159.49,
Prefab stainless steel crown,D2933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,108.56,1159.49,APC
Prefab stainless steel crown,D2933,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,108.56,1159.49,APC
Prefab stainless steel crown,D2933,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,108.56,1159.49,APC
Prefab steel crown primary,D2934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.59,,,,,,,fee schedule,108.56,1159.49,
Prefab steel crown primary,D2934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.54,,,,,,,fee schedule,108.56,1159.49,
Prefab steel crown primary,D2934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.56,,,,,,,fee schedule,108.56,1159.49,
Prefab steel crown primary,D2934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.43,,,,,,,fee schedule,108.56,1159.49,
Prefab steel crown primary,D2934,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,108.56,1159.49,APC
Prefab steel crown primary,D2934,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,108.56,1159.49,APC
Prefab steel crown primary,D2934,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,108.56,1159.49,APC
Protective restoration,D2940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,1159.49,
Protective restoration,D2940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,1159.49,
Protective restoration,D2940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,1159.49,
Protective restoration,D2940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,1159.49,
Protective restoration,D2940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,30.19,1159.49,APC
Protective restoration,D2940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,30.19,1159.49,APC
Protective restoration,D2940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,30.19,1159.49,APC
Core build-up incl any pins,D2950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.64,,,,,,,fee schedule,75.16,1159.49,
Core build-up incl any pins,D2950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.83,,,,,,,fee schedule,75.16,1159.49,
Core build-up incl any pins,D2950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.16,,,,,,,fee schedule,75.16,1159.49,
Core build-up incl any pins,D2950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.84,,,,,,,fee schedule,75.16,1159.49,
Core build-up incl any pins,D2950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,75.16,1159.49,APC
Core build-up incl any pins,D2950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,75.16,1159.49,APC
Core build-up incl any pins,D2950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,75.16,1159.49,APC
Tooth pin retention,D2951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.47,,,,,,,fee schedule,16.7,1159.49,
Tooth pin retention,D2951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.85,,,,,,,fee schedule,16.7,1159.49,
Tooth pin retention,D2951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.7,,,,,,,fee schedule,16.7,1159.49,
Tooth pin retention,D2951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.29,,,,,,,fee schedule,16.7,1159.49,
Tooth pin retention,D2951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,16.7,1159.49,APC
Tooth pin retention,D2951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,16.7,1159.49,APC
Tooth pin retention,D2951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,16.7,1159.49,APC
Post and core cast + crown,D2952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,1159.49,
Post and core cast + crown,D2952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,1159.49,
Post and core cast + crown,D2952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,1159.49,
Post and core cast + crown,D2952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,1159.49,
Post and core cast + crown,D2952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,118.83,1159.49,APC
Post and core cast + crown,D2952,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,118.83,1159.49,APC
Post and core cast + crown,D2952,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,118.83,1159.49,APC
Each addtnl cast post,D2953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.13,,,,,,,fee schedule,59.09,103.65,
Each addtnl cast post,D2953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.77,,,,,,,fee schedule,59.09,103.65,
Each addtnl cast post,D2953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.09,,,,,,,fee schedule,59.09,103.65,
Each addtnl cast post,D2953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.65,,,,,,,fee schedule,59.09,103.65,
Prefab post/core + crown,D2954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.05,,,,,,,fee schedule,95.09,1159.49,
Prefab post/core + crown,D2954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.72,,,,,,,fee schedule,95.09,1159.49,
Prefab post/core + crown,D2954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.09,,,,,,,fee schedule,95.09,1159.49,
Prefab post/core + crown,D2954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,166.81,,,,,,,fee schedule,95.09,1159.49,
Prefab post/core + crown,D2954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,95.09,1159.49,APC
Prefab post/core + crown,D2954,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,95.09,1159.49,APC
Prefab post/core + crown,D2954,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,95.09,1159.49,APC
Post removal,D2955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.67,,,,,,,fee schedule,73.21,128.42,
Post removal,D2955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.4,,,,,,,fee schedule,73.21,128.42,
Post removal,D2955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.21,,,,,,,fee schedule,73.21,128.42,
Post removal,D2955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.42,,,,,,,fee schedule,73.21,128.42,
Each addtnl prefab post,D2957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.51,,,,,,,fee schedule,47.54,1159.49,
Each addtnl prefab post,D2957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.35,,,,,,,fee schedule,47.54,1159.49,
Each addtnl prefab post,D2957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.54,,,,,,,fee schedule,47.54,1159.49,
Each addtnl prefab post,D2957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.39,,,,,,,fee schedule,47.54,1159.49,
Each addtnl prefab post,D2957,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,47.54,1159.49,APC
Each addtnl prefab post,D2957,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,47.54,1159.49,APC
Each addtnl prefab post,D2957,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,47.54,1159.49,APC
Laminate labial veneer,D2960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,350.77,,,,,,,fee schedule,229.96,1159.49,
Laminate labial veneer,D2960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,287.11,,,,,,,fee schedule,229.96,1159.49,
Laminate labial veneer,D2960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,229.96,,,,,,,fee schedule,229.96,1159.49,
Laminate labial veneer,D2960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,403.39,,,,,,,fee schedule,229.96,1159.49,
Laminate labial veneer,D2960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,229.96,1159.49,APC
Laminate labial veneer,D2960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,229.96,1159.49,APC
Laminate labial veneer,D2960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,229.96,1159.49,APC
Lab labial veneer resin,D2961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,397.83,,,,,,,fee schedule,260.82,1159.49,
Lab labial veneer resin,D2961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,325.62,,,,,,,fee schedule,260.82,1159.49,
Lab labial veneer resin,D2961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,260.82,,,,,,,fee schedule,260.82,1159.49,
Lab labial veneer resin,D2961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,457.5,,,,,,,fee schedule,260.82,1159.49,
Lab labial veneer resin,D2961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,260.82,1159.49,APC
Lab labial veneer resin,D2961,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,260.82,1159.49,APC
Lab labial veneer resin,D2961,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,260.82,1159.49,APC
Lab labial veneer porcelain,D2962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,432.12,,,,,,,fee schedule,283.3,1159.49,
Lab labial veneer porcelain,D2962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.69,,,,,,,fee schedule,283.3,1159.49,
Lab labial veneer porcelain,D2962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.3,,,,,,,fee schedule,283.3,1159.49,
Lab labial veneer porcelain,D2962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.94,,,,,,,fee schedule,283.3,1159.49,
Lab labial veneer porcelain,D2962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,283.3,1159.49,APC
Lab labial veneer porcelain,D2962,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,283.3,1159.49,APC
Lab labial veneer porcelain,D2962,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,283.3,1159.49,APC
Add proc construct new crown,D2971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,45.6,1159.49,
Add proc construct new crown,D2971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,45.6,1159.49,
Add proc construct new crown,D2971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,45.6,1159.49,
Add proc construct new crown,D2971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,45.6,1159.49,
Add proc construct new crown,D2971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,45.6,1159.49,APC
Add proc construct new crown,D2971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,45.6,1159.49,APC
Add proc construct new crown,D2971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,45.6,1159.49,APC
Coping,D2975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.63,,,,,,,fee schedule,138.74,1159.49,
Coping,D2975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.22,,,,,,,fee schedule,138.74,1159.49,
Coping,D2975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.74,,,,,,,fee schedule,138.74,1159.49,
Coping,D2975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.37,,,,,,,fee schedule,138.74,1159.49,
Coping,D2975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,138.74,1159.49,APC
Coping,D2975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,138.74,1159.49,APC
Coping,D2975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,138.74,1159.49,APC
Pulp cap direct,D3110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,1159.49,
Pulp cap direct,D3110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,1159.49,
Pulp cap direct,D3110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,1159.49,
Pulp cap direct,D3110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,1159.49,
Pulp cap direct,D3110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,23.77,1159.49,APC
Pulp cap direct,D3110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,23.77,1159.49,APC
Pulp cap direct,D3110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,23.77,1159.49,APC
Pulp cap indirect,D3120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.4,,,,,,,fee schedule,19.27,1159.49,
Pulp cap indirect,D3120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.06,,,,,,,fee schedule,19.27,1159.49,
Pulp cap indirect,D3120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.27,,,,,,,fee schedule,19.27,1159.49,
Pulp cap indirect,D3120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.81,,,,,,,fee schedule,19.27,1159.49,
Pulp cap indirect,D3120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,19.27,1159.49,APC
Pulp cap indirect,D3120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,19.27,1159.49,APC
Pulp cap indirect,D3120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,19.27,1159.49,APC
Therapeutic pulpotomy,D3220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.47,,,,,,,fee schedule,48.82,1159.49,
Therapeutic pulpotomy,D3220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.95,,,,,,,fee schedule,48.82,1159.49,
Therapeutic pulpotomy,D3220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.82,,,,,,,fee schedule,48.82,1159.49,
Therapeutic pulpotomy,D3220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.64,,,,,,,fee schedule,48.82,1159.49,
Therapeutic pulpotomy,D3220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,48.82,1159.49,APC
Therapeutic pulpotomy,D3220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,48.82,1159.49,APC
Therapeutic pulpotomy,D3220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,48.82,1159.49,APC
Gross pulpal debridement,D3221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.32,,,,,,,fee schedule,53.31,1159.49,
Gross pulpal debridement,D3221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.56,,,,,,,fee schedule,53.31,1159.49,
Gross pulpal debridement,D3221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.31,,,,,,,fee schedule,53.31,1159.49,
Gross pulpal debridement,D3221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.52,,,,,,,fee schedule,53.31,1159.49,
Gross pulpal debridement,D3221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,53.31,1159.49,APC
Gross pulpal debridement,D3221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,53.31,1159.49,APC
Gross pulpal debridement,D3221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,53.31,1159.49,APC
Part pulp for apexogenesis,D3222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.44,,,,,,,fee schedule,49.46,1159.49,
Part pulp for apexogenesis,D3222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.75,,,,,,,fee schedule,49.46,1159.49,
Part pulp for apexogenesis,D3222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.46,,,,,,,fee schedule,49.46,1159.49,
Part pulp for apexogenesis,D3222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.76,,,,,,,fee schedule,49.46,1159.49,
Part pulp for apexogenesis,D3222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,49.46,1159.49,APC
Part pulp for apexogenesis,D3222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,49.46,1159.49,APC
Part pulp for apexogenesis,D3222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,49.46,1159.49,APC
Pulpal therapy anterior prim,D3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,1159.49,
Pulpal therapy anterior prim,D3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,1159.49,
Pulpal therapy anterior prim,D3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,1159.49,
Pulpal therapy anterior prim,D3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,1159.49,
Pulpal therapy anterior prim,D3230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,51.38,1159.49,APC
Pulpal therapy anterior prim,D3230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,51.38,1159.49,APC
Pulpal therapy anterior prim,D3230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,51.38,1159.49,APC
Pulpal therapy posterior pri,D3240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97,,,,,,,fee schedule,63.59,1159.49,
Pulpal therapy posterior pri,D3240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.39,,,,,,,fee schedule,63.59,1159.49,
Pulpal therapy posterior pri,D3240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.59,,,,,,,fee schedule,63.59,1159.49,
Pulpal therapy posterior pri,D3240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.55,,,,,,,fee schedule,63.59,1159.49,
Pulpal therapy posterior pri,D3240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,63.59,1159.49,APC
Pulpal therapy posterior pri,D3240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,63.59,1159.49,APC
Pulpal therapy posterior pri,D3240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,63.59,1159.49,APC
"End thxpy, anterior tooth",D3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,308.64,,,,,,,fee schedule,202.34,1159.49,
"End thxpy, anterior tooth",D3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,252.62,,,,,,,fee schedule,202.34,1159.49,
"End thxpy, anterior tooth",D3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.34,,,,,,,fee schedule,202.34,1159.49,
"End thxpy, anterior tooth",D3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,354.94,,,,,,,fee schedule,202.34,1159.49,
"End thxpy, anterior tooth",D3310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,202.34,1159.49,APC
"End thxpy, anterior tooth",D3310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,202.34,1159.49,APC
"End thxpy, anterior tooth",D3310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,202.34,1159.49,APC
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,377.23,,,,,,,fee schedule,247.31,1159.49,
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,308.76,,,,,,,fee schedule,247.31,1159.49,
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,247.31,,,,,,,fee schedule,247.31,1159.49,
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,433.81,,,,,,,fee schedule,247.31,1159.49,
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,247.31,1159.49,APC
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,247.31,1159.49,APC
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,247.31,1159.49,APC
"End thxpy, molar",D3330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,468.36,,,,,,,fee schedule,307.06,1159.49,
"End thxpy, molar",D3330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,383.35,,,,,,,fee schedule,307.06,1159.49,
"End thxpy, molar",D3330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,307.06,,,,,,,fee schedule,307.06,1159.49,
"End thxpy, molar",D3330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,538.61,,,,,,,fee schedule,307.06,1159.49,
"End thxpy, molar",D3330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,307.06,1159.49,APC
"End thxpy, molar",D3330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,307.06,1159.49,APC
"End thxpy, molar",D3330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,307.06,1159.49,APC
Non-surg tx root canal obs,D3331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,1159.49,
Non-surg tx root canal obs,D3331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,1159.49,
Non-surg tx root canal obs,D3331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,1159.49,
Non-surg tx root canal obs,D3331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,1159.49,
Non-surg tx root canal obs,D3331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,79.01,1159.49,APC
Non-surg tx root canal obs,D3331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,79.01,1159.49,APC
Non-surg tx root canal obs,D3331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,79.01,1159.49,APC
Incomplete endodontic tx,D3332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.28,,,,,,,fee schedule,150.32,1159.49,
Incomplete endodontic tx,D3332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.67,,,,,,,fee schedule,150.32,1159.49,
Incomplete endodontic tx,D3332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.32,,,,,,,fee schedule,150.32,1159.49,
Incomplete endodontic tx,D3332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.67,,,,,,,fee schedule,150.32,1159.49,
Incomplete endodontic tx,D3332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,150.32,1159.49,APC
Incomplete endodontic tx,D3332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,150.32,1159.49,APC
Incomplete endodontic tx,D3332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,150.32,1159.49,APC
Internal root repair,D3333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.81,,,,,,,fee schedule,69.37,1159.49,
Internal root repair,D3333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.61,,,,,,,fee schedule,69.37,1159.49,
Internal root repair,D3333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.37,,,,,,,fee schedule,69.37,1159.49,
Internal root repair,D3333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.68,,,,,,,fee schedule,69.37,1159.49,
Internal root repair,D3333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,69.37,1159.49,APC
Internal root repair,D3333,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,69.37,1159.49,APC
Internal root repair,D3333,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,69.37,1159.49,APC
Retreat root canal anterior,D3346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,411.52,,,,,,,fee schedule,269.79,1159.49,
Retreat root canal anterior,D3346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,336.83,,,,,,,fee schedule,269.79,1159.49,
Retreat root canal anterior,D3346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,269.79,,,,,,,fee schedule,269.79,1159.49,
Retreat root canal anterior,D3346,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,473.25,,,,,,,fee schedule,269.79,1159.49,
Retreat root canal anterior,D3346,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,269.79,1159.49,APC
Retreat root canal anterior,D3346,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,269.79,1159.49,APC
Retreat root canal anterior,D3346,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,269.79,1159.49,APC
Retreat root canal bicuspid,D3347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,483.06,,,,,,,fee schedule,316.69,1159.49,
Retreat root canal bicuspid,D3347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.38,,,,,,,fee schedule,316.69,1159.49,
Retreat root canal bicuspid,D3347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.69,,,,,,,fee schedule,316.69,1159.49,
Retreat root canal bicuspid,D3347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,555.52,,,,,,,fee schedule,316.69,1159.49,
Retreat root canal bicuspid,D3347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,316.69,1159.49,APC
Retreat root canal bicuspid,D3347,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,316.69,1159.49,APC
Retreat root canal bicuspid,D3347,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,316.69,1159.49,APC
Retreat root canal molar,D3348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,598.67,,,,,,,fee schedule,392.49,1159.49,
Retreat root canal molar,D3348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,490.01,,,,,,,fee schedule,392.49,1159.49,
Retreat root canal molar,D3348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,392.49,,,,,,,fee schedule,392.49,1159.49,
Retreat root canal molar,D3348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,688.47,,,,,,,fee schedule,392.49,1159.49,
Retreat root canal molar,D3348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,392.49,1159.49,APC
Retreat root canal molar,D3348,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,392.49,1159.49,APC
Retreat root canal molar,D3348,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,392.49,1159.49,APC
Apexification/recalc initial,D3351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,175.38,,,,,,,fee schedule,114.98,1159.49,
Apexification/recalc initial,D3351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,143.55,,,,,,,fee schedule,114.98,1159.49,
Apexification/recalc initial,D3351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.98,,,,,,,fee schedule,114.98,1159.49,
Apexification/recalc initial,D3351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,201.69,,,,,,,fee schedule,114.98,1159.49,
Apexification/recalc initial,D3351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,114.98,1159.49,APC
Apexification/recalc initial,D3351,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,114.98,1159.49,APC
Apexification/recalc initial,D3351,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,114.98,1159.49,APC
Apexification/recalc interim,D3352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,1159.49,
Apexification/recalc interim,D3352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,1159.49,
Apexification/recalc interim,D3352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,1159.49,
Apexification/recalc interim,D3352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,1159.49,
Apexification/recalc interim,D3352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,51.38,1159.49,APC
Apexification/recalc interim,D3352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,51.38,1159.49,APC
Apexification/recalc interim,D3352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,51.38,1159.49,APC
Apexification/recalc final,D3353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.02,,,,,,,fee schedule,158.67,1159.49,
Apexification/recalc final,D3353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.09,,,,,,,fee schedule,158.67,1159.49,
Apexification/recalc final,D3353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.67,,,,,,,fee schedule,158.67,1159.49,
Apexification/recalc final,D3353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.32,,,,,,,fee schedule,158.67,1159.49,
Apexification/recalc final,D3353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,158.67,1159.49,APC
Apexification/recalc final,D3353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,158.67,1159.49,APC
Apexification/recalc final,D3353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,158.67,1159.49,APC
Apicoectomy - anterior,D3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.81,,,,,,,fee schedule,228.02,1159.49,
Apicoectomy - anterior,D3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.68,,,,,,,fee schedule,228.02,1159.49,
Apicoectomy - anterior,D3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,228.02,,,,,,,fee schedule,228.02,1159.49,
Apicoectomy - anterior,D3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.98,,,,,,,fee schedule,228.02,1159.49,
Apicoectomy - anterior,D3410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,228.02,1159.49,APC
Apicoectomy - anterior,D3410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,228.02,1159.49,APC
Apicoectomy - anterior,D3410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,228.02,1159.49,APC
Root surgery bicuspid,D3421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,387.04,,,,,,,fee schedule,253.74,1159.49,
Root surgery bicuspid,D3421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,316.79,,,,,,,fee schedule,253.74,1159.49,
Root surgery bicuspid,D3421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,253.74,,,,,,,fee schedule,253.74,1159.49,
Root surgery bicuspid,D3421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,445.1,,,,,,,fee schedule,253.74,1159.49,
Root surgery bicuspid,D3421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,253.74,1159.49,APC
Root surgery bicuspid,D3421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,253.74,1159.49,APC
Root surgery bicuspid,D3421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,253.74,1159.49,APC
Root surgery molar,D3425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.98,,,,,,,fee schedule,287.14,1159.49,
Root surgery molar,D3425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.49,,,,,,,fee schedule,287.14,1159.49,
Root surgery molar,D3425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,287.14,,,,,,,fee schedule,287.14,1159.49,
Root surgery molar,D3425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.68,,,,,,,fee schedule,287.14,1159.49,
Root surgery molar,D3425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,287.14,1159.49,APC
Root surgery molar,D3425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,287.14,1159.49,APC
Root surgery molar,D3425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,287.14,1159.49,APC
Root surgery ea add root,D3426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.95,,,,,,,fee schedule,97,170.14,
Root surgery ea add root,D3426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.1,,,,,,,fee schedule,97,170.14,
Root surgery ea add root,D3426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97,,,,,,,fee schedule,97,170.14,
Root surgery ea add root,D3426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.14,,,,,,,fee schedule,97,170.14,
Retrograde filling,D3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.77,,,,,,,fee schedule,71.31,1159.49,
Retrograde filling,D3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.03,,,,,,,fee schedule,71.31,1159.49,
Retrograde filling,D3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.31,,,,,,,fee schedule,71.31,1159.49,
Retrograde filling,D3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.09,,,,,,,fee schedule,71.31,1159.49,
Retrograde filling,D3430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,71.31,1159.49,APC
Retrograde filling,D3430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,71.31,1159.49,APC
Retrograde filling,D3430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,71.31,1159.49,APC
Root amputation,D3450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.34,,,,,,,fee schedule,148.39,1159.49,
Root amputation,D3450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.26,,,,,,,fee schedule,148.39,1159.49,
Root amputation,D3450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.39,,,,,,,fee schedule,148.39,1159.49,
Root amputation,D3450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.29,,,,,,,fee schedule,148.39,1159.49,
Root amputation,D3450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,148.39,1159.49,APC
Root amputation,D3450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,148.39,1159.49,APC
Root amputation,D3450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,148.39,1159.49,APC
Endodontic endosseous implan,D3460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Endodontic endosseous implan,D3460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Endodontic endosseous implan,D3460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Endodontic endosseous implan,D3460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Endodontic endosseous implan,D3460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Endodontic endosseous implan,D3460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Endodontic endosseous implan,D3460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Intentional replantation,D3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,432.12,,,,,,,fee schedule,283.3,1159.49,
Intentional replantation,D3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.69,,,,,,,fee schedule,283.3,1159.49,
Intentional replantation,D3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.3,,,,,,,fee schedule,283.3,1159.49,
Intentional replantation,D3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.94,,,,,,,fee schedule,283.3,1159.49,
Intentional replantation,D3470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,283.3,1159.49,APC
Intentional replantation,D3470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,283.3,1159.49,APC
Intentional replantation,D3470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,283.3,1159.49,APC
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.73,,,,,,,fee schedule,39.81,1159.49,
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.71,,,,,,,fee schedule,39.81,1159.49,
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.81,,,,,,,fee schedule,39.81,1159.49,
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.84,,,,,,,fee schedule,39.81,1159.49,
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,39.81,1159.49,APC
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,39.81,1159.49,APC
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,39.81,1159.49,APC
Tooth splitting,D3920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.43,,,,,,,fee schedule,113.05,1159.49,
Tooth splitting,D3920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.13,,,,,,,fee schedule,113.05,1159.49,
Tooth splitting,D3920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.05,,,,,,,fee schedule,113.05,1159.49,
Tooth splitting,D3920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.29,,,,,,,fee schedule,113.05,1159.49,
Tooth splitting,D3920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,113.05,1159.49,APC
Tooth splitting,D3920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,113.05,1159.49,APC
Tooth splitting,D3920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,113.05,1159.49,APC
Canal prep/fitting of dowel,D3950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,1159.49,
Canal prep/fitting of dowel,D3950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,1159.49,
Canal prep/fitting of dowel,D3950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,1159.49,
Canal prep/fitting of dowel,D3950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,1159.49,
Canal prep/fitting of dowel,D3950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,51.38,1159.49,APC
Canal prep/fitting of dowel,D3950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,51.38,1159.49,APC
Canal prep/fitting of dowel,D3950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,51.38,1159.49,APC
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.42,,,,,,,fee schedule,177.94,5946.37,
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.16,,,,,,,fee schedule,177.94,5946.37,
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.94,,,,,,,fee schedule,177.94,5946.37,
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.13,,,,,,,fee schedule,177.94,5946.37,
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,177.94,5946.37,APC
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,177.94,5946.37,APC
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,177.94,5946.37,APC
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,5946.37,
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,5946.37,
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,5946.37,
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,5946.37,
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,79.01,5946.37,APC
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,79.01,5946.37,APC
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,79.01,5946.37,APC
Gingivectomy/plasty rest,D4212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,3303.54,5946.37,APC
Gingivectomy/plasty rest,D4212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,3303.54,5946.37,APC
Gingivectomy/plasty rest,D4212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,3303.54,5946.37,APC
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,381.18,,,,,,,fee schedule,249.9,5946.37,
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312,,,,,,,fee schedule,249.9,5946.37,
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.9,,,,,,,fee schedule,249.9,5946.37,
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.36,,,,,,,fee schedule,249.9,5946.37,
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,249.9,5946.37,APC
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,249.9,5946.37,APC
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,249.9,5946.37,APC
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,2782.81,
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,2782.81,
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,2782.81,
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,2782.81,
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,118.83,2782.81,APC
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,118.83,2782.81,APC
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,118.83,2782.81,APC
Gingival flap proc w/ planin,D4240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,343.93,,,,,,,fee schedule,225.48,5946.37,
Gingival flap proc w/ planin,D4240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,281.51,,,,,,,fee schedule,225.48,5946.37,
Gingival flap proc w/ planin,D4240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,225.48,,,,,,,fee schedule,225.48,5946.37,
Gingival flap proc w/ planin,D4240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,395.52,,,,,,,fee schedule,225.48,5946.37,
Gingival flap proc w/ planin,D4240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,225.48,5946.37,APC
Gingival flap proc w/ planin,D4240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,225.48,5946.37,APC
Gingival flap proc w/ planin,D4240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,225.48,5946.37,APC
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.87,,,,,,,fee schedule,131.03,2782.81,
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.59,,,,,,,fee schedule,131.03,2782.81,
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.03,,,,,,,fee schedule,131.03,2782.81,
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.85,,,,,,,fee schedule,131.03,2782.81,
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,131.03,2782.81,APC
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,131.03,2782.81,APC
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,131.03,2782.81,APC
Apically positioned flap,D4245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,253.78,,,,,,,fee schedule,166.38,2782.81,
Apically positioned flap,D4245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.72,,,,,,,fee schedule,166.38,2782.81,
Apically positioned flap,D4245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.38,,,,,,,fee schedule,166.38,2782.81,
Apically positioned flap,D4245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,291.85,,,,,,,fee schedule,166.38,2782.81,
Apically positioned flap,D4245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,166.38,2782.81,APC
Apically positioned flap,D4245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,166.38,2782.81,APC
Apically positioned flap,D4245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,166.38,2782.81,APC
Crown lengthen hard tissue,D4249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,377.23,,,,,,,fee schedule,247.31,1159.49,
Crown lengthen hard tissue,D4249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,308.76,,,,,,,fee schedule,247.31,1159.49,
Crown lengthen hard tissue,D4249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,247.31,,,,,,,fee schedule,247.31,1159.49,
Crown lengthen hard tissue,D4249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,433.81,,,,,,,fee schedule,247.31,1159.49,
Crown lengthen hard tissue,D4249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,247.31,1159.49,APC
Crown lengthen hard tissue,D4249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,247.31,1159.49,APC
Crown lengthen hard tissue,D4249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,247.31,1159.49,APC
Osseous surgery 4 or more,D4260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,10617.38,
Osseous surgery 4 or more,D4260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,10617.38,
Osseous surgery 4 or more,D4260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,10617.38,
Osseous surgery 4 or more,D4260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,10617.38,
Osseous surgery 4 or more,D4260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,503.07,10617.38,APC
Osseous surgery 4 or more,D4260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,503.07,10617.38,APC
Osseous surgery 4 or more,D4260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,503.07,10617.38,APC
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,308.64,,,,,,,fee schedule,202.34,5946.37,
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,252.62,,,,,,,fee schedule,202.34,5946.37,
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.34,,,,,,,fee schedule,202.34,5946.37,
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,354.94,,,,,,,fee schedule,202.34,5946.37,
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,202.34,5946.37,APC
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,202.34,5946.37,APC
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,202.34,5946.37,APC
Bone replce graft first site,D4263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Bone replce graft first site,D4263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Bone replce graft first site,D4263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Bone replce graft first site,D4263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Bone replce graft first site,D4263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Bone replce graft first site,D4263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Bone replce graft first site,D4263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Bone replce graft each add,D4264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,882.44,
Bone replce graft each add,D4264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,882.44,
Bone replce graft each add,D4264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,882.44,
Bone replce graft each add,D4264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,882.44,
Guided tiss regen resorble,D4266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.63,,,,,,,fee schedule,138.74,2782.81,
Guided tiss regen resorble,D4266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.22,,,,,,,fee schedule,138.74,2782.81,
Guided tiss regen resorble,D4266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.74,,,,,,,fee schedule,138.74,2782.81,
Guided tiss regen resorble,D4266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.37,,,,,,,fee schedule,138.74,2782.81,
Guided tiss regen resorble,D4266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,138.74,2782.81,APC
Guided tiss regen resorble,D4266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,138.74,2782.81,APC
Guided tiss regen resorble,D4266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,138.74,2782.81,APC
Guided tiss regen nonresorb,D4267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.42,,,,,,,fee schedule,177.94,2782.81,
Guided tiss regen nonresorb,D4267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.16,,,,,,,fee schedule,177.94,2782.81,
Guided tiss regen nonresorb,D4267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.94,,,,,,,fee schedule,177.94,2782.81,
Guided tiss regen nonresorb,D4267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.13,,,,,,,fee schedule,177.94,2782.81,
Guided tiss regen nonresorb,D4267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,177.94,2782.81,APC
Guided tiss regen nonresorb,D4267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,177.94,2782.81,APC
Guided tiss regen nonresorb,D4267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,177.94,2782.81,APC
Surgical revision procedure,D4268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Surgical revision procedure,D4268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Surgical revision procedure,D4268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Surgical revision procedure,D4268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Surgical revision procedure,D4268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Surgical revision procedure,D4268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Surgical revision procedure,D4268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,2782.81,
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,2782.81,
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,2782.81,
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,2782.81,
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,503.07,2782.81,APC
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,503.07,2782.81,APC
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,503.07,2782.81,APC
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,2782.81,
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,2782.81,
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,2782.81,
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,2782.81,
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,503.07,2782.81,APC
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,503.07,2782.81,APC
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,503.07,2782.81,APC
Mesial/distal wedge proc,D4274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.18,,,,,,,fee schedule,185.65,1159.49,
Mesial/distal wedge proc,D4274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,231.78,,,,,,,fee schedule,185.65,1159.49,
Mesial/distal wedge proc,D4274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.65,,,,,,,fee schedule,185.65,1159.49,
Mesial/distal wedge proc,D4274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,325.66,,,,,,,fee schedule,185.65,1159.49,
Mesial/distal wedge proc,D4274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,185.65,1159.49,APC
Mesial/distal wedge proc,D4274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,185.65,1159.49,APC
Mesial/distal wedge proc,D4274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,185.65,1159.49,APC
Non-auto graft 1st tooth,D4275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,374.28,,,,,,,fee schedule,245.38,2782.81,
Non-auto graft 1st tooth,D4275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,306.35,,,,,,,fee schedule,245.38,2782.81,
Non-auto graft 1st tooth,D4275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,245.38,,,,,,,fee schedule,245.38,2782.81,
Non-auto graft 1st tooth,D4275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,430.42,,,,,,,fee schedule,245.38,2782.81,
Non-auto graft 1st tooth,D4275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,245.38,2782.81,APC
Non-auto graft 1st tooth,D4275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,245.38,2782.81,APC
Non-auto graft 1st tooth,D4275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,245.38,2782.81,APC
Con tissue w dble ped graft,D4276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,559.46,,,,,,,fee schedule,366.78,2782.81,
Con tissue w dble ped graft,D4276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,457.92,,,,,,,fee schedule,366.78,2782.81,
Con tissue w dble ped graft,D4276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,366.78,,,,,,,fee schedule,366.78,2782.81,
Con tissue w dble ped graft,D4276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,643.38,,,,,,,fee schedule,366.78,2782.81,
Con tissue w dble ped graft,D4276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,366.78,2782.81,APC
Con tissue w dble ped graft,D4276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,366.78,2782.81,APC
Con tissue w dble ped graft,D4276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,366.78,2782.81,APC
Soft tissue graft firsttooth,D4277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,1546,2782.81,APC
Soft tissue graft firsttooth,D4277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,1546,2782.81,APC
Soft tissue graft firsttooth,D4277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,1546,2782.81,APC
Periodontal scaling & root,D4341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.64,,,,,,,fee schedule,75.16,1159.49,
Periodontal scaling & root,D4341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.83,,,,,,,fee schedule,75.16,1159.49,
Periodontal scaling & root,D4341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.16,,,,,,,fee schedule,75.16,1159.49,
Periodontal scaling & root,D4341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.84,,,,,,,fee schedule,75.16,1159.49,
Periodontal scaling & root,D4341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,75.16,1159.49,APC
Periodontal scaling & root,D4341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,75.16,1159.49,APC
Periodontal scaling & root,D4341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,75.16,1159.49,APC
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.6,,,,,,,fee schedule,43.66,1159.49,
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.51,,,,,,,fee schedule,43.66,1159.49,
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.66,,,,,,,fee schedule,43.66,1159.49,
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.59,,,,,,,fee schedule,43.66,1159.49,
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,43.66,1159.49,APC
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,43.66,1159.49,APC
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,43.66,1159.49,APC
Full mouth debridement,D4355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Full mouth debridement,D4355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Full mouth debridement,D4355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Full mouth debridement,D4355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Full mouth debridement,D4355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Full mouth debridement,D4355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Full mouth debridement,D4355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Localized delivery antimicro,D4381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Localized delivery antimicro,D4381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Localized delivery antimicro,D4381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Localized delivery antimicro,D4381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Localized delivery antimicro,D4381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Localized delivery antimicro,D4381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Localized delivery antimicro,D4381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Periodontal maint procedures,D4910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.54,,,,,,,fee schedule,46.25,1159.49,
Periodontal maint procedures,D4910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.74,,,,,,,fee schedule,46.25,1159.49,
Periodontal maint procedures,D4910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.25,,,,,,,fee schedule,46.25,1159.49,
Periodontal maint procedures,D4910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,81.12,,,,,,,fee schedule,46.25,1159.49,
Periodontal maint procedures,D4910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,46.25,1159.49,APC
Periodontal maint procedures,D4910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,46.25,1159.49,APC
Periodontal maint procedures,D4910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,46.25,1159.49,APC
Unscheduled dressing change,D4920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.95,,,,,,,fee schedule,33.4,1159.49,
Unscheduled dressing change,D4920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.7,,,,,,,fee schedule,33.4,1159.49,
Unscheduled dressing change,D4920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.4,,,,,,,fee schedule,33.4,1159.49,
Unscheduled dressing change,D4920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.59,,,,,,,fee schedule,33.4,1159.49,
Unscheduled dressing change,D4920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,33.4,1159.49,APC
Unscheduled dressing change,D4920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,33.4,1159.49,APC
Unscheduled dressing change,D4920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,33.4,1159.49,APC
Gingival irrigation per quad,D4921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,238.78,APC
Gingival irrigation per quad,D4921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,238.78,APC
Gingival irrigation per quad,D4921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,238.78,APC
Unspecified periodontal proc,D4999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,247.8,,,,,,,fee schedule,236,424.8,APC
Unspecified periodontal proc,D4999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,236,,,,,,,fee schedule,236,424.8,APC
Unspecified periodontal proc,D4999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,424.8,,,,,,,fee schedule,236,424.8,APC
Dentures complete maxillary,D5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,662.38,,,,,,,fee schedule,434.26,761.74,
Dentures complete maxillary,D5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,542.16,,,,,,,fee schedule,434.26,761.74,
Dentures complete maxillary,D5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,434.26,,,,,,,fee schedule,434.26,761.74,
Dentures complete maxillary,D5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,761.74,,,,,,,fee schedule,434.26,761.74,
Dentures complete mandible,D5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,662.38,,,,,,,fee schedule,434.26,761.74,
Dentures complete mandible,D5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,542.16,,,,,,,fee schedule,434.26,761.74,
Dentures complete mandible,D5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,434.26,,,,,,,fee schedule,434.26,761.74,
Dentures complete mandible,D5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,761.74,,,,,,,fee schedule,434.26,761.74,
Dentures immediat maxillary,D5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,722.14,,,,,,,fee schedule,473.43,830.46,
Dentures immediat maxillary,D5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,591.07,,,,,,,fee schedule,473.43,830.46,
Dentures immediat maxillary,D5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.43,,,,,,,fee schedule,473.43,830.46,
Dentures immediat maxillary,D5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,830.46,,,,,,,fee schedule,473.43,830.46,
Dentures immediat mandible,D5140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,722.14,,,,,,,fee schedule,473.43,830.46,
Dentures immediat mandible,D5140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,591.07,,,,,,,fee schedule,473.43,830.46,
Dentures immediat mandible,D5140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.43,,,,,,,fee schedule,473.43,830.46,
Dentures immediat mandible,D5140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,830.46,,,,,,,fee schedule,473.43,830.46,
Dentures maxill part resin,D5211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,559.46,,,,,,,fee schedule,366.78,643.38,
Dentures maxill part resin,D5211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,457.92,,,,,,,fee schedule,366.78,643.38,
Dentures maxill part resin,D5211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,366.78,,,,,,,fee schedule,366.78,643.38,
Dentures maxill part resin,D5211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,643.38,,,,,,,fee schedule,366.78,643.38,
Dentures mand part resin,D5212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,649.65,,,,,,,fee schedule,425.91,747.1,
Dentures mand part resin,D5212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,531.74,,,,,,,fee schedule,425.91,747.1,
Dentures mand part resin,D5212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,425.91,,,,,,,fee schedule,425.91,747.1,
Dentures mand part resin,D5212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,747.1,,,,,,,fee schedule,425.91,747.1,
Dentures maxill part metal,D5213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,731.95,,,,,,,fee schedule,479.87,841.74,
Dentures maxill part metal,D5213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,599.1,,,,,,,fee schedule,479.87,841.74,
Dentures maxill part metal,D5213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,479.87,,,,,,,fee schedule,479.87,841.74,
Dentures maxill part metal,D5213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,841.74,,,,,,,fee schedule,479.87,841.74,
Dentures mandibl part metal,D5214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,731.95,,,,,,,fee schedule,479.87,841.74,
Dentures mandibl part metal,D5214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,599.1,,,,,,,fee schedule,479.87,841.74,
Dentures mandibl part metal,D5214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,479.87,,,,,,,fee schedule,479.87,841.74,
Dentures mandibl part metal,D5214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,841.74,,,,,,,fee schedule,479.87,841.74,
Maxillary part denture flex,D5225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,559.46,,,,,,,fee schedule,366.78,643.38,
Maxillary part denture flex,D5225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,457.92,,,,,,,fee schedule,366.78,643.38,
Maxillary part denture flex,D5225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,366.78,,,,,,,fee schedule,366.78,643.38,
Maxillary part denture flex,D5225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,643.38,,,,,,,fee schedule,366.78,643.38,
Mandibular part denture flex,D5226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,649.65,,,,,,,fee schedule,425.91,747.1,
Mandibular part denture flex,D5226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,531.74,,,,,,,fee schedule,425.91,747.1,
Mandibular part denture flex,D5226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,425.91,,,,,,,fee schedule,425.91,747.1,
Mandibular part denture flex,D5226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,747.1,,,,,,,fee schedule,425.91,747.1,
Removable partial denture,D5281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,427.2,,,,,,,fee schedule,280.07,491.28,
Removable partial denture,D5281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,349.66,,,,,,,fee schedule,280.07,491.28,
Removable partial denture,D5281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,280.07,,,,,,,fee schedule,280.07,491.28,
Removable partial denture,D5281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,491.28,,,,,,,fee schedule,280.07,491.28,
Dentures adjust cmplt maxil,D5410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Dentures adjust cmplt maxil,D5410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Dentures adjust cmplt maxil,D5410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Dentures adjust cmplt maxil,D5410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Dentures adjust cmplt mand,D5411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Dentures adjust cmplt mand,D5411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Dentures adjust cmplt mand,D5411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Dentures adjust cmplt mand,D5411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Dentures adjust part maxill,D5421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Dentures adjust part maxill,D5421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Dentures adjust part maxill,D5421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Dentures adjust part maxill,D5421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Dentures adjust part mandbl,D5422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Dentures adjust part mandbl,D5422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Dentures adjust part mandbl,D5422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Dentures adjust part mandbl,D5422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Replace denture teeth complt,D5520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.73,,,,,,,fee schedule,39.81,69.84,
Replace denture teeth complt,D5520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.71,,,,,,,fee schedule,39.81,69.84,
Replace denture teeth complt,D5520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.81,,,,,,,fee schedule,39.81,69.84,
Replace denture teeth complt,D5520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.84,,,,,,,fee schedule,39.81,69.84,
Rep partial denture clasp,D5630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.85,,,,,,,fee schedule,67.43,118.28,
Rep partial denture clasp,D5630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.18,,,,,,,fee schedule,67.43,118.28,
Rep partial denture clasp,D5630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.43,,,,,,,fee schedule,67.43,118.28,
Rep partial denture clasp,D5630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.28,,,,,,,fee schedule,67.43,118.28,
Replace part denture teeth,D5640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.6,,,,,,,fee schedule,43.66,76.59,
Replace part denture teeth,D5640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.51,,,,,,,fee schedule,43.66,76.59,
Replace part denture teeth,D5640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.66,,,,,,,fee schedule,43.66,76.59,
Replace part denture teeth,D5640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.59,,,,,,,fee schedule,43.66,76.59,
Add tooth to partial denture,D5650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.13,,,,,,,fee schedule,59.09,103.65,
Add tooth to partial denture,D5650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.77,,,,,,,fee schedule,59.09,103.65,
Add tooth to partial denture,D5650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.09,,,,,,,fee schedule,59.09,103.65,
Add tooth to partial denture,D5650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.65,,,,,,,fee schedule,59.09,103.65,
Add clasp to partial denture,D5660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.77,,,,,,,fee schedule,71.31,125.09,
Add clasp to partial denture,D5660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.03,,,,,,,fee schedule,71.31,125.09,
Add clasp to partial denture,D5660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.31,,,,,,,fee schedule,71.31,125.09,
Add clasp to partial denture,D5660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.09,,,,,,,fee schedule,71.31,125.09,
Replc tth&acrlc on mtl frmwk,D5670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,266.52,,,,,,,fee schedule,174.73,306.5,
Replc tth&acrlc on mtl frmwk,D5670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.15,,,,,,,fee schedule,174.73,306.5,
Replc tth&acrlc on mtl frmwk,D5670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.73,,,,,,,fee schedule,174.73,306.5,
Replc tth&acrlc on mtl frmwk,D5670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,306.5,,,,,,,fee schedule,174.73,306.5,
Replc tth&acrlc mandibular,D5671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,266.52,,,,,,,fee schedule,174.73,306.5,
Replc tth&acrlc mandibular,D5671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.15,,,,,,,fee schedule,174.73,306.5,
Replc tth&acrlc mandibular,D5671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.73,,,,,,,fee schedule,174.73,306.5,
Replc tth&acrlc mandibular,D5671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,306.5,,,,,,,fee schedule,174.73,306.5,
Dentures rebase cmplt maxil,D5710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.49,,,,,,,fee schedule,176.02,308.76,
Dentures rebase cmplt maxil,D5710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,219.76,,,,,,,fee schedule,176.02,308.76,
Dentures rebase cmplt maxil,D5710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.02,,,,,,,fee schedule,176.02,308.76,
Dentures rebase cmplt maxil,D5710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.76,,,,,,,fee schedule,176.02,308.76,
Dentures rebase cmplt mand,D5711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.72,,,,,,,fee schedule,168.31,295.23,
Dentures rebase cmplt mand,D5711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.13,,,,,,,fee schedule,168.31,295.23,
Dentures rebase cmplt mand,D5711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.31,,,,,,,fee schedule,168.31,295.23,
Dentures rebase cmplt mand,D5711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,295.23,,,,,,,fee schedule,168.31,295.23,
Dentures rebase part maxill,D5720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,253.78,,,,,,,fee schedule,166.38,291.85,
Dentures rebase part maxill,D5720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.72,,,,,,,fee schedule,166.38,291.85,
Dentures rebase part maxill,D5720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.38,,,,,,,fee schedule,166.38,291.85,
Dentures rebase part maxill,D5720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,291.85,,,,,,,fee schedule,166.38,291.85,
Dentures rebase part mandbl,D5721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,253.78,,,,,,,fee schedule,166.38,291.85,
Dentures rebase part mandbl,D5721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207.72,,,,,,,fee schedule,166.38,291.85,
Dentures rebase part mandbl,D5721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.38,,,,,,,fee schedule,166.38,291.85,
Dentures rebase part mandbl,D5721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,291.85,,,,,,,fee schedule,166.38,291.85,
Denture reln cmplt maxil ch,D5730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.87,,,,,,,fee schedule,99.57,174.65,
Denture reln cmplt maxil ch,D5730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.31,,,,,,,fee schedule,99.57,174.65,
Denture reln cmplt maxil ch,D5730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.57,,,,,,,fee schedule,99.57,174.65,
Denture reln cmplt maxil ch,D5730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.65,,,,,,,fee schedule,99.57,174.65,
Denture reln cmplt mand chr,D5731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.87,,,,,,,fee schedule,99.57,174.65,
Denture reln cmplt mand chr,D5731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,124.31,,,,,,,fee schedule,99.57,174.65,
Denture reln cmplt mand chr,D5731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.57,,,,,,,fee schedule,99.57,174.65,
Denture reln cmplt mand chr,D5731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.65,,,,,,,fee schedule,99.57,174.65,
Denture reln part maxil chr,D5740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.14,,,,,,,fee schedule,91.22,160.01,
Denture reln part maxil chr,D5740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.89,,,,,,,fee schedule,91.22,160.01,
Denture reln part maxil chr,D5740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.22,,,,,,,fee schedule,91.22,160.01,
Denture reln part maxil chr,D5740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.01,,,,,,,fee schedule,91.22,160.01,
Denture reln part mand chr,D5741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.14,,,,,,,fee schedule,91.22,160.01,
Denture reln part mand chr,D5741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.89,,,,,,,fee schedule,91.22,160.01,
Denture reln part mand chr,D5741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.22,,,,,,,fee schedule,91.22,160.01,
Denture reln part mand chr,D5741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.01,,,,,,,fee schedule,91.22,160.01,
Denture reln cmplt max lab,D5750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,202.82,,,,,,,fee schedule,132.97,233.24,
Denture reln cmplt max lab,D5750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.01,,,,,,,fee schedule,132.97,233.24,
Denture reln cmplt max lab,D5750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.97,,,,,,,fee schedule,132.97,233.24,
Denture reln cmplt max lab,D5750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.24,,,,,,,fee schedule,132.97,233.24,
Denture reln cmplt mand lab,D5751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,202.82,,,,,,,fee schedule,132.97,233.24,
Denture reln cmplt mand lab,D5751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.01,,,,,,,fee schedule,132.97,233.24,
Denture reln cmplt mand lab,D5751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.97,,,,,,,fee schedule,132.97,233.24,
Denture reln cmplt mand lab,D5751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.24,,,,,,,fee schedule,132.97,233.24,
Denture reln part maxil lab,D5760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.87,,,,,,,fee schedule,131.03,229.85,
Denture reln part maxil lab,D5760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.59,,,,,,,fee schedule,131.03,229.85,
Denture reln part maxil lab,D5760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.03,,,,,,,fee schedule,131.03,229.85,
Denture reln part maxil lab,D5760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.85,,,,,,,fee schedule,131.03,229.85,
Denture reln part mand lab,D5761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.87,,,,,,,fee schedule,131.03,229.85,
Denture reln part mand lab,D5761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.59,,,,,,,fee schedule,131.03,229.85,
Denture reln part mand lab,D5761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.03,,,,,,,fee schedule,131.03,229.85,
Denture reln part mand lab,D5761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.85,,,,,,,fee schedule,131.03,229.85,
Denture interm cmplt maxill,D5810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,320.43,,,,,,,fee schedule,210.07,368.49,
Denture interm cmplt maxill,D5810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.27,,,,,,,fee schedule,210.07,368.49,
Denture interm cmplt maxill,D5810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,210.07,,,,,,,fee schedule,210.07,368.49,
Denture interm cmplt maxill,D5810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,368.49,,,,,,,fee schedule,210.07,368.49,
Denture interm cmplt mandbl,D5811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,343.93,,,,,,,fee schedule,225.48,395.52,
Denture interm cmplt mandbl,D5811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,281.51,,,,,,,fee schedule,225.48,395.52,
Denture interm cmplt mandbl,D5811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,225.48,,,,,,,fee schedule,225.48,395.52,
Denture interm cmplt mandbl,D5811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,395.52,,,,,,,fee schedule,225.48,395.52,
Denture interm part maxill,D5820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,247.9,,,,,,,fee schedule,162.52,285.09,
Denture interm part maxill,D5820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.91,,,,,,,fee schedule,162.52,285.09,
Denture interm part maxill,D5820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,162.52,,,,,,,fee schedule,162.52,285.09,
Denture interm part maxill,D5820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,285.09,,,,,,,fee schedule,162.52,285.09,
Denture interm part mandbl,D5821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,262.59,,,,,,,fee schedule,172.15,301.98,
Denture interm part mandbl,D5821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.93,,,,,,,fee schedule,172.15,301.98,
Denture interm part mandbl,D5821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.15,,,,,,,fee schedule,172.15,301.98,
Denture interm part mandbl,D5821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,301.98,,,,,,,fee schedule,172.15,301.98,
Denture tiss conditn maxill,D5850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.7,,,,,,,fee schedule,41.76,73.26,
Denture tiss conditn maxill,D5850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.14,,,,,,,fee schedule,41.76,73.26,
Denture tiss conditn maxill,D5850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.76,,,,,,,fee schedule,41.76,73.26,
Denture tiss conditn maxill,D5850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.26,,,,,,,fee schedule,41.76,73.26,
Denture tiss condtin mandbl,D5851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.7,,,,,,,fee schedule,41.76,73.26,
Denture tiss condtin mandbl,D5851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.14,,,,,,,fee schedule,41.76,73.26,
Denture tiss condtin mandbl,D5851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.76,,,,,,,fee schedule,41.76,73.26,
Denture tiss condtin mandbl,D5851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.26,,,,,,,fee schedule,41.76,73.26,
Facial moulage sectional,D5911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Facial moulage sectional,D5911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Facial moulage sectional,D5911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Facial moulage sectional,D5911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Facial moulage sectional,D5911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Facial moulage sectional,D5911,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Facial moulage sectional,D5911,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Facial moulage complete,D5912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Facial moulage complete,D5912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Facial moulage complete,D5912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Facial moulage complete,D5912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Facial moulage complete,D5912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Facial moulage complete,D5912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Facial moulage complete,D5912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Nasal prosthesis,D5913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3538.25,,,,,,,fee schedule,2319.68,4068.99,
Nasal prosthesis,D5913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2896.06,,,,,,,fee schedule,2319.68,4068.99,
Nasal prosthesis,D5913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2319.68,,,,,,,fee schedule,2319.68,4068.99,
Nasal prosthesis,D5913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4068.99,,,,,,,fee schedule,2319.68,4068.99,
Auricular prosthesis,D5914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3538.25,,,,,,,fee schedule,2319.68,4068.99,
Auricular prosthesis,D5914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2896.06,,,,,,,fee schedule,2319.68,4068.99,
Auricular prosthesis,D5914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2319.68,,,,,,,fee schedule,2319.68,4068.99,
Auricular prosthesis,D5914,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4068.99,,,,,,,fee schedule,2319.68,4068.99,
Orbital prosthesis,D5915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4787.54,,,,,,,fee schedule,3138.71,5505.67,
Orbital prosthesis,D5915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3918.6,,,,,,,fee schedule,3138.71,5505.67,
Orbital prosthesis,D5915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3138.71,,,,,,,fee schedule,3138.71,5505.67,
Orbital prosthesis,D5915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5505.67,,,,,,,fee schedule,3138.71,5505.67,
Ocular prosthesis,D5916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1276.76,,,,,,,fee schedule,837.04,1468.27,
Ocular prosthesis,D5916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1045.03,,,,,,,fee schedule,837.04,1468.27,
Ocular prosthesis,D5916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,837.04,,,,,,,fee schedule,837.04,1468.27,
Ocular prosthesis,D5916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1468.27,,,,,,,fee schedule,837.04,1468.27,
Surgical obturator,D5931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1904.84,,,,,,,fee schedule,1248.81,2190.57,
Surgical obturator,D5931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1559.11,,,,,,,fee schedule,1248.81,2190.57,
Surgical obturator,D5931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1248.81,,,,,,,fee schedule,1248.81,2190.57,
Surgical obturator,D5931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2190.57,,,,,,,fee schedule,1248.81,2190.57,
Postsurgical obturator,D5932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3562.73,,,,,,,fee schedule,2335.73,4097.14,
Postsurgical obturator,D5932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2916.09,,,,,,,fee schedule,2335.73,4097.14,
Postsurgical obturator,D5932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2335.73,,,,,,,fee schedule,2335.73,4097.14,
Postsurgical obturator,D5932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4097.14,,,,,,,fee schedule,2335.73,4097.14,
Mandibular flange prosthesis,D5934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3247.22,,,,,,,fee schedule,2128.88,3734.3,
Mandibular flange prosthesis,D5934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2657.85,,,,,,,fee schedule,2128.88,3734.3,
Mandibular flange prosthesis,D5934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2128.88,,,,,,,fee schedule,2128.88,3734.3,
Mandibular flange prosthesis,D5934,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3734.3,,,,,,,fee schedule,2128.88,3734.3,
Mandibular denture prosth,D5935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2825.88,,,,,,,fee schedule,1852.65,3249.76,
Mandibular denture prosth,D5935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2312.98,,,,,,,fee schedule,1852.65,3249.76,
Mandibular denture prosth,D5935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1852.65,,,,,,,fee schedule,1852.65,3249.76,
Mandibular denture prosth,D5935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3249.76,,,,,,,fee schedule,1852.65,3249.76,
Temp obturator prosthesis,D5936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3173.72,,,,,,,fee schedule,2080.69,3649.78,
Temp obturator prosthesis,D5936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2597.69,,,,,,,fee schedule,2080.69,3649.78,
Temp obturator prosthesis,D5936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2080.69,,,,,,,fee schedule,2080.69,3649.78,
Temp obturator prosthesis,D5936,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3649.78,,,,,,,fee schedule,2080.69,3649.78,
Trismus appliance,D5937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,398.82,,,,,,,fee schedule,261.47,458.64,
Trismus appliance,D5937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,326.43,,,,,,,fee schedule,261.47,458.64,
Trismus appliance,D5937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,261.47,,,,,,,fee schedule,261.47,458.64,
Trismus appliance,D5937,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,458.64,,,,,,,fee schedule,261.47,458.64,
Feeding aid,D5951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,518.34,,,,,,,fee schedule,339.82,596.09,
Feeding aid,D5951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,424.26,,,,,,,fee schedule,339.82,596.09,
Feeding aid,D5951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,339.82,,,,,,,fee schedule,339.82,596.09,
Feeding aid,D5951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,596.09,,,,,,,fee schedule,339.82,596.09,
Pediatric speech aid,D5952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1683.4,,,,,,,fee schedule,1103.64,1935.91,
Pediatric speech aid,D5952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1377.86,,,,,,,fee schedule,1103.64,1935.91,
Pediatric speech aid,D5952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1103.64,,,,,,,fee schedule,1103.64,1935.91,
Pediatric speech aid,D5952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1935.91,,,,,,,fee schedule,1103.64,1935.91,
Adult speech aid,D5953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3198.25,,,,,,,fee schedule,2096.77,3677.99,
Adult speech aid,D5953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2617.77,,,,,,,fee schedule,2096.77,3677.99,
Adult speech aid,D5953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2096.77,,,,,,,fee schedule,2096.77,3677.99,
Adult speech aid,D5953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3677.99,,,,,,,fee schedule,2096.77,3677.99,
Superimposed prosthesis,D5954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2963.07,,,,,,,fee schedule,1942.59,3407.53,
Superimposed prosthesis,D5954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2425.27,,,,,,,fee schedule,1942.59,3407.53,
Superimposed prosthesis,D5954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1942.59,,,,,,,fee schedule,1942.59,3407.53,
Superimposed prosthesis,D5954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3407.53,,,,,,,fee schedule,1942.59,3407.53,
Palatal lift prosthesis,D5955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2740.64,,,,,,,fee schedule,1796.76,3151.74,
Palatal lift prosthesis,D5955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2243.21,,,,,,,fee schedule,1796.76,3151.74,
Palatal lift prosthesis,D5955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1796.76,,,,,,,fee schedule,1796.76,3151.74,
Palatal lift prosthesis,D5955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3151.74,,,,,,,fee schedule,1796.76,3151.74,
Surgical stent,D5982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.49,,,,,,,fee schedule,176.02,308.76,
Surgical stent,D5982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,219.76,,,,,,,fee schedule,176.02,308.76,
Surgical stent,D5982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.02,,,,,,,fee schedule,176.02,308.76,
Surgical stent,D5982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.76,,,,,,,fee schedule,176.02,308.76,
Radiation applicator,D5983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Radiation applicator,D5983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Radiation applicator,D5983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Radiation applicator,D5983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Radiation applicator,D5983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Radiation applicator,D5983,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Radiation applicator,D5983,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Radiation shield,D5984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Radiation shield,D5984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Radiation shield,D5984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Radiation shield,D5984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Radiation shield,D5984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Radiation shield,D5984,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Radiation shield,D5984,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Radiation cone locator,D5985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Radiation cone locator,D5985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Radiation cone locator,D5985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Radiation cone locator,D5985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Radiation cone locator,D5985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Radiation cone locator,D5985,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Radiation cone locator,D5985,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Fluoride applicator,D5986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.73,,,,,,,fee schedule,39.81,69.84,
Fluoride applicator,D5986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.71,,,,,,,fee schedule,39.81,69.84,
Fluoride applicator,D5986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.81,,,,,,,fee schedule,39.81,69.84,
Fluoride applicator,D5986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.84,,,,,,,fee schedule,39.81,69.84,
Commissure splint,D5987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Commissure splint,D5987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Commissure splint,D5987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Commissure splint,D5987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Commissure splint,D5987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Commissure splint,D5987,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Commissure splint,D5987,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Surgical splint,D5988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,1159.49,
Surgical splint,D5988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,1159.49,
Surgical splint,D5988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,1159.49,
Surgical splint,D5988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,1159.49,
Surgical splint,D5988,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,118.83,1159.49,APC
Surgical splint,D5988,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,118.83,1159.49,APC
Surgical splint,D5988,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,118.83,1159.49,APC
Vesiculobullous disease carr,D5991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,45.6,79.99,
Vesiculobullous disease carr,D5991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,45.6,79.99,
Vesiculobullous disease carr,D5991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,45.6,79.99,
Vesiculobullous disease carr,D5991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,45.6,79.99,
Odontics endosteal implant,D6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1106.23,,,,,,,fee schedule,725.24,1272.16,
Odontics endosteal implant,D6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,905.45,,,,,,,fee schedule,725.24,1272.16,
Odontics endosteal implant,D6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,725.24,,,,,,,fee schedule,725.24,1272.16,
Odontics endosteal implant,D6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1272.16,,,,,,,fee schedule,725.24,1272.16,
Endosteal implant,D6012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1045.5,,,,,,,fee schedule,685.43,1202.33,
Endosteal implant,D6012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,855.74,,,,,,,fee schedule,685.43,1202.33,
Endosteal implant,D6012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,685.43,,,,,,,fee schedule,685.43,1202.33,
Endosteal implant,D6012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1202.33,,,,,,,fee schedule,685.43,1202.33,
Odontics eposteal implant,D6040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3807.7,,,,,,,fee schedule,2496.33,4378.86,
Odontics eposteal implant,D6040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3116.6,,,,,,,fee schedule,2496.33,4378.86,
Odontics eposteal implant,D6040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2496.33,,,,,,,fee schedule,2496.33,4378.86,
Odontics eposteal implant,D6040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4378.86,,,,,,,fee schedule,2496.33,4378.86,
Odontics transosteal implnt,D6050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2840.57,,,,,,,fee schedule,1862.28,3266.66,
Odontics transosteal implnt,D6050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2325.01,,,,,,,fee schedule,1862.28,3266.66,
Odontics transosteal implnt,D6050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1862.28,,,,,,,fee schedule,1862.28,3266.66,
Odontics transosteal implnt,D6050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3266.66,,,,,,,fee schedule,1862.28,3266.66,
Implant connecting bar,D6055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.16,,,,,,,fee schedule,217.76,381.98,
Implant connecting bar,D6055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,271.87,,,,,,,fee schedule,217.76,381.98,
Implant connecting bar,D6055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.76,,,,,,,fee schedule,217.76,381.98,
Implant connecting bar,D6055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,381.98,,,,,,,fee schedule,217.76,381.98,
Prefabricated abutment,D6056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.28,,,,,,,fee schedule,150.32,263.67,
Prefabricated abutment,D6056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.67,,,,,,,fee schedule,150.32,263.67,
Prefabricated abutment,D6056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.32,,,,,,,fee schedule,150.32,263.67,
Prefabricated abutment,D6056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.67,,,,,,,fee schedule,150.32,263.67,
Custom abutment,D6057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.17,,,,,,,fee schedule,186.3,326.8,
Custom abutment,D6057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.59,,,,,,,fee schedule,186.3,326.8,
Custom abutment,D6057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.3,,,,,,,fee schedule,186.3,326.8,
Custom abutment,D6057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.8,,,,,,,fee schedule,186.3,326.8,
Abutment supported crown,D6058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,636.91,,,,,,,fee schedule,417.56,732.45,
Abutment supported crown,D6058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,521.31,,,,,,,fee schedule,417.56,732.45,
Abutment supported crown,D6058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,417.56,,,,,,,fee schedule,417.56,732.45,
Abutment supported crown,D6058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,732.45,,,,,,,fee schedule,417.56,732.45,
Abutment supported mtl crown,D6059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,628.08,,,,,,,fee schedule,411.77,722.29,
Abutment supported mtl crown,D6059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,514.08,,,,,,,fee schedule,411.77,722.29,
Abutment supported mtl crown,D6059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,411.77,,,,,,,fee schedule,411.77,722.29,
Abutment supported mtl crown,D6059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,722.29,,,,,,,fee schedule,411.77,722.29,
Abutment supported mtl crown,D6060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,593.79,,,,,,,fee schedule,389.29,682.86,
Abutment supported mtl crown,D6060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,486.02,,,,,,,fee schedule,389.29,682.86,
Abutment supported mtl crown,D6060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,389.29,,,,,,,fee schedule,389.29,682.86,
Abutment supported mtl crown,D6060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,682.86,,,,,,,fee schedule,389.29,682.86,
Abutment supported mtl crown,D6061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,606.51,,,,,,,fee schedule,397.63,697.49,
Abutment supported mtl crown,D6061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,496.43,,,,,,,fee schedule,397.63,697.49,
Abutment supported mtl crown,D6061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,397.63,,,,,,,fee schedule,397.63,697.49,
Abutment supported mtl crown,D6061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,697.49,,,,,,,fee schedule,397.63,697.49,
Abutment supported mtl crown,D6062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,603.58,,,,,,,fee schedule,395.71,694.12,
Abutment supported mtl crown,D6062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,494.03,,,,,,,fee schedule,395.71,694.12,
Abutment supported mtl crown,D6062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,395.71,,,,,,,fee schedule,395.71,694.12,
Abutment supported mtl crown,D6062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,694.12,,,,,,,fee schedule,395.71,694.12,
Abutment supported mtl crown,D6063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,526.16,,,,,,,fee schedule,344.95,605.08,
Abutment supported mtl crown,D6063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,430.66,,,,,,,fee schedule,344.95,605.08,
Abutment supported mtl crown,D6063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,344.95,,,,,,,fee schedule,344.95,605.08,
Abutment supported mtl crown,D6063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,605.08,,,,,,,fee schedule,344.95,605.08,
Abutment supported mtl crown,D6064,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,549.7,,,,,,,fee schedule,360.38,632.16,
Abutment supported mtl crown,D6064,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,449.93,,,,,,,fee schedule,360.38,632.16,
Abutment supported mtl crown,D6064,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,360.38,,,,,,,fee schedule,360.38,632.16,
Abutment supported mtl crown,D6064,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,632.16,,,,,,,fee schedule,360.38,632.16,
Implant supported crown,D6065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,627.11,,,,,,,fee schedule,411.13,721.18,
Implant supported crown,D6065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,513.29,,,,,,,fee schedule,411.13,721.18,
Implant supported crown,D6065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,411.13,,,,,,,fee schedule,411.13,721.18,
Implant supported crown,D6065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,721.18,,,,,,,fee schedule,411.13,721.18,
Implant supported mtl crown,D6066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,610.47,,,,,,,fee schedule,400.22,702.04,
Implant supported mtl crown,D6066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,499.67,,,,,,,fee schedule,400.22,702.04,
Implant supported mtl crown,D6066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,400.22,,,,,,,fee schedule,400.22,702.04,
Implant supported mtl crown,D6066,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,702.04,,,,,,,fee schedule,400.22,702.04,
Implant supported mtl crown,D6067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,592.82,,,,,,,fee schedule,388.65,681.74,
Implant supported mtl crown,D6067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,485.22,,,,,,,fee schedule,388.65,681.74,
Implant supported mtl crown,D6067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,388.65,,,,,,,fee schedule,388.65,681.74,
Implant supported mtl crown,D6067,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,681.74,,,,,,,fee schedule,388.65,681.74,
Abutment supported retainer,D6068,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,631.99,,,,,,,fee schedule,414.33,726.79,
Abutment supported retainer,D6068,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,517.28,,,,,,,fee schedule,414.33,726.79,
Abutment supported retainer,D6068,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,414.33,,,,,,,fee schedule,414.33,726.79,
Abutment supported retainer,D6068,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,726.79,,,,,,,fee schedule,414.33,726.79,
Abutment supported retainer,D6069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,628.08,,,,,,,fee schedule,411.77,722.29,
Abutment supported retainer,D6069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,514.08,,,,,,,fee schedule,411.77,722.29,
Abutment supported retainer,D6069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,411.77,,,,,,,fee schedule,411.77,722.29,
Abutment supported retainer,D6069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,722.29,,,,,,,fee schedule,411.77,722.29,
Abutment supported retainer,D6070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,593.79,,,,,,,fee schedule,389.29,682.86,
Abutment supported retainer,D6070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,486.02,,,,,,,fee schedule,389.29,682.86,
Abutment supported retainer,D6070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,389.29,,,,,,,fee schedule,389.29,682.86,
Abutment supported retainer,D6070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,682.86,,,,,,,fee schedule,389.29,682.86,
Abutment supported retainer,D6071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,606.51,,,,,,,fee schedule,397.63,697.49,
Abutment supported retainer,D6071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,496.43,,,,,,,fee schedule,397.63,697.49,
Abutment supported retainer,D6071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,397.63,,,,,,,fee schedule,397.63,697.49,
Abutment supported retainer,D6071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,697.49,,,,,,,fee schedule,397.63,697.49,
Abutment supported retainer,D6072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,613.36,,,,,,,fee schedule,402.12,705.36,
Abutment supported retainer,D6072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,502.04,,,,,,,fee schedule,402.12,705.36,
Abutment supported retainer,D6072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,402.12,,,,,,,fee schedule,402.12,705.36,
Abutment supported retainer,D6072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,705.36,,,,,,,fee schedule,402.12,705.36,
Abutment supported retainer,D6073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,560.47,,,,,,,fee schedule,367.44,644.54,
Abutment supported retainer,D6073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,458.74,,,,,,,fee schedule,367.44,644.54,
Abutment supported retainer,D6073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,367.44,,,,,,,fee schedule,367.44,644.54,
Abutment supported retainer,D6073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,644.54,,,,,,,fee schedule,367.44,644.54,
Abutment supported retainer,D6074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,595.73,,,,,,,fee schedule,390.56,685.09,
Abutment supported retainer,D6074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,487.61,,,,,,,fee schedule,390.56,685.09,
Abutment supported retainer,D6074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,390.56,,,,,,,fee schedule,390.56,685.09,
Abutment supported retainer,D6074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,685.09,,,,,,,fee schedule,390.56,685.09,
Implant supported retainer,D6075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,627.11,,,,,,,fee schedule,411.13,721.18,
Implant supported retainer,D6075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,513.29,,,,,,,fee schedule,411.13,721.18,
Implant supported retainer,D6075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,411.13,,,,,,,fee schedule,411.13,721.18,
Implant supported retainer,D6075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,721.18,,,,,,,fee schedule,411.13,721.18,
Implant supported retainer,D6076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,610.47,,,,,,,fee schedule,400.22,702.04,
Implant supported retainer,D6076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,499.67,,,,,,,fee schedule,400.22,702.04,
Implant supported retainer,D6076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,400.22,,,,,,,fee schedule,400.22,702.04,
Implant supported retainer,D6076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,702.04,,,,,,,fee schedule,400.22,702.04,
Implant supported retainer,D6077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,592.82,,,,,,,fee schedule,388.65,681.74,
Implant supported retainer,D6077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,485.22,,,,,,,fee schedule,388.65,681.74,
Implant supported retainer,D6077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,388.65,,,,,,,fee schedule,388.65,681.74,
Implant supported retainer,D6077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,681.74,,,,,,,fee schedule,388.65,681.74,
Implant maintenance,D6080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.93,,,,,,,fee schedule,34.05,59.72,
Implant maintenance,D6080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.5,,,,,,,fee schedule,34.05,59.72,
Implant maintenance,D6080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.05,,,,,,,fee schedule,34.05,59.72,
Implant maintenance,D6080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.72,,,,,,,fee schedule,34.05,59.72,
Repl semi/precision attach,D6091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,250.84,,,,,,,fee schedule,164.45,288.47,
Repl semi/precision attach,D6091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,205.31,,,,,,,fee schedule,164.45,288.47,
Repl semi/precision attach,D6091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.45,,,,,,,fee schedule,164.45,288.47,
Repl semi/precision attach,D6091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,288.47,,,,,,,fee schedule,164.45,288.47,
Recement supp crown,D6092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.98,,,,,,,fee schedule,32.11,56.33,
Recement supp crown,D6092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.09,,,,,,,fee schedule,32.11,56.33,
Recement supp crown,D6092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.11,,,,,,,fee schedule,32.11,56.33,
Recement supp crown,D6092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.33,,,,,,,fee schedule,32.11,56.33,
Recement supp part denture,D6093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.42,,,,,,,fee schedule,50.1,87.88,
Recement supp part denture,D6093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.55,,,,,,,fee schedule,50.1,87.88,
Recement supp part denture,D6093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.1,,,,,,,fee schedule,50.1,87.88,
Recement supp part denture,D6093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.88,,,,,,,fee schedule,50.1,87.88,
Abut support crown titanium,D6094,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.73,,,,,,,fee schedule,326.97,573.54,
Abut support crown titanium,D6094,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408.21,,,,,,,fee schedule,326.97,573.54,
Abut support crown titanium,D6094,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.97,,,,,,,fee schedule,326.97,573.54,
Abut support crown titanium,D6094,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,573.54,,,,,,,fee schedule,326.97,573.54,
Radio/surgical implant index,D6190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.67,,,,,,,fee schedule,73.21,128.42,
Radio/surgical implant index,D6190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.4,,,,,,,fee schedule,73.21,128.42,
Radio/surgical implant index,D6190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.21,,,,,,,fee schedule,73.21,128.42,
Radio/surgical implant index,D6190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.42,,,,,,,fee schedule,73.21,128.42,
Abut support retainer titani,D6194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,513.44,,,,,,,fee schedule,336.61,590.46,
Abut support retainer titani,D6194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,420.25,,,,,,,fee schedule,336.61,590.46,
Abut support retainer titani,D6194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,336.61,,,,,,,fee schedule,336.61,590.46,
Abut support retainer titani,D6194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,590.46,,,,,,,fee schedule,336.61,590.46,
Pontic-indirect resin based,D6205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,314.52,,,,,,,fee schedule,206.2,361.7,
Pontic-indirect resin based,D6205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,257.43,,,,,,,fee schedule,206.2,361.7,
Pontic-indirect resin based,D6205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.2,,,,,,,fee schedule,206.2,361.7,
Pontic-indirect resin based,D6205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,361.7,,,,,,,fee schedule,206.2,361.7,
Prosthodont high noble metal,D6210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,480.1,,,,,,,fee schedule,314.75,552.12,
Prosthodont high noble metal,D6210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,392.96,,,,,,,fee schedule,314.75,552.12,
Prosthodont high noble metal,D6210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,314.75,,,,,,,fee schedule,314.75,552.12,
Prosthodont high noble metal,D6210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,552.12,,,,,,,fee schedule,314.75,552.12,
Bridge base metal cast,D6211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,449.76,,,,,,,fee schedule,294.86,517.22,
Bridge base metal cast,D6211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,368.13,,,,,,,fee schedule,294.86,517.22,
Bridge base metal cast,D6211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,294.86,,,,,,,fee schedule,294.86,517.22,
Bridge base metal cast,D6211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,517.22,,,,,,,fee schedule,294.86,517.22,
Bridge noble metal cast,D6212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,468.36,,,,,,,fee schedule,307.06,538.61,
Bridge noble metal cast,D6212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,383.35,,,,,,,fee schedule,307.06,538.61,
Bridge noble metal cast,D6212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,307.06,,,,,,,fee schedule,307.06,538.61,
Bridge noble metal cast,D6212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,538.61,,,,,,,fee schedule,307.06,538.61,
Pontic titanium,D6214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,483.06,,,,,,,fee schedule,316.69,555.52,
Pontic titanium,D6214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,395.38,,,,,,,fee schedule,316.69,555.52,
Pontic titanium,D6214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.69,,,,,,,fee schedule,316.69,555.52,
Pontic titanium,D6214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,555.52,,,,,,,fee schedule,316.69,555.52,
Bridge porcelain high noble,D6240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,474.25,,,,,,,fee schedule,310.92,545.39,
Bridge porcelain high noble,D6240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,388.17,,,,,,,fee schedule,310.92,545.39,
Bridge porcelain high noble,D6240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.92,,,,,,,fee schedule,310.92,545.39,
Bridge porcelain high noble,D6240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,545.39,,,,,,,fee schedule,310.92,545.39,
Bridge porcelain base metal,D6241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.98,,,,,,,fee schedule,287.14,503.68,
Bridge porcelain base metal,D6241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,358.49,,,,,,,fee schedule,287.14,503.68,
Bridge porcelain base metal,D6241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,287.14,,,,,,,fee schedule,287.14,503.68,
Bridge porcelain base metal,D6241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,503.68,,,,,,,fee schedule,287.14,503.68,
Bridge porcelain nobel metal,D6242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,462.47,,,,,,,fee schedule,303.2,531.84,
Bridge porcelain nobel metal,D6242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,378.53,,,,,,,fee schedule,303.2,531.84,
Bridge porcelain nobel metal,D6242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,303.2,,,,,,,fee schedule,303.2,531.84,
Bridge porcelain nobel metal,D6242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,531.84,,,,,,,fee schedule,303.2,531.84,
Bridge porcelain/ceramic,D6245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,489.9,,,,,,,fee schedule,321.18,563.39,
Bridge porcelain/ceramic,D6245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,400.98,,,,,,,fee schedule,321.18,563.39,
Bridge porcelain/ceramic,D6245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,321.18,,,,,,,fee schedule,321.18,563.39,
Bridge porcelain/ceramic,D6245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,563.39,,,,,,,fee schedule,321.18,563.39,
Bridge resin w/high noble,D6250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,468.36,,,,,,,fee schedule,307.06,538.61,
Bridge resin w/high noble,D6250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,383.35,,,,,,,fee schedule,307.06,538.61,
Bridge resin w/high noble,D6250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,307.06,,,,,,,fee schedule,307.06,538.61,
Bridge resin w/high noble,D6250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,538.61,,,,,,,fee schedule,307.06,538.61,
Bridge resin base metal,D6251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,432.12,,,,,,,fee schedule,283.3,496.94,
Bridge resin base metal,D6251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,353.69,,,,,,,fee schedule,283.3,496.94,
Bridge resin base metal,D6251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,283.3,,,,,,,fee schedule,283.3,496.94,
Bridge resin base metal,D6251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,496.94,,,,,,,fee schedule,283.3,496.94,
Bridge resin w/noble metal,D6252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,445.82,,,,,,,fee schedule,292.28,512.69,
Bridge resin w/noble metal,D6252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,364.9,,,,,,,fee schedule,292.28,512.69,
Bridge resin w/noble metal,D6252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,292.28,,,,,,,fee schedule,292.28,512.69,
Bridge resin w/noble metal,D6252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,512.69,,,,,,,fee schedule,292.28,512.69,
Provisional pontic,D6253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.85,,,,,,,fee schedule,132.33,232.13,
Provisional pontic,D6253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,165.21,,,,,,,fee schedule,132.33,232.13,
Provisional pontic,D6253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.33,,,,,,,fee schedule,132.33,232.13,
Provisional pontic,D6253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,232.13,,,,,,,fee schedule,132.33,232.13,
Dental retainr cast metl,D6545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.87,,,,,,,fee schedule,131.03,229.85,
Dental retainr cast metl,D6545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.59,,,,,,,fee schedule,131.03,229.85,
Dental retainr cast metl,D6545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.03,,,,,,,fee schedule,131.03,229.85,
Dental retainr cast metl,D6545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.85,,,,,,,fee schedule,131.03,229.85,
Porcelain/ceramic retainer,D6548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,219.47,,,,,,,fee schedule,143.88,252.39,
Porcelain/ceramic retainer,D6548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,179.64,,,,,,,fee schedule,143.88,252.39,
Porcelain/ceramic retainer,D6548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.88,,,,,,,fee schedule,143.88,252.39,
Porcelain/ceramic retainer,D6548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,252.39,,,,,,,fee schedule,143.88,252.39,
Porcelain/ceramic inlay 2srf,D6600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.86,,,,,,,fee schedule,259.53,455.24,
Porcelain/ceramic inlay 2srf,D6600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.01,,,,,,,fee schedule,259.53,455.24,
Porcelain/ceramic inlay 2srf,D6600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.53,,,,,,,fee schedule,259.53,455.24,
Porcelain/ceramic inlay 2srf,D6600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.24,,,,,,,fee schedule,259.53,455.24,
Porc/ceram inlay >= 3 surfac,D6601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,415.45,,,,,,,fee schedule,272.37,477.77,
Porc/ceram inlay >= 3 surfac,D6601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,340.05,,,,,,,fee schedule,272.37,477.77,
Porc/ceram inlay >= 3 surfac,D6601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,272.37,,,,,,,fee schedule,272.37,477.77,
Porc/ceram inlay >= 3 surfac,D6601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,477.77,,,,,,,fee schedule,272.37,477.77,
Cst hgh nble mtl inlay 2 srf,D6602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.29,,,,,,,fee schedule,277.51,486.78,
Cst hgh nble mtl inlay 2 srf,D6602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.46,,,,,,,fee schedule,277.51,486.78,
Cst hgh nble mtl inlay 2 srf,D6602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.51,,,,,,,fee schedule,277.51,486.78,
Cst hgh nble mtl inlay 2 srf,D6602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.78,,,,,,,fee schedule,277.51,486.78,
Cst hgh nble mtl inlay >=3sr,D6603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,465.42,,,,,,,fee schedule,305.13,535.23,
Cst hgh nble mtl inlay >=3sr,D6603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,380.95,,,,,,,fee schedule,305.13,535.23,
Cst hgh nble mtl inlay >=3sr,D6603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,305.13,,,,,,,fee schedule,305.13,535.23,
Cst hgh nble mtl inlay >=3sr,D6603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,535.23,,,,,,,fee schedule,305.13,535.23,
Cst bse mtl inlay 2 surfaces,D6604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,414.47,,,,,,,fee schedule,271.73,476.64,
Cst bse mtl inlay 2 surfaces,D6604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,339.24,,,,,,,fee schedule,271.73,476.64,
Cst bse mtl inlay 2 surfaces,D6604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,271.73,,,,,,,fee schedule,271.73,476.64,
Cst bse mtl inlay 2 surfaces,D6604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,476.64,,,,,,,fee schedule,271.73,476.64,
Cst bse mtl inlay >= 3 surfa,D6605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,439.95,,,,,,,fee schedule,288.43,505.94,
Cst bse mtl inlay >= 3 surfa,D6605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,360.1,,,,,,,fee schedule,288.43,505.94,
Cst bse mtl inlay >= 3 surfa,D6605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,288.43,,,,,,,fee schedule,288.43,505.94,
Cst bse mtl inlay >= 3 surfa,D6605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,505.94,,,,,,,fee schedule,288.43,505.94,
Cast noble metal inlay 2 sur,D6606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.62,,,,,,,fee schedule,267.24,468.76,
Cast noble metal inlay 2 sur,D6606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.64,,,,,,,fee schedule,267.24,468.76,
Cast noble metal inlay 2 sur,D6606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,267.24,,,,,,,fee schedule,267.24,468.76,
Cast noble metal inlay 2 sur,D6606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.76,,,,,,,fee schedule,267.24,468.76,
Cst noble mtl inlay >=3 surf,D6607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,452.69,,,,,,,fee schedule,296.78,520.59,
Cst noble mtl inlay >=3 surf,D6607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,370.53,,,,,,,fee schedule,296.78,520.59,
Cst noble mtl inlay >=3 surf,D6607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,296.78,,,,,,,fee schedule,296.78,520.59,
Cst noble mtl inlay >=3 surf,D6607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,520.59,,,,,,,fee schedule,296.78,520.59,
Onlay porc/crmc 2 surfaces,D6608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,430.16,,,,,,,fee schedule,282.01,494.68,
Onlay porc/crmc 2 surfaces,D6608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,352.09,,,,,,,fee schedule,282.01,494.68,
Onlay porc/crmc 2 surfaces,D6608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,282.01,,,,,,,fee schedule,282.01,494.68,
Onlay porc/crmc 2 surfaces,D6608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,494.68,,,,,,,fee schedule,282.01,494.68,
Onlay porc/crmc >=3 surfaces,D6609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,448.76,,,,,,,fee schedule,294.21,516.07,
Onlay porc/crmc >=3 surfaces,D6609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,367.31,,,,,,,fee schedule,294.21,516.07,
Onlay porc/crmc >=3 surfaces,D6609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,294.21,,,,,,,fee schedule,294.21,516.07,
Onlay porc/crmc >=3 surfaces,D6609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,516.07,,,,,,,fee schedule,294.21,516.07,
Onlay cst hgh nbl mtl 2 srfc,D6610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,456.59,,,,,,,fee schedule,299.34,525.08,
Onlay cst hgh nbl mtl 2 srfc,D6610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,373.72,,,,,,,fee schedule,299.34,525.08,
Onlay cst hgh nbl mtl 2 srfc,D6610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.34,,,,,,,fee schedule,299.34,525.08,
Onlay cst hgh nbl mtl 2 srfc,D6610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,525.08,,,,,,,fee schedule,299.34,525.08,
Onlay cst hgh nbl mtl >=3srf,D6611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,499.7,,,,,,,fee schedule,327.6,574.66,
Onlay cst hgh nbl mtl >=3srf,D6611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,409,,,,,,,fee schedule,327.6,574.66,
Onlay cst hgh nbl mtl >=3srf,D6611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,327.6,,,,,,,fee schedule,327.6,574.66,
Onlay cst hgh nbl mtl >=3srf,D6611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,574.66,,,,,,,fee schedule,327.6,574.66,
Onlay cst base mtl 2 surface,D6612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,453.65,,,,,,,fee schedule,297.41,521.7,
Onlay cst base mtl 2 surface,D6612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,371.31,,,,,,,fee schedule,297.41,521.7,
Onlay cst base mtl 2 surface,D6612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,297.41,,,,,,,fee schedule,297.41,521.7,
Onlay cst base mtl 2 surface,D6612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,521.7,,,,,,,fee schedule,297.41,521.7,
Onlay cst base mtl >=3 surfa,D6613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,474.25,,,,,,,fee schedule,310.92,545.39,
Onlay cst base mtl >=3 surfa,D6613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,388.17,,,,,,,fee schedule,310.92,545.39,
Onlay cst base mtl >=3 surfa,D6613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.92,,,,,,,fee schedule,310.92,545.39,
Onlay cst base mtl >=3 surfa,D6613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,545.39,,,,,,,fee schedule,310.92,545.39,
Onlay cst nbl mtl 2 surfaces,D6614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,444.83,,,,,,,fee schedule,291.63,511.55,
Onlay cst nbl mtl 2 surfaces,D6614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,364.09,,,,,,,fee schedule,291.63,511.55,
Onlay cst nbl mtl 2 surfaces,D6614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.63,,,,,,,fee schedule,291.63,511.55,
Onlay cst nbl mtl 2 surfaces,D6614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,511.55,,,,,,,fee schedule,291.63,511.55,
Onlay cst nbl mtl >=3 surfac,D6615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,461.51,,,,,,,fee schedule,302.57,530.74,
Onlay cst nbl mtl >=3 surfac,D6615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,377.75,,,,,,,fee schedule,302.57,530.74,
Onlay cst nbl mtl >=3 surfac,D6615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,302.57,,,,,,,fee schedule,302.57,530.74,
Onlay cst nbl mtl >=3 surfac,D6615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,530.74,,,,,,,fee schedule,302.57,530.74,
Inlay titanium,D6624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.29,,,,,,,fee schedule,277.51,486.78,
Inlay titanium,D6624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.46,,,,,,,fee schedule,277.51,486.78,
Inlay titanium,D6624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.51,,,,,,,fee schedule,277.51,486.78,
Inlay titanium,D6624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.78,,,,,,,fee schedule,277.51,486.78,
Onlay titanium,D6634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,444.83,,,,,,,fee schedule,291.63,511.55,
Onlay titanium,D6634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,364.09,,,,,,,fee schedule,291.63,511.55,
Onlay titanium,D6634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.63,,,,,,,fee schedule,291.63,511.55,
Onlay titanium,D6634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,511.55,,,,,,,fee schedule,291.63,511.55,
Crown-indirect resin based,D6710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,453.65,,,,,,,fee schedule,297.41,521.7,
Crown-indirect resin based,D6710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,371.31,,,,,,,fee schedule,297.41,521.7,
Crown-indirect resin based,D6710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,297.41,,,,,,,fee schedule,297.41,521.7,
Crown-indirect resin based,D6710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,521.7,,,,,,,fee schedule,297.41,521.7,
Retain crown resin w hi nble,D6720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,529.12,,,,,,,fee schedule,346.89,608.49,
Retain crown resin w hi nble,D6720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,433.08,,,,,,,fee schedule,346.89,608.49,
Retain crown resin w hi nble,D6720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,346.89,,,,,,,fee schedule,346.89,608.49,
Retain crown resin w hi nble,D6720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,608.49,,,,,,,fee schedule,346.89,608.49,
Crown resin w/base metal,D6721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,501.66,,,,,,,fee schedule,328.89,576.91,
Crown resin w/base metal,D6721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,410.61,,,,,,,fee schedule,328.89,576.91,
Crown resin w/base metal,D6721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,328.89,,,,,,,fee schedule,328.89,576.91,
Crown resin w/base metal,D6721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,576.91,,,,,,,fee schedule,328.89,576.91,
Crown resin w/noble metal,D6722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,510.5,,,,,,,fee schedule,334.68,587.08,
Crown resin w/noble metal,D6722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,417.84,,,,,,,fee schedule,334.68,587.08,
Crown resin w/noble metal,D6722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.68,,,,,,,fee schedule,334.68,587.08,
Crown resin w/noble metal,D6722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.08,,,,,,,fee schedule,334.68,587.08,
Crown porcelain/ceramic,D6740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,555.57,,,,,,,fee schedule,364.23,638.91,
Crown porcelain/ceramic,D6740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,454.73,,,,,,,fee schedule,364.23,638.91,
Crown porcelain/ceramic,D6740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,364.23,,,,,,,fee schedule,364.23,638.91,
Crown porcelain/ceramic,D6740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,638.91,,,,,,,fee schedule,364.23,638.91,
Crown porcelain high noble,D6750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,541.85,,,,,,,fee schedule,355.24,623.13,
Crown porcelain high noble,D6750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,443.5,,,,,,,fee schedule,355.24,623.13,
Crown porcelain high noble,D6750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,355.24,,,,,,,fee schedule,355.24,623.13,
Crown porcelain high noble,D6750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,623.13,,,,,,,fee schedule,355.24,623.13,
Crown porcelain base metal,D6751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,505.62,,,,,,,fee schedule,331.48,581.46,
Crown porcelain base metal,D6751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,413.85,,,,,,,fee schedule,331.48,581.46,
Crown porcelain base metal,D6751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,331.48,,,,,,,fee schedule,331.48,581.46,
Crown porcelain base metal,D6751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,581.46,,,,,,,fee schedule,331.48,581.46,
Crown porcelain noble metal,D6752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,517.36,,,,,,,fee schedule,339.18,594.96,
Crown porcelain noble metal,D6752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,423.46,,,,,,,fee schedule,339.18,594.96,
Crown porcelain noble metal,D6752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,339.18,,,,,,,fee schedule,339.18,594.96,
Crown porcelain noble metal,D6752,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,594.96,,,,,,,fee schedule,339.18,594.96,
Crown 3/4 high noble metal,D6780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,510.5,,,,,,,fee schedule,334.68,587.08,
Crown 3/4 high noble metal,D6780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,417.84,,,,,,,fee schedule,334.68,587.08,
Crown 3/4 high noble metal,D6780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.68,,,,,,,fee schedule,334.68,587.08,
Crown 3/4 high noble metal,D6780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.08,,,,,,,fee schedule,334.68,587.08,
Crown 3/4 cast based metal,D6781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,510.5,,,,,,,fee schedule,334.68,587.08,
Crown 3/4 cast based metal,D6781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,417.84,,,,,,,fee schedule,334.68,587.08,
Crown 3/4 cast based metal,D6781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,334.68,,,,,,,fee schedule,334.68,587.08,
Crown 3/4 cast based metal,D6781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.08,,,,,,,fee schedule,334.68,587.08,
Crown 3/4 cast noble metal,D6782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,474.25,,,,,,,fee schedule,310.92,545.39,
Crown 3/4 cast noble metal,D6782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,388.17,,,,,,,fee schedule,310.92,545.39,
Crown 3/4 cast noble metal,D6782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.92,,,,,,,fee schedule,310.92,545.39,
Crown 3/4 cast noble metal,D6782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,545.39,,,,,,,fee schedule,310.92,545.39,
Crown 3/4 porcelain/ceramic,D6783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,526.16,,,,,,,fee schedule,344.95,605.08,
Crown 3/4 porcelain/ceramic,D6783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,430.66,,,,,,,fee schedule,344.95,605.08,
Crown 3/4 porcelain/ceramic,D6783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,344.95,,,,,,,fee schedule,344.95,605.08,
Crown 3/4 porcelain/ceramic,D6783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,605.08,,,,,,,fee schedule,344.95,605.08,
Crown full high noble metal,D6790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,522.25,,,,,,,fee schedule,342.39,600.59,
Crown full high noble metal,D6790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,427.46,,,,,,,fee schedule,342.39,600.59,
Crown full high noble metal,D6790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,342.39,,,,,,,fee schedule,342.39,600.59,
Crown full high noble metal,D6790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,600.59,,,,,,,fee schedule,342.39,600.59,
Crown full base metal cast,D6791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,495.82,,,,,,,fee schedule,325.06,570.19,
Crown full base metal cast,D6791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,405.83,,,,,,,fee schedule,325.06,570.19,
Crown full base metal cast,D6791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.06,,,,,,,fee schedule,325.06,570.19,
Crown full base metal cast,D6791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,570.19,,,,,,,fee schedule,325.06,570.19,
Crown full noble metal cast,D6792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,513.44,,,,,,,fee schedule,336.61,590.46,
Crown full noble metal cast,D6792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,420.25,,,,,,,fee schedule,336.61,590.46,
Crown full noble metal cast,D6792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,336.61,,,,,,,fee schedule,336.61,590.46,
Crown full noble metal cast,D6792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,590.46,,,,,,,fee schedule,336.61,590.46,
Provisional retainer crown,D6793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.6,,,,,,,fee schedule,140.69,246.79,
Provisional retainer crown,D6793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.65,,,,,,,fee schedule,140.69,246.79,
Provisional retainer crown,D6793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.69,,,,,,,fee schedule,140.69,246.79,
Provisional retainer crown,D6793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.79,,,,,,,fee schedule,140.69,246.79,
Crown titanium,D6794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,513.44,,,,,,,fee schedule,336.61,590.46,
Crown titanium,D6794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,420.25,,,,,,,fee schedule,336.61,590.46,
Crown titanium,D6794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,336.61,,,,,,,fee schedule,336.61,590.46,
Crown titanium,D6794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,590.46,,,,,,,fee schedule,336.61,590.46,
Dental connector bar,D6920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Dental connector bar,D6920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Dental connector bar,D6920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Dental connector bar,D6920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Dental connector bar,D6920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Dental connector bar,D6920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Dental connector bar,D6920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Recement/bond part denture,D6930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.7,,,,,,,fee schedule,41.76,73.26,
Recement/bond part denture,D6930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.14,,,,,,,fee schedule,41.76,73.26,
Recement/bond part denture,D6930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.76,,,,,,,fee schedule,41.76,73.26,
Recement/bond part denture,D6930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.26,,,,,,,fee schedule,41.76,73.26,
Stress breaker,D6940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,165.65,
Stress breaker,D6940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,165.65,
Stress breaker,D6940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,165.65,
Stress breaker,D6940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,165.65,
Precision attachment,D6950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,278.24,,,,,,,fee schedule,182.41,319.98,
Precision attachment,D6950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.74,,,,,,,fee schedule,182.41,319.98,
Precision attachment,D6950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.41,,,,,,,fee schedule,182.41,319.98,
Precision attachment,D6950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.98,,,,,,,fee schedule,182.41,319.98,
Pediatric partial denture fx,D6985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.02,,,,,,,fee schedule,158.67,278.32,
Pediatric partial denture fx,D6985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.09,,,,,,,fee schedule,158.67,278.32,
Pediatric partial denture fx,D6985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.67,,,,,,,fee schedule,158.67,278.32,
Pediatric partial denture fx,D6985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.32,,,,,,,fee schedule,158.67,278.32,
Extraction coronal remnants,D7111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Extraction coronal remnants,D7111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Extraction coronal remnants,D7111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Extraction coronal remnants,D7111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Extraction coronal remnants,D7111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Extraction coronal remnants,D7111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Extraction coronal remnants,D7111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Extraction erupted tooth/exr,D7140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Extraction erupted tooth/exr,D7140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Extraction erupted tooth/exr,D7140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Extraction erupted tooth/exr,D7140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Extraction erupted tooth/exr,D7140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Extraction erupted tooth/exr,D7140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Extraction erupted tooth/exr,D7140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,2782.81,
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,2782.81,
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,2782.81,
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,2782.81,
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,503.07,2782.81,APC
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,503.07,2782.81,APC
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,503.07,2782.81,APC
Impact tooth remov soft tiss,D7220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov soft tiss,D7220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov soft tiss,D7220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov soft tiss,D7220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov soft tiss,D7220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth remov soft tiss,D7220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth remov soft tiss,D7220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth remov part bony,D7230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov part bony,D7230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov part bony,D7230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov part bony,D7230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov part bony,D7230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth remov part bony,D7230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth remov part bony,D7230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth remov comp bony,D7240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov comp bony,D7240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov comp bony,D7240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov comp bony,D7240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Impact tooth remov comp bony,D7240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth remov comp bony,D7240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth remov comp bony,D7240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Tooth root removal,D7250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Tooth root removal,D7250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Tooth root removal,D7250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Tooth root removal,D7250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Tooth root removal,D7250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Tooth root removal,D7250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Tooth root removal,D7250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Coronectomy,D7251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.02,,,,,,,fee schedule,158.67,2782.81,
Coronectomy,D7251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.09,,,,,,,fee schedule,158.67,2782.81,
Coronectomy,D7251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.67,,,,,,,fee schedule,158.67,2782.81,
Coronectomy,D7251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.32,,,,,,,fee schedule,158.67,2782.81,
Coronectomy,D7251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,158.67,2782.81,APC
Coronectomy,D7251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,158.67,2782.81,APC
Coronectomy,D7251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,158.67,2782.81,APC
Oral antral fistula closure,D7260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Oral antral fistula closure,D7260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Oral antral fistula closure,D7260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Oral antral fistula closure,D7260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Oral antral fistula closure,D7260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Oral antral fistula closure,D7260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Oral antral fistula closure,D7260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Primary closure sinus perf,D7261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Primary closure sinus perf,D7261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Primary closure sinus perf,D7261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Primary closure sinus perf,D7261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Primary closure sinus perf,D7261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Primary closure sinus perf,D7261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Primary closure sinus perf,D7261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Tooth reimplantation,D7270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.34,,,,,,,fee schedule,148.39,1159.49,
Tooth reimplantation,D7270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.26,,,,,,,fee schedule,148.39,1159.49,
Tooth reimplantation,D7270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.39,,,,,,,fee schedule,148.39,1159.49,
Tooth reimplantation,D7270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.29,,,,,,,fee schedule,148.39,1159.49,
Tooth reimplantation,D7270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,148.39,1159.49,APC
Tooth reimplantation,D7270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,148.39,1159.49,APC
Tooth reimplantation,D7270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,148.39,1159.49,APC
Tooth transplantation,D7272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,301.78,,,,,,,fee schedule,197.85,1159.49,
Tooth transplantation,D7272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,247.01,,,,,,,fee schedule,197.85,1159.49,
Tooth transplantation,D7272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.85,,,,,,,fee schedule,197.85,1159.49,
Tooth transplantation,D7272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,347.05,,,,,,,fee schedule,197.85,1159.49,
Tooth transplantation,D7272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,197.85,1159.49,APC
Tooth transplantation,D7272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,197.85,1159.49,APC
Tooth transplantation,D7272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,197.85,1159.49,APC
Exposure of unerupted tooth,D7280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,211.63,,,,,,,fee schedule,138.74,1159.49,
Exposure of unerupted tooth,D7280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.22,,,,,,,fee schedule,138.74,1159.49,
Exposure of unerupted tooth,D7280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.74,,,,,,,fee schedule,138.74,1159.49,
Exposure of unerupted tooth,D7280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.37,,,,,,,fee schedule,138.74,1159.49,
Exposure of unerupted tooth,D7280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,138.74,1159.49,APC
Exposure of unerupted tooth,D7280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,138.74,1159.49,APC
Exposure of unerupted tooth,D7280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,138.74,1159.49,APC
Mobilize erupted/malpos toot,D7282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.81,,,,,,,fee schedule,69.37,121.68,
Mobilize erupted/malpos toot,D7282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.61,,,,,,,fee schedule,69.37,121.68,
Mobilize erupted/malpos toot,D7282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.37,,,,,,,fee schedule,69.37,121.68,
Mobilize erupted/malpos toot,D7282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.68,,,,,,,fee schedule,69.37,121.68,
Place device impacted tooth,D7283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.13,,,,,,,fee schedule,59.09,103.65,
Place device impacted tooth,D7283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.77,,,,,,,fee schedule,59.09,103.65,
Place device impacted tooth,D7283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.09,,,,,,,fee schedule,59.09,103.65,
Place device impacted tooth,D7283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.65,,,,,,,fee schedule,59.09,103.65,
Biopsy of oral tissue hard,D7285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.29,,,,,,,fee schedule,277.51,486.78,
Biopsy of oral tissue hard,D7285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.46,,,,,,,fee schedule,277.51,486.78,
Biopsy of oral tissue hard,D7285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.51,,,,,,,fee schedule,277.51,486.78,
Biopsy of oral tissue hard,D7285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.78,,,,,,,fee schedule,277.51,486.78,
Biopsy of oral tissue soft,D7286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,208.45,
Biopsy of oral tissue soft,D7286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,208.45,
Biopsy of oral tissue soft,D7286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,208.45,
Biopsy of oral tissue soft,D7286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,208.45,
Exfoliative cytolog collect,D7287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.51,,,,,,,fee schedule,47.54,83.39,
Exfoliative cytolog collect,D7287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.35,,,,,,,fee schedule,47.54,83.39,
Exfoliative cytolog collect,D7287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.54,,,,,,,fee schedule,47.54,83.39,
Exfoliative cytolog collect,D7287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.39,,,,,,,fee schedule,47.54,83.39,
Brush biopsy,D7288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.51,,,,,,,fee schedule,47.54,83.39,
Brush biopsy,D7288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.35,,,,,,,fee schedule,47.54,83.39,
Brush biopsy,D7288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.54,,,,,,,fee schedule,47.54,83.39,
Brush biopsy,D7288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.39,,,,,,,fee schedule,47.54,83.39,
Repositioning of teeth,D7290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,208.45,
Repositioning of teeth,D7290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,208.45,
Repositioning of teeth,D7290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,208.45,
Repositioning of teeth,D7290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,208.45,
Transseptal fiberotomy,D7291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Transseptal fiberotomy,D7291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Transseptal fiberotomy,D7291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Transseptal fiberotomy,D7291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Transseptal fiberotomy,D7291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Transseptal fiberotomy,D7291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Transseptal fiberotomy,D7291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Screw retained plate,D7292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,290.03,,,,,,,fee schedule,190.14,333.53,
Screw retained plate,D7292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,237.39,,,,,,,fee schedule,190.14,333.53,
Screw retained plate,D7292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,190.14,,,,,,,fee schedule,190.14,333.53,
Screw retained plate,D7292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,333.53,,,,,,,fee schedule,190.14,333.53,
Temp anchorage dev w flap,D7293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.26,,,,,,,fee schedule,118.83,208.45,
Temp anchorage dev w flap,D7293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.36,,,,,,,fee schedule,118.83,208.45,
Temp anchorage dev w flap,D7293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.83,,,,,,,fee schedule,118.83,208.45,
Temp anchorage dev w flap,D7293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.45,,,,,,,fee schedule,118.83,208.45,
Temp anchorage dev w/o flap,D7294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.9,,,,,,,fee schedule,98.93,173.54,
Temp anchorage dev w/o flap,D7294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.51,,,,,,,fee schedule,98.93,173.54,
Temp anchorage dev w/o flap,D7294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.93,,,,,,,fee schedule,98.93,173.54,
Temp anchorage dev w/o flap,D7294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.54,,,,,,,fee schedule,98.93,173.54,
Alveoplasty w/ extraction,D7310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,2782.81,
Alveoplasty w/ extraction,D7310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,2782.81,
Alveoplasty w/ extraction,D7310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,2782.81,
Alveoplasty w/ extraction,D7310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,2782.81,
Alveoplasty w/ extraction,D7310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,79.01,2782.81,APC
Alveoplasty w/ extraction,D7310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,79.01,2782.81,APC
Alveoplasty w/ extraction,D7310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,79.01,2782.81,APC
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.81,,,,,,,fee schedule,69.37,2782.81,
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.61,,,,,,,fee schedule,69.37,2782.81,
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.37,,,,,,,fee schedule,69.37,2782.81,
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.68,,,,,,,fee schedule,69.37,2782.81,
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,69.37,2782.81,APC
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,69.37,2782.81,APC
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,69.37,2782.81,APC
Alveoplasty w/o extraction,D7320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.96,,,,,,,fee schedule,128.47,2782.81,
Alveoplasty w/o extraction,D7320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.39,,,,,,,fee schedule,128.47,2782.81,
Alveoplasty w/o extraction,D7320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.47,,,,,,,fee schedule,128.47,2782.81,
Alveoplasty w/o extraction,D7320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.35,,,,,,,fee schedule,128.47,2782.81,
Alveoplasty w/o extraction,D7320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,128.47,2782.81,APC
Alveoplasty w/o extraction,D7320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,128.47,2782.81,APC
Alveoplasty w/o extraction,D7320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,128.47,2782.81,APC
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.59,,,,,,,fee schedule,108.56,2782.81,
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.54,,,,,,,fee schedule,108.56,2782.81,
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.56,,,,,,,fee schedule,108.56,2782.81,
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.43,,,,,,,fee schedule,108.56,2782.81,
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,108.56,2782.81,APC
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,108.56,2782.81,APC
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,108.56,2782.81,APC
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,830.92,,,,,,,fee schedule,544.75,10617.38,
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,680.11,,,,,,,fee schedule,544.75,10617.38,
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,544.75,,,,,,,fee schedule,544.75,10617.38,
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,955.56,,,,,,,fee schedule,544.75,10617.38,
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,544.75,10617.38,APC
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,544.75,10617.38,APC
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,544.75,10617.38,APC
Vestibuloplasty exten graft,D7350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2417.29,,,,,,,fee schedule,1584.78,10617.38,
Vestibuloplasty exten graft,D7350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1978.55,,,,,,,fee schedule,1584.78,10617.38,
Vestibuloplasty exten graft,D7350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1584.78,,,,,,,fee schedule,1584.78,10617.38,
Vestibuloplasty exten graft,D7350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2779.88,,,,,,,fee schedule,1584.78,10617.38,
Vestibuloplasty exten graft,D7350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,1584.78,10617.38,APC
Vestibuloplasty exten graft,D7350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,1584.78,10617.38,APC
Vestibuloplasty exten graft,D7350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,1584.78,10617.38,APC
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,362.54,,,,,,,fee schedule,237.68,2782.81,
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,296.74,,,,,,,fee schedule,237.68,2782.81,
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,237.68,,,,,,,fee schedule,237.68,2782.81,
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,416.92,,,,,,,fee schedule,237.68,2782.81,
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,237.68,2782.81,APC
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,237.68,2782.81,APC
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,237.68,2782.81,APC
Excision benign lesion>1.25c,D7411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,574.19,,,,,,,fee schedule,376.44,2782.81,
Excision benign lesion>1.25c,D7411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,469.97,,,,,,,fee schedule,376.44,2782.81,
Excision benign lesion>1.25c,D7411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,376.44,,,,,,,fee schedule,376.44,2782.81,
Excision benign lesion>1.25c,D7411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,660.32,,,,,,,fee schedule,376.44,2782.81,
Excision benign lesion>1.25c,D7411,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,376.44,2782.81,APC
Excision benign lesion>1.25c,D7411,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,376.44,2782.81,APC
Excision benign lesion>1.25c,D7411,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,376.44,2782.81,APC
Excision benign lesion compl,D7412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,634.94,,,,,,,fee schedule,416.27,2782.81,
Excision benign lesion compl,D7412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,519.7,,,,,,,fee schedule,416.27,2782.81,
Excision benign lesion compl,D7412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.27,,,,,,,fee schedule,416.27,2782.81,
Excision benign lesion compl,D7412,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,730.18,,,,,,,fee schedule,416.27,2782.81,
Excision benign lesion compl,D7412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,416.27,2782.81,APC
Excision benign lesion compl,D7412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,416.27,2782.81,APC
Excision benign lesion compl,D7412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,416.27,2782.81,APC
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.29,,,,,,,fee schedule,277.51,2782.81,
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.46,,,,,,,fee schedule,277.51,2782.81,
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.51,,,,,,,fee schedule,277.51,2782.81,
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.78,,,,,,,fee schedule,277.51,2782.81,
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,277.51,2782.81,APC
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,277.51,2782.81,APC
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,277.51,2782.81,APC
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,634.94,,,,,,,fee schedule,416.27,2782.81,
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,519.7,,,,,,,fee schedule,416.27,2782.81,
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,416.27,,,,,,,fee schedule,416.27,2782.81,
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,730.18,,,,,,,fee schedule,416.27,2782.81,
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,416.27,2782.81,APC
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,416.27,2782.81,APC
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,416.27,2782.81,APC
Excision malig les complicat,D7415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,710.39,,,,,,,fee schedule,465.73,2782.81,
Excision malig les complicat,D7415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,581.45,,,,,,,fee schedule,465.73,2782.81,
Excision malig les complicat,D7415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,465.73,,,,,,,fee schedule,465.73,2782.81,
Excision malig les complicat,D7415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,816.95,,,,,,,fee schedule,465.73,2782.81,
Excision malig les complicat,D7415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1623.3,,,,,,,fee schedule,465.73,2782.81,APC
Excision malig les complicat,D7415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1546,,,,,,,fee schedule,465.73,2782.81,APC
Excision malig les complicat,D7415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2782.81,,,,,,,fee schedule,465.73,2782.81,APC
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,574.19,,,,,,,fee schedule,376.44,5946.37,
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,469.97,,,,,,,fee schedule,376.44,5946.37,
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,376.44,,,,,,,fee schedule,376.44,5946.37,
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,660.32,,,,,,,fee schedule,376.44,5946.37,
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,376.44,5946.37,APC
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,376.44,5946.37,APC
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,376.44,5946.37,APC
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,846.59,,,,,,,fee schedule,555.02,5946.37,
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,692.93,,,,,,,fee schedule,555.02,5946.37,
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,555.02,,,,,,,fee schedule,555.02,5946.37,
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,973.58,,,,,,,fee schedule,555.02,5946.37,
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,555.02,5946.37,APC
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,555.02,5946.37,APC
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,555.02,5946.37,APC
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,362.54,,,,,,,fee schedule,237.68,5946.37,
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,296.74,,,,,,,fee schedule,237.68,5946.37,
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,237.68,,,,,,,fee schedule,237.68,5946.37,
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,416.92,,,,,,,fee schedule,237.68,5946.37,
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,237.68,5946.37,APC
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,237.68,5946.37,APC
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,237.68,5946.37,APC
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,495.82,,,,,,,fee schedule,325.06,5946.37,
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,405.83,,,,,,,fee schedule,325.06,5946.37,
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.06,,,,,,,fee schedule,325.06,5946.37,
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,570.19,,,,,,,fee schedule,325.06,5946.37,
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,325.06,5946.37,APC
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,325.06,5946.37,APC
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,325.06,5946.37,APC
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,362.54,,,,,,,fee schedule,237.68,1159.49,
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,296.74,,,,,,,fee schedule,237.68,1159.49,
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,237.68,,,,,,,fee schedule,237.68,1159.49,
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,416.92,,,,,,,fee schedule,237.68,1159.49,
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,237.68,1159.49,APC
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,237.68,1159.49,APC
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,237.68,1159.49,APC
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,495.82,,,,,,,fee schedule,325.06,1159.49,
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,405.83,,,,,,,fee schedule,325.06,1159.49,
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.06,,,,,,,fee schedule,325.06,1159.49,
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,570.19,,,,,,,fee schedule,325.06,1159.49,
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,325.06,1159.49,APC
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,325.06,1159.49,APC
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,325.06,1159.49,APC
Lesion destruction,D7465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.96,,,,,,,fee schedule,128.47,225.35,
Lesion destruction,D7465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.39,,,,,,,fee schedule,128.47,225.35,
Lesion destruction,D7465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.47,,,,,,,fee schedule,128.47,225.35,
Lesion destruction,D7465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.35,,,,,,,fee schedule,128.47,225.35,
Rem exostosis any site,D7471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,448.76,,,,,,,fee schedule,294.21,5946.37,
Rem exostosis any site,D7471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,367.31,,,,,,,fee schedule,294.21,5946.37,
Rem exostosis any site,D7471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,294.21,,,,,,,fee schedule,294.21,5946.37,
Rem exostosis any site,D7471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,516.07,,,,,,,fee schedule,294.21,5946.37,
Rem exostosis any site,D7471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,294.21,5946.37,APC
Rem exostosis any site,D7471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,294.21,5946.37,APC
Rem exostosis any site,D7471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,294.21,5946.37,APC
Removal of torus palatinus,D7472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,534.01,,,,,,,fee schedule,350.1,1159.49,
Removal of torus palatinus,D7472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,437.09,,,,,,,fee schedule,350.1,1159.49,
Removal of torus palatinus,D7472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,350.1,,,,,,,fee schedule,350.1,1159.49,
Removal of torus palatinus,D7472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,614.11,,,,,,,fee schedule,350.1,1159.49,
Removal of torus palatinus,D7472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,350.1,1159.49,APC
Removal of torus palatinus,D7472,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,350.1,1159.49,APC
Removal of torus palatinus,D7472,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,350.1,1159.49,APC
Remove torus mandibularis,D7473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,503.65,,,,,,,fee schedule,330.19,1159.49,
Remove torus mandibularis,D7473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,412.24,,,,,,,fee schedule,330.19,1159.49,
Remove torus mandibularis,D7473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,330.19,,,,,,,fee schedule,330.19,1159.49,
Remove torus mandibularis,D7473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,579.2,,,,,,,fee schedule,330.19,1159.49,
Remove torus mandibularis,D7473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,330.19,1159.49,APC
Remove torus mandibularis,D7473,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,330.19,1159.49,APC
Remove torus mandibularis,D7473,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,330.19,1159.49,APC
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,448.76,,,,,,,fee schedule,294.21,10617.38,
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,367.31,,,,,,,fee schedule,294.21,10617.38,
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,294.21,,,,,,,fee schedule,294.21,10617.38,
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,516.07,,,,,,,fee schedule,294.21,10617.38,
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,294.21,10617.38,APC
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,294.21,10617.38,APC
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,294.21,10617.38,APC
Maxilla or mandible resectio,D7490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3626.43,,,,,,,fee schedule,2377.49,4170.39,
Maxilla or mandible resectio,D7490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2968.23,,,,,,,fee schedule,2377.49,4170.39,
Maxilla or mandible resectio,D7490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2377.49,,,,,,,fee schedule,2377.49,4170.39,
Maxilla or mandible resectio,D7490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4170.39,,,,,,,fee schedule,2377.49,4170.39,
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.31,,,,,,,fee schedule,85.43,1270.05,
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.66,,,,,,,fee schedule,85.43,1270.05,
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.43,,,,,,,fee schedule,85.43,1270.05,
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.86,,,,,,,fee schedule,85.43,1270.05,
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,85.43,1270.05,APC
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,85.43,1270.05,APC
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,85.43,1270.05,APC
Incision/drain abscess intra,D7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.96,,,,,,,fee schedule,128.47,1270.05,
Incision/drain abscess intra,D7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.39,,,,,,,fee schedule,128.47,1270.05,
Incision/drain abscess intra,D7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.47,,,,,,,fee schedule,128.47,1270.05,
Incision/drain abscess intra,D7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.35,,,,,,,fee schedule,128.47,1270.05,
Incision/drain abscess intra,D7511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,128.47,1270.05,APC
Incision/drain abscess intra,D7511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,128.47,1270.05,APC
Incision/drain abscess intra,D7511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,128.47,1270.05,APC
I&d abscess extraoral,D7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,619.26,,,,,,,fee schedule,405.99,1270.05,
I&d abscess extraoral,D7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,506.86,,,,,,,fee schedule,405.99,1270.05,
I&d abscess extraoral,D7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,405.99,,,,,,,fee schedule,405.99,1270.05,
I&d abscess extraoral,D7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,712.15,,,,,,,fee schedule,405.99,1270.05,
I&d abscess extraoral,D7520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,405.99,1270.05,APC
I&d abscess extraoral,D7520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,405.99,1270.05,APC
I&d abscess extraoral,D7520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,405.99,1270.05,APC
Incision/drain abscess extra,D7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,680.02,,,,,,,fee schedule,445.82,1270.05,
Incision/drain abscess extra,D7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,556.6,,,,,,,fee schedule,445.82,1270.05,
Incision/drain abscess extra,D7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.82,,,,,,,fee schedule,445.82,1270.05,
Incision/drain abscess extra,D7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,782.02,,,,,,,fee schedule,445.82,1270.05,
Incision/drain abscess extra,D7521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,740.87,,,,,,,fee schedule,445.82,1270.05,APC
Incision/drain abscess extra,D7521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.59,,,,,,,fee schedule,445.82,1270.05,APC
Incision/drain abscess extra,D7521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.05,,,,,,,fee schedule,445.82,1270.05,APC
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,223.41,,,,,,,fee schedule,146.47,1159.49,
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.86,,,,,,,fee schedule,146.47,1159.49,
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.47,,,,,,,fee schedule,146.47,1159.49,
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,256.92,,,,,,,fee schedule,146.47,1159.49,
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,146.47,1159.49,APC
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,146.47,1159.49,APC
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,146.47,1159.49,APC
Removal of fb reaction,D7540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.92,,,,,,,fee schedule,161.88,1159.49,
Removal of fb reaction,D7540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.1,,,,,,,fee schedule,161.88,1159.49,
Removal of fb reaction,D7540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.88,,,,,,,fee schedule,161.88,1159.49,
Removal of fb reaction,D7540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.96,,,,,,,fee schedule,161.88,1159.49,
Removal of fb reaction,D7540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,161.88,1159.49,APC
Removal of fb reaction,D7540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,161.88,1159.49,APC
Removal of fb reaction,D7540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,161.88,1159.49,APC
Removal of sloughed off bone,D7550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.84,,,,,,,fee schedule,100.86,1159.49,
Removal of sloughed off bone,D7550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.92,,,,,,,fee schedule,100.86,1159.49,
Removal of sloughed off bone,D7550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.86,,,,,,,fee schedule,100.86,1159.49,
Removal of sloughed off bone,D7550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.92,,,,,,,fee schedule,100.86,1159.49,
Removal of sloughed off bone,D7550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,100.86,1159.49,APC
Removal of sloughed off bone,D7550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,100.86,1159.49,APC
Removal of sloughed off bone,D7550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,100.86,1159.49,APC
Maxillary sinusotomy,D7560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1223.84,,,,,,,fee schedule,802.35,1407.42,
Maxillary sinusotomy,D7560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1001.71,,,,,,,fee schedule,802.35,1407.42,
Maxillary sinusotomy,D7560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,802.35,,,,,,,fee schedule,802.35,1407.42,
Maxillary sinusotomy,D7560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1407.42,,,,,,,fee schedule,802.35,1407.42,
Maxilla open reduct simple,D7610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1979.3,,,,,,,fee schedule,1297.63,2276.2,
Maxilla open reduct simple,D7610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1620.06,,,,,,,fee schedule,1297.63,2276.2,
Maxilla open reduct simple,D7610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1297.63,,,,,,,fee schedule,1297.63,2276.2,
Maxilla open reduct simple,D7610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2276.2,,,,,,,fee schedule,1297.63,2276.2,
Clsd reduct simpl maxilla fx,D7620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1484.46,,,,,,,fee schedule,973.21,1707.13,
Clsd reduct simpl maxilla fx,D7620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1215.03,,,,,,,fee schedule,973.21,1707.13,
Clsd reduct simpl maxilla fx,D7620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,973.21,,,,,,,fee schedule,973.21,1707.13,
Clsd reduct simpl maxilla fx,D7620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1707.13,,,,,,,fee schedule,973.21,1707.13,
Open red simpl mandible fx,D7630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2574.06,,,,,,,fee schedule,1687.55,2960.17,
Open red simpl mandible fx,D7630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2106.87,,,,,,,fee schedule,1687.55,2960.17,
Open red simpl mandible fx,D7630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1687.55,,,,,,,fee schedule,1687.55,2960.17,
Open red simpl mandible fx,D7630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2960.17,,,,,,,fee schedule,1687.55,2960.17,
Clsd red simpl mandible fx,D7640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1633.39,,,,,,,fee schedule,1070.85,1878.4,
Clsd red simpl mandible fx,D7640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1336.93,,,,,,,fee schedule,1070.85,1878.4,
Clsd red simpl mandible fx,D7640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1070.85,,,,,,,fee schedule,1070.85,1878.4,
Clsd red simpl mandible fx,D7640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1878.4,,,,,,,fee schedule,1070.85,1878.4,
Open red simp malar/zygom fx,D7650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1237.53,,,,,,,fee schedule,811.32,1423.16,
Open red simp malar/zygom fx,D7650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1012.92,,,,,,,fee schedule,811.32,1423.16,
Open red simp malar/zygom fx,D7650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,811.32,,,,,,,fee schedule,811.32,1423.16,
Open red simp malar/zygom fx,D7650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1423.16,,,,,,,fee schedule,811.32,1423.16,
Clsd red simp malar/zygom fx,D7660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,728.99,,,,,,,fee schedule,477.93,838.34,
Clsd red simp malar/zygom fx,D7660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,596.68,,,,,,,fee schedule,477.93,838.34,
Clsd red simp malar/zygom fx,D7660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,477.93,,,,,,,fee schedule,477.93,838.34,
Clsd red simp malar/zygom fx,D7660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,838.34,,,,,,,fee schedule,477.93,838.34,
Closd rductn splint alveolus,D7670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.27,,,,,,,fee schedule,373.21,5946.37,
Closd rductn splint alveolus,D7670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,465.95,,,,,,,fee schedule,373.21,5946.37,
Closd rductn splint alveolus,D7670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,373.21,,,,,,,fee schedule,373.21,5946.37,
Closd rductn splint alveolus,D7670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,654.66,,,,,,,fee schedule,373.21,5946.37,
Closd rductn splint alveolus,D7670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,373.21,5946.37,APC
Closd rductn splint alveolus,D7670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,373.21,5946.37,APC
Closd rductn splint alveolus,D7670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,373.21,5946.37,APC
Alveolus open reduction,D7671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1072.94,,,,,,,fee schedule,703.42,10617.38,
Alveolus open reduction,D7671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,878.2,,,,,,,fee schedule,703.42,10617.38,
Alveolus open reduction,D7671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,703.42,,,,,,,fee schedule,703.42,10617.38,
Alveolus open reduction,D7671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1233.88,,,,,,,fee schedule,703.42,10617.38,
Alveolus open reduction,D7671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,703.42,10617.38,APC
Alveolus open reduction,D7671,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,703.42,10617.38,APC
Alveolus open reduction,D7671,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,703.42,10617.38,APC
Reduct simple facial bone fx,D7680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3711.68,,,,,,,fee schedule,2433.38,4268.43,
Reduct simple facial bone fx,D7680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3038.01,,,,,,,fee schedule,2433.38,4268.43,
Reduct simple facial bone fx,D7680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2433.38,,,,,,,fee schedule,2433.38,4268.43,
Reduct simple facial bone fx,D7680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4268.43,,,,,,,fee schedule,2433.38,4268.43,
Maxilla open reduct compound,D7710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2326.18,,,,,,,fee schedule,1525.04,2675.11,
Maxilla open reduct compound,D7710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1903.98,,,,,,,fee schedule,1525.04,2675.11,
Maxilla open reduct compound,D7710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1525.04,,,,,,,fee schedule,1525.04,2675.11,
Maxilla open reduct compound,D7710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2675.11,,,,,,,fee schedule,1525.04,2675.11,
Clsd reduct compd maxilla fx,D7720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1633.39,,,,,,,fee schedule,1070.85,1878.4,
Clsd reduct compd maxilla fx,D7720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1336.93,,,,,,,fee schedule,1070.85,1878.4,
Clsd reduct compd maxilla fx,D7720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1070.85,,,,,,,fee schedule,1070.85,1878.4,
Clsd reduct compd maxilla fx,D7720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1878.4,,,,,,,fee schedule,1070.85,1878.4,
Open reduct compd mandble fx,D7730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3365.79,,,,,,,fee schedule,2206.61,3870.66,
Open reduct compd mandble fx,D7730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2754.9,,,,,,,fee schedule,2206.61,3870.66,
Open reduct compd mandble fx,D7730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2206.61,,,,,,,fee schedule,2206.61,3870.66,
Open reduct compd mandble fx,D7730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3870.66,,,,,,,fee schedule,2206.61,3870.66,
Clsd reduct compd mandble fx,D7740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1665.75,,,,,,,fee schedule,1092.07,1915.61,
Clsd reduct compd mandble fx,D7740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1363.42,,,,,,,fee schedule,1092.07,1915.61,
Clsd reduct compd mandble fx,D7740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1092.07,,,,,,,fee schedule,1092.07,1915.61,
Clsd reduct compd mandble fx,D7740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1915.61,,,,,,,fee schedule,1092.07,1915.61,
Open red comp malar/zygma fx,D7750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2117.43,,,,,,,fee schedule,1388.19,2435.04,
Open red comp malar/zygma fx,D7750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1733.12,,,,,,,fee schedule,1388.19,2435.04,
Open red comp malar/zygma fx,D7750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1388.19,,,,,,,fee schedule,1388.19,2435.04,
Open red comp malar/zygma fx,D7750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2435.04,,,,,,,fee schedule,1388.19,2435.04,
Clsd red comp malar/zygma fx,D7760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,849.55,,,,,,,fee schedule,556.96,976.98,
Clsd red comp malar/zygma fx,D7760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,695.36,,,,,,,fee schedule,556.96,976.98,
Clsd red comp malar/zygma fx,D7760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,556.96,,,,,,,fee schedule,556.96,976.98,
Clsd red comp malar/zygma fx,D7760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,976.98,,,,,,,fee schedule,556.96,976.98,
Open reduc compd alveolus fx,D7770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1151.32,,,,,,,fee schedule,754.81,10617.38,
Open reduc compd alveolus fx,D7770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,942.36,,,,,,,fee schedule,754.81,10617.38,
Open reduc compd alveolus fx,D7770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,754.81,,,,,,,fee schedule,754.81,10617.38,
Open reduc compd alveolus fx,D7770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1324.02,,,,,,,fee schedule,754.81,10617.38,
Open reduc compd alveolus fx,D7770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,754.81,10617.38,APC
Open reduc compd alveolus fx,D7770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,754.81,10617.38,APC
Open reduc compd alveolus fx,D7770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,754.81,10617.38,APC
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,888.72,,,,,,,fee schedule,582.64,5946.37,
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,727.42,,,,,,,fee schedule,582.64,5946.37,
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,582.64,,,,,,,fee schedule,582.64,5946.37,
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1022.03,,,,,,,fee schedule,582.64,5946.37,
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,582.64,5946.37,APC
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,582.64,5946.37,APC
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,582.64,5946.37,APC
Reduct compnd facial bone fx,D7780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4949.23,,,,,,,fee schedule,3244.72,5691.61,
Reduct compnd facial bone fx,D7780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4050.94,,,,,,,fee schedule,3244.72,5691.61,
Reduct compnd facial bone fx,D7780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3244.72,,,,,,,fee schedule,3244.72,5691.61,
Reduct compnd facial bone fx,D7780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5691.61,,,,,,,fee schedule,3244.72,5691.61,
Tmj open reduct-dislocation,D7810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2177.24,,,,,,,fee schedule,1427.4,2503.83,
Tmj open reduct-dislocation,D7810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1782.07,,,,,,,fee schedule,1427.4,2503.83,
Tmj open reduct-dislocation,D7810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1427.4,,,,,,,fee schedule,1427.4,2503.83,
Tmj open reduct-dislocation,D7810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2503.83,,,,,,,fee schedule,1427.4,2503.83,
Closed tmp manipulation,D7820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,356.65,,,,,,,fee schedule,233.82,410.15,
Closed tmp manipulation,D7820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.92,,,,,,,fee schedule,233.82,410.15,
Closed tmp manipulation,D7820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.82,,,,,,,fee schedule,233.82,410.15,
Closed tmp manipulation,D7820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.15,,,,,,,fee schedule,233.82,410.15,
Tmj manipulation under anest,D7830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.81,,,,,,,fee schedule,133.62,234.38,
Tmj manipulation under anest,D7830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.82,,,,,,,fee schedule,133.62,234.38,
Tmj manipulation under anest,D7830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.62,,,,,,,fee schedule,133.62,234.38,
Tmj manipulation under anest,D7830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,234.38,,,,,,,fee schedule,133.62,234.38,
Removal of tmj condyle,D7840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2967.96,,,,,,,fee schedule,1945.79,3413.15,
Removal of tmj condyle,D7840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2429.28,,,,,,,fee schedule,1945.79,3413.15,
Removal of tmj condyle,D7840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1945.79,,,,,,,fee schedule,1945.79,3413.15,
Removal of tmj condyle,D7840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3413.15,,,,,,,fee schedule,1945.79,3413.15,
Tmj meniscectomy,D7850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2562.32,,,,,,,fee schedule,1679.86,2946.67,
Tmj meniscectomy,D7850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2097.26,,,,,,,fee schedule,1679.86,2946.67,
Tmj meniscectomy,D7850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1679.86,,,,,,,fee schedule,1679.86,2946.67,
Tmj meniscectomy,D7850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2946.67,,,,,,,fee schedule,1679.86,2946.67,
Tmj repair of joint disc,D7852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2934.66,,,,,,,fee schedule,1923.96,3374.86,
Tmj repair of joint disc,D7852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2402.02,,,,,,,fee schedule,1923.96,3374.86,
Tmj repair of joint disc,D7852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1923.96,,,,,,,fee schedule,1923.96,3374.86,
Tmj repair of joint disc,D7852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3374.86,,,,,,,fee schedule,1923.96,3374.86,
Tmj excisn of joint membrane,D7854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3027.74,,,,,,,fee schedule,1984.99,3481.9,
Tmj excisn of joint membrane,D7854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2478.21,,,,,,,fee schedule,1984.99,3481.9,
Tmj excisn of joint membrane,D7854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1984.99,,,,,,,fee schedule,1984.99,3481.9,
Tmj excisn of joint membrane,D7854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3481.9,,,,,,,fee schedule,1984.99,3481.9,
Tmj cutting of a muscle,D7856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2148.8,,,,,,,fee schedule,1408.75,2471.12,
Tmj cutting of a muscle,D7856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1758.79,,,,,,,fee schedule,1408.75,2471.12,
Tmj cutting of a muscle,D7856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1408.75,,,,,,,fee schedule,1408.75,2471.12,
Tmj cutting of a muscle,D7856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2471.12,,,,,,,fee schedule,1408.75,2471.12,
Tmj reconstruction,D7858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6124.07,,,,,,,fee schedule,4014.94,7042.68,
Tmj reconstruction,D7858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5012.55,,,,,,,fee schedule,4014.94,7042.68,
Tmj reconstruction,D7858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4014.94,,,,,,,fee schedule,4014.94,7042.68,
Tmj reconstruction,D7858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7042.68,,,,,,,fee schedule,4014.94,7042.68,
Tmj cutting into joint,D7860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2610.31,,,,,,,fee schedule,1711.32,3001.86,
Tmj cutting into joint,D7860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2136.54,,,,,,,fee schedule,1711.32,3001.86,
Tmj cutting into joint,D7860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1711.32,,,,,,,fee schedule,1711.32,3001.86,
Tmj cutting into joint,D7860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3001.86,,,,,,,fee schedule,1711.32,3001.86,
Tmj reshaping components,D7865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4206.52,,,,,,,fee schedule,2757.79,4837.5,
Tmj reshaping components,D7865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3443.04,,,,,,,fee schedule,2757.79,4837.5,
Tmj reshaping components,D7865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2757.79,,,,,,,fee schedule,2757.79,4837.5,
Tmj reshaping components,D7865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4837.5,,,,,,,fee schedule,2757.79,4837.5,
Tmj aspiration joint fluid,D7870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.14,,,,,,,fee schedule,91.22,160.01,
Tmj aspiration joint fluid,D7870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.89,,,,,,,fee schedule,91.22,160.01,
Tmj aspiration joint fluid,D7870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.22,,,,,,,fee schedule,91.22,160.01,
Tmj aspiration joint fluid,D7870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.01,,,,,,,fee schedule,91.22,160.01,
Lysis + lavage w catheters,D7871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,278.24,,,,,,,fee schedule,182.41,319.98,
Lysis + lavage w catheters,D7871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.74,,,,,,,fee schedule,182.41,319.98,
Lysis + lavage w catheters,D7871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.41,,,,,,,fee schedule,182.41,319.98,
Lysis + lavage w catheters,D7871,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.98,,,,,,,fee schedule,182.41,319.98,
Tmj diagnostic arthroscopy,D7872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1483.47,,,,,,,fee schedule,972.56,1705.99,
Tmj diagnostic arthroscopy,D7872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1214.22,,,,,,,fee schedule,972.56,1705.99,
Tmj diagnostic arthroscopy,D7872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,972.56,,,,,,,fee schedule,972.56,1705.99,
Tmj diagnostic arthroscopy,D7872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1705.99,,,,,,,fee schedule,972.56,1705.99,
Tmj arthroscopy lysis adhesn,D7873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1786.27,,,,,,,fee schedule,1171.08,2054.21,
Tmj arthroscopy lysis adhesn,D7873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1462.06,,,,,,,fee schedule,1171.08,2054.21,
Tmj arthroscopy lysis adhesn,D7873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1171.08,,,,,,,fee schedule,1171.08,2054.21,
Tmj arthroscopy lysis adhesn,D7873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2054.21,,,,,,,fee schedule,1171.08,2054.21,
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2562.32,,,,,,,fee schedule,1679.86,5868.42,
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2097.26,,,,,,,fee schedule,1679.86,5868.42,
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1679.86,,,,,,,fee schedule,1679.86,5868.42,
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2946.67,,,,,,,fee schedule,1679.86,5868.42,
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,1679.86,5868.42,APC
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,1679.86,5868.42,APC
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,1679.86,5868.42,APC
Tmj arthroscopy synovectomy,D7875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2807.28,,,,,,,fee schedule,1840.45,3228.37,
Tmj arthroscopy synovectomy,D7875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2297.76,,,,,,,fee schedule,1840.45,3228.37,
Tmj arthroscopy synovectomy,D7875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1840.45,,,,,,,fee schedule,1840.45,3228.37,
Tmj arthroscopy synovectomy,D7875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3228.37,,,,,,,fee schedule,1840.45,3228.37,
Tmj arthroscopy discectomy,D7876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3026.77,,,,,,,fee schedule,1984.35,3480.79,
Tmj arthroscopy discectomy,D7876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2477.41,,,,,,,fee schedule,1984.35,3480.79,
Tmj arthroscopy discectomy,D7876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1984.35,,,,,,,fee schedule,1984.35,3480.79,
Tmj arthroscopy discectomy,D7876,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3480.79,,,,,,,fee schedule,1984.35,3480.79,
Tmj arthroscopy debridement,D7877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2671.1,,,,,,,fee schedule,1751.17,3071.77,
Tmj arthroscopy debridement,D7877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2186.3,,,,,,,fee schedule,1751.17,3071.77,
Tmj arthroscopy debridement,D7877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1751.17,,,,,,,fee schedule,1751.17,3071.77,
Tmj arthroscopy debridement,D7877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3071.77,,,,,,,fee schedule,1751.17,3071.77,
Occlusal orthotic appliance,D7880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,334.12,,,,,,,fee schedule,219.05,384.24,
Occlusal orthotic appliance,D7880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,273.48,,,,,,,fee schedule,219.05,384.24,
Occlusal orthotic appliance,D7880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,219.05,,,,,,,fee schedule,219.05,384.24,
Occlusal orthotic appliance,D7880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,384.24,,,,,,,fee schedule,219.05,384.24,
Dent sutur recent wnd to 5cm,D7910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.89,,,,,,,fee schedule,130.39,228.72,
Dent sutur recent wnd to 5cm,D7910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.79,,,,,,,fee schedule,130.39,228.72,
Dent sutur recent wnd to 5cm,D7910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,130.39,,,,,,,fee schedule,130.39,228.72,
Dent sutur recent wnd to 5cm,D7910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.72,,,,,,,fee schedule,130.39,228.72,
Dental suture wound to 5 cm,D7911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,494.83,,,,,,,fee schedule,324.41,569.05,
Dental suture wound to 5 cm,D7911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,405.02,,,,,,,fee schedule,324.41,569.05,
Dental suture wound to 5 cm,D7911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,324.41,,,,,,,fee schedule,324.41,569.05,
Dental suture wound to 5 cm,D7911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,569.05,,,,,,,fee schedule,324.41,569.05,
Suture complicate wnd > 5 cm,D7912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.69,,,,,,,fee schedule,583.94,1024.29,
Suture complicate wnd > 5 cm,D7912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,729.03,,,,,,,fee schedule,583.94,1024.29,
Suture complicate wnd > 5 cm,D7912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,583.94,,,,,,,fee schedule,583.94,1024.29,
Suture complicate wnd > 5 cm,D7912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.29,,,,,,,fee schedule,583.94,1024.29,
Dental skin graft,D7920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1459.97,,,,,,,fee schedule,957.16,1678.97,
Dental skin graft,D7920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1194.99,,,,,,,fee schedule,957.16,1678.97,
Dental skin graft,D7920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,957.16,,,,,,,fee schedule,957.16,1678.97,
Dental skin graft,D7920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1678.97,,,,,,,fee schedule,957.16,1678.97,
Reshaping bone orthognathic,D7940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Reshaping bone orthognathic,D7940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Reshaping bone orthognathic,D7940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Reshaping bone orthognathic,D7940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Reshaping bone orthognathic,D7940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Reshaping bone orthognathic,D7940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Reshaping bone orthognathic,D7940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Bone cutting ramus closed,D7941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3717.56,,,,,,,fee schedule,2437.23,4275.19,
Bone cutting ramus closed,D7941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3042.82,,,,,,,fee schedule,2437.23,4275.19,
Bone cutting ramus closed,D7941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2437.23,,,,,,,fee schedule,2437.23,4275.19,
Bone cutting ramus closed,D7941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4275.19,,,,,,,fee schedule,2437.23,4275.19,
Cutting ramus open w/graft,D7943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3414.78,,,,,,,fee schedule,2238.73,3927,
Cutting ramus open w/graft,D7943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2795,,,,,,,fee schedule,2238.73,3927,
Cutting ramus open w/graft,D7943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2238.73,,,,,,,fee schedule,2238.73,3927,
Cutting ramus open w/graft,D7943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3927,,,,,,,fee schedule,2238.73,3927,
Bone cutting segmented,D7944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3043.42,,,,,,,fee schedule,1995.27,3499.93,
Bone cutting segmented,D7944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2491.04,,,,,,,fee schedule,1995.27,3499.93,
Bone cutting segmented,D7944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1995.27,,,,,,,fee schedule,1995.27,3499.93,
Bone cutting segmented,D7944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3499.93,,,,,,,fee schedule,1995.27,3499.93,
Bone cutting body mandible,D7945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4049.73,,,,,,,fee schedule,2655,4657.19,
Bone cutting body mandible,D7945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3314.7,,,,,,,fee schedule,2655,4657.19,
Bone cutting body mandible,D7945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2655,,,,,,,fee schedule,2655,4657.19,
Bone cutting body mandible,D7945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4657.19,,,,,,,fee schedule,2655,4657.19,
Reconstruction maxilla total,D7946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5016.83,,,,,,,fee schedule,3289.03,5769.35,
Reconstruction maxilla total,D7946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4106.28,,,,,,,fee schedule,3289.03,5769.35,
Reconstruction maxilla total,D7946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3289.03,,,,,,,fee schedule,3289.03,5769.35,
Reconstruction maxilla total,D7946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5769.35,,,,,,,fee schedule,3289.03,5769.35,
Reconstruct maxilla segment,D7947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4219.25,,,,,,,fee schedule,2766.14,4852.14,
Reconstruct maxilla segment,D7947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3453.46,,,,,,,fee schedule,2766.14,4852.14,
Reconstruct maxilla segment,D7947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2766.14,,,,,,,fee schedule,2766.14,4852.14,
Reconstruct maxilla segment,D7947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4852.14,,,,,,,fee schedule,2766.14,4852.14,
Reconstruct midface no graft,D7948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5476.41,,,,,,,fee schedule,3590.33,6297.87,
Reconstruct midface no graft,D7948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4482.44,,,,,,,fee schedule,3590.33,6297.87,
Reconstruct midface no graft,D7948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3590.33,,,,,,,fee schedule,3590.33,6297.87,
Reconstruct midface no graft,D7948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6297.87,,,,,,,fee schedule,3590.33,6297.87,
Reconstruct midface w/graft,D7949,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7132.35,,,,,,,fee schedule,4675.97,8202.2,
Reconstruct midface w/graft,D7949,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5837.83,,,,,,,fee schedule,4675.97,8202.2,
Reconstruct midface w/graft,D7949,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4675.97,,,,,,,fee schedule,4675.97,8202.2,
Reconstruct midface w/graft,D7949,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8202.2,,,,,,,fee schedule,4675.97,8202.2,
Mandible graft,D7950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6193.47,,,,,,,fee schedule,5898.54,10617.38,APC
Mandible graft,D7950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5898.54,,,,,,,fee schedule,5898.54,10617.38,APC
Mandible graft,D7950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10617.38,,,,,,,fee schedule,5898.54,10617.38,APC
Bone replacement graft,D7953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.85,,,,,,,fee schedule,67.43,118.28,
Bone replacement graft,D7953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.18,,,,,,,fee schedule,67.43,118.28,
Bone replacement graft,D7953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.43,,,,,,,fee schedule,67.43,118.28,
Bone replacement graft,D7953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.28,,,,,,,fee schedule,67.43,118.28,
Frenulectomy/frenectomy,D7960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.59,,,,,,,fee schedule,108.56,190.43,
Frenulectomy/frenectomy,D7960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.54,,,,,,,fee schedule,108.56,190.43,
Frenulectomy/frenectomy,D7960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.56,,,,,,,fee schedule,108.56,190.43,
Frenulectomy/frenectomy,D7960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.43,,,,,,,fee schedule,108.56,190.43,
Frenuloplasty,D7963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.42,,,,,,,fee schedule,177.94,312.13,
Frenuloplasty,D7963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.16,,,,,,,fee schedule,177.94,312.13,
Frenuloplasty,D7963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.94,,,,,,,fee schedule,177.94,312.13,
Frenuloplasty,D7963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.13,,,,,,,fee schedule,177.94,312.13,
Excision hyperplastic tissue,D7970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,242.02,,,,,,,fee schedule,158.67,278.32,
Excision hyperplastic tissue,D7970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.09,,,,,,,fee schedule,158.67,278.32,
Excision hyperplastic tissue,D7970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.67,,,,,,,fee schedule,158.67,278.32,
Excision hyperplastic tissue,D7970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,278.32,,,,,,,fee schedule,158.67,278.32,
Excision pericoronal gingiva,D7971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.13,,,,,,,fee schedule,59.09,103.65,
Excision pericoronal gingiva,D7971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.77,,,,,,,fee schedule,59.09,103.65,
Excision pericoronal gingiva,D7971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.09,,,,,,,fee schedule,59.09,103.65,
Excision pericoronal gingiva,D7971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.65,,,,,,,fee schedule,59.09,103.65,
Surg redct fibrous tuberosit,D7972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,339.01,,,,,,,fee schedule,222.25,389.86,
Surg redct fibrous tuberosit,D7972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.48,,,,,,,fee schedule,222.25,389.86,
Surg redct fibrous tuberosit,D7972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.25,,,,,,,fee schedule,222.25,389.86,
Surg redct fibrous tuberosit,D7972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,389.86,,,,,,,fee schedule,222.25,389.86,
Sialolithotomy,D7980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,381.18,,,,,,,fee schedule,249.9,438.36,
Sialolithotomy,D7980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312,,,,,,,fee schedule,249.9,438.36,
Sialolithotomy,D7980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.9,,,,,,,fee schedule,249.9,438.36,
Sialolithotomy,D7980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.36,,,,,,,fee schedule,249.9,438.36,
Sialodochoplasty,D7982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,900.48,,,,,,,fee schedule,590.35,1035.55,
Sialodochoplasty,D7982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,737.04,,,,,,,fee schedule,590.35,1035.55,
Sialodochoplasty,D7982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,590.35,,,,,,,fee schedule,590.35,1035.55,
Sialodochoplasty,D7982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1035.55,,,,,,,fee schedule,590.35,1035.55,
Closure of salivary fistula,D7983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,864.21,,,,,,,fee schedule,566.58,993.84,
Closure of salivary fistula,D7983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,707.36,,,,,,,fee schedule,566.58,993.84,
Closure of salivary fistula,D7983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,566.58,,,,,,,fee schedule,566.58,993.84,
Closure of salivary fistula,D7983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,993.84,,,,,,,fee schedule,566.58,993.84,
Emergency tracheotomy,D7990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,743.72,,,,,,,fee schedule,487.58,855.28,
Emergency tracheotomy,D7990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,608.73,,,,,,,fee schedule,487.58,855.28,
Emergency tracheotomy,D7990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,487.58,,,,,,,fee schedule,487.58,855.28,
Emergency tracheotomy,D7990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,855.28,,,,,,,fee schedule,487.58,855.28,
Dental coronoidectomy,D7991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1813.71,,,,,,,fee schedule,1189.07,2085.77,
Dental coronoidectomy,D7991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1484.52,,,,,,,fee schedule,1189.07,2085.77,
Dental coronoidectomy,D7991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1189.07,,,,,,,fee schedule,1189.07,2085.77,
Dental coronoidectomy,D7991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2085.77,,,,,,,fee schedule,1189.07,2085.77,
Appliance removal,D7997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.14,,,,,,,fee schedule,91.22,160.01,
Appliance removal,D7997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.89,,,,,,,fee schedule,91.22,160.01,
Appliance removal,D7997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.22,,,,,,,fee schedule,91.22,160.01,
Appliance removal,D7997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.01,,,,,,,fee schedule,91.22,160.01,
Intraoral place of fix dev,D7998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,604.55,,,,,,,fee schedule,396.34,695.23,
Intraoral place of fix dev,D7998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,494.82,,,,,,,fee schedule,396.34,695.23,
Intraoral place of fix dev,D7998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,396.34,,,,,,,fee schedule,396.34,695.23,
Intraoral place of fix dev,D7998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,695.23,,,,,,,fee schedule,396.34,695.23,
Tx dental pain minor proc,D9110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.54,,,,,,,fee schedule,46.9,82.27,
Tx dental pain minor proc,D9110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.56,,,,,,,fee schedule,46.9,82.27,
Tx dental pain minor proc,D9110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.9,,,,,,,fee schedule,46.9,82.27,
Tx dental pain minor proc,D9110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.27,,,,,,,fee schedule,46.9,82.27,
Fix partial denture section,D9120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.33,,,,,,,fee schedule,52.66,92.38,
Fix partial denture section,D9120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.75,,,,,,,fee schedule,52.66,92.38,
Fix partial denture section,D9120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.66,,,,,,,fee schedule,52.66,92.38,
Fix partial denture section,D9120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.38,,,,,,,fee schedule,52.66,92.38,
Dent anesthesia w/o surgery,D9210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,17.36,30.45,
Dent anesthesia w/o surgery,D9210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.67,,,,,,,fee schedule,17.36,30.45,
Dent anesthesia w/o surgery,D9210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.36,,,,,,,fee schedule,17.36,30.45,
Dent anesthesia w/o surgery,D9210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,17.36,30.45,
Regional block anesthesia,D9211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.4,,,,,,,fee schedule,19.27,33.81,
Regional block anesthesia,D9211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.06,,,,,,,fee schedule,19.27,33.81,
Regional block anesthesia,D9211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.27,,,,,,,fee schedule,19.27,33.81,
Regional block anesthesia,D9211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.81,,,,,,,fee schedule,19.27,33.81,
Trigeminal block anesthesia,D9212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,52.96,
Trigeminal block anesthesia,D9212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,52.96,
Trigeminal block anesthesia,D9212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,52.96,
Trigeminal block anesthesia,D9212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,52.96,
Local anesthesia,D9215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.56,,,,,,,fee schedule,14.13,24.79,
Local anesthesia,D9215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.65,,,,,,,fee schedule,14.13,24.79,
Local anesthesia,D9215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.13,,,,,,,fee schedule,14.13,24.79,
Local anesthesia,D9215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.79,,,,,,,fee schedule,14.13,24.79,
Analgesia,D9230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.09,,,,,,,fee schedule,28.91,50.7,
Analgesia,D9230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.09,,,,,,,fee schedule,28.91,50.7,
Analgesia,D9230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,28.91,50.7,
Analgesia,D9230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.7,,,,,,,fee schedule,28.91,50.7,
Sedation (non-iv),D9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.67,,,,,,,fee schedule,42.4,74.37,
Sedation (non-iv),D9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.93,,,,,,,fee schedule,42.4,74.37,
Sedation (non-iv),D9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.4,,,,,,,fee schedule,42.4,74.37,
Sedation (non-iv),D9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.37,,,,,,,fee schedule,42.4,74.37,
Dental consultation,D9310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.95,,,,,,,fee schedule,97,170.14,
Dental consultation,D9310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.1,,,,,,,fee schedule,97,170.14,
Dental consultation,D9310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97,,,,,,,fee schedule,97,170.14,
Dental consultation,D9310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.14,,,,,,,fee schedule,97,170.14,
Dental house call,D9410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.52,,,,,,,fee schedule,111.14,194.95,
Dental house call,D9410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.75,,,,,,,fee schedule,111.14,194.95,
Dental house call,D9410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.14,,,,,,,fee schedule,111.14,194.95,
Dental house call,D9410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.95,,,,,,,fee schedule,111.14,194.95,
Hospital/asc call,D9420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,273.38,,,,,,,fee schedule,179.23,314.39,
Hospital/asc call,D9420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,223.76,,,,,,,fee schedule,179.23,314.39,
Hospital/asc call,D9420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.23,,,,,,,fee schedule,179.23,314.39,
Hospital/asc call,D9420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,314.39,,,,,,,fee schedule,179.23,314.39,
Office visit after hours,D9440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.13,,,,,,,fee schedule,60.4,105.95,
Office visit after hours,D9440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.41,,,,,,,fee schedule,60.4,105.95,
Office visit after hours,D9440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.4,,,,,,,fee schedule,60.4,105.95,
Office visit after hours,D9440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.95,,,,,,,fee schedule,60.4,105.95,
Case presentation tx plan,D9450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.05,,,,,,,fee schedule,30.19,52.96,
Case presentation tx plan,D9450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.69,,,,,,,fee schedule,30.19,52.96,
Case presentation tx plan,D9450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.19,,,,,,,fee schedule,30.19,52.96,
Case presentation tx plan,D9450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.96,,,,,,,fee schedule,30.19,52.96,
Dent appl desensitizing med,D9910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,37.19,
Dent appl desensitizing med,D9910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,37.19,
Dent appl desensitizing med,D9910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,37.19,
Dent appl desensitizing med,D9910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,37.19,
Appl desensitizing resin,D9911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,29.55,51.83,
Appl desensitizing resin,D9911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,29.55,51.83,
Appl desensitizing resin,D9911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,29.55,51.83,
Appl desensitizing resin,D9911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,29.55,51.83,
Treatment of complications,D9930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Treatment of complications,D9930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Treatment of complications,D9930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Treatment of complications,D9930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Treatment of complications,D9930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Treatment of complications,D9930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Treatment of complications,D9930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Dental occlusal guard,D9940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,882.44,
Dental occlusal guard,D9940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,882.44,
Dental occlusal guard,D9940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,882.44,
Dental occlusal guard,D9940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,882.44,
Fabrication athletic guard,D9941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.13,,,,,,,fee schedule,60.4,105.95,
Fabrication athletic guard,D9941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.41,,,,,,,fee schedule,60.4,105.95,
Fabrication athletic guard,D9941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.4,,,,,,,fee schedule,60.4,105.95,
Fabrication athletic guard,D9941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,105.95,,,,,,,fee schedule,60.4,105.95,
Repair/reline occlusal guard,D9942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.7,,,,,,,fee schedule,72.57,127.31,
Repair/reline occlusal guard,D9942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.61,,,,,,,fee schedule,72.57,127.31,
Repair/reline occlusal guard,D9942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.57,,,,,,,fee schedule,72.57,127.31,
Repair/reline occlusal guard,D9942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.31,,,,,,,fee schedule,72.57,127.31,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2360.56,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1932.12,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1547.58,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2714.64,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,644.16,2714.64,APC
"Occ guard, hard, full arch",D9944,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,644.16,2714.64,APC
"Occ guard, hard, full arch",D9944,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,644.16,2714.64,APC
"Occ guard, soft, full arch",D9945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2360.56,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, soft, full arch",D9945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1932.12,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, soft, full arch",D9945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1547.58,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, soft, full arch",D9945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2714.64,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, soft, full arch",D9945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,644.16,2714.64,APC
"Occ guard, soft, full arch",D9945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,644.16,2714.64,APC
"Occ guard, soft, full arch",D9945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,644.16,2714.64,APC
"Occ guard, hard, part arch",D9946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2360.56,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, hard, part arch",D9946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1932.12,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, hard, part arch",D9946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1547.58,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, hard, part arch",D9946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2714.64,,,,,,,fee schedule,644.16,2714.64,
"Occ guard, hard, part arch",D9946,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,644.16,2714.64,APC
"Occ guard, hard, part arch",D9946,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,644.16,2714.64,APC
"Occ guard, hard, part arch",D9946,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,644.16,2714.64,APC
Occlusion analysis,D9950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Occlusion analysis,D9950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Occlusion analysis,D9950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Occlusion analysis,D9950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Occlusion analysis,D9950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Occlusion analysis,D9950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Occlusion analysis,D9950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Limited occlusal adjustment,D9951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Limited occlusal adjustment,D9951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Limited occlusal adjustment,D9951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Limited occlusal adjustment,D9951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Limited occlusal adjustment,D9951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Limited occlusal adjustment,D9951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Limited occlusal adjustment,D9951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Complete occlusal adjustment,D9952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,767.34,,,,,,,fee schedule,503.07,1159.49,
Complete occlusal adjustment,D9952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.07,,,,,,,fee schedule,503.07,1159.49,
Complete occlusal adjustment,D9952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.07,,,,,,,fee schedule,503.07,1159.49,
Complete occlusal adjustment,D9952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,882.44,,,,,,,fee schedule,503.07,1159.49,
Complete occlusal adjustment,D9952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,676.37,,,,,,,fee schedule,503.07,1159.49,APC
Complete occlusal adjustment,D9952,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,644.16,,,,,,,fee schedule,503.07,1159.49,APC
Complete occlusal adjustment,D9952,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1159.49,,,,,,,fee schedule,503.07,1159.49,APC
Enamel microabrasion,D9970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,47.32,
Enamel microabrasion,D9970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,47.32,
Enamel microabrasion,D9970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,47.32,
Enamel microabrasion,D9970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,47.32,
Odontoplasty 1-2 teeth,D9971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.9,,,,,,,fee schedule,35.34,61.99,
Odontoplasty 1-2 teeth,D9971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.12,,,,,,,fee schedule,35.34,61.99,
Odontoplasty 1-2 teeth,D9971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.34,,,,,,,fee schedule,35.34,61.99,
Odontoplasty 1-2 teeth,D9971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.99,,,,,,,fee schedule,35.34,61.99,
Extrnl bleaching per arch,D9972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,185.2,,,,,,,fee schedule,121.42,212.98,
Extrnl bleaching per arch,D9972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.59,,,,,,,fee schedule,121.42,212.98,
Extrnl bleaching per arch,D9972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.42,,,,,,,fee schedule,121.42,212.98,
Extrnl bleaching per arch,D9972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,212.98,,,,,,,fee schedule,121.42,212.98,
Extrnl bleaching per tooth,D9973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.39,,,,,,,fee schedule,19.92,34.95,
Extrnl bleaching per tooth,D9973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.87,,,,,,,fee schedule,19.92,34.95,
Extrnl bleaching per tooth,D9973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.92,,,,,,,fee schedule,19.92,34.95,
Extrnl bleaching per tooth,D9973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.95,,,,,,,fee schedule,19.92,34.95,
Intrnl bleaching per tooth,D9974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.69,,,,,,,fee schedule,106,185.94,
Intrnl bleaching per tooth,D9974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.34,,,,,,,fee schedule,106,185.94,
Intrnl bleaching per tooth,D9974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106,,,,,,,fee schedule,106,185.94,
Intrnl bleaching per tooth,D9974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.94,,,,,,,fee schedule,106,185.94,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.43,,,,,,,fee schedule,35.68,62.59,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.55,,,,,,,fee schedule,35.68,62.59,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.68,,,,,,,fee schedule,35.68,62.59,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.59,,,,,,,fee schedule,35.68,62.59,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.07,,,,,,,fee schedule,96.42,169.13,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.38,,,,,,,fee schedule,96.42,169.13,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.42,,,,,,,fee schedule,96.42,169.13,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.13,,,,,,,fee schedule,96.42,169.13,
Crutch forearm pair,E0110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,200.45,,,,,,,fee schedule,131.42,230.52,
Crutch forearm pair,E0110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.07,,,,,,,fee schedule,131.42,230.52,
Crutch forearm pair,E0110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.42,,,,,,,fee schedule,131.42,230.52,
Crutch forearm pair,E0110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,230.52,,,,,,,fee schedule,131.42,230.52,
Crutch forearm each,E0111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.83,,,,,,,fee schedule,106.1,186.1,
Crutch forearm each,E0111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.46,,,,,,,fee schedule,106.1,186.1,
Crutch forearm each,E0111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.1,,,,,,,fee schedule,106.1,186.1,
Crutch forearm each,E0111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,186.1,,,,,,,fee schedule,106.1,186.1,
Crutch underarm pair wood,E0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.6,,,,,,,fee schedule,62.68,109.94,
Crutch underarm pair wood,E0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.25,,,,,,,fee schedule,62.68,109.94,
Crutch underarm pair wood,E0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.68,,,,,,,fee schedule,62.68,109.94,
Crutch underarm pair wood,E0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.94,,,,,,,fee schedule,62.68,109.94,
Crutch underarm each wood,E0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.23,,,,,,,fee schedule,42.11,73.86,
Crutch underarm each wood,E0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.57,,,,,,,fee schedule,42.11,73.86,
Crutch underarm each wood,E0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.11,,,,,,,fee schedule,42.11,73.86,
Crutch underarm each wood,E0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.86,,,,,,,fee schedule,42.11,73.86,
Crutch underarm pair no wood,E0114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.91,,,,,,,fee schedule,85.82,150.55,
Crutch underarm pair no wood,E0114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.15,,,,,,,fee schedule,85.82,150.55,
Crutch underarm pair no wood,E0114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.82,,,,,,,fee schedule,85.82,150.55,
Crutch underarm pair no wood,E0114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.55,,,,,,,fee schedule,85.82,150.55,
Crutch underarm each no wood,E0116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.32,,,,,,,fee schedule,55.28,96.97,
Crutch underarm each no wood,E0116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.02,,,,,,,fee schedule,55.28,96.97,
Crutch underarm each no wood,E0116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.28,,,,,,,fee schedule,55.28,96.97,
Crutch underarm each no wood,E0116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.97,,,,,,,fee schedule,55.28,96.97,
Underarm springassist crutch,E0117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.54,,,,,,,fee schedule,38.38,67.32,
Underarm springassist crutch,E0117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.91,,,,,,,fee schedule,38.38,67.32,
Underarm springassist crutch,E0117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.38,,,,,,,fee schedule,38.38,67.32,
Underarm springassist crutch,E0117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.32,,,,,,,fee schedule,38.38,67.32,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.65,,,,,,,fee schedule,81.72,143.35,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.03,,,,,,,fee schedule,81.72,143.35,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.72,,,,,,,fee schedule,81.72,143.35,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.35,,,,,,,fee schedule,81.72,143.35,
Walker folding adjust/fixed,E0135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.11,,,,,,,fee schedule,82.02,143.88,
Walker folding adjust/fixed,E0135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.4,,,,,,,fee schedule,82.02,143.88,
Walker folding adjust/fixed,E0135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.02,,,,,,,fee schedule,82.02,143.88,
Walker folding adjust/fixed,E0135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.88,,,,,,,fee schedule,82.02,143.88,
Walker w trunk support,E0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.15,,,,,,,fee schedule,53.2,93.32,
Walker w trunk support,E0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.42,,,,,,,fee schedule,53.2,93.32,
Walker w trunk support,E0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.2,,,,,,,fee schedule,53.2,93.32,
Walker w trunk support,E0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.32,,,,,,,fee schedule,53.2,93.32,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.47,,,,,,,fee schedule,84.22,147.74,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.15,,,,,,,fee schedule,84.22,147.74,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.22,,,,,,,fee schedule,84.22,147.74,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.74,,,,,,,fee schedule,84.22,147.74,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.47,,,,,,,fee schedule,84.22,147.74,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.15,,,,,,,fee schedule,84.22,147.74,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.22,,,,,,,fee schedule,84.22,147.74,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,147.74,,,,,,,fee schedule,84.22,147.74,
Enclosed walker w rear seat,E0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.05,,,,,,,fee schedule,45.92,80.56,
Enclosed walker w rear seat,E0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.34,,,,,,,fee schedule,45.92,80.56,
Enclosed walker w rear seat,E0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.92,,,,,,,fee schedule,45.92,80.56,
Enclosed walker w rear seat,E0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.56,,,,,,,fee schedule,45.92,80.56,
Walker variable wheel resist,E0147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1042.54,,,,,,,fee schedule,683.49,1198.92,
Walker variable wheel resist,E0147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,853.32,,,,,,,fee schedule,683.49,1198.92,
Walker variable wheel resist,E0147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,683.49,,,,,,,fee schedule,683.49,1198.92,
Walker variable wheel resist,E0147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1198.92,,,,,,,fee schedule,683.49,1198.92,
Heavyduty walker no wheels,E0148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.77,,,,,,,fee schedule,147.36,258.49,
Heavyduty walker no wheels,E0148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,183.97,,,,,,,fee schedule,147.36,258.49,
Heavyduty walker no wheels,E0148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.36,,,,,,,fee schedule,147.36,258.49,
Heavyduty walker no wheels,E0148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.49,,,,,,,fee schedule,147.36,258.49,
Heavy duty wheeled walker,E0149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.96,,,,,,,fee schedule,20.95,36.75,
Heavy duty wheeled walker,E0149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.16,,,,,,,fee schedule,20.95,36.75,
Heavy duty wheeled walker,E0149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.95,,,,,,,fee schedule,20.95,36.75,
Heavy duty wheeled walker,E0149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.75,,,,,,,fee schedule,20.95,36.75,
Forearm crutch platform atta,E0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,179.26,,,,,,,fee schedule,117.52,206.15,
Forearm crutch platform atta,E0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.72,,,,,,,fee schedule,117.52,206.15,
Forearm crutch platform atta,E0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.52,,,,,,,fee schedule,117.52,206.15,
Forearm crutch platform atta,E0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,206.15,,,,,,,fee schedule,117.52,206.15,
Walker platform attachment,E0154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.97,,,,,,,fee schedule,86.52,151.77,
Walker platform attachment,E0154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.02,,,,,,,fee schedule,86.52,151.77,
Walker platform attachment,E0154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.52,,,,,,,fee schedule,86.52,151.77,
Walker platform attachment,E0154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.77,,,,,,,fee schedule,86.52,151.77,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.78,,,,,,,fee schedule,37.22,65.3,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.47,,,,,,,fee schedule,37.22,65.3,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.22,,,,,,,fee schedule,37.22,65.3,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.3,,,,,,,fee schedule,37.22,65.3,
Walker seat attachment,E0156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.97,,,,,,,fee schedule,27.52,48.27,
Walker seat attachment,E0156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.35,,,,,,,fee schedule,27.52,48.27,
Walker seat attachment,E0156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.52,,,,,,,fee schedule,27.52,48.27,
Walker seat attachment,E0156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.27,,,,,,,fee schedule,27.52,48.27,
Walker crutch attachment,E0157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.62,,,,,,,fee schedule,105.3,184.71,
Walker crutch attachment,E0157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.47,,,,,,,fee schedule,105.3,184.71,
Walker crutch attachment,E0157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.3,,,,,,,fee schedule,105.3,184.71,
Walker crutch attachment,E0157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.71,,,,,,,fee schedule,105.3,184.71,
Walker leg extenders set of4,E0158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.93,,,,,,,fee schedule,39.95,70.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.87,,,,,,,fee schedule,39.95,70.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.95,,,,,,,fee schedule,39.95,70.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.07,,,,,,,fee schedule,39.95,70.07,
Brake for wheeled walker,E0159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.7,,,,,,,fee schedule,27.34,47.96,
Brake for wheeled walker,E0159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.13,,,,,,,fee schedule,27.34,47.96,
Brake for wheeled walker,E0159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.34,,,,,,,fee schedule,27.34,47.96,
Brake for wheeled walker,E0159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.96,,,,,,,fee schedule,27.34,47.96,
Sitz type bath or equipment,E0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.68,,,,,,,fee schedule,52.89,92.78,
Sitz type bath or equipment,E0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.04,,,,,,,fee schedule,52.89,92.78,
Sitz type bath or equipment,E0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.89,,,,,,,fee schedule,52.89,92.78,
Sitz type bath or equipment,E0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.78,,,,,,,fee schedule,52.89,92.78,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.58,,,,,,,fee schedule,44.96,78.87,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.13,,,,,,,fee schedule,44.96,78.87,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.96,,,,,,,fee schedule,44.96,78.87,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.87,,,,,,,fee schedule,44.96,78.87,
Sitz bath chair,E0162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,425.21,,,,,,,fee schedule,278.77,488.99,
Sitz bath chair,E0162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,348.03,,,,,,,fee schedule,278.77,488.99,
Sitz bath chair,E0162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,278.77,,,,,,,fee schedule,278.77,488.99,
Sitz bath chair,E0162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,488.99,,,,,,,fee schedule,278.77,488.99,
Commode chair with fixed arm,E0163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.06,,,,,,,fee schedule,93.13,163.37,
Commode chair with fixed arm,E0163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,116.28,,,,,,,fee schedule,93.13,163.37,
Commode chair with fixed arm,E0163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.13,,,,,,,fee schedule,93.13,163.37,
Commode chair with fixed arm,E0163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,163.37,,,,,,,fee schedule,93.13,163.37,
Commode chair with detacharm,E0165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.22,,,,,,,fee schedule,21.78,38.2,
Commode chair with detacharm,E0165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.19,,,,,,,fee schedule,21.78,38.2,
Commode chair with detacharm,E0165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.78,,,,,,,fee schedule,21.78,38.2,
Commode chair with detacharm,E0165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.2,,,,,,,fee schedule,21.78,38.2,
Commode chair pail or pan,E0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.81,,,,,,,fee schedule,20.2,35.43,
Commode chair pail or pan,E0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.22,,,,,,,fee schedule,20.2,35.43,
Commode chair pail or pan,E0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.2,,,,,,,fee schedule,20.2,35.43,
Commode chair pail or pan,E0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.43,,,,,,,fee schedule,20.2,35.43,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.63,,,,,,,fee schedule,206.93,362.97,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.34,,,,,,,fee schedule,206.93,362.97,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.93,,,,,,,fee schedule,206.93,362.97,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,362.97,,,,,,,fee schedule,206.93,362.97,
Commode chair electric,E0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,444.92,,,,,,,fee schedule,291.69,511.66,
Commode chair electric,E0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,364.17,,,,,,,fee schedule,291.69,511.66,
Commode chair electric,E0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,291.69,,,,,,,fee schedule,291.69,511.66,
Commode chair electric,E0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,511.66,,,,,,,fee schedule,291.69,511.66,
Commode chair non-electric,E0171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.41,,,,,,,fee schedule,54.68,95.92,
Commode chair non-electric,E0171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.27,,,,,,,fee schedule,54.68,95.92,
Commode chair non-electric,E0171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.68,,,,,,,fee schedule,54.68,95.92,
Commode chair non-electric,E0171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.92,,,,,,,fee schedule,54.68,95.92,
Commode chair foot rest,E0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.32,,,,,,,fee schedule,131.99,231.52,
Commode chair foot rest,E0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.78,,,,,,,fee schedule,131.99,231.52,
Commode chair foot rest,E0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.99,,,,,,,fee schedule,131.99,231.52,
Commode chair foot rest,E0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.52,,,,,,,fee schedule,131.99,231.52,
Press pad alternating w/ pum,E0181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.15,,,,,,,fee schedule,26.98,47.32,
Press pad alternating w/ pum,E0181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.68,,,,,,,fee schedule,26.98,47.32,
Press pad alternating w/ pum,E0181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.98,,,,,,,fee schedule,26.98,47.32,
Press pad alternating w/ pum,E0181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.32,,,,,,,fee schedule,26.98,47.32,
"Replace pump, alt press pad",E0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.53,,,,,,,fee schedule,39.68,69.61,
"Replace pump, alt press pad",E0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.54,,,,,,,fee schedule,39.68,69.61,
"Replace pump, alt press pad",E0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.68,,,,,,,fee schedule,39.68,69.61,
"Replace pump, alt press pad",E0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.61,,,,,,,fee schedule,39.68,69.61,
Dry pressure mattress,E0184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,414.89,,,,,,,fee schedule,272,477.12,
Dry pressure mattress,E0184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,339.59,,,,,,,fee schedule,272,477.12,
Dry pressure mattress,E0184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,272,,,,,,,fee schedule,272,477.12,
Dry pressure mattress,E0184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,477.12,,,,,,,fee schedule,272,477.12,
Gel pressure mattress pad,E0185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,443.82,,,,,,,fee schedule,290.97,510.39,
Gel pressure mattress pad,E0185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,363.27,,,,,,,fee schedule,290.97,510.39,
Gel pressure mattress pad,E0185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,290.97,,,,,,,fee schedule,290.97,510.39,
Gel pressure mattress pad,E0185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,510.39,,,,,,,fee schedule,290.97,510.39,
Air pressure mattress,E0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.26,,,,,,,fee schedule,33.61,58.95,
Air pressure mattress,E0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.96,,,,,,,fee schedule,33.61,58.95,
Air pressure mattress,E0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.61,,,,,,,fee schedule,33.61,58.95,
Air pressure mattress,E0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.95,,,,,,,fee schedule,33.61,58.95,
Water pressure mattress,E0187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.47,,,,,,,fee schedule,39.64,69.54,
Water pressure mattress,E0187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.49,,,,,,,fee schedule,39.64,69.54,
Water pressure mattress,E0187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.64,,,,,,,fee schedule,39.64,69.54,
Water pressure mattress,E0187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.54,,,,,,,fee schedule,39.64,69.54,
Synthetic sheepskin pad,E0188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.83,,,,,,,fee schedule,45.12,79.15,
Synthetic sheepskin pad,E0188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.34,,,,,,,fee schedule,45.12,79.15,
Synthetic sheepskin pad,E0188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.12,,,,,,,fee schedule,45.12,79.15,
Synthetic sheepskin pad,E0188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.15,,,,,,,fee schedule,45.12,79.15,
Lambswool sheepskin pad,E0189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.45,,,,,,,fee schedule,85.52,150.02,
Lambswool sheepskin pad,E0189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.77,,,,,,,fee schedule,85.52,150.02,
Lambswool sheepskin pad,E0189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.52,,,,,,,fee schedule,85.52,150.02,
Lambswool sheepskin pad,E0189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.02,,,,,,,fee schedule,85.52,150.02,
Protector heel or elbow,E0191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.39,,,,,,,fee schedule,19.92,34.95,
Protector heel or elbow,E0191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.87,,,,,,,fee schedule,19.92,34.95,
Protector heel or elbow,E0191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.92,,,,,,,fee schedule,19.92,34.95,
Protector heel or elbow,E0191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.95,,,,,,,fee schedule,19.92,34.95,
Powered air flotation bed,E0193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1932.03,,,,,,,fee schedule,1266.64,2221.83,
Powered air flotation bed,E0193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1581.37,,,,,,,fee schedule,1266.64,2221.83,
Powered air flotation bed,E0193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1266.64,,,,,,,fee schedule,1266.64,2221.83,
Powered air flotation bed,E0193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2221.83,,,,,,,fee schedule,1266.64,2221.83,
Air fluidized bed,E0194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9324.55,,,,,,,fee schedule,6113.17,10723.23,
Air fluidized bed,E0194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7632.14,,,,,,,fee schedule,6113.17,10723.23,
Air fluidized bed,E0194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6113.17,,,,,,,fee schedule,6113.17,10723.23,
Air fluidized bed,E0194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10723.23,,,,,,,fee schedule,6113.17,10723.23,
Gel pressure mattress,E0196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.93,,,,,,,fee schedule,58.96,103.42,
Gel pressure mattress,E0196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.61,,,,,,,fee schedule,58.96,103.42,
Gel pressure mattress,E0196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.96,,,,,,,fee schedule,58.96,103.42,
Gel pressure mattress,E0196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.42,,,,,,,fee schedule,58.96,103.42,
Air pressure pad for mattres,E0197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.09,,,,,,,fee schedule,32.84,57.6,
Air pressure pad for mattres,E0197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41,,,,,,,fee schedule,32.84,57.6,
Air pressure pad for mattres,E0197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.84,,,,,,,fee schedule,32.84,57.6,
Air pressure pad for mattres,E0197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.6,,,,,,,fee schedule,32.84,57.6,
Water pressure pad for mattr,E0198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.04,,,,,,,fee schedule,42.64,74.8,
Water pressure pad for mattr,E0198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.24,,,,,,,fee schedule,42.64,74.8,
Water pressure pad for mattr,E0198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.64,,,,,,,fee schedule,42.64,74.8,
Water pressure pad for mattr,E0198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.8,,,,,,,fee schedule,42.64,74.8,
Dry pressure pad for mattres,E0199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.66,,,,,,,fee schedule,50.91,89.31,
Dry pressure pad for mattres,E0199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.56,,,,,,,fee schedule,50.91,89.31,
Dry pressure pad for mattres,E0199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.91,,,,,,,fee schedule,50.91,89.31,
Dry pressure pad for mattres,E0199,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.31,,,,,,,fee schedule,50.91,89.31,
Heat lamp without stand,E0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.81,,,,,,,fee schedule,134.27,235.53,
Heat lamp without stand,E0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.64,,,,,,,fee schedule,134.27,235.53,
Heat lamp without stand,E0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.27,,,,,,,fee schedule,134.27,235.53,
Heat lamp without stand,E0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.53,,,,,,,fee schedule,134.27,235.53,
Penile contractur devic manu,E0201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,153.85,,,,,,,fee schedule,146.52,263.74,APC
Penile contractur devic manu,E0201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,146.52,,,,,,,fee schedule,146.52,263.74,APC
Penile contractur devic manu,E0201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,263.74,,,,,,,fee schedule,146.52,263.74,APC
Phototherapy light w/ photom,E0202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.29,,,,,,,fee schedule,124.75,218.83,
Phototherapy light w/ photom,E0202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.75,,,,,,,fee schedule,124.75,218.83,
Phototherapy light w/ photom,E0202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.75,,,,,,,fee schedule,124.75,218.83,
Phototherapy light w/ photom,E0202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.83,,,,,,,fee schedule,124.75,218.83,
Heat lamp with stand,E0205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,501.35,,,,,,,fee schedule,328.69,576.55,
Heat lamp with stand,E0205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,410.35,,,,,,,fee schedule,328.69,576.55,
Heat lamp with stand,E0205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,328.69,,,,,,,fee schedule,328.69,576.55,
Heat lamp with stand,E0205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,576.55,,,,,,,fee schedule,328.69,576.55,
Electric heat pad standard,E0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.21,,,,,,,fee schedule,65.04,114.09,
Electric heat pad standard,E0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.2,,,,,,,fee schedule,65.04,114.09,
Electric heat pad standard,E0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.04,,,,,,,fee schedule,65.04,114.09,
Electric heat pad standard,E0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.09,,,,,,,fee schedule,65.04,114.09,
Electric heat pad moist,E0215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,183.02,,,,,,,fee schedule,119.99,210.47,
Electric heat pad moist,E0215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.8,,,,,,,fee schedule,119.99,210.47,
Electric heat pad moist,E0215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.99,,,,,,,fee schedule,119.99,210.47,
Electric heat pad moist,E0215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,210.47,,,,,,,fee schedule,119.99,210.47,
Water circ heat pad w pump,E0217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1282.66,,,,,,,fee schedule,840.91,1475.06,
Water circ heat pad w pump,E0217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1049.86,,,,,,,fee schedule,840.91,1475.06,
Water circ heat pad w pump,E0217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,840.91,,,,,,,fee schedule,840.91,1475.06,
Water circ heat pad w pump,E0217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1475.06,,,,,,,fee schedule,840.91,1475.06,
Hydrocollator unit,E0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1004.06,,,,,,,fee schedule,658.26,1154.67,
Hydrocollator unit,E0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,821.82,,,,,,,fee schedule,658.26,1154.67,
Hydrocollator unit,E0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,658.26,,,,,,,fee schedule,658.26,1154.67,
Hydrocollator unit,E0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1154.67,,,,,,,fee schedule,658.26,1154.67,
Paraffin bath unit portable,E0235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.1,,,,,,,fee schedule,31.53,55.32,
Paraffin bath unit portable,E0235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.37,,,,,,,fee schedule,31.53,55.32,
Paraffin bath unit portable,E0235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.53,,,,,,,fee schedule,31.53,55.32,
Paraffin bath unit portable,E0235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.32,,,,,,,fee schedule,31.53,55.32,
Pump for water circulating p,E0236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.29,,,,,,,fee schedule,74.93,131.43,
Pump for water circulating p,E0236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.55,,,,,,,fee schedule,74.93,131.43,
Pump for water circulating p,E0236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.93,,,,,,,fee schedule,74.93,131.43,
Pump for water circulating p,E0236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.43,,,,,,,fee schedule,74.93,131.43,
Hydrocollator unit portable,E0239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1162.14,,,,,,,fee schedule,761.9,1336.46,
Hydrocollator unit portable,E0239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,951.21,,,,,,,fee schedule,761.9,1336.46,
Hydrocollator unit portable,E0239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,761.9,,,,,,,fee schedule,761.9,1336.46,
Hydrocollator unit portable,E0239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1336.46,,,,,,,fee schedule,761.9,1336.46,
Bath tub wall rail,E0241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.76,,,,,,,fee schedule,39.18,68.72,
Bath tub wall rail,E0241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.91,,,,,,,fee schedule,39.18,68.72,
Bath tub wall rail,E0241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.18,,,,,,,fee schedule,39.18,68.72,
Bath tub wall rail,E0241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.72,,,,,,,fee schedule,39.18,68.72,
Bath tub rail floor,E0242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.24,,,,,,,fee schedule,88.01,154.38,
Bath tub rail floor,E0242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.88,,,,,,,fee schedule,88.01,154.38,
Bath tub rail floor,E0242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.01,,,,,,,fee schedule,88.01,154.38,
Bath tub rail floor,E0242,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.38,,,,,,,fee schedule,88.01,154.38,
Toilet rail,E0243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.79,,,,,,,fee schedule,70.01,122.81,
Toilet rail,E0243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.41,,,,,,,fee schedule,70.01,122.81,
Toilet rail,E0243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.01,,,,,,,fee schedule,70.01,122.81,
Toilet rail,E0243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.81,,,,,,,fee schedule,70.01,122.81,
Toilet seat raised,E0244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.32,,,,,,,fee schedule,53.31,93.52,
Toilet seat raised,E0244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.56,,,,,,,fee schedule,53.31,93.52,
Toilet seat raised,E0244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.31,,,,,,,fee schedule,53.31,93.52,
Toilet seat raised,E0244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.52,,,,,,,fee schedule,53.31,93.52,
Tub stool or bench,E0245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.26,,,,,,,fee schedule,87.37,153.25,
Tub stool or bench,E0245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.07,,,,,,,fee schedule,87.37,153.25,
Tub stool or bench,E0245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.37,,,,,,,fee schedule,87.37,153.25,
Tub stool or bench,E0245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.25,,,,,,,fee schedule,87.37,153.25,
Transfer tub rail attachment,E0246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.25,,,,,,,fee schedule,119.48,209.59,
Transfer tub rail attachment,E0246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.17,,,,,,,fee schedule,119.48,209.59,
Transfer tub rail attachment,E0246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.48,,,,,,,fee schedule,119.48,209.59,
Transfer tub rail attachment,E0246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.59,,,,,,,fee schedule,119.48,209.59,
Pad water circulating heat u,E0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,257.35,,,,,,,fee schedule,168.72,295.95,
Pad water circulating heat u,E0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.64,,,,,,,fee schedule,168.72,295.95,
Pad water circulating heat u,E0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.72,,,,,,,fee schedule,168.72,295.95,
Pad water circulating heat u,E0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,295.95,,,,,,,fee schedule,168.72,295.95,
Hosp bed fixed ht w/ mattres,E0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.89,,,,,,,fee schedule,104.82,183.87,
Hosp bed fixed ht w/ mattres,E0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.87,,,,,,,fee schedule,104.82,183.87,
Hosp bed fixed ht w/ mattres,E0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.82,,,,,,,fee schedule,104.82,183.87,
Hosp bed fixed ht w/ mattres,E0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.87,,,,,,,fee schedule,104.82,183.87,
Hosp bed fixd ht w/o mattres,E0251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,155.22,,,,,,,fee schedule,101.76,178.5,
Hosp bed fixd ht w/o mattres,E0251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.05,,,,,,,fee schedule,101.76,178.5,
Hosp bed fixd ht w/o mattres,E0251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.76,,,,,,,fee schedule,101.76,178.5,
Hosp bed fixd ht w/o mattres,E0251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.5,,,,,,,fee schedule,101.76,178.5,
Hospital bed var ht w/ mattr,E0255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.81,,,,,,,fee schedule,106.08,186.08,
Hospital bed var ht w/ mattr,E0255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.44,,,,,,,fee schedule,106.08,186.08,
Hospital bed var ht w/ mattr,E0255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.08,,,,,,,fee schedule,106.08,186.08,
Hospital bed var ht w/ mattr,E0255,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,186.08,,,,,,,fee schedule,106.08,186.08,
Hospital bed var ht w/o matt,E0256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.49,,,,,,,fee schedule,102.59,179.96,
Hospital bed var ht w/o matt,E0256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.09,,,,,,,fee schedule,102.59,179.96,
Hospital bed var ht w/o matt,E0256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.59,,,,,,,fee schedule,102.59,179.96,
Hospital bed var ht w/o matt,E0256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.96,,,,,,,fee schedule,102.59,179.96,
Hosp bed semi-electr w/ matt,E0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.81,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-electr w/ matt,E0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.44,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-electr w/ matt,E0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.08,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-electr w/ matt,E0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,186.08,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-electr w/o mat,E0261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.81,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-electr w/o mat,E0261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.44,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-electr w/o mat,E0261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.08,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-electr w/o mat,E0261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,186.08,,,,,,,fee schedule,106.08,186.08,
Hosp bed total electr w/ mat,E0265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.27,,,,,,,fee schedule,246.03,431.56,
Hosp bed total electr w/ mat,E0265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.16,,,,,,,fee schedule,246.03,431.56,
Hosp bed total electr w/ mat,E0265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.03,,,,,,,fee schedule,246.03,431.56,
Hosp bed total electr w/ mat,E0265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.56,,,,,,,fee schedule,246.03,431.56,
Hosp bed total elec w/o matt,E0266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,326.5,,,,,,,fee schedule,214.05,375.48,
Hosp bed total elec w/o matt,E0266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,267.24,,,,,,,fee schedule,214.05,375.48,
Hosp bed total elec w/o matt,E0266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.05,,,,,,,fee schedule,214.05,375.48,
Hosp bed total elec w/o matt,E0266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,375.48,,,,,,,fee schedule,214.05,375.48,
Mattress innerspring,E0271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.75,,,,,,,fee schedule,218.81,383.81,
Mattress innerspring,E0271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,273.17,,,,,,,fee schedule,218.81,383.81,
Mattress innerspring,E0271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.81,,,,,,,fee schedule,218.81,383.81,
Mattress innerspring,E0271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.81,,,,,,,fee schedule,218.81,383.81,
Mattress foam rubber,E0272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,376.45,,,,,,,fee schedule,246.8,432.92,
Mattress foam rubber,E0272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,308.12,,,,,,,fee schedule,246.8,432.92,
Mattress foam rubber,E0272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.8,,,,,,,fee schedule,246.8,432.92,
Mattress foam rubber,E0272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,432.92,,,,,,,fee schedule,246.8,432.92,
Bed pan standard,E0275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.14,,,,,,,fee schedule,24.35,42.71,
Bed pan standard,E0275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.4,,,,,,,fee schedule,24.35,42.71,
Bed pan standard,E0275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.35,,,,,,,fee schedule,24.35,42.71,
Bed pan standard,E0275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.71,,,,,,,fee schedule,24.35,42.71,
Bed pan fracture,E0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.04,,,,,,,fee schedule,21.66,38,
Bed pan fracture,E0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.04,,,,,,,fee schedule,21.66,38,
Bed pan fracture,E0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.66,,,,,,,fee schedule,21.66,38,
Bed pan fracture,E0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38,,,,,,,fee schedule,21.66,38,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,490.42,,,,,,,fee schedule,321.52,563.98,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,401.41,,,,,,,fee schedule,321.52,563.98,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,321.52,,,,,,,fee schedule,321.52,563.98,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,563.98,,,,,,,fee schedule,321.52,563.98,
Bed cradle,E0280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.12,,,,,,,fee schedule,55.15,96.74,
Bed cradle,E0280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.85,,,,,,,fee schedule,55.15,96.74,
Bed cradle,E0280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.15,,,,,,,fee schedule,55.15,96.74,
Bed cradle,E0280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.74,,,,,,,fee schedule,55.15,96.74,
Hosp bed fx ht w/o rails w/m,E0290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.43,,,,,,,fee schedule,100.59,176.44,
Hosp bed fx ht w/o rails w/m,E0290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.58,,,,,,,fee schedule,100.59,176.44,
Hosp bed fx ht w/o rails w/m,E0290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.59,,,,,,,fee schedule,100.59,176.44,
Hosp bed fx ht w/o rails w/m,E0290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.44,,,,,,,fee schedule,100.59,176.44,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.47,,,,,,,fee schedule,77.01,135.09,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.15,,,,,,,fee schedule,77.01,135.09,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.01,,,,,,,fee schedule,77.01,135.09,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.09,,,,,,,fee schedule,77.01,135.09,
Hosp bed var ht no sr w/matt,E0292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.88,,,,,,,fee schedule,104.16,182.71,
Hosp bed var ht no sr w/matt,E0292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.04,,,,,,,fee schedule,104.16,182.71,
Hosp bed var ht no sr w/matt,E0292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.16,,,,,,,fee schedule,104.16,182.71,
Hosp bed var ht no sr w/matt,E0292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.71,,,,,,,fee schedule,104.16,182.71,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.89,,,,,,,fee schedule,98.27,172.37,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.68,,,,,,,fee schedule,98.27,172.37,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.27,,,,,,,fee schedule,98.27,172.37,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.37,,,,,,,fee schedule,98.27,172.37,
Hosp bed semi-elect w/ mattr,E0294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.81,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-elect w/ mattr,E0294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.44,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-elect w/ mattr,E0294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.08,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-elect w/ mattr,E0294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,186.08,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.81,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.44,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.08,,,,,,,fee schedule,106.08,186.08,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,186.08,,,,,,,fee schedule,106.08,186.08,
Hosp bed total elect w/ matt,E0296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.8,,,,,,,fee schedule,191.96,336.72,
Hosp bed total elect w/ matt,E0296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.66,,,,,,,fee schedule,191.96,336.72,
Hosp bed total elect w/ matt,E0296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.96,,,,,,,fee schedule,191.96,336.72,
Hosp bed total elect w/ matt,E0296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,336.72,,,,,,,fee schedule,191.96,336.72,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,258.34,,,,,,,fee schedule,169.37,297.09,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,211.45,,,,,,,fee schedule,169.37,297.09,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.37,,,,,,,fee schedule,169.37,297.09,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,297.09,,,,,,,fee schedule,169.37,297.09,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,652.42,,,,,,,fee schedule,427.73,750.28,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,534.01,,,,,,,fee schedule,427.73,750.28,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,427.73,,,,,,,fee schedule,427.73,750.28,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,750.28,,,,,,,fee schedule,427.73,750.28,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,429.43,,,,,,,fee schedule,281.53,493.84,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,351.49,,,,,,,fee schedule,281.53,493.84,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,281.53,,,,,,,fee schedule,281.53,493.84,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,493.84,,,,,,,fee schedule,281.53,493.84,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1229.31,,,,,,,fee schedule,805.94,1413.71,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1006.19,,,,,,,fee schedule,805.94,1413.71,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,805.94,,,,,,,fee schedule,805.94,1413.71,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1413.71,,,,,,,fee schedule,805.94,1413.71,
Hosp bed hvy dty xtra wide,E0303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,437.09,,,,,,,fee schedule,286.56,502.65,
Hosp bed hvy dty xtra wide,E0303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,357.76,,,,,,,fee schedule,286.56,502.65,
Hosp bed hvy dty xtra wide,E0303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,286.56,,,,,,,fee schedule,286.56,502.65,
Hosp bed hvy dty xtra wide,E0303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,502.65,,,,,,,fee schedule,286.56,502.65,
Hosp bed xtra hvy dty x wide,E0304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1297.55,,,,,,,fee schedule,850.67,1492.18,
Hosp bed xtra hvy dty x wide,E0304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1062.04,,,,,,,fee schedule,850.67,1492.18,
Hosp bed xtra hvy dty x wide,E0304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,850.67,,,,,,,fee schedule,850.67,1492.18,
Hosp bed xtra hvy dty x wide,E0304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1492.18,,,,,,,fee schedule,850.67,1492.18,
Rails bed side half length,E0305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.73,,,,,,,fee schedule,18.84,33.04,
Rails bed side half length,E0305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.52,,,,,,,fee schedule,18.84,33.04,
Rails bed side half length,E0305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.84,,,,,,,fee schedule,18.84,33.04,
Rails bed side half length,E0305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.04,,,,,,,fee schedule,18.84,33.04,
Rails bed side full length,E0310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,292.62,,,,,,,fee schedule,191.84,336.51,
Rails bed side full length,E0310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,239.51,,,,,,,fee schedule,191.84,336.51,
Rails bed side full length,E0310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.84,,,,,,,fee schedule,191.84,336.51,
Rails bed side full length,E0310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,336.51,,,,,,,fee schedule,191.84,336.51,
Bed safety enclosure,E0316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,456.22,,,,,,,fee schedule,299.1,524.65,
Bed safety enclosure,E0316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,373.42,,,,,,,fee schedule,299.1,524.65,
Bed safety enclosure,E0316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.1,,,,,,,fee schedule,299.1,524.65,
Bed safety enclosure,E0316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,524.65,,,,,,,fee schedule,299.1,524.65,
Urinal male jug-type,E0325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.23,,,,,,,fee schedule,15.89,27.86,
Urinal male jug-type,E0325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.83,,,,,,,fee schedule,15.89,27.86,
Urinal male jug-type,E0325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.89,,,,,,,fee schedule,15.89,27.86,
Urinal male jug-type,E0325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.86,,,,,,,fee schedule,15.89,27.86,
Urinal female jug-type,E0326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.52,,,,,,,fee schedule,17.39,30.5,
Urinal female jug-type,E0326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.71,,,,,,,fee schedule,17.39,30.5,
Urinal female jug-type,E0326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.39,,,,,,,fee schedule,17.39,30.5,
Urinal female jug-type,E0326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.5,,,,,,,fee schedule,17.39,30.5,
Nonpower mattress overlay,E0371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,490.42,,,,,,,fee schedule,321.52,563.98,
Nonpower mattress overlay,E0371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,401.41,,,,,,,fee schedule,321.52,563.98,
Nonpower mattress overlay,E0371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,321.52,,,,,,,fee schedule,321.52,563.98,
Nonpower mattress overlay,E0371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,563.98,,,,,,,fee schedule,321.52,563.98,
Powered air mattress overlay,E0372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,490.42,,,,,,,fee schedule,321.52,563.98,
Powered air mattress overlay,E0372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,401.41,,,,,,,fee schedule,321.52,563.98,
Powered air mattress overlay,E0372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,321.52,,,,,,,fee schedule,321.52,563.98,
Powered air mattress overlay,E0372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,563.98,,,,,,,fee schedule,321.52,563.98,
Nonpowered pressure mattress,E0373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,490.42,,,,,,,fee schedule,321.52,563.98,
Nonpowered pressure mattress,E0373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,401.41,,,,,,,fee schedule,321.52,563.98,
Nonpowered pressure mattress,E0373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,321.52,,,,,,,fee schedule,321.52,563.98,
Nonpowered pressure mattress,E0373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,563.98,,,,,,,fee schedule,321.52,563.98,
Stationary compressed gas 02,E0424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.72,,,,,,,fee schedule,126.35,221.63,
Stationary compressed gas 02,E0424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.74,,,,,,,fee schedule,126.35,221.63,
Stationary compressed gas 02,E0424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.35,,,,,,,fee schedule,126.35,221.63,
Stationary compressed gas 02,E0424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.63,,,,,,,fee schedule,126.35,221.63,
Portable gaseous 02,E0431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.14,,,,,,,fee schedule,30.9,54.21,
Portable gaseous 02,E0431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.58,,,,,,,fee schedule,30.9,54.21,
Portable gaseous 02,E0431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.9,,,,,,,fee schedule,30.9,54.21,
Portable gaseous 02,E0431,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.21,,,,,,,fee schedule,30.9,54.21,
Portable liquid oxygen sys,E0433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.67,,,,,,,fee schedule,64.69,113.47,
Portable liquid oxygen sys,E0433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.76,,,,,,,fee schedule,64.69,113.47,
Portable liquid oxygen sys,E0433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.69,,,,,,,fee schedule,64.69,113.47,
Portable liquid oxygen sys,E0433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.47,,,,,,,fee schedule,64.69,113.47,
Portable liquid 02,E0434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.14,,,,,,,fee schedule,30.9,54.21,
Portable liquid 02,E0434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.58,,,,,,,fee schedule,30.9,54.21,
Portable liquid 02,E0434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.9,,,,,,,fee schedule,30.9,54.21,
Portable liquid 02,E0434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.21,,,,,,,fee schedule,30.9,54.21,
Stationary liquid 02,E0439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.72,,,,,,,fee schedule,126.35,221.63,
Stationary liquid 02,E0439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.74,,,,,,,fee schedule,126.35,221.63,
Stationary liquid 02,E0439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.35,,,,,,,fee schedule,126.35,221.63,
Stationary liquid 02,E0439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.63,,,,,,,fee schedule,126.35,221.63,
"Stationary o2 contents, gas",E0441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,165.65,
"Stationary o2 contents, gas",E0441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,165.65,
"Stationary o2 contents, gas",E0441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,165.65,
"Stationary o2 contents, gas",E0441,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,165.65,
"Stationary o2 contents, liq",E0442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.04,,,,,,,fee schedule,94.43,165.65,
"Stationary o2 contents, liq",E0442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.9,,,,,,,fee schedule,94.43,165.65,
"Stationary o2 contents, liq",E0442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.43,,,,,,,fee schedule,94.43,165.65,
"Stationary o2 contents, liq",E0442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.65,,,,,,,fee schedule,94.43,165.65,
"Portable 02 contents, gas",E0443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.34,,,,,,,fee schedule,84.8,148.74,
"Portable 02 contents, gas",E0443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.86,,,,,,,fee schedule,84.8,148.74,
"Portable 02 contents, gas",E0443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.8,,,,,,,fee schedule,84.8,148.74,
"Portable 02 contents, gas",E0443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.74,,,,,,,fee schedule,84.8,148.74,
"Portable 02 contents, liquid",E0444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.34,,,,,,,fee schedule,84.8,148.74,
"Portable 02 contents, liquid",E0444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.86,,,,,,,fee schedule,84.8,148.74,
"Portable 02 contents, liquid",E0444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.8,,,,,,,fee schedule,84.8,148.74,
"Portable 02 contents, liquid",E0444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.74,,,,,,,fee schedule,84.8,148.74,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,752.86,,,,,,,fee schedule,493.58,865.79,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,616.22,,,,,,,fee schedule,493.58,865.79,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,493.58,,,,,,,fee schedule,493.58,865.79,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,865.79,,,,,,,fee schedule,493.58,865.79,
Home vent invasive interface,E0465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2901.21,,,,,,,fee schedule,1902.03,3336.39,
Home vent invasive interface,E0465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2374.64,,,,,,,fee schedule,1902.03,3336.39,
Home vent invasive interface,E0465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1902.03,,,,,,,fee schedule,1902.03,3336.39,
Home vent invasive interface,E0465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3336.39,,,,,,,fee schedule,1902.03,3336.39,
Home vent non-invasive inter,E0466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2901.21,,,,,,,fee schedule,1902.03,3336.39,
Home vent non-invasive inter,E0466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2374.64,,,,,,,fee schedule,1902.03,3336.39,
Home vent non-invasive inter,E0466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1902.03,,,,,,,fee schedule,1902.03,3336.39,
Home vent non-invasive inter,E0466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3336.39,,,,,,,fee schedule,1902.03,3336.39,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,291.39,,,,,,,fee schedule,191.04,335.1,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,238.5,,,,,,,fee schedule,191.04,335.1,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.04,,,,,,,fee schedule,191.04,335.1,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,335.1,,,,,,,fee schedule,191.04,335.1,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,733.48,,,,,,,fee schedule,480.87,843.5,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,600.35,,,,,,,fee schedule,480.87,843.5,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,480.87,,,,,,,fee schedule,480.87,843.5,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,843.5,,,,,,,fee schedule,480.87,843.5,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1138.45,,,,,,,fee schedule,746.37,1309.22,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,931.82,,,,,,,fee schedule,746.37,1309.22,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,746.37,,,,,,,fee schedule,746.37,1309.22,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1309.22,,,,,,,fee schedule,746.37,1309.22,
Percussor elect/pneum home m,E0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.52,,,,,,,fee schedule,74.42,130.55,
Percussor elect/pneum home m,E0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.92,,,,,,,fee schedule,74.42,130.55,
Percussor elect/pneum home m,E0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.42,,,,,,,fee schedule,74.42,130.55,
Percussor elect/pneum home m,E0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.55,,,,,,,fee schedule,74.42,130.55,
Cough stimulating device,E0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1249.9,,,,,,,fee schedule,819.43,1437.39,
Cough stimulating device,E0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1023.04,,,,,,,fee schedule,819.43,1437.39,
Cough stimulating device,E0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,819.43,,,,,,,fee schedule,819.43,1437.39,
Cough stimulating device,E0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1437.39,,,,,,,fee schedule,819.43,1437.39,
Chest compression gen system,E0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3231.34,,,,,,,fee schedule,2118.47,3716.04,
Chest compression gen system,E0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2644.85,,,,,,,fee schedule,2118.47,3716.04,
Chest compression gen system,E0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2118.47,,,,,,,fee schedule,2118.47,3716.04,
Chest compression gen system,E0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3716.04,,,,,,,fee schedule,2118.47,3716.04,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.27,,,,,,,fee schedule,73.6,129.11,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.89,,,,,,,fee schedule,73.6,129.11,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.6,,,,,,,fee schedule,73.6,129.11,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.11,,,,,,,fee schedule,73.6,129.11,
Ippb all types,E0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,333.61,,,,,,,fee schedule,218.71,383.65,
Ippb all types,E0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,273.06,,,,,,,fee schedule,218.71,383.65,
Ippb all types,E0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.71,,,,,,,fee schedule,218.71,383.65,
Ippb all types,E0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,383.65,,,,,,,fee schedule,218.71,383.65,
Humidif extens supple w ippb,E0550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.54,,,,,,,fee schedule,84.93,148.97,
Humidif extens supple w ippb,E0550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.03,,,,,,,fee schedule,84.93,148.97,
Humidif extens supple w ippb,E0550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.93,,,,,,,fee schedule,84.93,148.97,
Humidif extens supple w ippb,E0550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.97,,,,,,,fee schedule,84.93,148.97,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,425.54,,,,,,,fee schedule,278.98,489.37,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,348.3,,,,,,,fee schedule,278.98,489.37,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,278.98,,,,,,,fee schedule,278.98,489.37,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,489.37,,,,,,,fee schedule,278.98,489.37,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.95,,,,,,,fee schedule,134.37,235.69,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.75,,,,,,,fee schedule,134.37,235.69,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.37,,,,,,,fee schedule,134.37,235.69,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.69,,,,,,,fee schedule,134.37,235.69,
Humidifier heated used w PAP,E0562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,363.18,,,,,,,fee schedule,238.1,417.66,
Humidifier heated used w PAP,E0562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,297.26,,,,,,,fee schedule,238.1,417.66,
Humidifier heated used w PAP,E0562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,238.1,,,,,,,fee schedule,238.1,417.66,
Humidifier heated used w PAP,E0562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,417.66,,,,,,,fee schedule,238.1,417.66,
Compressor air power source,E0565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.41,,,,,,,fee schedule,75.66,132.72,
Compressor air power source,E0565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.46,,,,,,,fee schedule,75.66,132.72,
Compressor air power source,E0565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.66,,,,,,,fee schedule,75.66,132.72,
Compressor air power source,E0565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.72,,,,,,,fee schedule,75.66,132.72,
Nebulizer with compression,E0570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.04,,,,,,,fee schedule,85.91,150.7,
Nebulizer with compression,E0570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.26,,,,,,,fee schedule,85.91,150.7,
Nebulizer with compression,E0570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.91,,,,,,,fee schedule,85.91,150.7,
Nebulizer with compression,E0570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.7,,,,,,,fee schedule,85.91,150.7,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.8,,,,,,,fee schedule,54.94,96.37,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.59,,,,,,,fee schedule,54.94,96.37,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.94,,,,,,,fee schedule,54.94,96.37,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.37,,,,,,,fee schedule,54.94,96.37,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.7,,,,,,,fee schedule,77.16,135.36,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.34,,,,,,,fee schedule,77.16,135.36,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.16,,,,,,,fee schedule,77.16,135.36,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.36,,,,,,,fee schedule,77.16,135.36,
Nebulizer ultrasonic,E0575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,312.38,,,,,,,fee schedule,204.8,359.24,
Nebulizer ultrasonic,E0575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,255.68,,,,,,,fee schedule,204.8,359.24,
Nebulizer ultrasonic,E0575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,204.8,,,,,,,fee schedule,204.8,359.24,
Nebulizer ultrasonic,E0575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,359.24,,,,,,,fee schedule,204.8,359.24,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,351.17,,,,,,,fee schedule,230.23,403.85,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,287.43,,,,,,,fee schedule,230.23,403.85,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,230.23,,,,,,,fee schedule,230.23,403.85,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,403.85,,,,,,,fee schedule,230.23,403.85,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.07,,,,,,,fee schedule,53.81,94.38,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.17,,,,,,,fee schedule,53.81,94.38,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.81,,,,,,,fee schedule,53.81,94.38,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.38,,,,,,,fee schedule,53.81,94.38,
Suction pump portab hom modl,E0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,118.29,,,,,,,fee schedule,77.55,136.03,
Suction pump portab hom modl,E0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.82,,,,,,,fee schedule,77.55,136.03,
Suction pump portab hom modl,E0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.55,,,,,,,fee schedule,77.55,136.03,
Suction pump portab hom modl,E0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.03,,,,,,,fee schedule,77.55,136.03,
Cont airway pressure device,E0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.25,,,,,,,fee schedule,73.59,129.09,
Cont airway pressure device,E0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.88,,,,,,,fee schedule,73.59,129.09,
Cont airway pressure device,E0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.59,,,,,,,fee schedule,73.59,129.09,
Cont airway pressure device,E0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.09,,,,,,,fee schedule,73.59,129.09,
Manual breast pump,E0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.72,,,,,,,fee schedule,58.82,103.18,
Manual breast pump,E0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.44,,,,,,,fee schedule,58.82,103.18,
Manual breast pump,E0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.82,,,,,,,fee schedule,58.82,103.18,
Manual breast pump,E0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.18,,,,,,,fee schedule,58.82,103.18,
Vaporizer room type,E0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.31,,,,,,,fee schedule,52.65,92.36,
Vaporizer room type,E0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.73,,,,,,,fee schedule,52.65,92.36,
Vaporizer room type,E0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.65,,,,,,,fee schedule,52.65,92.36,
Vaporizer room type,E0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.36,,,,,,,fee schedule,52.65,92.36,
Drainage board postural,E0606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.21,,,,,,,fee schedule,41.44,72.69,
Drainage board postural,E0606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.74,,,,,,,fee schedule,41.44,72.69,
Drainage board postural,E0606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.44,,,,,,,fee schedule,41.44,72.69,
Drainage board postural,E0606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.69,,,,,,,fee schedule,41.44,72.69,
Blood glucose monitor home,E0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.34,,,,,,,fee schedule,49.39,86.64,
Blood glucose monitor home,E0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.67,,,,,,,fee schedule,49.39,86.64,
Blood glucose monitor home,E0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.39,,,,,,,fee schedule,49.39,86.64,
Blood glucose monitor home,E0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.64,,,,,,,fee schedule,49.39,86.64,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,722.92,,,,,,,fee schedule,473.95,831.36,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,591.71,,,,,,,fee schedule,473.95,831.36,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,473.95,,,,,,,fee schedule,473.95,831.36,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,831.36,,,,,,,fee schedule,473.95,831.36,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1320.85,,,,,,,fee schedule,865.95,1518.98,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1081.12,,,,,,,fee schedule,865.95,1518.98,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,865.95,,,,,,,fee schedule,865.95,1518.98,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1518.98,,,,,,,fee schedule,865.95,1518.98,
Automatic ext defibrillator,E0617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,924.11,,,,,,,fee schedule,605.85,1062.73,
Automatic ext defibrillator,E0617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,756.38,,,,,,,fee schedule,605.85,1062.73,
Automatic ext defibrillator,E0617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,605.85,,,,,,,fee schedule,605.85,1062.73,
Automatic ext defibrillator,E0617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1062.73,,,,,,,fee schedule,605.85,1062.73,
Apnea monitor,E0618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,724.32,,,,,,,fee schedule,474.86,832.97,
Apnea monitor,E0618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,592.86,,,,,,,fee schedule,474.86,832.97,
Apnea monitor,E0618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,474.86,,,,,,,fee schedule,474.86,832.97,
Apnea monitor,E0618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,832.97,,,,,,,fee schedule,474.86,832.97,
Cap bld skin piercing laser,E0620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,265.73,,,,,,,fee schedule,174.21,305.59,
Cap bld skin piercing laser,E0620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,217.5,,,,,,,fee schedule,174.21,305.59,
Cap bld skin piercing laser,E0620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.21,,,,,,,fee schedule,174.21,305.59,
Cap bld skin piercing laser,E0620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,305.59,,,,,,,fee schedule,174.21,305.59,
Patient lift sling or seat,E0621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.38,,,,,,,fee schedule,150.38,263.79,
Patient lift sling or seat,E0621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.75,,,,,,,fee schedule,150.38,263.79,
Patient lift sling or seat,E0621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.38,,,,,,,fee schedule,150.38,263.79,
Patient lift sling or seat,E0621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.79,,,,,,,fee schedule,150.38,263.79,
"Seat lift mech, electric any",E0627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,721.17,,,,,,,fee schedule,472.8,829.35,
"Seat lift mech, electric any",E0627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,590.28,,,,,,,fee schedule,472.8,829.35,
"Seat lift mech, electric any",E0627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,472.8,,,,,,,fee schedule,472.8,829.35,
"Seat lift mech, electric any",E0627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,829.35,,,,,,,fee schedule,472.8,829.35,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,712.64,,,,,,,fee schedule,467.21,819.54,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,583.3,,,,,,,fee schedule,467.21,819.54,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,467.21,,,,,,,fee schedule,467.21,819.54,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,819.54,,,,,,,fee schedule,467.21,819.54,
Patient lift hydraulic,E0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.14,,,,,,,fee schedule,103.68,181.86,
Patient lift hydraulic,E0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.44,,,,,,,fee schedule,103.68,181.86,
Patient lift hydraulic,E0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.68,,,,,,,fee schedule,103.68,181.86,
Patient lift hydraulic,E0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,181.86,,,,,,,fee schedule,103.68,181.86,
Patient lift electric,E0635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,307.83,,,,,,,fee schedule,201.81,354,
Patient lift electric,E0635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.96,,,,,,,fee schedule,201.81,354,
Patient lift electric,E0635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.81,,,,,,,fee schedule,201.81,354,
Patient lift electric,E0635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,354,,,,,,,fee schedule,201.81,354,
PT support & positioning sys,E0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2658.64,,,,,,,fee schedule,1743,3057.44,
PT support & positioning sys,E0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2176.1,,,,,,,fee schedule,1743,3057.44,
PT support & positioning sys,E0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1743,,,,,,,fee schedule,1743,3057.44,
PT support & positioning sys,E0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3057.44,,,,,,,fee schedule,1743,3057.44,
Moveable patient lift system,E0639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,339.03,,,,,,,fee schedule,222.27,389.88,
Moveable patient lift system,E0639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.5,,,,,,,fee schedule,222.27,389.88,
Moveable patient lift system,E0639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.27,,,,,,,fee schedule,222.27,389.88,
Moveable patient lift system,E0639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,389.88,,,,,,,fee schedule,222.27,389.88,
Fixed patient lift system,E0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,339.03,,,,,,,fee schedule,222.27,389.88,
Fixed patient lift system,E0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.5,,,,,,,fee schedule,222.27,389.88,
Fixed patient lift system,E0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.27,,,,,,,fee schedule,222.27,389.88,
Fixed patient lift system,E0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,389.88,,,,,,,fee schedule,222.27,389.88,
Pneuma compresor non-segment,E0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1860.65,,,,,,,fee schedule,1219.84,2139.75,
Pneuma compresor non-segment,E0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1522.94,,,,,,,fee schedule,1219.84,2139.75,
Pneuma compresor non-segment,E0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1219.84,,,,,,,fee schedule,1219.84,2139.75,
Pneuma compresor non-segment,E0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2139.75,,,,,,,fee schedule,1219.84,2139.75,
Pneum compressor segmental,E0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2791.46,,,,,,,fee schedule,1830.08,3210.18,
Pneum compressor segmental,E0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2284.81,,,,,,,fee schedule,1830.08,3210.18,
Pneum compressor segmental,E0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1830.08,,,,,,,fee schedule,1830.08,3210.18,
Pneum compressor segmental,E0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3210.18,,,,,,,fee schedule,1830.08,3210.18,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16113.47,,,,,,,fee schedule,10563.99,18530.49,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13188.88,,,,,,,fee schedule,10563.99,18530.49,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10563.99,,,,,,,fee schedule,10563.99,18530.49,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18530.49,,,,,,,fee schedule,10563.99,18530.49,
Pneumatic appliance half arm,E0655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,328.06,,,,,,,fee schedule,215.08,377.27,
Pneumatic appliance half arm,E0655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.52,,,,,,,fee schedule,215.08,377.27,
Pneumatic appliance half arm,E0655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,215.08,,,,,,,fee schedule,215.08,377.27,
Pneumatic appliance half arm,E0655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,377.27,,,,,,,fee schedule,215.08,377.27,
Segmental pneumatic trunk,E0656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,175.63,,,,,,,fee schedule,115.14,201.97,
Segmental pneumatic trunk,E0656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,143.75,,,,,,,fee schedule,115.14,201.97,
Segmental pneumatic trunk,E0656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,115.14,,,,,,,fee schedule,115.14,201.97,
Segmental pneumatic trunk,E0656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,201.97,,,,,,,fee schedule,115.14,201.97,
Segmental pneumatic chest,E0657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.98,,,,,,,fee schedule,108.16,189.73,
Segmental pneumatic chest,E0657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.04,,,,,,,fee schedule,108.16,189.73,
Segmental pneumatic chest,E0657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.16,,,,,,,fee schedule,108.16,189.73,
Segmental pneumatic chest,E0657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.73,,,,,,,fee schedule,108.16,189.73,
Pneumatic appliance full leg,E0660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,485.55,,,,,,,fee schedule,318.33,558.38,
Pneumatic appliance full leg,E0660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.42,,,,,,,fee schedule,318.33,558.38,
Pneumatic appliance full leg,E0660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.33,,,,,,,fee schedule,318.33,558.38,
Pneumatic appliance full leg,E0660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,558.38,,,,,,,fee schedule,318.33,558.38,
Pneumatic appliance full arm,E0665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,380.93,,,,,,,fee schedule,249.74,438.07,
Pneumatic appliance full arm,E0665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,311.79,,,,,,,fee schedule,249.74,438.07,
Pneumatic appliance full arm,E0665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.74,,,,,,,fee schedule,249.74,438.07,
Pneumatic appliance full arm,E0665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.07,,,,,,,fee schedule,249.74,438.07,
Pneumatic appliance half leg,E0666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,419.75,,,,,,,fee schedule,275.19,482.71,
Pneumatic appliance half leg,E0666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,343.57,,,,,,,fee schedule,275.19,482.71,
Pneumatic appliance half leg,E0666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,275.19,,,,,,,fee schedule,275.19,482.71,
Pneumatic appliance half leg,E0666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,482.71,,,,,,,fee schedule,275.19,482.71,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,984.11,,,,,,,fee schedule,645.18,1131.73,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,805.49,,,,,,,fee schedule,645.18,1131.73,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.18,,,,,,,fee schedule,645.18,1131.73,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1131.73,,,,,,,fee schedule,645.18,1131.73,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1141.61,,,,,,,fee schedule,748.44,1312.85,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,934.41,,,,,,,fee schedule,748.44,1312.85,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,748.44,,,,,,,fee schedule,748.44,1312.85,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1312.85,,,,,,,fee schedule,748.44,1312.85,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,550.2,,,,,,,fee schedule,360.71,632.73,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,450.34,,,,,,,fee schedule,360.71,632.73,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,360.71,,,,,,,fee schedule,360.71,632.73,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,632.73,,,,,,,fee schedule,360.71,632.73,
Seg pneum int legs/trunk,E0670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3820.73,,,,,,,fee schedule,2504.87,4393.84,
Seg pneum int legs/trunk,E0670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3127.27,,,,,,,fee schedule,2504.87,4393.84,
Seg pneum int legs/trunk,E0670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2504.87,,,,,,,fee schedule,2504.87,4393.84,
Seg pneum int legs/trunk,E0670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4393.84,,,,,,,fee schedule,2504.87,4393.84,
Pressure pneum appl full leg,E0671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1262.44,,,,,,,fee schedule,827.66,1451.81,
Pressure pneum appl full leg,E0671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1033.31,,,,,,,fee schedule,827.66,1451.81,
Pressure pneum appl full leg,E0671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,827.66,,,,,,,fee schedule,827.66,1451.81,
Pressure pneum appl full leg,E0671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1451.81,,,,,,,fee schedule,827.66,1451.81,
Pressure pneum appl full arm,E0672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,980.89,,,,,,,fee schedule,643.07,1128.02,
Pressure pneum appl full arm,E0672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,802.86,,,,,,,fee schedule,643.07,1128.02,
Pressure pneum appl full arm,E0672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,643.07,,,,,,,fee schedule,643.07,1128.02,
Pressure pneum appl full arm,E0672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1128.02,,,,,,,fee schedule,643.07,1128.02,
Pressure pneum appl half leg,E0673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,815.08,,,,,,,fee schedule,534.37,937.34,
Pressure pneum appl half leg,E0673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,667.14,,,,,,,fee schedule,534.37,937.34,
Pressure pneum appl half leg,E0673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,534.37,,,,,,,fee schedule,534.37,937.34,
Pressure pneum appl half leg,E0673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,937.34,,,,,,,fee schedule,534.37,937.34,
Pneumatic compression device,E0675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1168.83,,,,,,,fee schedule,766.28,1344.15,
Pneumatic compression device,E0675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,956.69,,,,,,,fee schedule,766.28,1344.15,
Pneumatic compression device,E0675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,766.28,,,,,,,fee schedule,766.28,1344.15,
Pneumatic compression device,E0675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1344.15,,,,,,,fee schedule,766.28,1344.15,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2731.19,,,,,,,fee schedule,1790.57,3140.87,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2235.48,,,,,,,fee schedule,1790.57,3140.87,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1790.57,,,,,,,fee schedule,1790.57,3140.87,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3140.87,,,,,,,fee schedule,1790.57,3140.87,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3429.65,,,,,,,fee schedule,2248.48,3944.1,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2807.17,,,,,,,fee schedule,2248.48,3944.1,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2248.48,,,,,,,fee schedule,2248.48,3944.1,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3944.1,,,,,,,fee schedule,2248.48,3944.1,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4227.8,,,,,,,fee schedule,2771.75,4861.97,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3460.45,,,,,,,fee schedule,2771.75,4861.97,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2771.75,,,,,,,fee schedule,2771.75,4861.97,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4861.97,,,,,,,fee schedule,2771.75,4861.97,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13456.66,,,,,,,fee schedule,8822.19,15475.16,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11014.28,,,,,,,fee schedule,8822.19,15475.16,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8822.19,,,,,,,fee schedule,8822.19,15475.16,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15475.16,,,,,,,fee schedule,8822.19,15475.16,
Transfer device,E0705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.06,,,,,,,fee schedule,79.37,139.22,
Transfer device,E0705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.09,,,,,,,fee schedule,79.37,139.22,
Transfer device,E0705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.37,,,,,,,fee schedule,79.37,139.22,
Transfer device,E0705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.22,,,,,,,fee schedule,79.37,139.22,
Tens two lead,E0720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,194.84,,,,,,,fee schedule,127.74,224.07,
Tens two lead,E0720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,159.48,,,,,,,fee schedule,127.74,224.07,
Tens two lead,E0720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.74,,,,,,,fee schedule,127.74,224.07,
Tens two lead,E0720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,224.07,,,,,,,fee schedule,127.74,224.07,
Tens four lead,E0730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.88,,,,,,,fee schedule,129.07,226.41,
Tens four lead,E0730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.15,,,,,,,fee schedule,129.07,226.41,
Tens four lead,E0730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.07,,,,,,,fee schedule,129.07,226.41,
Tens four lead,E0730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,226.41,,,,,,,fee schedule,129.07,226.41,
Conductive garment for tens/,E0731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,238.69,,,,,,,fee schedule,156.49,274.49,
Conductive garment for tens/,E0731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.37,,,,,,,fee schedule,156.49,274.49,
Conductive garment for tens/,E0731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.49,,,,,,,fee schedule,156.49,274.49,
Conductive garment for tens/,E0731,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,274.49,,,,,,,fee schedule,156.49,274.49,
Transcut tibial nerv stimula,E0736,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.92,,,,,,,fee schedule,49.45,89.01,APC
Transcut tibial nerv stimula,E0736,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.45,,,,,,,fee schedule,49.45,89.01,APC
Transcut tibial nerv stimula,E0736,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,89.01,,,,,,,fee schedule,49.45,89.01,APC
Upper extremity rehab,E0738,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2141.62,,,,,,,fee schedule,2039.64,3671.35,APC
Upper extremity rehab,E0738,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2039.64,,,,,,,fee schedule,2039.64,3671.35,APC
Upper extremity rehab,E0738,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3671.35,,,,,,,fee schedule,2039.64,3671.35,APC
Rehab sys active assist rt,E0739,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1677.54,,,,,,,fee schedule,1597.66,2875.79,APC
Rehab sys active assist rt,E0739,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1597.66,,,,,,,fee schedule,1597.66,2875.79,APC
Rehab sys active assist rt,E0739,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2875.79,,,,,,,fee schedule,1597.66,2875.79,APC
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.95,,,,,,,fee schedule,104.21,182.79,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.1,,,,,,,fee schedule,104.21,182.79,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.21,,,,,,,fee schedule,104.21,182.79,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.79,,,,,,,fee schedule,104.21,182.79,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.57,,,,,,,fee schedule,155.1,272.06,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.63,,,,,,,fee schedule,155.1,272.06,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,155.1,,,,,,,fee schedule,155.1,272.06,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,272.06,,,,,,,fee schedule,155.1,272.06,
Neuromuscular stim for shock,E0745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,231.25,,,,,,,fee schedule,151.61,265.94,
Neuromuscular stim for shock,E0745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.28,,,,,,,fee schedule,151.61,265.94,
Neuromuscular stim for shock,E0745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.61,,,,,,,fee schedule,151.61,265.94,
Neuromuscular stim for shock,E0745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.94,,,,,,,fee schedule,151.61,265.94,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.05,,,,,,,fee schedule,186.22,326.66,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.49,,,,,,,fee schedule,186.22,326.66,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.22,,,,,,,fee schedule,186.22,326.66,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.66,,,,,,,fee schedule,186.22,326.66,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.7,,,,,,,fee schedule,167.64,294.06,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.29,,,,,,,fee schedule,167.64,294.06,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.64,,,,,,,fee schedule,167.64,294.06,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.06,,,,,,,fee schedule,167.64,294.06,
Iv pole,E0776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,376.1,,,,,,,fee schedule,246.57,432.52,
Iv pole,E0776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.84,,,,,,,fee schedule,246.57,432.52,
Iv pole,E0776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.57,,,,,,,fee schedule,246.57,432.52,
Iv pole,E0776,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,432.52,,,,,,,fee schedule,246.57,432.52,
Amb infusion pump mechanical,E0779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.79,,,,,,,fee schedule,31.99,56.11,
Amb infusion pump mechanical,E0779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.93,,,,,,,fee schedule,31.99,56.11,
Amb infusion pump mechanical,E0779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.99,,,,,,,fee schedule,31.99,56.11,
Amb infusion pump mechanical,E0779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.11,,,,,,,fee schedule,31.99,56.11,
Mech amb infusion pump <8hrs,E0780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.01,,,,,,,fee schedule,20.33,35.66,
Mech amb infusion pump <8hrs,E0780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.38,,,,,,,fee schedule,20.33,35.66,
Mech amb infusion pump <8hrs,E0780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.33,,,,,,,fee schedule,20.33,35.66,
Mech amb infusion pump <8hrs,E0780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.66,,,,,,,fee schedule,20.33,35.66,
External ambulatory infus pu,E0781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,633.28,,,,,,,fee schedule,415.18,728.27,
External ambulatory infus pu,E0781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,518.34,,,,,,,fee schedule,415.18,728.27,
External ambulatory infus pu,E0781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,415.18,,,,,,,fee schedule,415.18,728.27,
External ambulatory infus pu,E0781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,728.27,,,,,,,fee schedule,415.18,728.27,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1141.87,,,,,,,fee schedule,748.61,1313.15,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,934.62,,,,,,,fee schedule,748.61,1313.15,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,748.61,,,,,,,fee schedule,748.61,1313.15,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1313.15,,,,,,,fee schedule,748.61,1313.15,
Replacement impl pump cathet,E0785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1436.18,,,,,,,fee schedule,941.56,1651.61,
Replacement impl pump cathet,E0785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1175.51,,,,,,,fee schedule,941.56,1651.61,
Replacement impl pump cathet,E0785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,941.56,,,,,,,fee schedule,941.56,1651.61,
Replacement impl pump cathet,E0785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1651.61,,,,,,,fee schedule,941.56,1651.61,
Parenteral infusion pump sta,E0791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,752.34,,,,,,,fee schedule,493.23,865.19,
Parenteral infusion pump sta,E0791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,615.79,,,,,,,fee schedule,493.23,865.19,
Parenteral infusion pump sta,E0791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,493.23,,,,,,,fee schedule,493.23,865.19,
Parenteral infusion pump sta,E0791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,865.19,,,,,,,fee schedule,493.23,865.19,
Tract frame attach headboard,E0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.28,,,,,,,fee schedule,124.09,217.67,
Tract frame attach headboard,E0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.93,,,,,,,fee schedule,124.09,217.67,
Tract frame attach headboard,E0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.09,,,,,,,fee schedule,124.09,217.67,
Tract frame attach headboard,E0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.67,,,,,,,fee schedule,124.09,217.67,
Cervical pneum trac equip,E0849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.65,,,,,,,fee schedule,102.7,180.15,
Cervical pneum trac equip,E0849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.22,,,,,,,fee schedule,102.7,180.15,
Cervical pneum trac equip,E0849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.7,,,,,,,fee schedule,102.7,180.15,
Cervical pneum trac equip,E0849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.15,,,,,,,fee schedule,102.7,180.15,
Traction stand free standing,E0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.4,,,,,,,fee schedule,177.93,312.11,
Traction stand free standing,E0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.14,,,,,,,fee schedule,177.93,312.11,
Traction stand free standing,E0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.93,,,,,,,fee schedule,177.93,312.11,
Traction stand free standing,E0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.11,,,,,,,fee schedule,177.93,312.11,
Cervical traction equipment,E0855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.75,,,,,,,fee schedule,100.14,175.66,
Cervical traction equipment,E0855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.03,,,,,,,fee schedule,100.14,175.66,
Cervical traction equipment,E0855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.14,,,,,,,fee schedule,100.14,175.66,
Cervical traction equipment,E0855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.66,,,,,,,fee schedule,100.14,175.66,
Cervic collar w air bladders,E0856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.77,,,,,,,fee schedule,30.66,53.79,
Cervic collar w air bladders,E0856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.28,,,,,,,fee schedule,30.66,53.79,
Cervic collar w air bladders,E0856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.66,,,,,,,fee schedule,30.66,53.79,
Cervic collar w air bladders,E0856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.79,,,,,,,fee schedule,30.66,53.79,
Tract equip cervical tract,E0860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.54,,,,,,,fee schedule,67.88,119.07,
Tract equip cervical tract,E0860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.75,,,,,,,fee schedule,67.88,119.07,
Tract equip cervical tract,E0860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.88,,,,,,,fee schedule,67.88,119.07,
Tract equip cervical tract,E0860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.07,,,,,,,fee schedule,67.88,119.07,
Tract frame attach footboard,E0870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,353.54,,,,,,,fee schedule,231.78,406.57,
Tract frame attach footboard,E0870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,289.37,,,,,,,fee schedule,231.78,406.57,
Tract frame attach footboard,E0870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,231.78,,,,,,,fee schedule,231.78,406.57,
Tract frame attach footboard,E0870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,406.57,,,,,,,fee schedule,231.78,406.57,
Trac stand free stand extrem,E0880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,381.58,,,,,,,fee schedule,250.16,438.82,
Trac stand free stand extrem,E0880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312.32,,,,,,,fee schedule,250.16,438.82,
Trac stand free stand extrem,E0880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,250.16,,,,,,,fee schedule,250.16,438.82,
Trac stand free stand extrem,E0880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.82,,,,,,,fee schedule,250.16,438.82,
Traction frame attach pelvic,E0890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,311.03,,,,,,,fee schedule,203.91,357.68,
Traction frame attach pelvic,E0890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.58,,,,,,,fee schedule,203.91,357.68,
Traction frame attach pelvic,E0890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.91,,,,,,,fee schedule,203.91,357.68,
Traction frame attach pelvic,E0890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.68,,,,,,,fee schedule,203.91,357.68,
Trac stand free stand pelvic,E0900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,331.02,,,,,,,fee schedule,217.02,380.67,
Trac stand free stand pelvic,E0900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.94,,,,,,,fee schedule,217.02,380.67,
Trac stand free stand pelvic,E0900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.02,,,,,,,fee schedule,217.02,380.67,
Trac stand free stand pelvic,E0900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.67,,,,,,,fee schedule,217.02,380.67,
Trapeze bar attached to bed,E0910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.68,,,,,,,fee schedule,20.11,35.28,
Trapeze bar attached to bed,E0910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.11,,,,,,,fee schedule,20.11,35.28,
Trapeze bar attached to bed,E0910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.11,,,,,,,fee schedule,20.11,35.28,
Trapeze bar attached to bed,E0910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.28,,,,,,,fee schedule,20.11,35.28,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.54,,,,,,,fee schedule,73.13,128.27,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.3,,,,,,,fee schedule,73.13,128.27,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.13,,,,,,,fee schedule,73.13,128.27,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.27,,,,,,,fee schedule,73.13,128.27,
Hd trapeze bar free standing,E0912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,219.52,,,,,,,fee schedule,143.92,252.45,
Hd trapeze bar free standing,E0912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,179.68,,,,,,,fee schedule,143.92,252.45,
Hd trapeze bar free standing,E0912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.92,,,,,,,fee schedule,143.92,252.45,
Hd trapeze bar free standing,E0912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,252.45,,,,,,,fee schedule,143.92,252.45,
Fracture frame attached to b,E0920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.22,,,,,,,fee schedule,78.16,137.1,
Fracture frame attached to b,E0920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.58,,,,,,,fee schedule,78.16,137.1,
Fracture frame attached to b,E0920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.16,,,,,,,fee schedule,78.16,137.1,
Fracture frame attached to b,E0920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.1,,,,,,,fee schedule,78.16,137.1,
Fracture frame free standing,E0930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.99,,,,,,,fee schedule,77.35,135.69,
Fracture frame free standing,E0930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.57,,,,,,,fee schedule,77.35,135.69,
Fracture frame free standing,E0930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.35,,,,,,,fee schedule,77.35,135.69,
Fracture frame free standing,E0930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.69,,,,,,,fee schedule,77.35,135.69,
Cont pas motion exercise dev,E0935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.14,,,,,,,fee schedule,45.33,79.51,
Cont pas motion exercise dev,E0935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.59,,,,,,,fee schedule,45.33,79.51,
Cont pas motion exercise dev,E0935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.33,,,,,,,fee schedule,45.33,79.51,
Cont pas motion exercise dev,E0935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.51,,,,,,,fee schedule,45.33,79.51,
Trapeze bar free standing,E0940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.09,,,,,,,fee schedule,37.43,65.65,
Trapeze bar free standing,E0940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.73,,,,,,,fee schedule,37.43,65.65,
Trapeze bar free standing,E0940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.43,,,,,,,fee schedule,37.43,65.65,
Trapeze bar free standing,E0940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.65,,,,,,,fee schedule,37.43,65.65,
Gravity assisted traction de,E0941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.13,,,,,,,fee schedule,73.51,128.95,
Gravity assisted traction de,E0941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.78,,,,,,,fee schedule,73.51,128.95,
Gravity assisted traction de,E0941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.51,,,,,,,fee schedule,73.51,128.95,
Gravity assisted traction de,E0941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.95,,,,,,,fee schedule,73.51,128.95,
Cervical head harness/halter,E0942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.31,,,,,,,fee schedule,39.54,69.36,
Cervical head harness/halter,E0942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.36,,,,,,,fee schedule,39.54,69.36,
Cervical head harness/halter,E0942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.54,,,,,,,fee schedule,39.54,69.36,
Cervical head harness/halter,E0942,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.36,,,,,,,fee schedule,39.54,69.36,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,118.48,,,,,,,fee schedule,77.68,136.25,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.98,,,,,,,fee schedule,77.68,136.25,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.68,,,,,,,fee schedule,77.68,136.25,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.25,,,,,,,fee schedule,77.68,136.25,
Belt/harness extremity,E0945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.71,,,,,,,fee schedule,82.42,144.57,
Belt/harness extremity,E0945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.89,,,,,,,fee schedule,82.42,144.57,
Belt/harness extremity,E0945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.42,,,,,,,fee schedule,82.42,144.57,
Belt/harness extremity,E0945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,144.57,,,,,,,fee schedule,82.42,144.57,
Fracture frame dual w cross,E0946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,152.87,,,,,,,fee schedule,100.22,175.8,
Fracture frame dual w cross,E0946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.12,,,,,,,fee schedule,100.22,175.8,
Fracture frame dual w cross,E0946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.22,,,,,,,fee schedule,100.22,175.8,
Fracture frame dual w cross,E0946,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.8,,,,,,,fee schedule,100.22,175.8,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1566.82,,,,,,,fee schedule,1027.21,1801.84,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1282.44,,,,,,,fee schedule,1027.21,1801.84,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1027.21,,,,,,,fee schedule,1027.21,1801.84,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1801.84,,,,,,,fee schedule,1027.21,1801.84,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1515.48,,,,,,,fee schedule,993.55,1742.8,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1240.42,,,,,,,fee schedule,993.55,1742.8,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,993.55,,,,,,,fee schedule,993.55,1742.8,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1742.8,,,,,,,fee schedule,993.55,1742.8,
Tray,E0950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,202.91,,,,,,,fee schedule,133.03,233.35,
Tray,E0950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.08,,,,,,,fee schedule,133.03,233.35,
Tray,E0950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.03,,,,,,,fee schedule,133.03,233.35,
Tray,E0950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.35,,,,,,,fee schedule,133.03,233.35,
Loop heel,E0951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.68,,,,,,,fee schedule,23.39,41.03,
Loop heel,E0951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.2,,,,,,,fee schedule,23.39,41.03,
Loop heel,E0951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.39,,,,,,,fee schedule,23.39,41.03,
Loop heel,E0951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.03,,,,,,,fee schedule,23.39,41.03,
"Toe loop/holder, each",E0952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.97,,,,,,,fee schedule,27.52,48.27,
"Toe loop/holder, each",E0952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.35,,,,,,,fee schedule,27.52,48.27,
"Toe loop/holder, each",E0952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.52,,,,,,,fee schedule,27.52,48.27,
"Toe loop/holder, each",E0952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.27,,,,,,,fee schedule,27.52,48.27,
Cushioned headrest,E0955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.79,,,,,,,fee schedule,25.43,44.61,
Cushioned headrest,E0955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.75,,,,,,,fee schedule,25.43,44.61,
Cushioned headrest,E0955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.43,,,,,,,fee schedule,25.43,44.61,
Cushioned headrest,E0955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.61,,,,,,,fee schedule,25.43,44.61,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,207.34,,,,,,,fee schedule,135.93,238.44,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.71,,,,,,,fee schedule,135.93,238.44,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.93,,,,,,,fee schedule,135.93,238.44,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,238.44,,,,,,,fee schedule,135.93,238.44,
W/c medial thigh support,E0957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,316.15,,,,,,,fee schedule,207.27,363.57,
W/c medial thigh support,E0957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.77,,,,,,,fee schedule,207.27,363.57,
W/c medial thigh support,E0957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,207.27,,,,,,,fee schedule,207.27,363.57,
W/c medial thigh support,E0957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,363.57,,,,,,,fee schedule,207.27,363.57,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.57,,,,,,,fee schedule,72.49,127.16,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.5,,,,,,,fee schedule,72.49,127.16,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.49,,,,,,,fee schedule,72.49,127.16,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.16,,,,,,,fee schedule,72.49,127.16,
Amputee adapter,E0959,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.58,,,,,,,fee schedule,73.15,128.32,
Amputee adapter,E0959,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.33,,,,,,,fee schedule,73.15,128.32,
Amputee adapter,E0959,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.15,,,,,,,fee schedule,73.15,128.32,
Amputee adapter,E0959,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.32,,,,,,,fee schedule,73.15,128.32,
W/c shoulder harness/straps,E0960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.1,,,,,,,fee schedule,129.87,227.82,
W/c shoulder harness/straps,E0960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.14,,,,,,,fee schedule,129.87,227.82,
W/c shoulder harness/straps,E0960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.87,,,,,,,fee schedule,129.87,227.82,
W/c shoulder harness/straps,E0960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227.82,,,,,,,fee schedule,129.87,227.82,
Wheelchair brake extension,E0961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.22,,,,,,,fee schedule,34.89,61.2,
Wheelchair brake extension,E0961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.56,,,,,,,fee schedule,34.89,61.2,
Wheelchair brake extension,E0961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.89,,,,,,,fee schedule,34.89,61.2,
Wheelchair brake extension,E0961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.2,,,,,,,fee schedule,34.89,61.2,
Wheelchair head rest extensi,E0966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.37,,,,,,,fee schedule,125.46,220.08,
Wheelchair head rest extensi,E0966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.64,,,,,,,fee schedule,125.46,220.08,
Wheelchair head rest extensi,E0966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.46,,,,,,,fee schedule,125.46,220.08,
Wheelchair head rest extensi,E0966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.08,,,,,,,fee schedule,125.46,220.08,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.45,,,,,,,fee schedule,126.17,221.32,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.52,,,,,,,fee schedule,126.17,221.32,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.17,,,,,,,fee schedule,126.17,221.32,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.32,,,,,,,fee schedule,126.17,221.32,
Wheelchair commode seat,E0968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.27,,,,,,,fee schedule,35.58,62.41,
Wheelchair commode seat,E0968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.42,,,,,,,fee schedule,35.58,62.41,
Wheelchair commode seat,E0968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.58,,,,,,,fee schedule,35.58,62.41,
Wheelchair commode seat,E0968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.41,,,,,,,fee schedule,35.58,62.41,
Wheelchair narrowing device,E0969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,476.07,,,,,,,fee schedule,312.11,547.48,
Wheelchair narrowing device,E0969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,389.66,,,,,,,fee schedule,312.11,547.48,
Wheelchair narrowing device,E0969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,312.11,,,,,,,fee schedule,312.11,547.48,
Wheelchair narrowing device,E0969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,547.48,,,,,,,fee schedule,312.11,547.48,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.35,,,,,,,fee schedule,52.02,91.25,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.95,,,,,,,fee schedule,52.02,91.25,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.02,,,,,,,fee schedule,52.02,91.25,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.25,,,,,,,fee schedule,52.02,91.25,
W/ch access det adj armrest,E0973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.28,,,,,,,fee schedule,91.97,161.32,
W/ch access det adj armrest,E0973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.82,,,,,,,fee schedule,91.97,161.32,
W/ch access det adj armrest,E0973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.97,,,,,,,fee schedule,91.97,161.32,
W/ch access det adj armrest,E0973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.32,,,,,,,fee schedule,91.97,161.32,
W/ch access anti-rollback,E0974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,197.54,,,,,,,fee schedule,129.51,227.17,
W/ch access anti-rollback,E0974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.69,,,,,,,fee schedule,129.51,227.17,
W/ch access anti-rollback,E0974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.51,,,,,,,fee schedule,129.51,227.17,
W/ch access anti-rollback,E0974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227.17,,,,,,,fee schedule,129.51,227.17,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.79,,,,,,,fee schedule,43.13,75.66,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.85,,,,,,,fee schedule,43.13,75.66,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.13,,,,,,,fee schedule,43.13,75.66,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.66,,,,,,,fee schedule,43.13,75.66,
Wheelchair safety vest,E0980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.14,,,,,,,fee schedule,63.68,111.71,
Wheelchair safety vest,E0980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.51,,,,,,,fee schedule,63.68,111.71,
Wheelchair safety vest,E0980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.68,,,,,,,fee schedule,63.68,111.71,
Wheelchair safety vest,E0980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.71,,,,,,,fee schedule,63.68,111.71,
"Seat upholstery, replacement",E0981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.99,,,,,,,fee schedule,69.49,121.89,
"Seat upholstery, replacement",E0981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.75,,,,,,,fee schedule,69.49,121.89,
"Seat upholstery, replacement",E0981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.49,,,,,,,fee schedule,69.49,121.89,
"Seat upholstery, replacement",E0981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.89,,,,,,,fee schedule,69.49,121.89,
"Back upholstery, replacement",E0982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.7,,,,,,,fee schedule,75.2,131.91,
"Back upholstery, replacement",E0982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.88,,,,,,,fee schedule,75.2,131.91,
"Back upholstery, replacement",E0982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.2,,,,,,,fee schedule,75.2,131.91,
"Back upholstery, replacement",E0982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.91,,,,,,,fee schedule,75.2,131.91,
Add pwr joystick,E0983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,727.97,,,,,,,fee schedule,477.26,837.17,
Add pwr joystick,E0983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,595.84,,,,,,,fee schedule,477.26,837.17,
Add pwr joystick,E0983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,477.26,,,,,,,fee schedule,477.26,837.17,
Add pwr joystick,E0983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,837.17,,,,,,,fee schedule,477.26,837.17,
Add pwr tiller,E0984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.56,,,,,,,fee schedule,323.58,567.59,
Add pwr tiller,E0984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,403.98,,,,,,,fee schedule,323.58,567.59,
Add pwr tiller,E0984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,323.58,,,,,,,fee schedule,323.58,567.59,
Add pwr tiller,E0984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,567.59,,,,,,,fee schedule,323.58,567.59,
W/c seat lift mechanism,E0985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.35,,,,,,,fee schedule,38.91,68.25,
W/c seat lift mechanism,E0985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.58,,,,,,,fee schedule,38.91,68.25,
W/c seat lift mechanism,E0985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.91,,,,,,,fee schedule,38.91,68.25,
W/c seat lift mechanism,E0985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.25,,,,,,,fee schedule,38.91,68.25,
Man w/c push-rim powr system,E0986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1478.48,,,,,,,fee schedule,969.29,1700.25,
Man w/c push-rim powr system,E0986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1210.14,,,,,,,fee schedule,969.29,1700.25,
Man w/c push-rim powr system,E0986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,969.29,,,,,,,fee schedule,969.29,1700.25,
Man w/c push-rim powr system,E0986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1700.25,,,,,,,fee schedule,969.29,1700.25,
Lever-activated wheel drive,E0988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,909.86,,,,,,,fee schedule,596.5,1046.34,
Lever-activated wheel drive,E0988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,744.72,,,,,,,fee schedule,596.5,1046.34,
Lever-activated wheel drive,E0988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,596.5,,,,,,,fee schedule,596.5,1046.34,
Lever-activated wheel drive,E0988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1046.34,,,,,,,fee schedule,596.5,1046.34,
Wheelchair elevating leg res,E0990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,187.37,,,,,,,fee schedule,122.84,215.48,
Wheelchair elevating leg res,E0990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.36,,,,,,,fee schedule,122.84,215.48,
Wheelchair elevating leg res,E0990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.84,,,,,,,fee schedule,122.84,215.48,
Wheelchair elevating leg res,E0990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,215.48,,,,,,,fee schedule,122.84,215.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,216.34,,,,,,,fee schedule,141.83,248.79,
Wheelchair solid seat insert,E0992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.07,,,,,,,fee schedule,141.83,248.79,
Wheelchair solid seat insert,E0992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.83,,,,,,,fee schedule,141.83,248.79,
Wheelchair solid seat insert,E0992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,248.79,,,,,,,fee schedule,141.83,248.79,
Wheelchair arm rest,E0994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.57,,,,,,,fee schedule,35.12,61.61,
Wheelchair arm rest,E0994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.85,,,,,,,fee schedule,35.12,61.61,
Wheelchair arm rest,E0994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.12,,,,,,,fee schedule,35.12,61.61,
Wheelchair arm rest,E0994,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.61,,,,,,,fee schedule,35.12,61.61,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.09,,,,,,,fee schedule,44.64,78.3,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.73,,,,,,,fee schedule,44.64,78.3,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.64,,,,,,,fee schedule,44.64,78.3,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.3,,,,,,,fee schedule,44.64,78.3,
Pwr seat tilt,E1002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.11,,,,,,,fee schedule,619.61,1086.88,
Pwr seat tilt,E1002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,773.57,,,,,,,fee schedule,619.61,1086.88,
Pwr seat tilt,E1002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,619.61,,,,,,,fee schedule,619.61,1086.88,
Pwr seat tilt,E1002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.88,,,,,,,fee schedule,619.61,1086.88,
Pwr seat recline,E1003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1106.21,,,,,,,fee schedule,725.23,1272.14,
Pwr seat recline,E1003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,905.43,,,,,,,fee schedule,725.23,1272.14,
Pwr seat recline,E1003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,725.23,,,,,,,fee schedule,725.23,1272.14,
Pwr seat recline,E1003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1272.14,,,,,,,fee schedule,725.23,1272.14,
Pwr seat recline mech,E1004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1215.9,,,,,,,fee schedule,797.14,1398.29,
Pwr seat recline mech,E1004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,995.21,,,,,,,fee schedule,797.14,1398.29,
Pwr seat recline mech,E1004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,797.14,,,,,,,fee schedule,797.14,1398.29,
Pwr seat recline mech,E1004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1398.29,,,,,,,fee schedule,797.14,1398.29,
Pwr seat recline pwr,E1005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1330.08,,,,,,,fee schedule,872,1529.59,
Pwr seat recline pwr,E1005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1088.67,,,,,,,fee schedule,872,1529.59,
Pwr seat recline pwr,E1005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,872,,,,,,,fee schedule,872,1529.59,
Pwr seat recline pwr,E1005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1529.59,,,,,,,fee schedule,872,1529.59,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1639.97,,,,,,,fee schedule,1075.16,1885.97,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1342.32,,,,,,,fee schedule,1075.16,1885.97,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1075.16,,,,,,,fee schedule,1075.16,1885.97,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1885.97,,,,,,,fee schedule,1075.16,1885.97,
Pwr seat combo w/shear,E1007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2035.71,,,,,,,fee schedule,1334.61,2341.07,
Pwr seat combo w/shear,E1007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1666.23,,,,,,,fee schedule,1334.61,2341.07,
Pwr seat combo w/shear,E1007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1334.61,,,,,,,fee schedule,1334.61,2341.07,
Pwr seat combo w/shear,E1007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2341.07,,,,,,,fee schedule,1334.61,2341.07,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2088.06,,,,,,,fee schedule,1368.93,2401.27,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1709.08,,,,,,,fee schedule,1368.93,2401.27,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1368.93,,,,,,,fee schedule,1368.93,2401.27,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2401.27,,,,,,,fee schedule,1368.93,2401.27,
Add pwr leg elevation,E1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.74,,,,,,,fee schedule,186.02,326.3,
Add pwr leg elevation,E1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.24,,,,,,,fee schedule,186.02,326.3,
Add pwr leg elevation,E1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.02,,,,,,,fee schedule,186.02,326.3,
Add pwr leg elevation,E1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.3,,,,,,,fee schedule,186.02,326.3,
Ctr mount pwr elev leg rest,E1012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.74,,,,,,,fee schedule,186.02,326.3,
Ctr mount pwr elev leg rest,E1012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.24,,,,,,,fee schedule,186.02,326.3,
Ctr mount pwr elev leg rest,E1012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.02,,,,,,,fee schedule,186.02,326.3,
Ctr mount pwr elev leg rest,E1012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.3,,,,,,,fee schedule,186.02,326.3,
Reclining back add ped w/c,E1014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.02,,,,,,,fee schedule,72.78,127.67,
Reclining back add ped w/c,E1014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.87,,,,,,,fee schedule,72.78,127.67,
Reclining back add ped w/c,E1014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.78,,,,,,,fee schedule,72.78,127.67,
Reclining back add ped w/c,E1014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.67,,,,,,,fee schedule,72.78,127.67,
Shock absorber for man w/c,E1015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,331.11,,,,,,,fee schedule,217.08,380.78,
Shock absorber for man w/c,E1015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,271.01,,,,,,,fee schedule,217.08,380.78,
Shock absorber for man w/c,E1015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.08,,,,,,,fee schedule,217.08,380.78,
Shock absorber for man w/c,E1015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.78,,,,,,,fee schedule,217.08,380.78,
Shock absorber for power w/c,E1016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,316.15,,,,,,,fee schedule,207.27,363.57,
Shock absorber for power w/c,E1016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.77,,,,,,,fee schedule,207.27,363.57,
Shock absorber for power w/c,E1016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,207.27,,,,,,,fee schedule,207.27,363.57,
Shock absorber for power w/c,E1016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,363.57,,,,,,,fee schedule,207.27,363.57,
Residual limb support system,E1020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.88,,,,,,,fee schedule,31.39,55.06,
Residual limb support system,E1020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.19,,,,,,,fee schedule,31.39,55.06,
Residual limb support system,E1020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.39,,,,,,,fee schedule,31.39,55.06,
Residual limb support system,E1020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.06,,,,,,,fee schedule,31.39,55.06,
W/c manual swingaway,E1028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.87,,,,,,,fee schedule,22.86,40.1,
W/c manual swingaway,E1028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.54,,,,,,,fee schedule,22.86,40.1,
W/c manual swingaway,E1028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.86,,,,,,,fee schedule,22.86,40.1,
W/c manual swingaway,E1028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.1,,,,,,,fee schedule,22.86,40.1,
W/c vent tray fixed,E1029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.6,,,,,,,fee schedule,62.68,109.94,
W/c vent tray fixed,E1029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.25,,,,,,,fee schedule,62.68,109.94,
W/c vent tray fixed,E1029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.68,,,,,,,fee schedule,62.68,109.94,
W/c vent tray fixed,E1029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.94,,,,,,,fee schedule,62.68,109.94,
W/c vent tray gimbaled,E1030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,298.62,,,,,,,fee schedule,195.78,343.41,
W/c vent tray gimbaled,E1030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,244.42,,,,,,,fee schedule,195.78,343.41,
W/c vent tray gimbaled,E1030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.78,,,,,,,fee schedule,195.78,343.41,
W/c vent tray gimbaled,E1030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,343.41,,,,,,,fee schedule,195.78,343.41,
Rollabout chair with casters,E1031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.61,,,,,,,fee schedule,75.14,131.8,
Rollabout chair with casters,E1031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.81,,,,,,,fee schedule,75.14,131.8,
Rollabout chair with casters,E1031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.14,,,,,,,fee schedule,75.14,131.8,
Rollabout chair with casters,E1031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.8,,,,,,,fee schedule,75.14,131.8,
Patient transfer system <300,E1035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1560.38,,,,,,,fee schedule,1022.99,1794.44,
Patient transfer system <300,E1035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1277.17,,,,,,,fee schedule,1022.99,1794.44,
Patient transfer system <300,E1035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1022.99,,,,,,,fee schedule,1022.99,1794.44,
Patient transfer system <300,E1035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1794.44,,,,,,,fee schedule,1022.99,1794.44,
Patient transfer system >300,E1036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2293.29,,,,,,,fee schedule,1503.48,2637.28,
Patient transfer system >300,E1036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1877.06,,,,,,,fee schedule,1503.48,2637.28,
Patient transfer system >300,E1036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1503.48,,,,,,,fee schedule,1503.48,2637.28,
Patient transfer system >300,E1036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2637.28,,,,,,,fee schedule,1503.48,2637.28,
"Transport chair, ped size",E1037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,294.56,,,,,,,fee schedule,193.11,338.74,
"Transport chair, ped size",E1037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.1,,,,,,,fee schedule,193.11,338.74,
"Transport chair, ped size",E1037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.11,,,,,,,fee schedule,193.11,338.74,
"Transport chair, ped size",E1037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,338.74,,,,,,,fee schedule,193.11,338.74,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.14,,,,,,,fee schedule,25,43.86,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.22,,,,,,,fee schedule,25,43.86,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25,,,,,,,fee schedule,25,43.86,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.86,,,,,,,fee schedule,25,43.86,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.7,,,,,,,fee schedule,57.5,100.86,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.78,,,,,,,fee schedule,57.5,100.86,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.5,,,,,,,fee schedule,57.5,100.86,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.86,,,,,,,fee schedule,57.5,100.86,
Whelchr fxd full length arms,E1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,309.53,,,,,,,fee schedule,202.93,355.96,
Whelchr fxd full length arms,E1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,253.35,,,,,,,fee schedule,202.93,355.96,
Whelchr fxd full length arms,E1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.93,,,,,,,fee schedule,202.93,355.96,
Whelchr fxd full length arms,E1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,355.96,,,,,,,fee schedule,202.93,355.96,
Wheelchair detachable arms,E1060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,383.17,,,,,,,fee schedule,251.21,440.65,
Wheelchair detachable arms,E1060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,313.62,,,,,,,fee schedule,251.21,440.65,
Wheelchair detachable arms,E1060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.21,,,,,,,fee schedule,251.21,440.65,
Wheelchair detachable arms,E1060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,440.65,,,,,,,fee schedule,251.21,440.65,
Wheelchair detachable foot r,E1070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.93,,,,,,,fee schedule,218.27,382.87,
Wheelchair detachable foot r,E1070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.5,,,,,,,fee schedule,218.27,382.87,
Wheelchair detachable foot r,E1070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.27,,,,,,,fee schedule,218.27,382.87,
Wheelchair detachable foot r,E1070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,382.87,,,,,,,fee schedule,218.27,382.87,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,239.33,,,,,,,fee schedule,156.9,275.23,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.89,,,,,,,fee schedule,156.9,275.23,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.9,,,,,,,fee schedule,156.9,275.23,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,275.23,,,,,,,fee schedule,156.9,275.23,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,259.2,,,,,,,fee schedule,169.93,298.08,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,212.16,,,,,,,fee schedule,169.93,298.08,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.93,,,,,,,fee schedule,169.93,298.08,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,298.08,,,,,,,fee schedule,169.93,298.08,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.58,,,,,,,fee schedule,252.13,442.27,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.78,,,,,,,fee schedule,252.13,442.27,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,252.13,,,,,,,fee schedule,252.13,442.27,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,442.27,,,,,,,fee schedule,252.13,442.27,
Wheelchair lightweight det a,E1088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,389.51,,,,,,,fee schedule,255.36,447.94,
Wheelchair lightweight det a,E1088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,318.81,,,,,,,fee schedule,255.36,447.94,
Wheelchair lightweight det a,E1088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255.36,,,,,,,fee schedule,255.36,447.94,
Wheelchair lightweight det a,E1088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,447.94,,,,,,,fee schedule,255.36,447.94,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.01,,,,,,,fee schedule,217.67,381.81,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,271.75,,,,,,,fee schedule,217.67,381.81,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.67,,,,,,,fee schedule,217.67,381.81,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,381.81,,,,,,,fee schedule,217.67,381.81,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,286.3,,,,,,,fee schedule,187.7,329.25,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.34,,,,,,,fee schedule,187.7,329.25,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,187.7,,,,,,,fee schedule,187.7,329.25,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,329.25,,,,,,,fee schedule,187.7,329.25,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.47,,,,,,,fee schedule,206.82,362.79,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.21,,,,,,,fee schedule,206.82,362.79,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.82,,,,,,,fee schedule,206.82,362.79,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,362.79,,,,,,,fee schedule,206.82,362.79,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,308.97,,,,,,,fee schedule,202.56,355.32,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,252.89,,,,,,,fee schedule,202.56,355.32,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.56,,,,,,,fee schedule,202.56,355.32,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,355.32,,,,,,,fee schedule,202.56,355.32,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,247.92,,,,,,,fee schedule,162.54,285.11,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.92,,,,,,,fee schedule,162.54,285.11,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,162.54,,,,,,,fee schedule,162.54,285.11,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,285.11,,,,,,,fee schedule,162.54,285.11,
Wheelchair fixed arms,E1160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.06,,,,,,,fee schedule,123.29,216.27,
Wheelchair fixed arms,E1160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.93,,,,,,,fee schedule,123.29,216.27,
Wheelchair fixed arms,E1160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.29,,,,,,,fee schedule,123.29,216.27,
Wheelchair fixed arms,E1160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.27,,,,,,,fee schedule,123.29,216.27,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,719.14,,,,,,,fee schedule,471.47,827.01,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,588.62,,,,,,,fee schedule,471.47,827.01,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,471.47,,,,,,,fee schedule,471.47,827.01,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,827.01,,,,,,,fee schedule,471.47,827.01,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.5,,,,,,,fee schedule,178,312.23,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.22,,,,,,,fee schedule,178,312.23,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,178,,,,,,,fee schedule,178,312.23,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.23,,,,,,,fee schedule,178,312.23,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,243.62,,,,,,,fee schedule,159.72,280.16,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.4,,,,,,,fee schedule,159.72,280.16,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.72,,,,,,,fee schedule,159.72,280.16,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,280.16,,,,,,,fee schedule,159.72,280.16,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,297.76,,,,,,,fee schedule,195.21,342.42,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,243.72,,,,,,,fee schedule,195.21,342.42,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.21,,,,,,,fee schedule,195.21,342.42,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,342.42,,,,,,,fee schedule,195.21,342.42,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,307.98,,,,,,,fee schedule,201.91,354.18,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,252.08,,,,,,,fee schedule,201.91,354.18,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.91,,,,,,,fee schedule,201.91,354.18,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,354.18,,,,,,,fee schedule,201.91,354.18,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,355.86,,,,,,,fee schedule,233.3,409.24,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,291.27,,,,,,,fee schedule,233.3,409.24,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.3,,,,,,,fee schedule,233.3,409.24,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,409.24,,,,,,,fee schedule,233.3,409.24,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,324.54,,,,,,,fee schedule,212.77,373.22,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,265.64,,,,,,,fee schedule,212.77,373.22,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,212.77,,,,,,,fee schedule,212.77,373.22,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,373.22,,,,,,,fee schedule,212.77,373.22,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,264.44,,,,,,,fee schedule,173.37,304.11,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,216.44,,,,,,,fee schedule,173.37,304.11,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.37,,,,,,,fee schedule,173.37,304.11,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,304.11,,,,,,,fee schedule,173.37,304.11,
Wheelchair spec size w foot,E1221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.56,,,,,,,fee schedule,84.94,148.99,
Wheelchair spec size w foot,E1221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.04,,,,,,,fee schedule,84.94,148.99,
Wheelchair spec size w foot,E1221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.94,,,,,,,fee schedule,84.94,148.99,
Wheelchair spec size w foot,E1221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.99,,,,,,,fee schedule,84.94,148.99,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,206.01,,,,,,,fee schedule,135.06,236.91,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,168.62,,,,,,,fee schedule,135.06,236.91,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.06,,,,,,,fee schedule,135.06,236.91,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,236.91,,,,,,,fee schedule,135.06,236.91,
Wheelchair spec size w foot,E1223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.19,,,,,,,fee schedule,125.34,219.87,
Wheelchair spec size w foot,E1223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.49,,,,,,,fee schedule,125.34,219.87,
Wheelchair spec size w foot,E1223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.34,,,,,,,fee schedule,125.34,219.87,
Wheelchair spec size w foot,E1223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,219.87,,,,,,,fee schedule,125.34,219.87,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,215.61,,,,,,,fee schedule,141.35,247.95,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,176.48,,,,,,,fee schedule,141.35,247.95,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.35,,,,,,,fee schedule,141.35,247.95,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,247.95,,,,,,,fee schedule,141.35,247.95,
Manual semi-reclining back,E1225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.36,,,,,,,fee schedule,69.07,121.16,
Manual semi-reclining back,E1225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.24,,,,,,,fee schedule,69.07,121.16,
Manual semi-reclining back,E1225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.07,,,,,,,fee schedule,69.07,121.16,
Manual semi-reclining back,E1225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.16,,,,,,,fee schedule,69.07,121.16,
Manual fully reclining back,E1226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,984.42,,,,,,,fee schedule,645.39,1132.08,
Manual fully reclining back,E1226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,805.75,,,,,,,fee schedule,645.39,1132.08,
Manual fully reclining back,E1226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,645.39,,,,,,,fee schedule,645.39,1132.08,
Manual fully reclining back,E1226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1132.08,,,,,,,fee schedule,645.39,1132.08,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,843.44,,,,,,,fee schedule,552.96,969.96,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,690.36,,,,,,,fee schedule,552.96,969.96,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,552.96,,,,,,,fee schedule,552.96,969.96,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,969.96,,,,,,,fee schedule,552.96,969.96,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.18,,,,,,,fee schedule,55.84,97.96,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.72,,,,,,,fee schedule,55.84,97.96,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.84,,,,,,,fee schedule,55.84,97.96,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.96,,,,,,,fee schedule,55.84,97.96,
Power operated vehicle,E1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5843.41,,,,,,,fee schedule,3830.94,6719.92,
Power operated vehicle,E1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4782.83,,,,,,,fee schedule,3830.94,6719.92,
Power operated vehicle,E1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3830.94,,,,,,,fee schedule,3830.94,6719.92,
Power operated vehicle,E1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6719.92,,,,,,,fee schedule,3830.94,6719.92,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,650,,,,,,,fee schedule,426.14,747.5,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,532.03,,,,,,,fee schedule,426.14,747.5,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,426.14,,,,,,,fee schedule,426.14,747.5,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,747.5,,,,,,,fee schedule,426.14,747.5,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,673.43,,,,,,,fee schedule,441.5,774.44,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,551.2,,,,,,,fee schedule,441.5,774.44,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,441.5,,,,,,,fee schedule,441.5,774.44,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,774.44,,,,,,,fee schedule,441.5,774.44,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,586.32,,,,,,,fee schedule,384.39,674.27,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,479.9,,,,,,,fee schedule,384.39,674.27,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,384.39,,,,,,,fee schedule,384.39,674.27,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,674.27,,,,,,,fee schedule,384.39,674.27,
Rigid ped wc adjustable,E1235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,564.6,,,,,,,fee schedule,370.15,649.29,
Rigid ped wc adjustable,E1235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,462.13,,,,,,,fee schedule,370.15,649.29,
Rigid ped wc adjustable,E1235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,370.15,,,,,,,fee schedule,370.15,649.29,
Rigid ped wc adjustable,E1235,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,649.29,,,,,,,fee schedule,370.15,649.29,
Folding ped wc adjustable,E1236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.08,,,,,,,fee schedule,326.54,572.79,
Folding ped wc adjustable,E1236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,407.68,,,,,,,fee schedule,326.54,572.79,
Folding ped wc adjustable,E1236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.54,,,,,,,fee schedule,326.54,572.79,
Folding ped wc adjustable,E1236,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,572.79,,,,,,,fee schedule,326.54,572.79,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,502.44,,,,,,,fee schedule,329.4,577.81,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,411.25,,,,,,,fee schedule,329.4,577.81,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,329.4,,,,,,,fee schedule,329.4,577.81,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,577.81,,,,,,,fee schedule,329.4,577.81,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,498.08,,,,,,,fee schedule,326.54,572.79,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,407.68,,,,,,,fee schedule,326.54,572.79,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.54,,,,,,,fee schedule,326.54,572.79,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,572.79,,,,,,,fee schedule,326.54,572.79,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,286.95,,,,,,,fee schedule,188.12,329.99,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.87,,,,,,,fee schedule,188.12,329.99,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,188.12,,,,,,,fee schedule,188.12,329.99,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,329.99,,,,,,,fee schedule,188.12,329.99,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.94,,,,,,,fee schedule,133.7,234.53,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.92,,,,,,,fee schedule,133.7,234.53,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.7,,,,,,,fee schedule,133.7,234.53,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,234.53,,,,,,,fee schedule,133.7,234.53,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,372.04,,,,,,,fee schedule,243.91,427.85,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,304.51,,,,,,,fee schedule,243.91,427.85,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,243.91,,,,,,,fee schedule,243.91,427.85,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,427.85,,,,,,,fee schedule,243.91,427.85,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,369.17,,,,,,,fee schedule,242.03,424.55,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,302.17,,,,,,,fee schedule,242.03,424.55,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,242.03,,,,,,,fee schedule,242.03,424.55,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,424.55,,,,,,,fee schedule,242.03,424.55,
Wheelchair special seat heig,E1296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1270.19,,,,,,,fee schedule,832.74,1460.72,
Wheelchair special seat heig,E1296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1039.65,,,,,,,fee schedule,832.74,1460.72,
Wheelchair special seat heig,E1296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,832.74,,,,,,,fee schedule,832.74,1460.72,
Wheelchair special seat heig,E1296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1460.72,,,,,,,fee schedule,832.74,1460.72,
Wheelchair special seat dept,E1297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,317.96,,,,,,,fee schedule,208.45,365.65,
Wheelchair special seat dept,E1297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,260.25,,,,,,,fee schedule,208.45,365.65,
Wheelchair special seat dept,E1297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,208.45,,,,,,,fee schedule,208.45,365.65,
Wheelchair special seat dept,E1297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,365.65,,,,,,,fee schedule,208.45,365.65,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1094.52,,,,,,,fee schedule,717.57,1258.7,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,895.86,,,,,,,fee schedule,717.57,1258.7,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,717.57,,,,,,,fee schedule,717.57,1258.7,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1258.7,,,,,,,fee schedule,717.57,1258.7,
Whirlpool non-portable,E1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5547.87,,,,,,,fee schedule,3637.18,6380.05,
Whirlpool non-portable,E1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4540.93,,,,,,,fee schedule,3637.18,6380.05,
Whirlpool non-portable,E1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3637.18,,,,,,,fee schedule,3637.18,6380.05,
Whirlpool non-portable,E1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6380.05,,,,,,,fee schedule,3637.18,6380.05,
Oxygen supplies regulator,E1353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.09,,,,,,,fee schedule,56.44,99,
Oxygen supplies regulator,E1353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.46,,,,,,,fee schedule,56.44,99,
Oxygen supplies regulator,E1353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.44,,,,,,,fee schedule,56.44,99,
Oxygen supplies regulator,E1353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99,,,,,,,fee schedule,56.44,99,
Oxygen supplies stand/rack,E1355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.86,,,,,,,fee schedule,42.52,74.59,
Oxygen supplies stand/rack,E1355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.09,,,,,,,fee schedule,42.52,74.59,
Oxygen supplies stand/rack,E1355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.52,,,,,,,fee schedule,42.52,74.59,
Oxygen supplies stand/rack,E1355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.59,,,,,,,fee schedule,42.52,74.59,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.61,,,,,,,fee schedule,235.76,413.55,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.34,,,,,,,fee schedule,235.76,413.55,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.76,,,,,,,fee schedule,235.76,413.55,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.55,,,,,,,fee schedule,235.76,413.55,
Oxygen concentrator,E1390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.72,,,,,,,fee schedule,126.35,221.63,
Oxygen concentrator,E1390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.74,,,,,,,fee schedule,126.35,221.63,
Oxygen concentrator,E1390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.35,,,,,,,fee schedule,126.35,221.63,
Oxygen concentrator,E1390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.63,,,,,,,fee schedule,126.35,221.63,
"Oxygen concentrator, dual",E1391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.72,,,,,,,fee schedule,126.35,221.63,
"Oxygen concentrator, dual",E1391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.74,,,,,,,fee schedule,126.35,221.63,
"Oxygen concentrator, dual",E1391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.35,,,,,,,fee schedule,126.35,221.63,
"Oxygen concentrator, dual",E1391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.63,,,,,,,fee schedule,126.35,221.63,
Portable oxygen concentrator,E1392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.67,,,,,,,fee schedule,64.69,113.47,
Portable oxygen concentrator,E1392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.76,,,,,,,fee schedule,64.69,113.47,
Portable oxygen concentrator,E1392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.69,,,,,,,fee schedule,64.69,113.47,
Portable oxygen concentrator,E1392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.47,,,,,,,fee schedule,64.69,113.47,
O2/water vapor enrich w/heat,E1405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,274.79,,,,,,,fee schedule,180.15,316.01,
O2/water vapor enrich w/heat,E1405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.92,,,,,,,fee schedule,180.15,316.01,
O2/water vapor enrich w/heat,E1405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,180.15,,,,,,,fee schedule,180.15,316.01,
O2/water vapor enrich w/heat,E1405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,316.01,,,,,,,fee schedule,180.15,316.01,
O2/water vapor enrich w/o he,E1406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,209.16,,,,,,,fee schedule,137.13,240.53,
O2/water vapor enrich w/o he,E1406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.2,,,,,,,fee schedule,137.13,240.53,
O2/water vapor enrich w/o he,E1406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.13,,,,,,,fee schedule,137.13,240.53,
O2/water vapor enrich w/o he,E1406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,240.53,,,,,,,fee schedule,137.13,240.53,
Jaw motion rehab system,E1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.12,,,,,,,fee schedule,58.43,102.49,
Jaw motion rehab system,E1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.94,,,,,,,fee schedule,58.43,102.49,
Jaw motion rehab system,E1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.43,,,,,,,fee schedule,58.43,102.49,
Jaw motion rehab system,E1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.49,,,,,,,fee schedule,58.43,102.49,
Repl cushions for jaw motion,E1701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.39,,,,,,,fee schedule,17.96,31.5,
Repl cushions for jaw motion,E1701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.42,,,,,,,fee schedule,17.96,31.5,
Repl cushions for jaw motion,E1701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.96,,,,,,,fee schedule,17.96,31.5,
Repl cushions for jaw motion,E1701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.5,,,,,,,fee schedule,17.96,31.5,
Repl measr scales jaw motion,E1702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.28,,,,,,,fee schedule,38.21,67.02,
Repl measr scales jaw motion,E1702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.7,,,,,,,fee schedule,38.21,67.02,
Repl measr scales jaw motion,E1702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.21,,,,,,,fee schedule,38.21,67.02,
Repl measr scales jaw motion,E1702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.02,,,,,,,fee schedule,38.21,67.02,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,372.33,,,,,,,fee schedule,244.1,428.18,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,304.75,,,,,,,fee schedule,244.1,428.18,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,244.1,,,,,,,fee schedule,244.1,428.18,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,428.18,,,,,,,fee schedule,244.1,428.18,
Sps elbow device,E1801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,374.99,,,,,,,fee schedule,245.84,431.24,
Sps elbow device,E1801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,306.93,,,,,,,fee schedule,245.84,431.24,
Sps elbow device,E1801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,245.84,,,,,,,fee schedule,245.84,431.24,
Sps elbow device,E1801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.24,,,,,,,fee schedule,245.84,431.24,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,993.33,,,,,,,fee schedule,651.23,1142.33,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,813.04,,,,,,,fee schedule,651.23,1142.33,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,651.23,,,,,,,fee schedule,651.23,1142.33,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1142.33,,,,,,,fee schedule,651.23,1142.33,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.01,,,,,,,fee schedule,251.76,441.61,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.31,,,,,,,fee schedule,251.76,441.61,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.76,,,,,,,fee schedule,251.76,441.61,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,441.61,,,,,,,fee schedule,251.76,441.61,
Sps wrist device,E1806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,307.77,,,,,,,fee schedule,201.77,353.94,
Sps wrist device,E1806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.91,,,,,,,fee schedule,201.77,353.94,
Sps wrist device,E1806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.77,,,,,,,fee schedule,201.77,353.94,
Sps wrist device,E1806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,353.94,,,,,,,fee schedule,201.77,353.94,
Adjust knee ext/flex device,E1810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,378.64,,,,,,,fee schedule,248.24,435.44,
Adjust knee ext/flex device,E1810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,309.92,,,,,,,fee schedule,248.24,435.44,
Adjust knee ext/flex device,E1810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,248.24,,,,,,,fee schedule,248.24,435.44,
Adjust knee ext/flex device,E1810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,435.44,,,,,,,fee schedule,248.24,435.44,
Sps knee device,E1811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,389.86,,,,,,,fee schedule,255.59,448.34,
Sps knee device,E1811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,319.1,,,,,,,fee schedule,255.59,448.34,
Sps knee device,E1811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255.59,,,,,,,fee schedule,255.59,448.34,
Sps knee device,E1811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,448.34,,,,,,,fee schedule,255.59,448.34,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.35,,,,,,,fee schedule,171.34,300.55,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.91,,,,,,,fee schedule,171.34,300.55,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.34,,,,,,,fee schedule,171.34,300.55,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.55,,,,,,,fee schedule,171.34,300.55,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.01,,,,,,,fee schedule,251.76,441.61,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.31,,,,,,,fee schedule,251.76,441.61,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.76,,,,,,,fee schedule,251.76,441.61,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,441.61,,,,,,,fee schedule,251.76,441.61,
Sps ankle device,E1816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,395.99,,,,,,,fee schedule,259.61,455.39,
Sps ankle device,E1816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,324.12,,,,,,,fee schedule,259.61,455.39,
Sps ankle device,E1816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,259.61,,,,,,,fee schedule,259.61,455.39,
Sps ankle device,E1816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.39,,,,,,,fee schedule,259.61,455.39,
Sps forearm device,E1818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,404.29,,,,,,,fee schedule,265.05,464.93,
Sps forearm device,E1818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,330.91,,,,,,,fee schedule,265.05,464.93,
Sps forearm device,E1818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,265.05,,,,,,,fee schedule,265.05,464.93,
Sps forearm device,E1818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,464.93,,,,,,,fee schedule,265.05,464.93,
Soft interface material,E1820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,243.75,,,,,,,fee schedule,159.8,280.31,
Soft interface material,E1820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.51,,,,,,,fee schedule,159.8,280.31,
Soft interface material,E1820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.8,,,,,,,fee schedule,159.8,280.31,
Soft interface material,E1820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,280.31,,,,,,,fee schedule,159.8,280.31,
Replacement interface spsd,E1821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,319.86,,,,,,,fee schedule,209.7,367.84,
Replacement interface spsd,E1821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.81,,,,,,,fee schedule,209.7,367.84,
Replacement interface spsd,E1821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,209.7,,,,,,,fee schedule,209.7,367.84,
Replacement interface spsd,E1821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,367.84,,,,,,,fee schedule,209.7,367.84,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.01,,,,,,,fee schedule,251.76,441.61,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.31,,,,,,,fee schedule,251.76,441.61,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.76,,,,,,,fee schedule,251.76,441.61,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,441.61,,,,,,,fee schedule,251.76,441.61,
Adjust toe ext/flex device,E1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,384.01,,,,,,,fee schedule,251.76,441.61,
Adjust toe ext/flex device,E1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.31,,,,,,,fee schedule,251.76,441.61,
Adjust toe ext/flex device,E1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.76,,,,,,,fee schedule,251.76,441.61,
Adjust toe ext/flex device,E1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,441.61,,,,,,,fee schedule,251.76,441.61,
Static str toe dev ext/flex,E1831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,200.82,,,,,,,fee schedule,131.66,230.94,
Static str toe dev ext/flex,E1831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.37,,,,,,,fee schedule,131.66,230.94,
Static str toe dev ext/flex,E1831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.66,,,,,,,fee schedule,131.66,230.94,
Static str toe dev ext/flex,E1831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,230.94,,,,,,,fee schedule,131.66,230.94,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.92,,,,,,,fee schedule,723.73,1269.51,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,903.56,,,,,,,fee schedule,723.73,1269.51,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,723.73,,,,,,,fee schedule,723.73,1269.51,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1269.51,,,,,,,fee schedule,723.73,1269.51,
Static str shldr dev rom adj,E1841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1376.82,,,,,,,fee schedule,902.64,1583.34,
Static str shldr dev rom adj,E1841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1126.93,,,,,,,fee schedule,902.64,1583.34,
Static str shldr dev rom adj,E1841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,902.64,,,,,,,fee schedule,902.64,1583.34,
Static str shldr dev rom adj,E1841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1583.34,,,,,,,fee schedule,902.64,1583.34,
Vr cbt therapy,E1905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,708.51,,,,,,,fee schedule,674.77,1214.59,APC
Vr cbt therapy,E1905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,674.77,,,,,,,fee schedule,674.77,1214.59,APC
Vr cbt therapy,E1905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1214.59,,,,,,,fee schedule,674.77,1214.59,APC
Gastric suction pump hme mdl,E2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.63,,,,,,,fee schedule,98.75,173.22,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.29,,,,,,,fee schedule,98.75,173.22,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.75,,,,,,,fee schedule,98.75,173.22,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.22,,,,,,,fee schedule,98.75,173.22,
Bld glucose monitor w voice,E2100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.17,,,,,,,fee schedule,108.29,189.95,
Bld glucose monitor w voice,E2100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.19,,,,,,,fee schedule,108.29,189.95,
Bld glucose monitor w voice,E2100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.29,,,,,,,fee schedule,108.29,189.95,
Bld glucose monitor w voice,E2100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.95,,,,,,,fee schedule,108.29,189.95,
Bld glucose monitor w lance,E2101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,573.11,,,,,,,fee schedule,375.73,659.08,
Bld glucose monitor w lance,E2101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,469.09,,,,,,,fee schedule,375.73,659.08,
Bld glucose monitor w lance,E2101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,375.73,,,,,,,fee schedule,375.73,659.08,
Bld glucose monitor w lance,E2101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,659.08,,,,,,,fee schedule,375.73,659.08,
Glucose monitor w cartridge,E2104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.25,,,,,,,fee schedule,54.52,98.14,APC
Glucose monitor w cartridge,E2104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.52,,,,,,,fee schedule,54.52,98.14,APC
Glucose monitor w cartridge,E2104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,98.14,,,,,,,fee schedule,54.52,98.14,APC
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,861.74,,,,,,,fee schedule,564.96,991,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,705.33,,,,,,,fee schedule,564.96,991,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,564.96,,,,,,,fee schedule,564.96,991,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,991,,,,,,,fee schedule,564.96,991,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,809.87,,,,,,,fee schedule,530.95,931.35,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,662.88,,,,,,,fee schedule,530.95,931.35,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,530.95,,,,,,,fee schedule,530.95,931.35,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,931.35,,,,,,,fee schedule,530.95,931.35,
Seat width 24-27 in,E2202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1200.08,,,,,,,fee schedule,786.77,1380.09,
Seat width 24-27 in,E2202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,982.27,,,,,,,fee schedule,786.77,1380.09,
Seat width 24-27 in,E2202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,786.77,,,,,,,fee schedule,786.77,1380.09,
Seat width 24-27 in,E2202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1380.09,,,,,,,fee schedule,786.77,1380.09,
Frame depth less than 22 in,E2203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1121.57,,,,,,,fee schedule,735.3,1289.81,
Frame depth less than 22 in,E2203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,918.01,,,,,,,fee schedule,735.3,1289.81,
Frame depth less than 22 in,E2203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,735.3,,,,,,,fee schedule,735.3,1289.81,
Frame depth less than 22 in,E2203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1289.81,,,,,,,fee schedule,735.3,1289.81,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2001.51,,,,,,,fee schedule,1312.19,2301.74,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1638.24,,,,,,,fee schedule,1312.19,2301.74,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1312.19,,,,,,,fee schedule,1312.19,2301.74,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2301.74,,,,,,,fee schedule,1312.19,2301.74,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,93.12,,,,,,,fee schedule,61.05,107.09,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.22,,,,,,,fee schedule,61.05,107.09,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.05,,,,,,,fee schedule,61.05,107.09,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,107.09,,,,,,,fee schedule,61.05,107.09,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.12,,,,,,,fee schedule,66.29,116.29,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.77,,,,,,,fee schedule,66.29,116.29,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.29,,,,,,,fee schedule,66.29,116.29,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.29,,,,,,,fee schedule,66.29,116.29,
Crutch and cane holder,E2207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.16,,,,,,,fee schedule,80.74,141.63,
Crutch and cane holder,E2207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.81,,,,,,,fee schedule,80.74,141.63,
Crutch and cane holder,E2207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.74,,,,,,,fee schedule,80.74,141.63,
Crutch and cane holder,E2207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.63,,,,,,,fee schedule,80.74,141.63,
Cylinder tank carrier,E2208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,205.23,,,,,,,fee schedule,134.55,236.01,
Cylinder tank carrier,E2208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.98,,,,,,,fee schedule,134.55,236.01,
Cylinder tank carrier,E2208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.55,,,,,,,fee schedule,134.55,236.01,
Cylinder tank carrier,E2208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,236.01,,,,,,,fee schedule,134.55,236.01,
Arm trough each,E2209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.11,,,,,,,fee schedule,148.24,260.03,
Arm trough each,E2209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.07,,,,,,,fee schedule,148.24,260.03,
Arm trough each,E2209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.24,,,,,,,fee schedule,148.24,260.03,
Arm trough each,E2209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.03,,,,,,,fee schedule,148.24,260.03,
Wheelchair bearings,E2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.19,,,,,,,fee schedule,9.96,17.47,
Wheelchair bearings,E2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.43,,,,,,,fee schedule,9.96,17.47,
Wheelchair bearings,E2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.96,,,,,,,fee schedule,9.96,17.47,
Wheelchair bearings,E2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.47,,,,,,,fee schedule,9.96,17.47,
Pneumatic propulsion tire,E2211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.42,,,,,,,fee schedule,57.97,101.68,
Pneumatic propulsion tire,E2211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.37,,,,,,,fee schedule,57.97,101.68,
Pneumatic propulsion tire,E2211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.97,,,,,,,fee schedule,57.97,101.68,
Pneumatic propulsion tire,E2211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.68,,,,,,,fee schedule,57.97,101.68,
Pneumatic prop tire tube,E2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.04,,,,,,,fee schedule,11.17,19.6,
Pneumatic prop tire tube,E2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.95,,,,,,,fee schedule,11.17,19.6,
Pneumatic prop tire tube,E2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.17,,,,,,,fee schedule,11.17,19.6,
Pneumatic prop tire tube,E2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.6,,,,,,,fee schedule,11.17,19.6,
Pneumatic prop tire insert,E2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.24,,,,,,,fee schedule,51.95,91.13,
Pneumatic prop tire insert,E2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.86,,,,,,,fee schedule,51.95,91.13,
Pneumatic prop tire insert,E2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.95,,,,,,,fee schedule,51.95,91.13,
Pneumatic prop tire insert,E2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.13,,,,,,,fee schedule,51.95,91.13,
Pneumatic caster tire each,E2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.84,,,,,,,fee schedule,56.93,99.87,
Pneumatic caster tire each,E2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.08,,,,,,,fee schedule,56.93,99.87,
Pneumatic caster tire each,E2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.93,,,,,,,fee schedule,56.93,99.87,
Pneumatic caster tire each,E2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.87,,,,,,,fee schedule,56.93,99.87,
Pneumatic caster tire tube,E2215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.37,,,,,,,fee schedule,17.94,31.48,
Pneumatic caster tire tube,E2215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.4,,,,,,,fee schedule,17.94,31.48,
Pneumatic caster tire tube,E2215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.94,,,,,,,fee schedule,17.94,31.48,
Pneumatic caster tire tube,E2215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.48,,,,,,,fee schedule,17.94,31.48,
Foam caster tire any size ea,E2219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.29,,,,,,,fee schedule,73.62,129.13,
Foam caster tire any size ea,E2219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.91,,,,,,,fee schedule,73.62,129.13,
Foam caster tire any size ea,E2219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.62,,,,,,,fee schedule,73.62,129.13,
Foam caster tire any size ea,E2219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.13,,,,,,,fee schedule,73.62,129.13,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.55,,,,,,,fee schedule,48.22,84.58,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.2,,,,,,,fee schedule,48.22,84.58,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.22,,,,,,,fee schedule,48.22,84.58,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.58,,,,,,,fee schedule,48.22,84.58,
"Solid caster tire repl, each",E2221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.38,,,,,,,fee schedule,47.45,83.24,
"Solid caster tire repl, each",E2221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.24,,,,,,,fee schedule,47.45,83.24,
"Solid caster tire repl, each",E2221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.45,,,,,,,fee schedule,47.45,83.24,
"Solid caster tire repl, each",E2221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.24,,,,,,,fee schedule,47.45,83.24,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.86,,,,,,,fee schedule,39.24,68.84,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49,,,,,,,fee schedule,39.24,68.84,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.24,,,,,,,fee schedule,39.24,68.84,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.84,,,,,,,fee schedule,39.24,68.84,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,239.51,,,,,,,fee schedule,157.02,275.44,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,196.04,,,,,,,fee schedule,157.02,275.44,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,157.02,,,,,,,fee schedule,157.02,275.44,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,275.44,,,,,,,fee schedule,157.02,275.44,
Caster wheel excludes tire,E2225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.15,,,,,,,fee schedule,32.88,57.67,
Caster wheel excludes tire,E2225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.05,,,,,,,fee schedule,32.88,57.67,
Caster wheel excludes tire,E2225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.88,,,,,,,fee schedule,32.88,57.67,
Caster wheel excludes tire,E2225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.67,,,,,,,fee schedule,32.88,57.67,
Caster fork replacement only,E2226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.9,,,,,,,fee schedule,70.08,122.94,
Caster fork replacement only,E2226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.5,,,,,,,fee schedule,70.08,122.94,
Caster fork replacement only,E2226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.08,,,,,,,fee schedule,70.08,122.94,
Caster fork replacement only,E2226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.94,,,,,,,fee schedule,70.08,122.94,
Gear reduction drive wheel,E2227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,568.62,,,,,,,fee schedule,372.79,653.91,
Gear reduction drive wheel,E2227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,465.42,,,,,,,fee schedule,372.79,653.91,
Gear reduction drive wheel,E2227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,372.79,,,,,,,fee schedule,372.79,653.91,
Gear reduction drive wheel,E2227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,653.91,,,,,,,fee schedule,372.79,653.91,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.11,,,,,,,fee schedule,167.25,293.38,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.81,,,,,,,fee schedule,167.25,293.38,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.25,,,,,,,fee schedule,167.25,293.38,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,293.38,,,,,,,fee schedule,167.25,293.38,
Solid seat support base,E2231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.81,,,,,,,fee schedule,246.38,432.18,
Solid seat support base,E2231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.6,,,,,,,fee schedule,246.38,432.18,
Solid seat support base,E2231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.38,,,,,,,fee schedule,246.38,432.18,
Solid seat support base,E2231,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,432.18,,,,,,,fee schedule,246.38,432.18,
Electro connect btw control,E2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,276.73,,,,,,,fee schedule,181.42,318.24,
Electro connect btw control,E2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,226.5,,,,,,,fee schedule,181.42,318.24,
Electro connect btw control,E2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,181.42,,,,,,,fee schedule,181.42,318.24,
Electro connect btw control,E2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,318.24,,,,,,,fee schedule,181.42,318.24,
Electro connect btw 2 sys,E2311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,558.44,,,,,,,fee schedule,366.11,642.21,
Electro connect btw 2 sys,E2311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,457.08,,,,,,,fee schedule,366.11,642.21,
Electro connect btw 2 sys,E2311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,366.11,,,,,,,fee schedule,366.11,642.21,
Electro connect btw 2 sys,E2311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,642.21,,,,,,,fee schedule,366.11,642.21,
Mini-prop remote joystick,E2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,612.94,,,,,,,fee schedule,401.84,704.88,
Mini-prop remote joystick,E2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,501.69,,,,,,,fee schedule,401.84,704.88,
Mini-prop remote joystick,E2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,401.84,,,,,,,fee schedule,401.84,704.88,
Mini-prop remote joystick,E2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,704.88,,,,,,,fee schedule,401.84,704.88,
"PWC harness, expand control",E2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.4,,,,,,,fee schedule,63.86,112.01,
"PWC harness, expand control",E2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.72,,,,,,,fee schedule,63.86,112.01,
"PWC harness, expand control",E2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.86,,,,,,,fee schedule,63.86,112.01,
"PWC harness, expand control",E2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.01,,,,,,,fee schedule,63.86,112.01,
Hand interface joystick,E2321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,376,,,,,,,fee schedule,246.51,432.4,
Hand interface joystick,E2321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.76,,,,,,,fee schedule,246.51,432.4,
Hand interface joystick,E2321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.51,,,,,,,fee schedule,246.51,432.4,
Hand interface joystick,E2321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,432.4,,,,,,,fee schedule,246.51,432.4,
Mult mech switches,E2322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,355.26,,,,,,,fee schedule,232.91,408.55,
Mult mech switches,E2322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,290.78,,,,,,,fee schedule,232.91,408.55,
Mult mech switches,E2322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,232.91,,,,,,,fee schedule,232.91,408.55,
Mult mech switches,E2322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,408.55,,,,,,,fee schedule,232.91,408.55,
Special joystick handle,E2323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.17,,,,,,,fee schedule,113.53,199.15,
Special joystick handle,E2323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.74,,,,,,,fee schedule,113.53,199.15,
Special joystick handle,E2323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.53,,,,,,,fee schedule,113.53,199.15,
Special joystick handle,E2323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.15,,,,,,,fee schedule,113.53,199.15,
Chin cup interface,E2324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,114.33,,,,,,,fee schedule,74.95,131.48,
Chin cup interface,E2324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.58,,,,,,,fee schedule,74.95,131.48,
Chin cup interface,E2324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.95,,,,,,,fee schedule,74.95,131.48,
Chin cup interface,E2324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,131.48,,,,,,,fee schedule,74.95,131.48,
Sip and puff interface,E2325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,339.54,,,,,,,fee schedule,222.6,390.47,
Sip and puff interface,E2325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.91,,,,,,,fee schedule,222.6,390.47,
Sip and puff interface,E2325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.6,,,,,,,fee schedule,222.6,390.47,
Sip and puff interface,E2325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,390.47,,,,,,,fee schedule,222.6,390.47,
Breath tube kit,E2326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.05,,,,,,,fee schedule,58.38,102.41,
Breath tube kit,E2326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.89,,,,,,,fee schedule,58.38,102.41,
Breath tube kit,E2326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.38,,,,,,,fee schedule,58.38,102.41,
Breath tube kit,E2326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.41,,,,,,,fee schedule,58.38,102.41,
Head control interface mech,E2327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,664.16,,,,,,,fee schedule,435.42,763.78,
Head control interface mech,E2327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,543.61,,,,,,,fee schedule,435.42,763.78,
Head control interface mech,E2327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,435.42,,,,,,,fee schedule,435.42,763.78,
Head control interface mech,E2327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,763.78,,,,,,,fee schedule,435.42,763.78,
Head/extremity control inter,E2328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1253.59,,,,,,,fee schedule,821.85,1441.63,
Head/extremity control inter,E2328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1026.06,,,,,,,fee schedule,821.85,1441.63,
Head/extremity control inter,E2328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,821.85,,,,,,,fee schedule,821.85,1441.63,
Head/extremity control inter,E2328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1441.63,,,,,,,fee schedule,821.85,1441.63,
Head control nonproportional,E2329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,452.69,,,,,,,fee schedule,296.78,520.59,
Head control nonproportional,E2329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,370.53,,,,,,,fee schedule,296.78,520.59,
Head control nonproportional,E2329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,296.78,,,,,,,fee schedule,296.78,520.59,
Head control nonproportional,E2329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,520.59,,,,,,,fee schedule,296.78,520.59,
Head control proximity switc,E2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,869.17,,,,,,,fee schedule,569.83,999.55,
Head control proximity switc,E2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,711.42,,,,,,,fee schedule,569.83,999.55,
Head control proximity switc,E2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,569.83,,,,,,,fee schedule,569.83,999.55,
Head control proximity switc,E2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,999.55,,,,,,,fee schedule,569.83,999.55,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1089.2,,,,,,,fee schedule,714.08,1252.58,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,891.51,,,,,,,fee schedule,714.08,1252.58,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,714.08,,,,,,,fee schedule,714.08,1252.58,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1252.58,,,,,,,fee schedule,714.08,1252.58,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1633.95,,,,,,,fee schedule,1071.22,1879.04,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1337.39,,,,,,,fee schedule,1071.22,1879.04,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1071.22,,,,,,,fee schedule,1071.22,1879.04,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1879.04,,,,,,,fee schedule,1071.22,1879.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1361.64,,,,,,,fee schedule,892.69,1565.89,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1114.5,,,,,,,fee schedule,892.69,1565.89,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,892.69,,,,,,,fee schedule,892.69,1565.89,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1565.89,,,,,,,fee schedule,892.69,1565.89,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2178.64,,,,,,,fee schedule,1428.32,2505.44,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1783.22,,,,,,,fee schedule,1428.32,2505.44,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1428.32,,,,,,,fee schedule,1428.32,2505.44,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2505.44,,,,,,,fee schedule,1428.32,2505.44,
Electronic SGD interface,E2351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1800.53,,,,,,,fee schedule,1180.43,2070.61,
Electronic SGD interface,E2351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1473.73,,,,,,,fee schedule,1180.43,2070.61,
Electronic SGD interface,E2351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1180.43,,,,,,,fee schedule,1180.43,2070.61,
Electronic SGD interface,E2351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2070.61,,,,,,,fee schedule,1180.43,2070.61,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,457.19,,,,,,,fee schedule,299.73,525.77,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.21,,,,,,,fee schedule,299.73,525.77,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.73,,,,,,,fee schedule,299.73,525.77,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,525.77,,,,,,,fee schedule,299.73,525.77,
22nf nonsealed leadacid,E2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,257.48,,,,,,,fee schedule,168.8,296.1,
22nf nonsealed leadacid,E2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.75,,,,,,,fee schedule,168.8,296.1,
22nf nonsealed leadacid,E2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.8,,,,,,,fee schedule,168.8,296.1,
22nf nonsealed leadacid,E2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,296.1,,,,,,,fee schedule,168.8,296.1,
22nf sealed leadacid battery,E2361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,306.7,,,,,,,fee schedule,201.07,352.71,
22nf sealed leadacid battery,E2361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.03,,,,,,,fee schedule,201.07,352.71,
22nf sealed leadacid battery,E2361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.07,,,,,,,fee schedule,201.07,352.71,
22nf sealed leadacid battery,E2361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,352.71,,,,,,,fee schedule,201.07,352.71,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,239.55,,,,,,,fee schedule,157.05,275.48,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,196.07,,,,,,,fee schedule,157.05,275.48,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,157.05,,,,,,,fee schedule,157.05,275.48,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,275.48,,,,,,,fee schedule,157.05,275.48,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,400.86,,,,,,,fee schedule,262.8,460.99,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,328.1,,,,,,,fee schedule,262.8,460.99,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.8,,,,,,,fee schedule,262.8,460.99,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,460.99,,,,,,,fee schedule,262.8,460.99,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,248.09,,,,,,,fee schedule,162.65,285.3,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,203.06,,,,,,,fee schedule,162.65,285.3,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,162.65,,,,,,,fee schedule,162.65,285.3,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,285.3,,,,,,,fee schedule,162.65,285.3,
U1 sealed leadacid battery,E2365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.73,,,,,,,fee schedule,134.22,235.44,
U1 sealed leadacid battery,E2365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.57,,,,,,,fee schedule,134.22,235.44,
U1 sealed leadacid battery,E2365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.22,,,,,,,fee schedule,134.22,235.44,
U1 sealed leadacid battery,E2365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.44,,,,,,,fee schedule,134.22,235.44,
"Battery charger, single mode",E2366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,426.02,,,,,,,fee schedule,279.3,489.92,
"Battery charger, single mode",E2366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,348.7,,,,,,,fee schedule,279.3,489.92,
"Battery charger, single mode",E2366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,279.3,,,,,,,fee schedule,279.3,489.92,
"Battery charger, single mode",E2366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,489.92,,,,,,,fee schedule,279.3,489.92,
"Battery charger, dual mode",E2367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,830.72,,,,,,,fee schedule,544.62,955.33,
"Battery charger, dual mode",E2367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,679.94,,,,,,,fee schedule,544.62,955.33,
"Battery charger, dual mode",E2367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,544.62,,,,,,,fee schedule,544.62,955.33,
"Battery charger, dual mode",E2367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,955.33,,,,,,,fee schedule,544.62,955.33,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.56,,,,,,,fee schedule,74.45,130.59,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.95,,,,,,,fee schedule,74.45,130.59,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.45,,,,,,,fee schedule,74.45,130.59,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.59,,,,,,,fee schedule,74.45,130.59,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.38,,,,,,,fee schedule,70.4,123.49,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.89,,,,,,,fee schedule,70.4,123.49,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.4,,,,,,,fee schedule,70.4,123.49,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.49,,,,,,,fee schedule,70.4,123.49,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.97,,,,,,,fee schedule,90.45,158.67,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112.93,,,,,,,fee schedule,90.45,158.67,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.45,,,,,,,fee schedule,90.45,158.67,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,158.67,,,,,,,fee schedule,90.45,158.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,379.07,,,,,,,fee schedule,248.52,435.93,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,310.27,,,,,,,fee schedule,248.52,435.93,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,248.52,,,,,,,fee schedule,248.52,435.93,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,435.93,,,,,,,fee schedule,248.52,435.93,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.6,,,,,,,fee schedule,132.17,231.84,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,165.01,,,,,,,fee schedule,132.17,231.84,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.17,,,,,,,fee schedule,132.17,231.84,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.84,,,,,,,fee schedule,132.17,231.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.52,,,,,,,fee schedule,83.6,146.65,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.38,,,,,,,fee schedule,83.6,146.65,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.6,,,,,,,fee schedule,83.6,146.65,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.65,,,,,,,fee schedule,83.6,146.65,
Non-expandable controller,E2375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.85,,,,,,,fee schedule,117.25,205.68,
Non-expandable controller,E2375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.39,,,,,,,fee schedule,117.25,205.68,
Non-expandable controller,E2375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.25,,,,,,,fee schedule,117.25,205.68,
Non-expandable controller,E2375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.68,,,,,,,fee schedule,117.25,205.68,
"Expandable controller, repl",E2376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,316.81,,,,,,,fee schedule,207.7,364.33,
"Expandable controller, repl",E2376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,259.31,,,,,,,fee schedule,207.7,364.33,
"Expandable controller, repl",E2376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,207.7,,,,,,,fee schedule,207.7,364.33,
"Expandable controller, repl",E2376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,364.33,,,,,,,fee schedule,207.7,364.33,
"Expandable controller, initl",E2377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.36,,,,,,,fee schedule,76.94,134.96,
"Expandable controller, initl",E2377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.06,,,,,,,fee schedule,76.94,134.96,
"Expandable controller, initl",E2377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.94,,,,,,,fee schedule,76.94,134.96,
"Expandable controller, initl",E2377,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,134.96,,,,,,,fee schedule,76.94,134.96,
Pw actuator replacement,E2378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.8,,,,,,,fee schedule,96.24,168.82,
Pw actuator replacement,E2378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.16,,,,,,,fee schedule,96.24,168.82,
Pw actuator replacement,E2378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.24,,,,,,,fee schedule,96.24,168.82,
Pw actuator replacement,E2378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,168.82,,,,,,,fee schedule,96.24,168.82,
Pneum drive wheel tire,E2381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.93,,,,,,,fee schedule,111.41,195.42,
Pneum drive wheel tire,E2381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.09,,,,,,,fee schedule,111.41,195.42,
Pneum drive wheel tire,E2381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.41,,,,,,,fee schedule,111.41,195.42,
Pneum drive wheel tire,E2381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.42,,,,,,,fee schedule,111.41,195.42,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.48,,,,,,,fee schedule,30.47,53.45,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.04,,,,,,,fee schedule,30.47,53.45,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.47,,,,,,,fee schedule,30.47,53.45,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.45,,,,,,,fee schedule,30.47,53.45,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,350.27,,,,,,,fee schedule,229.64,402.81,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,286.7,,,,,,,fee schedule,229.64,402.81,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,229.64,,,,,,,fee schedule,229.64,402.81,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,402.81,,,,,,,fee schedule,229.64,402.81,
Pneumatic caster tire,E2384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.59,,,,,,,fee schedule,113.15,198.48,
Pneumatic caster tire,E2384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.26,,,,,,,fee schedule,113.15,198.48,
Pneumatic caster tire,E2384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.15,,,,,,,fee schedule,113.15,198.48,
Pneumatic caster tire,E2384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.48,,,,,,,fee schedule,113.15,198.48,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.52,,,,,,,fee schedule,73.11,128.25,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.28,,,,,,,fee schedule,73.11,128.25,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.11,,,,,,,fee schedule,73.11,128.25,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.25,,,,,,,fee schedule,73.11,128.25,
Foam filled drive wheel tire,E2386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,274.9,,,,,,,fee schedule,180.22,316.14,
Foam filled drive wheel tire,E2386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,225.01,,,,,,,fee schedule,180.22,316.14,
Foam filled drive wheel tire,E2386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,180.22,,,,,,,fee schedule,180.22,316.14,
Foam filled drive wheel tire,E2386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,316.14,,,,,,,fee schedule,180.22,316.14,
Foam filled caster tire,E2387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.93,,,,,,,fee schedule,91.74,160.92,
Foam filled caster tire,E2387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.53,,,,,,,fee schedule,91.74,160.92,
Foam filled caster tire,E2387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.74,,,,,,,fee schedule,91.74,160.92,
Foam filled caster tire,E2387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.92,,,,,,,fee schedule,91.74,160.92,
Foam drive wheel tire,E2388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.38,,,,,,,fee schedule,79.58,139.59,
Foam drive wheel tire,E2388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.35,,,,,,,fee schedule,79.58,139.59,
Foam drive wheel tire,E2388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.58,,,,,,,fee schedule,79.58,139.59,
Foam drive wheel tire,E2388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.59,,,,,,,fee schedule,79.58,139.59,
Foam caster tire,E2389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.84,,,,,,,fee schedule,44.48,78.02,
Foam caster tire,E2389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.53,,,,,,,fee schedule,44.48,78.02,
Foam caster tire,E2389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.48,,,,,,,fee schedule,44.48,78.02,
Foam caster tire,E2389,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.02,,,,,,,fee schedule,44.48,78.02,
Solid drive wheel tire,E2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.03,,,,,,,fee schedule,68.86,120.78,
Solid drive wheel tire,E2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.97,,,,,,,fee schedule,68.86,120.78,
Solid drive wheel tire,E2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.86,,,,,,,fee schedule,68.86,120.78,
Solid drive wheel tire,E2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.78,,,,,,,fee schedule,68.86,120.78,
Solid caster tire,E2391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.81,,,,,,,fee schedule,32,56.13,
Solid caster tire,E2391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.95,,,,,,,fee schedule,32,56.13,
Solid caster tire,E2391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32,,,,,,,fee schedule,32,56.13,
Solid caster tire,E2391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.13,,,,,,,fee schedule,32,56.13,
"Solid caster tire, integrate",E2392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.38,,,,,,,fee schedule,78.92,138.44,
"Solid caster tire, integrate",E2392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.53,,,,,,,fee schedule,78.92,138.44,
"Solid caster tire, integrate",E2392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.92,,,,,,,fee schedule,78.92,138.44,
"Solid caster tire, integrate",E2392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.44,,,,,,,fee schedule,78.92,138.44,
Drive wheel excludes tire,E2394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,157.11,,,,,,,fee schedule,103,180.68,
Drive wheel excludes tire,E2394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.59,,,,,,,fee schedule,103,180.68,
Drive wheel excludes tire,E2394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103,,,,,,,fee schedule,103,180.68,
Drive wheel excludes tire,E2394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.68,,,,,,,fee schedule,103,180.68,
Caster wheel excludes tire,E2395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.36,,,,,,,fee schedule,80.22,140.71,
Caster wheel excludes tire,E2395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.15,,,,,,,fee schedule,80.22,140.71,
Caster wheel excludes tire,E2395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.22,,,,,,,fee schedule,80.22,140.71,
Caster wheel excludes tire,E2395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,140.71,,,,,,,fee schedule,80.22,140.71,
Caster fork,E2396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,135.56,,,,,,,fee schedule,88.87,155.89,
Caster fork,E2396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.96,,,,,,,fee schedule,88.87,155.89,
Caster fork,E2396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.87,,,,,,,fee schedule,88.87,155.89,
Caster fork,E2396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.89,,,,,,,fee schedule,88.87,155.89,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1199.01,,,,,,,fee schedule,786.07,1378.86,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,981.39,,,,,,,fee schedule,786.07,1378.86,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,786.07,,,,,,,fee schedule,786.07,1378.86,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1378.86,,,,,,,fee schedule,786.07,1378.86,
Neg press wound therapy pump,E2402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1752.8,,,,,,,fee schedule,1149.14,2015.72,
Neg press wound therapy pump,E2402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1434.67,,,,,,,fee schedule,1149.14,2015.72,
Neg press wound therapy pump,E2402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1149.14,,,,,,,fee schedule,1149.14,2015.72,
Neg press wound therapy pump,E2402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2015.72,,,,,,,fee schedule,1149.14,2015.72,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1188.56,,,,,,,fee schedule,779.22,1366.84,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,972.84,,,,,,,fee schedule,779.22,1366.84,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,779.22,,,,,,,fee schedule,779.22,1366.84,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1366.84,,,,,,,fee schedule,779.22,1366.84,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3634.54,,,,,,,fee schedule,2382.8,4179.72,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2974.87,,,,,,,fee schedule,2382.8,4179.72,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2382.8,,,,,,,fee schedule,2382.8,4179.72,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4179.72,,,,,,,fee schedule,2382.8,4179.72,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4794.44,,,,,,,fee schedule,3143.23,5513.61,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3924.25,,,,,,,fee schedule,3143.23,5513.61,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3143.23,,,,,,,fee schedule,3143.23,5513.61,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5513.61,,,,,,,fee schedule,3143.23,5513.61,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7030.13,,,,,,,fee schedule,4608.95,8084.65,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5754.16,,,,,,,fee schedule,4608.95,8084.65,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4608.95,,,,,,,fee schedule,4608.95,8084.65,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8084.65,,,,,,,fee schedule,4608.95,8084.65,
SGD spelling phys contact,E2508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10870.89,,,,,,,fee schedule,7126.96,12501.52,
SGD spelling phys contact,E2508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8897.82,,,,,,,fee schedule,7126.96,12501.52,
SGD spelling phys contact,E2508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7126.96,,,,,,,fee schedule,7126.96,12501.52,
SGD spelling phys contact,E2508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12501.52,,,,,,,fee schedule,7126.96,12501.52,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20571.72,,,,,,,fee schedule,13486.82,23657.48,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16837.95,,,,,,,fee schedule,13486.82,23657.48,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13486.82,,,,,,,fee schedule,13486.82,23657.48,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23657.48,,,,,,,fee schedule,13486.82,23657.48,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.97,,,,,,,fee schedule,66.85,117.27,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.46,,,,,,,fee schedule,66.85,117.27,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.85,,,,,,,fee schedule,66.85,117.27,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.27,,,,,,,fee schedule,66.85,117.27,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.6,,,,,,,fee schedule,149.21,261.74,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.29,,,,,,,fee schedule,149.21,261.74,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.21,,,,,,,fee schedule,149.21,261.74,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.74,,,,,,,fee schedule,149.21,261.74,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,274.1,,,,,,,fee schedule,179.7,315.22,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.35,,,,,,,fee schedule,179.7,315.22,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.7,,,,,,,fee schedule,179.7,315.22,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,315.22,,,,,,,fee schedule,179.7,315.22,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,381.36,,,,,,,fee schedule,250.02,438.56,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,312.14,,,,,,,fee schedule,250.02,438.56,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,250.02,,,,,,,fee schedule,250.02,438.56,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,438.56,,,,,,,fee schedule,250.02,438.56,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,556.98,,,,,,,fee schedule,365.16,640.53,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,455.89,,,,,,,fee schedule,365.16,640.53,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,365.16,,,,,,,fee schedule,365.16,640.53,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,640.53,,,,,,,fee schedule,365.16,640.53,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,931.83,,,,,,,fee schedule,610.91,1071.6,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,762.7,,,,,,,fee schedule,610.91,1071.6,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,610.91,,,,,,,fee schedule,610.91,1071.6,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1071.6,,,,,,,fee schedule,610.91,1071.6,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,548.15,,,,,,,fee schedule,359.37,630.37,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,448.66,,,,,,,fee schedule,359.37,630.37,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,359.37,,,,,,,fee schedule,359.37,630.37,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,630.37,,,,,,,fee schedule,359.37,630.37,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,684.61,,,,,,,fee schedule,448.83,787.3,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,560.35,,,,,,,fee schedule,448.83,787.3,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,448.83,,,,,,,fee schedule,448.83,787.3,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,787.3,,,,,,,fee schedule,448.83,787.3,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,388.59,,,,,,,fee schedule,254.76,446.88,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,318.06,,,,,,,fee schedule,254.76,446.88,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,254.76,,,,,,,fee schedule,254.76,446.88,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,446.88,,,,,,,fee schedule,254.76,446.88,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,804.71,,,,,,,fee schedule,527.57,925.42,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,658.66,,,,,,,fee schedule,527.57,925.42,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,527.57,,,,,,,fee schedule,527.57,925.42,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,925.42,,,,,,,fee schedule,527.57,925.42,
Position back cush wd <22in,E2613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,823.66,,,,,,,fee schedule,539.99,947.21,
Position back cush wd <22in,E2613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,674.17,,,,,,,fee schedule,539.99,947.21,
Position back cush wd <22in,E2613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,539.99,,,,,,,fee schedule,539.99,947.21,
Position back cush wd <22in,E2613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,947.21,,,,,,,fee schedule,539.99,947.21,
Position back cush wd>=22in,E2614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1265.45,,,,,,,fee schedule,829.63,1455.27,
Position back cush wd>=22in,E2614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1035.77,,,,,,,fee schedule,829.63,1455.27,
Position back cush wd>=22in,E2614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,829.63,,,,,,,fee schedule,829.63,1455.27,
Position back cush wd>=22in,E2614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1455.27,,,,,,,fee schedule,829.63,1455.27,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,925.4,,,,,,,fee schedule,606.69,1064.21,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,757.44,,,,,,,fee schedule,606.69,1064.21,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,606.69,,,,,,,fee schedule,606.69,1064.21,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1064.21,,,,,,,fee schedule,606.69,1064.21,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1287.99,,,,,,,fee schedule,844.41,1481.19,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1054.22,,,,,,,fee schedule,844.41,1481.19,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,844.41,,,,,,,fee schedule,844.41,1481.19,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1481.19,,,,,,,fee schedule,844.41,1481.19,
Replace cover w/c seat cush,E2619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,124.98,,,,,,,fee schedule,81.94,143.73,
Replace cover w/c seat cush,E2619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.3,,,,,,,fee schedule,81.94,143.73,
Replace cover w/c seat cush,E2619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.94,,,,,,,fee schedule,81.94,143.73,
Replace cover w/c seat cush,E2619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.73,,,,,,,fee schedule,81.94,143.73,
WC planar back cush wd <22in,E2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1005.09,,,,,,,fee schedule,658.94,1155.85,
WC planar back cush wd <22in,E2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,822.67,,,,,,,fee schedule,658.94,1155.85,
WC planar back cush wd <22in,E2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,658.94,,,,,,,fee schedule,658.94,1155.85,
WC planar back cush wd <22in,E2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1155.85,,,,,,,fee schedule,658.94,1155.85,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1214.29,,,,,,,fee schedule,796.09,1396.43,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,993.9,,,,,,,fee schedule,796.09,1396.43,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,796.09,,,,,,,fee schedule,796.09,1396.43,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1396.43,,,,,,,fee schedule,796.09,1396.43,
Adj skin pro w/c cus wd<22in,E2622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,792.79,,,,,,,fee schedule,519.75,911.71,
Adj skin pro w/c cus wd<22in,E2622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,648.9,,,,,,,fee schedule,519.75,911.71,
Adj skin pro w/c cus wd<22in,E2622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,519.75,,,,,,,fee schedule,519.75,911.71,
Adj skin pro w/c cus wd<22in,E2622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,911.71,,,,,,,fee schedule,519.75,911.71,
Adj skin pro wc cus wd>=22in,E2623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1002.55,,,,,,,fee schedule,657.27,1152.93,
Adj skin pro wc cus wd>=22in,E2623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,820.59,,,,,,,fee schedule,657.27,1152.93,
Adj skin pro wc cus wd>=22in,E2623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,657.27,,,,,,,fee schedule,657.27,1152.93,
Adj skin pro wc cus wd>=22in,E2623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1152.93,,,,,,,fee schedule,657.27,1152.93,
Adj skin pro/pos cus<22in,E2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,805.61,,,,,,,fee schedule,528.16,926.45,
Adj skin pro/pos cus<22in,E2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,659.39,,,,,,,fee schedule,528.16,926.45,
Adj skin pro/pos cus<22in,E2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,528.16,,,,,,,fee schedule,528.16,926.45,
Adj skin pro/pos cus<22in,E2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,926.45,,,,,,,fee schedule,528.16,926.45,
Adj skin pro/pos wc cus>=22,E2625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,997.02,,,,,,,fee schedule,653.65,1146.57,
Adj skin pro/pos wc cus>=22,E2625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,816.06,,,,,,,fee schedule,653.65,1146.57,
Adj skin pro/pos wc cus>=22,E2625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,653.65,,,,,,,fee schedule,653.65,1146.57,
Adj skin pro/pos wc cus>=22,E2625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1146.57,,,,,,,fee schedule,653.65,1146.57,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1695.81,,,,,,,fee schedule,1111.77,1950.18,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1388.02,,,,,,,fee schedule,1111.77,1950.18,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1111.77,,,,,,,fee schedule,1111.77,1950.18,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1950.18,,,,,,,fee schedule,1111.77,1950.18,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2474.44,,,,,,,fee schedule,1622.24,2845.61,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2025.33,,,,,,,fee schedule,1622.24,2845.61,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1622.24,,,,,,,fee schedule,1622.24,2845.61,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2845.61,,,,,,,fee schedule,1622.24,2845.61,
Mobile arm supports reclinin,E2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1962.37,,,,,,,fee schedule,1286.53,2256.73,
Mobile arm supports reclinin,E2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1606.2,,,,,,,fee schedule,1286.53,2256.73,
Mobile arm supports reclinin,E2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1286.53,,,,,,,fee schedule,1286.53,2256.73,
Mobile arm supports reclinin,E2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2256.73,,,,,,,fee schedule,1286.53,2256.73,
Friction dampening arm supp,E2629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2441.09,,,,,,,fee schedule,1600.38,2807.25,
Friction dampening arm supp,E2629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1998.03,,,,,,,fee schedule,1600.38,2807.25,
Friction dampening arm supp,E2629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1600.38,,,,,,,fee schedule,1600.38,2807.25,
Friction dampening arm supp,E2629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2807.25,,,,,,,fee schedule,1600.38,2807.25,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1720.79,,,,,,,fee schedule,1128.15,1978.91,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1408.47,,,,,,,fee schedule,1128.15,1978.91,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1128.15,,,,,,,fee schedule,1128.15,1978.91,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1978.91,,,,,,,fee schedule,1128.15,1978.91,
Elevat proximal arm support,E2631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,714.64,,,,,,,fee schedule,468.52,821.84,
Elevat proximal arm support,E2631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,584.93,,,,,,,fee schedule,468.52,821.84,
Elevat proximal arm support,E2631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,468.52,,,,,,,fee schedule,468.52,821.84,
Elevat proximal arm support,E2631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,821.84,,,,,,,fee schedule,468.52,821.84,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,448.76,,,,,,,fee schedule,294.21,516.07,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,367.31,,,,,,,fee schedule,294.21,516.07,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,294.21,,,,,,,fee schedule,294.21,516.07,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,516.07,,,,,,,fee schedule,294.21,516.07,
Mobile arm support supinator,E2633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,366.56,,,,,,,fee schedule,240.32,421.54,
Mobile arm support supinator,E2633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,300.03,,,,,,,fee schedule,240.32,421.54,
Mobile arm support supinator,E2633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,240.32,,,,,,,fee schedule,240.32,421.54,
Mobile arm support supinator,E2633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,421.54,,,,,,,fee schedule,240.32,421.54,
Admin influenza virus vac,G0008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Admin influenza virus vac,G0008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Admin influenza virus vac,G0008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Admin influenza virus vac,G0008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Admin influenza virus vac,G0008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Admin influenza virus vac,G0008,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Admin influenza virus vac,G0008,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Admin pneumococcal vaccine,G0009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Admin pneumococcal vaccine,G0009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Admin pneumococcal vaccine,G0009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Admin pneumococcal vaccine,G0009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Admin pneumococcal vaccine,G0009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Admin pneumococcal vaccine,G0009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Admin pneumococcal vaccine,G0009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
Admin hepatitis b vaccine,G0010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52,,,,,,,fee schedule,34.09,83.98,
Admin hepatitis b vaccine,G0010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.56,,,,,,,fee schedule,34.09,83.98,
Admin hepatitis b vaccine,G0010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.09,,,,,,,fee schedule,34.09,83.98,
Admin hepatitis b vaccine,G0010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.8,,,,,,,fee schedule,34.09,83.98,
Admin hepatitis b vaccine,G0010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.99,,,,,,,fee schedule,34.09,83.98,APC
Admin hepatitis b vaccine,G0010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.66,,,,,,,fee schedule,34.09,83.98,APC
Admin hepatitis b vaccine,G0010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.98,,,,,,,fee schedule,34.09,83.98,APC
"Hiv prep counsel, md 15-30m",G0011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.32,,,,,,,fee schedule,12.01,21.07,
"Hiv prep counsel, md 15-30m",G0011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.99,,,,,,,fee schedule,12.01,21.07,
"Hiv prep counsel, md 15-30m",G0011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.01,,,,,,,fee schedule,12.01,21.07,
"Hiv prep counsel, md 15-30m",G0011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.07,,,,,,,fee schedule,12.01,21.07,
Injection of hiv prep drug,G0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.79,,,,,,,fee schedule,9.7,129.13,
Injection of hiv prep drug,G0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.11,,,,,,,fee schedule,9.7,129.13,
Injection of hiv prep drug,G0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.7,,,,,,,fee schedule,9.7,129.13,
Injection of hiv prep drug,G0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.01,,,,,,,fee schedule,9.7,129.13,
Injection of hiv prep drug,G0012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.33,,,,,,,fee schedule,9.7,129.13,APC
Injection of hiv prep drug,G0012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.74,,,,,,,fee schedule,9.7,129.13,APC
Injection of hiv prep drug,G0012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.13,,,,,,,fee schedule,9.7,129.13,APC
"Hiv prep counsel, clin staff",G0013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.14,,,,,,,fee schedule,19.76,67.2,
"Hiv prep counsel, clin staff",G0013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.67,,,,,,,fee schedule,19.76,67.2,
"Hiv prep counsel, clin staff",G0013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.76,,,,,,,fee schedule,19.76,67.2,
"Hiv prep counsel, clin staff",G0013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.66,,,,,,,fee schedule,19.76,67.2,
"Hiv prep counsel, clin staff",G0013,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,19.76,67.2,APC
"Hiv prep counsel, clin staff",G0013,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,19.76,67.2,APC
"Hiv prep counsel, clin staff",G0013,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,19.76,67.2,APC
Crisis psychotherapy 60m,G0017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.84,,,,,,,fee schedule,58.9,103.32,
Crisis psychotherapy 60m,G0017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.53,,,,,,,fee schedule,58.9,103.32,
Crisis psychotherapy 60m,G0017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.9,,,,,,,fee schedule,58.9,103.32,
Crisis psychotherapy 60m,G0017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.32,,,,,,,fee schedule,58.9,103.32,
Crisis psychotherapy add 30m,G0018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.7,,,,,,,fee schedule,30.62,53.71,
Crisis psychotherapy add 30m,G0018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.22,,,,,,,fee schedule,30.62,53.71,
Crisis psychotherapy add 30m,G0018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.62,,,,,,,fee schedule,30.62,53.71,
Crisis psychotherapy add 30m,G0018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.71,,,,,,,fee schedule,30.62,53.71,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.44,,,,,,,fee schedule,100.6,182.2,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.59,,,,,,,fee schedule,100.6,182.2,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.6,,,,,,,fee schedule,100.6,182.2,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.46,,,,,,,fee schedule,100.6,182.2,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,100.6,182.2,APC
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,100.6,182.2,APC
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,100.6,182.2,APC
Comm hlth intg svs add 30 m,G0022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.93,,,,,,,fee schedule,29.46,51.67,
Comm hlth intg svs add 30 m,G0022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.78,,,,,,,fee schedule,29.46,51.67,
Comm hlth intg svs add 30 m,G0022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.46,,,,,,,fee schedule,29.46,51.67,
Comm hlth intg svs add 30 m,G0022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.67,,,,,,,fee schedule,29.46,51.67,
Pin service 60m per month,G0023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.44,,,,,,,fee schedule,100.6,182.2,
Pin service 60m per month,G0023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.59,,,,,,,fee schedule,100.6,182.2,
Pin service 60m per month,G0023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.6,,,,,,,fee schedule,100.6,182.2,
Pin service 60m per month,G0023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.46,,,,,,,fee schedule,100.6,182.2,
Pin service 60m per month,G0023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,100.6,182.2,APC
Pin service 60m per month,G0023,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,100.6,182.2,APC
Pin service 60m per month,G0023,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,100.6,182.2,APC
Pin srv add 30 min pr m,G0024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.93,,,,,,,fee schedule,29.46,51.67,
Pin srv add 30 min pr m,G0024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.78,,,,,,,fee schedule,29.46,51.67,
Pin srv add 30 min pr m,G0024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.46,,,,,,,fee schedule,29.46,51.67,
Pin srv add 30 min pr m,G0024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.67,,,,,,,fee schedule,29.46,51.67,
Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.69,,,,,,,fee schedule,6.5,27.24,
Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.39,,,,,,,fee schedule,6.5,27.24,
Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.53,,,,,,,fee schedule,6.5,27.24,
Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.24,,,,,,,fee schedule,6.5,27.24,
Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.82,,,,,,,fee schedule,6.5,27.24,APC
Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.5,,,,,,,fee schedule,6.5,27.24,APC
Semen analysis,G0027,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.7,,,,,,,fee schedule,6.5,27.24,APC
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
Prostate ca screening; dre,G0102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,24.4,42.8,
Prostate ca screening; dre,G0102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,24.4,42.8,
Prostate ca screening; dre,G0102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,24.4,42.8,
Prostate ca screening; dre,G0102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,24.4,42.8,
PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.04,,,,,,,fee schedule,19.31,48.35,
PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.41,,,,,,,fee schedule,19.31,48.35,
PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.56,,,,,,,fee schedule,19.31,48.35,
PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.35,,,,,,,fee schedule,19.31,48.35,
PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.28,,,,,,,fee schedule,19.31,48.35,APC
PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.31,,,,,,,fee schedule,19.31,48.35,APC
PSA Screening,G0103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.76,,,,,,,fee schedule,19.31,48.35,APC
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,240.12,,,,,,,fee schedule,240.12,1667.9,
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,240.12,,,,,,,fee schedule,240.12,1667.9,
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,276.14,,,,,,,fee schedule,240.12,1667.9,
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,240.12,,,,,,,fee schedule,240.12,1667.9,
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,240.12,1667.9,APC
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,240.12,1667.9,APC
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,240.12,1667.9,APC
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,860.99,,,,,,,fee schedule,860.99,1667.9,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,860.99,,,,,,,fee schedule,860.99,1667.9,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,990.14,,,,,,,fee schedule,860.99,1667.9,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,860.99,,,,,,,fee schedule,860.99,1667.9,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,860.99,1667.9,APC
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,860.99,1667.9,APC
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,860.99,1667.9,APC
Diab manage trn  per indiv,G0108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.23,,,,,,,fee schedule,55.84,126.76,
Diab manage trn  per indiv,G0108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.22,,,,,,,fee schedule,55.84,126.76,
Diab manage trn  per indiv,G0108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.27,,,,,,,fee schedule,55.84,126.76,
Diab manage trn  per indiv,G0108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.76,,,,,,,fee schedule,55.84,126.76,
Diab manage trn  per indiv,G0108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.63,,,,,,,fee schedule,55.84,126.76,APC
Diab manage trn  per indiv,G0108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55.84,,,,,,,fee schedule,55.84,126.76,APC
Diab manage trn  per indiv,G0108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,100.51,,,,,,,fee schedule,55.84,126.76,APC
Diab manage trn ind/group,G0109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.1,,,,,,,fee schedule,15.44,71.42,
Diab manage trn ind/group,G0109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.83,,,,,,,fee schedule,15.44,71.42,
Diab manage trn ind/group,G0109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.71,,,,,,,fee schedule,15.44,71.42,
Diab manage trn ind/group,G0109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.42,,,,,,,fee schedule,15.44,71.42,
Diab manage trn ind/group,G0109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.21,,,,,,,fee schedule,15.44,71.42,APC
Diab manage trn ind/group,G0109,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.44,,,,,,,fee schedule,15.44,71.42,APC
Diab manage trn ind/group,G0109,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.79,,,,,,,fee schedule,15.44,71.42,APC
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,51.88,
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,51.88,
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,51.88,
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,51.88,
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,27.82,51.88,APC
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,27.82,51.88,APC
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,27.82,51.88,APC
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,860.99,,,,,,,fee schedule,860.99,1667.9,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,860.99,,,,,,,fee schedule,860.99,1667.9,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,990.14,,,,,,,fee schedule,860.99,1667.9,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,860.99,,,,,,,fee schedule,860.99,1667.9,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,860.99,1667.9,APC
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,860.99,1667.9,APC
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,860.99,1667.9,APC
Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.86,,,,,,,fee schedule,20.26,87.24,
Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.09,,,,,,,fee schedule,20.26,87.24,
Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.73,,,,,,,fee schedule,20.26,87.24,
Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.24,,,,,,,fee schedule,20.26,87.24,
Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.27,,,,,,,fee schedule,20.26,87.24,APC
Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.26,,,,,,,fee schedule,20.26,87.24,APC
Screen cerv/vag thin layer,G0123,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.47,,,,,,,fee schedule,20.26,87.24,APC
Screen c/v thin layer by MD,G0124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.04,,,,,,,fee schedule,30.84,54.1,
Screen c/v thin layer by MD,G0124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.5,,,,,,,fee schedule,30.84,54.1,
Screen c/v thin layer by MD,G0124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.84,,,,,,,fee schedule,30.84,54.1,
Screen c/v thin layer by MD,G0124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.1,,,,,,,fee schedule,30.84,54.1,
Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.56,,,,,,,fee schedule,53.47,105.8,
Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.76,,,,,,,fee schedule,53.47,105.8,
Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.47,,,,,,,fee schedule,53.47,105.8,
Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.79,,,,,,,fee schedule,53.47,105.8,
Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,53.47,105.8,APC
Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,53.47,105.8,APC
Trim nail(s),G0127,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,53.47,105.8,APC
CORF skilled nursing service,G0128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.56,,,,,,,fee schedule,14.13,24.79,
CORF skilled nursing service,G0128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.65,,,,,,,fee schedule,14.13,24.79,
CORF skilled nursing service,G0128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.13,,,,,,,fee schedule,14.13,24.79,
CORF skilled nursing service,G0128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.79,,,,,,,fee schedule,14.13,24.79,
Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.7,,,,,,,fee schedule,41.76,187.51,
Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.14,,,,,,,fee schedule,41.76,187.51,
Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.76,,,,,,,fee schedule,41.76,187.51,
Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.26,,,,,,,fee schedule,41.76,187.51,
Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.38,,,,,,,fee schedule,41.76,187.51,APC
Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.17,,,,,,,fee schedule,41.76,187.51,APC
Single energy x-ray study,G0130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.51,,,,,,,fee schedule,41.76,187.51,APC
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.42,,,,,,,fee schedule,32.4,67.2,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.45,,,,,,,fee schedule,32.4,67.2,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.4,,,,,,,fee schedule,32.4,67.2,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.83,,,,,,,fee schedule,32.4,67.2,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,32.4,67.2,APC
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,32.4,67.2,APC
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,32.4,67.2,APC
Iv cipaglucosidase alfa-atga,G0138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.14,,,,,,,fee schedule,634.42,1141.96,APC
Iv cipaglucosidase alfa-atga,G0138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,634.42,,,,,,,fee schedule,634.42,1141.96,APC
Iv cipaglucosidase alfa-atga,G0138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1141.96,,,,,,,fee schedule,634.42,1141.96,APC
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.44,,,,,,,fee schedule,100.6,182.2,
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.59,,,,,,,fee schedule,100.6,182.2,
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.6,,,,,,,fee schedule,100.6,182.2,
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.46,,,,,,,fee schedule,100.6,182.2,
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,100.6,182.2,APC
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,100.6,182.2,APC
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,100.6,182.2,APC
"Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.04,,,,,,,fee schedule,30.84,54.1,
"Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.5,,,,,,,fee schedule,30.84,54.1,
"Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.84,,,,,,,fee schedule,30.84,54.1,
"Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.1,,,,,,,fee schedule,30.84,54.1,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.86,,,,,,,fee schedule,27.05,87.24,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.09,,,,,,,fee schedule,27.05,87.24,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.73,,,,,,,fee schedule,27.05,87.24,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.24,,,,,,,fee schedule,27.05,87.24,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.4,,,,,,,fee schedule,27.05,87.24,APC
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.05,,,,,,,fee schedule,27.05,87.24,APC
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.69,,,,,,,fee schedule,27.05,87.24,APC
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80,,,,,,,fee schedule,43.97,92,
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.48,,,,,,,fee schedule,43.97,92,
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.45,,,,,,,fee schedule,43.97,92,
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92,,,,,,,fee schedule,43.97,92,
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.17,,,,,,,fee schedule,43.97,92,APC
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.97,,,,,,,fee schedule,43.97,92,APC
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,79.15,,,,,,,fee schedule,43.97,92,APC
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.2,,,,,,,fee schedule,26.49,118.68,
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.47,,,,,,,fee schedule,26.49,118.68,
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.66,,,,,,,fee schedule,26.49,118.68,
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.68,,,,,,,fee schedule,26.49,118.68,
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.81,,,,,,,fee schedule,26.49,118.68,APC
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.49,,,,,,,fee schedule,26.49,118.68,APC
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.68,,,,,,,fee schedule,26.49,118.68,APC
Nav srv peer sup add 30 pr m,G0146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.93,,,,,,,fee schedule,29.46,51.67,
Nav srv peer sup add 30 pr m,G0146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.78,,,,,,,fee schedule,29.46,51.67,
Nav srv peer sup add 30 pr m,G0146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.46,,,,,,,fee schedule,29.46,51.67,
Nav srv peer sup add 30 pr m,G0146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.67,,,,,,,fee schedule,29.46,51.67,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,18.54,45.48,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,18.54,45.48,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,18.54,45.48,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,18.54,45.48,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,18.54,45.48,APC
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,18.54,45.48,APC
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,18.54,45.48,APC
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,25.93,57.49,
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,25.93,57.49,
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,25.93,57.49,
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,25.93,57.49,
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.54,,,,,,,fee schedule,25.93,57.49,APC
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.94,,,,,,,fee schedule,25.93,57.49,APC
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57.49,,,,,,,fee schedule,25.93,57.49,APC
"HHCP-serv of pt,ea 15 min",G0151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
"HHCP-serv of pt,ea 15 min",G0151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
"HHCP-serv of pt,ea 15 min",G0151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
"HHCP-serv of pt,ea 15 min",G0151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
"HHCP-serv of ot,ea 15 min",G0152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
"HHCP-serv of ot,ea 15 min",G0152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
"HHCP-serv of ot,ea 15 min",G0152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
"HHCP-serv of ot,ea 15 min",G0152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
"HHCP-svs of s/l path,ea 15mn",G0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
"HHCP-svs of s/l path,ea 15mn",G0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,107.5,123.63,
"HHCP-svs of s/l path,ea 15mn",G0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,107.5,123.63,
"HHCP-svs of s/l path,ea 15mn",G0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,107.5,123.63,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,363.58,,,,,,,fee schedule,132.57,418.12,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,297.59,,,,,,,fee schedule,132.57,418.12,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,238.36,,,,,,,fee schedule,132.57,418.12,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,418.12,,,,,,,fee schedule,132.57,418.12,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.2,,,,,,,fee schedule,132.57,418.12,APC
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.57,,,,,,,fee schedule,132.57,418.12,APC
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.63,,,,,,,fee schedule,132.57,418.12,APC
Wound closure by adhesive,G0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,234.16,,,,,,,fee schedule,153.52,269.28,
Wound closure by adhesive,G0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.66,,,,,,,fee schedule,153.52,269.28,
Wound closure by adhesive,G0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,153.52,,,,,,,fee schedule,153.52,269.28,
Wound closure by adhesive,G0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,269.28,,,,,,,fee schedule,153.52,269.28,
"Opps service,sched team conf",G0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,497.13,,,,,,,fee schedule,325.92,748.37,
"Opps service,sched team conf",G0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,406.9,,,,,,,fee schedule,325.92,748.37,
"Opps service,sched team conf",G0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,325.92,,,,,,,fee schedule,325.92,748.37,
"Opps service,sched team conf",G0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,571.7,,,,,,,fee schedule,325.92,748.37,
"Opps service,sched team conf",G0175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,436.55,,,,,,,fee schedule,325.92,748.37,APC
"Opps service,sched team conf",G0175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,415.76,,,,,,,fee schedule,325.92,748.37,APC
"Opps service,sched team conf",G0175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,748.37,,,,,,,fee schedule,325.92,748.37,APC
MD recertification HHA PT,G0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.6,,,,,,,fee schedule,44.32,77.74,
MD recertification HHA PT,G0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.33,,,,,,,fee schedule,44.32,77.74,
MD recertification HHA PT,G0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.32,,,,,,,fee schedule,44.32,77.74,
MD recertification HHA PT,G0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.74,,,,,,,fee schedule,44.32,77.74,
MD certification HHA patient,G0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,90.13,
MD certification HHA patient,G0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,90.13,
MD certification HHA patient,G0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,90.13,
MD certification HHA patient,G0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,90.13,
Home health care supervision,G0181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.59,,,,,,,fee schedule,77.09,135.23,
Home health care supervision,G0181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.25,,,,,,,fee schedule,77.09,135.23,
Home health care supervision,G0181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.09,,,,,,,fee schedule,77.09,135.23,
Home health care supervision,G0181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.23,,,,,,,fee schedule,77.09,135.23,
Hospice care supervision,G0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.51,,,,,,,fee schedule,79.01,138.59,
Hospice care supervision,G0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.64,,,,,,,fee schedule,79.01,138.59,
Hospice care supervision,G0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.01,,,,,,,fee schedule,79.01,138.59,
Hospice care supervision,G0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.59,,,,,,,fee schedule,79.01,138.59,
Software meas of cardiac vol,G0183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.05,,,,,,,fee schedule,86.71,156.08,APC
Software meas of cardiac vol,G0183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.71,,,,,,,fee schedule,86.71,156.08,APC
Software meas of cardiac vol,G0183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156.08,,,,,,,fee schedule,86.71,156.08,APC
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.61,,,,,,,fee schedule,454.73,986.44,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.87,,,,,,,fee schedule,454.73,986.44,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.72,,,,,,,fee schedule,454.73,986.44,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.73,,,,,,,fee schedule,454.73,986.44,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,676.05,,,,,,,fee schedule,454.73,986.44,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.65,,,,,,,fee schedule,454.73,986.44,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,587.87,,,,,,,fee schedule,454.73,986.44,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.42,,,,,,,fee schedule,454.73,986.44,APC
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,548.02,,,,,,,fee schedule,454.73,986.44,APC
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,986.44,,,,,,,fee schedule,454.73,986.44,APC
PET not otherwise specified,G0235,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.25,,,,,,,fee schedule,398.33,717,APC
PET not otherwise specified,G0235,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.33,,,,,,,fee schedule,398.33,717,APC
PET not otherwise specified,G0235,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717,,,,,,,fee schedule,398.33,717,APC
Therapeutic procd strg endur,G0237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,51.88,
Therapeutic procd strg endur,G0237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,51.88,
Therapeutic procd strg endur,G0237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,51.88,
Therapeutic procd strg endur,G0237,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,51.88,
Therapeutic procd strg endur,G0237,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,27.82,51.88,APC
Therapeutic procd strg endur,G0237,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,27.82,51.88,APC
Therapeutic procd strg endur,G0237,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,27.82,51.88,APC
"Oth resp proc, indiv",G0238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,51.88,
"Oth resp proc, indiv",G0238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,51.88,
"Oth resp proc, indiv",G0238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,51.88,
"Oth resp proc, indiv",G0238,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,51.88,
"Oth resp proc, indiv",G0238,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,27.82,51.88,APC
"Oth resp proc, indiv",G0238,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,27.82,51.88,APC
"Oth resp proc, indiv",G0238,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,27.82,51.88,APC
"Oth resp proc, group",G0239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
"Oth resp proc, group",G0239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
"Oth resp proc, group",G0239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
"Oth resp proc, group",G0239,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
"Oth resp proc, group",G0239,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
"Oth resp proc, group",G0239,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
"Oth resp proc, group",G0239,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Initial foot exam pt lops,G0245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Initial foot exam pt lops,G0245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Initial foot exam pt lops,G0245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Initial foot exam pt lops,G0245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Initial foot exam pt lops,G0245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Initial foot exam pt lops,G0245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Initial foot exam pt lops,G0245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Followup eval of foot pt lop,G0246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Followup eval of foot pt lop,G0246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Followup eval of foot pt lop,G0246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Followup eval of foot pt lop,G0246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Followup eval of foot pt lop,G0246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Followup eval of foot pt lop,G0246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Followup eval of foot pt lop,G0246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
Routine footcare pt w lops,G0247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.98,,,,,,,fee schedule,150.12,359.84,
Routine footcare pt w lops,G0247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.42,,,,,,,fee schedule,150.12,359.84,
Routine footcare pt w lops,G0247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.12,,,,,,,fee schedule,150.12,359.84,
Routine footcare pt w lops,G0247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.33,,,,,,,fee schedule,150.12,359.84,
Routine footcare pt w lops,G0247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.91,,,,,,,fee schedule,150.12,359.84,APC
Routine footcare pt w lops,G0247,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.91,,,,,,,fee schedule,150.12,359.84,APC
Routine footcare pt w lops,G0247,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.84,,,,,,,fee schedule,150.12,359.84,APC
Demonstrate use home inr mon,G0248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,302.77,,,,,,,fee schedule,132.66,348.19,
Demonstrate use home inr mon,G0248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,247.82,,,,,,,fee schedule,132.66,348.19,
Demonstrate use home inr mon,G0248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,198.5,,,,,,,fee schedule,132.66,348.19,
Demonstrate use home inr mon,G0248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,348.19,,,,,,,fee schedule,132.66,348.19,
Demonstrate use home inr mon,G0248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,348.19,APC
Demonstrate use home inr mon,G0248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,348.19,APC
Demonstrate use home inr mon,G0248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,348.19,APC
Provide INR test mater/equip,G0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,303.73,,,,,,,fee schedule,132.66,349.29,
Provide INR test mater/equip,G0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,248.6,,,,,,,fee schedule,132.66,349.29,
Provide INR test mater/equip,G0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.13,,,,,,,fee schedule,132.66,349.29,
Provide INR test mater/equip,G0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,349.29,,,,,,,fee schedule,132.66,349.29,
Provide INR test mater/equip,G0249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,349.29,APC
Provide INR test mater/equip,G0249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,349.29,APC
Provide INR test mater/equip,G0249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,349.29,APC
MD INR test revie inter mgmt,G0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.87,,,,,,,fee schedule,4.5,7.9,
MD INR test revie inter mgmt,G0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.62,,,,,,,fee schedule,4.5,7.9,
MD INR test revie inter mgmt,G0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.5,,,,,,,fee schedule,4.5,7.9,
MD INR test revie inter mgmt,G0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.9,,,,,,,fee schedule,4.5,7.9,
PET imaging initial dx,G0252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.83,,,,,,,fee schedule,37.26,65.35,
PET imaging initial dx,G0252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.52,,,,,,,fee schedule,37.26,65.35,
PET imaging initial dx,G0252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.26,,,,,,,fee schedule,37.26,65.35,
PET imaging initial dx,G0252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.35,,,,,,,fee schedule,37.26,65.35,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1016.13,,,,,,,fee schedule,666.17,1230.92,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,831.7,,,,,,,fee schedule,666.17,1230.92,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,666.17,,,,,,,fee schedule,666.17,1230.92,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1168.55,,,,,,,fee schedule,666.17,1230.92,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,718.04,,,,,,,fee schedule,666.17,1230.92,APC
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,683.85,,,,,,,fee schedule,666.17,1230.92,APC
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1230.92,,,,,,,fee schedule,666.17,1230.92,APC
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3975.72,,,,,,,fee schedule,703.34,4572.08,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.55,,,,,,,fee schedule,703.34,4572.08,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,890.55,,,,,,,fee schedule,703.34,4572.08,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3254.13,,,,,,,fee schedule,703.34,4572.08,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2606.48,,,,,,,fee schedule,703.34,4572.08,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1024.13,,,,,,,fee schedule,703.34,4572.08,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4572.08,,,,,,,fee schedule,703.34,4572.08,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,890.55,,,,,,,fee schedule,703.34,4572.08,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.51,,,,,,,fee schedule,703.34,4572.08,APC
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,703.34,,,,,,,fee schedule,703.34,4572.08,APC
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1266.02,,,,,,,fee schedule,703.34,4572.08,APC
Removal of impacted wax md,G0268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,90.13,
Removal of impacted wax md,G0268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,90.13,
Removal of impacted wax md,G0268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,90.13,
Removal of impacted wax md,G0268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,90.13,
MNT subs tx for change dx,G0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.22,,,,,,,fee schedule,22.04,42.8,
MNT subs tx for change dx,G0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.46,,,,,,,fee schedule,22.04,42.8,
MNT subs tx for change dx,G0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.4,,,,,,,fee schedule,22.04,42.8,
MNT subs tx for change dx,G0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.8,,,,,,,fee schedule,22.04,42.8,
MNT subs tx for change dx,G0270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.14,,,,,,,fee schedule,22.04,42.8,APC
MNT subs tx for change dx,G0270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.04,,,,,,,fee schedule,22.04,42.8,APC
MNT subs tx for change dx,G0270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.67,,,,,,,fee schedule,22.04,42.8,APC
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.63,,,,,,,fee schedule,12.08,21.74,
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.25,,,,,,,fee schedule,12.08,21.74,
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.21,,,,,,,fee schedule,12.08,21.74,
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.42,,,,,,,fee schedule,12.08,21.74,
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.68,,,,,,,fee schedule,12.08,21.74,APC
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.08,,,,,,,fee schedule,12.08,21.74,APC
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.74,,,,,,,fee schedule,12.08,21.74,APC
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7238.15,,,,,,,fee schedule,4745.33,13014.22,
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5924.43,,,,,,,fee schedule,4745.33,13014.22,
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4745.33,,,,,,,fee schedule,4745.33,13014.22,
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6268.08,,,,,,,fee schedule,4745.33,13014.22,
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8323.87,,,,,,,fee schedule,4745.33,13014.22,
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5450.5,,,,,,,fee schedule,4745.33,13014.22,
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,4745.33,13014.22,APC
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,4745.33,13014.22,APC
Pild/placebo control clin tr,G0276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,4745.33,13014.22,APC
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.2,,,,,,,fee schedule,127.97,246.81,
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,159.77,,,,,,,fee schedule,127.97,246.81,
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.97,,,,,,,fee schedule,127.97,246.81,
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,224.48,,,,,,,fee schedule,127.97,246.81,
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.97,,,,,,,fee schedule,127.97,246.81,APC
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137.11,,,,,,,fee schedule,127.97,246.81,APC
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.81,,,,,,,fee schedule,127.97,246.81,APC
"Iliac art angio,cardiac cath",G0278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1006.07,,,,,,,fee schedule,659.58,1156.98,
"Iliac art angio,cardiac cath",G0278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,823.47,,,,,,,fee schedule,659.58,1156.98,
"Iliac art angio,cardiac cath",G0278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,659.58,,,,,,,fee schedule,659.58,1156.98,
"Iliac art angio,cardiac cath",G0278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1156.98,,,,,,,fee schedule,659.58,1156.98,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.28,,,,,,,fee schedule,83.44,146.37,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.18,,,,,,,fee schedule,83.44,146.37,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.44,,,,,,,fee schedule,83.44,146.37,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.37,,,,,,,fee schedule,83.44,146.37,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,12.17,,,,,,,fee schedule,11.59,20.86,APC
"Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,TC,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.59,,,,,,,fee schedule,11.59,20.86,APC
"Tomosynthesis, mammo",G0279,HCPCS,,,,,facility,outpatient,,,TC,,,Meridian Health Plan,Ambetter Exchange,20.86,,,,,,,fee schedule,11.59,20.86,APC
Elec stim unattend for press,G0281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,11.73,22.54,
Elec stim unattend for press,G0281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,11.73,22.54,
Elec stim unattend for press,G0281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,11.73,22.54,
Elec stim unattend for press,G0281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,11.73,22.54,
Elec stim unattend for press,G0281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.32,,,,,,,fee schedule,11.73,22.54,APC
Elec stim unattend for press,G0281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.73,,,,,,,fee schedule,11.73,22.54,APC
Elec stim unattend for press,G0281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.11,,,,,,,fee schedule,11.73,22.54,APC
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.6,,,,,,,fee schedule,12.18,123.63,
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.5,,,,,,,fee schedule,12.18,123.63,
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.5,,,,,,,fee schedule,12.18,123.63,
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.04,,,,,,,fee schedule,12.18,123.63,
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.85,,,,,,,fee schedule,12.18,123.63,
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.63,,,,,,,fee schedule,12.18,123.63,
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.54,,,,,,,fee schedule,12.18,123.63,
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.5,,,,,,,fee schedule,12.18,123.63,
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.79,,,,,,,fee schedule,12.18,123.63,APC
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.18,,,,,,,fee schedule,12.18,123.63,APC
Elec stim other than wound,G0283,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.92,,,,,,,fee schedule,12.18,123.63,APC
"Recon, CTA for surg plan",G0288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.31,,,,,,,fee schedule,133.29,233.81,
"Recon, CTA for surg plan",G0288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.41,,,,,,,fee schedule,133.29,233.81,
"Recon, CTA for surg plan",G0288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.29,,,,,,,fee schedule,133.29,233.81,
"Recon, CTA for surg plan",G0288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.81,,,,,,,fee schedule,133.29,233.81,
"Arthro, loose body + chondro",G0289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.49,,,,,,,fee schedule,48.18,84.51,
"Arthro, loose body + chondro",G0289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.15,,,,,,,fee schedule,48.18,84.51,
"Arthro, loose body + chondro",G0289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.18,,,,,,,fee schedule,48.18,84.51,
"Arthro, loose body + chondro",G0289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.51,,,,,,,fee schedule,48.18,84.51,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.44,,,,,,,fee schedule,27.82,66.99,
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.74,,,,,,,fee schedule,27.82,66.99,
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.82,,,,,,,fee schedule,27.82,66.99,
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.81,,,,,,,fee schedule,27.82,66.99,
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,27.82,66.99,APC
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,27.82,66.99,APC
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,27.82,66.99,APC
Visit to determ ldct elig,G0296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
Visit to determ ldct elig,G0296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
Visit to determ ldct elig,G0296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
Visit to determ ldct elig,G0296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
Visit to determ ldct elig,G0296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
Visit to determ ldct elig,G0296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
Visit to determ ldct elig,G0296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
Pre-op service LVRS complete,G0302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1292.96,,,,,,,fee schedule,371.82,1486.9,
Pre-op service LVRS complete,G0302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1058.29,,,,,,,fee schedule,371.82,1486.9,
Pre-op service LVRS complete,G0302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,847.66,,,,,,,fee schedule,371.82,1486.9,
Pre-op service LVRS complete,G0302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1486.9,,,,,,,fee schedule,371.82,1486.9,
Pre-op service LVRS complete,G0302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1486.9,APC
Pre-op service LVRS complete,G0302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1486.9,APC
Pre-op service LVRS complete,G0302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1486.9,APC
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,387.26,
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,387.26,
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,387.26,
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,387.26,
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,124.61,387.26,APC
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,124.61,387.26,APC
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,124.61,387.26,APC
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1292.96,,,,,,,fee schedule,371.82,1486.9,
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1058.29,,,,,,,fee schedule,371.82,1486.9,
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,847.66,,,,,,,fee schedule,371.82,1486.9,
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1486.9,,,,,,,fee schedule,371.82,1486.9,
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1486.9,APC
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1486.9,APC
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1486.9,APC
Post op service LVRS min 6,G0305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1292.96,,,,,,,fee schedule,371.82,1486.9,
Post op service LVRS min 6,G0305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1058.29,,,,,,,fee schedule,371.82,1486.9,
Post op service LVRS min 6,G0305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,847.66,,,,,,,fee schedule,371.82,1486.9,
Post op service LVRS min 6,G0305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1486.9,,,,,,,fee schedule,371.82,1486.9,
Post op service LVRS min 6,G0305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1486.9,APC
Post op service LVRS min 6,G0305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1486.9,APC
Post op service LVRS min 6,G0305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1486.9,APC
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.07,,,,,,,fee schedule,7.77,33.43,
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.79,,,,,,,fee schedule,7.77,33.43,
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.06,,,,,,,fee schedule,7.77,33.43,
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.43,,,,,,,fee schedule,7.77,33.43,
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.16,,,,,,,fee schedule,7.77,33.43,APC
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.77,,,,,,,fee schedule,7.77,33.43,APC
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.99,,,,,,,fee schedule,7.77,33.43,APC
CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.37,,,,,,,fee schedule,6.47,19.98,
CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.22,,,,,,,fee schedule,6.47,19.98,
CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.39,,,,,,,fee schedule,6.47,19.98,
CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.98,,,,,,,fee schedule,6.47,19.98,
CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.47,19.98,APC
CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.47,,,,,,,fee schedule,6.47,19.98,APC
CBC without platelet,G0307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.65,,,,,,,fee schedule,6.47,19.98,APC
Prolong inpt eval add15 m,G0316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.33,,,,,,,fee schedule,12.02,21.08,
Prolong inpt eval add15 m,G0316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15,,,,,,,fee schedule,12.02,21.08,
Prolong inpt eval add15 m,G0316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.02,,,,,,,fee schedule,12.02,21.08,
Prolong inpt eval add15 m,G0316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.08,,,,,,,fee schedule,12.02,21.08,
Prolong nursin fac eval 15m,G0317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.33,,,,,,,fee schedule,12.02,21.08,
Prolong nursin fac eval 15m,G0317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15,,,,,,,fee schedule,12.02,21.08,
Prolong nursin fac eval 15m,G0317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.02,,,,,,,fee schedule,12.02,21.08,
Prolong nursin fac eval 15m,G0317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.08,,,,,,,fee schedule,12.02,21.08,
Prolong home eval add 15m,G0318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.08,,,,,,,fee schedule,11.2,19.64,
Prolong home eval add 15m,G0318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.98,,,,,,,fee schedule,11.2,19.64,
Prolong home eval add 15m,G0318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.2,,,,,,,fee schedule,11.2,19.64,
Prolong home eval add 15m,G0318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.64,,,,,,,fee schedule,11.2,19.64,
Care manage beh svs 20mins,G0323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.73,,,,,,,fee schedule,37.19,67.2,
Care manage beh svs 20mins,G0323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.43,,,,,,,fee schedule,37.19,67.2,
Care manage beh svs 20mins,G0323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.19,,,,,,,fee schedule,37.19,67.2,
Care manage beh svs 20mins,G0323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.24,,,,,,,fee schedule,37.19,67.2,
Care manage beh svs 20mins,G0323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.19,67.2,APC
Care manage beh svs 20mins,G0323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.19,67.2,APC
Care manage beh svs 20mins,G0323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.19,67.2,APC
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.13,,,,,,,fee schedule,18.05,53.05,
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.76,,,,,,,fee schedule,18.05,53.05,
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.24,,,,,,,fee schedule,18.05,53.05,
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.05,,,,,,,fee schedule,18.05,53.05,
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.95,,,,,,,fee schedule,18.05,53.05,APC
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.05,,,,,,,fee schedule,18.05,53.05,APC
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.49,,,,,,,fee schedule,18.05,53.05,APC
Electromagntic tx for ulcers,G0329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.58,,,,,,,fee schedule,10,23.67,
Electromagntic tx for ulcers,G0329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.84,,,,,,,fee schedule,10,23.67,
Electromagntic tx for ulcers,G0329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.49,,,,,,,fee schedule,10,23.67,
Electromagntic tx for ulcers,G0329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.67,,,,,,,fee schedule,10,23.67,
Electromagntic tx for ulcers,G0329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.5,,,,,,,fee schedule,10,23.67,APC
Electromagntic tx for ulcers,G0329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10,,,,,,,fee schedule,10,23.67,APC
Electromagntic tx for ulcers,G0329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18,,,,,,,fee schedule,10,23.67,APC
Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3292.2,,,,,,,fee schedule,2158.37,5946.37,
Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2694.67,,,,,,,fee schedule,2158.37,5946.37,
Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2158.37,,,,,,,fee schedule,2158.37,5946.37,
Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3786.03,,,,,,,fee schedule,2158.37,5946.37,
Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3468.71,,,,,,,fee schedule,2158.37,5946.37,APC
Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3303.54,,,,,,,fee schedule,2158.37,5946.37,APC
Facility svs dental rehab,G0330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5946.37,,,,,,,fee schedule,2158.37,5946.37,APC
Hospice evaluation preelecti,G0337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.9,,,,,,,fee schedule,35.34,61.99,
Hospice evaluation preelecti,G0337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.12,,,,,,,fee schedule,35.34,61.99,
Hospice evaluation preelecti,G0337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.34,,,,,,,fee schedule,35.34,61.99,
Hospice evaluation preelecti,G0337,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.99,,,,,,,fee schedule,35.34,61.99,
Md service required for pmd,G0372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.87,,,,,,,fee schedule,4.5,7.9,
Md service required for pmd,G0372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.62,,,,,,,fee schedule,4.5,7.9,
Md service required for pmd,G0372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.5,,,,,,,fee schedule,4.5,7.9,
Md service required for pmd,G0372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.9,,,,,,,fee schedule,4.5,7.9,
Hospital observation per hr,G0378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.23,,,,,,,fee schedule,68.33,119.86,
Hospital observation per hr,G0378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.31,,,,,,,fee schedule,68.33,119.86,
Hospital observation per hr,G0378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.33,,,,,,,fee schedule,68.33,119.86,
Hospital observation per hr,G0378,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.86,,,,,,,fee schedule,68.33,119.86,
Direct refer hospital observ,G0379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,730.91,,,,,,,fee schedule,479.18,1068.1,
Direct refer hospital observ,G0379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,598.25,,,,,,,fee schedule,479.18,1068.1,
Direct refer hospital observ,G0379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,479.18,,,,,,,fee schedule,479.18,1068.1,
Direct refer hospital observ,G0379,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,840.55,,,,,,,fee schedule,479.18,1068.1,
Direct refer hospital observ,G0379,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,623.06,,,,,,,fee schedule,479.18,1068.1,APC
Direct refer hospital observ,G0379,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,593.39,,,,,,,fee schedule,479.18,1068.1,APC
Direct refer hospital observ,G0379,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1068.1,,,,,,,fee schedule,479.18,1068.1,APC
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.29,,,,,,,fee schedule,74.06,146.38,
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.19,,,,,,,fee schedule,74.06,146.38,
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.45,,,,,,,fee schedule,74.06,146.38,
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.38,,,,,,,fee schedule,74.06,146.38,
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.77,,,,,,,fee schedule,74.06,146.38,APC
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.06,,,,,,,fee schedule,74.06,146.38,APC
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,133.31,,,,,,,fee schedule,74.06,146.38,APC
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.02,,,,,,,fee schedule,74.1,166.6,
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.51,,,,,,,fee schedule,74.1,166.6,
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.1,,,,,,,fee schedule,74.1,166.6,
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.97,,,,,,,fee schedule,74.1,166.6,
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,97.18,,,,,,,fee schedule,74.1,166.6,APC
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,92.55,,,,,,,fee schedule,74.1,166.6,APC
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,166.6,,,,,,,fee schedule,74.1,166.6,APC
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,186.95,,,,,,,fee schedule,122.56,308.28,
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153.02,,,,,,,fee schedule,122.56,308.28,
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.56,,,,,,,fee schedule,122.56,308.28,
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,214.99,,,,,,,fee schedule,122.56,308.28,
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,179.83,,,,,,,fee schedule,122.56,308.28,APC
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,171.27,,,,,,,fee schedule,122.56,308.28,APC
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,308.28,,,,,,,fee schedule,122.56,308.28,APC
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,267,,,,,,,fee schedule,175.05,474.04,
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.54,,,,,,,fee schedule,175.05,474.04,
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.05,,,,,,,fee schedule,175.05,474.04,
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,307.05,,,,,,,fee schedule,175.05,474.04,
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.52,,,,,,,fee schedule,175.05,474.04,APC
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,263.35,,,,,,,fee schedule,175.05,474.04,APC
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,474.04,,,,,,,fee schedule,175.05,474.04,APC
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,550.2,,,,,,,fee schedule,360.71,736.64,
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,450.34,,,,,,,fee schedule,360.71,736.64,
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,360.71,,,,,,,fee schedule,360.71,736.64,
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,632.73,,,,,,,fee schedule,360.71,736.64,
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,429.71,,,,,,,fee schedule,360.71,736.64,APC
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,409.25,,,,,,,fee schedule,360.71,736.64,APC
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,736.64,,,,,,,fee schedule,360.71,736.64,APC
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6842.95,,,,,,,fee schedule,1328.12,7869.39,
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5600.95,,,,,,,fee schedule,1328.12,7869.39,
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4486.24,,,,,,,fee schedule,1328.12,7869.39,
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7869.39,,,,,,,fee schedule,1328.12,7869.39,
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1394.52,,,,,,,fee schedule,1328.12,7869.39,APC
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1328.12,,,,,,,fee schedule,1328.12,7869.39,APC
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2390.61,,,,,,,fee schedule,1328.12,7869.39,APC
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,24.74,67.2,
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.89,,,,,,,fee schedule,24.74,67.2,
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.74,,,,,,,fee schedule,24.74,67.2,
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,24.74,67.2,
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,24.74,67.2,APC
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,24.74,67.2,APC
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,24.74,67.2,APC
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.47,,,,,,,fee schedule,123.56,318.34,
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.26,,,,,,,fee schedule,123.56,318.34,
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.56,,,,,,,fee schedule,123.56,318.34,
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.74,,,,,,,fee schedule,123.56,318.34,
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,123.56,318.34,APC
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,123.56,318.34,APC
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,123.56,318.34,APC
Home sleep test/type 2 porta,G0398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,387.26,
Home sleep test/type 2 porta,G0398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,387.26,
Home sleep test/type 2 porta,G0398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,387.26,
Home sleep test/type 2 porta,G0398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,387.26,
Home sleep test/type 2 porta,G0398,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,124.61,387.26,APC
Home sleep test/type 2 porta,G0398,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,124.61,387.26,APC
Home sleep test/type 2 porta,G0398,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,124.61,387.26,APC
Home sleep test/type 3 porta,G0399,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,357.31,,,,,,,fee schedule,215.15,410.91,
Home sleep test/type 3 porta,G0399,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,292.46,,,,,,,fee schedule,215.15,410.91,
Home sleep test/type 3 porta,G0399,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,234.25,,,,,,,fee schedule,215.15,410.91,
Home sleep test/type 3 porta,G0399,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,410.91,,,,,,,fee schedule,215.15,410.91,
Home sleep test/type 3 porta,G0399,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,215.15,410.91,APC
Home sleep test/type 3 porta,G0399,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,215.15,410.91,APC
Home sleep test/type 3 porta,G0399,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,215.15,410.91,APC
Home sleep test/type 4 porta,G0400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.07,,,,,,,fee schedule,124.61,387.26,
Home sleep test/type 4 porta,G0400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,155.57,,,,,,,fee schedule,124.61,387.26,
Home sleep test/type 4 porta,G0400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.61,,,,,,,fee schedule,124.61,387.26,
Home sleep test/type 4 porta,G0400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.58,,,,,,,fee schedule,124.61,387.26,
Home sleep test/type 4 porta,G0400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.9,,,,,,,fee schedule,124.61,387.26,APC
Home sleep test/type 4 porta,G0400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.15,,,,,,,fee schedule,124.61,387.26,APC
Home sleep test/type 4 porta,G0400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.26,,,,,,,fee schedule,124.61,387.26,APC
Initial preventive exam,G0402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.41,,,,,,,fee schedule,104.51,238.78,
Initial preventive exam,G0402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.48,,,,,,,fee schedule,104.51,238.78,
Initial preventive exam,G0402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.51,,,,,,,fee schedule,104.51,238.78,
Initial preventive exam,G0402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.32,,,,,,,fee schedule,104.51,238.78,
Initial preventive exam,G0402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,104.51,238.78,APC
Initial preventive exam,G0402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,104.51,238.78,APC
Initial preventive exam,G0402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,104.51,238.78,APC
EKG for initial prevent exam,G0403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.04,,,,,,,fee schedule,30.84,54.1,
EKG for initial prevent exam,G0403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.5,,,,,,,fee schedule,30.84,54.1,
EKG for initial prevent exam,G0403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.84,,,,,,,fee schedule,30.84,54.1,
EKG for initial prevent exam,G0403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.1,,,,,,,fee schedule,30.84,54.1,
EKG tracing for initial prev,G0404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.51,,,,,,,fee schedule,15.41,51.88,
EKG tracing for initial prev,G0404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.24,,,,,,,fee schedule,15.41,51.88,
EKG tracing for initial prev,G0404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.41,,,,,,,fee schedule,15.41,51.88,
EKG tracing for initial prev,G0404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.04,,,,,,,fee schedule,15.41,51.88,
EKG tracing for initial prev,G0404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,15.41,51.88,APC
EKG tracing for initial prev,G0404,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,15.41,51.88,APC
EKG tracing for initial prev,G0404,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,15.41,51.88,APC
EKG interpret & report preve,G0405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.86,,,,,,,fee schedule,3.84,6.74,
EKG interpret & report preve,G0405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.8,,,,,,,fee schedule,3.84,6.74,
EKG interpret & report preve,G0405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.84,,,,,,,fee schedule,3.84,6.74,
EKG interpret & report preve,G0405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.74,,,,,,,fee schedule,3.84,6.74,
Inpt/tele follow up 15,G0406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.43,,,,,,,fee schedule,18.64,32.69,
Inpt/tele follow up 15,G0406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.27,,,,,,,fee schedule,18.64,32.69,
Inpt/tele follow up 15,G0406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.64,,,,,,,fee schedule,18.64,32.69,
Inpt/tele follow up 15,G0406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.69,,,,,,,fee schedule,18.64,32.69,
Inpt/tele follow up 25,G0407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.87,,,,,,,fee schedule,35.97,63.1,
Inpt/tele follow up 25,G0407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.91,,,,,,,fee schedule,35.97,63.1,
Inpt/tele follow up 25,G0407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.97,,,,,,,fee schedule,35.97,63.1,
Inpt/tele follow up 25,G0407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.1,,,,,,,fee schedule,35.97,63.1,
Inpt/tele follow up 35,G0408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.35,,,,,,,fee schedule,52.02,91.25,
Inpt/tele follow up 35,G0408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.95,,,,,,,fee schedule,52.02,91.25,
Inpt/tele follow up 35,G0408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.02,,,,,,,fee schedule,52.02,91.25,
Inpt/tele follow up 35,G0408,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.25,,,,,,,fee schedule,52.02,91.25,
CORF related serv 15 mins ea,G0409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.4,,,,,,,fee schedule,19.27,33.81,
CORF related serv 15 mins ea,G0409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.06,,,,,,,fee schedule,19.27,33.81,
CORF related serv 15 mins ea,G0409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.27,,,,,,,fee schedule,19.27,33.81,
CORF related serv 15 mins ea,G0409,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.81,,,,,,,fee schedule,19.27,33.81,
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1820.68,,,,,,,fee schedule,1193.64,13014.22,
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1490.23,,,,,,,fee schedule,1193.64,13014.22,
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1193.64,,,,,,,fee schedule,1193.64,13014.22,
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2093.78,,,,,,,fee schedule,1193.64,13014.22,
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,1193.64,13014.22,APC
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,1193.64,13014.22,APC
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,1193.64,13014.22,APC
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7591.63,,,,,,,fee schedule,7230.12,13014.22,APC
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7230.12,,,,,,,fee schedule,7230.12,13014.22,APC
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13014.22,,,,,,,fee schedule,7230.12,13014.22,APC
Open tx post pelvic fxcture,G0415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3423.25,,,,,,,fee schedule,3260.23,5868.42,APC
Open tx post pelvic fxcture,G0415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3260.23,,,,,,,fee schedule,3260.23,5868.42,APC
Open tx post pelvic fxcture,G0415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5868.42,,,,,,,fee schedule,3260.23,5868.42,APC
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,831.91,,,,,,,fee schedule,357.16,956.7,
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,680.92,,,,,,,fee schedule,357.16,956.7,
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,545.4,,,,,,,fee schedule,357.16,956.7,
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,956.7,,,,,,,fee schedule,357.16,956.7,
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.02,,,,,,,fee schedule,357.16,956.7,APC
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.16,,,,,,,fee schedule,357.16,956.7,APC
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,642.88,,,,,,,fee schedule,357.16,956.7,APC
Ed svc CKD ind per session,G0420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.33,,,,,,,fee schedule,52.66,207.36,
Ed svc CKD ind per session,G0420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.75,,,,,,,fee schedule,52.66,207.36,
Ed svc CKD ind per session,G0420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.66,,,,,,,fee schedule,52.66,207.36,
Ed svc CKD ind per session,G0420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.38,,,,,,,fee schedule,52.66,207.36,
Ed svc CKD ind per session,G0420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.96,,,,,,,fee schedule,52.66,207.36,APC
Ed svc CKD ind per session,G0420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,115.2,,,,,,,fee schedule,52.66,207.36,APC
Ed svc CKD ind per session,G0420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,207.36,,,,,,,fee schedule,52.66,207.36,APC
Ed svc CKD grp per session,G0421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.64,,,,,,,fee schedule,11.56,49.93,
Ed svc CKD grp per session,G0421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.44,,,,,,,fee schedule,11.56,49.93,
Ed svc CKD grp per session,G0421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.56,,,,,,,fee schedule,11.56,49.93,
Ed svc CKD grp per session,G0421,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.29,,,,,,,fee schedule,11.56,49.93,
Ed svc CKD grp per session,G0421,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.13,,,,,,,fee schedule,11.56,49.93,APC
Ed svc CKD grp per session,G0421,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.74,,,,,,,fee schedule,11.56,49.93,APC
Ed svc CKD grp per session,G0421,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49.93,,,,,,,fee schedule,11.56,49.93,APC
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.84,,,,,,,fee schedule,108.07,231.2,
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.92,,,,,,,fee schedule,108.07,231.2,
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.07,,,,,,,fee schedule,108.07,231.2,
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.57,,,,,,,fee schedule,108.07,231.2,
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.87,,,,,,,fee schedule,108.07,231.2,APC
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.44,,,,,,,fee schedule,108.07,231.2,APC
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.2,,,,,,,fee schedule,108.07,231.2,APC
Intens cardiac rehab no exer,G0423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.84,,,,,,,fee schedule,108.07,231.2,
Intens cardiac rehab no exer,G0423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.92,,,,,,,fee schedule,108.07,231.2,
Intens cardiac rehab no exer,G0423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.07,,,,,,,fee schedule,108.07,231.2,
Intens cardiac rehab no exer,G0423,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.57,,,,,,,fee schedule,108.07,231.2,
Intens cardiac rehab no exer,G0423,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.87,,,,,,,fee schedule,108.07,231.2,APC
Intens cardiac rehab no exer,G0423,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.44,,,,,,,fee schedule,108.07,231.2,APC
Intens cardiac rehab no exer,G0423,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.2,,,,,,,fee schedule,108.07,231.2,APC
Inpt/ed teleconsult30,G0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.47,,,,,,,fee schedule,48.82,85.64,
Inpt/ed teleconsult30,G0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.95,,,,,,,fee schedule,48.82,85.64,
Inpt/ed teleconsult30,G0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.82,,,,,,,fee schedule,48.82,85.64,
Inpt/ed teleconsult30,G0425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.64,,,,,,,fee schedule,48.82,85.64,
Inpt/ed teleconsult50,G0426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.85,,,,,,,fee schedule,67.43,118.28,
Inpt/ed teleconsult50,G0426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.18,,,,,,,fee schedule,67.43,118.28,
Inpt/ed teleconsult50,G0426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.43,,,,,,,fee schedule,67.43,118.28,
Inpt/ed teleconsult50,G0426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.28,,,,,,,fee schedule,67.43,118.28,
Inpt/ed teleconsult70,G0427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.81,,,,,,,fee schedule,101.49,178.03,
Inpt/ed teleconsult70,G0427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,126.71,,,,,,,fee schedule,101.49,178.03,
Inpt/ed teleconsult70,G0427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.49,,,,,,,fee schedule,101.49,178.03,
Inpt/ed teleconsult70,G0427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.03,,,,,,,fee schedule,101.49,178.03,
Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.06,,,,,,,fee schedule,93.79,3700.55,
Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.09,,,,,,,fee schedule,93.79,3700.55,
Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.79,,,,,,,fee schedule,93.79,3700.55,
Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.52,,,,,,,fee schedule,93.79,3700.55,
Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,93.79,3700.55,APC
Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,93.79,3700.55,APC
Dermal filler injection(s),G0429,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,93.79,3700.55,APC
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.69,,,,,,,fee schedule,19.57,113.49,
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.78,,,,,,,fee schedule,19.57,113.49,
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.7,,,,,,,fee schedule,19.57,113.49,
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.49,,,,,,,fee schedule,19.57,113.49,
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.55,,,,,,,fee schedule,19.57,113.49,APC
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.57,,,,,,,fee schedule,19.57,113.49,APC
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.23,,,,,,,fee schedule,19.57,113.49,APC
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.77,,,,,,,fee schedule,18.29,57.24,
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.74,,,,,,,fee schedule,18.29,57.24,
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.63,,,,,,,fee schedule,18.29,57.24,
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.24,,,,,,,fee schedule,18.29,57.24,
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.2,,,,,,,fee schedule,18.29,57.24,APC
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.29,,,,,,,fee schedule,18.29,57.24,APC
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.92,,,,,,,fee schedule,18.29,57.24,APC
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.89,,,,,,,fee schedule,11.98,51.62,
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.74,,,,,,,fee schedule,11.98,51.62,
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.43,,,,,,,fee schedule,11.98,51.62,
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.62,,,,,,,fee schedule,11.98,51.62,
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,11.98,51.62,APC
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.98,,,,,,,fee schedule,11.98,51.62,APC
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.56,,,,,,,fee schedule,11.98,51.62,APC
"PPPS, initial visit",G0438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.43,,,,,,,fee schedule,145.17,302.35,
"PPPS, initial visit",G0438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.24,,,,,,,fee schedule,145.17,302.35,
"PPPS, initial visit",G0438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.17,,,,,,,fee schedule,145.17,302.35,
"PPPS, initial visit",G0438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,254.64,,,,,,,fee schedule,145.17,302.35,
"PPPS, initial visit",G0438,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,176.37,,,,,,,fee schedule,145.17,302.35,APC
"PPPS, initial visit",G0438,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,167.97,,,,,,,fee schedule,145.17,302.35,APC
"PPPS, initial visit",G0438,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,302.35,,,,,,,fee schedule,145.17,302.35,APC
"PPPS, subseq visit",G0439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.6,,,,,,,fee schedule,107.91,237.89,
"PPPS, subseq visit",G0439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.73,,,,,,,fee schedule,107.91,237.89,
"PPPS, subseq visit",G0439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.91,,,,,,,fee schedule,107.91,237.89,
"PPPS, subseq visit",G0439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.29,,,,,,,fee schedule,107.91,237.89,
"PPPS, subseq visit",G0439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.77,,,,,,,fee schedule,107.91,237.89,APC
"PPPS, subseq visit",G0439,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.16,,,,,,,fee schedule,107.91,237.89,APC
"PPPS, subseq visit",G0439,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,237.89,,,,,,,fee schedule,107.91,237.89,APC
Annual alcohol screen 15 min,G0442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,24.74,67.2,
Annual alcohol screen 15 min,G0442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.89,,,,,,,fee schedule,24.74,67.2,
Annual alcohol screen 15 min,G0442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.74,,,,,,,fee schedule,24.74,67.2,
Annual alcohol screen 15 min,G0442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,24.74,67.2,
Annual alcohol screen 15 min,G0442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,24.74,67.2,APC
Annual alcohol screen 15 min,G0442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,24.74,67.2,APC
Annual alcohol screen 15 min,G0442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,24.74,67.2,APC
Brief alcohol misuse counsel,G0443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
Brief alcohol misuse counsel,G0443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
Brief alcohol misuse counsel,G0443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
Brief alcohol misuse counsel,G0443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
Brief alcohol misuse counsel,G0443,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
Brief alcohol misuse counsel,G0443,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
Brief alcohol misuse counsel,G0443,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
Depression Screen annual,G0444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,24.74,67.2,
Depression Screen annual,G0444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.89,,,,,,,fee schedule,24.74,67.2,
Depression Screen annual,G0444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.74,,,,,,,fee schedule,24.74,67.2,
Depression Screen annual,G0444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,24.74,67.2,
Depression Screen annual,G0444,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,24.74,67.2,APC
Depression Screen annual,G0444,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,24.74,67.2,APC
Depression Screen annual,G0444,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,24.74,67.2,APC
High inten beh couns STD 30m,G0445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
High inten beh couns STD 30m,G0445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
High inten beh couns STD 30m,G0445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
High inten beh couns STD 30m,G0445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
High inten beh couns STD 30m,G0445,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
High inten beh couns STD 30m,G0445,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
High inten beh couns STD 30m,G0445,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
Intens behave ther cardio dx,G0446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,24.74,67.2,
Intens behave ther cardio dx,G0446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.89,,,,,,,fee schedule,24.74,67.2,
Intens behave ther cardio dx,G0446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.74,,,,,,,fee schedule,24.74,67.2,
Intens behave ther cardio dx,G0446,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,24.74,67.2,
Intens behave ther cardio dx,G0446,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,24.74,67.2,APC
Intens behave ther cardio dx,G0446,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,24.74,67.2,APC
Intens behave ther cardio dx,G0446,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,24.74,67.2,APC
Behavior counsel obesity 15m,G0447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
Behavior counsel obesity 15m,G0447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
Behavior counsel obesity 15m,G0447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
Behavior counsel obesity 15m,G0447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
Behavior counsel obesity 15m,G0447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
Behavior counsel obesity 15m,G0447,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
Behavior counsel obesity 15m,G0447,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
Devlopment test interpt&rep,G0451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,68.9,182.2,
Devlopment test interpt&rep,G0451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,68.9,182.2,
Devlopment test interpt&rep,G0451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,68.9,182.2,
Devlopment test interpt&rep,G0451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,68.9,182.2,
Devlopment test interpt&rep,G0451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,68.9,182.2,APC
Devlopment test interpt&rep,G0451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,68.9,182.2,APC
Devlopment test interpt&rep,G0451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,68.9,182.2,APC
Molecular pathology interpr,G0452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.69,,,,,,,fee schedule,8.98,15.74,
Molecular pathology interpr,G0452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.21,,,,,,,fee schedule,8.98,15.74,
Molecular pathology interpr,G0452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.98,,,,,,,fee schedule,8.98,15.74,
Molecular pathology interpr,G0452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.74,,,,,,,fee schedule,8.98,15.74,
Cont intraop neuro monitor,G0453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.44,,,,,,,fee schedule,17.99,31.56,
Cont intraop neuro monitor,G0453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.46,,,,,,,fee schedule,17.99,31.56,
Cont intraop neuro monitor,G0453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.99,,,,,,,fee schedule,17.99,31.56,
Cont intraop neuro monitor,G0453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.56,,,,,,,fee schedule,17.99,31.56,
MD document visit by NPP,G0454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.87,,,,,,,fee schedule,4.5,7.9,
MD document visit by NPP,G0454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.62,,,,,,,fee schedule,4.5,7.9,
MD document visit by NPP,G0454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.5,,,,,,,fee schedule,4.5,7.9,
MD document visit by NPP,G0454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.9,,,,,,,fee schedule,4.5,7.9,
Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.21,,,,,,,fee schedule,258.44,1667.9,
Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,322.66,,,,,,,fee schedule,258.44,1667.9,
Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,258.44,,,,,,,fee schedule,258.44,1667.9,
Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.34,,,,,,,fee schedule,258.44,1667.9,
Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,972.94,,,,,,,fee schedule,258.44,1667.9,APC
Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,926.61,,,,,,,fee schedule,258.44,1667.9,APC
Fecal microbiota prep instil,G0455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1667.9,,,,,,,fee schedule,258.44,1667.9,APC
LDR Prostate Brachy comp rat,G0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5167.15,,,,,,,fee schedule,3387.58,5942.22,
LDR Prostate Brachy comp rat,G0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4783.55,,,,,,,fee schedule,3387.58,5942.22,
LDR Prostate Brachy comp rat,G0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4783.55,,,,,,,fee schedule,3387.58,5942.22,
LDR Prostate Brachy comp rat,G0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4229.31,,,,,,,fee schedule,3387.58,5942.22,
LDR Prostate Brachy comp rat,G0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3387.58,,,,,,,fee schedule,3387.58,5942.22,
LDR Prostate Brachy comp rat,G0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5501.08,,,,,,,fee schedule,3387.58,5942.22,
LDR Prostate Brachy comp rat,G0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5942.22,,,,,,,fee schedule,3387.58,5942.22,
LDR Prostate Brachy comp rat,G0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4783.55,,,,,,,fee schedule,3387.58,5942.22,
Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.66,,,,,,,fee schedule,10.92,19.16,
Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.64,,,,,,,fee schedule,10.92,19.16,
Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.92,,,,,,,fee schedule,10.92,19.16,
Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.16,,,,,,,fee schedule,10.92,19.16,
Autologous PRP for ulcers,G0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2135.29,,,,,,,fee schedule,1399.9,3700.55,
Autologous PRP for ulcers,G0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1747.73,,,,,,,fee schedule,1399.9,3700.55,
Autologous PRP for ulcers,G0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1399.9,,,,,,,fee schedule,1399.9,3700.55,
Autologous PRP for ulcers,G0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2455.58,,,,,,,fee schedule,1399.9,3700.55,
Autologous PRP for ulcers,G0460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2158.65,,,,,,,fee schedule,1399.9,3700.55,APC
Autologous PRP for ulcers,G0460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2055.86,,,,,,,fee schedule,1399.9,3700.55,APC
Autologous PRP for ulcers,G0460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3700.55,,,,,,,fee schedule,1399.9,3700.55,APC
Hospital outpt clinic visit,G0463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.79,,,,,,,fee schedule,73.29,238.78,
Hospital outpt clinic visit,G0463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.5,,,,,,,fee schedule,73.29,238.78,
Hospital outpt clinic visit,G0463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.29,,,,,,,fee schedule,73.29,238.78,
Hospital outpt clinic visit,G0463,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.56,,,,,,,fee schedule,73.29,238.78,
Hospital outpt clinic visit,G0463,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,73.29,238.78,APC
Hospital outpt clinic visit,G0463,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,73.29,238.78,APC
Hospital outpt clinic visit,G0463,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,73.29,238.78,APC
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3398.3,,,,,,,fee schedule,2227.93,3908.05,
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2781.51,,,,,,,fee schedule,2227.93,3908.05,
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2227.93,,,,,,,fee schedule,2227.93,3908.05,
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3908.05,,,,,,,fee schedule,2227.93,3908.05,
Ven blood coll snf/hha,G0471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.65,,,,,,,fee schedule,8.95,20.41,
Ven blood coll snf/hha,G0471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.17,,,,,,,fee schedule,8.95,20.41,
Ven blood coll snf/hha,G0471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.95,,,,,,,fee schedule,8.95,20.41,
Ven blood coll snf/hha,G0471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.7,,,,,,,fee schedule,8.95,20.41,
Ven blood coll snf/hha,G0471,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.91,,,,,,,fee schedule,8.95,20.41,APC
Ven blood coll snf/hha,G0471,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.34,,,,,,,fee schedule,8.95,20.41,APC
Ven blood coll snf/hha,G0471,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.41,,,,,,,fee schedule,8.95,20.41,APC
Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.64,,,,,,,fee schedule,35.82,83.43,
Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.72,,,,,,,fee schedule,35.82,83.43,
Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.82,,,,,,,fee schedule,35.82,83.43,
Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.84,,,,,,,fee schedule,35.82,83.43,
Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,35.82,83.43,APC
Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.35,,,,,,,fee schedule,35.82,83.43,APC
Hep c screen high risk/other,G0472,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.43,,,,,,,fee schedule,35.82,83.43,APC
Group behave couns 2-10,G0473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.09,,,,,,,fee schedule,37.33,120.85,
Group behave couns 2-10,G0473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.02,,,,,,,fee schedule,37.33,120.85,
Group behave couns 2-10,G0473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.9,,,,,,,fee schedule,37.33,120.85,
Group behave couns 2-10,G0473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.85,,,,,,,fee schedule,37.33,120.85,
Group behave couns 2-10,G0473,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,120.85,APC
Group behave couns 2-10,G0473,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,120.85,APC
Group behave couns 2-10,G0473,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,120.85,APC
Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.92,,,,,,,fee schedule,24.08,79.26,
Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.41,,,,,,,fee schedule,24.08,79.26,
Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.18,,,,,,,fee schedule,24.08,79.26,
Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.26,,,,,,,fee schedule,24.08,79.26,
Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.28,,,,,,,fee schedule,24.08,79.26,APC
Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.08,,,,,,,fee schedule,24.08,79.26,APC
Hiv combination assay,G0475,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.34,,,,,,,fee schedule,24.08,79.26,APC
Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.42,,,,,,,fee schedule,35.09,151.13,
Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.57,,,,,,,fee schedule,35.09,151.13,
Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.16,,,,,,,fee schedule,35.09,151.13,
Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.13,,,,,,,fee schedule,35.09,151.13,
Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,151.13,APC
Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,151.13,APC
Hpv combo assay ca screen,G0476,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,151.13,APC
Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,218.16,,,,,,,fee schedule,114.43,250.88,
Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.56,,,,,,,fee schedule,114.43,250.88,
Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.03,,,,,,,fee schedule,114.43,250.88,
Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.88,,,,,,,fee schedule,114.43,250.88,
Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,114.43,250.88,APC
Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,114.43,,,,,,,fee schedule,114.43,250.88,APC
Drug test def 1-7 classes,G0480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,205.97,,,,,,,fee schedule,114.43,250.88,APC
Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.57,,,,,,,fee schedule,156.59,326.11,
Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.1,,,,,,,fee schedule,156.59,326.11,
Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.91,,,,,,,fee schedule,156.59,326.11,
Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.11,,,,,,,fee schedule,156.59,326.11,
Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.42,,,,,,,fee schedule,156.59,326.11,APC
Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,156.59,,,,,,,fee schedule,156.59,326.11,APC
Drug test def 8-14 classes,G0481,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,281.86,,,,,,,fee schedule,156.59,326.11,APC
Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.96,,,,,,,fee schedule,198.74,413.95,
Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,294.63,,,,,,,fee schedule,198.74,413.95,
Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.99,,,,,,,fee schedule,198.74,413.95,
Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.95,,,,,,,fee schedule,198.74,413.95,
Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,198.74,413.95,APC
Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.74,,,,,,,fee schedule,198.74,413.95,APC
Drug test def 15-21 classes,G0482,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,357.73,,,,,,,fee schedule,198.74,413.95,APC
Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,447.19,,,,,,,fee schedule,246.92,514.27,
Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,366.03,,,,,,,fee schedule,246.92,514.27,
Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,293.18,,,,,,,fee schedule,246.92,514.27,
Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,514.27,,,,,,,fee schedule,246.92,514.27,
Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,246.92,514.27,APC
Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,246.92,,,,,,,fee schedule,246.92,514.27,APC
Drug test def 22+ classes,G0483,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.46,,,,,,,fee schedule,246.92,514.27,APC
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,417.92,,,,,,,fee schedule,273.99,592.41,
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.07,,,,,,,fee schedule,273.99,592.41,
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.99,,,,,,,fee schedule,273.99,592.41,
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.61,,,,,,,fee schedule,273.99,592.41,
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.57,,,,,,,fee schedule,273.99,592.41,APC
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.12,,,,,,,fee schedule,273.99,592.41,APC
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,592.41,,,,,,,fee schedule,273.99,592.41,APC
Hepb screen high risk indiv,G0499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.68,,,,,,,fee schedule,28.27,50.89,APC
Hepb screen high risk indiv,G0499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.27,,,,,,,fee schedule,28.27,50.89,APC
Hepb screen high risk indiv,G0499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.89,,,,,,,fee schedule,28.27,50.89,APC
Mod sedat endo service >5yrs,G0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,149.91,,,,,,,fee schedule,98.28,172.4,
Mod sedat endo service >5yrs,G0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122.7,,,,,,,fee schedule,98.28,172.4,
Mod sedat endo service >5yrs,G0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,98.28,,,,,,,fee schedule,98.28,172.4,
Mod sedat endo service >5yrs,G0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.4,,,,,,,fee schedule,98.28,172.4,
Comp asses care plan ccm svc,G0506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.29,,,,,,,fee schedule,54.6,95.78,
Comp asses care plan ccm svc,G0506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.17,,,,,,,fee schedule,54.6,95.78,
Comp asses care plan ccm svc,G0506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.6,,,,,,,fee schedule,54.6,95.78,
Comp asses care plan ccm svc,G0506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.78,,,,,,,fee schedule,54.6,95.78,
Crit care telehea consult 60,G0508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.3,,,,,,,fee schedule,86.08,151,
Crit care telehea consult 60,G0508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.47,,,,,,,fee schedule,86.08,151,
Crit care telehea consult 60,G0508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.08,,,,,,,fee schedule,86.08,151,
Crit care telehea consult 60,G0508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151,,,,,,,fee schedule,86.08,151,
Crit care telehea consult 50,G0509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,126.4,,,,,,,fee schedule,82.87,145.36,
Crit care telehea consult 50,G0509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.46,,,,,,,fee schedule,82.87,145.36,
Crit care telehea consult 50,G0509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.87,,,,,,,fee schedule,82.87,145.36,
Crit care telehea consult 50,G0509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,145.36,,,,,,,fee schedule,82.87,145.36,
Ccm/bhi by rhc/fqhc 20min mo,G0511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.4,,,,,,,fee schedule,60.58,106.26,
Ccm/bhi by rhc/fqhc 20min mo,G0511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.63,,,,,,,fee schedule,60.58,106.26,
Ccm/bhi by rhc/fqhc 20min mo,G0511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.58,,,,,,,fee schedule,60.58,106.26,
Ccm/bhi by rhc/fqhc 20min mo,G0511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.26,,,,,,,fee schedule,60.58,106.26,
Cocm by rhc/fqhc 60 min mo,G0512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.03,,,,,,,fee schedule,148.84,261.08,
Cocm by rhc/fqhc 60 min mo,G0512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.82,,,,,,,fee schedule,148.84,261.08,
Cocm by rhc/fqhc 60 min mo,G0512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.84,,,,,,,fee schedule,148.84,261.08,
Cocm by rhc/fqhc 60 min mo,G0512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.08,,,,,,,fee schedule,148.84,261.08,
"Prolong prev svcs, first 30m",G0513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57,,,,,,,fee schedule,37.37,65.55,
"Prolong prev svcs, first 30m",G0513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.65,,,,,,,fee schedule,37.37,65.55,
"Prolong prev svcs, first 30m",G0513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.37,,,,,,,fee schedule,37.37,65.55,
"Prolong prev svcs, first 30m",G0513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.55,,,,,,,fee schedule,37.37,65.55,
"Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57,,,,,,,fee schedule,37.37,65.55,
"Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.65,,,,,,,fee schedule,37.37,65.55,
"Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.37,,,,,,,fee schedule,37.37,65.55,
"Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.55,,,,,,,fee schedule,37.37,65.55,
"Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,900.96,,,,,,,fee schedule,445.12,1036.1,
"Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,737.44,,,,,,,fee schedule,445.12,1036.1,
"Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,590.67,,,,,,,fee schedule,445.12,1036.1,
"Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1036.1,,,,,,,fee schedule,445.12,1036.1,
"Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,445.12,1036.1,APC
"Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,445.12,1036.1,APC
"Insert drug del implant, >4",G0516,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,445.12,1036.1,APC
Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,900.96,,,,,,,fee schedule,445.12,1036.1,
Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,737.44,,,,,,,fee schedule,445.12,1036.1,
Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,590.67,,,,,,,fee schedule,445.12,1036.1,
Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1036.1,,,,,,,fee schedule,445.12,1036.1,
Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,445.12,1036.1,APC
Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,445.12,1036.1,APC
Remove drug implant,G0517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,445.12,1036.1,APC
Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,900.96,,,,,,,fee schedule,445.12,1036.1,
Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,737.44,,,,,,,fee schedule,445.12,1036.1,
Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,590.67,,,,,,,fee schedule,445.12,1036.1,
Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1036.1,,,,,,,fee schedule,445.12,1036.1,
Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.37,,,,,,,fee schedule,445.12,1036.1,APC
Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,445.12,,,,,,,fee schedule,445.12,1036.1,APC
Remove w insert drug implant,G0518,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,801.21,,,,,,,fee schedule,445.12,1036.1,APC
Risk ascvd tst once pr 12 mo,G0537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.71,,,,,,,fee schedule,31.93,67.2,
Risk ascvd tst once pr 12 mo,G0537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.87,,,,,,,fee schedule,31.93,67.2,
Risk ascvd tst once pr 12 mo,G0537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.93,,,,,,,fee schedule,31.93,67.2,
Risk ascvd tst once pr 12 mo,G0537,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.02,,,,,,,fee schedule,31.93,67.2,
Risk ascvd tst once pr 12 mo,G0537,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,31.93,67.2,APC
Risk ascvd tst once pr 12 mo,G0537,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,31.93,67.2,APC
Risk ascvd tst once pr 12 mo,G0537,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,31.93,67.2,APC
Ascvd rsk mng clin stf pr mo,G0538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.24,,,,,,,fee schedule,99.15,182.2,
Ascvd rsk mng clin stf pr mo,G0538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.79,,,,,,,fee schedule,99.15,182.2,
Ascvd rsk mng clin stf pr mo,G0538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.15,,,,,,,fee schedule,99.15,182.2,
Ascvd rsk mng clin stf pr mo,G0538,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.93,,,,,,,fee schedule,99.15,182.2,
Ascvd rsk mng clin stf pr mo,G0538,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,99.15,182.2,APC
Ascvd rsk mng clin stf pr mo,G0538,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,99.15,182.2,APC
Ascvd rsk mng clin stf pr mo,G0538,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,99.15,182.2,APC
Initial care training 30 m,G0539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.67,,,,,,,fee schedule,20.11,70.69,
Initial care training 30 m,G0539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.1,,,,,,,fee schedule,20.11,70.69,
Initial care training 30 m,G0539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.11,,,,,,,fee schedule,20.11,70.69,
Initial care training 30 m,G0539,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.27,,,,,,,fee schedule,20.11,70.69,
Initial care training 30 m,G0539,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.23,,,,,,,fee schedule,20.11,70.69,APC
Initial care training 30 m,G0539,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.27,,,,,,,fee schedule,20.11,70.69,APC
Initial care training 30 m,G0539,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.69,,,,,,,fee schedule,20.11,70.69,APC
Train for caregiver add 15,G0540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.69,,,,,,,fee schedule,8.32,37.4,
Train for caregiver add 15,G0540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.39,,,,,,,fee schedule,8.32,37.4,
Train for caregiver add 15,G0540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.32,,,,,,,fee schedule,8.32,37.4,
Train for caregiver add 15,G0540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.59,,,,,,,fee schedule,8.32,37.4,
Train for caregiver add 15,G0540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.82,,,,,,,fee schedule,8.32,37.4,APC
Train for caregiver add 15,G0540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.78,,,,,,,fee schedule,8.32,37.4,APC
Train for caregiver add 15,G0540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.4,,,,,,,fee schedule,8.32,37.4,APC
No pt prsnt train initial 30,G0541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.67,,,,,,,fee schedule,20.11,51.88,
No pt prsnt train initial 30,G0541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.1,,,,,,,fee schedule,20.11,51.88,
No pt prsnt train initial 30,G0541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.11,,,,,,,fee schedule,20.11,51.88,
No pt prsnt train initial 30,G0541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.27,,,,,,,fee schedule,20.11,51.88,
No pt prsnt train initial 30,G0541,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,20.11,51.88,APC
No pt prsnt train initial 30,G0541,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,20.11,51.88,APC
No pt prsnt train initial 30,G0541,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,20.11,51.88,APC
No pt prsnt train add 15,G0542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.69,,,,,,,fee schedule,8.32,14.59,
No pt prsnt train add 15,G0542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.39,,,,,,,fee schedule,8.32,14.59,
No pt prsnt train add 15,G0542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.32,,,,,,,fee schedule,8.32,14.59,
No pt prsnt train add 15,G0542,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.59,,,,,,,fee schedule,8.32,14.59,
Group train w/o patient,G0543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.27,,,,,,,fee schedule,15.26,51.88,
Group train w/o patient,G0543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.05,,,,,,,fee schedule,15.26,51.88,
Group train w/o patient,G0543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.26,,,,,,,fee schedule,15.26,51.88,
Group train w/o patient,G0543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.76,,,,,,,fee schedule,15.26,51.88,
Group train w/o patient,G0543,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,15.26,51.88,APC
Group train w/o patient,G0543,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,15.26,51.88,APC
Group train w/o patient,G0543,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,15.26,51.88,APC
Post d/c phone follow up,G0544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.24,,,,,,,fee schedule,99.15,182.2,
Post d/c phone follow up,G0544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.79,,,,,,,fee schedule,99.15,182.2,
Post d/c phone follow up,G0544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.15,,,,,,,fee schedule,99.15,182.2,
Post d/c phone follow up,G0544,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.93,,,,,,,fee schedule,99.15,182.2,
Post d/c phone follow up,G0544,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,99.15,182.2,APC
Post d/c phone follow up,G0544,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,99.15,182.2,APC
Post d/c phone follow up,G0544,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,99.15,182.2,APC
Inherent visit to inpt,G0545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.1,,,,,,,fee schedule,13.18,23.12,
Inherent visit to inpt,G0545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.45,,,,,,,fee schedule,13.18,23.12,
Inherent visit to inpt,G0545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.18,,,,,,,fee schedule,13.18,23.12,
Inherent visit to inpt,G0545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.12,,,,,,,fee schedule,13.18,23.12,
Phone/internet ehr assess,G0546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.94,,,,,,,fee schedule,5.21,9.13,
Phone/internet ehr assess,G0546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.5,,,,,,,fee schedule,5.21,9.13,
Phone/internet ehr assess,G0546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.21,,,,,,,fee schedule,5.21,9.13,
Phone/internet ehr assess,G0546,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.13,,,,,,,fee schedule,5.21,9.13,
Phone/internet svs 11-20 m,G0547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.4,,,,,,,fee schedule,10.75,18.86,
Phone/internet svs 11-20 m,G0547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.42,,,,,,,fee schedule,10.75,18.86,
Phone/internet svs 11-20 m,G0547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.75,,,,,,,fee schedule,10.75,18.86,
Phone/internet svs 11-20 m,G0547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.86,,,,,,,fee schedule,10.75,18.86,
Phone/inter svs 21-30 m,G0548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.85,,,,,,,fee schedule,16.29,28.58,
Phone/inter svs 21-30 m,G0548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.34,,,,,,,fee schedule,16.29,28.58,
Phone/inter svs 21-30 m,G0548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.29,,,,,,,fee schedule,16.29,28.58,
Phone/inter svs 21-30 m,G0548,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.58,,,,,,,fee schedule,16.29,28.58,
Phone/inter for treat>31m,G0549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.84,,,,,,,fee schedule,22.19,38.92,
Phone/inter for treat>31m,G0549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.7,,,,,,,fee schedule,22.19,38.92,
Phone/inter for treat>31m,G0549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.19,,,,,,,fee schedule,22.19,38.92,
Phone/inter for treat>31m,G0549,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.92,,,,,,,fee schedule,22.19,38.92,
Phone/inter for dx/treat >5m,G0550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.76,,,,,,,fee schedule,9.02,15.82,
Phone/inter for dx/treat >5m,G0550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.26,,,,,,,fee schedule,9.02,15.82,
Phone/inter for dx/treat >5m,G0550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.02,,,,,,,fee schedule,9.02,15.82,
Phone/inter for dx/treat >5m,G0550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.82,,,,,,,fee schedule,9.02,15.82,
Phn/intr svs fr dx treat 30m,G0551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.4,,,,,,,fee schedule,10.75,18.86,
Phn/intr svs fr dx treat 30m,G0551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.42,,,,,,,fee schedule,10.75,18.86,
Phn/intr svs fr dx treat 30m,G0551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.75,,,,,,,fee schedule,10.75,18.86,
Phn/intr svs fr dx treat 30m,G0551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.86,,,,,,,fee schedule,10.75,18.86,
Supply of digital device,G0552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,210.71,,,,,,,fee schedule,132.66,242.32,
Supply of digital device,G0552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,172.47,,,,,,,fee schedule,132.66,242.32,
Supply of digital device,G0552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.14,,,,,,,fee schedule,132.66,242.32,
Supply of digital device,G0552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,242.32,,,,,,,fee schedule,132.66,242.32,
Supply of digital device,G0552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,242.32,APC
Supply of digital device,G0552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,242.32,APC
Supply of digital device,G0552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,242.32,APC
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,210.71,,,,,,,fee schedule,132.66,242.32,
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,172.47,,,,,,,fee schedule,132.66,242.32,
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,138.14,,,,,,,fee schedule,132.66,242.32,
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,242.32,,,,,,,fee schedule,132.66,242.32,
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.29,,,,,,,fee schedule,132.66,242.32,APC
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.66,,,,,,,fee schedule,132.66,242.32,APC
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.78,,,,,,,fee schedule,132.66,242.32,APC
Add 20 m of monthly tx,G0554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.67,,,,,,,fee schedule,20.11,35.27,
Add 20 m of monthly tx,G0554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.1,,,,,,,fee schedule,20.11,35.27,
Add 20 m of monthly tx,G0554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.11,,,,,,,fee schedule,20.11,35.27,
Add 20 m of monthly tx,G0554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.27,,,,,,,fee schedule,20.11,35.27,
Replacment pt electronic sys,G0555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1663.44,,,,,,,fee schedule,855.65,1912.96,
Replacment pt electronic sys,G0555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1361.53,,,,,,,fee schedule,855.65,1912.96,
Replacment pt electronic sys,G0555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1090.55,,,,,,,fee schedule,855.65,1912.96,
Replacment pt electronic sys,G0555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1912.96,,,,,,,fee schedule,855.65,1912.96,
Replacment pt electronic sys,G0555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.43,,,,,,,fee schedule,855.65,1912.96,APC
Replacment pt electronic sys,G0555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,855.65,,,,,,,fee schedule,855.65,1912.96,APC
Replacment pt electronic sys,G0555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1540.17,,,,,,,fee schedule,855.65,1912.96,APC
Adv prim care mgmt lvl 1,G0556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.71,,,,,,,fee schedule,31.93,67.2,
Adv prim care mgmt lvl 1,G0556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.87,,,,,,,fee schedule,31.93,67.2,
Adv prim care mgmt lvl 1,G0556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.93,,,,,,,fee schedule,31.93,67.2,
Adv prim care mgmt lvl 1,G0556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.02,,,,,,,fee schedule,31.93,67.2,
Adv prim care mgmt lvl 1,G0556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,31.93,67.2,APC
Adv prim care mgmt lvl 1,G0556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,31.93,67.2,APC
Adv prim care mgmt lvl 1,G0556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,31.93,67.2,APC
Adv prim care mgmt lvl 2,G0557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.71,,,,,,,fee schedule,31.93,67.2,
Adv prim care mgmt lvl 2,G0557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.87,,,,,,,fee schedule,31.93,67.2,
Adv prim care mgmt lvl 2,G0557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.93,,,,,,,fee schedule,31.93,67.2,
Adv prim care mgmt lvl 2,G0557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.02,,,,,,,fee schedule,31.93,67.2,
Adv prim care mgmt lvl 2,G0557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,31.93,67.2,APC
Adv prim care mgmt lvl 2,G0557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,31.93,67.2,APC
Adv prim care mgmt lvl 2,G0557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,31.93,67.2,APC
Adv prim care mgmt lvl 3,G0558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.24,,,,,,,fee schedule,99.15,182.2,
Adv prim care mgmt lvl 3,G0558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.79,,,,,,,fee schedule,99.15,182.2,
Adv prim care mgmt lvl 3,G0558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.15,,,,,,,fee schedule,99.15,182.2,
Adv prim care mgmt lvl 3,G0558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.93,,,,,,,fee schedule,99.15,182.2,
Adv prim care mgmt lvl 3,G0558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,99.15,182.2,APC
Adv prim care mgmt lvl 3,G0558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,99.15,182.2,APC
Adv prim care mgmt lvl 3,G0558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,99.15,182.2,APC
Unrelat prac follow up visit,G0559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.24,,,,,,,fee schedule,2.78,4.88,
Unrelat prac follow up visit,G0559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.47,,,,,,,fee schedule,2.78,4.88,
Unrelat prac follow up visit,G0559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.78,,,,,,,fee schedule,2.78,4.88,
Unrelat prac follow up visit,G0559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.88,,,,,,,fee schedule,2.78,4.88,
Safety plan interven,G0560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.47,,,,,,,fee schedule,5.55,70.6,
Safety plan interven,G0560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.93,,,,,,,fee schedule,5.55,70.6,
Safety plan interven,G0560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.55,,,,,,,fee schedule,5.55,70.6,
Safety plan interven,G0560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.74,,,,,,,fee schedule,5.55,70.6,
Safety plan interven,G0560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.18,,,,,,,fee schedule,5.55,70.6,APC
Safety plan interven,G0560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.22,,,,,,,fee schedule,5.55,70.6,APC
Safety plan interven,G0560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.6,,,,,,,fee schedule,5.55,70.6,APC
Complex simulation w/pet-ct,G0562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3189.07,,,,,,,fee schedule,1902.28,3667.43,
Complex simulation w/pet-ct,G0562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2610.25,,,,,,,fee schedule,1902.28,3667.43,
Complex simulation w/pet-ct,G0562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2090.75,,,,,,,fee schedule,1902.28,3667.43,
Complex simulation w/pet-ct,G0562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3667.43,,,,,,,fee schedule,1902.28,3667.43,
Complex simulation w/pet-ct,G0562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1997.4,,,,,,,fee schedule,1902.28,3667.43,APC
Complex simulation w/pet-ct,G0562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1902.28,,,,,,,fee schedule,1902.28,3667.43,APC
Complex simulation w/pet-ct,G0562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3424.11,,,,,,,fee schedule,1902.28,3667.43,APC
Sbrt w/positron emission del,G0563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6132.07,,,,,,,fee schedule,3170.15,7051.88,
Sbrt w/positron emission del,G0563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5019.1,,,,,,,fee schedule,3170.15,7051.88,
Sbrt w/positron emission del,G0563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4020.19,,,,,,,fee schedule,3170.15,7051.88,
Sbrt w/positron emission del,G0563,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7051.88,,,,,,,fee schedule,3170.15,7051.88,
Sbrt w/positron emission del,G0563,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3328.66,,,,,,,fee schedule,3170.15,7051.88,APC
Sbrt w/positron emission del,G0563,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3170.15,,,,,,,fee schedule,3170.15,7051.88,APC
Sbrt w/positron emission del,G0563,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5706.27,,,,,,,fee schedule,3170.15,7051.88,APC
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.62,,,,,,,fee schedule,128.21,230.78,APC
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.21,,,,,,,fee schedule,128.21,230.78,APC
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,230.78,,,,,,,fee schedule,128.21,230.78,APC
Screening Hep C detect,G0567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.09,63.16,APC
Screening Hep C detect,G0567,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.09,,,,,,,fee schedule,35.09,63.16,APC
Screening Hep C detect,G0567,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.16,,,,,,,fee schedule,35.09,63.16,APC
"Int psych care mng, 1 cal mo",G0568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,101.22,182.2,APC
"Int psych care mng, 1 cal mo",G0568,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,101.22,182.2,APC
"Int psych care mng, 1 cal mo",G0568,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,101.22,182.2,APC
"Subs psych care mng, subs mo",G0569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,101.22,182.2,APC
"Subs psych care mng, subs mo",G0569,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,101.22,182.2,APC
"Subs psych care mng, subs mo",G0569,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,101.22,182.2,APC
"Care manage serv, pr cal mo",G0570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.2,,,,,,,fee schedule,37.33,67.2,APC
"Care manage serv, pr cal mo",G0570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.33,,,,,,,fee schedule,37.33,67.2,APC
"Care manage serv, pr cal mo",G0570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.2,,,,,,,fee schedule,37.33,67.2,APC
Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,132.63,,,,,,,fee schedule,62.14,152.52,
Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.56,,,,,,,fee schedule,62.14,152.52,
Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.95,,,,,,,fee schedule,62.14,152.52,
Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,152.52,,,,,,,fee schedule,62.14,152.52,
Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,62.14,152.52,APC
Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.14,,,,,,,fee schedule,62.14,152.52,APC
Drug test def simple all cl,G0659,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,111.85,,,,,,,fee schedule,62.14,152.52,APC
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1195.2,,,,,,,fee schedule,371.82,1374.48,
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,978.27,,,,,,,fee schedule,371.82,1374.48,
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,783.57,,,,,,,fee schedule,371.82,1374.48,
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1374.48,,,,,,,fee schedule,371.82,1374.48,
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.41,,,,,,,fee schedule,371.82,1374.48,APC
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,371.82,,,,,,,fee schedule,371.82,1374.48,APC
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,669.27,,,,,,,fee schedule,371.82,1374.48,APC
Alcohol/sub abuse assess,G2011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.07,,,,,,,fee schedule,28.82,51.88,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.89,,,,,,,fee schedule,28.82,51.88,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.55,,,,,,,fee schedule,28.82,51.88,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.83,,,,,,,fee schedule,28.82,51.88,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,28.82,51.88,APC
Alcohol/sub abuse assess,G2011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,28.82,51.88,APC
Alcohol/sub abuse assess,G2011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,28.82,51.88,APC
Qual nonMD est pt 5-10m,G2061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.84,,,,,,,fee schedule,15.63,27.42,
Qual nonMD est pt 5-10m,G2061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.51,,,,,,,fee schedule,15.63,27.42,
Qual nonMD est pt 5-10m,G2061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.63,,,,,,,fee schedule,15.63,27.42,
Qual nonMD est pt 5-10m,G2061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.42,,,,,,,fee schedule,15.63,27.42,
Qual nonMD est pt 11-20m,G2062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.06,,,,,,,fee schedule,27.57,48.37,
Qual nonMD est pt 11-20m,G2062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.43,,,,,,,fee schedule,27.57,48.37,
Qual nonMD est pt 11-20m,G2062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.57,,,,,,,fee schedule,27.57,48.37,
Qual nonMD est pt 11-20m,G2062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.37,,,,,,,fee schedule,27.57,48.37,
Qual nonMD est pt 21>min,G2063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.2,,,,,,,fee schedule,42.75,74.98,
Qual nonMD est pt 21>min,G2063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.37,,,,,,,fee schedule,42.75,74.98,
Qual nonMD est pt 21>min,G2063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.75,,,,,,,fee schedule,42.75,74.98,
Qual nonMD est pt 21>min,G2063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.98,,,,,,,fee schedule,42.75,74.98,
Visit esketamine 56m or less,G2082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1263.72,,,,,,,fee schedule,828.49,1844.16,
Visit esketamine 56m or less,G2082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1034.35,,,,,,,fee schedule,828.49,1844.16,
Visit esketamine 56m or less,G2082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,828.49,,,,,,,fee schedule,828.49,1844.16,
Visit esketamine 56m or less,G2082,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1453.28,,,,,,,fee schedule,828.49,1844.16,
Visit esketamine 56m or less,G2082,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1075.76,,,,,,,fee schedule,828.49,1844.16,APC
Visit esketamine 56m or less,G2082,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1024.53,,,,,,,fee schedule,828.49,1844.16,APC
Visit esketamine 56m or less,G2082,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1844.16,,,,,,,fee schedule,828.49,1844.16,APC
"Visit esketamine, > 56m",G2083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1846.54,,,,,,,fee schedule,1210.59,2897.46,
"Visit esketamine, > 56m",G2083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1511.39,,,,,,,fee schedule,1210.59,2897.46,
"Visit esketamine, > 56m",G2083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1210.59,,,,,,,fee schedule,1210.59,2897.46,
"Visit esketamine, > 56m",G2083,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2123.52,,,,,,,fee schedule,1210.59,2897.46,
"Visit esketamine, > 56m",G2083,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1690.18,,,,,,,fee schedule,1210.59,2897.46,APC
"Visit esketamine, > 56m",G2083,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1609.7,,,,,,,fee schedule,1210.59,2897.46,APC
"Visit esketamine, > 56m",G2083,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2897.46,,,,,,,fee schedule,1210.59,2897.46,APC
Off base opioid tx 70min,G2086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.19,,,,,,,fee schedule,167.3,318.34,
Off base opioid tx 70min,G2086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.87,,,,,,,fee schedule,167.3,318.34,
Off base opioid tx 70min,G2086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.3,,,,,,,fee schedule,167.3,318.34,
Off base opioid tx 70min,G2086,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,293.47,,,,,,,fee schedule,167.3,318.34,
Off base opioid tx 70min,G2086,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,167.3,318.34,APC
Off base opioid tx 70min,G2086,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,167.3,318.34,APC
Off base opioid tx 70min,G2086,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,167.3,318.34,APC
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255.19,,,,,,,fee schedule,167.3,318.34,
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.87,,,,,,,fee schedule,167.3,318.34,
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.3,,,,,,,fee schedule,167.3,318.34,
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,293.47,,,,,,,fee schedule,167.3,318.34,
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.7,,,,,,,fee schedule,167.3,318.34,APC
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.86,,,,,,,fee schedule,167.3,318.34,APC
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,318.34,,,,,,,fee schedule,167.3,318.34,APC
"Off base opioid tx, add30",G2088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.01,,,,,,,fee schedule,44.59,78.21,
"Off base opioid tx, add30",G2088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.67,,,,,,,fee schedule,44.59,78.21,
"Off base opioid tx, add30",G2088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.59,,,,,,,fee schedule,44.59,78.21,
"Off base opioid tx, add30",G2088,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.21,,,,,,,fee schedule,44.59,78.21,
Prolong outpt/office vis,G2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.34,,,,,,,fee schedule,13.33,23.39,
Prolong outpt/office vis,G2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.65,,,,,,,fee schedule,13.33,23.39,
Prolong outpt/office vis,G2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.33,,,,,,,fee schedule,13.33,23.39,
Prolong outpt/office vis,G2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.39,,,,,,,fee schedule,13.33,23.39,
Initiat med assist tx in er,G2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.28,,,,,,,fee schedule,24.44,42.87,
Initiat med assist tx in er,G2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.51,,,,,,,fee schedule,24.44,42.87,
Initiat med assist tx in er,G2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.44,,,,,,,fee schedule,24.44,42.87,
Initiat med assist tx in er,G2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.87,,,,,,,fee schedule,24.44,42.87,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.45,,,,,,,fee schedule,95.36,182.2,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.05,,,,,,,fee schedule,95.36,182.2,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.36,,,,,,,fee schedule,95.36,182.2,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.27,,,,,,,fee schedule,95.36,182.2,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.29,,,,,,,fee schedule,95.36,182.2,APC
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.22,,,,,,,fee schedule,95.36,182.2,APC
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,182.2,,,,,,,fee schedule,95.36,182.2,APC
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.85,,,,,,,fee schedule,7.11,14.24,
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.88,,,,,,,fee schedule,7.11,14.24,
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.11,,,,,,,fee schedule,7.11,14.24,
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.48,,,,,,,fee schedule,7.11,14.24,
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.31,,,,,,,fee schedule,7.11,14.24,APC
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.91,,,,,,,fee schedule,7.11,14.24,APC
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.24,,,,,,,fee schedule,7.11,14.24,APC
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.17,,,,,,,fee schedule,6.67,19.53,
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.32,,,,,,,fee schedule,6.67,19.53,
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.67,,,,,,,fee schedule,6.67,19.53,
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.7,,,,,,,fee schedule,6.67,19.53,
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.39,,,,,,,fee schedule,6.67,19.53,APC
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.85,,,,,,,fee schedule,6.67,19.53,APC
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.53,,,,,,,fee schedule,6.67,19.53,APC
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.61,,,,,,,fee schedule,10.23,41.65,
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.78,,,,,,,fee schedule,10.23,41.65,
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.23,,,,,,,fee schedule,10.23,41.65,
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.95,,,,,,,fee schedule,10.23,41.65,
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.3,,,,,,,fee schedule,10.23,41.65,APC
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.14,,,,,,,fee schedule,10.23,41.65,APC
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.65,,,,,,,fee schedule,10.23,41.65,APC
Chronic pain mgmt 30 mins,G3002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.08,,,,,,,fee schedule,34.8,61.04,
Chronic pain mgmt 30 mins,G3002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.45,,,,,,,fee schedule,34.8,61.04,
Chronic pain mgmt 30 mins,G3002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.8,,,,,,,fee schedule,34.8,61.04,
Chronic pain mgmt 30 mins,G3002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.04,,,,,,,fee schedule,34.8,61.04,
Chronic pain mgmt addl 15m,G3003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.86,,,,,,,fee schedule,13.68,23.99,
Chronic pain mgmt addl 15m,G3003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.07,,,,,,,fee schedule,13.68,23.99,
Chronic pain mgmt addl 15m,G3003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.68,,,,,,,fee schedule,13.68,23.99,
Chronic pain mgmt addl 15m,G3003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.99,,,,,,,fee schedule,13.68,23.99,
Echo guidance radiotherapy,G6001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.73,,,,,,,fee schedule,39.81,69.84,
Echo guidance radiotherapy,G6001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.71,,,,,,,fee schedule,39.81,69.84,
Echo guidance radiotherapy,G6001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.81,,,,,,,fee schedule,39.81,69.84,
Echo guidance radiotherapy,G6001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.84,,,,,,,fee schedule,39.81,69.84,
Stereoscopic x-ray guidance,G6002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.84,,,,,,,fee schedule,100.86,176.92,
Stereoscopic x-ray guidance,G6002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.92,,,,,,,fee schedule,100.86,176.92,
Stereoscopic x-ray guidance,G6002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.86,,,,,,,fee schedule,100.86,176.92,
Stereoscopic x-ray guidance,G6002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.92,,,,,,,fee schedule,100.86,176.92,
Radiation treatment delivery,G6003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,528.14,,,,,,,fee schedule,346.25,607.36,
Radiation treatment delivery,G6003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,432.28,,,,,,,fee schedule,346.25,607.36,
Radiation treatment delivery,G6003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,346.25,,,,,,,fee schedule,346.25,607.36,
Radiation treatment delivery,G6003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,607.36,,,,,,,fee schedule,346.25,607.36,
Radiation treatment delivery,G6004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,400.73,,,,,,,fee schedule,262.72,460.84,
Radiation treatment delivery,G6004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,328,,,,,,,fee schedule,262.72,460.84,
Radiation treatment delivery,G6004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.72,,,,,,,fee schedule,262.72,460.84,
Radiation treatment delivery,G6004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,460.84,,,,,,,fee schedule,262.72,460.84,
Radiation treatment delivery,G6005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,399.78,,,,,,,fee schedule,262.1,459.75,
Radiation treatment delivery,G6005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,327.22,,,,,,,fee schedule,262.1,459.75,
Radiation treatment delivery,G6005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.1,,,,,,,fee schedule,262.1,459.75,
Radiation treatment delivery,G6005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,459.75,,,,,,,fee schedule,262.1,459.75,
Radiation treatment delivery,G6006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,399.78,,,,,,,fee schedule,262.1,459.75,
Radiation treatment delivery,G6006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,327.22,,,,,,,fee schedule,262.1,459.75,
Radiation treatment delivery,G6006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.1,,,,,,,fee schedule,262.1,459.75,
Radiation treatment delivery,G6006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,459.75,,,,,,,fee schedule,262.1,459.75,
Radiation treatment delivery,G6007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,825.02,,,,,,,fee schedule,540.88,948.77,
Radiation treatment delivery,G6007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,675.28,,,,,,,fee schedule,540.88,948.77,
Radiation treatment delivery,G6007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,540.88,,,,,,,fee schedule,540.88,948.77,
Radiation treatment delivery,G6007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,948.77,,,,,,,fee schedule,540.88,948.77,
Radiation treatment delivery,G6008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,551.64,,,,,,,fee schedule,361.66,634.39,
Radiation treatment delivery,G6008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,451.52,,,,,,,fee schedule,361.66,634.39,
Radiation treatment delivery,G6008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,361.66,,,,,,,fee schedule,361.66,634.39,
Radiation treatment delivery,G6008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,634.39,,,,,,,fee schedule,361.66,634.39,
Radiation treatment delivery,G6009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,549.7,,,,,,,fee schedule,360.38,632.16,
Radiation treatment delivery,G6009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,449.93,,,,,,,fee schedule,360.38,632.16,
Radiation treatment delivery,G6009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,360.38,,,,,,,fee schedule,360.38,632.16,
Radiation treatment delivery,G6009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,632.16,,,,,,,fee schedule,360.38,632.16,
Radiation treatment delivery,G6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,547.74,,,,,,,fee schedule,359.1,629.9,
Radiation treatment delivery,G6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,448.33,,,,,,,fee schedule,359.1,629.9,
Radiation treatment delivery,G6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,359.1,,,,,,,fee schedule,359.1,629.9,
Radiation treatment delivery,G6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,629.9,,,,,,,fee schedule,359.1,629.9,
Radiation treatment delivery,G6011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,799.55,,,,,,,fee schedule,524.18,919.48,
Radiation treatment delivery,G6011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,654.43,,,,,,,fee schedule,524.18,919.48,
Radiation treatment delivery,G6011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,524.18,,,,,,,fee schedule,524.18,919.48,
Radiation treatment delivery,G6011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,919.48,,,,,,,fee schedule,524.18,919.48,
Radiation treatment delivery,G6012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,729.97,,,,,,,fee schedule,478.57,839.47,
Radiation treatment delivery,G6012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,597.48,,,,,,,fee schedule,478.57,839.47,
Radiation treatment delivery,G6012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,478.57,,,,,,,fee schedule,478.57,839.47,
Radiation treatment delivery,G6012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,839.47,,,,,,,fee schedule,478.57,839.47,
Radiation treatment delivery,G6013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,730.98,,,,,,,fee schedule,479.23,840.63,
Radiation treatment delivery,G6013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,598.31,,,,,,,fee schedule,479.23,840.63,
Radiation treatment delivery,G6013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,479.23,,,,,,,fee schedule,479.23,840.63,
Radiation treatment delivery,G6013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,840.63,,,,,,,fee schedule,479.23,840.63,
Radiation treatment delivery,G6014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,731.95,,,,,,,fee schedule,479.87,841.74,
Radiation treatment delivery,G6014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,599.1,,,,,,,fee schedule,479.87,841.74,
Radiation treatment delivery,G6014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,479.87,,,,,,,fee schedule,479.87,841.74,
Radiation treatment delivery,G6014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,841.74,,,,,,,fee schedule,479.87,841.74,
Radiation tx delivery imrt,G6015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,955.33,,,,,,,fee schedule,626.31,1098.63,
Radiation tx delivery imrt,G6015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,781.94,,,,,,,fee schedule,626.31,1098.63,
Radiation tx delivery imrt,G6015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,626.31,,,,,,,fee schedule,626.31,1098.63,
Radiation tx delivery imrt,G6015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1098.63,,,,,,,fee schedule,626.31,1098.63,
Delivery comp imrt,G6016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,952.42,,,,,,,fee schedule,624.41,1095.28,
Delivery comp imrt,G6016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,779.56,,,,,,,fee schedule,624.41,1095.28,
Delivery comp imrt,G6016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,624.41,,,,,,,fee schedule,624.41,1095.28,
Delivery comp imrt,G6016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1095.28,,,,,,,fee schedule,624.41,1095.28,
Warfarin respon genetic test,G9143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,452.09,,,,,,,fee schedule,296.39,519.9,
Warfarin respon genetic test,G9143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,370.04,,,,,,,fee schedule,296.39,519.9,
Warfarin respon genetic test,G9143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,296.39,,,,,,,fee schedule,296.39,519.9,
Warfarin respon genetic test,G9143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,519.9,,,,,,,fee schedule,296.39,519.9,
Transesoph doppl cardiac mon,G9157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Transesoph doppl cardiac mon,G9157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Transesoph doppl cardiac mon,G9157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Transesoph doppl cardiac mon,G9157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Tetracyclin injection,J0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.23,,,,,,,fee schedule,18.23,20.96,
Tetracyclin injection,J0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.23,,,,,,,fee schedule,18.23,20.96,
Tetracyclin injection,J0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.23,,,,,,,fee schedule,18.23,20.96,
Tetracyclin injection,J0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.96,,,,,,,fee schedule,18.23,20.96,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.16,,,,,,,fee schedule,4.16,7.54,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.16,,,,,,,fee schedule,4.16,7.54,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.16,,,,,,,fee schedule,4.16,7.54,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.78,,,,,,,fee schedule,4.16,7.54,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.4,,,,,,,fee schedule,4.16,7.54,APC
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.19,,,,,,,fee schedule,4.16,7.54,APC
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.54,,,,,,,fee schedule,4.16,7.54,APC
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.34,,,,,,,fee schedule,1.34,2.49,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.34,,,,,,,fee schedule,1.34,2.49,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.34,,,,,,,fee schedule,1.34,2.49,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.54,,,,,,,fee schedule,1.34,2.49,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.45,,,,,,,fee schedule,1.34,2.49,APC
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.38,,,,,,,fee schedule,1.34,2.49,APC
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.49,,,,,,,fee schedule,1.34,2.49,APC
Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.17,,,,,,,fee schedule,45.86,82.55,
Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.17,,,,,,,fee schedule,45.86,82.55,
Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.17,,,,,,,fee schedule,45.86,82.55,
Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.1,,,,,,,fee schedule,45.86,82.55,
Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.15,,,,,,,fee schedule,45.86,82.55,APC
Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,45.86,,,,,,,fee schedule,45.86,82.55,APC
Abatacept injection,J0129,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,82.55,,,,,,,fee schedule,45.86,82.55,APC
Abciximab injection,J0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1375.15,,,,,,,fee schedule,1375.15,1581.42,
Abciximab injection,J0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1375.15,,,,,,,fee schedule,1375.15,1581.42,
Abciximab injection,J0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1375.15,,,,,,,fee schedule,1375.15,1581.42,
Abciximab injection,J0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1581.42,,,,,,,fee schedule,1375.15,1581.42,
Acetaminophen injection,J0131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Acetaminophen injection,J0131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Acetaminophen injection,J0131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.07,
Acetaminophen injection,J0131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.07,
Acetylcysteine injection,J0132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.38,,,,,,,fee schedule,0.38,0.44,
Acetylcysteine injection,J0132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.38,,,,,,,fee schedule,0.38,0.44,
Acetylcysteine injection,J0132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.38,,,,,,,fee schedule,0.38,0.44,
Acetylcysteine injection,J0132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.44,,,,,,,fee schedule,0.38,0.44,
Acyclovir injection,J0133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Acyclovir injection,J0133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Acyclovir injection,J0133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
Acyclovir injection,J0133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Inj acetaminophen -fresenius,J0134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Inj acetaminophen -fresenius,J0134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Inj acetaminophen -fresenius,J0134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.07,
Inj acetaminophen -fresenius,J0134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.07,
"Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
"Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
"Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.05,,,,,,,fee schedule,0.05,0.06,
"Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.06,,,,,,,fee schedule,0.05,0.06,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.05,,,,,,,fee schedule,0.05,0.06,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.06,,,,,,,fee schedule,0.05,0.06,
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.23,,,,,,,fee schedule,0.09,0.26,
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.23,,,,,,,fee schedule,0.09,0.26,
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.09,0.26,
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.26,,,,,,,fee schedule,0.09,0.26,
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.1,,,,,,,fee schedule,0.09,0.26,APC
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.09,,,,,,,fee schedule,0.09,0.26,APC
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.17,,,,,,,fee schedule,0.09,0.26,APC
Adenosine inj 1mg,J0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.47,,,,,,,fee schedule,0.47,0.54,
Adenosine inj 1mg,J0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.47,,,,,,,fee schedule,0.47,0.54,
Adenosine inj 1mg,J0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.47,,,,,,,fee schedule,0.47,0.54,
Adenosine inj 1mg,J0153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.54,,,,,,,fee schedule,0.47,0.54,
Inj epinephrine nos 0.1 mg,J0165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.6,,,,,,,fee schedule,0.6,0.69,
Inj epinephrine nos 0.1 mg,J0165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.6,,,,,,,fee schedule,0.6,0.69,
Inj epinephrine nos 0.1 mg,J0165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.6,,,,,,,fee schedule,0.6,0.69,
Inj epinephrine nos 0.1 mg,J0165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.69,,,,,,,fee schedule,0.6,0.69,
Inj epinephrine (bpi),J0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.37,,,,,,,fee schedule,2.37,2.73,
Inj epinephrine (bpi),J0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.37,,,,,,,fee schedule,2.37,2.73,
Inj epinephrine (bpi),J0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.37,,,,,,,fee schedule,2.37,2.73,
Inj epinephrine (bpi),J0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.73,,,,,,,fee schedule,2.37,2.73,
Inj epinephrine (hospira),J0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.76,,,,,,,fee schedule,0.76,0.87,
Inj epinephrine (hospira),J0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.76,,,,,,,fee schedule,0.76,0.87,
Inj epinephrine (hospira),J0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.76,,,,,,,fee schedule,0.76,0.87,
Inj epinephrine (hospira),J0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.87,,,,,,,fee schedule,0.76,0.87,
Epinephrine (intl med sys),J0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.26,,,,,,,fee schedule,2.26,2.6,
Epinephrine (intl med sys),J0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.26,,,,,,,fee schedule,2.26,2.6,
Epinephrine (intl med sys),J0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.26,,,,,,,fee schedule,2.26,2.6,
Epinephrine (intl med sys),J0168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.6,,,,,,,fee schedule,2.26,2.6,
Inj epinephrine (adrenalin),J0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.37,,,,,,,fee schedule,1.37,1.58,
Inj epinephrine (adrenalin),J0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.37,,,,,,,fee schedule,1.37,1.58,
Inj epinephrine (adrenalin),J0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.37,,,,,,,fee schedule,1.37,1.58,
Inj epinephrine (adrenalin),J0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.58,,,,,,,fee schedule,1.37,1.58,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.2,,,,,,,fee schedule,6.2,7.13,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.2,,,,,,,fee schedule,6.2,7.13,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.2,,,,,,,fee schedule,6.2,7.13,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.13,,,,,,,fee schedule,6.2,7.13,
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.3,,,,,,,fee schedule,4.16,7.5,
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.3,,,,,,,fee schedule,4.16,7.5,
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.3,,,,,,,fee schedule,4.16,7.5,
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.95,,,,,,,fee schedule,4.16,7.5,
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.37,,,,,,,fee schedule,4.16,7.5,APC
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.16,,,,,,,fee schedule,4.16,7.5,APC
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.5,,,,,,,fee schedule,4.16,7.5,APC
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,331.8,,,,,,,fee schedule,298.68,537.63,
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,331.8,,,,,,,fee schedule,298.68,537.63,
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,331.8,,,,,,,fee schedule,298.68,537.63,
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,381.57,,,,,,,fee schedule,298.68,537.63,
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,313.62,,,,,,,fee schedule,298.68,537.63,APC
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,298.68,,,,,,,fee schedule,298.68,537.63,APC
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,537.63,,,,,,,fee schedule,298.68,537.63,APC
Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,819.85,,,,,,,fee schedule,743.6,1338.49,
Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,819.85,,,,,,,fee schedule,743.6,1338.49,
Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,819.85,,,,,,,fee schedule,743.6,1338.49,
Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,942.83,,,,,,,fee schedule,743.6,1338.49,
Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,780.79,,,,,,,fee schedule,743.6,1338.49,APC
Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,743.6,,,,,,,fee schedule,743.6,1338.49,APC
Aflibercept injection,J0178,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1338.49,,,,,,,fee schedule,743.6,1338.49,APC
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,359.26,,,,,,,fee schedule,359.26,647.48,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,359.26,,,,,,,fee schedule,359.26,647.48,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,359.26,,,,,,,fee schedule,359.26,647.48,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,413.15,,,,,,,fee schedule,359.26,647.48,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,377.7,,,,,,,fee schedule,359.26,647.48,APC
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,359.71,,,,,,,fee schedule,359.26,647.48,APC
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,647.48,,,,,,,fee schedule,359.26,647.48,APC
Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,238.95,,,,,,,fee schedule,232.72,418.9,
Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,238.95,,,,,,,fee schedule,232.72,418.9,
Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,238.95,,,,,,,fee schedule,232.72,418.9,
Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,274.79,,,,,,,fee schedule,232.72,418.9,
Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.36,,,,,,,fee schedule,232.72,418.9,APC
Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.72,,,,,,,fee schedule,232.72,418.9,APC
Agalsidase beta injection,J0180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.9,,,,,,,fee schedule,232.72,418.9,APC
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.73,,,,,,,fee schedule,9.57,17.22,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.73,,,,,,,fee schedule,9.57,17.22,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.73,,,,,,,fee schedule,9.57,17.22,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.19,,,,,,,fee schedule,9.57,17.22,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.05,,,,,,,fee schedule,9.57,17.22,APC
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.57,,,,,,,fee schedule,9.57,17.22,APC
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.22,,,,,,,fee schedule,9.57,17.22,APC
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.84,,,,,,,fee schedule,1.59,2.86,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.84,,,,,,,fee schedule,1.59,2.86,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.84,,,,,,,fee schedule,1.59,2.86,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.12,,,,,,,fee schedule,1.59,2.86,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.67,,,,,,,fee schedule,1.59,2.86,APC
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.59,,,,,,,fee schedule,1.59,2.86,APC
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.86,,,,,,,fee schedule,1.59,2.86,APC
Inj biperiden lactate/5 mg,J0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.75,,,,,,,fee schedule,3.75,4.31,
Inj biperiden lactate/5 mg,J0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.75,,,,,,,fee schedule,3.75,4.31,
Inj biperiden lactate/5 mg,J0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.75,,,,,,,fee schedule,3.75,4.31,
Inj biperiden lactate/5 mg,J0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.31,,,,,,,fee schedule,3.75,4.31,
Alatrofloxacin mesylate,J0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.03,,,,,,,fee schedule,17.03,19.58,
Alatrofloxacin mesylate,J0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.03,,,,,,,fee schedule,17.03,19.58,
Alatrofloxacin mesylate,J0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.03,,,,,,,fee schedule,17.03,19.58,
Alatrofloxacin mesylate,J0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.58,,,,,,,fee schedule,17.03,19.58,
"Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2532.8,,,,,,,fee schedule,2532.8,4580.89,
"Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2532.8,,,,,,,fee schedule,2532.8,4580.89,
"Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2532.8,,,,,,,fee schedule,2532.8,4580.89,
"Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2912.72,,,,,,,fee schedule,2532.8,4580.89,
"Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2672.18,,,,,,,fee schedule,2532.8,4580.89,APC
"Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2544.94,,,,,,,fee schedule,2532.8,4580.89,APC
"Injection, alemtuzumab",J0202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4580.89,,,,,,,fee schedule,2532.8,4580.89,APC
Alglucerase injection,J0205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.44,,,,,,,fee schedule,40.44,46.51,
Alglucerase injection,J0205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.44,,,,,,,fee schedule,40.44,46.51,
Alglucerase injection,J0205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.44,,,,,,,fee schedule,40.44,46.51,
Alglucerase injection,J0205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.51,,,,,,,fee schedule,40.44,46.51,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.71,,,,,,,fee schedule,4.07,7.33,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.71,,,,,,,fee schedule,4.07,7.33,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.71,,,,,,,fee schedule,4.07,7.33,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.42,,,,,,,fee schedule,4.07,7.33,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.28,,,,,,,fee schedule,4.07,7.33,APC
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.07,,,,,,,fee schedule,4.07,7.33,APC
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.33,,,,,,,fee schedule,4.07,7.33,APC
Amifostine,J0207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1092.84,,,,,,,fee schedule,1092.84,1256.77,
Amifostine,J0207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1092.84,,,,,,,fee schedule,1092.84,1256.77,
Amifostine,J0207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1092.84,,,,,,,fee schedule,1092.84,1256.77,
Amifostine,J0207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1256.77,,,,,,,fee schedule,1092.84,1256.77,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,93.16,,,,,,,fee schedule,93.16,174.2,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.16,,,,,,,fee schedule,93.16,174.2,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.16,,,,,,,fee schedule,93.16,174.2,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,107.13,,,,,,,fee schedule,93.16,174.2,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.62,,,,,,,fee schedule,93.16,174.2,APC
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.78,,,,,,,fee schedule,93.16,174.2,APC
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,174.2,,,,,,,fee schedule,93.16,174.2,APC
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.82,,,,,,,fee schedule,0.82,1.51,
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.82,,,,,,,fee schedule,0.82,1.51,
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.82,,,,,,,fee schedule,0.82,1.51,
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.94,,,,,,,fee schedule,0.82,1.51,
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.88,,,,,,,fee schedule,0.82,1.51,APC
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.84,,,,,,,fee schedule,0.82,1.51,APC
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.51,,,,,,,fee schedule,0.82,1.51,APC
Methyldopate hcl injection,J0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.8,,,,,,,fee schedule,40.8,46.92,
Methyldopate hcl injection,J0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.8,,,,,,,fee schedule,40.8,46.92,
Methyldopate hcl injection,J0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.8,,,,,,,fee schedule,40.8,46.92,
Methyldopate hcl injection,J0210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.92,,,,,,,fee schedule,40.8,46.92,
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2,,,,,,,fee schedule,2,3.9,
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2,,,,,,,fee schedule,2,3.9,
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2,,,,,,,fee schedule,2,3.9,
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.3,,,,,,,fee schedule,2,3.9,
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.27,,,,,,,fee schedule,2,3.9,APC
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.17,,,,,,,fee schedule,2,3.9,APC
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.9,,,,,,,fee schedule,2,3.9,APC
Alefacept,J0215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.07,,,,,,,fee schedule,40.07,46.08,
Alefacept,J0215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.07,,,,,,,fee schedule,40.07,46.08,
Alefacept,J0215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.07,,,,,,,fee schedule,40.07,46.08,
Alefacept,J0215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.08,,,,,,,fee schedule,40.07,46.08,
"Inj, alfentanil hcl, 500mcg",J0216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.66,,,,,,,fee schedule,2.66,3.06,
"Inj, alfentanil hcl, 500mcg",J0216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.66,,,,,,,fee schedule,2.66,3.06,
"Inj, alfentanil hcl, 500mcg",J0216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.66,,,,,,,fee schedule,2.66,3.06,
"Inj, alfentanil hcl, 500mcg",J0216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.06,,,,,,,fee schedule,2.66,3.06,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,482.6,,,,,,,fee schedule,479.19,862.54,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,482.6,,,,,,,fee schedule,479.19,862.54,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,482.6,,,,,,,fee schedule,479.19,862.54,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,554.99,,,,,,,fee schedule,479.19,862.54,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,503.15,,,,,,,fee schedule,479.19,862.54,APC
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,479.19,,,,,,,fee schedule,479.19,862.54,APC
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,862.54,,,,,,,fee schedule,479.19,862.54,APC
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,408.68,,,,,,,fee schedule,404.95,728.9,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408.68,,,,,,,fee schedule,404.95,728.9,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,408.68,,,,,,,fee schedule,404.95,728.9,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,469.98,,,,,,,fee schedule,404.95,728.9,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.19,,,,,,,fee schedule,404.95,728.9,APC
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,404.95,,,,,,,fee schedule,404.95,728.9,APC
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,728.9,,,,,,,fee schedule,404.95,728.9,APC
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.8,,,,,,,fee schedule,83.8,151.1,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.8,,,,,,,fee schedule,83.8,151.1,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.8,,,,,,,fee schedule,83.8,151.1,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.37,,,,,,,fee schedule,83.8,151.1,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,88.14,,,,,,,fee schedule,83.8,151.1,APC
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,83.94,,,,,,,fee schedule,83.8,151.1,APC
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,151.1,,,,,,,fee schedule,83.8,151.1,APC
Alglucosidase alfa injection,J0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.9,,,,,,,fee schedule,198.9,228.74,
Alglucosidase alfa injection,J0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,198.9,,,,,,,fee schedule,198.9,228.74,
Alglucosidase alfa injection,J0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,198.9,,,,,,,fee schedule,198.9,228.74,
Alglucosidase alfa injection,J0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,228.74,,,,,,,fee schedule,198.9,228.74,
Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.41,,,,,,,fee schedule,211.13,380.03,
Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.41,,,,,,,fee schedule,211.13,380.03,
Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.41,,,,,,,fee schedule,211.13,380.03,
Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.57,,,,,,,fee schedule,211.13,380.03,
Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.68,,,,,,,fee schedule,211.13,380.03,APC
Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,211.13,,,,,,,fee schedule,211.13,380.03,APC
Lumizyme injection,J0221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,380.03,,,,,,,fee schedule,211.13,380.03,APC
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.59,,,,,,,fee schedule,101.03,181.85,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.59,,,,,,,fee schedule,101.03,181.85,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.59,,,,,,,fee schedule,101.03,181.85,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.13,,,,,,,fee schedule,101.03,181.85,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.08,,,,,,,fee schedule,101.03,181.85,APC
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.03,,,,,,,fee schedule,101.03,181.85,APC
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,181.85,,,,,,,fee schedule,101.03,181.85,APC
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.61,,,,,,,fee schedule,120.92,217.65,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.61,,,,,,,fee schedule,120.92,217.65,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.61,,,,,,,fee schedule,120.92,217.65,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.85,,,,,,,fee schedule,120.92,217.65,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,126.96,,,,,,,fee schedule,120.92,217.65,APC
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,120.92,,,,,,,fee schedule,120.92,217.65,APC
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,217.65,,,,,,,fee schedule,120.92,217.65,APC
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,341.52,,,,,,,fee schedule,336.97,606.55,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,341.52,,,,,,,fee schedule,336.97,606.55,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,341.52,,,,,,,fee schedule,336.97,606.55,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.75,,,,,,,fee schedule,336.97,606.55,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,353.82,,,,,,,fee schedule,336.97,606.55,APC
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,336.97,,,,,,,fee schedule,336.97,606.55,APC
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,606.55,,,,,,,fee schedule,336.97,606.55,APC
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5171.93,,,,,,,fee schedule,5012.6,9022.68,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5171.93,,,,,,,fee schedule,5012.6,9022.68,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5171.93,,,,,,,fee schedule,5012.6,9022.68,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5947.72,,,,,,,fee schedule,5012.6,9022.68,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5263.23,,,,,,,fee schedule,5012.6,9022.68,APC
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5012.6,,,,,,,fee schedule,5012.6,9022.68,APC
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9022.68,,,,,,,fee schedule,5012.6,9022.68,APC
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.98,,,,,,,fee schedule,6.98,13.52,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.98,,,,,,,fee schedule,6.98,13.52,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.98,,,,,,,fee schedule,6.98,13.52,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.03,,,,,,,fee schedule,6.98,13.52,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.89,,,,,,,fee schedule,6.98,13.52,APC
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.51,,,,,,,fee schedule,6.98,13.52,APC
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.52,,,,,,,fee schedule,6.98,13.52,APC
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.38,,,,,,,fee schedule,5.13,9.24,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.38,,,,,,,fee schedule,5.13,9.24,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.38,,,,,,,fee schedule,5.13,9.24,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.19,,,,,,,fee schedule,5.13,9.24,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,5.13,9.24,APC
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.13,,,,,,,fee schedule,5.13,9.24,APC
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.24,,,,,,,fee schedule,5.13,9.24,APC
Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.93,,,,,,,fee schedule,5.58,10.05,
Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.93,,,,,,,fee schedule,5.58,10.05,
Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.93,,,,,,,fee schedule,5.58,10.05,
Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.82,,,,,,,fee schedule,5.58,10.05,
Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.86,,,,,,,fee schedule,5.58,10.05,APC
Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.58,,,,,,,fee schedule,5.58,10.05,APC
Glassia injection,J0257,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.05,,,,,,,fee schedule,5.58,10.05,APC
Alprostadil for injection,J0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.48,,,,,,,fee schedule,10.48,12.05,
Alprostadil for injection,J0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.48,,,,,,,fee schedule,10.48,12.05,
Alprostadil for injection,J0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.48,,,,,,,fee schedule,10.48,12.05,
Alprostadil for injection,J0270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.05,,,,,,,fee schedule,10.48,12.05,
Alprostadil urethral suppos,J0275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.18,,,,,,,fee schedule,27.18,31.26,
Alprostadil urethral suppos,J0275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.18,,,,,,,fee schedule,27.18,31.26,
Alprostadil urethral suppos,J0275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.18,,,,,,,fee schedule,27.18,31.26,
Alprostadil urethral suppos,J0275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.26,,,,,,,fee schedule,27.18,31.26,
Amikacin sulfate injection,J0278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.64,,,,,,,fee schedule,0.64,0.74,
Amikacin sulfate injection,J0278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.64,,,,,,,fee schedule,0.64,0.74,
Amikacin sulfate injection,J0278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.64,,,,,,,fee schedule,0.64,0.74,
Amikacin sulfate injection,J0278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.74,,,,,,,fee schedule,0.64,0.74,
Aminophyllin 250 MG inj,J0280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.61,,,,,,,fee schedule,8.61,9.9,
Aminophyllin 250 MG inj,J0280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.61,,,,,,,fee schedule,8.61,9.9,
Aminophyllin 250 MG inj,J0280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.61,,,,,,,fee schedule,8.61,9.9,
Aminophyllin 250 MG inj,J0280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.9,,,,,,,fee schedule,8.61,9.9,
Inj aminocaproic acid 1 gram,J0281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.55,,,,,,,fee schedule,1.55,1.78,
Inj aminocaproic acid 1 gram,J0281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.55,,,,,,,fee schedule,1.55,1.78,
Inj aminocaproic acid 1 gram,J0281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.55,,,,,,,fee schedule,1.55,1.78,
Inj aminocaproic acid 1 gram,J0281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.78,,,,,,,fee schedule,1.55,1.78,
Amiodarone HCl,J0282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.53,,,,,,,fee schedule,0.53,0.61,
Amiodarone HCl,J0282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.53,,,,,,,fee schedule,0.53,0.61,
Amiodarone HCl,J0282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.53,,,,,,,fee schedule,0.53,0.61,
Amiodarone HCl,J0282,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.61,,,,,,,fee schedule,0.53,0.61,
"Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.71,,,,,,,fee schedule,2.71,3.12,
"Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.71,,,,,,,fee schedule,2.71,3.12,
"Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.71,,,,,,,fee schedule,2.71,3.12,
"Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.12,,,,,,,fee schedule,2.71,3.12,
Amphotericin B,J0285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.41,,,,,,,fee schedule,35.41,40.72,
Amphotericin B,J0285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.41,,,,,,,fee schedule,35.41,40.72,
Amphotericin B,J0285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.41,,,,,,,fee schedule,35.41,40.72,
Amphotericin B,J0285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.72,,,,,,,fee schedule,35.41,40.72,
Amphotericin b lipid complex,J0287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.69,,,,,,,fee schedule,10.69,12.29,
Amphotericin b lipid complex,J0287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.69,,,,,,,fee schedule,10.69,12.29,
Amphotericin b lipid complex,J0287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.69,,,,,,,fee schedule,10.69,12.29,
Amphotericin b lipid complex,J0287,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.29,,,,,,,fee schedule,10.69,12.29,
Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.6,,,,,,,fee schedule,13.6,15.64,
Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.6,,,,,,,fee schedule,13.6,15.64,
Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.6,,,,,,,fee schedule,13.6,15.64,
Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.64,,,,,,,fee schedule,13.6,15.64,
Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.47,,,,,,,fee schedule,19.84,35.72,
Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.47,,,,,,,fee schedule,19.84,35.72,
Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.47,,,,,,,fee schedule,19.84,35.72,
Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.99,,,,,,,fee schedule,19.84,35.72,
Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.84,,,,,,,fee schedule,19.84,35.72,APC
Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.84,,,,,,,fee schedule,19.84,35.72,APC
Amphotericin b liposome inj,J0289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.72,,,,,,,fee schedule,19.84,35.72,APC
Ampicillin 500 MG inj,J0290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.51,,,,,,,fee schedule,0.51,0.59,
Ampicillin 500 MG inj,J0290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.51,,,,,,,fee schedule,0.51,0.59,
Ampicillin 500 MG inj,J0290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.51,,,,,,,fee schedule,0.51,0.59,
Ampicillin 500 MG inj,J0290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.59,,,,,,,fee schedule,0.51,0.59,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.71,,,,,,,fee schedule,3.52,6.33,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.71,,,,,,,fee schedule,3.52,6.33,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.71,,,,,,,fee schedule,3.52,6.33,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.27,,,,,,,fee schedule,3.52,6.33,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.69,,,,,,,fee schedule,3.52,6.33,APC
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.52,,,,,,,fee schedule,3.52,6.33,APC
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.33,,,,,,,fee schedule,3.52,6.33,APC
Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.55,,,,,,,fee schedule,1.55,1.78,
Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.55,,,,,,,fee schedule,1.55,1.78,
Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.55,,,,,,,fee schedule,1.55,1.78,
Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.78,,,,,,,fee schedule,1.55,1.78,
Amobarbital 125 MG inj,J0300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,186.93,,,,,,,fee schedule,186.93,214.97,
Amobarbital 125 MG inj,J0300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.93,,,,,,,fee schedule,186.93,214.97,
Amobarbital 125 MG inj,J0300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.93,,,,,,,fee schedule,186.93,214.97,
Amobarbital 125 MG inj,J0300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,214.97,,,,,,,fee schedule,186.93,214.97,
Succinycholine chloride inj,J0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.84,,,,,,,fee schedule,0.84,0.97,
Succinycholine chloride inj,J0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.84,,,,,,,fee schedule,0.84,0.97,
Succinycholine chloride inj,J0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.84,,,,,,,fee schedule,0.84,0.97,
Succinycholine chloride inj,J0330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.97,,,,,,,fee schedule,0.84,0.97,
Anidulafungin injection,J0348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.5,,,,,,,fee schedule,0.5,0.58,
Anidulafungin injection,J0348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.5,,,,,,,fee schedule,0.5,0.58,
Anidulafungin injection,J0348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.5,,,,,,,fee schedule,0.5,0.58,
Anidulafungin injection,J0348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.58,,,,,,,fee schedule,0.5,0.58,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.02,,,,,,,fee schedule,11,19.8,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.02,,,,,,,fee schedule,11,19.8,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.02,,,,,,,fee schedule,11,19.8,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.67,,,,,,,fee schedule,11,19.8,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.55,,,,,,,fee schedule,11,19.8,APC
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11,,,,,,,fee schedule,11,19.8,APC
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.8,,,,,,,fee schedule,11,19.8,APC
Injection anistreplase 30 u,J0350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2410.24,,,,,,,fee schedule,2410.24,2771.78,
Injection anistreplase 30 u,J0350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2410.24,,,,,,,fee schedule,2410.24,2771.78,
Injection anistreplase 30 u,J0350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2410.24,,,,,,,fee schedule,2410.24,2771.78,
Injection anistreplase 30 u,J0350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2771.78,,,,,,,fee schedule,2410.24,2771.78,
Hydralazine hcl injection,J0360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.38,,,,,,,fee schedule,5.38,6.19,
Hydralazine hcl injection,J0360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.38,,,,,,,fee schedule,5.38,6.19,
Hydralazine hcl injection,J0360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.38,,,,,,,fee schedule,5.38,6.19,
Hydralazine hcl injection,J0360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.19,,,,,,,fee schedule,5.38,6.19,
Apomorphine hydrochloride,J0364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.41,,,,,,,fee schedule,35.41,40.72,
Apomorphine hydrochloride,J0364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.41,,,,,,,fee schedule,35.41,40.72,
Apomorphine hydrochloride,J0364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.41,,,,,,,fee schedule,35.41,40.72,
Apomorphine hydrochloride,J0364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.72,,,,,,,fee schedule,35.41,40.72,
"Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.75,,,,,,,fee schedule,2.75,3.16,
"Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.75,,,,,,,fee schedule,2.75,3.16,
"Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.75,,,,,,,fee schedule,2.75,3.16,
"Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.16,,,,,,,fee schedule,2.75,3.16,
Inj metaraminol bitartrate,J0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.14,,,,,,,fee schedule,1.14,1.31,
Inj metaraminol bitartrate,J0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.14,,,,,,,fee schedule,1.14,1.31,
Inj metaraminol bitartrate,J0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.14,,,,,,,fee schedule,1.14,1.31,
Inj metaraminol bitartrate,J0380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.31,,,,,,,fee schedule,1.14,1.31,
Chloroquine injection,J0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.61,,,,,,,fee schedule,17.61,20.25,
Chloroquine injection,J0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.61,,,,,,,fee schedule,17.61,20.25,
Chloroquine injection,J0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.61,,,,,,,fee schedule,17.61,20.25,
Chloroquine injection,J0390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.25,,,,,,,fee schedule,17.61,20.25,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.87,,,,,,,fee schedule,49.87,93.29,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.87,,,,,,,fee schedule,49.87,93.29,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.87,,,,,,,fee schedule,49.87,93.29,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.35,,,,,,,fee schedule,49.87,93.29,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.42,,,,,,,fee schedule,49.87,93.29,APC
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.83,,,,,,,fee schedule,49.87,93.29,APC
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.29,,,,,,,fee schedule,49.87,93.29,APC
Arbutamine HCl injection,J0395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.2,,,,,,,fee schedule,163.2,187.68,
Arbutamine HCl injection,J0395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.2,,,,,,,fee schedule,163.2,187.68,
Arbutamine HCl injection,J0395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.2,,,,,,,fee schedule,163.2,187.68,
Arbutamine HCl injection,J0395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.68,,,,,,,fee schedule,163.2,187.68,
Aripiprazole injection,J0400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.73,,,,,,,fee schedule,0.73,0.84,
Aripiprazole injection,J0400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.73,,,,,,,fee schedule,0.73,0.84,
Aripiprazole injection,J0400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.73,,,,,,,fee schedule,0.73,0.84,
Aripiprazole injection,J0400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.84,,,,,,,fee schedule,0.73,0.84,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.51,,,,,,,fee schedule,7.46,13.43,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.51,,,,,,,fee schedule,7.46,13.43,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.51,,,,,,,fee schedule,7.46,13.43,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.64,,,,,,,fee schedule,7.46,13.43,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.84,,,,,,,fee schedule,7.46,13.43,APC
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.46,,,,,,,fee schedule,7.46,13.43,APC
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.43,,,,,,,fee schedule,7.46,13.43,APC
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.26,,,,,,,fee schedule,6.18,11.13,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.26,,,,,,,fee schedule,6.18,11.13,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.26,,,,,,,fee schedule,6.18,11.13,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.2,,,,,,,fee schedule,6.18,11.13,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.49,,,,,,,fee schedule,6.18,11.13,APC
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.18,,,,,,,fee schedule,6.18,11.13,APC
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.13,,,,,,,fee schedule,6.18,11.13,APC
Azithromycin,J0456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.71,,,,,,,fee schedule,2.71,3.12,
Azithromycin,J0456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.71,,,,,,,fee schedule,2.71,3.12,
Azithromycin,J0456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.71,,,,,,,fee schedule,2.71,3.12,
Azithromycin,J0456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.12,,,,,,,fee schedule,2.71,3.12,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.77,,,,,,,fee schedule,2.77,3.19,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.77,,,,,,,fee schedule,2.77,3.19,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.77,,,,,,,fee schedule,2.77,3.19,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.19,,,,,,,fee schedule,2.77,3.19,
Atropine sulfate injection,J0461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.07,,,,,,,fee schedule,0.07,0.08,
Atropine sulfate injection,J0461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.07,,,,,,,fee schedule,0.07,0.08,
Atropine sulfate injection,J0461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.07,,,,,,,fee schedule,0.07,0.08,
Atropine sulfate injection,J0461,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.08,,,,,,,fee schedule,0.07,0.08,
Dimecaprol injection,J0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.55,,,,,,,fee schedule,54.55,62.73,
Dimecaprol injection,J0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.55,,,,,,,fee schedule,54.55,62.73,
Dimecaprol injection,J0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.55,,,,,,,fee schedule,54.55,62.73,
Dimecaprol injection,J0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.73,,,,,,,fee schedule,54.55,62.73,
Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.45,,,,,,,fee schedule,182.45,334.99,
Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.45,,,,,,,fee schedule,182.45,334.99,
Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.45,,,,,,,fee schedule,182.45,334.99,
Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.82,,,,,,,fee schedule,182.45,334.99,
Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,195.41,,,,,,,fee schedule,182.45,334.99,APC
Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,186.11,,,,,,,fee schedule,182.45,334.99,APC
Baclofen 10 mg injection,J0475,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,334.99,,,,,,,fee schedule,182.45,334.99,APC
Baclofen intrathecal trial,J0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.74,,,,,,,fee schedule,69.74,80.2,
Baclofen intrathecal trial,J0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69.74,,,,,,,fee schedule,69.74,80.2,
Baclofen intrathecal trial,J0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.74,,,,,,,fee schedule,69.74,80.2,
Baclofen intrathecal trial,J0476,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.2,,,,,,,fee schedule,69.74,80.2,
Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4848.79,,,,,,,fee schedule,4848.79,8829.09,
Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4848.79,,,,,,,fee schedule,4848.79,8829.09,
Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4848.79,,,,,,,fee schedule,4848.79,8829.09,
Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5576.11,,,,,,,fee schedule,4848.79,8829.09,
Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5150.3,,,,,,,fee schedule,4848.79,8829.09,APC
Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4905.05,,,,,,,fee schedule,4848.79,8829.09,APC
Basiliximab,J0480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8829.09,,,,,,,fee schedule,4848.79,8829.09,APC
Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.03,,,,,,,fee schedule,3.88,6.99,
Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.03,,,,,,,fee schedule,3.88,6.99,
Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.03,,,,,,,fee schedule,3.88,6.99,
Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.63,,,,,,,fee schedule,3.88,6.99,
Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.08,,,,,,,fee schedule,3.88,6.99,APC
Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.88,,,,,,,fee schedule,3.88,6.99,APC
Belatacept injection,J0485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.99,,,,,,,fee schedule,3.88,6.99,APC
Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.12,,,,,,,fee schedule,58.12,104.93,
Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.12,,,,,,,fee schedule,58.12,104.93,
Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.12,,,,,,,fee schedule,58.12,104.93,
Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.84,,,,,,,fee schedule,58.12,104.93,
Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.21,,,,,,,fee schedule,58.12,104.93,APC
Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.3,,,,,,,fee schedule,58.12,104.93,APC
Belimumab injection,J0490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.93,,,,,,,fee schedule,58.12,104.93,APC
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.79,,,,,,,fee schedule,18.51,33.31,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.79,,,,,,,fee schedule,18.51,33.31,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.79,,,,,,,fee schedule,18.51,33.31,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.61,,,,,,,fee schedule,18.51,33.31,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.43,,,,,,,fee schedule,18.51,33.31,APC
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.51,,,,,,,fee schedule,18.51,33.31,APC
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.31,,,,,,,fee schedule,18.51,33.31,APC
Dicyclomine injection,J0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.12,,,,,,,fee schedule,12.12,13.94,
Dicyclomine injection,J0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.12,,,,,,,fee schedule,12.12,13.94,
Dicyclomine injection,J0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.12,,,,,,,fee schedule,12.12,13.94,
Dicyclomine injection,J0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.94,,,,,,,fee schedule,12.12,13.94,
Inj benztropine mesylate,J0515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.92,,,,,,,fee schedule,17.92,20.61,
Inj benztropine mesylate,J0515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.92,,,,,,,fee schedule,17.92,20.61,
Inj benztropine mesylate,J0515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.92,,,,,,,fee schedule,17.92,20.61,
Inj benztropine mesylate,J0515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.61,,,,,,,fee schedule,17.92,20.61,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,174.47,,,,,,,fee schedule,165.56,298.01,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.47,,,,,,,fee schedule,165.56,298.01,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.47,,,,,,,fee schedule,165.56,298.01,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,200.64,,,,,,,fee schedule,165.56,298.01,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.84,,,,,,,fee schedule,165.56,298.01,APC
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,165.56,,,,,,,fee schedule,165.56,298.01,APC
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,298.01,,,,,,,fee schedule,165.56,298.01,APC
Bethanechol chloride inject,J0520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.78,,,,,,,fee schedule,4.78,5.5,
Bethanechol chloride inject,J0520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.78,,,,,,,fee schedule,4.78,5.5,
Bethanechol chloride inject,J0520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.78,,,,,,,fee schedule,4.78,5.5,
Bethanechol chloride inject,J0520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.5,,,,,,,fee schedule,4.78,5.5,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.02,,,,,,,fee schedule,18.02,35.14,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.02,,,,,,,fee schedule,18.02,35.14,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.02,,,,,,,fee schedule,18.02,35.14,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.72,,,,,,,fee schedule,18.02,35.14,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.5,,,,,,,fee schedule,18.02,35.14,APC
PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.52,,,,,,,fee schedule,18.02,35.14,APC
PenG benzathine/procaine inj,J0558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.14,,,,,,,fee schedule,18.02,35.14,APC
Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.41,,,,,,,fee schedule,30.41,58.67,
Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.41,,,,,,,fee schedule,30.41,58.67,
Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.41,,,,,,,fee schedule,30.41,58.67,
Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.97,,,,,,,fee schedule,30.41,58.67,
Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.22,,,,,,,fee schedule,30.41,58.67,APC
Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.59,,,,,,,fee schedule,30.41,58.67,APC
Penicillin g benzathine inj,J0561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.67,,,,,,,fee schedule,30.41,58.67,APC
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.33,,,,,,,fee schedule,39.82,71.68,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.33,,,,,,,fee schedule,39.82,71.68,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.33,,,,,,,fee schedule,39.82,71.68,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.53,,,,,,,fee schedule,39.82,71.68,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.82,,,,,,,fee schedule,39.82,71.68,APC
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.82,,,,,,,fee schedule,39.82,71.68,APC
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,71.68,,,,,,,fee schedule,39.82,71.68,APC
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,119.58,,,,,,,fee schedule,119.58,222.08,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.58,,,,,,,fee schedule,119.58,222.08,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.58,,,,,,,fee schedule,119.58,222.08,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,137.52,,,,,,,fee schedule,119.58,222.08,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.55,,,,,,,fee schedule,119.58,222.08,APC
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,123.38,,,,,,,fee schedule,119.58,222.08,APC
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,222.08,,,,,,,fee schedule,119.58,222.08,APC
Buprenorphine oral 1mg,J0571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.27,,,,,,,fee schedule,0.27,0.31,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.27,,,,,,,fee schedule,0.27,0.31,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.27,,,,,,,fee schedule,0.27,0.31,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.31,,,,,,,fee schedule,0.27,0.31,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4,,,,,,,fee schedule,4,4.6,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4,,,,,,,fee schedule,4,4.6,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4,,,,,,,fee schedule,4,4.6,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.6,,,,,,,fee schedule,4,4.6,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.91,,,,,,,fee schedule,7.91,9.1,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.91,,,,,,,fee schedule,7.91,9.1,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.91,,,,,,,fee schedule,7.91,9.1,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.1,,,,,,,fee schedule,7.91,9.1,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.91,,,,,,,fee schedule,7.91,9.1,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.91,,,,,,,fee schedule,7.91,9.1,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.91,,,,,,,fee schedule,7.91,9.1,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.1,,,,,,,fee schedule,7.91,9.1,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.83,,,,,,,fee schedule,15.83,18.2,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.83,,,,,,,fee schedule,15.83,18.2,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.83,,,,,,,fee schedule,15.83,18.2,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.2,,,,,,,fee schedule,15.83,18.2,
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,438.78,,,,,,,fee schedule,430.58,775.04,
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.78,,,,,,,fee schedule,430.58,775.04,
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,438.78,,,,,,,fee schedule,430.58,775.04,
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,504.6,,,,,,,fee schedule,430.58,775.04,
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,452.1,,,,,,,fee schedule,430.58,775.04,APC
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,430.58,,,,,,,fee schedule,430.58,775.04,APC
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,775.04,,,,,,,fee schedule,430.58,775.04,APC
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1755.13,,,,,,,fee schedule,1722.3,3100.15,
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1755.13,,,,,,,fee schedule,1722.3,3100.15,
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1755.13,,,,,,,fee schedule,1722.3,3100.15,
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2018.4,,,,,,,fee schedule,1722.3,3100.15,
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1808.42,,,,,,,fee schedule,1722.3,3100.15,APC
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1722.3,,,,,,,fee schedule,1722.3,3100.15,APC
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3100.15,,,,,,,fee schedule,1722.3,3100.15,APC
Bivalirudin,J0583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Bivalirudin,J0583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.17,,,,,,,fee schedule,0.17,0.2,
Bivalirudin,J0583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Bivalirudin,J0583,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.2,,,,,,,fee schedule,0.17,0.2,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,499.74,,,,,,,fee schedule,499.74,924.07,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,499.74,,,,,,,fee schedule,499.74,924.07,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,499.74,,,,,,,fee schedule,499.74,924.07,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,574.7,,,,,,,fee schedule,499.74,924.07,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,539.04,,,,,,,fee schedule,499.74,924.07,APC
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,513.37,,,,,,,fee schedule,499.74,924.07,APC
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,924.07,,,,,,,fee schedule,499.74,924.07,APC
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.75,,,,,,,fee schedule,6.51,11.71,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.75,,,,,,,fee schedule,6.51,11.71,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.75,,,,,,,fee schedule,6.51,11.71,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.76,,,,,,,fee schedule,6.51,11.71,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.83,,,,,,,fee schedule,6.51,11.71,APC
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.51,,,,,,,fee schedule,6.51,11.71,APC
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.71,,,,,,,fee schedule,6.51,11.71,APC
Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.52,,,,,,,fee schedule,8.95,16.1,
Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.52,,,,,,,fee schedule,8.95,16.1,
Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.52,,,,,,,fee schedule,8.95,16.1,
Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.95,,,,,,,fee schedule,8.95,16.1,
Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.39,,,,,,,fee schedule,8.95,16.1,APC
Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.95,,,,,,,fee schedule,8.95,16.1,APC
Abobotulinumtoxina,J0586,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.1,,,,,,,fee schedule,8.95,16.1,APC
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.85,,,,,,,fee schedule,13.29,23.92,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.85,,,,,,,fee schedule,13.29,23.92,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.85,,,,,,,fee schedule,13.29,23.92,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.93,,,,,,,fee schedule,13.29,23.92,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.95,,,,,,,fee schedule,13.29,23.92,APC
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.29,,,,,,,fee schedule,13.29,23.92,APC
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.92,,,,,,,fee schedule,13.29,23.92,APC
Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.51,,,,,,,fee schedule,5.28,9.51,
Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.51,,,,,,,fee schedule,5.28,9.51,
Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.51,,,,,,,fee schedule,5.28,9.51,
Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.34,,,,,,,fee schedule,5.28,9.51,
Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.55,,,,,,,fee schedule,5.28,9.51,APC
Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.28,,,,,,,fee schedule,5.28,9.51,APC
Incobotulinumtoxin a,J0588,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.51,,,,,,,fee schedule,5.28,9.51,APC
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.23,,,,,,,fee schedule,3.07,5.52,
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.23,,,,,,,fee schedule,3.07,5.52,
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.23,,,,,,,fee schedule,3.07,5.52,
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.71,,,,,,,fee schedule,3.07,5.52,
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.22,,,,,,,fee schedule,3.07,5.52,APC
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.07,,,,,,,fee schedule,3.07,5.52,APC
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.52,,,,,,,fee schedule,3.07,5.52,APC
"Inj deoxycholic acid, 1 mg",J0591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.3,,,,,,,fee schedule,15.3,17.6,
"Inj deoxycholic acid, 1 mg",J0591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.3,,,,,,,fee schedule,15.3,17.6,
"Inj deoxycholic acid, 1 mg",J0591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.3,,,,,,,fee schedule,15.3,17.6,
"Inj deoxycholic acid, 1 mg",J0591,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.6,,,,,,,fee schedule,15.3,17.6,
Buprenorphine hydrochloride,J0592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.29,,,,,,,fee schedule,4.29,4.93,
Buprenorphine hydrochloride,J0592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.29,,,,,,,fee schedule,4.29,4.93,
Buprenorphine hydrochloride,J0592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.29,,,,,,,fee schedule,4.29,4.93,
Buprenorphine hydrochloride,J0592,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.93,,,,,,,fee schedule,4.29,4.93,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.22,,,,,,,fee schedule,88.22,158.79,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.22,,,,,,,fee schedule,88.22,158.79,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.22,,,,,,,fee schedule,88.22,158.79,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.75,,,,,,,fee schedule,88.22,158.79,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.63,,,,,,,fee schedule,88.22,158.79,APC
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,88.22,,,,,,,fee schedule,88.22,158.79,APC
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,158.79,,,,,,,fee schedule,88.22,158.79,APC
Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.91,,,,,,,fee schedule,1.03,2.2,
Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.91,,,,,,,fee schedule,1.03,2.2,
Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.91,,,,,,,fee schedule,1.03,2.2,
Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.2,,,,,,,fee schedule,1.03,2.2,
Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.08,,,,,,,fee schedule,1.03,2.2,APC
Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.03,,,,,,,fee schedule,1.03,2.2,APC
Busulfan injection,J0594,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.86,,,,,,,fee schedule,1.03,2.2,APC
Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.24,,,,,,,fee schedule,5.24,6.03,
Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.24,,,,,,,fee schedule,5.24,6.03,
Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.24,,,,,,,fee schedule,5.24,6.03,
Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.03,,,,,,,fee schedule,5.24,6.03,
"Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.12,,,,,,,fee schedule,37.83,68.1,
"Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.12,,,,,,,fee schedule,37.83,68.1,
"Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.12,,,,,,,fee schedule,37.83,68.1,
"Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.84,,,,,,,fee schedule,37.83,68.1,
"Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.72,,,,,,,fee schedule,37.83,68.1,APC
"Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.83,,,,,,,fee schedule,37.83,68.1,APC
"Injection, ruconest",J0596,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,68.1,,,,,,,fee schedule,37.83,68.1,APC
"C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.73,,,,,,,fee schedule,78.73,142.67,
"C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.73,,,,,,,fee schedule,78.73,142.67,
"C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.73,,,,,,,fee schedule,78.73,142.67,
"C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.54,,,,,,,fee schedule,78.73,142.67,
"C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.23,,,,,,,fee schedule,78.73,142.67,APC
"C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.26,,,,,,,fee schedule,78.73,142.67,APC
"C-1 esterase, berinert",J0597,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,142.67,,,,,,,fee schedule,78.73,142.67,APC
"C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.21,,,,,,,fee schedule,66.75,120.16,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.21,,,,,,,fee schedule,66.75,120.16,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.21,,,,,,,fee schedule,66.75,120.16,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.44,,,,,,,fee schedule,66.75,120.16,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.09,,,,,,,fee schedule,66.75,120.16,APC
"C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,66.75,,,,,,,fee schedule,66.75,120.16,APC
"C-1 esterase, cinryze",J0598,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120.16,,,,,,,fee schedule,66.75,120.16,APC
"Inj., haegarda 10 units",J0599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.34,,,,,,,fee schedule,12.34,14.19,
"Inj., haegarda 10 units",J0599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.34,,,,,,,fee schedule,12.34,14.19,
"Inj., haegarda 10 units",J0599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.34,,,,,,,fee schedule,12.34,14.19,
"Inj., haegarda 10 units",J0599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.19,,,,,,,fee schedule,12.34,14.19,
Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6698.14,,,,,,,fee schedule,6189.49,11141.08,
Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6698.14,,,,,,,fee schedule,6189.49,11141.08,
Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6698.14,,,,,,,fee schedule,6189.49,11141.08,
Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7702.86,,,,,,,fee schedule,6189.49,11141.08,
Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6498.96,,,,,,,fee schedule,6189.49,11141.08,APC
Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6189.49,,,,,,,fee schedule,6189.49,11141.08,APC
Edetate calcium disodium inj,J0600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11141.08,,,,,,,fee schedule,6189.49,11141.08,APC
Sevelamer carbonate 20 mg,J0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Sevelamer carbonate 20 mg,J0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Sevelamer carbonate 20 mg,J0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
Sevelamer carbonate 20 mg,J0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Sevelamer carbonate pdr 20mg,J0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Sevelamer carbonate pdr 20mg,J0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Sevelamer carbonate pdr 20mg,J0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.05,,,,,,,fee schedule,0.05,0.06,
Sevelamer carbonate pdr 20mg,J0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.06,,,,,,,fee schedule,0.05,0.06,
Sevelamer hydrochloride 20mg,J0603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
Sevelamer hydrochloride 20mg,J0603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
Sevelamer hydrochloride 20mg,J0603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.1,
Sevelamer hydrochloride 20mg,J0603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.1,,,,,,,fee schedule,0.09,0.1,
"Cinacalcet, esrd on dialysis",J0604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Cinacalcet, esrd on dialysis",J0604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Cinacalcet, esrd on dialysis",J0604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.02,,,,,,,fee schedule,0.02,0.02,
"Cinacalcet, esrd on dialysis",J0604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
Sucroferric oxyhydroxide 5mg,J0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Sucroferric oxyhydroxide 5mg,J0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Sucroferric oxyhydroxide 5mg,J0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.18,,,,,,,fee schedule,0.18,0.21,
Sucroferric oxyhydroxide 5mg,J0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.21,,,,,,,fee schedule,0.18,0.21,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.21,,,,,,,fee schedule,2.47,4.84,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.21,,,,,,,fee schedule,2.47,4.84,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.21,,,,,,,fee schedule,2.47,4.84,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.84,,,,,,,fee schedule,2.47,4.84,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.59,,,,,,,fee schedule,2.47,4.84,APC
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.47,,,,,,,fee schedule,2.47,4.84,APC
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.44,,,,,,,fee schedule,2.47,4.84,APC
Lanthanum carbonate oral 5mg,J0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
Lanthanum carbonate oral 5mg,J0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
Lanthanum carbonate oral 5mg,J0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.04,,,,,,,fee schedule,0.04,0.05,
Lanthanum carbonate oral 5mg,J0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.05,,,,,,,fee schedule,0.04,0.05,
Lanthanum carbonate pwdr 5mg,J0608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Lanthanum carbonate pwdr 5mg,J0608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Lanthanum carbonate pwdr 5mg,J0608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.07,
Lanthanum carbonate pwdr 5mg,J0608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.07,
Ferric citrate orl 3 mg iron,J0609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.11,,,,,,,fee schedule,0.11,0.13,
Ferric citrate orl 3 mg iron,J0609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.11,,,,,,,fee schedule,0.11,0.13,
Ferric citrate orl 3 mg iron,J0609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.11,,,,,,,fee schedule,0.11,0.13,
Ferric citrate orl 3 mg iron,J0609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.13,,,,,,,fee schedule,0.11,0.13,
Calcium glucon (fresenius),J0612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
Calcium glucon (fresenius),J0612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
Calcium glucon (fresenius),J0612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.04,,,,,,,fee schedule,0.04,0.05,
Calcium glucon (fresenius),J0612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.05,,,,,,,fee schedule,0.04,0.05,
Calcium glucon (wg critical),J0613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.08,,,,,,,fee schedule,0.08,0.09,
Calcium glucon (wg critical),J0613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.08,,,,,,,fee schedule,0.08,0.09,
Calcium glucon (wg critical),J0613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.08,,,,,,,fee schedule,0.08,0.09,
Calcium glucon (wg critical),J0613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.09,,,,,,,fee schedule,0.08,0.09,
"Calcium acetate, oral, 23 mg",J0615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Calcium acetate, oral, 23 mg",J0615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Calcium acetate, oral, 23 mg",J0615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.02,,,,,,,fee schedule,0.02,0.02,
"Calcium acetate, oral, 23 mg",J0615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
Inj metoprolol tartrate 1 mg,J0616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.14,,,,,,,fee schedule,0.14,0.16,
Inj metoprolol tartrate 1 mg,J0616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.14,,,,,,,fee schedule,0.14,0.16,
Inj metoprolol tartrate 1 mg,J0616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.14,,,,,,,fee schedule,0.14,0.16,
Inj metoprolol tartrate 1 mg,J0616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.16,,,,,,,fee schedule,0.14,0.16,
"Inj, calcium chloride, 2 mg",J0618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, calcium chloride, 2 mg",J0618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, calcium chloride, 2 mg",J0618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, calcium chloride, 2 mg",J0618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Calcium glycer & lact/10 ML,J0620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.09,,,,,,,fee schedule,13.09,15.05,
Calcium glycer & lact/10 ML,J0620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.09,,,,,,,fee schedule,13.09,15.05,
Calcium glycer & lact/10 ML,J0620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.09,,,,,,,fee schedule,13.09,15.05,
Calcium glycer & lact/10 ML,J0620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.05,,,,,,,fee schedule,13.09,15.05,
Calcitonin salmon injection,J0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,816,,,,,,,fee schedule,816,938.4,
Calcitonin salmon injection,J0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,816,,,,,,,fee schedule,816,938.4,
Calcitonin salmon injection,J0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,816,,,,,,,fee schedule,816,938.4,
Calcitonin salmon injection,J0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,938.4,,,,,,,fee schedule,816,938.4,
Inj calcitriol per 0.1 mcg,J0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.01,,,,,,,fee schedule,1.01,1.16,
Inj calcitriol per 0.1 mcg,J0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.01,,,,,,,fee schedule,1.01,1.16,
Inj calcitriol per 0.1 mcg,J0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.01,,,,,,,fee schedule,1.01,1.16,
Inj calcitriol per 0.1 mcg,J0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.16,,,,,,,fee schedule,1.01,1.16,
Caspofungin acetate,J0637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.35,,,,,,,fee schedule,2.35,2.7,
Caspofungin acetate,J0637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.35,,,,,,,fee schedule,2.35,2.7,
Caspofungin acetate,J0637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.35,,,,,,,fee schedule,2.35,2.7,
Caspofungin acetate,J0637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.7,,,,,,,fee schedule,2.35,2.7,
Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.32,,,,,,,fee schedule,146.32,281.77,
Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.32,,,,,,,fee schedule,146.32,281.77,
Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.32,,,,,,,fee schedule,146.32,281.77,
Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,168.27,,,,,,,fee schedule,146.32,281.77,
Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.37,,,,,,,fee schedule,146.32,281.77,APC
Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,156.54,,,,,,,fee schedule,146.32,281.77,APC
Canakinumab injection,J0638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,281.77,,,,,,,fee schedule,146.32,281.77,APC
Leucovorin calcium injection,J0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.1,,,,,,,fee schedule,4.1,4.72,
Leucovorin calcium injection,J0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.1,,,,,,,fee schedule,4.1,4.72,
Leucovorin calcium injection,J0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.1,,,,,,,fee schedule,4.1,4.72,
Leucovorin calcium injection,J0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.72,,,,,,,fee schedule,4.1,4.72,
Levoleucovorin injection,J0641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
Levoleucovorin injection,J0641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
Levoleucovorin injection,J0641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.04,,,,,,,fee schedule,0.04,0.05,
Levoleucovorin injection,J0641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.05,,,,,,,fee schedule,0.04,0.05,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.16,,,,,,,fee schedule,1.16,1.33,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.16,,,,,,,fee schedule,1.16,1.33,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.16,,,,,,,fee schedule,1.16,1.33,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.33,,,,,,,fee schedule,1.16,1.33,
"Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.99,,,,,,,fee schedule,7.99,9.19,
"Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.99,,,,,,,fee schedule,7.99,9.19,
"Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.99,,,,,,,fee schedule,7.99,9.19,
"Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.19,,,,,,,fee schedule,7.99,9.19,
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.36,,,,,,,fee schedule,6.84,12.3,
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.36,,,,,,,fee schedule,6.84,12.3,
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.36,,,,,,,fee schedule,6.84,12.3,
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.46,,,,,,,fee schedule,6.84,12.3,
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.18,,,,,,,fee schedule,6.84,12.3,APC
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.84,,,,,,,fee schedule,6.84,12.3,APC
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.3,,,,,,,fee schedule,6.84,12.3,APC
"Inj, levothyroxine, hikma",J0652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.33,,,,,,,fee schedule,5.33,6.13,
"Inj, levothyroxine, hikma",J0652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.33,,,,,,,fee schedule,5.33,6.13,
"Inj, levothyroxine, hikma",J0652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.33,,,,,,,fee schedule,5.33,6.13,
"Inj, levothyroxine, hikma",J0652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.13,,,,,,,fee schedule,5.33,6.13,
"Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.55,,,,,,,fee schedule,1.45,2.62,
"Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.55,,,,,,,fee schedule,1.45,2.62,
"Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.55,,,,,,,fee schedule,1.45,2.62,
"Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.78,,,,,,,fee schedule,1.45,2.62,
"Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.53,,,,,,,fee schedule,1.45,2.62,APC
"Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.45,,,,,,,fee schedule,1.45,2.62,APC
"Inj, bupivacaine liposome",J0666,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.62,,,,,,,fee schedule,1.45,2.62,APC
"Instill, bupivac and meloxic",J0668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.89,,,,,,,fee schedule,0.85,1.52,APC
"Instill, bupivac and meloxic",J0668,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.85,,,,,,,fee schedule,0.85,1.52,APC
"Instill, bupivac and meloxic",J0668,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.52,,,,,,,fee schedule,0.85,1.52,APC
Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.97,,,,,,,fee schedule,3.97,4.57,
Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.97,,,,,,,fee schedule,3.97,4.57,
Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.97,,,,,,,fee schedule,3.97,4.57,
Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.57,,,,,,,fee schedule,3.97,4.57,
Inj cefazolin (wg crit care),J0687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.04,,,,,,,fee schedule,1.04,1.2,
Inj cefazolin (wg crit care),J0687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.04,,,,,,,fee schedule,1.04,1.2,
Inj cefazolin (wg crit care),J0687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.04,,,,,,,fee schedule,1.04,1.2,
Inj cefazolin (wg crit care),J0687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.2,,,,,,,fee schedule,1.04,1.2,
"Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.95,,,,,,,fee schedule,0.95,1.09,
"Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.95,,,,,,,fee schedule,0.95,1.09,
"Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.95,,,,,,,fee schedule,0.95,1.09,
"Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.09,,,,,,,fee schedule,0.95,1.09,
"Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.38,,,,,,,fee schedule,1.38,1.59,
"Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.38,,,,,,,fee schedule,1.38,1.59,
"Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.38,,,,,,,fee schedule,1.38,1.59,
"Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.59,,,,,,,fee schedule,1.38,1.59,
Cefazolin sodium injection,J0690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.87,,,,,,,fee schedule,0.87,1,
Cefazolin sodium injection,J0690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.87,,,,,,,fee schedule,0.87,1,
Cefazolin sodium injection,J0690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.87,,,,,,,fee schedule,0.87,1,
Cefazolin sodium injection,J0690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1,,,,,,,fee schedule,0.87,1,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.7,,,,,,,fee schedule,0.7,0.81,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.7,,,,,,,fee schedule,0.7,0.81,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.7,,,,,,,fee schedule,0.7,0.81,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.81,,,,,,,fee schedule,0.7,0.81,
Cefepime hcl for injection,J0692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.28,,,,,,,fee schedule,1.28,1.47,
Cefepime hcl for injection,J0692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.28,,,,,,,fee schedule,1.28,1.47,
Cefepime hcl for injection,J0692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.28,,,,,,,fee schedule,1.28,1.47,
Cefepime hcl for injection,J0692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.47,,,,,,,fee schedule,1.28,1.47,
Cefoxitin sodium injection,J0694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.33,,,,,,,fee schedule,5.33,6.13,
Cefoxitin sodium injection,J0694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.33,,,,,,,fee schedule,5.33,6.13,
Cefoxitin sodium injection,J0694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.33,,,,,,,fee schedule,5.33,6.13,
Cefoxitin sodium injection,J0694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.13,,,,,,,fee schedule,5.33,6.13,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.47,,,,,,,fee schedule,9.47,18.07,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.47,,,,,,,fee schedule,9.47,18.07,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.47,,,,,,,fee schedule,9.47,18.07,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.89,,,,,,,fee schedule,9.47,18.07,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.54,,,,,,,fee schedule,9.47,18.07,APC
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.04,,,,,,,fee schedule,9.47,18.07,APC
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.07,,,,,,,fee schedule,9.47,18.07,APC
Ceftriaxone sodium injection,J0696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.5,,,,,,,fee schedule,0.5,0.58,
Ceftriaxone sodium injection,J0696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.5,,,,,,,fee schedule,0.5,0.58,
Ceftriaxone sodium injection,J0696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.5,,,,,,,fee schedule,0.5,0.58,
Ceftriaxone sodium injection,J0696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.58,,,,,,,fee schedule,0.5,0.58,
Sterile cefuroxime injection,J0697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.38,,,,,,,fee schedule,2.38,2.74,
Sterile cefuroxime injection,J0697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.38,,,,,,,fee schedule,2.38,2.74,
Sterile cefuroxime injection,J0697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.38,,,,,,,fee schedule,2.38,2.74,
Sterile cefuroxime injection,J0697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.74,,,,,,,fee schedule,2.38,2.74,
Cefotaxime sodium injection,J0698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10,,,,,,,fee schedule,10,11.5,
Cefotaxime sodium injection,J0698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10,,,,,,,fee schedule,10,11.5,
Cefotaxime sodium injection,J0698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10,,,,,,,fee schedule,10,11.5,
Cefotaxime sodium injection,J0698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.5,,,,,,,fee schedule,10,11.5,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.49,,,,,,,fee schedule,2.49,4.59,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.49,,,,,,,fee schedule,2.49,4.59,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.49,,,,,,,fee schedule,2.49,4.59,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.86,,,,,,,fee schedule,2.49,4.59,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.68,,,,,,,fee schedule,2.49,4.59,APC
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.55,,,,,,,fee schedule,2.49,4.59,APC
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.59,,,,,,,fee schedule,2.49,4.59,APC
Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.09,,,,,,,fee schedule,6.09,7,
Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.09,,,,,,,fee schedule,6.09,7,
Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.09,,,,,,,fee schedule,6.09,7,
Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7,,,,,,,fee schedule,6.09,7,
Betamethasone acet&sod phosp,J0702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.15,,,,,,,fee schedule,7.15,8.22,
Betamethasone acet&sod phosp,J0702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.15,,,,,,,fee schedule,7.15,8.22,
Betamethasone acet&sod phosp,J0702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.15,,,,,,,fee schedule,7.15,8.22,
Betamethasone acet&sod phosp,J0702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.22,,,,,,,fee schedule,7.15,8.22,
"Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.27,,,,,,,fee schedule,5.27,6.06,
"Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.27,,,,,,,fee schedule,5.27,6.06,
"Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.27,,,,,,,fee schedule,5.27,6.06,
"Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.06,,,,,,,fee schedule,5.27,6.06,
Caffeine citrate injection,J0706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.23,,,,,,,fee schedule,1.23,1.41,
Caffeine citrate injection,J0706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.23,,,,,,,fee schedule,1.23,1.41,
Caffeine citrate injection,J0706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.23,,,,,,,fee schedule,1.23,1.41,
Caffeine citrate injection,J0706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.41,,,,,,,fee schedule,1.23,1.41,
Cephapirin sodium injection,J0710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.39,,,,,,,fee schedule,1.39,1.6,
Cephapirin sodium injection,J0710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.39,,,,,,,fee schedule,1.39,1.6,
Cephapirin sodium injection,J0710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.39,,,,,,,fee schedule,1.39,1.6,
Cephapirin sodium injection,J0710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.6,,,,,,,fee schedule,1.39,1.6,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.4,,,,,,,fee schedule,4.39,7.9,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.4,,,,,,,fee schedule,4.39,7.9,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.4,,,,,,,fee schedule,4.39,7.9,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.06,,,,,,,fee schedule,4.39,7.9,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.61,,,,,,,fee schedule,4.39,7.9,APC
Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.39,,,,,,,fee schedule,4.39,7.9,APC
Ceftaroline fosamil inj,J0712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.9,,,,,,,fee schedule,4.39,7.9,APC
Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.7,,,,,,,fee schedule,1.7,1.96,
Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.7,,,,,,,fee schedule,1.7,1.96,
Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.7,,,,,,,fee schedule,1.7,1.96,
Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.96,,,,,,,fee schedule,1.7,1.96,
Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.91,,,,,,,fee schedule,108.91,197.58,
Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.91,,,,,,,fee schedule,108.91,197.58,
Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.91,,,,,,,fee schedule,108.91,197.58,
Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,125.25,,,,,,,fee schedule,108.91,197.58,
Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,115.26,,,,,,,fee schedule,108.91,197.58,APC
Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,109.77,,,,,,,fee schedule,108.91,197.58,APC
Ceftazidime and avibactam,J0714,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,197.58,,,,,,,fee schedule,108.91,197.58,APC
Ceftizoxime sodium / 500 MG,J0715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.54,,,,,,,fee schedule,5.54,6.37,
Ceftizoxime sodium / 500 MG,J0715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.54,,,,,,,fee schedule,5.54,6.37,
Ceftizoxime sodium / 500 MG,J0715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.54,,,,,,,fee schedule,5.54,6.37,
Ceftizoxime sodium / 500 MG,J0715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.37,,,,,,,fee schedule,5.54,6.37,
Centruroides immune f(ab),J0716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5351.02,,,,,,,fee schedule,5351.02,6153.67,
Centruroides immune f(ab),J0716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5351.02,,,,,,,fee schedule,5351.02,6153.67,
Centruroides immune f(ab),J0716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5351.02,,,,,,,fee schedule,5351.02,6153.67,
Centruroides immune f(ab),J0716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6153.67,,,,,,,fee schedule,5351.02,6153.67,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.66,,,,,,,fee schedule,3.44,6.2,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.66,,,,,,,fee schedule,3.44,6.2,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.66,,,,,,,fee schedule,3.44,6.2,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.36,,,,,,,fee schedule,3.44,6.2,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.62,,,,,,,fee schedule,3.44,6.2,APC
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.44,,,,,,,fee schedule,3.44,6.2,APC
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.2,,,,,,,fee schedule,3.44,6.2,APC
Chloramphenicol sodium injec,J0720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.62,,,,,,,fee schedule,49.62,57.06,
Chloramphenicol sodium injec,J0720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.62,,,,,,,fee schedule,49.62,57.06,
Chloramphenicol sodium injec,J0720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.62,,,,,,,fee schedule,49.62,57.06,
Chloramphenicol sodium injec,J0720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.06,,,,,,,fee schedule,49.62,57.06,
Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.17,,,,,,,fee schedule,18.17,20.9,
Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.17,,,,,,,fee schedule,18.17,20.9,
Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.17,,,,,,,fee schedule,18.17,20.9,
Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.9,,,,,,,fee schedule,18.17,20.9,
Clonidine hydrochloride,J0735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.34,,,,,,,fee schedule,18.34,21.09,
Clonidine hydrochloride,J0735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.34,,,,,,,fee schedule,18.34,21.09,
Clonidine hydrochloride,J0735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.34,,,,,,,fee schedule,18.34,21.09,
Clonidine hydrochloride,J0735,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.09,,,,,,,fee schedule,18.34,21.09,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.73,,,,,,,fee schedule,1.73,1.99,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.73,,,,,,,fee schedule,1.73,1.99,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.73,,,,,,,fee schedule,1.73,1.99,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.99,,,,,,,fee schedule,1.73,1.99,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.78,,,,,,,fee schedule,1.78,2.05,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.78,,,,,,,fee schedule,1.78,2.05,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.78,,,,,,,fee schedule,1.78,2.05,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.05,,,,,,,fee schedule,1.78,2.05,
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.3,,,,,,,fee schedule,7.29,13.13,
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.3,,,,,,,fee schedule,7.29,13.13,
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.3,,,,,,,fee schedule,7.29,13.13,
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.4,,,,,,,fee schedule,7.29,13.13,
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.66,,,,,,,fee schedule,7.29,13.13,APC
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.29,,,,,,,fee schedule,7.29,13.13,APC
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.13,,,,,,,fee schedule,7.29,13.13,APC
Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,549.35,,,,,,,fee schedule,535.74,964.32,
Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,549.35,,,,,,,fee schedule,535.74,964.32,
Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,549.35,,,,,,,fee schedule,535.74,964.32,
Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,631.75,,,,,,,fee schedule,535.74,964.32,
Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,562.52,,,,,,,fee schedule,535.74,964.32,APC
Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,535.74,,,,,,,fee schedule,535.74,964.32,APC
Cidofovir injection,J0740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,964.32,,,,,,,fee schedule,535.74,964.32,APC
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.52,,,,,,,fee schedule,24.52,44.4,
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.52,,,,,,,fee schedule,24.52,44.4,
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.52,,,,,,,fee schedule,24.52,44.4,
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.2,,,,,,,fee schedule,24.52,44.4,
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.9,,,,,,,fee schedule,24.52,44.4,APC
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.67,,,,,,,fee schedule,24.52,44.4,APC
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.4,,,,,,,fee schedule,24.52,44.4,APC
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.71,,,,,,,fee schedule,2.71,3.12,
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.71,,,,,,,fee schedule,2.71,3.12,
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.71,,,,,,,fee schedule,2.71,3.12,
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.12,,,,,,,fee schedule,2.71,3.12,
Cilastatin sodium injection,J0743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.24,,,,,,,fee schedule,7.24,8.33,
Cilastatin sodium injection,J0743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.24,,,,,,,fee schedule,7.24,8.33,
Cilastatin sodium injection,J0743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.24,,,,,,,fee schedule,7.24,8.33,
Cilastatin sodium injection,J0743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.33,,,,,,,fee schedule,7.24,8.33,
Ciprofloxacin iv,J0744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.41,,,,,,,fee schedule,2.41,2.77,
Ciprofloxacin iv,J0744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.41,,,,,,,fee schedule,2.41,2.77,
Ciprofloxacin iv,J0744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.41,,,,,,,fee schedule,2.41,2.77,
Ciprofloxacin iv,J0744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.77,,,,,,,fee schedule,2.41,2.77,
Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.29,,,,,,,fee schedule,1.29,1.48,
Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.29,,,,,,,fee schedule,1.29,1.48,
Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.29,,,,,,,fee schedule,1.29,1.48,
Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.48,,,,,,,fee schedule,1.29,1.48,
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.8,,,,,,,fee schedule,0.45,2.07,
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.8,,,,,,,fee schedule,0.45,2.07,
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.8,,,,,,,fee schedule,0.45,2.07,
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.07,,,,,,,fee schedule,0.45,2.07,
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.48,,,,,,,fee schedule,0.45,2.07,APC
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.45,,,,,,,fee schedule,0.45,2.07,APC
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.82,,,,,,,fee schedule,0.45,2.07,APC
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.96,,,,,,,fee schedule,71.43,128.57,
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.96,,,,,,,fee schedule,71.43,128.57,
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.96,,,,,,,fee schedule,71.43,128.57,
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.05,,,,,,,fee schedule,71.43,128.57,
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75,,,,,,,fee schedule,71.43,128.57,APC
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.43,,,,,,,fee schedule,71.43,128.57,APC
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,128.57,,,,,,,fee schedule,71.43,128.57,APC
Colistimethate sodium inj,J0770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.82,,,,,,,fee schedule,11.82,13.59,
Colistimethate sodium inj,J0770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.82,,,,,,,fee schedule,11.82,13.59,
Colistimethate sodium inj,J0770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.82,,,,,,,fee schedule,11.82,13.59,
Colistimethate sodium inj,J0770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.59,,,,,,,fee schedule,11.82,13.59,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.76,,,,,,,fee schedule,78.3,140.94,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.76,,,,,,,fee schedule,78.3,140.94,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.76,,,,,,,fee schedule,78.3,140.94,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.87,,,,,,,fee schedule,78.3,140.94,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.21,,,,,,,fee schedule,78.3,140.94,APC
"Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,78.3,,,,,,,fee schedule,78.3,140.94,APC
"Collagenase, clost hist inj",J0775,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,140.94,,,,,,,fee schedule,78.3,140.94,APC
Prochlorperazine injection,J0780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.62,,,,,,,fee schedule,2.62,3.01,
Prochlorperazine injection,J0780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.62,,,,,,,fee schedule,2.62,3.01,
Prochlorperazine injection,J0780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.62,,,,,,,fee schedule,2.62,3.01,
Prochlorperazine injection,J0780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.01,,,,,,,fee schedule,2.62,3.01,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.47,,,,,,,fee schedule,129.94,233.89,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.47,,,,,,,fee schedule,129.94,233.89,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.47,,,,,,,fee schedule,129.94,233.89,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.64,,,,,,,fee schedule,129.94,233.89,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,136.43,,,,,,,fee schedule,129.94,233.89,APC
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,129.94,,,,,,,fee schedule,129.94,233.89,APC
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,233.89,,,,,,,fee schedule,129.94,233.89,APC
Corticorelin ovine triflutal,J0795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.31,,,,,,,fee schedule,9.31,10.71,
Corticorelin ovine triflutal,J0795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.31,,,,,,,fee schedule,9.31,10.71,
Corticorelin ovine triflutal,J0795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.31,,,,,,,fee schedule,9.31,10.71,
Corticorelin ovine triflutal,J0795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.71,,,,,,,fee schedule,9.31,10.71,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4345.44,,,,,,,fee schedule,4133.45,7440.21,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4345.44,,,,,,,fee schedule,4133.45,7440.21,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4345.44,,,,,,,fee schedule,4133.45,7440.21,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4997.26,,,,,,,fee schedule,4133.45,7440.21,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4340.12,,,,,,,fee schedule,4133.45,7440.21,APC
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4133.45,,,,,,,fee schedule,4133.45,7440.21,APC
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7440.21,,,,,,,fee schedule,4133.45,7440.21,APC
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3681.18,,,,,,,fee schedule,3674.68,6614.42,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3681.18,,,,,,,fee schedule,3674.68,6614.42,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3681.18,,,,,,,fee schedule,3674.68,6614.42,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4233.36,,,,,,,fee schedule,3674.68,6614.42,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3858.41,,,,,,,fee schedule,3674.68,6614.42,APC
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3674.68,,,,,,,fee schedule,3674.68,6614.42,APC
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6614.42,,,,,,,fee schedule,3674.68,6614.42,APC
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.08,,,,,,,fee schedule,29.08,33.44,
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.08,,,,,,,fee schedule,29.08,33.44,
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.08,,,,,,,fee schedule,29.08,33.44,
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.44,,,,,,,fee schedule,29.08,33.44,
Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1931.36,,,,,,,fee schedule,1906.91,3432.43,
Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1931.36,,,,,,,fee schedule,1906.91,3432.43,
Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1931.36,,,,,,,fee schedule,1906.91,3432.43,
Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2221.06,,,,,,,fee schedule,1906.91,3432.43,
Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2002.25,,,,,,,fee schedule,1906.91,3432.43,APC
Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1906.91,,,,,,,fee schedule,1906.91,3432.43,APC
Crotalidae poly immune fab,J0840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3432.43,,,,,,,fee schedule,1906.91,3432.43,APC
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1083.54,,,,,,,fee schedule,1083.54,1246.07,
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1083.54,,,,,,,fee schedule,1083.54,1246.07,
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1083.54,,,,,,,fee schedule,1083.54,1246.07,
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1246.07,,,,,,,fee schedule,1083.54,1246.07,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1877.72,,,,,,,fee schedule,1858.82,3345.88,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1877.72,,,,,,,fee schedule,1858.82,3345.88,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1877.72,,,,,,,fee schedule,1858.82,3345.88,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2159.38,,,,,,,fee schedule,1858.82,3345.88,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1951.76,,,,,,,fee schedule,1858.82,3345.88,APC
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1858.82,,,,,,,fee schedule,1858.82,3345.88,APC
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3345.88,,,,,,,fee schedule,1858.82,3345.88,APC
"Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.17,,,,,,,fee schedule,59.17,107.16,
"Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.17,,,,,,,fee schedule,59.17,107.16,
"Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.17,,,,,,,fee schedule,59.17,107.16,
"Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.05,,,,,,,fee schedule,59.17,107.16,
"Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,62.51,,,,,,,fee schedule,59.17,107.16,APC
"Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,59.53,,,,,,,fee schedule,59.17,107.16,APC
"Injection, imetelstat, 1 mg",J0870,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,107.16,,,,,,,fee schedule,59.17,107.16,APC
Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.05,,,,,,,fee schedule,0.05,0.06,
Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.06,,,,,,,fee schedule,0.05,0.06,
"Inj, daptomycin (xellia)",J0873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
"Inj, daptomycin (xellia)",J0873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
"Inj, daptomycin (xellia)",J0873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.04,,,,,,,fee schedule,0.04,0.05,
"Inj, daptomycin (xellia)",J0873,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.05,,,,,,,fee schedule,0.04,0.05,
"Inj, daptomycin (baxter)",J0874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, daptomycin (baxter)",J0874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, daptomycin (baxter)",J0874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, daptomycin (baxter)",J0874,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.07,
"Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.14,,,,,,,fee schedule,11.29,20.33,
"Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.14,,,,,,,fee schedule,11.29,20.33,
"Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.14,,,,,,,fee schedule,11.29,20.33,
"Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.56,,,,,,,fee schedule,11.29,20.33,
"Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.86,,,,,,,fee schedule,11.29,20.33,APC
"Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.29,,,,,,,fee schedule,11.29,20.33,APC
"Injection, dalbavancin",J0875,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.33,,,,,,,fee schedule,11.29,20.33,APC
"Inj, daptomycin (hospira)",J0877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, daptomycin (hospira)",J0877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, daptomycin (hospira)",J0877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, daptomycin (hospira)",J0877,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.07,
Daptomycin injection,J0878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Daptomycin injection,J0878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Daptomycin injection,J0878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
Daptomycin injection,J0878,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.24,,,,,,,fee schedule,0.24,0.28,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.24,,,,,,,fee schedule,0.24,0.28,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.24,,,,,,,fee schedule,0.24,0.28,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.28,,,,,,,fee schedule,0.24,0.28,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.11,,,,,,,fee schedule,2.92,5.26,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.11,,,,,,,fee schedule,2.92,5.26,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.11,,,,,,,fee schedule,2.92,5.26,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.58,,,,,,,fee schedule,2.92,5.26,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.07,,,,,,,fee schedule,2.92,5.26,APC
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.92,,,,,,,fee schedule,2.92,5.26,APC
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.26,,,,,,,fee schedule,2.92,5.26,APC
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.11,,,,,,,fee schedule,2.92,5.26,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.11,,,,,,,fee schedule,2.92,5.26,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.11,,,,,,,fee schedule,2.92,5.26,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.58,,,,,,,fee schedule,2.92,5.26,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.07,,,,,,,fee schedule,2.92,5.26,APC
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.92,,,,,,,fee schedule,2.92,5.26,APC
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.26,,,,,,,fee schedule,2.92,5.26,APC
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.77,,,,,,,fee schedule,0.77,1.56,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.77,,,,,,,fee schedule,0.77,1.56,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.77,,,,,,,fee schedule,0.77,1.56,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.89,,,,,,,fee schedule,0.77,1.56,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.91,,,,,,,fee schedule,0.77,1.56,APC
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.86,,,,,,,fee schedule,0.77,1.56,APC
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.56,,,,,,,fee schedule,0.77,1.56,APC
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.77,,,,,,,fee schedule,0.77,0.89,
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.77,,,,,,,fee schedule,0.77,0.89,
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.77,,,,,,,fee schedule,0.77,0.89,
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.89,,,,,,,fee schedule,0.77,0.89,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.97,,,,,,,fee schedule,6.88,12.38,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.97,,,,,,,fee schedule,6.88,12.38,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.97,,,,,,,fee schedule,6.88,12.38,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.17,,,,,,,fee schedule,6.88,12.38,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.22,,,,,,,fee schedule,6.88,12.38,APC
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.88,,,,,,,fee schedule,6.88,12.38,APC
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.38,,,,,,,fee schedule,6.88,12.38,APC
Epoetin beta esrd use,J0887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.47,,,,,,,fee schedule,1.47,1.69,
Epoetin beta esrd use,J0887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.47,,,,,,,fee schedule,1.47,1.69,
Epoetin beta esrd use,J0887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.47,,,,,,,fee schedule,1.47,1.69,
Epoetin beta esrd use,J0887,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.69,,,,,,,fee schedule,1.47,1.69,
Epoetin beta non esrd,J0888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.47,,,,,,,fee schedule,1.47,1.69,
Epoetin beta non esrd,J0888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.47,,,,,,,fee schedule,1.47,1.69,
Epoetin beta non esrd,J0888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.47,,,,,,,fee schedule,1.47,1.69,
Epoetin beta non esrd,J0888,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.69,,,,,,,fee schedule,1.47,1.69,
Daprodustat oral 1mg esrd,J0889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.99,,,,,,,fee schedule,3.99,4.59,
Daprodustat oral 1mg esrd,J0889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.99,,,,,,,fee schedule,3.99,4.59,
Daprodustat oral 1mg esrd,J0889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.99,,,,,,,fee schedule,3.99,4.59,
Daprodustat oral 1mg esrd,J0889,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.59,,,,,,,fee schedule,3.99,4.59,
Peginesatide injection,J0890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.02,,,,,,,fee schedule,11.02,12.67,
Peginesatide injection,J0890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.02,,,,,,,fee schedule,11.02,12.67,
Peginesatide injection,J0890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.02,,,,,,,fee schedule,11.02,12.67,
Peginesatide injection,J0890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.67,,,,,,,fee schedule,11.02,12.67,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.04,,,,,,,fee schedule,1.82,4.65,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.04,,,,,,,fee schedule,1.82,4.65,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.04,,,,,,,fee schedule,1.82,4.65,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.65,,,,,,,fee schedule,1.82,4.65,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.91,,,,,,,fee schedule,1.82,4.65,APC
Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.82,,,,,,,fee schedule,1.82,4.65,APC
Argatroban nonesrd (accord),J0891,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.27,,,,,,,fee schedule,1.82,4.65,APC
Argatroban dialysis (accord),J0892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.04,,,,,,,fee schedule,4.04,4.65,
Argatroban dialysis (accord),J0892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.04,,,,,,,fee schedule,4.04,4.65,
Argatroban dialysis (accord),J0892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.04,,,,,,,fee schedule,4.04,4.65,
Argatroban dialysis (accord),J0892,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.65,,,,,,,fee schedule,4.04,4.65,
"Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.81,,,,,,,fee schedule,0.81,0.93,
"Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.81,0.93,
"Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.81,,,,,,,fee schedule,0.81,0.93,
"Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.93,,,,,,,fee schedule,0.81,0.93,
Decitabine injection,J0894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.65,,,,,,,fee schedule,1.65,1.9,
Decitabine injection,J0894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.65,,,,,,,fee schedule,1.65,1.9,
Decitabine injection,J0894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.65,,,,,,,fee schedule,1.65,1.9,
Decitabine injection,J0894,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.9,,,,,,,fee schedule,1.65,1.9,
Deferoxamine mesylate inj,J0895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.36,,,,,,,fee schedule,9.36,10.76,
Deferoxamine mesylate inj,J0895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.36,,,,,,,fee schedule,9.36,10.76,
Deferoxamine mesylate inj,J0895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.36,,,,,,,fee schedule,9.36,10.76,
Deferoxamine mesylate inj,J0895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.76,,,,,,,fee schedule,9.36,10.76,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.55,,,,,,,fee schedule,43.51,78.33,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.55,,,,,,,fee schedule,43.51,78.33,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.55,,,,,,,fee schedule,43.51,78.33,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.08,,,,,,,fee schedule,43.51,78.33,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.69,,,,,,,fee schedule,43.51,78.33,APC
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.51,,,,,,,fee schedule,43.51,78.33,APC
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78.33,,,,,,,fee schedule,43.51,78.33,APC
Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.34,,,,,,,fee schedule,30.1,54.18,
Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.34,,,,,,,fee schedule,30.1,54.18,
Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.34,,,,,,,fee schedule,30.1,54.18,
Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.89,,,,,,,fee schedule,30.1,54.18,
Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.61,,,,,,,fee schedule,30.1,54.18,APC
Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.1,,,,,,,fee schedule,30.1,54.18,APC
Denosumab injection,J0897,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54.18,,,,,,,fee schedule,30.1,54.18,APC
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.5,,,,,,,fee schedule,1.5,1.73,
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.5,,,,,,,fee schedule,1.5,1.73,
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.5,,,,,,,fee schedule,1.5,1.73,
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.73,,,,,,,fee schedule,1.5,1.73,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.5,,,,,,,fee schedule,1.5,1.73,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.5,,,,,,,fee schedule,1.5,1.73,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.5,,,,,,,fee schedule,1.5,1.73,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.73,,,,,,,fee schedule,1.5,1.73,
Vadadustat oral 1mg for esrd,J0901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.14,,,,,,,fee schedule,0.14,0.16,
Vadadustat oral 1mg for esrd,J0901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.14,,,,,,,fee schedule,0.14,0.16,
Vadadustat oral 1mg for esrd,J0901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.14,,,,,,,fee schedule,0.14,0.16,
Vadadustat oral 1mg for esrd,J0901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.16,,,,,,,fee schedule,0.14,0.16,
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.5,,,,,,,fee schedule,4.21,9.78,
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.5,,,,,,,fee schedule,4.21,9.78,
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.5,,,,,,,fee schedule,4.21,9.78,
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.78,,,,,,,fee schedule,4.21,9.78,
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.42,,,,,,,fee schedule,4.21,9.78,APC
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.21,,,,,,,fee schedule,4.21,9.78,APC
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.57,,,,,,,fee schedule,4.21,9.78,APC
Brompheniramine maleate inj,J0945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.74,,,,,,,fee schedule,0.74,0.85,
Brompheniramine maleate inj,J0945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.74,,,,,,,fee schedule,0.74,0.85,
Brompheniramine maleate inj,J0945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.74,,,,,,,fee schedule,0.74,0.85,
Brompheniramine maleate inj,J0945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.85,,,,,,,fee schedule,0.74,0.85,
Depo-estradiol cypionate inj,J1000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.68,,,,,,,fee schedule,48.68,55.98,
Depo-estradiol cypionate inj,J1000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.68,,,,,,,fee schedule,48.68,55.98,
Depo-estradiol cypionate inj,J1000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.68,,,,,,,fee schedule,48.68,55.98,
Depo-estradiol cypionate inj,J1000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.98,,,,,,,fee schedule,48.68,55.98,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.12,,,,,,,fee schedule,0.12,0.14,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.14,,,,,,,fee schedule,0.12,0.14,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.55,,,,,,,fee schedule,0.55,0.63,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.55,,,,,,,fee schedule,0.55,0.63,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.55,,,,,,,fee schedule,0.55,0.63,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.63,,,,,,,fee schedule,0.55,0.63,
Inj testosterone cypionate,J1071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Inj testosterone cypionate,J1071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Inj testosterone cypionate,J1071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
Inj testosterone cypionate,J1071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.38,,,,,,,fee schedule,1.3,2.33,
"Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.38,,,,,,,fee schedule,1.3,2.33,
"Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.38,,,,,,,fee schedule,1.3,2.33,
"Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.59,,,,,,,fee schedule,1.3,2.33,
"Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.36,,,,,,,fee schedule,1.3,2.33,APC
"Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.3,,,,,,,fee schedule,1.3,2.33,APC
"Inj, testosterone, azmiro",J1072,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.33,,,,,,,fee schedule,1.3,2.33,APC
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.17,,,,,,,fee schedule,1.17,1.35,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.17,,,,,,,fee schedule,1.17,1.35,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.17,,,,,,,fee schedule,1.17,1.35,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.35,,,,,,,fee schedule,1.17,1.35,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.32,,,,,,,fee schedule,90.02,162.03,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.32,,,,,,,fee schedule,90.02,162.03,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.32,,,,,,,fee schedule,90.02,162.03,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.12,,,,,,,fee schedule,90.02,162.03,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.52,,,,,,,fee schedule,90.02,162.03,APC
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,90.02,,,,,,,fee schedule,90.02,162.03,APC
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,162.03,,,,,,,fee schedule,90.02,162.03,APC
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.36,,,,,,,fee schedule,96.31,173.35,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,120.36,,,,,,,fee schedule,96.31,173.35,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,120.36,,,,,,,fee schedule,96.31,173.35,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.41,,,,,,,fee schedule,96.31,173.35,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.12,,,,,,,fee schedule,96.31,173.35,APC
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.31,,,,,,,fee schedule,96.31,173.35,APC
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.35,,,,,,,fee schedule,96.31,173.35,APC
Dexamethasone sodium phos,J1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Dexamethasone sodium phos,J1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Dexamethasone sodium phos,J1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.12,,,,,,,fee schedule,0.12,0.14,
Dexamethasone sodium phos,J1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.14,,,,,,,fee schedule,0.12,0.14,
Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.74,,,,,,,fee schedule,100.74,115.85,
Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.74,,,,,,,fee schedule,100.74,115.85,
Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.74,,,,,,,fee schedule,100.74,115.85,
Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.85,,,,,,,fee schedule,100.74,115.85,
Acetazolamid sodium injectio,J1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.88,,,,,,,fee schedule,17.88,20.56,
Acetazolamid sodium injectio,J1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.88,,,,,,,fee schedule,17.88,20.56,
Acetazolamid sodium injectio,J1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.88,,,,,,,fee schedule,17.88,20.56,
Acetazolamid sodium injectio,J1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.56,,,,,,,fee schedule,17.88,20.56,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.21,,,,,,,fee schedule,0.21,0.24,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.21,,,,,,,fee schedule,0.21,0.24,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.21,,,,,,,fee schedule,0.21,0.24,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.24,,,,,,,fee schedule,0.21,0.24,
Digoxin injection,J1160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.15,,,,,,,fee schedule,4.15,4.77,
Digoxin injection,J1160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.15,,,,,,,fee schedule,4.15,4.77,
Digoxin injection,J1160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.15,,,,,,,fee schedule,4.15,4.77,
Digoxin injection,J1160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.77,,,,,,,fee schedule,4.15,4.77,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5156.07,,,,,,,fee schedule,5156.07,9689.98,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5156.07,,,,,,,fee schedule,5156.07,9689.98,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5156.07,,,,,,,fee schedule,5156.07,9689.98,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5929.48,,,,,,,fee schedule,5156.07,9689.98,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5652.49,,,,,,,fee schedule,5156.07,9689.98,APC
Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5383.32,,,,,,,fee schedule,5156.07,9689.98,APC
Digoxin immune fab (ovine),J1162,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9689.98,,,,,,,fee schedule,5156.07,9689.98,APC
"Inj, diltiazem hcl, 0.5 mg",J1163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
"Inj, diltiazem hcl, 0.5 mg",J1163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
"Inj, diltiazem hcl, 0.5 mg",J1163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.04,,,,,,,fee schedule,0.04,0.05,
"Inj, diltiazem hcl, 0.5 mg",J1163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.05,,,,,,,fee schedule,0.04,0.05,
Phenytoin sodium injection,J1165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.68,,,,,,,fee schedule,0.68,0.78,
Phenytoin sodium injection,J1165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.68,,,,,,,fee schedule,0.68,0.78,
Phenytoin sodium injection,J1165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.68,,,,,,,fee schedule,0.68,0.78,
Phenytoin sodium injection,J1165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.78,,,,,,,fee schedule,0.68,0.78,
"Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.1,,,,,,,fee schedule,0.09,0.1,
Dyphylline injection,J1180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.07,,,,,,,fee schedule,8.07,9.28,
Dyphylline injection,J1180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.07,,,,,,,fee schedule,8.07,9.28,
Dyphylline injection,J1180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.07,,,,,,,fee schedule,8.07,9.28,
Dyphylline injection,J1180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.28,,,,,,,fee schedule,8.07,9.28,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.3,,,,,,,fee schedule,33.3,74.59,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.3,,,,,,,fee schedule,33.3,74.59,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.3,,,,,,,fee schedule,33.3,74.59,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.3,,,,,,,fee schedule,33.3,74.59,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.51,,,,,,,fee schedule,33.3,74.59,APC
Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.44,,,,,,,fee schedule,33.3,74.59,APC
Dexrazoxane hcl injection,J1190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74.59,,,,,,,fee schedule,33.3,74.59,APC
Diphenhydramine hcl injectio,J1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.94,,,,,,,fee schedule,0.94,1.08,
Diphenhydramine hcl injectio,J1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.94,,,,,,,fee schedule,0.94,1.08,
Diphenhydramine hcl injectio,J1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.94,,,,,,,fee schedule,0.94,1.08,
Diphenhydramine hcl injectio,J1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.08,,,,,,,fee schedule,0.94,1.08,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.02,,,,,,,fee schedule,17.02,30.88,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.02,,,,,,,fee schedule,17.02,30.88,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.02,,,,,,,fee schedule,17.02,30.88,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.57,,,,,,,fee schedule,17.02,30.88,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.01,,,,,,,fee schedule,17.02,30.88,APC
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.16,,,,,,,fee schedule,17.02,30.88,APC
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.88,,,,,,,fee schedule,17.02,30.88,APC
Miglustat oral 65 mg,J1202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.19,,,,,,,fee schedule,34.19,39.32,
Miglustat oral 65 mg,J1202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.19,,,,,,,fee schedule,34.19,39.32,
Miglustat oral 65 mg,J1202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.19,,,,,,,fee schedule,34.19,39.32,
Miglustat oral 65 mg,J1202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.32,,,,,,,fee schedule,34.19,39.32,
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,93.19,,,,,,,fee schedule,93.19,173.34,
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93.19,,,,,,,fee schedule,93.19,173.34,
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.19,,,,,,,fee schedule,93.19,173.34,
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,107.17,,,,,,,fee schedule,93.19,173.34,
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.12,,,,,,,fee schedule,93.19,173.34,APC
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.3,,,,,,,fee schedule,93.19,173.34,APC
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.34,,,,,,,fee schedule,93.19,173.34,APC
Chlorothiazide sodium inj,J1205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.91,,,,,,,fee schedule,41.91,48.2,
Chlorothiazide sodium inj,J1205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.91,,,,,,,fee schedule,41.91,48.2,
Chlorothiazide sodium inj,J1205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.91,,,,,,,fee schedule,41.91,48.2,
Chlorothiazide sodium inj,J1205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.2,,,,,,,fee schedule,41.91,48.2,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,770.93,,,,,,,fee schedule,748.88,1347.98,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,770.93,,,,,,,fee schedule,748.88,1347.98,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,770.93,,,,,,,fee schedule,748.88,1347.98,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,886.57,,,,,,,fee schedule,748.88,1347.98,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,786.32,,,,,,,fee schedule,748.88,1347.98,APC
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,748.88,,,,,,,fee schedule,748.88,1347.98,APC
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1347.98,,,,,,,fee schedule,748.88,1347.98,APC
Methadone injection,J1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.78,,,,,,,fee schedule,23.78,27.35,
Methadone injection,J1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.78,,,,,,,fee schedule,23.78,27.35,
Methadone injection,J1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.78,,,,,,,fee schedule,23.78,27.35,
Methadone injection,J1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.35,,,,,,,fee schedule,23.78,27.35,
Dimenhydrinate injection,J1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.03,,,,,,,fee schedule,8.03,9.23,
Dimenhydrinate injection,J1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.03,,,,,,,fee schedule,8.03,9.23,
Dimenhydrinate injection,J1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.03,,,,,,,fee schedule,8.03,9.23,
Dimenhydrinate injection,J1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.23,,,,,,,fee schedule,8.03,9.23,
Dipyridamole injection,J1245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.01,,,,,,,fee schedule,4.01,4.61,
Dipyridamole injection,J1245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.01,,,,,,,fee schedule,4.01,4.61,
Dipyridamole injection,J1245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.01,,,,,,,fee schedule,4.01,4.61,
Dipyridamole injection,J1245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.61,,,,,,,fee schedule,4.01,4.61,
Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.28,,,,,,,fee schedule,8.28,9.52,
Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.28,,,,,,,fee schedule,8.28,9.52,
Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.28,,,,,,,fee schedule,8.28,9.52,
Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.52,,,,,,,fee schedule,8.28,9.52,
Dolasetron mesylate,J1260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.98,,,,,,,fee schedule,5.98,6.88,
Dolasetron mesylate,J1260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.98,,,,,,,fee schedule,5.98,6.88,
Dolasetron mesylate,J1260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.98,,,,,,,fee schedule,5.98,6.88,
Dolasetron mesylate,J1260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.88,,,,,,,fee schedule,5.98,6.88,
Dopamine injection,J1265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.68,,,,,,,fee schedule,0.68,0.78,
Dopamine injection,J1265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.68,,,,,,,fee schedule,0.68,0.78,
Dopamine injection,J1265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.68,,,,,,,fee schedule,0.68,0.78,
Dopamine injection,J1265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.78,,,,,,,fee schedule,0.68,0.78,
Doripenem injection,J1267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.81,,,,,,,fee schedule,0.81,0.93,
Doripenem injection,J1267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.81,0.93,
Doripenem injection,J1267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.81,,,,,,,fee schedule,0.81,0.93,
Doripenem injection,J1267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.93,,,,,,,fee schedule,0.81,0.93,
"Injection, doxercalciferol",J1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.39,,,,,,,fee schedule,0.39,0.45,
"Injection, doxercalciferol",J1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.39,,,,,,,fee schedule,0.39,0.45,
"Injection, doxercalciferol",J1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.39,,,,,,,fee schedule,0.39,0.45,
"Injection, doxercalciferol",J1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.45,,,,,,,fee schedule,0.39,0.45,
Inj doxycycline hyclate 1 mg,J1271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Inj doxycycline hyclate 1 mg,J1271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Inj doxycycline hyclate 1 mg,J1271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.12,,,,,,,fee schedule,0.12,0.14,
Inj doxycycline hyclate 1 mg,J1271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.14,,,,,,,fee schedule,0.12,0.14,
Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,601.87,,,,,,,fee schedule,595.94,1072.7,
Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,601.87,,,,,,,fee schedule,595.94,1072.7,
Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,601.87,,,,,,,fee schedule,595.94,1072.7,
Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,692.15,,,,,,,fee schedule,595.94,1072.7,
Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,625.74,,,,,,,fee schedule,595.94,1072.7,APC
Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,595.94,,,,,,,fee schedule,595.94,1072.7,APC
Ecallantide injection,J1290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1072.7,,,,,,,fee schedule,595.94,1072.7,APC
"Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.46,,,,,,,fee schedule,44.2,79.56,
"Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.46,,,,,,,fee schedule,44.2,79.56,
"Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.46,,,,,,,fee schedule,44.2,79.56,
"Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.43,,,,,,,fee schedule,44.2,79.56,
"Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.41,,,,,,,fee schedule,44.2,79.56,APC
"Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,44.2,,,,,,,fee schedule,44.2,79.56,APC
"Inj, eculizumab, 2 mg",J1299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,79.56,,,,,,,fee schedule,44.2,79.56,APC
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.55,,,,,,,fee schedule,6.46,22.48,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.55,,,,,,,fee schedule,6.46,22.48,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.55,,,,,,,fee schedule,6.46,22.48,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.48,,,,,,,fee schedule,6.46,22.48,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.46,22.48,APC
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.46,,,,,,,fee schedule,6.46,22.48,APC
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.63,,,,,,,fee schedule,6.46,22.48,APC
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.79,,,,,,,fee schedule,18.79,35.36,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.79,,,,,,,fee schedule,18.79,35.36,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.79,,,,,,,fee schedule,18.79,35.36,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.61,,,,,,,fee schedule,18.79,35.36,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.62,,,,,,,fee schedule,18.79,35.36,APC
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.64,,,,,,,fee schedule,18.79,35.36,APC
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35.36,,,,,,,fee schedule,18.79,35.36,APC
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,233.69,,,,,,,fee schedule,226.92,408.46,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,233.69,,,,,,,fee schedule,226.92,408.46,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,233.69,,,,,,,fee schedule,226.92,408.46,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,268.74,,,,,,,fee schedule,226.92,408.46,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,238.27,,,,,,,fee schedule,226.92,408.46,APC
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,226.92,,,,,,,fee schedule,226.92,408.46,APC
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,408.46,,,,,,,fee schedule,226.92,408.46,APC
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.2,,,,,,,fee schedule,161.2,296.67,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.2,,,,,,,fee schedule,161.2,296.67,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.2,,,,,,,fee schedule,161.2,296.67,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.38,,,,,,,fee schedule,161.2,296.67,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.06,,,,,,,fee schedule,161.2,296.67,APC
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,164.82,,,,,,,fee schedule,161.2,296.67,APC
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,296.67,,,,,,,fee schedule,161.2,296.67,APC
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.91,,,,,,,fee schedule,196.91,355.74,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,196.91,,,,,,,fee schedule,196.91,355.74,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,196.91,,,,,,,fee schedule,196.91,355.74,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,226.45,,,,,,,fee schedule,196.91,355.74,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.51,,,,,,,fee schedule,196.91,355.74,APC
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,197.63,,,,,,,fee schedule,196.91,355.74,APC
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,355.74,,,,,,,fee schedule,196.91,355.74,APC
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.82,,,,,,,fee schedule,12.82,23.23,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.82,,,,,,,fee schedule,12.82,23.23,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.82,,,,,,,fee schedule,12.82,23.23,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.74,,,,,,,fee schedule,12.82,23.23,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.55,,,,,,,fee schedule,12.82,23.23,APC
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.9,,,,,,,fee schedule,12.82,23.23,APC
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.23,,,,,,,fee schedule,12.82,23.23,APC
"Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.7,,,,,,,fee schedule,530.7,992.72,
"Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,530.7,,,,,,,fee schedule,530.7,992.72,
"Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,530.7,,,,,,,fee schedule,530.7,992.72,
"Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,610.31,,,,,,,fee schedule,530.7,992.72,
"Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,579.09,,,,,,,fee schedule,530.7,992.72,APC
"Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,551.51,,,,,,,fee schedule,530.7,992.72,APC
"Inj, crovalimab-akkz, 10 mg",J1307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,992.72,,,,,,,fee schedule,530.7,992.72,APC
"Inj, famotidine, 0.25 mg",J1308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, famotidine, 0.25 mg",J1308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, famotidine, 0.25 mg",J1308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, famotidine, 0.25 mg",J1308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Amitriptyline injection,J1320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.24,,,,,,,fee schedule,2.24,2.58,
Amitriptyline injection,J1320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.24,,,,,,,fee schedule,2.24,2.58,
Amitriptyline injection,J1320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.24,,,,,,,fee schedule,2.24,2.58,
Amitriptyline injection,J1320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.58,,,,,,,fee schedule,2.24,2.58,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,318.37,,,,,,,fee schedule,318.37,575.13,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,318.37,,,,,,,fee schedule,318.37,575.13,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.37,,,,,,,fee schedule,318.37,575.13,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,366.13,,,,,,,fee schedule,318.37,575.13,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,335.49,,,,,,,fee schedule,318.37,575.13,APC
"Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,319.52,,,,,,,fee schedule,318.37,575.13,APC
"Elosulfase alfa, injection",J1322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,575.13,,,,,,,fee schedule,318.37,575.13,APC
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.3,,,,,,,fee schedule,192.3,346.47,
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,192.3,,,,,,,fee schedule,192.3,346.47,
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.3,,,,,,,fee schedule,192.3,346.47,
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.15,,,,,,,fee schedule,192.3,346.47,
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.11,,,,,,,fee schedule,192.3,346.47,APC
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,192.48,,,,,,,fee schedule,192.3,346.47,APC
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,346.47,,,,,,,fee schedule,192.3,346.47,APC
Enfuvirtide injection,J1324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.68,,,,,,,fee schedule,0.68,0.78,
Enfuvirtide injection,J1324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.68,,,,,,,fee schedule,0.68,0.78,
Enfuvirtide injection,J1324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.68,,,,,,,fee schedule,0.68,0.78,
Enfuvirtide injection,J1324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.78,,,,,,,fee schedule,0.68,0.78,
Epoprostenol injection,J1325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.81,,,,,,,fee schedule,16.81,19.33,
Epoprostenol injection,J1325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.81,,,,,,,fee schedule,16.81,19.33,
Epoprostenol injection,J1325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.81,,,,,,,fee schedule,16.81,19.33,
Epoprostenol injection,J1325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.33,,,,,,,fee schedule,16.81,19.33,
"Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.82,,,,,,,fee schedule,33.92,61.06,
"Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.82,,,,,,,fee schedule,33.92,61.06,
"Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.82,,,,,,,fee schedule,33.92,61.06,
"Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.04,,,,,,,fee schedule,33.92,61.06,
"Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.62,,,,,,,fee schedule,33.92,61.06,APC
"Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.92,,,,,,,fee schedule,33.92,61.06,APC
"Inj, zolbetuximab-clzb, 2 mg",J1326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.06,,,,,,,fee schedule,33.92,61.06,APC
Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.84,,,,,,,fee schedule,3.87,12.47,
Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.84,,,,,,,fee schedule,3.87,12.47,
Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.84,,,,,,,fee schedule,3.87,12.47,
Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.47,,,,,,,fee schedule,3.87,12.47,
Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.06,,,,,,,fee schedule,3.87,12.47,APC
Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.87,,,,,,,fee schedule,3.87,12.47,APC
Eptifibatide injection,J1327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.96,,,,,,,fee schedule,3.87,12.47,APC
Ergonovine maleate injection,J1330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.87,,,,,,,fee schedule,4.87,5.6,
Ergonovine maleate injection,J1330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.87,,,,,,,fee schedule,4.87,5.6,
Ergonovine maleate injection,J1330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.87,,,,,,,fee schedule,4.87,5.6,
Ergonovine maleate injection,J1330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.6,,,,,,,fee schedule,4.87,5.6,
Ertapenem injection,J1335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.36,,,,,,,fee schedule,9.36,10.76,
Ertapenem injection,J1335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.36,,,,,,,fee schedule,9.36,10.76,
Ertapenem injection,J1335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.36,,,,,,,fee schedule,9.36,10.76,
Ertapenem injection,J1335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.76,,,,,,,fee schedule,9.36,10.76,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.89,,,,,,,fee schedule,77.89,89.57,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.89,,,,,,,fee schedule,77.89,89.57,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.89,,,,,,,fee schedule,77.89,89.57,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.57,,,,,,,fee schedule,77.89,89.57,
Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8,,,,,,,fee schedule,8,9.2,
Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8,,,,,,,fee schedule,8,9.2,
Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8,,,,,,,fee schedule,8,9.2,
Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.2,,,,,,,fee schedule,8,9.2,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,405.49,,,,,,,fee schedule,401.5,722.71,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,405.49,,,,,,,fee schedule,401.5,722.71,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,405.49,,,,,,,fee schedule,401.5,722.71,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,466.31,,,,,,,fee schedule,401.5,722.71,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,421.58,,,,,,,fee schedule,401.5,722.71,APC
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,401.5,,,,,,,fee schedule,401.5,722.71,APC
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,722.71,,,,,,,fee schedule,401.5,722.71,APC
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.2,,,,,,,fee schedule,163.2,299.11,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.2,,,,,,,fee schedule,163.2,299.11,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.2,,,,,,,fee schedule,163.2,299.11,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.68,,,,,,,fee schedule,163.2,299.11,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,174.48,,,,,,,fee schedule,163.2,299.11,APC
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,166.17,,,,,,,fee schedule,163.2,299.11,APC
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,299.11,,,,,,,fee schedule,163.2,299.11,APC
Inj. viltolarsen,J1427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.53,,,,,,,fee schedule,57.53,66.16,
Inj. viltolarsen,J1427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.53,,,,,,,fee schedule,57.53,66.16,
Inj. viltolarsen,J1427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.53,,,,,,,fee schedule,57.53,66.16,
Inj. viltolarsen,J1427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.16,,,,,,,fee schedule,57.53,66.16,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.2,,,,,,,fee schedule,163.2,301.36,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.2,,,,,,,fee schedule,163.2,301.36,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.2,,,,,,,fee schedule,163.2,301.36,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.68,,,,,,,fee schedule,163.2,301.36,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,175.8,,,,,,,fee schedule,163.2,301.36,APC
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,167.42,,,,,,,fee schedule,163.2,301.36,APC
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,301.36,,,,,,,fee schedule,163.2,301.36,APC
Inj golodirsen 10 mg,J1429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.2,,,,,,,fee schedule,163.2,187.68,
Inj golodirsen 10 mg,J1429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.2,,,,,,,fee schedule,163.2,187.68,
Inj golodirsen 10 mg,J1429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.2,,,,,,,fee schedule,163.2,187.68,
Inj golodirsen 10 mg,J1429,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.68,,,,,,,fee schedule,163.2,187.68,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,539.12,,,,,,,fee schedule,539.12,985.09,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,539.12,,,,,,,fee schedule,539.12,985.09,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,539.12,,,,,,,fee schedule,539.12,985.09,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,619.99,,,,,,,fee schedule,539.12,985.09,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.63,,,,,,,fee schedule,539.12,985.09,APC
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,547.27,,,,,,,fee schedule,539.12,985.09,APC
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,985.09,,,,,,,fee schedule,539.12,985.09,APC
"Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.98,,,,,,,fee schedule,2.46,4.42,
"Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.98,,,,,,,fee schedule,2.46,4.42,
"Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.98,,,,,,,fee schedule,2.46,4.42,
"Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.43,,,,,,,fee schedule,2.46,4.42,
"Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.58,,,,,,,fee schedule,2.46,4.42,APC
"Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.46,,,,,,,fee schedule,2.46,4.42,APC
"Inj, focinvez, 1mg",J1434,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.42,,,,,,,fee schedule,2.46,4.42,APC
Injection estrone per 1 MG,J1435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Injection estrone per 1 MG,J1435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Injection estrone per 1 MG,J1435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.17,,,,,,,fee schedule,0.17,0.2,
Injection estrone per 1 MG,J1435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.2,,,,,,,fee schedule,0.17,0.2,
Etidronate disodium inj,J1436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.71,,,,,,,fee schedule,68.71,79.02,
Etidronate disodium inj,J1436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.71,,,,,,,fee schedule,68.71,79.02,
Etidronate disodium inj,J1436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.71,,,,,,,fee schedule,68.71,79.02,
Etidronate disodium inj,J1436,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.02,,,,,,,fee schedule,68.71,79.02,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.67,,,,,,,fee schedule,19.67,37.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.67,,,,,,,fee schedule,19.67,37.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.67,,,,,,,fee schedule,19.67,37.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.62,,,,,,,fee schedule,19.67,37.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.13,,,,,,,fee schedule,19.67,37.94,APC
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.08,,,,,,,fee schedule,19.67,37.94,APC
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.94,,,,,,,fee schedule,19.67,37.94,APC
Etanercept injection,J1438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1040.09,,,,,,,fee schedule,1040.09,1196.1,
Etanercept injection,J1438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1040.09,,,,,,,fee schedule,1040.09,1196.1,
Etanercept injection,J1438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1040.09,,,,,,,fee schedule,1040.09,1196.1,
Etanercept injection,J1438,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1196.1,,,,,,,fee schedule,1040.09,1196.1,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.19,,,,,,,fee schedule,1.13,2.04,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.19,,,,,,,fee schedule,1.13,2.04,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.19,,,,,,,fee schedule,1.13,2.04,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.37,,,,,,,fee schedule,1.13,2.04,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.19,,,,,,,fee schedule,1.13,2.04,APC
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.13,,,,,,,fee schedule,1.13,2.04,APC
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.04,,,,,,,fee schedule,1.13,2.04,APC
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.02,,,,,,,fee schedule,1.01,1.81,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.02,,,,,,,fee schedule,1.01,1.81,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.02,,,,,,,fee schedule,1.01,1.81,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.17,,,,,,,fee schedule,1.01,1.81,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.06,,,,,,,fee schedule,1.01,1.81,APC
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.01,,,,,,,fee schedule,1.01,1.81,APC
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.81,,,,,,,fee schedule,1.01,1.81,APC
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Fe pyro cit pow 0.1 mg iron,J1444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Fe pyro cit pow 0.1 mg iron,J1444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Fe pyro cit pow 0.1 mg iron,J1444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
Fe pyro cit pow 0.1 mg iron,J1444,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Inj triferic avnu 0.1mg iron,J1445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Inj triferic avnu 0.1mg iron,J1445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Inj triferic avnu 0.1mg iron,J1445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.18,,,,,,,fee schedule,0.18,0.21,
Inj triferic avnu 0.1mg iron,J1445,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.21,,,,,,,fee schedule,0.18,0.21,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.31,,,,,,,fee schedule,0.24,0.42,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.31,,,,,,,fee schedule,0.24,0.42,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.31,,,,,,,fee schedule,0.24,0.42,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.36,,,,,,,fee schedule,0.24,0.42,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.25,,,,,,,fee schedule,0.24,0.42,APC
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.24,,,,,,,fee schedule,0.24,0.42,APC
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.42,,,,,,,fee schedule,0.24,0.42,APC
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.6,,,,,,,fee schedule,5.46,9.83,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.6,,,,,,,fee schedule,5.46,9.83,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.6,,,,,,,fee schedule,5.46,9.83,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.44,,,,,,,fee schedule,5.46,9.83,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.74,,,,,,,fee schedule,5.46,9.83,APC
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.46,,,,,,,fee schedule,5.46,9.83,APC
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.83,,,,,,,fee schedule,5.46,9.83,APC
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.91,,,,,,,fee schedule,21.91,69.41,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.91,,,,,,,fee schedule,21.91,69.41,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.91,,,,,,,fee schedule,21.91,69.41,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.2,,,,,,,fee schedule,21.91,69.41,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.49,,,,,,,fee schedule,21.91,69.41,APC
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.56,,,,,,,fee schedule,21.91,69.41,APC
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.41,,,,,,,fee schedule,21.91,69.41,APC
Fluconazole,J1450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.34,,,,,,,fee schedule,2.34,2.69,
Fluconazole,J1450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.34,,,,,,,fee schedule,2.34,2.69,
Fluconazole,J1450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.34,,,,,,,fee schedule,2.34,2.69,
Fluconazole,J1450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.69,,,,,,,fee schedule,2.34,2.69,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.89,,,,,,,fee schedule,6.18,14.82,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.89,,,,,,,fee schedule,6.18,14.82,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.89,,,,,,,fee schedule,6.18,14.82,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.82,,,,,,,fee schedule,6.18,14.82,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.49,,,,,,,fee schedule,6.18,14.82,APC
"Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.18,,,,,,,fee schedule,6.18,14.82,APC
"Fomepizole, 15 mg",J1451,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.13,,,,,,,fee schedule,6.18,14.82,APC
Intraocular Fomivirsen na,J1452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,850,,,,,,,fee schedule,850,977.5,
Intraocular Fomivirsen na,J1452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,850,,,,,,,fee schedule,850,977.5,
Intraocular Fomivirsen na,J1452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,850,,,,,,,fee schedule,850,977.5,
Intraocular Fomivirsen na,J1452,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,977.5,,,,,,,fee schedule,850,977.5,
Fosaprepitant injection,J1453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Fosaprepitant injection,J1453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Fosaprepitant injection,J1453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.12,,,,,,,fee schedule,0.12,0.14,
Fosaprepitant injection,J1453,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.14,,,,,,,fee schedule,0.12,0.14,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,629.24,,,,,,,fee schedule,503.85,906.93,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,629.24,,,,,,,fee schedule,503.85,906.93,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,629.24,,,,,,,fee schedule,503.85,906.93,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,723.63,,,,,,,fee schedule,503.85,906.93,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,529.04,,,,,,,fee schedule,503.85,906.93,APC
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,503.85,,,,,,,fee schedule,503.85,906.93,APC
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,906.93,,,,,,,fee schedule,503.85,906.93,APC
Foscarnet sodium injection,J1455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.17,,,,,,,fee schedule,16.17,18.6,
Foscarnet sodium injection,J1455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.17,,,,,,,fee schedule,16.17,18.6,
Foscarnet sodium injection,J1455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.17,,,,,,,fee schedule,16.17,18.6,
Foscarnet sodium injection,J1455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.6,,,,,,,fee schedule,16.17,18.6,
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.17,,,,,,,fee schedule,0.04,1.35,
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.17,,,,,,,fee schedule,0.04,1.35,
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.17,,,,,,,fee schedule,0.04,1.35,
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.35,,,,,,,fee schedule,0.04,1.35,
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.04,,,,,,,fee schedule,0.04,1.35,APC
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.04,,,,,,,fee schedule,0.04,1.35,APC
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.06,,,,,,,fee schedule,0.04,1.35,APC
Gallium nitrate injection,J1457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.04,,,,,,,fee schedule,2.04,2.35,
Gallium nitrate injection,J1457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.04,,,,,,,fee schedule,2.04,2.35,
Gallium nitrate injection,J1457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.04,,,,,,,fee schedule,2.04,2.35,
Gallium nitrate injection,J1457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.35,,,,,,,fee schedule,2.04,2.35,
Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,524.58,,,,,,,fee schedule,524.58,946.74,
Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,524.58,,,,,,,fee schedule,524.58,946.74,
Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,524.58,,,,,,,fee schedule,524.58,946.74,
Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,603.27,,,,,,,fee schedule,524.58,946.74,
Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,552.27,,,,,,,fee schedule,524.58,946.74,APC
Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,525.97,,,,,,,fee schedule,524.58,946.74,APC
Galsulfase injection,J1458,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,946.74,,,,,,,fee schedule,524.58,946.74,APC
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.34,,,,,,,fee schedule,51.22,92.19,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.34,,,,,,,fee schedule,51.22,92.19,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.34,,,,,,,fee schedule,51.22,92.19,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.19,,,,,,,fee schedule,51.22,92.19,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.78,,,,,,,fee schedule,51.22,92.19,APC
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.22,,,,,,,fee schedule,51.22,92.19,APC
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.19,,,,,,,fee schedule,51.22,92.19,APC
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.25,,,,,,,fee schedule,48.87,87.97,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.25,,,,,,,fee schedule,48.87,87.97,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.25,,,,,,,fee schedule,48.87,87.97,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.79,,,,,,,fee schedule,48.87,87.97,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.32,,,,,,,fee schedule,48.87,87.97,APC
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48.87,,,,,,,fee schedule,48.87,87.97,APC
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,87.97,,,,,,,fee schedule,48.87,87.97,APC
Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.74,,,,,,,fee schedule,14.03,25.25,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.74,,,,,,,fee schedule,14.03,25.25,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.74,,,,,,,fee schedule,14.03,25.25,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.95,,,,,,,fee schedule,14.03,25.25,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.73,,,,,,,fee schedule,14.03,25.25,APC
Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.03,,,,,,,fee schedule,14.03,25.25,APC
Inj cutaquig 100 mg,J1551,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.25,,,,,,,fee schedule,14.03,25.25,APC
"Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.07,,,,,,,fee schedule,121.54,218.78,
"Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136.07,,,,,,,fee schedule,121.54,218.78,
"Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.07,,,,,,,fee schedule,121.54,218.78,
"Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,156.48,,,,,,,fee schedule,121.54,218.78,
"Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,127.62,,,,,,,fee schedule,121.54,218.78,APC
"Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,121.54,,,,,,,fee schedule,121.54,218.78,APC
"Inj, alyglo, 500 mg",J1552,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,218.78,,,,,,,fee schedule,121.54,218.78,APC
Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,515.24,,,,,,,fee schedule,509.14,916.45,
Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,515.24,,,,,,,fee schedule,509.14,916.45,
Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,515.24,,,,,,,fee schedule,509.14,916.45,
Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,592.53,,,,,,,fee schedule,509.14,916.45,
Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,534.6,,,,,,,fee schedule,509.14,916.45,APC
Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,509.14,,,,,,,fee schedule,509.14,916.45,APC
Inj. asceniv,J1554,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,916.45,,,,,,,fee schedule,509.14,916.45,APC
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.25,,,,,,,fee schedule,18.15,32.66,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.25,,,,,,,fee schedule,18.15,32.66,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.25,,,,,,,fee schedule,18.15,32.66,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.99,,,,,,,fee schedule,18.15,32.66,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.05,,,,,,,fee schedule,18.15,32.66,APC
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.15,,,,,,,fee schedule,18.15,32.66,APC
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.66,,,,,,,fee schedule,18.15,32.66,APC
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.18,,,,,,,fee schedule,80.18,146.23,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.18,,,,,,,fee schedule,80.18,146.23,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.18,,,,,,,fee schedule,80.18,146.23,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.21,,,,,,,fee schedule,80.18,146.23,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.3,,,,,,,fee schedule,80.18,146.23,APC
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,81.24,,,,,,,fee schedule,80.18,146.23,APC
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,146.23,,,,,,,fee schedule,80.18,146.23,APC
Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,64.82,,,,,,,fee schedule,64.82,119.29,
Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.82,,,,,,,fee schedule,64.82,119.29,
Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.82,,,,,,,fee schedule,64.82,119.29,
Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,74.54,,,,,,,fee schedule,64.82,119.29,
Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.59,,,,,,,fee schedule,64.82,119.29,APC
Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,66.27,,,,,,,fee schedule,64.82,119.29,APC
Gammaplex injection,J1557,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,119.29,,,,,,,fee schedule,64.82,119.29,APC
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.47,,,,,,,fee schedule,15.24,27.44,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.47,,,,,,,fee schedule,15.24,27.44,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.47,,,,,,,fee schedule,15.24,27.44,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.79,,,,,,,fee schedule,15.24,27.44,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.01,,,,,,,fee schedule,15.24,27.44,APC
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.24,,,,,,,fee schedule,15.24,27.44,APC
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.44,,,,,,,fee schedule,15.24,27.44,APC
Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.66,,,,,,,fee schedule,14.66,26.79,
Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.66,,,,,,,fee schedule,14.66,26.79,
Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.66,,,,,,,fee schedule,14.66,26.79,
Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.86,,,,,,,fee schedule,14.66,26.79,
Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.63,,,,,,,fee schedule,14.66,26.79,APC
Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.88,,,,,,,fee schedule,14.66,26.79,APC
Hizentra injection,J1559,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.79,,,,,,,fee schedule,14.66,26.79,APC
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.37,,,,,,,fee schedule,162.52,292.53,
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.37,,,,,,,fee schedule,162.52,292.53,
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.37,,,,,,,fee schedule,162.52,292.53,
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.38,,,,,,,fee schedule,162.52,292.53,
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.64,,,,,,,fee schedule,162.52,292.53,APC
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,162.52,,,,,,,fee schedule,162.52,292.53,APC
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,292.53,,,,,,,fee schedule,162.52,292.53,APC
Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.84,,,,,,,fee schedule,49.01,88.23,
Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.84,,,,,,,fee schedule,49.01,88.23,
Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.84,,,,,,,fee schedule,49.01,88.23,
Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.32,,,,,,,fee schedule,49.01,88.23,
Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.46,,,,,,,fee schedule,49.01,88.23,APC
Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.01,,,,,,,fee schedule,49.01,88.23,APC
Gamunex-c/gammaked,J1561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88.23,,,,,,,fee schedule,49.01,88.23,APC
"Vivaglobin, inj",J1562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.24,,,,,,,fee schedule,12.24,14.08,
"Vivaglobin, inj",J1562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.24,,,,,,,fee schedule,12.24,14.08,
"Vivaglobin, inj",J1562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.24,,,,,,,fee schedule,12.24,14.08,
"Vivaglobin, inj",J1562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.08,,,,,,,fee schedule,12.24,14.08,
"Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,84.79,,,,,,,fee schedule,80.96,145.73,
"Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.79,,,,,,,fee schedule,80.96,145.73,
"Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.79,,,,,,,fee schedule,80.96,145.73,
"Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.51,,,,,,,fee schedule,80.96,145.73,
"Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.01,,,,,,,fee schedule,80.96,145.73,APC
"Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,80.96,,,,,,,fee schedule,80.96,145.73,APC
"Immune globulin, powder",J1566,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,145.73,,,,,,,fee schedule,80.96,145.73,APC
Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.2,,,,,,,fee schedule,47.06,84.7,
Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.2,,,,,,,fee schedule,47.06,84.7,
Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.2,,,,,,,fee schedule,47.06,84.7,
Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.73,,,,,,,fee schedule,47.06,84.7,
Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.41,,,,,,,fee schedule,47.06,84.7,APC
Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.06,,,,,,,fee schedule,47.06,84.7,APC
Octagam injection,J1568,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84.7,,,,,,,fee schedule,47.06,84.7,APC
Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.6,,,,,,,fee schedule,49.3,88.75,
Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.6,,,,,,,fee schedule,49.3,88.75,
Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.6,,,,,,,fee schedule,49.3,88.75,
Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.04,,,,,,,fee schedule,49.3,88.75,
Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.77,,,,,,,fee schedule,49.3,88.75,APC
Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.3,,,,,,,fee schedule,49.3,88.75,APC
Gammagard liquid injection,J1569,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88.75,,,,,,,fee schedule,49.3,88.75,APC
Ganciclovir sodium injection,J1570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.11,,,,,,,fee schedule,41.11,47.28,
Ganciclovir sodium injection,J1570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.11,,,,,,,fee schedule,41.11,47.28,
Ganciclovir sodium injection,J1570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.11,,,,,,,fee schedule,41.11,47.28,
Ganciclovir sodium injection,J1570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.28,,,,,,,fee schedule,41.11,47.28,
HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.37,,,,,,,fee schedule,65.61,118.1,
HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.37,,,,,,,fee schedule,65.61,118.1,
HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.37,,,,,,,fee schedule,65.61,118.1,
HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.53,,,,,,,fee schedule,65.61,118.1,
HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.89,,,,,,,fee schedule,65.61,118.1,APC
HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.61,,,,,,,fee schedule,65.61,118.1,APC
HepaGam B IM injection,J1571,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,118.1,,,,,,,fee schedule,65.61,118.1,APC
Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54,,,,,,,fee schedule,54,163.33,
Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54,,,,,,,fee schedule,54,163.33,
Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54,,,,,,,fee schedule,54,163.33,
Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.1,,,,,,,fee schedule,54,163.33,
Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.28,,,,,,,fee schedule,54,163.33,APC
Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,90.74,,,,,,,fee schedule,54,163.33,APC
Flebogamma injection,J1572,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,163.33,,,,,,,fee schedule,54,163.33,APC
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.37,,,,,,,fee schedule,65.61,118.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.37,,,,,,,fee schedule,65.61,118.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.37,,,,,,,fee schedule,65.61,118.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.53,,,,,,,fee schedule,65.61,118.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.89,,,,,,,fee schedule,65.61,118.1,APC
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.61,,,,,,,fee schedule,65.61,118.1,APC
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,118.1,,,,,,,fee schedule,65.61,118.1,APC
"Inj, ganciclovir (exela)",J1574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51,,,,,,,fee schedule,51,58.65,
"Inj, ganciclovir (exela)",J1574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51,,,,,,,fee schedule,51,58.65,
"Inj, ganciclovir (exela)",J1574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51,,,,,,,fee schedule,51,58.65,
"Inj, ganciclovir (exela)",J1574,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.65,,,,,,,fee schedule,51,58.65,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.08,,,,,,,fee schedule,18.35,33.02,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.08,,,,,,,fee schedule,18.35,33.02,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.08,,,,,,,fee schedule,18.35,33.02,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.94,,,,,,,fee schedule,18.35,33.02,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.26,,,,,,,fee schedule,18.35,33.02,APC
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.35,,,,,,,fee schedule,18.35,33.02,APC
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.02,,,,,,,fee schedule,18.35,33.02,APC
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.27,,,,,,,fee schedule,71.35,128.42,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.27,,,,,,,fee schedule,71.35,128.42,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.27,,,,,,,fee schedule,71.35,128.42,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.86,,,,,,,fee schedule,71.35,128.42,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.91,,,,,,,fee schedule,71.35,128.42,APC
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.35,,,,,,,fee schedule,71.35,128.42,APC
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,128.42,,,,,,,fee schedule,71.35,128.42,APC
Garamycin gentamicin inj,J1580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.71,,,,,,,fee schedule,2.71,3.12,
Garamycin gentamicin inj,J1580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.71,,,,,,,fee schedule,2.71,3.12,
Garamycin gentamicin inj,J1580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.71,,,,,,,fee schedule,2.71,3.12,
Garamycin gentamicin inj,J1580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.12,,,,,,,fee schedule,2.71,3.12,
Injection glatiramer acetate,J1595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.75,,,,,,,fee schedule,63.75,73.31,
Injection glatiramer acetate,J1595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.75,,,,,,,fee schedule,63.75,73.31,
Injection glatiramer acetate,J1595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.75,,,,,,,fee schedule,63.75,73.31,
Injection glatiramer acetate,J1595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.31,,,,,,,fee schedule,63.75,73.31,
"Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.45,,,,,,,fee schedule,0.45,0.52,
"Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.45,,,,,,,fee schedule,0.45,0.52,
"Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.45,,,,,,,fee schedule,0.45,0.52,
"Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.52,,,,,,,fee schedule,0.45,0.52,
"Inj glycopyrrolate, glyrx-pf",J1597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.63,,,,,,,fee schedule,1.63,1.87,
"Inj glycopyrrolate, glyrx-pf",J1597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.63,,,,,,,fee schedule,1.63,1.87,
"Inj glycopyrrolate, glyrx-pf",J1597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.63,,,,,,,fee schedule,1.63,1.87,
"Inj glycopyrrolate, glyrx-pf",J1597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.87,,,,,,,fee schedule,1.63,1.87,
Inj glycopyrrolate fres kabi,J1598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.92,,,,,,,fee schedule,1.92,2.21,
Inj glycopyrrolate fres kabi,J1598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.92,,,,,,,fee schedule,1.92,2.21,
Inj glycopyrrolate fres kabi,J1598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.92,,,,,,,fee schedule,1.92,2.21,
Inj glycopyrrolate fres kabi,J1598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.21,,,,,,,fee schedule,1.92,2.21,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.98,,,,,,,fee schedule,151.98,174.78,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,151.98,,,,,,,fee schedule,151.98,174.78,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.98,,,,,,,fee schedule,151.98,174.78,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,174.78,,,,,,,fee schedule,151.98,174.78,
Gold sodium thiomaleate inj,J1600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.88,,,,,,,fee schedule,14.88,17.11,
Gold sodium thiomaleate inj,J1600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.88,,,,,,,fee schedule,14.88,17.11,
Gold sodium thiomaleate inj,J1600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.88,,,,,,,fee schedule,14.88,17.11,
Gold sodium thiomaleate inj,J1600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.11,,,,,,,fee schedule,14.88,17.11,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.45,,,,,,,fee schedule,11.04,19.86,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.45,,,,,,,fee schedule,11.04,19.86,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.45,,,,,,,fee schedule,11.04,19.86,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.17,,,,,,,fee schedule,11.04,19.86,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.59,,,,,,,fee schedule,11.04,19.86,APC
Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.04,,,,,,,fee schedule,11.04,19.86,APC
Golimumab for iv use 1mg,J1602,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.86,,,,,,,fee schedule,11.04,19.86,APC
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.18,,,,,,,fee schedule,117.33,233.66,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,203.18,,,,,,,fee schedule,117.33,233.66,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.18,,,,,,,fee schedule,117.33,233.66,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.66,,,,,,,fee schedule,117.33,233.66,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,123.2,,,,,,,fee schedule,117.33,233.66,APC
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,117.33,,,,,,,fee schedule,117.33,233.66,APC
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,211.2,,,,,,,fee schedule,117.33,233.66,APC
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,150.35,,,,,,,fee schedule,129.28,232.71,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.35,,,,,,,fee schedule,129.28,232.71,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.35,,,,,,,fee schedule,129.28,232.71,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,172.9,,,,,,,fee schedule,129.28,232.71,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.75,,,,,,,fee schedule,129.28,232.71,APC
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,129.28,,,,,,,fee schedule,129.28,232.71,APC
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,232.71,,,,,,,fee schedule,129.28,232.71,APC
Gonadorelin hydroch/ 100 mcg,J1620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,180.72,,,,,,,fee schedule,180.72,207.83,
Gonadorelin hydroch/ 100 mcg,J1620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.72,,,,,,,fee schedule,180.72,207.83,
Gonadorelin hydroch/ 100 mcg,J1620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,180.72,,,,,,,fee schedule,180.72,207.83,
Gonadorelin hydroch/ 100 mcg,J1620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,207.83,,,,,,,fee schedule,180.72,207.83,
Granisetron hcl injection,J1626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.26,
Granisetron hcl injection,J1626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.26,
Granisetron hcl injection,J1626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.23,0.26,
Granisetron hcl injection,J1626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.26,,,,,,,fee schedule,0.23,0.26,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.15,,,,,,,fee schedule,3.22,5.92,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.15,,,,,,,fee schedule,3.22,5.92,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.15,,,,,,,fee schedule,3.22,5.92,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.92,,,,,,,fee schedule,3.22,5.92,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.38,,,,,,,fee schedule,3.22,5.92,APC
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.22,,,,,,,fee schedule,3.22,5.92,APC
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.79,,,,,,,fee schedule,3.22,5.92,APC
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.69,,,,,,,fee schedule,66.92,120.46,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.69,,,,,,,fee schedule,66.92,120.46,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.69,,,,,,,fee schedule,66.92,120.46,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.34,,,,,,,fee schedule,66.92,120.46,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.27,,,,,,,fee schedule,66.92,120.46,APC
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,66.92,,,,,,,fee schedule,66.92,120.46,APC
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120.46,,,,,,,fee schedule,66.92,120.46,APC
Haloperidol injection,J1630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.87,,,,,,,fee schedule,0.87,1,
Haloperidol injection,J1630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.87,,,,,,,fee schedule,0.87,1,
Haloperidol injection,J1630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.87,,,,,,,fee schedule,0.87,1,
Haloperidol injection,J1630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1,,,,,,,fee schedule,0.87,1,
Haloperidol decanoate inj,J1631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.86,,,,,,,fee schedule,4.86,5.59,
Haloperidol decanoate inj,J1631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.86,,,,,,,fee schedule,4.86,5.59,
Haloperidol decanoate inj,J1631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.86,,,,,,,fee schedule,4.86,5.59,
Haloperidol decanoate inj,J1631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.59,,,,,,,fee schedule,4.86,5.59,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.99,,,,,,,fee schedule,75.99,87.39,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.99,,,,,,,fee schedule,75.99,87.39,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.99,,,,,,,fee schedule,75.99,87.39,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.39,,,,,,,fee schedule,75.99,87.39,
"Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.45,,,,,,,fee schedule,35.45,64.48,
"Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.45,,,,,,,fee schedule,35.45,64.48,
"Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.45,,,,,,,fee schedule,35.45,64.48,
"Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.77,,,,,,,fee schedule,35.45,64.48,
"Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.61,,,,,,,fee schedule,35.45,64.48,APC
"Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.82,,,,,,,fee schedule,35.45,64.48,APC
"Hemin, 1 mg",J1640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,64.48,,,,,,,fee schedule,35.45,64.48,APC
Inj heparin sodium per 10 u,J1642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
Inj heparin sodium per 10 u,J1642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
Inj heparin sodium per 10 u,J1642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.02,,,,,,,fee schedule,0.02,0.02,
Inj heparin sodium per 10 u,J1642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.12,,,,,,,fee schedule,3.12,3.59,
"Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.12,,,,,,,fee schedule,3.12,3.59,
"Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.12,,,,,,,fee schedule,3.12,3.59,
"Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.59,,,,,,,fee schedule,3.12,3.59,
Inj heparin sodium per 1000u,J1644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.26,
Inj heparin sodium per 1000u,J1644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.26,
Inj heparin sodium per 1000u,J1644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.23,0.26,
Inj heparin sodium per 1000u,J1644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.26,,,,,,,fee schedule,0.23,0.26,
Dalteparin sodium,J1645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.72,,,,,,,fee schedule,18.72,21.53,
Dalteparin sodium,J1645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.72,,,,,,,fee schedule,18.72,21.53,
Dalteparin sodium,J1645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.72,,,,,,,fee schedule,18.72,21.53,
Dalteparin sodium,J1645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.53,,,,,,,fee schedule,18.72,21.53,
Inj enoxaparin sodium,J1650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.59,,,,,,,fee schedule,0.59,0.68,
Inj enoxaparin sodium,J1650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.59,,,,,,,fee schedule,0.59,0.68,
Inj enoxaparin sodium,J1650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.59,,,,,,,fee schedule,0.59,0.68,
Inj enoxaparin sodium,J1650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.68,,,,,,,fee schedule,0.59,0.68,
Fondaparinux sodium,J1652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.75,,,,,,,fee schedule,0.75,0.86,
Fondaparinux sodium,J1652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.75,,,,,,,fee schedule,0.75,0.86,
Fondaparinux sodium,J1652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.75,,,,,,,fee schedule,0.75,0.86,
Fondaparinux sodium,J1652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.86,,,,,,,fee schedule,0.75,0.86,
Tinzaparin sodium injection,J1655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.46,,,,,,,fee schedule,4.46,5.13,
Tinzaparin sodium injection,J1655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.46,,,,,,,fee schedule,4.46,5.13,
Tinzaparin sodium injection,J1655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.46,,,,,,,fee schedule,4.46,5.13,
Tinzaparin sodium injection,J1655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.13,,,,,,,fee schedule,4.46,5.13,
Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,598.82,,,,,,,fee schedule,595.02,1071.03,
Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,598.82,,,,,,,fee schedule,595.02,1071.03,
Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,598.82,,,,,,,fee schedule,595.02,1071.03,
Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,688.64,,,,,,,fee schedule,595.02,1071.03,
Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,624.77,,,,,,,fee schedule,595.02,1071.03,APC
Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,595.02,,,,,,,fee schedule,595.02,1071.03,APC
Tetanus immune globulin inj,J1670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1071.03,,,,,,,fee schedule,595.02,1071.03,APC
Hydrocortisone acetate inj,J1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.1,,,,,,,fee schedule,1.1,1.27,
Hydrocortisone acetate inj,J1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.1,,,,,,,fee schedule,1.1,1.27,
Hydrocortisone acetate inj,J1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.1,,,,,,,fee schedule,1.1,1.27,
Hydrocortisone acetate inj,J1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.27,,,,,,,fee schedule,1.1,1.27,
Hydrocortisone sodium ph inj,J1710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.98,,,,,,,fee schedule,4.98,5.73,
Hydrocortisone sodium ph inj,J1710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.98,,,,,,,fee schedule,4.98,5.73,
Hydrocortisone sodium ph inj,J1710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.98,,,,,,,fee schedule,4.98,5.73,
Hydrocortisone sodium ph inj,J1710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.73,,,,,,,fee schedule,4.98,5.73,
Hydrocortisone sodium succ i,J1720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22,,,,,,,fee schedule,22,25.3,
Hydrocortisone sodium succ i,J1720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22,,,,,,,fee schedule,22,25.3,
Hydrocortisone sodium succ i,J1720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22,,,,,,,fee schedule,22,25.3,
Hydrocortisone sodium succ i,J1720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.3,,,,,,,fee schedule,22,25.3,
"Makena, 10 mg",J1726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.62,,,,,,,fee schedule,20.62,23.71,
"Makena, 10 mg",J1726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.62,,,,,,,fee schedule,20.62,23.71,
"Makena, 10 mg",J1726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.62,,,,,,,fee schedule,20.62,23.71,
"Makena, 10 mg",J1726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.71,,,,,,,fee schedule,20.62,23.71,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.91,,,,,,,fee schedule,13.91,16,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.91,,,,,,,fee schedule,13.91,16,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.91,,,,,,,fee schedule,13.91,16,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16,,,,,,,fee schedule,13.91,16,
Diazoxide injection,J1730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.01,,,,,,,fee schedule,110.01,126.51,
Diazoxide injection,J1730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.01,,,,,,,fee schedule,110.01,126.51,
Diazoxide injection,J1730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.01,,,,,,,fee schedule,110.01,126.51,
Diazoxide injection,J1730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.51,,,,,,,fee schedule,110.01,126.51,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.2,,,,,,,fee schedule,3.2,3.68,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.2,,,,,,,fee schedule,3.2,3.68,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.2,,,,,,,fee schedule,3.2,3.68,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.68,,,,,,,fee schedule,3.2,3.68,
Ibandronate sodium injection,J1740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.96,,,,,,,fee schedule,31.96,36.75,
Ibandronate sodium injection,J1740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.96,,,,,,,fee schedule,31.96,36.75,
Ibandronate sodium injection,J1740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.96,,,,,,,fee schedule,31.96,36.75,
Ibandronate sodium injection,J1740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.75,,,,,,,fee schedule,31.96,36.75,
Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.16,,,,,,,fee schedule,3.16,5.85,
Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.16,,,,,,,fee schedule,3.16,5.85,
Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.16,,,,,,,fee schedule,3.16,5.85,
Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.63,,,,,,,fee schedule,3.16,5.85,
Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.41,,,,,,,fee schedule,3.16,5.85,APC
Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.25,,,,,,,fee schedule,3.16,5.85,APC
Ibuprofen injection,J1741,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.85,,,,,,,fee schedule,3.16,5.85,APC
Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,310.61,,,,,,,fee schedule,175.89,357.2,
Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,310.61,,,,,,,fee schedule,175.89,357.2,
Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.61,,,,,,,fee schedule,175.89,357.2,
Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.2,,,,,,,fee schedule,175.89,357.2,
Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.68,,,,,,,fee schedule,175.89,357.2,APC
Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,175.89,,,,,,,fee schedule,175.89,357.2,APC
Ibutilide fumarate injection,J1742,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,316.6,,,,,,,fee schedule,175.89,357.2,APC
Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,579.64,,,,,,,fee schedule,570.04,1026.08,
Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,579.64,,,,,,,fee schedule,570.04,1026.08,
Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,579.64,,,,,,,fee schedule,570.04,1026.08,
Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,666.59,,,,,,,fee schedule,570.04,1026.08,
Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,598.55,,,,,,,fee schedule,570.04,1026.08,APC
Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,570.04,,,,,,,fee schedule,570.04,1026.08,APC
Idursulfase injection,J1743,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1026.08,,,,,,,fee schedule,570.04,1026.08,APC
Icatibant injection,J1744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.33,,,,,,,fee schedule,71.33,82.03,
Icatibant injection,J1744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.33,,,,,,,fee schedule,71.33,82.03,
Icatibant injection,J1744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.33,,,,,,,fee schedule,71.33,82.03,
Icatibant injection,J1744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.03,,,,,,,fee schedule,71.33,82.03,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.36,,,,,,,fee schedule,31.48,56.66,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.36,,,,,,,fee schedule,31.48,56.66,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.36,,,,,,,fee schedule,31.48,56.66,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.21,,,,,,,fee schedule,31.48,56.66,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.05,,,,,,,fee schedule,31.48,56.66,APC
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.48,,,,,,,fee schedule,31.48,56.66,APC
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56.66,,,,,,,fee schedule,31.48,56.66,APC
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.38,,,,,,,fee schedule,79.51,143.12,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.38,,,,,,,fee schedule,79.51,143.12,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.38,,,,,,,fee schedule,79.51,143.12,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.74,,,,,,,fee schedule,79.51,143.12,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.49,,,,,,,fee schedule,79.51,143.12,APC
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.51,,,,,,,fee schedule,79.51,143.12,APC
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,143.12,,,,,,,fee schedule,79.51,143.12,APC
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.21,,,,,,,fee schedule,65.73,118.31,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.21,,,,,,,fee schedule,65.73,118.31,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.21,,,,,,,fee schedule,65.73,118.31,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.44,,,,,,,fee schedule,65.73,118.31,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.01,,,,,,,fee schedule,65.73,118.31,APC
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.73,,,,,,,fee schedule,65.73,118.31,APC
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,118.31,,,,,,,fee schedule,65.73,118.31,APC
"Inj, zymfentra, 10 mg",J1748,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,273.21,,,,,,,fee schedule,273.21,314.19,
"Inj, zymfentra, 10 mg",J1748,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,273.21,,,,,,,fee schedule,273.21,314.19,
"Inj, zymfentra, 10 mg",J1748,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,273.21,,,,,,,fee schedule,273.21,314.19,
"Inj, zymfentra, 10 mg",J1748,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,314.19,,,,,,,fee schedule,273.21,314.19,
"Inj, iloprost, 0.1 mcg",J1749,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.93,,,,,,,fee schedule,5.93,6.82,
"Inj, iloprost, 0.1 mcg",J1749,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.93,,,,,,,fee schedule,5.93,6.82,
"Inj, iloprost, 0.1 mcg",J1749,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.93,,,,,,,fee schedule,5.93,6.82,
"Inj, iloprost, 0.1 mcg",J1749,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.82,,,,,,,fee schedule,5.93,6.82,
Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.71,,,,,,,fee schedule,18.71,34.19,
Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.71,,,,,,,fee schedule,18.71,34.19,
Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.71,,,,,,,fee schedule,18.71,34.19,
Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.52,,,,,,,fee schedule,18.71,34.19,
Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.94,,,,,,,fee schedule,18.71,34.19,APC
Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.99,,,,,,,fee schedule,18.71,34.19,APC
Inj iron dextran,J1750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.19,,,,,,,fee schedule,18.71,34.19,APC
Iron sucrose injection,J1756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.26,
Iron sucrose injection,J1756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.26,
Iron sucrose injection,J1756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.23,0.26,
Iron sucrose injection,J1756,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.26,,,,,,,fee schedule,0.23,0.26,
Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.92,,,,,,,fee schedule,43.33,77.99,
Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.92,,,,,,,fee schedule,43.33,77.99,
Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.92,,,,,,,fee schedule,43.33,77.99,
Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.66,,,,,,,fee schedule,43.33,77.99,
Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.49,,,,,,,fee schedule,43.33,77.99,APC
Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.33,,,,,,,fee schedule,43.33,77.99,APC
Imuglucerase injection,J1786,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.99,,,,,,,fee schedule,43.33,77.99,APC
Droperidol injection,J1790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.56,,,,,,,fee schedule,5.56,6.39,
Droperidol injection,J1790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.56,,,,,,,fee schedule,5.56,6.39,
Droperidol injection,J1790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.56,,,,,,,fee schedule,5.56,6.39,
Droperidol injection,J1790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.39,,,,,,,fee schedule,5.56,6.39,
Propranolol injection,J1800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.94,,,,,,,fee schedule,9.94,11.43,
Propranolol injection,J1800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.94,,,,,,,fee schedule,9.94,11.43,
Propranolol injection,J1800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.94,,,,,,,fee schedule,9.94,11.43,
Propranolol injection,J1800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.43,,,,,,,fee schedule,9.94,11.43,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.29,,,,,,,fee schedule,0.29,0.33,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.29,,,,,,,fee schedule,0.29,0.33,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.29,,,,,,,fee schedule,0.29,0.33,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.33,,,,,,,fee schedule,0.29,0.33,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.43,,,,,,,fee schedule,0.43,0.49,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.43,,,,,,,fee schedule,0.43,0.49,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.43,,,,,,,fee schedule,0.43,0.49,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.49,,,,,,,fee schedule,0.43,0.49,
Fiasp for insulin pump use,J1811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.05,,,,,,,fee schedule,8.05,9.26,
Fiasp for insulin pump use,J1811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.05,,,,,,,fee schedule,8.05,9.26,
Fiasp for insulin pump use,J1811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.05,,,,,,,fee schedule,8.05,9.26,
Fiasp for insulin pump use,J1811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.26,,,,,,,fee schedule,8.05,9.26,
Inj. Insulin (fiasp),J1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.48,,,,,,,fee schedule,1.48,1.7,
Inj. Insulin (fiasp),J1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.48,,,,,,,fee schedule,1.48,1.7,
Inj. Insulin (fiasp),J1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.48,,,,,,,fee schedule,1.48,1.7,
Inj. Insulin (fiasp),J1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.7,,,,,,,fee schedule,1.48,1.7,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.85,,,,,,,fee schedule,15.85,18.23,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.85,,,,,,,fee schedule,15.85,18.23,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.85,,,,,,,fee schedule,15.85,18.23,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.23,,,,,,,fee schedule,15.85,18.23,
Inj. insulin (lyumjev),J1814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.4,,,,,,,fee schedule,1.4,1.61,
Inj. insulin (lyumjev),J1814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.4,,,,,,,fee schedule,1.4,1.61,
Inj. insulin (lyumjev),J1814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.4,,,,,,,fee schedule,1.4,1.61,
Inj. insulin (lyumjev),J1814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.61,,,,,,,fee schedule,1.4,1.61,
Insulin injection,J1815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.26,
Insulin injection,J1815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.26,
Insulin injection,J1815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.23,0.26,
Insulin injection,J1815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.26,,,,,,,fee schedule,0.23,0.26,
Insulin for insulin pump use,J1817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.36,,,,,,,fee schedule,3.36,3.86,
Insulin for insulin pump use,J1817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.36,,,,,,,fee schedule,3.36,3.86,
Insulin for insulin pump use,J1817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.36,,,,,,,fee schedule,3.36,3.86,
Insulin for insulin pump use,J1817,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.86,,,,,,,fee schedule,3.36,3.86,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,513.09,,,,,,,fee schedule,510.65,919.17,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,513.09,,,,,,,fee schedule,510.65,919.17,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,513.09,,,,,,,fee schedule,510.65,919.17,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,590.05,,,,,,,fee schedule,510.65,919.17,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,536.18,,,,,,,fee schedule,510.65,919.17,APC
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,510.65,,,,,,,fee schedule,510.65,919.17,APC
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,919.17,,,,,,,fee schedule,510.65,919.17,APC
Interferon Beta-1A inj,J1826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2202.64,,,,,,,fee schedule,2202.64,2533.04,
Interferon Beta-1A inj,J1826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2202.64,,,,,,,fee schedule,2202.64,2533.04,
Interferon Beta-1A inj,J1826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2202.64,,,,,,,fee schedule,2202.64,2533.04,
Interferon Beta-1A inj,J1826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2533.04,,,,,,,fee schedule,2202.64,2533.04,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,724.77,,,,,,,fee schedule,724.77,833.49,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,724.77,,,,,,,fee schedule,724.77,833.49,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,724.77,,,,,,,fee schedule,724.77,833.49,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,833.49,,,,,,,fee schedule,724.77,833.49,
"Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.08,,,,,,,fee schedule,1.03,1.85,
"Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.08,,,,,,,fee schedule,1.03,1.85,
"Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.08,,,,,,,fee schedule,1.03,1.85,
"Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.24,,,,,,,fee schedule,1.03,1.85,
"Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.08,,,,,,,fee schedule,1.03,1.85,APC
"Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.03,,,,,,,fee schedule,1.03,1.85,APC
"Injection, isavuconazonium",J1833,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.85,,,,,,,fee schedule,1.03,1.85,APC
Itraconazole injection,J1835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.67,,,,,,,fee schedule,44.67,51.37,
Itraconazole injection,J1835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.67,,,,,,,fee schedule,44.67,51.37,
Itraconazole injection,J1835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.67,,,,,,,fee schedule,44.67,51.37,
Itraconazole injection,J1835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.37,,,,,,,fee schedule,44.67,51.37,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.36,,,,,,,fee schedule,0.29,0.51,
Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.36,,,,,,,fee schedule,0.29,0.51,
Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.36,,,,,,,fee schedule,0.29,0.51,
Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.41,,,,,,,fee schedule,0.29,0.51,
Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.3,,,,,,,fee schedule,0.29,0.51,APC
Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.29,,,,,,,fee schedule,0.29,0.51,APC
Ketorolac tromethamine inj,J1885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.51,,,,,,,fee schedule,0.29,0.51,APC
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.4,,,,,,,fee schedule,0.4,0.46,
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.4,,,,,,,fee schedule,0.4,0.46,
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.4,,,,,,,fee schedule,0.4,0.46,
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.46,,,,,,,fee schedule,0.4,0.46,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.43,,,,,,,fee schedule,1.43,1.64,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.43,,,,,,,fee schedule,1.43,1.64,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.43,,,,,,,fee schedule,1.43,1.64,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.64,,,,,,,fee schedule,1.43,1.64,
Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.04,,,,,,,fee schedule,37.43,67.37,
Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.04,,,,,,,fee schedule,37.43,67.37,
Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.04,,,,,,,fee schedule,37.43,67.37,
Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.75,,,,,,,fee schedule,37.43,67.37,
Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.3,,,,,,,fee schedule,37.43,67.37,APC
Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.43,,,,,,,fee schedule,37.43,67.37,APC
Lanreotide injection,J1930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.37,,,,,,,fee schedule,37.43,67.37,APC
Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.39,,,,,,,fee schedule,41.39,74.68,
Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.39,,,,,,,fee schedule,41.39,74.68,
Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.39,,,,,,,fee schedule,41.39,74.68,
Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.6,,,,,,,fee schedule,41.39,74.68,
Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.56,,,,,,,fee schedule,41.39,74.68,APC
Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.49,,,,,,,fee schedule,41.39,74.68,APC
Laronidase injection,J1931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74.68,,,,,,,fee schedule,41.39,74.68,APC
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.37,,,,,,,fee schedule,20.33,36.59,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.37,,,,,,,fee schedule,20.33,36.59,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.37,,,,,,,fee schedule,20.33,36.59,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.18,,,,,,,fee schedule,20.33,36.59,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.35,,,,,,,fee schedule,20.33,36.59,APC
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.33,,,,,,,fee schedule,20.33,36.59,APC
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.59,,,,,,,fee schedule,20.33,36.59,APC
"Inj, furosemide, 1 mg",J1938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Inj, furosemide, 1 mg",J1938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Inj, furosemide, 1 mg",J1938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.02,,,,,,,fee schedule,0.02,0.02,
"Inj, furosemide, 1 mg",J1938,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.63,,,,,,,fee schedule,0.63,0.72,
"Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.63,,,,,,,fee schedule,0.63,0.72,
"Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.63,,,,,,,fee schedule,0.63,0.72,
"Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.72,,,,,,,fee schedule,0.63,0.72,
"Inj, furoscix, 20 mg",J1941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,241.6,,,,,,,fee schedule,241.6,277.84,
"Inj, furoscix, 20 mg",J1941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.6,,,,,,,fee schedule,241.6,277.84,
"Inj, furoscix, 20 mg",J1941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,241.6,,,,,,,fee schedule,241.6,277.84,
"Inj, furoscix, 20 mg",J1941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,277.84,,,,,,,fee schedule,241.6,277.84,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.38,,,,,,,fee schedule,3.38,6.23,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.38,,,,,,,fee schedule,3.38,6.23,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.38,,,,,,,fee schedule,3.38,6.23,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.89,,,,,,,fee schedule,3.38,6.23,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.63,,,,,,,fee schedule,3.38,6.23,APC
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.46,,,,,,,fee schedule,3.38,6.23,APC
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.23,,,,,,,fee schedule,3.38,6.23,APC
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.46,,,,,,,fee schedule,3.46,6.4,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.46,,,,,,,fee schedule,3.46,6.4,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.46,,,,,,,fee schedule,3.46,6.4,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.98,,,,,,,fee schedule,3.46,6.4,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.73,,,,,,,fee schedule,3.46,6.4,APC
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.56,,,,,,,fee schedule,3.46,6.4,APC
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.4,,,,,,,fee schedule,3.46,6.4,APC
Lepirudin,J1945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,549.01,,,,,,,fee schedule,549.01,631.36,
Lepirudin,J1945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,549.01,,,,,,,fee schedule,549.01,631.36,
Lepirudin,J1945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,549.01,,,,,,,fee schedule,549.01,631.36,
Lepirudin,J1945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,631.36,,,,,,,fee schedule,549.01,631.36,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1802.65,,,,,,,fee schedule,1802.65,3314.27,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1802.65,,,,,,,fee schedule,1802.65,3314.27,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1802.65,,,,,,,fee schedule,1802.65,3314.27,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2073.05,,,,,,,fee schedule,1802.65,3314.27,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1933.32,,,,,,,fee schedule,1802.65,3314.27,APC
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1841.26,,,,,,,fee schedule,1802.65,3314.27,APC
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3314.27,,,,,,,fee schedule,1802.65,3314.27,APC
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.73,,,,,,,fee schedule,145.31,261.56,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.73,,,,,,,fee schedule,145.31,261.56,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.73,,,,,,,fee schedule,145.31,261.56,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.59,,,,,,,fee schedule,145.31,261.56,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,152.58,,,,,,,fee schedule,145.31,261.56,APC
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,145.31,,,,,,,fee schedule,145.31,261.56,APC
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,261.56,,,,,,,fee schedule,145.31,261.56,APC
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.34,,,,,,,fee schedule,42.06,75.71,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.34,,,,,,,fee schedule,42.06,75.71,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.34,,,,,,,fee schedule,42.06,75.71,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.34,,,,,,,fee schedule,42.06,75.71,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.16,,,,,,,fee schedule,42.06,75.71,APC
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.06,,,,,,,fee schedule,42.06,75.71,APC
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.71,,,,,,,fee schedule,42.06,75.71,APC
Levetiracetam injection,J1953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Levetiracetam injection,J1953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Levetiracetam injection,J1953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.05,,,,,,,fee schedule,0.05,0.06,
Levetiracetam injection,J1953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.06,,,,,,,fee schedule,0.05,0.06,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.07,,,,,,,fee schedule,229.07,1237.12,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,229.07,,,,,,,fee schedule,229.07,1237.12,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,229.07,,,,,,,fee schedule,229.07,1237.12,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.43,,,,,,,fee schedule,229.07,1237.12,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,721.65,,,,,,,fee schedule,229.07,1237.12,APC
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,687.29,,,,,,,fee schedule,229.07,1237.12,APC
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1237.12,,,,,,,fee schedule,229.07,1237.12,APC
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.21,,,,,,,fee schedule,25.21,28.99,
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.21,,,,,,,fee schedule,25.21,28.99,
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.21,,,,,,,fee schedule,25.21,28.99,
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.99,,,,,,,fee schedule,25.21,28.99,
Levofloxacin injection,J1956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.03,,,,,,,fee schedule,2.03,2.33,
Levofloxacin injection,J1956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.03,,,,,,,fee schedule,2.03,2.33,
Levofloxacin injection,J1956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.03,,,,,,,fee schedule,2.03,2.33,
Levofloxacin injection,J1956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.33,,,,,,,fee schedule,2.03,2.33,
Levorphanol tartrate inj,J1960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.38,,,,,,,fee schedule,0.38,0.44,
Levorphanol tartrate inj,J1960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.38,,,,,,,fee schedule,0.38,0.44,
Levorphanol tartrate inj,J1960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.38,,,,,,,fee schedule,0.38,0.44,
Levorphanol tartrate inj,J1960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.44,,,,,,,fee schedule,0.38,0.44,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.86,,,,,,,fee schedule,22.86,41.28,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.86,,,,,,,fee schedule,22.86,41.28,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.86,,,,,,,fee schedule,22.86,41.28,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.29,,,,,,,fee schedule,22.86,41.28,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.08,,,,,,,fee schedule,22.86,41.28,APC
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.94,,,,,,,fee schedule,22.86,41.28,APC
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.28,,,,,,,fee schedule,22.86,41.28,APC
Hyoscyamine sulfate inj,J1980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.08,,,,,,,fee schedule,55.08,63.34,
Hyoscyamine sulfate inj,J1980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.08,,,,,,,fee schedule,55.08,63.34,
Hyoscyamine sulfate inj,J1980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.08,,,,,,,fee schedule,55.08,63.34,
Hyoscyamine sulfate inj,J1980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.34,,,,,,,fee schedule,55.08,63.34,
Chlordiazepoxide injection,J1990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.24,,,,,,,fee schedule,22.24,25.58,
Chlordiazepoxide injection,J1990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.24,,,,,,,fee schedule,22.24,25.58,
Chlordiazepoxide injection,J1990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.24,,,,,,,fee schedule,22.24,25.58,
Chlordiazepoxide injection,J1990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.58,,,,,,,fee schedule,22.24,25.58,
"Inj, lidocaine hcl, 1 mg",J2003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, lidocaine hcl, 1 mg",J2003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, lidocaine hcl, 1 mg",J2003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, lidocaine hcl, 1 mg",J2003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, lidocaine w epinephrine",J2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, lidocaine w epinephrine",J2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, lidocaine w epinephrine",J2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, lidocaine w epinephrine",J2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Lincomycin injection,J2010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.82,,,,,,,fee schedule,5.82,6.69,
Lincomycin injection,J2010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.82,,,,,,,fee schedule,5.82,6.69,
Lincomycin injection,J2010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.82,,,,,,,fee schedule,5.82,6.69,
Lincomycin injection,J2010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.69,,,,,,,fee schedule,5.82,6.69,
Linezolid injection,J2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.6,,,,,,,fee schedule,3.6,4.14,
Linezolid injection,J2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.6,,,,,,,fee schedule,3.6,4.14,
Linezolid injection,J2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.6,,,,,,,fee schedule,3.6,4.14,
Linezolid injection,J2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.14,,,,,,,fee schedule,3.6,4.14,
"Inj, linezolid (hospira)",J2021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.58,,,,,,,fee schedule,6.58,7.57,
"Inj, linezolid (hospira)",J2021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.58,,,,,,,fee schedule,6.58,7.57,
"Inj, linezolid (hospira)",J2021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.58,,,,,,,fee schedule,6.58,7.57,
"Inj, linezolid (hospira)",J2021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.57,,,,,,,fee schedule,6.58,7.57,
Lorazepam injection,J2060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.36,,,,,,,fee schedule,1.36,1.56,
Lorazepam injection,J2060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.36,,,,,,,fee schedule,1.36,1.56,
Lorazepam injection,J2060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.36,,,,,,,fee schedule,1.36,1.56,
Lorazepam injection,J2060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.56,,,,,,,fee schedule,1.36,1.56,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.3,,,,,,,fee schedule,15.3,17.6,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.3,,,,,,,fee schedule,15.3,17.6,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.3,,,,,,,fee schedule,15.3,17.6,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.6,,,,,,,fee schedule,15.3,17.6,
Mannitol injection,J2150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.32,,,,,,,fee schedule,2.32,2.67,
Mannitol injection,J2150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.32,,,,,,,fee schedule,2.32,2.67,
Mannitol injection,J2150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.32,,,,,,,fee schedule,2.32,2.67,
Mannitol injection,J2150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.67,,,,,,,fee schedule,2.32,2.67,
Mecasermin injection,J2170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,374.98,,,,,,,fee schedule,374.98,431.23,
Mecasermin injection,J2170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,374.98,,,,,,,fee schedule,374.98,431.23,
Mecasermin injection,J2170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.98,,,,,,,fee schedule,374.98,431.23,
Mecasermin injection,J2170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,431.23,,,,,,,fee schedule,374.98,431.23,
Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.29,,,,,,,fee schedule,16.29,18.73,
Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.29,,,,,,,fee schedule,16.29,18.73,
Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.29,,,,,,,fee schedule,16.29,18.73,
Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.73,,,,,,,fee schedule,16.29,18.73,
Meperidine/promethazine inj,J2180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.01,,,,,,,fee schedule,4.01,4.61,
Meperidine/promethazine inj,J2180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.01,,,,,,,fee schedule,4.01,4.61,
Meperidine/promethazine inj,J2180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.01,,,,,,,fee schedule,4.01,4.61,
Meperidine/promethazine inj,J2180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.61,,,,,,,fee schedule,4.01,4.61,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.51,,,,,,,fee schedule,32.28,58.11,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.51,,,,,,,fee schedule,32.28,58.11,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.51,,,,,,,fee schedule,32.28,58.11,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.39,,,,,,,fee schedule,32.28,58.11,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.9,,,,,,,fee schedule,32.28,58.11,APC
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.28,,,,,,,fee schedule,32.28,58.11,APC
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.11,,,,,,,fee schedule,32.28,58.11,APC
Inj meropenem (wg crit care),J2183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.69,,,,,,,fee schedule,1.69,1.94,
Inj meropenem (wg crit care),J2183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.69,,,,,,,fee schedule,1.69,1.94,
Inj meropenem (wg crit care),J2183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.69,,,,,,,fee schedule,1.69,1.94,
Inj meropenem (wg crit care),J2183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.94,,,,,,,fee schedule,1.69,1.94,
"Inj, meropenem (b. braun)",J2184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.15,,,,,,,fee schedule,2.15,2.47,
"Inj, meropenem (b. braun)",J2184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.15,,,,,,,fee schedule,2.15,2.47,
"Inj, meropenem (b. braun)",J2184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.15,,,,,,,fee schedule,2.15,2.47,
"Inj, meropenem (b. braun)",J2184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.47,,,,,,,fee schedule,2.15,2.47,
Meropenem,J2185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.45,,,,,,,fee schedule,0.45,0.52,
Meropenem,J2185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.45,,,,,,,fee schedule,0.45,0.52,
Meropenem,J2185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.45,,,,,,,fee schedule,0.45,0.52,
Meropenem,J2185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.52,,,,,,,fee schedule,0.45,0.52,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.27,,,,,,,fee schedule,2.22,4,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.27,,,,,,,fee schedule,2.22,4,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.27,,,,,,,fee schedule,2.22,4,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.61,,,,,,,fee schedule,2.22,4,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.33,,,,,,,fee schedule,2.22,4,APC
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.22,,,,,,,fee schedule,2.22,4,APC
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4,,,,,,,fee schedule,2.22,4,APC
Methylergonovin maleate inj,J2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.89,,,,,,,fee schedule,22.89,26.32,
Methylergonovin maleate inj,J2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.89,,,,,,,fee schedule,22.89,26.32,
Methylergonovin maleate inj,J2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.89,,,,,,,fee schedule,22.89,26.32,
Methylergonovin maleate inj,J2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.32,,,,,,,fee schedule,22.89,26.32,
Methylnaltrexone injection,J2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.45,,,,,,,fee schedule,1.45,1.67,
Methylnaltrexone injection,J2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.45,,,,,,,fee schedule,1.45,1.67,
Methylnaltrexone injection,J2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.45,,,,,,,fee schedule,1.45,1.67,
Methylnaltrexone injection,J2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.67,,,,,,,fee schedule,1.45,1.67,
"Inj, micafungin (baxter)",J2246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.53,,,,,,,fee schedule,0.53,0.61,
"Inj, micafungin (baxter)",J2246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.53,,,,,,,fee schedule,0.53,0.61,
"Inj, micafungin (baxter)",J2246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.53,,,,,,,fee schedule,0.53,0.61,
"Inj, micafungin (baxter)",J2246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.61,,,,,,,fee schedule,0.53,0.61,
"Inj, micafungin (par pharm)",J2247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.37,,,,,,,fee schedule,0.37,0.43,
"Inj, micafungin (par pharm)",J2247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.37,,,,,,,fee schedule,0.37,0.43,
"Inj, micafungin (par pharm)",J2247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.37,,,,,,,fee schedule,0.37,0.43,
"Inj, micafungin (par pharm)",J2247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.43,,,,,,,fee schedule,0.37,0.43,
Micafungin sodium injection,J2248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.32,,,,,,,fee schedule,0.32,0.37,
Micafungin sodium injection,J2248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.32,,,,,,,fee schedule,0.32,0.37,
Micafungin sodium injection,J2248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.32,,,,,,,fee schedule,0.32,0.37,
Micafungin sodium injection,J2248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.37,,,,,,,fee schedule,0.32,0.37,
"Inj, remimazolam, 1 mg",J2249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.24,,,,,,,fee schedule,2.24,2.58,
"Inj, remimazolam, 1 mg",J2249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.24,,,,,,,fee schedule,2.24,2.58,
"Inj, remimazolam, 1 mg",J2249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.24,,,,,,,fee schedule,2.24,2.58,
"Inj, remimazolam, 1 mg",J2249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.58,,,,,,,fee schedule,2.24,2.58,
Inj midazolam hydrochloride,J2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Inj midazolam hydrochloride,J2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.17,,,,,,,fee schedule,0.17,0.2,
Inj midazolam hydrochloride,J2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Inj midazolam hydrochloride,J2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.2,,,,,,,fee schedule,0.17,0.2,
Inj midazolam (wg crit care),J2251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Inj midazolam (wg crit care),J2251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.18,,,,,,,fee schedule,0.18,0.21,
Inj midazolam (wg crit care),J2251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Inj midazolam (wg crit care),J2251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.21,,,,,,,fee schedule,0.18,0.21,
Inj midazolam in 0.8% nacl,J2252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.07,,,,,,,fee schedule,0.07,0.08,
Inj midazolam in 0.8% nacl,J2252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.07,,,,,,,fee schedule,0.07,0.08,
Inj midazolam in 0.8% nacl,J2252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.07,,,,,,,fee schedule,0.07,0.08,
Inj midazolam in 0.8% nacl,J2252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.08,,,,,,,fee schedule,0.07,0.08,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.46,,,,,,,fee schedule,1.46,1.68,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.46,,,,,,,fee schedule,1.46,1.68,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.46,,,,,,,fee schedule,1.46,1.68,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.68,,,,,,,fee schedule,1.46,1.68,
Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.64,,,,,,,fee schedule,2.64,4.92,
Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.64,,,,,,,fee schedule,2.64,4.92,
Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.64,,,,,,,fee schedule,2.64,4.92,
Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.04,,,,,,,fee schedule,2.64,4.92,
Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.87,,,,,,,fee schedule,2.64,4.92,APC
Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.74,,,,,,,fee schedule,2.64,4.92,APC
Minocycline hydrochloride,J2265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.92,,,,,,,fee schedule,2.64,4.92,APC
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.09,,,,,,,fee schedule,32.66,58.78,
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.09,,,,,,,fee schedule,32.66,58.78,
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.09,,,,,,,fee schedule,32.66,58.78,
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.6,,,,,,,fee schedule,32.66,58.78,
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.29,,,,,,,fee schedule,32.66,58.78,APC
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.66,,,,,,,fee schedule,32.66,58.78,APC
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.78,,,,,,,fee schedule,32.66,58.78,APC
Morphine sulfate injection,J2270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.72,,,,,,,fee schedule,4.72,5.43,
Morphine sulfate injection,J2270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.72,,,,,,,fee schedule,4.72,5.43,
Morphine sulfate injection,J2270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.72,,,,,,,fee schedule,4.72,5.43,
Morphine sulfate injection,J2270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.43,,,,,,,fee schedule,4.72,5.43,
"Inj, morphine (fresenius)",J2272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.44,,,,,,,fee schedule,8.44,9.71,
"Inj, morphine (fresenius)",J2272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.44,,,,,,,fee schedule,8.44,9.71,
"Inj, morphine (fresenius)",J2272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.44,,,,,,,fee schedule,8.44,9.71,
"Inj, morphine (fresenius)",J2272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.71,,,,,,,fee schedule,8.44,9.71,
In morphine preservativ free,J2274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.2,,,,,,,fee schedule,11.2,12.88,
In morphine preservativ free,J2274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.2,,,,,,,fee schedule,11.2,12.88,
In morphine preservativ free,J2274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.2,,,,,,,fee schedule,11.2,12.88,
In morphine preservativ free,J2274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.88,,,,,,,fee schedule,11.2,12.88,
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.17,,,,,,,fee schedule,26.17,47.66,
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.17,,,,,,,fee schedule,26.17,47.66,
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.17,,,,,,,fee schedule,26.17,47.66,
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.1,,,,,,,fee schedule,26.17,47.66,
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.8,,,,,,,fee schedule,26.17,47.66,APC
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.48,,,,,,,fee schedule,26.17,47.66,APC
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.66,,,,,,,fee schedule,26.17,47.66,APC
Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.51,,,,,,,fee schedule,10.51,19.43,
Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.51,,,,,,,fee schedule,10.51,19.43,
Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.51,,,,,,,fee schedule,10.51,19.43,
Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.09,,,,,,,fee schedule,10.51,19.43,
Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.33,,,,,,,fee schedule,10.51,19.43,APC
Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.79,,,,,,,fee schedule,10.51,19.43,APC
Ziconotide injection,J2278,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.43,,,,,,,fee schedule,10.51,19.43,APC
"Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.04,,,,,,,fee schedule,9.04,10.4,
"Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.04,,,,,,,fee schedule,9.04,10.4,
"Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.04,,,,,,,fee schedule,9.04,10.4,
"Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.4,,,,,,,fee schedule,9.04,10.4,
Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.05,,,,,,,fee schedule,8.05,9.26,
Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.05,,,,,,,fee schedule,8.05,9.26,
Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.05,,,,,,,fee schedule,8.05,9.26,
Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.26,,,,,,,fee schedule,8.05,9.26,
"Inj, nafcillin sodium, 20 mg",J2290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, nafcillin sodium, 20 mg",J2290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, nafcillin sodium, 20 mg",J2290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.07,
"Inj, nafcillin sodium, 20 mg",J2290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.07,
Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.65,,,,,,,fee schedule,3.65,4.2,
Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.65,,,,,,,fee schedule,3.65,4.2,
Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.65,,,,,,,fee schedule,3.65,4.2,
Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.2,,,,,,,fee schedule,3.65,4.2,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.47,,,,,,,fee schedule,1.47,1.69,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.47,,,,,,,fee schedule,1.47,1.69,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.47,,,,,,,fee schedule,1.47,1.69,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.69,,,,,,,fee schedule,1.47,1.69,
"Inj naloxone hcl nos, 0.01mg",J2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.07,,,,,,,fee schedule,0.07,0.08,
"Inj naloxone hcl nos, 0.01mg",J2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.07,,,,,,,fee schedule,0.07,0.08,
"Inj naloxone hcl nos, 0.01mg",J2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.07,,,,,,,fee schedule,0.07,0.08,
"Inj naloxone hcl nos, 0.01mg",J2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.08,,,,,,,fee schedule,0.07,0.08,
"Inj, naloxone (zimhi) 0.01mg",J2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Inj, naloxone (zimhi) 0.01mg",J2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Inj, naloxone (zimhi) 0.01mg",J2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.02,,,,,,,fee schedule,0.02,0.02,
"Inj, naloxone (zimhi) 0.01mg",J2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.4,,,,,,,fee schedule,4.4,8.14,
"Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.4,,,,,,,fee schedule,4.4,8.14,
"Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.4,,,,,,,fee schedule,4.4,8.14,
"Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.06,,,,,,,fee schedule,4.4,8.14,
"Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.4,8.14,APC
"Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.52,,,,,,,fee schedule,4.4,8.14,APC
"Naltrexone, depot form",J2315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.14,,,,,,,fee schedule,4.4,8.14,APC
Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.96,,,,,,,fee schedule,3.96,4.55,
Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.96,,,,,,,fee schedule,3.96,4.55,
Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.96,,,,,,,fee schedule,3.96,4.55,
Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.55,,,,,,,fee schedule,3.96,4.55,
Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.04,,,,,,,fee schedule,24.41,43.93,
Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.04,,,,,,,fee schedule,24.41,43.93,
Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.04,,,,,,,fee schedule,24.41,43.93,
Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.8,,,,,,,fee schedule,24.41,43.93,
Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.63,,,,,,,fee schedule,24.41,43.93,APC
Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.41,,,,,,,fee schedule,24.41,43.93,APC
Natalizumab injection,J2323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43.93,,,,,,,fee schedule,24.41,43.93,APC
Nesiritide injection,J2325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,71.98,,,,,,,fee schedule,71.98,82.78,
Nesiritide injection,J2325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.98,,,,,,,fee schedule,71.98,82.78,
Nesiritide injection,J2325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.98,,,,,,,fee schedule,71.98,82.78,
Nesiritide injection,J2325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.78,,,,,,,fee schedule,71.98,82.78,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1243.54,,,,,,,fee schedule,1243.54,2400.21,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1243.54,,,,,,,fee schedule,1243.54,2400.21,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1243.54,,,,,,,fee schedule,1243.54,2400.21,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1430.07,,,,,,,fee schedule,1243.54,2400.21,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1400.12,,,,,,,fee schedule,1243.54,2400.21,APC
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1333.45,,,,,,,fee schedule,1243.54,2400.21,APC
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2400.21,,,,,,,fee schedule,1243.54,2400.21,APC
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.4,,,,,,,fee schedule,14.53,26.16,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.4,,,,,,,fee schedule,14.53,26.16,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.4,,,,,,,fee schedule,14.53,26.16,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.71,,,,,,,fee schedule,14.53,26.16,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.26,,,,,,,fee schedule,14.53,26.16,APC
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.53,,,,,,,fee schedule,14.53,26.16,APC
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26.16,,,,,,,fee schedule,14.53,26.16,APC
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.62,,,,,,,fee schedule,72.24,130.03,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.62,,,,,,,fee schedule,72.24,130.03,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.62,,,,,,,fee schedule,72.24,130.03,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.81,,,,,,,fee schedule,72.24,130.03,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.85,,,,,,,fee schedule,72.24,130.03,APC
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,72.24,,,,,,,fee schedule,72.24,130.03,APC
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,130.03,,,,,,,fee schedule,72.24,130.03,APC
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.96,,,,,,,fee schedule,60.97,109.75,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.96,,,,,,,fee schedule,60.97,109.75,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.96,,,,,,,fee schedule,60.97,109.75,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.25,,,,,,,fee schedule,60.97,109.75,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.02,,,,,,,fee schedule,60.97,109.75,APC
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.97,,,,,,,fee schedule,60.97,109.75,APC
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,109.75,,,,,,,fee schedule,60.97,109.75,APC
Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.02,,,,,,,fee schedule,48.06,86.51,
Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.02,,,,,,,fee schedule,48.06,86.51,
Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.02,,,,,,,fee schedule,48.06,86.51,
Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.37,,,,,,,fee schedule,48.06,86.51,
Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.46,,,,,,,fee schedule,48.06,86.51,APC
Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48.06,,,,,,,fee schedule,48.06,86.51,APC
Inj ocrelizumab 1mg hya-ocsq,J2351,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86.51,,,,,,,fee schedule,48.06,86.51,APC
"Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.21,,,,,,,fee schedule,208.1,374.57,
"Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.21,,,,,,,fee schedule,208.1,374.57,
"Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,220.21,,,,,,,fee schedule,208.1,374.57,
"Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,253.24,,,,,,,fee schedule,208.1,374.57,
"Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,218.5,,,,,,,fee schedule,208.1,374.57,APC
"Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,208.1,,,,,,,fee schedule,208.1,374.57,APC
"Octreotide injection, depot",J2353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,374.57,,,,,,,fee schedule,208.1,374.57,APC
"Octreotide inj, non-depot",J2354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.63,,,,,,,fee schedule,0.63,0.72,
"Octreotide inj, non-depot",J2354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.63,,,,,,,fee schedule,0.63,0.72,
"Octreotide inj, non-depot",J2354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.63,,,,,,,fee schedule,0.63,0.72,
"Octreotide inj, non-depot",J2354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.72,,,,,,,fee schedule,0.63,0.72,
Oprelvekin injection,J2355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,449.58,,,,,,,fee schedule,449.58,517.02,
Oprelvekin injection,J2355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,449.58,,,,,,,fee schedule,449.58,517.02,
Oprelvekin injection,J2355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,449.58,,,,,,,fee schedule,449.58,517.02,
Oprelvekin injection,J2355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,517.02,,,,,,,fee schedule,449.58,517.02,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.99,,,,,,,fee schedule,17.92,32.26,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.99,,,,,,,fee schedule,17.92,32.26,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.99,,,,,,,fee schedule,17.92,32.26,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.84,,,,,,,fee schedule,17.92,32.26,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.82,,,,,,,fee schedule,17.92,32.26,APC
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.92,,,,,,,fee schedule,17.92,32.26,APC
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.26,,,,,,,fee schedule,17.92,32.26,APC
Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.09,,,,,,,fee schedule,42.09,83.86,
Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.09,,,,,,,fee schedule,42.09,83.86,
Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.09,,,,,,,fee schedule,42.09,83.86,
Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.4,,,,,,,fee schedule,42.09,83.86,
Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.92,,,,,,,fee schedule,42.09,83.86,APC
Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.59,,,,,,,fee schedule,42.09,83.86,APC
Omalizumab injection,J2357,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.86,,,,,,,fee schedule,42.09,83.86,APC
Olanzapine long-acting inj,J2358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.03,,,,,,,fee schedule,3.03,3.48,
Olanzapine long-acting inj,J2358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.03,,,,,,,fee schedule,3.03,3.48,
Olanzapine long-acting inj,J2358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.03,,,,,,,fee schedule,3.03,3.48,
Olanzapine long-acting inj,J2358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.48,,,,,,,fee schedule,3.03,3.48,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.94,,,,,,,fee schedule,0.94,1.08,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.94,,,,,,,fee schedule,0.94,1.08,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.94,,,,,,,fee schedule,0.94,1.08,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.08,,,,,,,fee schedule,0.94,1.08,
Orphenadrine injection,J2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.8,,,,,,,fee schedule,9.8,11.27,
Orphenadrine injection,J2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.8,,,,,,,fee schedule,9.8,11.27,
Orphenadrine injection,J2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.8,,,,,,,fee schedule,9.8,11.27,
Orphenadrine injection,J2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.27,,,,,,,fee schedule,9.8,11.27,
Inj phenylephrine hcl 20 mcg,J2371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Inj phenylephrine hcl 20 mcg,J2371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Inj phenylephrine hcl 20 mcg,J2371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
Inj phenylephrine hcl 20 mcg,J2371,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.17,,,,,,,fee schedule,0.17,0.2,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.2,,,,,,,fee schedule,0.17,0.2,
"Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.13,,,,,,,fee schedule,0.13,0.15,
"Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.13,,,,,,,fee schedule,0.13,0.15,
"Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.13,,,,,,,fee schedule,0.13,0.15,
"Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.15,,,,,,,fee schedule,0.13,0.15,
Chloroprocaine hcl injection,J2401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
Chloroprocaine hcl injection,J2401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.04,,,,,,,fee schedule,0.04,0.05,
Chloroprocaine hcl injection,J2401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.04,,,,,,,fee schedule,0.04,0.05,
Chloroprocaine hcl injection,J2401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.05,,,,,,,fee schedule,0.04,0.05,
Chloroprocaine (clorotekal),J2402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.31,,,,,,,fee schedule,0.31,0.36,
Chloroprocaine (clorotekal),J2402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.31,,,,,,,fee schedule,0.31,0.36,
Chloroprocaine (clorotekal),J2402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.31,,,,,,,fee schedule,0.31,0.36,
Chloroprocaine (clorotekal),J2402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.36,,,,,,,fee schedule,0.31,0.36,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.62,,,,,,,fee schedule,0.62,0.71,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.62,,,,,,,fee schedule,0.62,0.71,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.62,,,,,,,fee schedule,0.62,0.71,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.71,,,,,,,fee schedule,0.62,0.71,
"Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.1,,,,,,,fee schedule,0.09,0.1,
Ondansetron hcl injection,J2405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.1,,,,,,,fee schedule,0.1,0.12,
Ondansetron hcl injection,J2405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.1,,,,,,,fee schedule,0.1,0.12,
Ondansetron hcl injection,J2405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.1,,,,,,,fee schedule,0.1,0.12,
Ondansetron hcl injection,J2405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.12,,,,,,,fee schedule,0.1,0.12,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.97,,,,,,,fee schedule,42.97,85.34,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.97,,,,,,,fee schedule,42.97,85.34,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.97,,,,,,,fee schedule,42.97,85.34,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.42,,,,,,,fee schedule,42.97,85.34,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.78,,,,,,,fee schedule,42.97,85.34,APC
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.41,,,,,,,fee schedule,42.97,85.34,APC
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,85.34,,,,,,,fee schedule,42.97,85.34,APC
"Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.6,,,,,,,fee schedule,29.6,53.51,
"Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.6,,,,,,,fee schedule,29.6,53.51,
"Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.6,,,,,,,fee schedule,29.6,53.51,
"Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.04,,,,,,,fee schedule,29.6,53.51,
"Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.21,,,,,,,fee schedule,29.6,53.51,APC
"Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.73,,,,,,,fee schedule,29.6,53.51,APC
"Injection, oritavancin",J2407,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.51,,,,,,,fee schedule,29.6,53.51,APC
Oxymorphone hcl injection,J2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.19,,,,,,,fee schedule,3.19,3.67,
Oxymorphone hcl injection,J2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.19,,,,,,,fee schedule,3.19,3.67,
Oxymorphone hcl injection,J2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.19,,,,,,,fee schedule,3.19,3.67,
Oxymorphone hcl injection,J2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.67,,,,,,,fee schedule,3.19,3.67,
Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.27,,,,,,,fee schedule,37.27,69.64,
Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.27,,,,,,,fee schedule,37.27,69.64,
Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.27,,,,,,,fee schedule,37.27,69.64,
Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.86,,,,,,,fee schedule,37.27,69.64,
Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.62,,,,,,,fee schedule,37.27,69.64,APC
Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.69,,,,,,,fee schedule,37.27,69.64,APC
Palifermin injection,J2425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.64,,,,,,,fee schedule,37.27,69.64,APC
Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.65,,,,,,,fee schedule,15.43,27.78,
Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.65,,,,,,,fee schedule,15.43,27.78,
Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.65,,,,,,,fee schedule,15.43,27.78,
Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18,,,,,,,fee schedule,15.43,27.78,
Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.2,,,,,,,fee schedule,15.43,27.78,APC
Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.43,,,,,,,fee schedule,15.43,27.78,APC
Paliperidone palmitate inj,J2426,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.78,,,,,,,fee schedule,15.43,27.78,APC
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.44,,,,,,,fee schedule,13.26,23.87,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.44,,,,,,,fee schedule,13.26,23.87,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.44,,,,,,,fee schedule,13.26,23.87,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.46,,,,,,,fee schedule,13.26,23.87,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.93,,,,,,,fee schedule,13.26,23.87,APC
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.26,,,,,,,fee schedule,13.26,23.87,APC
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.87,,,,,,,fee schedule,13.26,23.87,APC
"Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.98,,,,,,,fee schedule,15.87,28.57,
"Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.98,,,,,,,fee schedule,15.87,28.57,
"Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.98,,,,,,,fee schedule,15.87,28.57,
"Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.53,,,,,,,fee schedule,15.87,28.57,
"Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.67,,,,,,,fee schedule,15.87,28.57,APC
"Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.87,,,,,,,fee schedule,15.87,28.57,APC
"Inj, erzofri, 1 mg",J2428,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28.57,,,,,,,fee schedule,15.87,28.57,APC
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.84,,,,,,,fee schedule,39.84,45.82,
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.84,,,,,,,fee schedule,39.84,45.82,
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.84,,,,,,,fee schedule,39.84,45.82,
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.82,,,,,,,fee schedule,39.84,45.82,
Papaverin hcl injection,J2440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.25,,,,,,,fee schedule,38.25,43.99,
Papaverin hcl injection,J2440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.25,,,,,,,fee schedule,38.25,43.99,
Papaverin hcl injection,J2440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.25,,,,,,,fee schedule,38.25,43.99,
Papaverin hcl injection,J2440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.99,,,,,,,fee schedule,38.25,43.99,
Oxytetracycline injection,J2460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.94,,,,,,,fee schedule,0.94,1.08,
Oxytetracycline injection,J2460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.94,,,,,,,fee schedule,0.94,1.08,
Oxytetracycline injection,J2460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.94,,,,,,,fee schedule,0.94,1.08,
Oxytetracycline injection,J2460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.08,,,,,,,fee schedule,0.94,1.08,
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.06,,,,,,,fee schedule,55.23,99.41,
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.06,,,,,,,fee schedule,55.23,99.41,
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.06,,,,,,,fee schedule,55.23,99.41,
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.22,,,,,,,fee schedule,55.23,99.41,
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.99,,,,,,,fee schedule,55.23,99.41,APC
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55.23,,,,,,,fee schedule,55.23,99.41,APC
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,99.41,,,,,,,fee schedule,55.23,99.41,APC
Palonosetron hcl,J2469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.46,,,,,,,fee schedule,0.46,0.53,
Palonosetron hcl,J2469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.46,,,,,,,fee schedule,0.46,0.53,
Palonosetron hcl,J2469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.46,,,,,,,fee schedule,0.46,0.53,
Palonosetron hcl,J2469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.53,,,,,,,fee schedule,0.46,0.53,
Inj pantoprazole sodium 40mg,J2470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.93,,,,,,,fee schedule,1.93,2.22,
Inj pantoprazole sodium 40mg,J2470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.93,,,,,,,fee schedule,1.93,2.22,
Inj pantoprazole sodium 40mg,J2470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.93,,,,,,,fee schedule,1.93,2.22,
Inj pantoprazole sodium 40mg,J2470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.22,,,,,,,fee schedule,1.93,2.22,
Inj pantoprazole(hikma) 40mg,J2471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.63,,,,,,,fee schedule,6.63,7.62,
Inj pantoprazole(hikma) 40mg,J2471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.63,,,,,,,fee schedule,6.63,7.62,
Inj pantoprazole(hikma) 40mg,J2471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.63,,,,,,,fee schedule,6.63,7.62,
Inj pantoprazole(hikma) 40mg,J2471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.62,,,,,,,fee schedule,6.63,7.62,
"Inj, pantoprazole sodium chl",J2472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.99,,,,,,,fee schedule,8.99,10.34,
"Inj, pantoprazole sodium chl",J2472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.99,,,,,,,fee schedule,8.99,10.34,
"Inj, pantoprazole sodium chl",J2472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.99,,,,,,,fee schedule,8.99,10.34,
"Inj, pantoprazole sodium chl",J2472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.34,,,,,,,fee schedule,8.99,10.34,
Paricalcitol,J2501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.7,,,,,,,fee schedule,0.7,0.81,
Paricalcitol,J2501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.7,,,,,,,fee schedule,0.7,0.81,
Paricalcitol,J2501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.7,,,,,,,fee schedule,0.7,0.81,
Paricalcitol,J2501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.81,,,,,,,fee schedule,0.7,0.81,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,585.07,,,,,,,fee schedule,585.07,1110.07,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,585.07,,,,,,,fee schedule,585.07,1110.07,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,585.07,,,,,,,fee schedule,585.07,1110.07,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,672.83,,,,,,,fee schedule,585.07,1110.07,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,647.54,,,,,,,fee schedule,585.07,1110.07,APC
"Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,616.71,,,,,,,fee schedule,585.07,1110.07,APC
"Inj, pasireotide long acting",J2502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1110.07,,,,,,,fee schedule,585.07,1110.07,APC
Pegaptanib sodium injection,J2503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,755.86,,,,,,,fee schedule,755.86,869.24,
Pegaptanib sodium injection,J2503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,755.86,,,,,,,fee schedule,755.86,869.24,
Pegaptanib sodium injection,J2503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,755.86,,,,,,,fee schedule,755.86,869.24,
Pegaptanib sodium injection,J2503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,869.24,,,,,,,fee schedule,755.86,869.24,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,354.08,,,,,,,fee schedule,354.08,407.19,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,354.08,,,,,,,fee schedule,354.08,407.19,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,354.08,,,,,,,fee schedule,354.08,407.19,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,407.19,,,,,,,fee schedule,354.08,407.19,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.6,,,,,,,fee schedule,60.6,257.82,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.6,,,,,,,fee schedule,60.6,257.82,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.6,,,,,,,fee schedule,60.6,257.82,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.69,,,,,,,fee schedule,60.6,257.82,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,150.39,,,,,,,fee schedule,60.6,257.82,APC
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,143.23,,,,,,,fee schedule,60.6,257.82,APC
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,257.82,,,,,,,fee schedule,60.6,257.82,APC
Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3776.18,,,,,,,fee schedule,3776.18,7072.81,
Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3776.18,,,,,,,fee schedule,3776.18,7072.81,
Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3776.18,,,,,,,fee schedule,3776.18,7072.81,
Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4342.61,,,,,,,fee schedule,3776.18,7072.81,
Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4125.8,,,,,,,fee schedule,3776.18,7072.81,APC
Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3929.34,,,,,,,fee schedule,3776.18,7072.81,APC
Pegloticase injection,J2507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7072.81,,,,,,,fee schedule,3776.18,7072.81,APC
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,238.97,,,,,,,fee schedule,225.66,406.2,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,238.97,,,,,,,fee schedule,225.66,406.2,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,238.97,,,,,,,fee schedule,225.66,406.2,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,274.82,,,,,,,fee schedule,225.66,406.2,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,236.95,,,,,,,fee schedule,225.66,406.2,APC
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,225.66,,,,,,,fee schedule,225.66,406.2,APC
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,406.2,,,,,,,fee schedule,225.66,406.2,APC
Penicillin g procaine inj,J2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.87,,,,,,,fee schedule,46.87,53.9,
Penicillin g procaine inj,J2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.87,,,,,,,fee schedule,46.87,53.9,
Penicillin g procaine inj,J2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.87,,,,,,,fee schedule,46.87,53.9,
Penicillin g procaine inj,J2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.9,,,,,,,fee schedule,46.87,53.9,
Pentastarch 10% solution,J2513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.52,,,,,,,fee schedule,13.52,15.55,
Pentastarch 10% solution,J2513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.52,,,,,,,fee schedule,13.52,15.55,
Pentastarch 10% solution,J2513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.52,,,,,,,fee schedule,13.52,15.55,
Pentastarch 10% solution,J2513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.55,,,,,,,fee schedule,13.52,15.55,
Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.87,,,,,,,fee schedule,19.3,61.95,
Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.87,,,,,,,fee schedule,19.3,61.95,
Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.87,,,,,,,fee schedule,19.3,61.95,
Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.95,,,,,,,fee schedule,19.3,61.95,
Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.26,,,,,,,fee schedule,19.3,61.95,APC
Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.3,,,,,,,fee schedule,19.3,61.95,APC
Pentobarbital sodium inj,J2515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.74,,,,,,,fee schedule,19.3,61.95,APC
Penicillin g potassium inj,J2540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.91,,,,,,,fee schedule,0.91,1.05,
Penicillin g potassium inj,J2540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.91,,,,,,,fee schedule,0.91,1.05,
Penicillin g potassium inj,J2540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.91,,,,,,,fee schedule,0.91,1.05,
Penicillin g potassium inj,J2540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.05,,,,,,,fee schedule,0.91,1.05,
Piperacillin/tazobactam,J2543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.15,,,,,,,fee schedule,1.15,1.32,
Piperacillin/tazobactam,J2543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.15,,,,,,,fee schedule,1.15,1.32,
Piperacillin/tazobactam,J2543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.15,,,,,,,fee schedule,1.15,1.32,
Piperacillin/tazobactam,J2543,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.32,,,,,,,fee schedule,1.15,1.32,
Pentamidine non-comp unit,J2545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.48,,,,,,,fee schedule,85.48,98.3,
Pentamidine non-comp unit,J2545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.48,,,,,,,fee schedule,85.48,98.3,
Pentamidine non-comp unit,J2545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.48,,,,,,,fee schedule,85.48,98.3,
Pentamidine non-comp unit,J2545,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.3,,,,,,,fee schedule,85.48,98.3,
"Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.62,,,,,,,fee schedule,1.62,3.02,
"Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.62,,,,,,,fee schedule,1.62,3.02,
"Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.62,,,,,,,fee schedule,1.62,3.02,
"Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.86,,,,,,,fee schedule,1.62,3.02,
"Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.76,,,,,,,fee schedule,1.62,3.02,APC
"Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.68,,,,,,,fee schedule,1.62,3.02,APC
"Injection, peramivir",J2547,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.02,,,,,,,fee schedule,1.62,3.02,APC
Promethazine hcl injection,J2550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.98,,,,,,,fee schedule,2.98,3.43,
Promethazine hcl injection,J2550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.98,,,,,,,fee schedule,2.98,3.43,
Promethazine hcl injection,J2550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.98,,,,,,,fee schedule,2.98,3.43,
Promethazine hcl injection,J2550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.43,,,,,,,fee schedule,2.98,3.43,
Phenobarbital sodium inj,J2560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.39,,,,,,,fee schedule,28.39,32.65,
Phenobarbital sodium inj,J2560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.39,,,,,,,fee schedule,28.39,32.65,
Phenobarbital sodium inj,J2560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.39,,,,,,,fee schedule,28.39,32.65,
Phenobarbital sodium inj,J2560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.65,,,,,,,fee schedule,28.39,32.65,
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.36,,,,,,,fee schedule,1.12,2.01,
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.36,,,,,,,fee schedule,1.12,2.01,
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.36,,,,,,,fee schedule,1.12,2.01,
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.56,,,,,,,fee schedule,1.12,2.01,
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.17,,,,,,,fee schedule,1.12,2.01,APC
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.12,,,,,,,fee schedule,1.12,2.01,APC
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.01,,,,,,,fee schedule,1.12,2.01,APC
Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.98,,,,,,,fee schedule,28.49,142.58,
Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.98,,,,,,,fee schedule,28.49,142.58,
Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.98,,,,,,,fee schedule,28.49,142.58,
Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.58,,,,,,,fee schedule,28.49,142.58,
Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.91,,,,,,,fee schedule,28.49,142.58,APC
Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.49,,,,,,,fee schedule,28.49,142.58,APC
Plerixafor injection,J2562,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.28,,,,,,,fee schedule,28.49,142.58,APC
Oxytocin injection,J2590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.43,,,,,,,fee schedule,1.43,1.64,
Oxytocin injection,J2590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.43,,,,,,,fee schedule,1.43,1.64,
Oxytocin injection,J2590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.43,,,,,,,fee schedule,1.43,1.64,
Oxytocin injection,J2590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.64,,,,,,,fee schedule,1.43,1.64,
Inj desmopressin acetate,J2597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.04,,,,,,,fee schedule,4.04,4.65,
Inj desmopressin acetate,J2597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.04,,,,,,,fee schedule,4.04,4.65,
Inj desmopressin acetate,J2597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.04,,,,,,,fee schedule,4.04,4.65,
Inj desmopressin acetate,J2597,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.65,,,,,,,fee schedule,4.04,4.65,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.3,,,,,,,fee schedule,1.3,1.5,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.3,,,,,,,fee schedule,1.3,1.5,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.3,,,,,,,fee schedule,1.3,1.5,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.5,,,,,,,fee schedule,1.3,1.5,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.49,,,,,,,fee schedule,0.49,0.56,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.49,,,,,,,fee schedule,0.49,0.56,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.49,,,,,,,fee schedule,0.49,0.56,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.56,,,,,,,fee schedule,0.49,0.56,
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.05,,,,,,,fee schedule,1.75,3.51,
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.05,,,,,,,fee schedule,1.75,3.51,
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.05,,,,,,,fee schedule,1.75,3.51,
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.51,,,,,,,fee schedule,1.75,3.51,
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.84,,,,,,,fee schedule,1.75,3.51,APC
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.75,,,,,,,fee schedule,1.75,3.51,APC
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.16,,,,,,,fee schedule,1.75,3.51,APC
Prednisolone acetate inj,J2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.55,,,,,,,fee schedule,0.55,0.63,
Prednisolone acetate inj,J2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.55,,,,,,,fee schedule,0.55,0.63,
Prednisolone acetate inj,J2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.55,,,,,,,fee schedule,0.55,0.63,
Prednisolone acetate inj,J2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.63,,,,,,,fee schedule,0.55,0.63,
Totazoline hcl injection,J2670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.51,,,,,,,fee schedule,3.51,4.04,
Totazoline hcl injection,J2670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.51,,,,,,,fee schedule,3.51,4.04,
Totazoline hcl injection,J2670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.51,,,,,,,fee schedule,3.51,4.04,
Totazoline hcl injection,J2670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.04,,,,,,,fee schedule,3.51,4.04,
Inj progesterone per 50 MG,J2675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.65,,,,,,,fee schedule,0.65,0.75,
Inj progesterone per 50 MG,J2675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.65,,,,,,,fee schedule,0.65,0.75,
Inj progesterone per 50 MG,J2675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.65,0.75,
Inj progesterone per 50 MG,J2675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.75,,,,,,,fee schedule,0.65,0.75,
Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.71,,,,,,,fee schedule,7.71,8.87,
Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.71,,,,,,,fee schedule,7.71,8.87,
Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.71,,,,,,,fee schedule,7.71,8.87,
Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.87,,,,,,,fee schedule,7.71,8.87,
Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.82,,,,,,,fee schedule,7.82,8.99,
Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.82,,,,,,,fee schedule,7.82,8.99,
Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.82,,,,,,,fee schedule,7.82,8.99,
Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.99,,,,,,,fee schedule,7.82,8.99,
Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.65,,,,,,,fee schedule,201.65,531.65,
Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.65,,,,,,,fee schedule,201.65,531.65,
Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.65,,,,,,,fee schedule,201.65,531.65,
Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.9,,,,,,,fee schedule,201.65,531.65,
Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,310.13,,,,,,,fee schedule,201.65,531.65,APC
Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,295.36,,,,,,,fee schedule,201.65,531.65,APC
Procainamide hcl injection,J2690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,531.65,,,,,,,fee schedule,201.65,531.65,APC
Oxacillin sodium injeciton,J2700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.85,,,,,,,fee schedule,0.85,0.98,
Oxacillin sodium injeciton,J2700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.85,,,,,,,fee schedule,0.85,0.98,
Oxacillin sodium injeciton,J2700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.85,,,,,,,fee schedule,0.85,0.98,
Oxacillin sodium injeciton,J2700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.98,,,,,,,fee schedule,0.85,0.98,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.1,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.1,,,,,,,fee schedule,0.09,0.1,
Neostigmine methylslfte inj,J2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.82,,,,,,,fee schedule,0.82,0.94,
Neostigmine methylslfte inj,J2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.82,,,,,,,fee schedule,0.82,0.94,
Neostigmine methylslfte inj,J2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.82,,,,,,,fee schedule,0.82,0.94,
Neostigmine methylslfte inj,J2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.94,,,,,,,fee schedule,0.82,0.94,
Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.7,,,,,,,fee schedule,1.7,1.96,
Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.7,,,,,,,fee schedule,1.7,1.96,
Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.7,,,,,,,fee schedule,1.7,1.96,
Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.96,,,,,,,fee schedule,1.7,1.96,
Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.56,,,,,,,fee schedule,1.56,27.13,
Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.56,,,,,,,fee schedule,1.56,27.13,
Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.56,,,,,,,fee schedule,1.56,27.13,
Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.79,,,,,,,fee schedule,1.56,27.13,
Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.82,,,,,,,fee schedule,1.56,27.13,APC
Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.07,,,,,,,fee schedule,1.56,27.13,APC
Protein C concentrate,J2724,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.13,,,,,,,fee schedule,1.56,27.13,APC
Inj protirelin per 250 mcg,J2725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.83,,,,,,,fee schedule,21.83,25.1,
Inj protirelin per 250 mcg,J2725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.83,,,,,,,fee schedule,21.83,25.1,
Inj protirelin per 250 mcg,J2725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.83,,,,,,,fee schedule,21.83,25.1,
Inj protirelin per 250 mcg,J2725,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.1,,,,,,,fee schedule,21.83,25.1,
Pralidoxime chloride inj,J2730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.43,,,,,,,fee schedule,88.43,101.69,
Pralidoxime chloride inj,J2730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.43,,,,,,,fee schedule,88.43,101.69,
Pralidoxime chloride inj,J2730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.43,,,,,,,fee schedule,88.43,101.69,
Pralidoxime chloride inj,J2730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.69,,,,,,,fee schedule,88.43,101.69,
Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,452.98,,,,,,,fee schedule,288.62,520.93,
Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,452.98,,,,,,,fee schedule,288.62,520.93,
Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,452.98,,,,,,,fee schedule,288.62,520.93,
Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,520.93,,,,,,,fee schedule,288.62,520.93,
Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,303.06,,,,,,,fee schedule,288.62,520.93,APC
Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,288.62,,,,,,,fee schedule,288.62,520.93,APC
Phentolaine mesylate inj,J2760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,519.52,,,,,,,fee schedule,288.62,520.93,APC
Metoclopramide hcl injection,J2765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.03,,,,,,,fee schedule,1.03,1.18,
Metoclopramide hcl injection,J2765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.03,,,,,,,fee schedule,1.03,1.18,
Metoclopramide hcl injection,J2765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.03,,,,,,,fee schedule,1.03,1.18,
Metoclopramide hcl injection,J2765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.18,,,,,,,fee schedule,1.03,1.18,
Quinupristin/dalfopristin,J2770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,475.33,,,,,,,fee schedule,475.33,546.63,
Quinupristin/dalfopristin,J2770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,475.33,,,,,,,fee schedule,475.33,546.63,
Quinupristin/dalfopristin,J2770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,475.33,,,,,,,fee schedule,475.33,546.63,
Quinupristin/dalfopristin,J2770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,546.63,,,,,,,fee schedule,475.33,546.63,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.78,,,,,,,fee schedule,32.38,58.29,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.78,,,,,,,fee schedule,32.38,58.29,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.78,,,,,,,fee schedule,32.38,58.29,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.15,,,,,,,fee schedule,32.38,58.29,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34,,,,,,,fee schedule,32.38,58.29,APC
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.38,,,,,,,fee schedule,32.38,58.29,APC
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.29,,,,,,,fee schedule,32.38,58.29,APC
Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.55,,,,,,,fee schedule,51.09,108.73,
Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.55,,,,,,,fee schedule,51.09,108.73,
Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.55,,,,,,,fee schedule,51.09,108.73,
Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.73,,,,,,,fee schedule,51.09,108.73,
Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.64,,,,,,,fee schedule,51.09,108.73,APC
Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.09,,,,,,,fee schedule,51.09,108.73,APC
Ranibizumab injection,J2778,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,91.96,,,,,,,fee schedule,51.09,108.73,APC
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.39,,,,,,,fee schedule,74.8,134.63,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.39,,,,,,,fee schedule,74.8,134.63,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.39,,,,,,,fee schedule,74.8,134.63,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.6,,,,,,,fee schedule,74.8,134.63,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.53,,,,,,,fee schedule,74.8,134.63,APC
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.8,,,,,,,fee schedule,74.8,134.63,APC
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,134.63,,,,,,,fee schedule,74.8,134.63,APC
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.27,,,,,,,fee schedule,147.27,268.1,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.27,,,,,,,fee schedule,147.27,268.1,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.27,,,,,,,fee schedule,147.27,268.1,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,169.36,,,,,,,fee schedule,147.27,268.1,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,156.39,,,,,,,fee schedule,147.27,268.1,APC
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,148.94,,,,,,,fee schedule,147.27,268.1,APC
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,268.1,,,,,,,fee schedule,147.27,268.1,APC
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.89,,,,,,,fee schedule,103.2,185.77,
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.89,,,,,,,fee schedule,103.2,185.77,
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,109.89,,,,,,,fee schedule,103.2,185.77,
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.37,,,,,,,fee schedule,103.2,185.77,
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.36,,,,,,,fee schedule,103.2,185.77,APC
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,103.2,,,,,,,fee schedule,103.2,185.77,APC
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,185.77,,,,,,,fee schedule,103.2,185.77,APC
Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,390.69,,,,,,,fee schedule,387.45,697.42,
Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,390.69,,,,,,,fee schedule,387.45,697.42,
Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,390.69,,,,,,,fee schedule,387.45,697.42,
Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,449.29,,,,,,,fee schedule,387.45,697.42,
Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.83,,,,,,,fee schedule,387.45,697.42,APC
Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,387.45,,,,,,,fee schedule,387.45,697.42,APC
Rasburicase,J2783,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,697.42,,,,,,,fee schedule,387.45,697.42,APC
Regadenoson injection,J2785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3,,,,,,,fee schedule,3,3.45,
Regadenoson injection,J2785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3,,,,,,,fee schedule,3,3.45,
Regadenoson injection,J2785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3,,,,,,,fee schedule,3,3.45,
Regadenoson injection,J2785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.45,,,,,,,fee schedule,3,3.45,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.97,,,,,,,fee schedule,10.97,21.11,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.97,,,,,,,fee schedule,10.97,21.11,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.97,,,,,,,fee schedule,10.97,21.11,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.62,,,,,,,fee schedule,10.97,21.11,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.32,,,,,,,fee schedule,10.97,21.11,APC
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.73,,,,,,,fee schedule,10.97,21.11,APC
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.11,,,,,,,fee schedule,10.97,21.11,APC
Riboflavin 5?phos opth<=3ml,J2787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2325.6,,,,,,,fee schedule,2325.6,2674.44,
Riboflavin 5?phos opth<=3ml,J2787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2325.6,,,,,,,fee schedule,2325.6,2674.44,
Riboflavin 5?phos opth<=3ml,J2787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2325.6,,,,,,,fee schedule,2325.6,2674.44,
Riboflavin 5?phos opth<=3ml,J2787,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2674.44,,,,,,,fee schedule,2325.6,2674.44,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.91,,,,,,,fee schedule,28.91,33.25,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.91,,,,,,,fee schedule,28.91,33.25,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.91,,,,,,,fee schedule,28.91,33.25,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.25,,,,,,,fee schedule,28.91,33.25,
Rho d immune globulin inj,J2790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.53,,,,,,,fee schedule,85.53,98.36,
Rho d immune globulin inj,J2790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.53,,,,,,,fee schedule,85.53,98.36,
Rho d immune globulin inj,J2790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.53,,,,,,,fee schedule,85.53,98.36,
Rho d immune globulin inj,J2790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.36,,,,,,,fee schedule,85.53,98.36,
Rhophylac injection,J2791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.15,,,,,,,fee schedule,5.15,5.92,
Rhophylac injection,J2791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.15,,,,,,,fee schedule,5.15,5.92,
Rhophylac injection,J2791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.15,,,,,,,fee schedule,5.15,5.92,
Rhophylac injection,J2791,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.92,,,,,,,fee schedule,5.15,5.92,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.93,,,,,,,fee schedule,31.93,64.42,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.93,,,,,,,fee schedule,31.93,64.42,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.93,,,,,,,fee schedule,31.93,64.42,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.72,,,,,,,fee schedule,31.93,64.42,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.58,,,,,,,fee schedule,31.93,64.42,APC
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.79,,,,,,,fee schedule,31.93,64.42,APC
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,64.42,,,,,,,fee schedule,31.93,64.42,APC
Rilonacept injection,J2793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.64,,,,,,,fee schedule,27.64,31.79,
Rilonacept injection,J2793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.64,,,,,,,fee schedule,27.64,31.79,
Rilonacept injection,J2793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.64,,,,,,,fee schedule,27.64,31.79,
Rilonacept injection,J2793,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.79,,,,,,,fee schedule,27.64,31.79,
"Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.35,,,,,,,fee schedule,11.1,19.99,
"Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.35,,,,,,,fee schedule,11.1,19.99,
"Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.35,,,,,,,fee schedule,11.1,19.99,
"Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.05,,,,,,,fee schedule,11.1,19.99,
"Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.66,,,,,,,fee schedule,11.1,19.99,APC
"Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.1,,,,,,,fee schedule,11.1,19.99,APC
"Risperidone, long acting",J2794,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.99,,,,,,,fee schedule,11.1,19.99,APC
Ropivacaine HCl injection,J2795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Ropivacaine HCl injection,J2795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Ropivacaine HCl injection,J2795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.07,
Ropivacaine HCl injection,J2795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.07,
"Inj., rolapitant, 0.5 mg",J2797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.9,,,,,,,fee schedule,0.9,1.04,
"Inj., rolapitant, 0.5 mg",J2797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.9,,,,,,,fee schedule,0.9,1.04,
"Inj., rolapitant, 0.5 mg",J2797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.9,,,,,,,fee schedule,0.9,1.04,
"Inj., rolapitant, 0.5 mg",J2797,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.04,,,,,,,fee schedule,0.9,1.04,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.6,,,,,,,fee schedule,12.2,21.97,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.6,,,,,,,fee schedule,12.2,21.97,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.6,,,,,,,fee schedule,12.2,21.97,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.49,,,,,,,fee schedule,12.2,21.97,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.81,,,,,,,fee schedule,12.2,21.97,APC
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.2,,,,,,,fee schedule,12.2,21.97,APC
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21.97,,,,,,,fee schedule,12.2,21.97,APC
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.02,,,,,,,fee schedule,26.02,47.13,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.02,,,,,,,fee schedule,26.02,47.13,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.02,,,,,,,fee schedule,26.02,47.13,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.92,,,,,,,fee schedule,26.02,47.13,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.49,,,,,,,fee schedule,26.02,47.13,APC
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.18,,,,,,,fee schedule,26.02,47.13,APC
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.13,,,,,,,fee schedule,26.02,47.13,APC
Methocarbamol injection,J2800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.97,,,,,,,fee schedule,4.97,5.72,
Methocarbamol injection,J2800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.97,,,,,,,fee schedule,4.97,5.72,
Methocarbamol injection,J2800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.97,,,,,,,fee schedule,4.97,5.72,
Methocarbamol injection,J2800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.72,,,,,,,fee schedule,4.97,5.72,
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.54,,,,,,,fee schedule,12.54,23.45,
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.54,,,,,,,fee schedule,12.54,23.45,
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.54,,,,,,,fee schedule,12.54,23.45,
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.42,,,,,,,fee schedule,12.54,23.45,
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.68,,,,,,,fee schedule,12.54,23.45,APC
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.03,,,,,,,fee schedule,12.54,23.45,APC
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.45,,,,,,,fee schedule,12.54,23.45,APC
"Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.41,,,,,,,fee schedule,11.41,20.91,
"Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.41,,,,,,,fee schedule,11.41,20.91,
"Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.41,,,,,,,fee schedule,11.41,20.91,
"Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.12,,,,,,,fee schedule,11.41,20.91,
"Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.2,,,,,,,fee schedule,11.41,20.91,APC
"Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.62,,,,,,,fee schedule,11.41,20.91,APC
"Inj, romiplostim 1 microgram",J2802,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.91,,,,,,,fee schedule,11.41,20.91,APC
"Inj, rifampin, 1 mg",J2804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.16,,,,,,,fee schedule,0.16,0.18,
"Inj, rifampin, 1 mg",J2804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.16,,,,,,,fee schedule,0.16,0.18,
"Inj, rifampin, 1 mg",J2804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.16,,,,,,,fee schedule,0.16,0.18,
"Inj, rifampin, 1 mg",J2804,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.18,,,,,,,fee schedule,0.16,0.18,
Sincalide injection,J2805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.1,,,,,,,fee schedule,141.1,162.27,
Sincalide injection,J2805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.1,,,,,,,fee schedule,141.1,162.27,
Sincalide injection,J2805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.1,,,,,,,fee schedule,141.1,162.27,
Sincalide injection,J2805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.27,,,,,,,fee schedule,141.1,162.27,
Inj theophylline per 40 MG,J2810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.4,,,,,,,fee schedule,0.4,0.46,
Inj theophylline per 40 MG,J2810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.4,,,,,,,fee schedule,0.4,0.46,
Inj theophylline per 40 MG,J2810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.4,,,,,,,fee schedule,0.4,0.46,
Inj theophylline per 40 MG,J2810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.46,,,,,,,fee schedule,0.4,0.46,
Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.21,,,,,,,fee schedule,58.21,112.45,
Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.21,,,,,,,fee schedule,58.21,112.45,
Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.21,,,,,,,fee schedule,58.21,112.45,
Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.94,,,,,,,fee schedule,58.21,112.45,
Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.6,,,,,,,fee schedule,58.21,112.45,APC
Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.47,,,,,,,fee schedule,58.21,112.45,APC
Sargramostim injection,J2820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,112.45,,,,,,,fee schedule,58.21,112.45,APC
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,520.71,,,,,,,fee schedule,520.71,971.28,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,520.71,,,,,,,fee schedule,520.71,971.28,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,520.71,,,,,,,fee schedule,520.71,971.28,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,598.82,,,,,,,fee schedule,520.71,971.28,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,566.58,,,,,,,fee schedule,520.71,971.28,APC
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,539.6,,,,,,,fee schedule,520.71,971.28,APC
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,971.28,,,,,,,fee schedule,520.71,971.28,APC
Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.14,,,,,,,fee schedule,42.14,77.4,
Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.14,,,,,,,fee schedule,42.14,77.4,
Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.14,,,,,,,fee schedule,42.14,77.4,
Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.46,,,,,,,fee schedule,42.14,77.4,
Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.15,,,,,,,fee schedule,42.14,77.4,APC
Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43,,,,,,,fee schedule,42.14,77.4,APC
Inj secretin synthetic human,J2850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77.4,,,,,,,fee schedule,42.14,77.4,APC
"Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,168.07,,,,,,,fee schedule,168.07,313.32,
"Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,168.07,,,,,,,fee schedule,168.07,313.32,
"Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.07,,,,,,,fee schedule,168.07,313.32,
"Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,193.28,,,,,,,fee schedule,168.07,313.32,
"Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.77,,,,,,,fee schedule,168.07,313.32,APC
"Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.07,,,,,,,fee schedule,168.07,313.32,APC
"Injection, siltuximab",J2860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,313.32,,,,,,,fee schedule,168.07,313.32,APC
Inj sulfameth/trim 5 mg/1 mg,J2865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Inj sulfameth/trim 5 mg/1 mg,J2865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Inj sulfameth/trim 5 mg/1 mg,J2865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.05,,,,,,,fee schedule,0.05,0.06,
Inj sulfameth/trim 5 mg/1 mg,J2865,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.06,,,,,,,fee schedule,0.05,0.06,
Aurothioglucose injeciton,J2910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.99,,,,,,,fee schedule,24.99,28.74,
Aurothioglucose injeciton,J2910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.99,,,,,,,fee schedule,24.99,28.74,
Aurothioglucose injeciton,J2910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.99,,,,,,,fee schedule,24.99,28.74,
Aurothioglucose injeciton,J2910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.74,,,,,,,fee schedule,24.99,28.74,
Na ferric gluconate complex,J2916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.26,,,,,,,fee schedule,2.26,2.6,
Na ferric gluconate complex,J2916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.26,,,,,,,fee schedule,2.26,2.6,
Na ferric gluconate complex,J2916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.26,,,,,,,fee schedule,2.26,2.6,
Na ferric gluconate complex,J2916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.6,,,,,,,fee schedule,2.26,2.6,
"Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.27,,,,,,,fee schedule,0.27,0.31,
"Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.27,,,,,,,fee schedule,0.27,0.31,
"Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.27,,,,,,,fee schedule,0.27,0.31,
"Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.31,,,,,,,fee schedule,0.27,0.31,
Somatrem injection,J2940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.94,,,,,,,fee schedule,44.94,51.68,
Somatrem injection,J2940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.94,,,,,,,fee schedule,44.94,51.68,
Somatrem injection,J2940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.94,,,,,,,fee schedule,44.94,51.68,
Somatrem injection,J2940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.68,,,,,,,fee schedule,44.94,51.68,
Somatropin injection,J2941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.56,,,,,,,fee schedule,158.56,182.34,
Somatropin injection,J2941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.56,,,,,,,fee schedule,158.56,182.34,
Somatropin injection,J2941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.56,,,,,,,fee schedule,158.56,182.34,
Somatropin injection,J2941,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.34,,,,,,,fee schedule,158.56,182.34,
Promazine hcl injection,J2950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.88,,,,,,,fee schedule,0.88,1.01,
Promazine hcl injection,J2950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.88,,,,,,,fee schedule,0.88,1.01,
Promazine hcl injection,J2950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.88,,,,,,,fee schedule,0.88,1.01,
Promazine hcl injection,J2950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.01,,,,,,,fee schedule,0.88,1.01,
Reteplase injection,J2993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3081.45,,,,,,,fee schedule,3081.45,3543.67,
Reteplase injection,J2993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3081.45,,,,,,,fee schedule,3081.45,3543.67,
Reteplase injection,J2993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3081.45,,,,,,,fee schedule,3081.45,3543.67,
Reteplase injection,J2993,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3543.67,,,,,,,fee schedule,3081.45,3543.67,
Inj streptokinase /250000 IU,J2995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.69,,,,,,,fee schedule,79.69,91.64,
Inj streptokinase /250000 IU,J2995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.69,,,,,,,fee schedule,79.69,91.64,
Inj streptokinase /250000 IU,J2995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.69,,,,,,,fee schedule,79.69,91.64,
Inj streptokinase /250000 IU,J2995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.64,,,,,,,fee schedule,79.69,91.64,
Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.7,,,,,,,fee schedule,97.7,177.46,
Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.7,,,,,,,fee schedule,97.7,177.46,
Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.7,,,,,,,fee schedule,97.7,177.46,
Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.36,,,,,,,fee schedule,97.7,177.46,
Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,103.52,,,,,,,fee schedule,97.7,177.46,APC
Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,98.59,,,,,,,fee schedule,97.7,177.46,APC
Alteplase recombinant,J2997,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,177.46,,,,,,,fee schedule,97.7,177.46,APC
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37,,,,,,,fee schedule,37,69.16,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37,,,,,,,fee schedule,37,69.16,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37,,,,,,,fee schedule,37,69.16,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.55,,,,,,,fee schedule,37,69.16,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.34,,,,,,,fee schedule,37,69.16,APC
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.42,,,,,,,fee schedule,37,69.16,APC
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69.16,,,,,,,fee schedule,37,69.16,APC
Streptomycin injection,J3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.54,,,,,,,fee schedule,32.54,37.42,
Streptomycin injection,J3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.54,,,,,,,fee schedule,32.54,37.42,
Streptomycin injection,J3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.54,,,,,,,fee schedule,32.54,37.42,
Streptomycin injection,J3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.42,,,,,,,fee schedule,32.54,37.42,
Fentanyl citrate injeciton,J3010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1,,,,,,,fee schedule,1,1.15,
Fentanyl citrate injeciton,J3010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1,,,,,,,fee schedule,1,1.15,
Fentanyl citrate injeciton,J3010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1,,,,,,,fee schedule,1,1.15,
Fentanyl citrate injeciton,J3010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.15,,,,,,,fee schedule,1,1.15,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.74,,,,,,,fee schedule,37.74,43.4,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.74,,,,,,,fee schedule,37.74,43.4,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.74,,,,,,,fee schedule,37.74,43.4,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.4,,,,,,,fee schedule,37.74,43.4,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.43,,,,,,,fee schedule,3.43,3.94,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.43,,,,,,,fee schedule,3.43,3.94,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.43,,,,,,,fee schedule,3.43,3.94,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.94,,,,,,,fee schedule,3.43,3.94,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.6,,,,,,,fee schedule,20.6,37.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.6,,,,,,,fee schedule,20.6,37.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.6,,,,,,,fee schedule,20.6,37.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.69,,,,,,,fee schedule,20.6,37.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.16,,,,,,,fee schedule,20.6,37.98,APC
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.1,,,,,,,fee schedule,20.6,37.98,APC
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.98,,,,,,,fee schedule,20.6,37.98,APC
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.13,,,,,,,fee schedule,75.13,138.1,
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.13,,,,,,,fee schedule,75.13,138.1,
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.13,,,,,,,fee schedule,75.13,138.1,
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.4,,,,,,,fee schedule,75.13,138.1,
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.56,,,,,,,fee schedule,75.13,138.1,APC
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,76.72,,,,,,,fee schedule,75.13,138.1,APC
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,138.1,,,,,,,fee schedule,75.13,138.1,APC
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.61,,,,,,,fee schedule,42.61,76.82,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.61,,,,,,,fee schedule,42.61,76.82,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.61,,,,,,,fee schedule,42.61,76.82,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49,,,,,,,fee schedule,42.61,76.82,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.81,,,,,,,fee schedule,42.61,76.82,APC
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.68,,,,,,,fee schedule,42.61,76.82,APC
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,76.82,,,,,,,fee schedule,42.61,76.82,APC
Pentazocine injection,J3070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.3,,,,,,,fee schedule,104.3,119.95,
Pentazocine injection,J3070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.3,,,,,,,fee schedule,104.3,119.95,
Pentazocine injection,J3070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.3,,,,,,,fee schedule,104.3,119.95,
Pentazocine injection,J3070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.95,,,,,,,fee schedule,104.3,119.95,
Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.99,,,,,,,fee schedule,1.99,3.75,
Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.99,,,,,,,fee schedule,1.99,3.75,
Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.99,,,,,,,fee schedule,1.99,3.75,
Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.29,,,,,,,fee schedule,1.99,3.75,
Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.19,,,,,,,fee schedule,1.99,3.75,APC
Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.08,,,,,,,fee schedule,1.99,3.75,APC
Inj tedizolid phosphate,J3090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.75,,,,,,,fee schedule,1.99,3.75,APC
Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.75,,,,,,,fee schedule,7.48,13.47,
Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.75,,,,,,,fee schedule,7.48,13.47,
Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.75,,,,,,,fee schedule,7.48,13.47,
Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.91,,,,,,,fee schedule,7.48,13.47,
Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.86,,,,,,,fee schedule,7.48,13.47,APC
Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.48,,,,,,,fee schedule,7.48,13.47,APC
Telavancin injection,J3095,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13.47,,,,,,,fee schedule,7.48,13.47,APC
Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.43,,,,,,,fee schedule,178.43,391.36,
Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.43,,,,,,,fee schedule,178.43,391.36,
Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,178.43,,,,,,,fee schedule,178.43,391.36,
Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.19,,,,,,,fee schedule,178.43,391.36,
Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,228.29,,,,,,,fee schedule,178.43,391.36,APC
Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,217.42,,,,,,,fee schedule,178.43,391.36,APC
Tenecteplase injection,J3101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,391.36,,,,,,,fee schedule,178.43,391.36,APC
Terbutaline sulfate inj,J3105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.85,,,,,,,fee schedule,2.85,3.28,
Terbutaline sulfate inj,J3105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.85,,,,,,,fee schedule,2.85,3.28,
Terbutaline sulfate inj,J3105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.85,,,,,,,fee schedule,2.85,3.28,
Terbutaline sulfate inj,J3105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.28,,,,,,,fee schedule,2.85,3.28,
Teriparatide injection,J3110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.34,,,,,,,fee schedule,47.34,54.44,
Teriparatide injection,J3110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.34,,,,,,,fee schedule,47.34,54.44,
Teriparatide injection,J3110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.34,,,,,,,fee schedule,47.34,54.44,
Teriparatide injection,J3110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.44,,,,,,,fee schedule,47.34,54.44,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.46,,,,,,,fee schedule,12.46,22.92,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.46,,,,,,,fee schedule,12.46,22.92,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.46,,,,,,,fee schedule,12.46,22.92,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.33,,,,,,,fee schedule,12.46,22.92,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.37,,,,,,,fee schedule,12.46,22.92,APC
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.73,,,,,,,fee schedule,12.46,22.92,APC
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.92,,,,,,,fee schedule,12.46,22.92,APC
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.07,
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.07,
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.07,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.07,,,,,,,fee schedule,2.07,3.87,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.07,,,,,,,fee schedule,2.07,3.87,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.07,,,,,,,fee schedule,2.07,3.87,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.38,,,,,,,fee schedule,2.07,3.87,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.26,,,,,,,fee schedule,2.07,3.87,APC
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.15,,,,,,,fee schedule,2.07,3.87,APC
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.87,,,,,,,fee schedule,2.07,3.87,APC
Chlorpromazine hcl injection,J3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.09,,,,,,,fee schedule,28.09,32.3,
Chlorpromazine hcl injection,J3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.09,,,,,,,fee schedule,28.09,32.3,
Chlorpromazine hcl injection,J3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.09,,,,,,,fee schedule,28.09,32.3,
Chlorpromazine hcl injection,J3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.3,,,,,,,fee schedule,28.09,32.3,
Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2192.98,,,,,,,fee schedule,2158.66,3885.59,
Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2192.98,,,,,,,fee schedule,2158.66,3885.59,
Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2192.98,,,,,,,fee schedule,2158.66,3885.59,
Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2521.93,,,,,,,fee schedule,2158.66,3885.59,
Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2266.59,,,,,,,fee schedule,2158.66,3885.59,APC
Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2158.66,,,,,,,fee schedule,2158.66,3885.59,APC
Thyrotropin injection,J3240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3885.59,,,,,,,fee schedule,2158.66,3885.59,APC
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,372.64,,,,,,,fee schedule,372.64,683.82,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,372.64,,,,,,,fee schedule,372.64,683.82,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,372.64,,,,,,,fee schedule,372.64,683.82,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,428.54,,,,,,,fee schedule,372.64,683.82,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,398.9,,,,,,,fee schedule,372.64,683.82,APC
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,379.9,,,,,,,fee schedule,372.64,683.82,APC
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,683.82,,,,,,,fee schedule,372.64,683.82,APC
Tigecycline injection,J3243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.53,,,,,,,fee schedule,0.53,0.61,
Tigecycline injection,J3243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.53,,,,,,,fee schedule,0.53,0.61,
Tigecycline injection,J3243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.53,,,,,,,fee schedule,0.53,0.61,
Tigecycline injection,J3243,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.61,,,,,,,fee schedule,0.53,0.61,
Inj. tigecycline (accord),J3244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.55,,,,,,,fee schedule,2.55,2.93,
Inj. tigecycline (accord),J3244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.55,,,,,,,fee schedule,2.55,2.93,
Inj. tigecycline (accord),J3244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.55,,,,,,,fee schedule,2.55,2.93,
Inj. tigecycline (accord),J3244,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.93,,,,,,,fee schedule,2.55,2.93,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131,,,,,,,fee schedule,124.27,223.69,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131,,,,,,,fee schedule,124.27,223.69,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131,,,,,,,fee schedule,124.27,223.69,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.65,,,,,,,fee schedule,124.27,223.69,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.49,,,,,,,fee schedule,124.27,223.69,APC
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124.27,,,,,,,fee schedule,124.27,223.69,APC
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.69,,,,,,,fee schedule,124.27,223.69,APC
Tirofiban hcl,J3246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.56,,,,,,,fee schedule,3.56,4.09,
Tirofiban hcl,J3246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.56,,,,,,,fee schedule,3.56,4.09,
Tirofiban hcl,J3246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.56,,,,,,,fee schedule,3.56,4.09,
Tirofiban hcl,J3246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.09,,,,,,,fee schedule,3.56,4.09,
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.52,,,,,,,fee schedule,18.23,32.82,
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.52,,,,,,,fee schedule,18.23,32.82,
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.52,,,,,,,fee schedule,18.23,32.82,
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.3,,,,,,,fee schedule,18.23,32.82,
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.14,,,,,,,fee schedule,18.23,32.82,APC
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.23,,,,,,,fee schedule,18.23,32.82,APC
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.82,,,,,,,fee schedule,18.23,32.82,APC
Trimethobenzamide hcl inj,J3250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.42,,,,,,,fee schedule,55.42,63.73,
Trimethobenzamide hcl inj,J3250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.42,,,,,,,fee schedule,55.42,63.73,
Trimethobenzamide hcl inj,J3250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,55.42,,,,,,,fee schedule,55.42,63.73,
Trimethobenzamide hcl inj,J3250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.73,,,,,,,fee schedule,55.42,63.73,
Tobramycin sulfate injection,J3260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.55,,,,,,,fee schedule,2.55,2.93,
Tobramycin sulfate injection,J3260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.55,,,,,,,fee schedule,2.55,2.93,
Tobramycin sulfate injection,J3260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.55,,,,,,,fee schedule,2.55,2.93,
Tobramycin sulfate injection,J3260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.93,,,,,,,fee schedule,2.55,2.93,
Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6,,,,,,,fee schedule,5.41,9.73,
Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6,,,,,,,fee schedule,5.41,9.73,
Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6,,,,,,,fee schedule,5.41,9.73,
Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.9,,,,,,,fee schedule,5.41,9.73,
Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.68,,,,,,,fee schedule,5.41,9.73,APC
Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.41,,,,,,,fee schedule,5.41,9.73,APC
Tocilizumab injection,J3262,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.73,,,,,,,fee schedule,5.41,9.73,APC
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.99,,,,,,,fee schedule,40.89,73.61,
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.99,,,,,,,fee schedule,40.89,73.61,
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.99,,,,,,,fee schedule,40.89,73.61,
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.14,,,,,,,fee schedule,40.89,73.61,
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.94,,,,,,,fee schedule,40.89,73.61,APC
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40.89,,,,,,,fee schedule,40.89,73.61,APC
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,73.61,,,,,,,fee schedule,40.89,73.61,APC
Injection torsemide 10 mg/ml,J3265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.03,,,,,,,fee schedule,3.03,3.48,
Injection torsemide 10 mg/ml,J3265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.03,,,,,,,fee schedule,3.03,3.48,
Injection torsemide 10 mg/ml,J3265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.03,,,,,,,fee schedule,3.03,3.48,
Injection torsemide 10 mg/ml,J3265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.48,,,,,,,fee schedule,3.03,3.48,
Thiethylperazine maleate inj,J3280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.88,,,,,,,fee schedule,3.88,4.46,
Thiethylperazine maleate inj,J3280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.88,,,,,,,fee schedule,3.88,4.46,
Thiethylperazine maleate inj,J3280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.88,,,,,,,fee schedule,3.88,4.46,
Thiethylperazine maleate inj,J3280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.46,,,,,,,fee schedule,3.88,4.46,
Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.58,,,,,,,fee schedule,54.74,98.53,
Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.58,,,,,,,fee schedule,54.74,98.53,
Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.58,,,,,,,fee schedule,54.74,98.53,
Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.22,,,,,,,fee schedule,54.74,98.53,
Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.48,,,,,,,fee schedule,54.74,98.53,APC
Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.74,,,,,,,fee schedule,54.74,98.53,APC
Treprostinil injection,J3285,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,98.53,,,,,,,fee schedule,54.74,98.53,APC
Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.81,,,,,,,fee schedule,47.77,85.99,
Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.81,,,,,,,fee schedule,47.77,85.99,
Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.81,,,,,,,fee schedule,47.77,85.99,
Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.28,,,,,,,fee schedule,47.77,85.99,
Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.16,,,,,,,fee schedule,47.77,85.99,APC
Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.77,,,,,,,fee schedule,47.77,85.99,APC
Inj xipere 1 mg,J3299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,85.99,,,,,,,fee schedule,47.77,85.99,APC
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.43,,,,,,,fee schedule,19.19,34.53,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.43,,,,,,,fee schedule,19.19,34.53,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.43,,,,,,,fee schedule,19.19,34.53,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.24,,,,,,,fee schedule,19.19,34.53,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.15,,,,,,,fee schedule,19.19,34.53,APC
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.19,,,,,,,fee schedule,19.19,34.53,APC
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.53,,,,,,,fee schedule,19.19,34.53,APC
Triamcinolone acet inj nos,J3301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.89,,,,,,,fee schedule,0.89,1.02,
Triamcinolone acet inj nos,J3301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.89,,,,,,,fee schedule,0.89,1.02,
Triamcinolone acet inj nos,J3301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.89,,,,,,,fee schedule,0.89,1.02,
Triamcinolone acet inj nos,J3301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.02,,,,,,,fee schedule,0.89,1.02,
Triamcinolone diacetate inj,J3302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.29,,,,,,,fee schedule,0.29,0.33,
Triamcinolone diacetate inj,J3302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.29,,,,,,,fee schedule,0.29,0.33,
Triamcinolone diacetate inj,J3302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.29,,,,,,,fee schedule,0.29,0.33,
Triamcinolone diacetate inj,J3302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.33,,,,,,,fee schedule,0.29,0.33,
Triamcinolone hexacetonl inj,J3303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.29,,,,,,,fee schedule,8.29,9.53,
Triamcinolone hexacetonl inj,J3303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.29,,,,,,,fee schedule,8.29,9.53,
Triamcinolone hexacetonl inj,J3303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.29,,,,,,,fee schedule,8.29,9.53,
Triamcinolone hexacetonl inj,J3303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.53,,,,,,,fee schedule,8.29,9.53,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.9,,,,,,,fee schedule,18.9,34.7,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.9,,,,,,,fee schedule,18.9,34.7,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.9,,,,,,,fee schedule,18.9,34.7,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.74,,,,,,,fee schedule,18.9,34.7,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.24,,,,,,,fee schedule,18.9,34.7,APC
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.28,,,,,,,fee schedule,18.9,34.7,APC
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.7,,,,,,,fee schedule,18.9,34.7,APC
Inj trimetrexate glucoronate,J3305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.19,,,,,,,fee schedule,158.19,181.92,
Inj trimetrexate glucoronate,J3305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.19,,,,,,,fee schedule,158.19,181.92,
Inj trimetrexate glucoronate,J3305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,158.19,,,,,,,fee schedule,158.19,181.92,
Inj trimetrexate glucoronate,J3305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,181.92,,,,,,,fee schedule,158.19,181.92,
Perphenazine injeciton,J3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.38,,,,,,,fee schedule,6.38,7.34,
Perphenazine injeciton,J3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.38,,,,,,,fee schedule,6.38,7.34,
Perphenazine injeciton,J3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.38,,,,,,,fee schedule,6.38,7.34,
Perphenazine injeciton,J3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.34,,,,,,,fee schedule,6.38,7.34,
Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,510.46,,,,,,,fee schedule,466.36,839.46,
Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,510.46,,,,,,,fee schedule,466.36,839.46,
Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,510.46,,,,,,,fee schedule,466.36,839.46,
Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,587.03,,,,,,,fee schedule,466.36,839.46,
Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,489.68,,,,,,,fee schedule,466.36,839.46,APC
Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,466.36,,,,,,,fee schedule,466.36,839.46,APC
Triptorelin pamoate,J3315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,839.46,,,,,,,fee schedule,466.36,839.46,APC
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3915.22,,,,,,,fee schedule,3819.93,6875.88,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3915.22,,,,,,,fee schedule,3819.93,6875.88,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3915.22,,,,,,,fee schedule,3819.93,6875.88,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4502.5,,,,,,,fee schedule,3819.93,6875.88,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4010.93,,,,,,,fee schedule,3819.93,6875.88,APC
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3819.93,,,,,,,fee schedule,3819.93,6875.88,APC
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6875.88,,,,,,,fee schedule,3819.93,6875.88,APC
Spectinomycn di-hcl inj,J3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.16,,,,,,,fee schedule,30.16,34.68,
Spectinomycn di-hcl inj,J3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.16,,,,,,,fee schedule,30.16,34.68,
Spectinomycn di-hcl inj,J3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.16,,,,,,,fee schedule,30.16,34.68,
Spectinomycn di-hcl inj,J3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.68,,,,,,,fee schedule,30.16,34.68,
Urea injection,J3350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.55,,,,,,,fee schedule,75.55,86.88,
Urea injection,J3350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.55,,,,,,,fee schedule,75.55,86.88,
Urea injection,J3350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.55,,,,,,,fee schedule,75.55,86.88,
Urea injection,J3350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.88,,,,,,,fee schedule,75.55,86.88,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.65,,,,,,,fee schedule,127.65,146.8,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.65,,,,,,,fee schedule,127.65,146.8,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.65,,,,,,,fee schedule,127.65,146.8,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.8,,,,,,,fee schedule,127.65,146.8,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,289.09,,,,,,,fee schedule,289.09,332.45,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,289.09,,,,,,,fee schedule,289.09,332.45,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,289.09,,,,,,,fee schedule,289.09,332.45,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,332.45,,,,,,,fee schedule,289.09,332.45,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.79,,,,,,,fee schedule,11.36,20.44,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.79,,,,,,,fee schedule,11.36,20.44,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.79,,,,,,,fee schedule,11.36,20.44,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.86,,,,,,,fee schedule,11.36,20.44,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.92,,,,,,,fee schedule,11.36,20.44,APC
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.36,,,,,,,fee schedule,11.36,20.44,APC
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.44,,,,,,,fee schedule,11.36,20.44,APC
Diazepam injection,J3360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.4,,,,,,,fee schedule,6.4,7.36,
Diazepam injection,J3360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.4,,,,,,,fee schedule,6.4,7.36,
Diazepam injection,J3360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.4,,,,,,,fee schedule,6.4,7.36,
Diazepam injection,J3360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.36,,,,,,,fee schedule,6.4,7.36,
Urokinase 5000 IU injection,J3364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.81,,,,,,,fee schedule,8.81,10.13,
Urokinase 5000 IU injection,J3364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.81,,,,,,,fee schedule,8.81,10.13,
Urokinase 5000 IU injection,J3364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.81,,,,,,,fee schedule,8.81,10.13,
Urokinase 5000 IU injection,J3364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.13,,,,,,,fee schedule,8.81,10.13,
"Urokinase 250,000 IU inj",J3365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,440.45,,,,,,,fee schedule,440.45,506.52,
"Urokinase 250,000 IU inj",J3365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,440.45,,,,,,,fee schedule,440.45,506.52,
"Urokinase 250,000 IU inj",J3365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,440.45,,,,,,,fee schedule,440.45,506.52,
"Urokinase 250,000 IU inj",J3365,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,506.52,,,,,,,fee schedule,440.45,506.52,
"Inj, vancomycin hcl, 10 mg",J3373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, vancomycin hcl, 10 mg",J3373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, vancomycin hcl, 10 mg",J3373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, vancomycin hcl, 10 mg",J3373,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
"Inj, vancomycin (mylan) 10mg",J3374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.13,,,,,,,fee schedule,0.13,0.15,
"Inj, vancomycin (mylan) 10mg",J3374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.13,,,,,,,fee schedule,0.13,0.15,
"Inj, vancomycin (mylan) 10mg",J3374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.13,,,,,,,fee schedule,0.13,0.15,
"Inj, vancomycin (mylan) 10mg",J3374,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.15,,,,,,,fee schedule,0.13,0.15,
Inj vancomycin (xellia) 10mg,J3375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.14,,,,,,,fee schedule,0.14,0.16,
Inj vancomycin (xellia) 10mg,J3375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.14,,,,,,,fee schedule,0.14,0.16,
Inj vancomycin (xellia) 10mg,J3375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.14,,,,,,,fee schedule,0.14,0.16,
Inj vancomycin (xellia) 10mg,J3375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.16,,,,,,,fee schedule,0.14,0.16,
"Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.89,,,,,,,fee schedule,21.62,38.92,
"Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.89,,,,,,,fee schedule,21.62,38.92,
"Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.89,,,,,,,fee schedule,21.62,38.92,
"Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.32,,,,,,,fee schedule,21.62,38.92,
"Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.7,,,,,,,fee schedule,21.62,38.92,APC
"Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.62,,,,,,,fee schedule,21.62,38.92,APC
"Injection, vedolizumab",J3380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.92,,,,,,,fee schedule,21.62,38.92,APC
Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,394.53,,,,,,,fee schedule,392.84,707.12,
Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,394.53,,,,,,,fee schedule,392.84,707.12,
Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,394.53,,,,,,,fee schedule,392.84,707.12,
Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,453.71,,,,,,,fee schedule,392.84,707.12,
Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,412.49,,,,,,,fee schedule,392.84,707.12,APC
Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,392.84,,,,,,,fee schedule,392.84,707.12,APC
Velaglucerase alfa,J3385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,707.12,,,,,,,fee schedule,392.84,707.12,APC
Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.99,,,,,,,fee schedule,11.37,20.47,
Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.99,,,,,,,fee schedule,11.37,20.47,
Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.99,,,,,,,fee schedule,11.37,20.47,
Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.79,,,,,,,fee schedule,11.37,20.47,
Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.94,,,,,,,fee schedule,11.37,20.47,APC
Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.37,,,,,,,fee schedule,11.37,20.47,APC
Verteporfin injection,J3396,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.47,,,,,,,fee schedule,11.37,20.47,APC
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,277.03,,,,,,,fee schedule,277.03,524.76,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.03,,,,,,,fee schedule,277.03,524.76,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.03,,,,,,,fee schedule,277.03,524.76,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,318.58,,,,,,,fee schedule,277.03,524.76,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,306.11,,,,,,,fee schedule,277.03,524.76,APC
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,291.54,,,,,,,fee schedule,277.03,524.76,APC
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,524.76,,,,,,,fee schedule,277.03,524.76,APC
Triflupromazine hcl inj,J3400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.05,,,,,,,fee schedule,11.05,12.71,
Triflupromazine hcl inj,J3400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.05,,,,,,,fee schedule,11.05,12.71,
Triflupromazine hcl inj,J3400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.05,,,,,,,fee schedule,11.05,12.71,
Triflupromazine hcl inj,J3400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.71,,,,,,,fee schedule,11.05,12.71,
Hydroxyzine hcl injection,J3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.57,,,,,,,fee schedule,17.57,20.21,
Hydroxyzine hcl injection,J3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.57,,,,,,,fee schedule,17.57,20.21,
Hydroxyzine hcl injection,J3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.57,,,,,,,fee schedule,17.57,20.21,
Hydroxyzine hcl injection,J3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.21,,,,,,,fee schedule,17.57,20.21,
Thiamine hcl 100 mg,J3411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.85,,,,,,,fee schedule,1.85,2.13,
Thiamine hcl 100 mg,J3411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.85,,,,,,,fee schedule,1.85,2.13,
Thiamine hcl 100 mg,J3411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.85,,,,,,,fee schedule,1.85,2.13,
Thiamine hcl 100 mg,J3411,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.13,,,,,,,fee schedule,1.85,2.13,
Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.28,,,,,,,fee schedule,13.28,15.27,
Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.28,,,,,,,fee schedule,13.28,15.27,
Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.28,,,,,,,fee schedule,13.28,15.27,
Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.27,,,,,,,fee schedule,13.28,15.27,
Vitamin b12 injection,J3420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.98,,,,,,,fee schedule,0.98,1.13,
Vitamin b12 injection,J3420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.98,,,,,,,fee schedule,0.98,1.13,
Vitamin b12 injection,J3420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.98,,,,,,,fee schedule,0.98,1.13,
Vitamin b12 injection,J3420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.13,,,,,,,fee schedule,0.98,1.13,
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.09,,,,,,,fee schedule,5.09,9.8,
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.09,,,,,,,fee schedule,5.09,9.8,
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.09,,,,,,,fee schedule,5.09,9.8,
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.85,,,,,,,fee schedule,5.09,9.8,
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.72,,,,,,,fee schedule,5.09,9.8,APC
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.44,,,,,,,fee schedule,5.09,9.8,APC
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.8,,,,,,,fee schedule,5.09,9.8,APC
"Inj, hydroxocobalamin",J3425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, hydroxocobalamin",J3425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, hydroxocobalamin",J3425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
"Inj, hydroxocobalamin",J3425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Vitamin k phytonadione inj,J3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.95,,,,,,,fee schedule,2.95,3.39,
Vitamin k phytonadione inj,J3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.95,,,,,,,fee schedule,2.95,3.39,
Vitamin k phytonadione inj,J3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.95,,,,,,,fee schedule,2.95,3.39,
Vitamin k phytonadione inj,J3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.39,,,,,,,fee schedule,2.95,3.39,
"Injection, voriconazole",J3465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.81,,,,,,,fee schedule,0.81,0.93,
"Injection, voriconazole",J3465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.81,0.93,
"Injection, voriconazole",J3465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.81,,,,,,,fee schedule,0.81,0.93,
"Injection, voriconazole",J3465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.93,,,,,,,fee schedule,0.81,0.93,
Hyaluronidase injection,J3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.74,,,,,,,fee schedule,32.74,37.65,
Hyaluronidase injection,J3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.74,,,,,,,fee schedule,32.74,37.65,
Hyaluronidase injection,J3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.74,,,,,,,fee schedule,32.74,37.65,
Hyaluronidase injection,J3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.65,,,,,,,fee schedule,32.74,37.65,
"Ovine, up to 999 usp units",J3471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.52,,,,,,,fee schedule,0.52,0.6,
"Ovine, up to 999 usp units",J3471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.52,,,,,,,fee schedule,0.52,0.6,
"Ovine, up to 999 usp units",J3471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.52,,,,,,,fee schedule,0.52,0.6,
"Ovine, up to 999 usp units",J3471,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.6,,,,,,,fee schedule,0.52,0.6,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143,,,,,,,fee schedule,143,164.45,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,143,,,,,,,fee schedule,143,164.45,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143,,,,,,,fee schedule,143,164.45,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.45,,,,,,,fee schedule,143,164.45,
Hyaluronidase recombinant,J3473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.38,,,,,,,fee schedule,0.38,0.44,
Hyaluronidase recombinant,J3473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.38,,,,,,,fee schedule,0.38,0.44,
Hyaluronidase recombinant,J3473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.38,,,,,,,fee schedule,0.38,0.44,
Hyaluronidase recombinant,J3473,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.44,,,,,,,fee schedule,0.38,0.44,
Inj magnesium sulfate,J3475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.52,,,,,,,fee schedule,0.52,0.6,
Inj magnesium sulfate,J3475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.52,,,,,,,fee schedule,0.52,0.6,
Inj magnesium sulfate,J3475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.52,,,,,,,fee schedule,0.52,0.6,
Inj magnesium sulfate,J3475,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.6,,,,,,,fee schedule,0.52,0.6,
Inj potassium chloride,J3480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Inj potassium chloride,J3480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Inj potassium chloride,J3480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.18,,,,,,,fee schedule,0.18,0.21,
Inj potassium chloride,J3480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.21,,,,,,,fee schedule,0.18,0.21,
Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.57,,,,,,,fee schedule,1.51,2.72,
Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.57,,,,,,,fee schedule,1.51,2.72,
Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.57,,,,,,,fee schedule,1.51,2.72,
Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.81,,,,,,,fee schedule,1.51,2.72,
Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.59,,,,,,,fee schedule,1.51,2.72,APC
Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.51,,,,,,,fee schedule,1.51,2.72,APC
Zidovudine,J3485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.72,,,,,,,fee schedule,1.51,2.72,APC
Ziprasidone mesylate,J3486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.26,,,,,,,fee schedule,3.26,3.75,
Ziprasidone mesylate,J3486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.26,,,,,,,fee schedule,3.26,3.75,
Ziprasidone mesylate,J3486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.26,,,,,,,fee schedule,3.26,3.75,
Ziprasidone mesylate,J3486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.75,,,,,,,fee schedule,3.26,3.75,
Zoledronic acid 1mg,J3489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.4,,,,,,,fee schedule,5.4,6.21,
Zoledronic acid 1mg,J3489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.4,,,,,,,fee schedule,5.4,6.21,
Zoledronic acid 1mg,J3489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.4,,,,,,,fee schedule,5.4,6.21,
Zoledronic acid 1mg,J3489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.21,,,,,,,fee schedule,5.4,6.21,
Edetate disodium per 150 mg,J3520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.27,,,,,,,fee schedule,1.27,1.46,
Edetate disodium per 150 mg,J3520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.27,,,,,,,fee schedule,1.27,1.46,
Edetate disodium per 150 mg,J3520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.27,,,,,,,fee schedule,1.27,1.46,
Edetate disodium per 150 mg,J3520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.46,,,,,,,fee schedule,1.27,1.46,
Normal saline solution infus,J7030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.37,,,,,,,fee schedule,2.37,2.73,
Normal saline solution infus,J7030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.37,,,,,,,fee schedule,2.37,2.73,
Normal saline solution infus,J7030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.37,,,,,,,fee schedule,2.37,2.73,
Normal saline solution infus,J7030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.73,,,,,,,fee schedule,2.37,2.73,
Normal saline solution infus,J7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.43,,,,,,,fee schedule,1.43,1.64,
Normal saline solution infus,J7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.43,,,,,,,fee schedule,1.43,1.64,
Normal saline solution infus,J7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.43,,,,,,,fee schedule,1.43,1.64,
Normal saline solution infus,J7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.64,,,,,,,fee schedule,1.43,1.64,
5% dextrose/normal saline,J7042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.41,,,,,,,fee schedule,1.41,1.62,
5% dextrose/normal saline,J7042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.41,,,,,,,fee schedule,1.41,1.62,
5% dextrose/normal saline,J7042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.41,,,,,,,fee schedule,1.41,1.62,
5% dextrose/normal saline,J7042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.62,,,,,,,fee schedule,1.41,1.62,
Normal saline solution infus,J7050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.74,,,,,,,fee schedule,0.74,0.85,
Normal saline solution infus,J7050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.74,,,,,,,fee schedule,0.74,0.85,
Normal saline solution infus,J7050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.74,,,,,,,fee schedule,0.74,0.85,
Normal saline solution infus,J7050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.85,,,,,,,fee schedule,0.74,0.85,
5% dextrose/water,J7060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.1,,,,,,,fee schedule,2.1,2.42,
5% dextrose/water,J7060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.1,,,,,,,fee schedule,2.1,2.42,
5% dextrose/water,J7060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.1,,,,,,,fee schedule,2.1,2.42,
5% dextrose/water,J7060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.42,,,,,,,fee schedule,2.1,2.42,
D5w infusion,J7070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.16,,,,,,,fee schedule,3.16,3.63,
D5w infusion,J7070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.16,,,,,,,fee schedule,3.16,3.63,
D5w infusion,J7070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.16,,,,,,,fee schedule,3.16,3.63,
D5w infusion,J7070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.63,,,,,,,fee schedule,3.16,3.63,
Dextran 40 infusion,J7100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.89,,,,,,,fee schedule,67.89,78.07,
Dextran 40 infusion,J7100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.89,,,,,,,fee schedule,67.89,78.07,
Dextran 40 infusion,J7100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.89,,,,,,,fee schedule,67.89,78.07,
Dextran 40 infusion,J7100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.07,,,,,,,fee schedule,67.89,78.07,
Dextran 75 infusion,J7110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.07,,,,,,,fee schedule,15.07,17.33,
Dextran 75 infusion,J7110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.07,,,,,,,fee schedule,15.07,17.33,
Dextran 75 infusion,J7110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.07,,,,,,,fee schedule,15.07,17.33,
Dextran 75 infusion,J7110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.33,,,,,,,fee schedule,15.07,17.33,
Ringers lactate infusion,J7120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.55,,,,,,,fee schedule,2.55,2.93,
Ringers lactate infusion,J7120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.55,,,,,,,fee schedule,2.55,2.93,
Ringers lactate infusion,J7120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.55,,,,,,,fee schedule,2.55,2.93,
Ringers lactate infusion,J7120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.93,,,,,,,fee schedule,2.55,2.93,
5% dextrose in lac ringers,J7121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.14,,,,,,,fee schedule,8.14,9.36,
5% dextrose in lac ringers,J7121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.14,,,,,,,fee schedule,8.14,9.36,
5% dextrose in lac ringers,J7121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.14,,,,,,,fee schedule,8.14,9.36,
5% dextrose in lac ringers,J7121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.36,,,,,,,fee schedule,8.14,9.36,
Hypertonic saline sol,J7131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Hypertonic saline sol,J7131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Hypertonic saline sol,J7131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.17,,,,,,,fee schedule,0.17,0.2,
Hypertonic saline sol,J7131,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.2,,,,,,,fee schedule,0.17,0.2,
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.21,,,,,,,fee schedule,1.73,3.69,
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.21,,,,,,,fee schedule,1.73,3.69,
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.21,,,,,,,fee schedule,1.73,3.69,
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.69,,,,,,,fee schedule,1.73,3.69,
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.82,,,,,,,fee schedule,1.73,3.69,APC
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.73,,,,,,,fee schedule,1.73,3.69,APC
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.12,,,,,,,fee schedule,1.73,3.69,APC
Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.04,,,,,,,fee schedule,2.01,3.62,
Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.04,,,,,,,fee schedule,2.01,3.62,
Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.04,,,,,,,fee schedule,2.01,3.62,
Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.5,,,,,,,fee schedule,2.01,3.62,
Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.11,,,,,,,fee schedule,2.01,3.62,APC
Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.01,,,,,,,fee schedule,2.01,3.62,APC
Prothrombin complex kcentra,J7168,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.62,,,,,,,fee schedule,2.01,3.62,APC
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.5,,,,,,,fee schedule,127.5,236.1,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.5,,,,,,,fee schedule,127.5,236.1,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.5,,,,,,,fee schedule,127.5,236.1,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.63,,,,,,,fee schedule,127.5,236.1,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,137.72,,,,,,,fee schedule,127.5,236.1,APC
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,131.16,,,,,,,fee schedule,127.5,236.1,APC
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,236.1,,,,,,,fee schedule,127.5,236.1,APC
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.6,,,,,,,fee schedule,58.03,104.46,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.6,,,,,,,fee schedule,58.03,104.46,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.6,,,,,,,fee schedule,58.03,104.46,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.54,,,,,,,fee schedule,58.03,104.46,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.93,,,,,,,fee schedule,58.03,104.46,APC
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.03,,,,,,,fee schedule,58.03,104.46,APC
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.46,,,,,,,fee schedule,58.03,104.46,APC
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.93,,,,,,,fee schedule,36.21,65.19,
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.93,,,,,,,fee schedule,36.21,65.19,
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.93,,,,,,,fee schedule,36.21,65.19,
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.47,,,,,,,fee schedule,36.21,65.19,
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.02,,,,,,,fee schedule,36.21,65.19,APC
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.21,,,,,,,fee schedule,36.21,65.19,APC
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.19,,,,,,,fee schedule,36.21,65.19,APC
"Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.63,,,,,,,fee schedule,51.19,92.14,
"Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.63,,,,,,,fee schedule,51.19,92.14,
"Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.63,,,,,,,fee schedule,51.19,92.14,
"Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.52,,,,,,,fee schedule,51.19,92.14,
"Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.75,,,,,,,fee schedule,51.19,92.14,APC
"Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.19,,,,,,,fee schedule,51.19,92.14,APC
"Inj marstacim-hncq, 0.5 mg",J7172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.14,,,,,,,fee schedule,51.19,92.14,APC
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.29,,,,,,,fee schedule,9.95,17.92,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.29,,,,,,,fee schedule,9.95,17.92,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.29,,,,,,,fee schedule,9.95,17.92,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.83,,,,,,,fee schedule,9.95,17.92,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.45,,,,,,,fee schedule,9.95,17.92,APC
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.95,,,,,,,fee schedule,9.95,17.92,APC
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.92,,,,,,,fee schedule,9.95,17.92,APC
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.25,,,,,,,fee schedule,1.23,2.22,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.25,,,,,,,fee schedule,1.23,2.22,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.25,,,,,,,fee schedule,1.23,2.22,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.44,,,,,,,fee schedule,1.23,2.22,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.29,,,,,,,fee schedule,1.23,2.22,APC
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.23,,,,,,,fee schedule,1.23,2.22,APC
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.22,,,,,,,fee schedule,1.23,2.22,APC
Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.58,,,,,,,fee schedule,1.49,2.68,
Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.58,,,,,,,fee schedule,1.49,2.68,
Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.58,,,,,,,fee schedule,1.49,2.68,
Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.82,,,,,,,fee schedule,1.49,2.68,
Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.56,,,,,,,fee schedule,1.49,2.68,APC
Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.49,,,,,,,fee schedule,1.49,2.68,APC
Human fibrinogen conc inj,J7178,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.68,,,,,,,fee schedule,1.49,2.68,APC
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.92,,,,,,,fee schedule,1.81,3.26,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.92,,,,,,,fee schedule,1.81,3.26,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.92,,,,,,,fee schedule,1.81,3.26,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.21,,,,,,,fee schedule,1.81,3.26,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.9,,,,,,,fee schedule,1.81,3.26,APC
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.81,,,,,,,fee schedule,1.81,3.26,APC
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.26,,,,,,,fee schedule,1.81,3.26,APC
Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.19,,,,,,,fee schedule,11.19,20.22,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.19,,,,,,,fee schedule,11.19,20.22,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.19,,,,,,,fee schedule,11.19,20.22,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.87,,,,,,,fee schedule,11.19,20.22,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.8,,,,,,,fee schedule,11.19,20.22,APC
Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.24,,,,,,,fee schedule,11.19,20.22,APC
Factor XIII anti-hem factor,J7180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.22,,,,,,,fee schedule,11.19,20.22,APC
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.98,,,,,,,fee schedule,18.98,34.41,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.98,,,,,,,fee schedule,18.98,34.41,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.98,,,,,,,fee schedule,18.98,34.41,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.83,,,,,,,fee schedule,18.98,34.41,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.07,,,,,,,fee schedule,18.98,34.41,APC
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.11,,,,,,,fee schedule,18.98,34.41,APC
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.41,,,,,,,fee schedule,18.98,34.41,APC
Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.57,,,,,,,fee schedule,1.44,2.6,
Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.57,,,,,,,fee schedule,1.44,2.6,
Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.57,,,,,,,fee schedule,1.44,2.6,
Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.81,,,,,,,fee schedule,1.44,2.6,
Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.52,,,,,,,fee schedule,1.44,2.6,APC
Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.44,,,,,,,fee schedule,1.44,2.6,APC
Factor viii recomb novoeight,J7182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.6,,,,,,,fee schedule,1.44,2.6,APC
Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.32,,,,,,,fee schedule,1.32,2.39,
Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.32,,,,,,,fee schedule,1.32,2.39,
Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.32,,,,,,,fee schedule,1.32,2.39,
Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.52,,,,,,,fee schedule,1.32,2.39,
Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.39,,,,,,,fee schedule,1.32,2.39,APC
Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.33,,,,,,,fee schedule,1.32,2.39,APC
Wilate injection,J7183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.39,,,,,,,fee schedule,1.32,2.39,APC
Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.6,,,,,,,fee schedule,1.37,2.47,
Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.37,2.47,
Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.6,,,,,,,fee schedule,1.37,2.47,
Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.84,,,,,,,fee schedule,1.37,2.47,
Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.44,,,,,,,fee schedule,1.37,2.47,APC
Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.37,,,,,,,fee schedule,1.37,2.47,APC
Xyntha inj,J7185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.47,,,,,,,fee schedule,1.37,2.47,APC
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.27,,,,,,,fee schedule,1.27,2.28,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.27,,,,,,,fee schedule,1.27,2.28,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.27,,,,,,,fee schedule,1.27,2.28,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.46,,,,,,,fee schedule,1.27,2.28,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.33,,,,,,,fee schedule,1.27,2.28,APC
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.27,,,,,,,fee schedule,1.27,2.28,APC
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.28,,,,,,,fee schedule,1.27,2.28,APC
"Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.54,,,,,,,fee schedule,1.54,2.76,
"Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.54,,,,,,,fee schedule,1.54,2.76,
"Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.54,,,,,,,fee schedule,1.54,2.76,
"Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.77,,,,,,,fee schedule,1.54,2.76,
"Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.61,,,,,,,fee schedule,1.54,2.76,APC
"Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.54,,,,,,,fee schedule,1.54,2.76,APC
"Humate-P, inj",J7187,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.76,,,,,,,fee schedule,1.54,2.76,APC
Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.35,,,,,,,fee schedule,3.24,5.82,
Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.35,,,,,,,fee schedule,3.24,5.82,
Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.35,,,,,,,fee schedule,3.24,5.82,
Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.85,,,,,,,fee schedule,3.24,5.82,
Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.4,,,,,,,fee schedule,3.24,5.82,APC
Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.24,,,,,,,fee schedule,3.24,5.82,APC
Factor viii recomb obizur,J7188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.82,,,,,,,fee schedule,3.24,5.82,APC
Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.75,,,,,,,fee schedule,2.75,4.99,
Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.75,,,,,,,fee schedule,2.75,4.99,
Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.75,,,,,,,fee schedule,2.75,4.99,
Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.16,,,,,,,fee schedule,2.75,4.99,
Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.91,,,,,,,fee schedule,2.75,4.99,APC
Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.77,,,,,,,fee schedule,2.75,4.99,APC
Factor viia,J7189,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.99,,,,,,,fee schedule,2.75,4.99,APC
Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.17,,,,,,,fee schedule,1.17,2.24,
Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.17,,,,,,,fee schedule,1.17,2.24,
Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.17,,,,,,,fee schedule,1.17,2.24,
Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.35,,,,,,,fee schedule,1.17,2.24,
Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.31,,,,,,,fee schedule,1.17,2.24,APC
Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.25,,,,,,,fee schedule,1.17,2.24,APC
Factor viii,J7190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.24,,,,,,,fee schedule,1.17,2.24,APC
Factor viii (porcine),J7191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.87,,,,,,,fee schedule,1.87,9.83,
Factor viii (porcine),J7191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.87,,,,,,,fee schedule,1.87,9.83,
Factor viii (porcine),J7191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.87,,,,,,,fee schedule,1.87,9.83,
Factor viii (porcine),J7191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.15,,,,,,,fee schedule,1.87,9.83,
Factor viii (porcine),J7191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.73,,,,,,,fee schedule,1.87,9.83,APC
Factor viii (porcine),J7191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.46,,,,,,,fee schedule,1.87,9.83,APC
Factor viii (porcine),J7191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.83,,,,,,,fee schedule,1.87,9.83,APC
Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.59,,,,,,,fee schedule,1.58,2.84,
Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.59,,,,,,,fee schedule,1.58,2.84,
Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.59,,,,,,,fee schedule,1.58,2.84,
Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.83,,,,,,,fee schedule,1.58,2.84,
Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.66,,,,,,,fee schedule,1.58,2.84,APC
Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.58,,,,,,,fee schedule,1.58,2.84,APC
Factor viii recombinant nos,J7192,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.84,,,,,,,fee schedule,1.58,2.84,APC
Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.39,,,,,,,fee schedule,1.39,2.53,
Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.39,,,,,,,fee schedule,1.39,2.53,
Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.39,,,,,,,fee schedule,1.39,2.53,
Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.6,,,,,,,fee schedule,1.39,2.53,
Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.47,,,,,,,fee schedule,1.39,2.53,APC
Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.4,,,,,,,fee schedule,1.39,2.53,APC
Factor ix non-recombinant,J7193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.53,,,,,,,fee schedule,1.39,2.53,APC
Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.77,,,,,,,fee schedule,1.75,3.14,
Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.77,,,,,,,fee schedule,1.75,3.14,
Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.77,,,,,,,fee schedule,1.75,3.14,
Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.04,,,,,,,fee schedule,1.75,3.14,
Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.83,,,,,,,fee schedule,1.75,3.14,APC
Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.75,,,,,,,fee schedule,1.75,3.14,APC
Factor ix complex,J7194,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.14,,,,,,,fee schedule,1.75,3.14,APC
Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.95,,,,,,,fee schedule,1.86,3.36,
Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.95,,,,,,,fee schedule,1.86,3.36,
Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.95,,,,,,,fee schedule,1.86,3.36,
Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.24,,,,,,,fee schedule,1.86,3.36,
Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.96,,,,,,,fee schedule,1.86,3.36,APC
Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.86,,,,,,,fee schedule,1.86,3.36,APC
Factor ix recombinant nos,J7195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.36,,,,,,,fee schedule,1.86,3.36,APC
Antithrombin recombinant,J7196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.31,,,,,,,fee schedule,143.31,164.81,
Antithrombin recombinant,J7196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,143.31,,,,,,,fee schedule,143.31,164.81,
Antithrombin recombinant,J7196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.31,,,,,,,fee schedule,143.31,164.81,
Antithrombin recombinant,J7196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.81,,,,,,,fee schedule,143.31,164.81,
Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.24,,,,,,,fee schedule,4.17,7.51,
Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.24,,,,,,,fee schedule,4.17,7.51,
Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.24,,,,,,,fee schedule,4.17,7.51,
Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.88,,,,,,,fee schedule,4.17,7.51,
Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.38,,,,,,,fee schedule,4.17,7.51,APC
Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.17,,,,,,,fee schedule,4.17,7.51,APC
Antithrombin iii injection,J7197,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.51,,,,,,,fee schedule,4.17,7.51,APC
Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.54,,,,,,,fee schedule,2.45,4.4,
Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.54,,,,,,,fee schedule,2.45,4.4,
Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.54,,,,,,,fee schedule,2.45,4.4,
Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.92,,,,,,,fee schedule,2.45,4.4,
Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.57,,,,,,,fee schedule,2.45,4.4,APC
Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.45,,,,,,,fee schedule,2.45,4.4,APC
Anti-inhibitor,J7198,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.4,,,,,,,fee schedule,2.45,4.4,APC
Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.63,,,,,,,fee schedule,1.63,3.09,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.63,,,,,,,fee schedule,1.63,3.09,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.63,,,,,,,fee schedule,1.63,3.09,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.87,,,,,,,fee schedule,1.63,3.09,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.8,,,,,,,fee schedule,1.63,3.09,APC
Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.72,,,,,,,fee schedule,1.63,3.09,APC
Factor ix recombinan rixubis,J7200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.09,,,,,,,fee schedule,1.63,3.09,APC
Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.76,,,,,,,fee schedule,3.71,6.68,
Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.76,,,,,,,fee schedule,3.71,6.68,
Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.76,,,,,,,fee schedule,3.71,6.68,
Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.32,,,,,,,fee schedule,3.71,6.68,
Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.9,,,,,,,fee schedule,3.71,6.68,APC
Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.71,,,,,,,fee schedule,3.71,6.68,APC
Factor ix alprolix recomb,J7201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.68,,,,,,,fee schedule,3.71,6.68,APC
Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.54,,,,,,,fee schedule,5.51,9.91,
Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.54,,,,,,,fee schedule,5.51,9.91,
Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.54,,,,,,,fee schedule,5.51,9.91,
Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.37,,,,,,,fee schedule,5.51,9.91,
Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.78,,,,,,,fee schedule,5.51,9.91,APC
Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.51,,,,,,,fee schedule,5.51,9.91,APC
Factor ix idelvion inj,J7202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.91,,,,,,,fee schedule,5.51,9.91,APC
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.75,,,,,,,fee schedule,4.67,8.41,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.75,,,,,,,fee schedule,4.67,8.41,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.75,,,,,,,fee schedule,4.67,8.41,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.46,,,,,,,fee schedule,4.67,8.41,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.91,,,,,,,fee schedule,4.67,8.41,APC
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.67,,,,,,,fee schedule,4.67,8.41,APC
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.41,,,,,,,fee schedule,4.67,8.41,APC
Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.35,,,,,,,fee schedule,2.3,4.13,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.35,,,,,,,fee schedule,2.3,4.13,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.35,,,,,,,fee schedule,2.3,4.13,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.7,,,,,,,fee schedule,2.3,4.13,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.41,,,,,,,fee schedule,2.3,4.13,APC
Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.3,,,,,,,fee schedule,2.3,4.13,APC
Inj recombin esperoct per iu,J7204,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.13,,,,,,,fee schedule,2.3,4.13,APC
Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.51,,,,,,,fee schedule,2.51,4.64,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.51,,,,,,,fee schedule,2.51,4.64,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.51,,,,,,,fee schedule,2.51,4.64,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.89,,,,,,,fee schedule,2.51,4.64,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.71,,,,,,,fee schedule,2.51,4.64,APC
Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.58,,,,,,,fee schedule,2.51,4.64,APC
Factor viii fc fusion recomb,J7205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.64,,,,,,,fee schedule,2.51,4.64,APC
Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.24,,,,,,,fee schedule,2.12,3.81,
Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.24,,,,,,,fee schedule,2.12,3.81,
Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.24,,,,,,,fee schedule,2.12,3.81,
Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.58,,,,,,,fee schedule,2.12,3.81,
Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.22,,,,,,,fee schedule,2.12,3.81,APC
Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.12,,,,,,,fee schedule,2.12,3.81,APC
Factor viii pegylated recomb,J7207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.81,,,,,,,fee schedule,2.12,3.81,APC
Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.75,,,,,,,fee schedule,2.75,4.96,
Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.75,,,,,,,fee schedule,2.75,4.96,
Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.75,,,,,,,fee schedule,2.75,4.96,
Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.16,,,,,,,fee schedule,2.75,4.96,
Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.89,,,,,,,fee schedule,2.75,4.96,APC
Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.76,,,,,,,fee schedule,2.75,4.96,APC
Inj. jivi 1 iu,J7208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.96,,,,,,,fee schedule,2.75,4.96,APC
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.22,,,,,,,fee schedule,1.22,2.2,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.22,,,,,,,fee schedule,1.22,2.2,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.22,,,,,,,fee schedule,1.22,2.2,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.4,,,,,,,fee schedule,1.22,2.2,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.28,,,,,,,fee schedule,1.22,2.2,APC
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.22,,,,,,,fee schedule,1.22,2.2,APC
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.2,,,,,,,fee schedule,1.22,2.2,APC
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.64,,,,,,,fee schedule,1.62,2.91,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.64,,,,,,,fee schedule,1.62,2.91,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.64,,,,,,,fee schedule,1.62,2.91,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.89,,,,,,,fee schedule,1.62,2.91,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.7,,,,,,,fee schedule,1.62,2.91,APC
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.62,,,,,,,fee schedule,1.62,2.91,APC
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.91,,,,,,,fee schedule,1.62,2.91,APC
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.64,,,,,,,fee schedule,1.6,2.87,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.64,,,,,,,fee schedule,1.6,2.87,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.64,,,,,,,fee schedule,1.6,2.87,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.89,,,,,,,fee schedule,1.6,2.87,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.67,,,,,,,fee schedule,1.6,2.87,APC
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.6,,,,,,,fee schedule,1.6,2.87,APC
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2.87,,,,,,,fee schedule,1.6,2.87,APC
Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.49,,,,,,,fee schedule,2.19,3.95,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.49,,,,,,,fee schedule,2.19,3.95,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.49,,,,,,,fee schedule,2.19,3.95,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.86,,,,,,,fee schedule,2.19,3.95,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.3,,,,,,,fee schedule,2.19,3.95,APC
Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.19,,,,,,,fee schedule,2.19,3.95,APC
Factor viia recomb sevenfact,J7212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.95,,,,,,,fee schedule,2.19,3.95,APC
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.99,,,,,,,fee schedule,1.94,3.49,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.99,,,,,,,fee schedule,1.94,3.49,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.99,,,,,,,fee schedule,1.94,3.49,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.29,,,,,,,fee schedule,1.94,3.49,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.04,,,,,,,fee schedule,1.94,3.49,APC
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.94,,,,,,,fee schedule,1.94,3.49,APC
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.49,,,,,,,fee schedule,1.94,3.49,APC
Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.85,,,,,,,fee schedule,4.63,8.34,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.85,,,,,,,fee schedule,4.63,8.34,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.85,,,,,,,fee schedule,4.63,8.34,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.58,,,,,,,fee schedule,4.63,8.34,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.86,,,,,,,fee schedule,4.63,8.34,APC
Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.63,,,,,,,fee schedule,4.63,8.34,APC
Altuviiio per factor viii iu,J7214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.34,,,,,,,fee schedule,4.63,8.34,APC
Seg acet and eth estr yearly,J7294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2468.96,,,,,,,fee schedule,2468.96,2839.3,
Seg acet and eth estr yearly,J7294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2468.96,,,,,,,fee schedule,2468.96,2839.3,
Seg acet and eth estr yearly,J7294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2468.96,,,,,,,fee schedule,2468.96,2839.3,
Seg acet and eth estr yearly,J7294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2839.3,,,,,,,fee schedule,2468.96,2839.3,
Eth estr and eton monthly,J7295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.17,,,,,,,fee schedule,125.17,143.95,
Eth estr and eton monthly,J7295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.17,,,,,,,fee schedule,125.17,143.95,
Eth estr and eton monthly,J7295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.17,,,,,,,fee schedule,125.17,143.95,
Eth estr and eton monthly,J7295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.95,,,,,,,fee schedule,125.17,143.95,
"Kyleena, 19.5 mg",J7296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1238.93,,,,,,,fee schedule,1238.93,1424.77,
"Kyleena, 19.5 mg",J7296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1238.93,,,,,,,fee schedule,1238.93,1424.77,
"Kyleena, 19.5 mg",J7296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1238.93,,,,,,,fee schedule,1238.93,1424.77,
"Kyleena, 19.5 mg",J7296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1424.77,,,,,,,fee schedule,1238.93,1424.77,
"Liletta, 52 mg",J7297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,950.37,,,,,,,fee schedule,950.37,1092.93,
"Liletta, 52 mg",J7297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,950.37,,,,,,,fee schedule,950.37,1092.93,
"Liletta, 52 mg",J7297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,950.37,,,,,,,fee schedule,950.37,1092.93,
"Liletta, 52 mg",J7297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1092.93,,,,,,,fee schedule,950.37,1092.93,
"Mirena, 52 mg",J7298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1238.93,,,,,,,fee schedule,1238.93,1424.77,
"Mirena, 52 mg",J7298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1238.93,,,,,,,fee schedule,1238.93,1424.77,
"Mirena, 52 mg",J7298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1238.93,,,,,,,fee schedule,1238.93,1424.77,
"Mirena, 52 mg",J7298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1424.77,,,,,,,fee schedule,1238.93,1424.77,
Intraut copper contraceptive,J7300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1161.1,,,,,,,fee schedule,1161.1,1335.27,
Intraut copper contraceptive,J7300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1161.1,,,,,,,fee schedule,1161.1,1335.27,
Intraut copper contraceptive,J7300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1161.1,,,,,,,fee schedule,1161.1,1335.27,
Intraut copper contraceptive,J7300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1335.27,,,,,,,fee schedule,1161.1,1335.27,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1031.61,,,,,,,fee schedule,1031.61,1186.35,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1031.61,,,,,,,fee schedule,1031.61,1186.35,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1031.61,,,,,,,fee schedule,1031.61,1186.35,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1186.35,,,,,,,fee schedule,1031.61,1186.35,
Contraceptive hormone patch,J7304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.53,,,,,,,fee schedule,41.53,47.76,
Contraceptive hormone patch,J7304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.53,,,,,,,fee schedule,41.53,47.76,
Contraceptive hormone patch,J7304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.53,,,,,,,fee schedule,41.53,47.76,
Contraceptive hormone patch,J7304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.76,,,,,,,fee schedule,41.53,47.76,
Etonogestrel implant system,J7307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1238.93,,,,,,,fee schedule,1238.93,1424.77,
Etonogestrel implant system,J7307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1238.93,,,,,,,fee schedule,1238.93,1424.77,
Etonogestrel implant system,J7307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1238.93,,,,,,,fee schedule,1238.93,1424.77,
Etonogestrel implant system,J7307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1424.77,,,,,,,fee schedule,1238.93,1424.77,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,408.74,,,,,,,fee schedule,389.28,700.7,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408.74,,,,,,,fee schedule,389.28,700.7,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,408.74,,,,,,,fee schedule,389.28,700.7,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,470.05,,,,,,,fee schedule,389.28,700.7,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,408.74,,,,,,,fee schedule,389.28,700.7,APC
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.28,,,,,,,fee schedule,389.28,700.7,APC
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,700.7,,,,,,,fee schedule,389.28,700.7,APC
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.53,,,,,,,fee schedule,80.53,92.61,
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.53,,,,,,,fee schedule,80.53,92.61,
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.53,,,,,,,fee schedule,80.53,92.61,
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.61,,,,,,,fee schedule,80.53,92.61,
Ganciclovir long act implant,J7310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16320,,,,,,,fee schedule,16320,18768,
Ganciclovir long act implant,J7310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16320,,,,,,,fee schedule,16320,18768,
Ganciclovir long act implant,J7310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16320,,,,,,,fee schedule,16320,18768,
Ganciclovir long act implant,J7310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18768,,,,,,,fee schedule,16320,18768,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,352.58,,,,,,,fee schedule,338.8,609.85,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,352.58,,,,,,,fee schedule,338.8,609.85,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,352.58,,,,,,,fee schedule,338.8,609.85,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,405.47,,,,,,,fee schedule,338.8,609.85,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,355.74,,,,,,,fee schedule,338.8,609.85,APC
Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,338.8,,,,,,,fee schedule,338.8,609.85,APC
Fluocinolone acetonide implt,J7311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,609.85,,,,,,,fee schedule,338.8,609.85,APC
Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,213.02,,,,,,,fee schedule,203.66,366.58,
Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.02,,,,,,,fee schedule,203.66,366.58,
Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.02,,,,,,,fee schedule,203.66,366.58,
Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.97,,,,,,,fee schedule,203.66,366.58,
Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,213.84,,,,,,,fee schedule,203.66,366.58,APC
Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,203.66,,,,,,,fee schedule,203.66,366.58,APC
Dexamethasone intra implant,J7312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,366.58,,,,,,,fee schedule,203.66,366.58,APC
Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,516.58,,,,,,,fee schedule,516.41,929.53,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,516.58,,,,,,,fee schedule,516.41,929.53,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,516.58,,,,,,,fee schedule,516.41,929.53,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,594.07,,,,,,,fee schedule,516.41,929.53,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,542.23,,,,,,,fee schedule,516.41,929.53,APC
Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,516.41,,,,,,,fee schedule,516.41,929.53,APC
Fluocinol acet intravit imp,J7313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,929.53,,,,,,,fee schedule,516.41,929.53,APC
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,552.68,,,,,,,fee schedule,529.89,953.8,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,552.68,,,,,,,fee schedule,529.89,953.8,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,552.68,,,,,,,fee schedule,529.89,953.8,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,635.58,,,,,,,fee schedule,529.89,953.8,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,556.38,,,,,,,fee schedule,529.89,953.8,APC
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,529.89,,,,,,,fee schedule,529.89,953.8,APC
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,953.8,,,,,,,fee schedule,529.89,953.8,APC
Ophthalmic mitomycin,J7315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,438.6,,,,,,,fee schedule,438.6,504.39,
Ophthalmic mitomycin,J7315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,438.6,,,,,,,fee schedule,438.6,504.39,
Ophthalmic mitomycin,J7315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,438.6,,,,,,,fee schedule,438.6,504.39,
Ophthalmic mitomycin,J7315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,504.39,,,,,,,fee schedule,438.6,504.39,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1007.42,,,,,,,fee schedule,1007.42,1158.53,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1007.42,,,,,,,fee schedule,1007.42,1158.53,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1007.42,,,,,,,fee schedule,1007.42,1158.53,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1158.53,,,,,,,fee schedule,1007.42,1158.53,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.94,,,,,,,fee schedule,6.24,11.23,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.94,,,,,,,fee schedule,6.24,11.23,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.94,,,,,,,fee schedule,6.24,11.23,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.98,,,,,,,fee schedule,6.24,11.23,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.55,,,,,,,fee schedule,6.24,11.23,APC
"Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.24,,,,,,,fee schedule,6.24,11.23,APC
"Inj, durolane 1 mg",J7318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.23,,,,,,,fee schedule,6.24,11.23,APC
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.25,,,,,,,fee schedule,3.81,7.19,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.25,,,,,,,fee schedule,3.81,7.19,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.25,,,,,,,fee schedule,3.81,7.19,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.19,,,,,,,fee schedule,3.81,7.19,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4,,,,,,,fee schedule,3.81,7.19,APC
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.81,,,,,,,fee schedule,3.81,7.19,APC
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.85,,,,,,,fee schedule,3.81,7.19,APC
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.16,,,,,,,fee schedule,76.16,87.58,
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.16,,,,,,,fee schedule,76.16,87.58,
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.16,,,,,,,fee schedule,76.16,87.58,
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.58,,,,,,,fee schedule,76.16,87.58,
Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.1,,,,,,,fee schedule,18.1,32.64,
Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.1,,,,,,,fee schedule,18.1,32.64,
Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.1,,,,,,,fee schedule,18.1,32.64,
Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.82,,,,,,,fee schedule,18.1,32.64,
Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.04,,,,,,,fee schedule,18.1,32.64,APC
Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.13,,,,,,,fee schedule,18.1,32.64,APC
Hymovis injection 1 mg,J7322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.64,,,,,,,fee schedule,18.1,32.64,APC
Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,118.8,,,,,,,fee schedule,98.14,176.65,
Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.8,,,,,,,fee schedule,98.14,176.65,
Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,118.8,,,,,,,fee schedule,98.14,176.65,
Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,136.62,,,,,,,fee schedule,98.14,176.65,
Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,103.04,,,,,,,fee schedule,98.14,176.65,APC
Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,98.14,,,,,,,fee schedule,98.14,176.65,APC
Euflexxa inj per dose,J7323,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,176.65,,,,,,,fee schedule,98.14,176.65,APC
Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.38,,,,,,,fee schedule,100.33,180.6,
Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.38,,,,,,,fee schedule,100.33,180.6,
Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,101.38,,,,,,,fee schedule,100.33,180.6,
Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,116.59,,,,,,,fee schedule,100.33,180.6,
Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.35,,,,,,,fee schedule,100.33,180.6,APC
Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,100.33,,,,,,,fee schedule,100.33,180.6,APC
Orthovisc inj per dose,J7324,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,180.6,,,,,,,fee schedule,100.33,180.6,APC
Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.43,,,,,,,fee schedule,6.02,10.84,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.43,,,,,,,fee schedule,6.02,10.84,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.43,,,,,,,fee schedule,6.02,10.84,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.84,,,,,,,fee schedule,6.02,10.84,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.32,,,,,,,fee schedule,6.02,10.84,APC
Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.02,,,,,,,fee schedule,6.02,10.84,APC
Synvisc or Synvisc-One,J7325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.83,,,,,,,fee schedule,6.02,10.84,APC
Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,543.79,,,,,,,fee schedule,533.59,960.47,
Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,543.79,,,,,,,fee schedule,533.59,960.47,
Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,543.79,,,,,,,fee schedule,533.59,960.47,
Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,625.36,,,,,,,fee schedule,533.59,960.47,
Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.27,,,,,,,fee schedule,533.59,960.47,APC
Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,533.59,,,,,,,fee schedule,533.59,960.47,APC
Gel-one,J7326,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,960.47,,,,,,,fee schedule,533.59,960.47,APC
Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,548.52,,,,,,,fee schedule,548.52,1017.5,
Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,548.52,,,,,,,fee schedule,548.52,1017.5,
Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,548.52,,,,,,,fee schedule,548.52,1017.5,
Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,630.8,,,,,,,fee schedule,548.52,1017.5,
Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,593.54,,,,,,,fee schedule,548.52,1017.5,APC
Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,565.28,,,,,,,fee schedule,548.52,1017.5,APC
Monovisc inj per dose,J7327,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1017.5,,,,,,,fee schedule,548.52,1017.5,APC
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.68,,,,,,,fee schedule,0.58,1.05,
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.68,,,,,,,fee schedule,0.58,1.05,
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.68,,,,,,,fee schedule,0.58,1.05,
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.78,,,,,,,fee schedule,0.58,1.05,
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.61,,,,,,,fee schedule,0.58,1.05,APC
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.58,,,,,,,fee schedule,0.58,1.05,APC
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.05,,,,,,,fee schedule,0.58,1.05,APC
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.65,,,,,,,fee schedule,3.04,6.5,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.65,,,,,,,fee schedule,3.04,6.5,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.65,,,,,,,fee schedule,3.04,6.5,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.5,,,,,,,fee schedule,3.04,6.5,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.19,,,,,,,fee schedule,3.04,6.5,APC
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.04,,,,,,,fee schedule,3.04,6.5,APC
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.46,,,,,,,fee schedule,3.04,6.5,APC
Cultured chondrocytes implnt,J7330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67138.44,,,,,,,fee schedule,67138.44,77209.21,
Cultured chondrocytes implnt,J7330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67138.44,,,,,,,fee schedule,67138.44,77209.21,
Cultured chondrocytes implnt,J7330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67138.44,,,,,,,fee schedule,67138.44,77209.21,
Cultured chondrocytes implnt,J7330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77209.21,,,,,,,fee schedule,67138.44,77209.21,
"Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.82,,,,,,,fee schedule,5.82,6.69,
"Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.82,,,,,,,fee schedule,5.82,6.69,
"Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.82,,,,,,,fee schedule,5.82,6.69,
"Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.69,,,,,,,fee schedule,5.82,6.69,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.55,,,,,,,fee schedule,10.43,18.77,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.55,,,,,,,fee schedule,10.43,18.77,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.55,,,,,,,fee schedule,10.43,18.77,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.13,,,,,,,fee schedule,10.43,18.77,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.95,,,,,,,fee schedule,10.43,18.77,APC
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.43,,,,,,,fee schedule,10.43,18.77,APC
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.77,,,,,,,fee schedule,10.43,18.77,APC
Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.51,,,,,,,fee schedule,3.51,6.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.51,,,,,,,fee schedule,3.51,6.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.51,,,,,,,fee schedule,3.51,6.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.04,,,,,,,fee schedule,3.51,6.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.68,,,,,,,fee schedule,3.51,6.32,APC
Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.51,,,,,,,fee schedule,3.51,6.32,APC
Capsaicin 8% patch,J7336,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.32,,,,,,,fee schedule,3.51,6.32,APC
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.32,,,,,,,fee schedule,244.5,440.09,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,252.32,,,,,,,fee schedule,244.5,440.09,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,252.32,,,,,,,fee schedule,244.5,440.09,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.17,,,,,,,fee schedule,244.5,440.09,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.72,,,,,,,fee schedule,244.5,440.09,APC
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,244.5,,,,,,,fee schedule,244.5,440.09,APC
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,440.09,,,,,,,fee schedule,244.5,440.09,APC
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.88,,,,,,,fee schedule,28.88,33.21,
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.88,,,,,,,fee schedule,28.88,33.21,
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.88,,,,,,,fee schedule,28.88,33.21,
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.21,,,,,,,fee schedule,28.88,33.21,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.88,,,,,,,fee schedule,1.85,3.33,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.88,,,,,,,fee schedule,1.85,3.33,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.88,,,,,,,fee schedule,1.85,3.33,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.16,,,,,,,fee schedule,1.85,3.33,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.94,,,,,,,fee schedule,1.85,3.33,APC
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.85,,,,,,,fee schedule,1.85,3.33,APC
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.33,,,,,,,fee schedule,1.85,3.33,APC
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.38,,,,,,,fee schedule,213.76,384.76,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.38,,,,,,,fee schedule,213.76,384.76,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,220.38,,,,,,,fee schedule,213.76,384.76,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,253.44,,,,,,,fee schedule,213.76,384.76,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,384.76,APC
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,213.76,,,,,,,fee schedule,213.76,384.76,APC
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,384.76,,,,,,,fee schedule,213.76,384.76,APC
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3213.59,,,,,,,fee schedule,2943.42,5298.16,
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3213.59,,,,,,,fee schedule,2943.42,5298.16,
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3213.59,,,,,,,fee schedule,2943.42,5298.16,
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3695.63,,,,,,,fee schedule,2943.42,5298.16,
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3090.59,,,,,,,fee schedule,2943.42,5298.16,APC
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2943.42,,,,,,,fee schedule,2943.42,5298.16,APC
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5298.16,,,,,,,fee schedule,2943.42,5298.16,APC
"Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,694.86,,,,,,,fee schedule,694.86,1251.37,
"Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,694.86,,,,,,,fee schedule,694.86,1251.37,
"Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,694.86,,,,,,,fee schedule,694.86,1251.37,
"Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,799.09,,,,,,,fee schedule,694.86,1251.37,
"Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.97,,,,,,,fee schedule,694.86,1251.37,APC
"Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,695.21,,,,,,,fee schedule,694.86,1251.37,APC
"Cantharidin top, applicator",J7354,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1251.37,,,,,,,fee schedule,694.86,1251.37,APC
Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,202.62,,,,,,,fee schedule,196.75,354.14,
Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.62,,,,,,,fee schedule,196.75,354.14,
Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.62,,,,,,,fee schedule,196.75,354.14,
Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.01,,,,,,,fee schedule,196.75,354.14,
Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,206.58,,,,,,,fee schedule,196.75,354.14,APC
Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,196.75,,,,,,,fee schedule,196.75,354.14,APC
Inj travoprost intra impl,J7355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,354.14,,,,,,,fee schedule,196.75,354.14,APC
Inj foscarb/foslevodopa 5 mg,J7356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.7,,,,,,,fee schedule,0.7,0.81,
Inj foscarb/foslevodopa 5 mg,J7356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.7,,,,,,,fee schedule,0.7,0.81,
Inj foscarb/foslevodopa 5 mg,J7356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.7,,,,,,,fee schedule,0.7,0.81,
Inj foscarb/foslevodopa 5 mg,J7356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.81,,,,,,,fee schedule,0.7,0.81,
Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.77,,,,,,,fee schedule,11.34,20.42,
Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.77,,,,,,,fee schedule,11.34,20.42,
Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.77,,,,,,,fee schedule,11.34,20.42,
Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.54,,,,,,,fee schedule,11.34,20.42,
Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.91,,,,,,,fee schedule,11.34,20.42,APC
Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.34,,,,,,,fee schedule,11.34,20.42,APC
Mometasone sinus sinuva,J7402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.42,,,,,,,fee schedule,11.34,20.42,APC
Azathioprine oral 50mg,J7500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.22,,,,,,,fee schedule,2.22,2.55,
Azathioprine oral 50mg,J7500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.22,,,,,,,fee schedule,2.22,2.55,
Azathioprine oral 50mg,J7500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.22,,,,,,,fee schedule,2.22,2.55,
Azathioprine oral 50mg,J7500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.55,,,,,,,fee schedule,2.22,2.55,
Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,255,,,,,,,fee schedule,254.76,458.56,
Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,255,,,,,,,fee schedule,254.76,458.56,
Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255,,,,,,,fee schedule,254.76,458.56,
Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,293.25,,,,,,,fee schedule,254.76,458.56,
Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,267.5,,,,,,,fee schedule,254.76,458.56,APC
Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,254.76,,,,,,,fee schedule,254.76,458.56,APC
Azathioprine parenteral,J7501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,458.56,,,,,,,fee schedule,254.76,458.56,APC
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.15,,,,,,,fee schedule,2.15,2.47,
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.15,,,,,,,fee schedule,2.15,2.47,
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.15,,,,,,,fee schedule,2.15,2.47,
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.47,,,,,,,fee schedule,2.15,2.47,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.9,,,,,,,fee schedule,1.9,2.19,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.9,,,,,,,fee schedule,1.9,2.19,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.9,,,,,,,fee schedule,1.9,2.19,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.19,,,,,,,fee schedule,1.9,2.19,
Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5202.28,,,,,,,fee schedule,5202.28,9988.13,
Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5202.28,,,,,,,fee schedule,5202.28,9988.13,
Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5202.28,,,,,,,fee schedule,5202.28,9988.13,
Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5982.62,,,,,,,fee schedule,5202.28,9988.13,
Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5826.41,,,,,,,fee schedule,5202.28,9988.13,APC
Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5548.96,,,,,,,fee schedule,5202.28,9988.13,APC
Lymphocyte immune globulin,J7504,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9988.13,,,,,,,fee schedule,5202.28,9988.13,APC
Monoclonal antibodies,J7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1112.45,,,,,,,fee schedule,1112.45,1279.32,
Monoclonal antibodies,J7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1112.45,,,,,,,fee schedule,1112.45,1279.32,
Monoclonal antibodies,J7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1112.45,,,,,,,fee schedule,1112.45,1279.32,
Monoclonal antibodies,J7505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1279.32,,,,,,,fee schedule,1112.45,1279.32,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.16,,,,,,,fee schedule,0.16,0.18,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.16,,,,,,,fee schedule,0.16,0.18,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.16,,,,,,,fee schedule,0.16,0.18,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.18,,,,,,,fee schedule,0.16,0.18,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.61,,,,,,,fee schedule,0.61,0.7,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.61,,,,,,,fee schedule,0.61,0.7,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.61,,,,,,,fee schedule,0.61,0.7,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.7,,,,,,,fee schedule,0.61,0.7,
Methylprednisolone oral,J7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.24,,,,,,,fee schedule,0.24,0.28,
Methylprednisolone oral,J7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.24,,,,,,,fee schedule,0.24,0.28,
Methylprednisolone oral,J7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.24,,,,,,,fee schedule,0.24,0.28,
Methylprednisolone oral,J7509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.28,,,,,,,fee schedule,0.24,0.28,
Prednisolone oral per 5 mg,J7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.28,,,,,,,fee schedule,0.28,0.32,
Prednisolone oral per 5 mg,J7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.28,,,,,,,fee schedule,0.28,0.32,
Prednisolone oral per 5 mg,J7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.28,,,,,,,fee schedule,0.28,0.32,
Prednisolone oral per 5 mg,J7510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.32,,,,,,,fee schedule,0.28,0.32,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1033.99,,,,,,,fee schedule,1033.99,1904.02,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1033.99,,,,,,,fee schedule,1033.99,1904.02,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1033.99,,,,,,,fee schedule,1033.99,1904.02,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1189.09,,,,,,,fee schedule,1033.99,1904.02,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1110.68,,,,,,,fee schedule,1033.99,1904.02,APC
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1057.79,,,,,,,fee schedule,1033.99,1904.02,APC
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1904.02,,,,,,,fee schedule,1033.99,1904.02,APC
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
"Daclizumab, parenteral",J7513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,506.48,,,,,,,fee schedule,506.48,582.45,
"Daclizumab, parenteral",J7513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,506.48,,,,,,,fee schedule,506.48,582.45,
"Daclizumab, parenteral",J7513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,506.48,,,,,,,fee schedule,506.48,582.45,
"Daclizumab, parenteral",J7513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,582.45,,,,,,,fee schedule,506.48,582.45,
Mycophenol (myhibbin) 100 mg,J7514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.23,,,,,,,fee schedule,2.23,2.56,
Mycophenol (myhibbin) 100 mg,J7514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.23,,,,,,,fee schedule,2.23,2.56,
Mycophenol (myhibbin) 100 mg,J7514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.23,,,,,,,fee schedule,2.23,2.56,
Mycophenol (myhibbin) 100 mg,J7514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.56,,,,,,,fee schedule,2.23,2.56,
Cyclosporine oral 25 mg,J7515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.8,,,,,,,fee schedule,0.8,0.92,
Cyclosporine oral 25 mg,J7515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.8,,,,,,,fee schedule,0.8,0.92,
Cyclosporine oral 25 mg,J7515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.8,,,,,,,fee schedule,0.8,0.92,
Cyclosporine oral 25 mg,J7515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.92,,,,,,,fee schedule,0.8,0.92,
Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.43,,,,,,,fee schedule,75.43,86.74,
Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.43,,,,,,,fee schedule,75.43,86.74,
Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.43,,,,,,,fee schedule,75.43,86.74,
Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,86.74,,,,,,,fee schedule,75.43,86.74,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.16,,,,,,,fee schedule,0.16,0.18,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.16,,,,,,,fee schedule,0.16,0.18,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.16,,,,,,,fee schedule,0.16,0.18,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.18,,,,,,,fee schedule,0.16,0.18,
Mycophenolic acid,J7518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.38,,,,,,,fee schedule,0.38,0.44,
Mycophenolic acid,J7518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.38,,,,,,,fee schedule,0.38,0.44,
Mycophenolic acid,J7518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.38,,,,,,,fee schedule,0.38,0.44,
Mycophenolic acid,J7518,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.44,,,,,,,fee schedule,0.38,0.44,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.43,,,,,,,fee schedule,0.43,0.49,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.43,,,,,,,fee schedule,0.43,0.49,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.43,,,,,,,fee schedule,0.43,0.49,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.49,,,,,,,fee schedule,0.43,0.49,
"Sirolimus, oral",J7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.99,,,,,,,fee schedule,0.99,1.14,
"Sirolimus, oral",J7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.99,,,,,,,fee schedule,0.99,1.14,
"Sirolimus, oral",J7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.99,,,,,,,fee schedule,0.99,1.14,
"Sirolimus, oral",J7520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.14,,,,,,,fee schedule,0.99,1.14,
Tacrolim granules oral susp,J7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.3,,,,,,,fee schedule,1.3,1.5,
Tacrolim granules oral susp,J7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.3,,,,,,,fee schedule,1.3,1.5,
Tacrolim granules oral susp,J7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.3,,,,,,,fee schedule,1.3,1.5,
Tacrolim granules oral susp,J7521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.5,,,,,,,fee schedule,1.3,1.5,
Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,272.13,,,,,,,fee schedule,268.18,482.72,
Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,272.13,,,,,,,fee schedule,268.18,482.72,
Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,272.13,,,,,,,fee schedule,268.18,482.72,
Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.95,,,,,,,fee schedule,268.18,482.72,
Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,281.58,,,,,,,fee schedule,268.18,482.72,APC
Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,268.18,,,,,,,fee schedule,268.18,482.72,APC
Tacrolimus injection,J7525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,482.72,,,,,,,fee schedule,268.18,482.72,APC
Oral everolimus,J7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.06,,,,,,,fee schedule,2.06,2.37,
Oral everolimus,J7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.06,,,,,,,fee schedule,2.06,2.37,
Oral everolimus,J7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.06,,,,,,,fee schedule,2.06,2.37,
Oral everolimus,J7527,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.37,,,,,,,fee schedule,2.06,2.37,
Ensifentrine inh 3 mg,J7601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.08,,,,,,,fee schedule,54.08,62.19,
Ensifentrine inh 3 mg,J7601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.08,,,,,,,fee schedule,54.08,62.19,
Ensifentrine inh 3 mg,J7601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.08,,,,,,,fee schedule,54.08,62.19,
Ensifentrine inh 3 mg,J7601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.19,,,,,,,fee schedule,54.08,62.19,
Acetylcysteine comp unit,J7604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
Acetylcysteine comp unit,J7604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
Acetylcysteine comp unit,J7604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.22,,,,,,,fee schedule,0.22,0.25,
Acetylcysteine comp unit,J7604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.25,,,,,,,fee schedule,0.22,0.25,
Arformoterol non-comp unit,J7605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.82,,,,,,,fee schedule,0.82,0.94,
Arformoterol non-comp unit,J7605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.82,,,,,,,fee schedule,0.82,0.94,
Arformoterol non-comp unit,J7605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.82,,,,,,,fee schedule,0.82,0.94,
Arformoterol non-comp unit,J7605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.94,,,,,,,fee schedule,0.82,0.94,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.04,,,,,,,fee schedule,2.04,2.35,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.04,,,,,,,fee schedule,2.04,2.35,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.04,,,,,,,fee schedule,2.04,2.35,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.35,,,,,,,fee schedule,2.04,2.35,
Levalbuterol comp con,J7607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.55,,,,,,,fee schedule,2.55,2.93,
Levalbuterol comp con,J7607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.55,,,,,,,fee schedule,2.55,2.93,
Levalbuterol comp con,J7607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.55,,,,,,,fee schedule,2.55,2.93,
Levalbuterol comp con,J7607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.93,,,,,,,fee schedule,2.55,2.93,
Acetylcysteine non-comp unit,J7608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.23,,,,,,,fee schedule,9.23,10.61,
Acetylcysteine non-comp unit,J7608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.23,,,,,,,fee schedule,9.23,10.61,
Acetylcysteine non-comp unit,J7608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.23,,,,,,,fee schedule,9.23,10.61,
Acetylcysteine non-comp unit,J7608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.61,,,,,,,fee schedule,9.23,10.61,
Albuterol comp unit,J7609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.51,,,,,,,fee schedule,0.51,0.59,
Albuterol comp unit,J7609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.51,,,,,,,fee schedule,0.51,0.59,
Albuterol comp unit,J7609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.51,,,,,,,fee schedule,0.51,0.59,
Albuterol comp unit,J7609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.59,,,,,,,fee schedule,0.51,0.59,
Albuterol comp con,J7610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.23,,,,,,,fee schedule,1.23,1.41,
Albuterol comp con,J7610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.23,,,,,,,fee schedule,1.23,1.41,
Albuterol comp con,J7610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.23,,,,,,,fee schedule,1.23,1.41,
Albuterol comp con,J7610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.41,,,,,,,fee schedule,1.23,1.41,
Albuterol non-comp con,J7611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Albuterol non-comp con,J7611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.17,,,,,,,fee schedule,0.17,0.2,
Albuterol non-comp con,J7611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.17,,,,,,,fee schedule,0.17,0.2,
Albuterol non-comp con,J7611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.2,,,,,,,fee schedule,0.17,0.2,
Levalbuterol non-comp con,J7612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.31,,,,,,,fee schedule,0.31,0.36,
Levalbuterol non-comp con,J7612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.31,,,,,,,fee schedule,0.31,0.36,
Levalbuterol non-comp con,J7612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.31,,,,,,,fee schedule,0.31,0.36,
Levalbuterol non-comp con,J7612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.36,,,,,,,fee schedule,0.31,0.36,
Albuterol non-comp unit,J7613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.08,,,,,,,fee schedule,0.08,0.09,
Albuterol non-comp unit,J7613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.08,,,,,,,fee schedule,0.08,0.09,
Albuterol non-comp unit,J7613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.08,,,,,,,fee schedule,0.08,0.09,
Albuterol non-comp unit,J7613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.09,,,,,,,fee schedule,0.08,0.09,
Levalbuterol non-comp unit,J7614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
Levalbuterol non-comp unit,J7614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
Levalbuterol non-comp unit,J7614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.1,
Levalbuterol non-comp unit,J7614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.1,,,,,,,fee schedule,0.09,0.1,
Levalbuterol comp unit,J7615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.09,,,,,,,fee schedule,2.09,2.4,
Levalbuterol comp unit,J7615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.09,,,,,,,fee schedule,2.09,2.4,
Levalbuterol comp unit,J7615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.09,,,,,,,fee schedule,2.09,2.4,
Levalbuterol comp unit,J7615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.4,,,,,,,fee schedule,2.09,2.4,
Albuterol ipratrop non-comp,J7620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.21,,,,,,,fee schedule,0.21,0.24,
Albuterol ipratrop non-comp,J7620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.21,,,,,,,fee schedule,0.21,0.24,
Albuterol ipratrop non-comp,J7620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.21,,,,,,,fee schedule,0.21,0.24,
Albuterol ipratrop non-comp,J7620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.24,,,,,,,fee schedule,0.21,0.24,
Beclomethasone comp unit,J7622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Beclomethasone comp unit,J7622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Beclomethasone comp unit,J7622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.03,,,,,,,fee schedule,0.03,0.03,
Beclomethasone comp unit,J7622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.03,,,,,,,fee schedule,0.03,0.03,
Betamethasone comp unit,J7624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.36,,,,,,,fee schedule,1.36,1.56,
Betamethasone comp unit,J7624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.36,,,,,,,fee schedule,1.36,1.56,
Betamethasone comp unit,J7624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.36,,,,,,,fee schedule,1.36,1.56,
Betamethasone comp unit,J7624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.56,,,,,,,fee schedule,1.36,1.56,
Budesonide non-comp unit,J7626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.32,,,,,,,fee schedule,1.32,1.52,
Budesonide non-comp unit,J7626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.32,,,,,,,fee schedule,1.32,1.52,
Budesonide non-comp unit,J7626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.32,,,,,,,fee schedule,1.32,1.52,
Budesonide non-comp unit,J7626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.52,,,,,,,fee schedule,1.32,1.52,
Budesonide comp unit,J7627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.31,,,,,,,fee schedule,0.31,0.36,
Budesonide comp unit,J7627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.31,,,,,,,fee schedule,0.31,0.36,
Budesonide comp unit,J7627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.31,,,,,,,fee schedule,0.31,0.36,
Budesonide comp unit,J7627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.36,,,,,,,fee schedule,0.31,0.36,
Bitolterol mesylate comp con,J7628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
Bitolterol mesylate comp con,J7628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
Bitolterol mesylate comp con,J7628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.22,,,,,,,fee schedule,0.22,0.25,
Bitolterol mesylate comp con,J7628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.25,,,,,,,fee schedule,0.22,0.25,
Bitolterol mesylate comp unt,J7629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Bitolterol mesylate comp unt,J7629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.18,,,,,,,fee schedule,0.18,0.21,
Bitolterol mesylate comp unt,J7629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.18,,,,,,,fee schedule,0.18,0.21,
Bitolterol mesylate comp unt,J7629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.21,,,,,,,fee schedule,0.18,0.21,
Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.3,,,,,,,fee schedule,0.3,0.35,
Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.3,,,,,,,fee schedule,0.3,0.35,
Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.3,,,,,,,fee schedule,0.3,0.35,
Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.35,,,,,,,fee schedule,0.3,0.35,
Cromolyn sodium comp unit,J7632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.69,,,,,,,fee schedule,0.69,0.79,
Cromolyn sodium comp unit,J7632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.69,,,,,,,fee schedule,0.69,0.79,
Cromolyn sodium comp unit,J7632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.69,,,,,,,fee schedule,0.69,0.79,
Cromolyn sodium comp unit,J7632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.79,,,,,,,fee schedule,0.69,0.79,
Budesonide non-comp con,J7633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.51,,,,,,,fee schedule,4.51,5.19,
Budesonide non-comp con,J7633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.51,,,,,,,fee schedule,4.51,5.19,
Budesonide non-comp con,J7633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.51,,,,,,,fee schedule,4.51,5.19,
Budesonide non-comp con,J7633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.19,,,,,,,fee schedule,4.51,5.19,
Budesonide comp con,J7634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.44,,,,,,,fee schedule,4.44,5.11,
Budesonide comp con,J7634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.44,,,,,,,fee schedule,4.44,5.11,
Budesonide comp con,J7634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.44,,,,,,,fee schedule,4.44,5.11,
Budesonide comp con,J7634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.11,,,,,,,fee schedule,4.44,5.11,
Atropine comp con,J7635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Atropine comp con,J7635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Atropine comp con,J7635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.12,,,,,,,fee schedule,0.12,0.14,
Atropine comp con,J7635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.14,,,,,,,fee schedule,0.12,0.14,
Atropine comp unit,J7636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Atropine comp unit,J7636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.12,,,,,,,fee schedule,0.12,0.14,
Atropine comp unit,J7636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.12,,,,,,,fee schedule,0.12,0.14,
Atropine comp unit,J7636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.14,,,,,,,fee schedule,0.12,0.14,
Dexamethasone comp con,J7637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.13,,,,,,,fee schedule,0.13,0.15,
Dexamethasone comp con,J7637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.13,,,,,,,fee schedule,0.13,0.15,
Dexamethasone comp con,J7637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.13,,,,,,,fee schedule,0.13,0.15,
Dexamethasone comp con,J7637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.15,,,,,,,fee schedule,0.13,0.15,
Dexamethasone comp unit,J7638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.13,,,,,,,fee schedule,0.13,0.15,
Dexamethasone comp unit,J7638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.13,,,,,,,fee schedule,0.13,0.15,
Dexamethasone comp unit,J7638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.13,,,,,,,fee schedule,0.13,0.15,
Dexamethasone comp unit,J7638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.15,,,,,,,fee schedule,0.13,0.15,
Dornase alfa non-comp unit,J7639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.24,,,,,,,fee schedule,57.24,65.83,
Dornase alfa non-comp unit,J7639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.24,,,,,,,fee schedule,57.24,65.83,
Dornase alfa non-comp unit,J7639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.24,,,,,,,fee schedule,57.24,65.83,
Dornase alfa non-comp unit,J7639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.83,,,,,,,fee schedule,57.24,65.83,
Formoterol comp unit,J7640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.59,,,,,,,fee schedule,1.59,1.83,
Formoterol comp unit,J7640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.59,,,,,,,fee schedule,1.59,1.83,
Formoterol comp unit,J7640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.59,,,,,,,fee schedule,1.59,1.83,
Formoterol comp unit,J7640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.83,,,,,,,fee schedule,1.59,1.83,
Flunisolide comp unit,J7641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
Flunisolide comp unit,J7641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
Flunisolide comp unit,J7641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.22,,,,,,,fee schedule,0.22,0.25,
Flunisolide comp unit,J7641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.25,,,,,,,fee schedule,0.22,0.25,
Glycopyrrolate comp con,J7642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.1,,,,,,,fee schedule,1.1,1.27,
Glycopyrrolate comp con,J7642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.1,,,,,,,fee schedule,1.1,1.27,
Glycopyrrolate comp con,J7642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.1,,,,,,,fee schedule,1.1,1.27,
Glycopyrrolate comp con,J7642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.27,,,,,,,fee schedule,1.1,1.27,
Glycopyrrolate comp unit,J7643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.76,,,,,,,fee schedule,0.76,0.87,
Glycopyrrolate comp unit,J7643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.76,,,,,,,fee schedule,0.76,0.87,
Glycopyrrolate comp unit,J7643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.76,,,,,,,fee schedule,0.76,0.87,
Glycopyrrolate comp unit,J7643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.87,,,,,,,fee schedule,0.76,0.87,
Ipratropium bromide non-comp,J7644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.41,,,,,,,fee schedule,0.41,0.47,
Ipratropium bromide non-comp,J7644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.41,,,,,,,fee schedule,0.41,0.47,
Ipratropium bromide non-comp,J7644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.41,,,,,,,fee schedule,0.41,0.47,
Ipratropium bromide non-comp,J7644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.47,,,,,,,fee schedule,0.41,0.47,
Ipratropium bromide comp,J7645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Ipratropium bromide comp,J7645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.05,,,,,,,fee schedule,0.05,0.06,
Ipratropium bromide comp,J7645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.05,,,,,,,fee schedule,0.05,0.06,
Ipratropium bromide comp,J7645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.06,,,,,,,fee schedule,0.05,0.06,
Isoetharine comp con,J7647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine comp con,J7647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine comp con,J7647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine comp con,J7647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2,,,,,,,fee schedule,1.74,2,
Isoetharine non-comp con,J7648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine non-comp con,J7648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine non-comp con,J7648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine non-comp con,J7648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2,,,,,,,fee schedule,1.74,2,
Isoetharine non-comp unit,J7649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine non-comp unit,J7649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine non-comp unit,J7649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.74,,,,,,,fee schedule,1.74,2,
Isoetharine non-comp unit,J7649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2,,,,,,,fee schedule,1.74,2,
Isoetharine comp unit,J7650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.14,,,,,,,fee schedule,0.14,0.16,
Isoetharine comp unit,J7650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.14,,,,,,,fee schedule,0.14,0.16,
Isoetharine comp unit,J7650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.14,,,,,,,fee schedule,0.14,0.16,
Isoetharine comp unit,J7650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.16,,,,,,,fee schedule,0.14,0.16,
Isoproterenol comp con,J7657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol comp con,J7657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol comp con,J7657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol comp con,J7657,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.5,,,,,,,fee schedule,2.17,2.5,
Isoproterenol non-comp con,J7658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol non-comp con,J7658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol non-comp con,J7658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol non-comp con,J7658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.5,,,,,,,fee schedule,2.17,2.5,
Isoproterenol non-comp unit,J7659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol non-comp unit,J7659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol non-comp unit,J7659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol non-comp unit,J7659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.5,,,,,,,fee schedule,2.17,2.5,
Isoproterenol comp unit,J7660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol comp unit,J7660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol comp unit,J7660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.17,,,,,,,fee schedule,2.17,2.5,
Isoproterenol comp unit,J7660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.5,,,,,,,fee schedule,2.17,2.5,
Mannitol for inhaler,J7665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.71,,,,,,,fee schedule,6.71,7.72,
Mannitol for inhaler,J7665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.71,,,,,,,fee schedule,6.71,7.72,
Mannitol for inhaler,J7665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.71,,,,,,,fee schedule,6.71,7.72,
Mannitol for inhaler,J7665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.72,,,,,,,fee schedule,6.71,7.72,
Metaproterenol comp con,J7667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.37,,,,,,,fee schedule,1.37,1.58,
Metaproterenol comp con,J7667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.37,,,,,,,fee schedule,1.37,1.58,
Metaproterenol comp con,J7667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.37,,,,,,,fee schedule,1.37,1.58,
Metaproterenol comp con,J7667,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.58,,,,,,,fee schedule,1.37,1.58,
Metaproterenol non-comp con,J7668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.37,,,,,,,fee schedule,1.37,1.58,
Metaproterenol non-comp con,J7668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.37,,,,,,,fee schedule,1.37,1.58,
Metaproterenol non-comp con,J7668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.37,,,,,,,fee schedule,1.37,1.58,
Metaproterenol non-comp con,J7668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.58,,,,,,,fee schedule,1.37,1.58,
Metaproterenol non-comp unit,J7669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.45,,,,,,,fee schedule,0.45,0.52,
Metaproterenol non-comp unit,J7669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.45,,,,,,,fee schedule,0.45,0.52,
Metaproterenol non-comp unit,J7669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.45,,,,,,,fee schedule,0.45,0.52,
Metaproterenol non-comp unit,J7669,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.52,,,,,,,fee schedule,0.45,0.52,
Metaproterenol comp unit,J7670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.43,,,,,,,fee schedule,0.43,0.49,
Metaproterenol comp unit,J7670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.43,,,,,,,fee schedule,0.43,0.49,
Metaproterenol comp unit,J7670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.43,,,,,,,fee schedule,0.43,0.49,
Metaproterenol comp unit,J7670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.49,,,,,,,fee schedule,0.43,0.49,
"Methacholine chloride, neb",J7674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.79,,,,,,,fee schedule,1.79,2.06,
"Methacholine chloride, neb",J7674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.79,,,,,,,fee schedule,1.79,2.06,
"Methacholine chloride, neb",J7674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.79,,,,,,,fee schedule,1.79,2.06,
"Methacholine chloride, neb",J7674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.06,,,,,,,fee schedule,1.79,2.06,
Pentamidine comp unit dose,J7676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.34,,,,,,,fee schedule,103.34,118.84,
Pentamidine comp unit dose,J7676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103.34,,,,,,,fee schedule,103.34,118.84,
Pentamidine comp unit dose,J7676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.34,,,,,,,fee schedule,103.34,118.84,
Pentamidine comp unit dose,J7676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.84,,,,,,,fee schedule,103.34,118.84,
Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.2,,,,,,,fee schedule,0.2,0.23,
Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.2,,,,,,,fee schedule,0.2,0.23,
Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.2,,,,,,,fee schedule,0.2,0.23,
Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.23,,,,,,,fee schedule,0.2,0.23,
Terbutaline sulf comp con,J7680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.07,,,,,,,fee schedule,12.07,13.88,
Terbutaline sulf comp con,J7680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.07,,,,,,,fee schedule,12.07,13.88,
Terbutaline sulf comp con,J7680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.07,,,,,,,fee schedule,12.07,13.88,
Terbutaline sulf comp con,J7680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.88,,,,,,,fee schedule,12.07,13.88,
Terbutaline sulf comp unit,J7681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.07,,,,,,,fee schedule,12.07,13.88,
Terbutaline sulf comp unit,J7681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.07,,,,,,,fee schedule,12.07,13.88,
Terbutaline sulf comp unit,J7681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.07,,,,,,,fee schedule,12.07,13.88,
Terbutaline sulf comp unit,J7681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.88,,,,,,,fee schedule,12.07,13.88,
Tobramycin non-comp unit,J7682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15,,,,,,,fee schedule,15,17.25,
Tobramycin non-comp unit,J7682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15,,,,,,,fee schedule,15,17.25,
Tobramycin non-comp unit,J7682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15,,,,,,,fee schedule,15,17.25,
Tobramycin non-comp unit,J7682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.25,,,,,,,fee schedule,15,17.25,
Triamcinolone comp con,J7683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.59,,,,,,,fee schedule,0.59,0.68,
Triamcinolone comp con,J7683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.59,,,,,,,fee schedule,0.59,0.68,
Triamcinolone comp con,J7683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.59,,,,,,,fee schedule,0.59,0.68,
Triamcinolone comp con,J7683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.68,,,,,,,fee schedule,0.59,0.68,
Triamcinolone comp unit,J7684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.59,,,,,,,fee schedule,0.59,0.68,
Triamcinolone comp unit,J7684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.59,,,,,,,fee schedule,0.59,0.68,
Triamcinolone comp unit,J7684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.59,,,,,,,fee schedule,0.59,0.68,
Triamcinolone comp unit,J7684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.68,,,,,,,fee schedule,0.59,0.68,
Tobramycin comp unit,J7685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.43,,,,,,,fee schedule,56.43,64.89,
Tobramycin comp unit,J7685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.43,,,,,,,fee schedule,56.43,64.89,
Tobramycin comp unit,J7685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.43,,,,,,,fee schedule,56.43,64.89,
Tobramycin comp unit,J7685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.89,,,,,,,fee schedule,56.43,64.89,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,830.35,,,,,,,fee schedule,830.35,954.9,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,830.35,,,,,,,fee schedule,830.35,954.9,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,830.35,,,,,,,fee schedule,830.35,954.9,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,954.9,,,,,,,fee schedule,830.35,954.9,
Oral aprepitant,J8501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.82,,,,,,,fee schedule,2.82,3.24,
Oral aprepitant,J8501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.82,,,,,,,fee schedule,2.82,3.24,
Oral aprepitant,J8501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.82,,,,,,,fee schedule,2.82,3.24,
Oral aprepitant,J8501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.24,,,,,,,fee schedule,2.82,3.24,
Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.11,,,,,,,fee schedule,10.12,161.13,
Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.11,,,,,,,fee schedule,10.12,161.13,
Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.11,,,,,,,fee schedule,10.12,161.13,
Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.13,,,,,,,fee schedule,10.12,161.13,
Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.63,,,,,,,fee schedule,10.12,161.13,APC
Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.12,,,,,,,fee schedule,10.12,161.13,APC
Oral busulfan,J8510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.22,,,,,,,fee schedule,10.12,161.13,APC
"Cabergoline, oral 0.25mg",J8515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.6,,,,,,,fee schedule,1.6,1.84,
"Cabergoline, oral 0.25mg",J8515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.6,1.84,
"Cabergoline, oral 0.25mg",J8515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.6,,,,,,,fee schedule,1.6,1.84,
"Cabergoline, oral 0.25mg",J8515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.84,,,,,,,fee schedule,1.6,1.84,
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.14,
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.06,0.14,
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.06,,,,,,,fee schedule,0.06,0.14,
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.07,,,,,,,fee schedule,0.06,0.14,
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.08,,,,,,,fee schedule,0.06,0.14,APC
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.08,,,,,,,fee schedule,0.06,0.14,APC
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.14,,,,,,,fee schedule,0.06,0.14,APC
Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.06,,,,,,,fee schedule,2.06,2.37,
Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.06,,,,,,,fee schedule,2.06,2.37,
Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.06,,,,,,,fee schedule,2.06,2.37,
Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.37,,,,,,,fee schedule,2.06,2.37,
Oral dexamethasone,J8540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
Oral dexamethasone,J8540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
Oral dexamethasone,J8540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.02,,,,,,,fee schedule,0.02,0.02,
Oral dexamethasone,J8540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.02,,,,,,,fee schedule,0.02,0.02,
"Oral, hemady, 0.25 mg",J8541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.37,,,,,,,fee schedule,0.37,0.43,
"Oral, hemady, 0.25 mg",J8541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.37,,,,,,,fee schedule,0.37,0.43,
"Oral, hemady, 0.25 mg",J8541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.37,,,,,,,fee schedule,0.37,0.43,
"Oral, hemady, 0.25 mg",J8541,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.43,,,,,,,fee schedule,0.37,0.43,
Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.62,,,,,,,fee schedule,78.62,158.5,
Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.62,,,,,,,fee schedule,78.62,158.5,
Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.62,,,,,,,fee schedule,78.62,158.5,
Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.41,,,,,,,fee schedule,78.62,158.5,
Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.46,,,,,,,fee schedule,78.62,158.5,APC
Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,88.06,,,,,,,fee schedule,78.62,158.5,APC
Etoposide oral 50 mg,J8560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,158.5,,,,,,,fee schedule,78.62,158.5,APC
Oral fludarabine phosphate,J8562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.68,,,,,,,fee schedule,78.68,90.48,
Oral fludarabine phosphate,J8562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.68,,,,,,,fee schedule,78.68,90.48,
Oral fludarabine phosphate,J8562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.68,,,,,,,fee schedule,78.68,90.48,
Oral fludarabine phosphate,J8562,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.48,,,,,,,fee schedule,78.68,90.48,
Gefitinib oral,J8565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.01,,,,,,,fee schedule,143.01,164.46,
Gefitinib oral,J8565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,143.01,,,,,,,fee schedule,143.01,164.46,
Gefitinib oral,J8565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.01,,,,,,,fee schedule,143.01,164.46,
Gefitinib oral,J8565,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.46,,,,,,,fee schedule,143.01,164.46,
Melphalan oral 2 MG,J8600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.34,,,,,,,fee schedule,9.34,10.74,
Melphalan oral 2 MG,J8600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.34,,,,,,,fee schedule,9.34,10.74,
Melphalan oral 2 MG,J8600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.34,,,,,,,fee schedule,9.34,10.74,
Melphalan oral 2 MG,J8600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.74,,,,,,,fee schedule,9.34,10.74,
Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.21,,,,,,,fee schedule,0.21,0.24,
Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.21,,,,,,,fee schedule,0.21,0.24,
Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.21,,,,,,,fee schedule,0.21,0.24,
Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.24,,,,,,,fee schedule,0.21,0.24,
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.23,,,,,,,fee schedule,16.47,29.64,
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.23,,,,,,,fee schedule,16.47,29.64,
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.23,,,,,,,fee schedule,16.47,29.64,
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.11,,,,,,,fee schedule,16.47,29.64,
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.29,,,,,,,fee schedule,16.47,29.64,APC
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.47,,,,,,,fee schedule,16.47,29.64,APC
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.64,,,,,,,fee schedule,16.47,29.64,APC
Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.51,,,,,,,fee schedule,22.92,41.25,
Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.51,,,,,,,fee schedule,22.92,41.25,
Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.51,,,,,,,fee schedule,22.92,41.25,
Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.04,,,,,,,fee schedule,22.92,41.25,
Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.06,,,,,,,fee schedule,22.92,41.25,APC
Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22.92,,,,,,,fee schedule,22.92,41.25,APC
Oral methotrexate (xatmep),J8612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.25,,,,,,,fee schedule,22.92,41.25,APC
Nabilone oral,J8650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.98,,,,,,,fee schedule,39.98,45.98,
Nabilone oral,J8650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.98,,,,,,,fee schedule,39.98,45.98,
Nabilone oral,J8650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.98,,,,,,,fee schedule,39.98,45.98,
Nabilone oral,J8650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.98,,,,,,,fee schedule,39.98,45.98,
Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,424.97,,,,,,,fee schedule,424.97,853.27,
Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,424.97,,,,,,,fee schedule,424.97,853.27,
Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,424.97,,,,,,,fee schedule,424.97,853.27,
Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,488.72,,,,,,,fee schedule,424.97,853.27,
Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,497.74,,,,,,,fee schedule,424.97,853.27,APC
Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,474.04,,,,,,,fee schedule,424.97,853.27,APC
Netupitant palonosetron oral,J8655,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,853.27,,,,,,,fee schedule,424.97,853.27,APC
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.62,,,,,,,fee schedule,1.62,1.86,
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.62,,,,,,,fee schedule,1.62,1.86,
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.62,,,,,,,fee schedule,1.62,1.86,
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.86,,,,,,,fee schedule,1.62,1.86,
Temozolomide,J8700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.37,,,,,,,fee schedule,0.37,0.43,
Temozolomide,J8700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.37,,,,,,,fee schedule,0.37,0.43,
Temozolomide,J8700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.37,,,,,,,fee schedule,0.37,0.43,
Temozolomide,J8700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.43,,,,,,,fee schedule,0.37,0.43,
Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.61,,,,,,,fee schedule,125.33,225.6,
Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.61,,,,,,,fee schedule,125.33,225.6,
Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.61,,,,,,,fee schedule,125.33,225.6,
Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.05,,,,,,,fee schedule,125.33,225.6,
Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.6,,,,,,,fee schedule,125.33,225.6,APC
Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,125.33,,,,,,,fee schedule,125.33,225.6,APC
Topotecan oral,J8705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,225.6,,,,,,,fee schedule,125.33,225.6,APC
Doxorubicin hcl injection,J9000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.83,,,,,,,fee schedule,2.83,3.25,
Doxorubicin hcl injection,J9000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.83,,,,,,,fee schedule,2.83,3.25,
Doxorubicin hcl injection,J9000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.83,,,,,,,fee schedule,2.83,3.25,
Doxorubicin hcl injection,J9000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.25,,,,,,,fee schedule,2.83,3.25,
Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6181.2,,,,,,,fee schedule,3338.87,7108.38,
Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6181.2,,,,,,,fee schedule,3338.87,7108.38,
Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6181.2,,,,,,,fee schedule,3338.87,7108.38,
Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7108.38,,,,,,,fee schedule,3338.87,7108.38,
Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3505.81,,,,,,,fee schedule,3338.87,7108.38,APC
Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3338.87,,,,,,,fee schedule,3338.87,7108.38,APC
Aldesleukin injection,J9015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6009.97,,,,,,,fee schedule,3338.87,7108.38,APC
Arsenic trioxide injection,J9017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.08,,,,,,,fee schedule,6.08,6.99,
Arsenic trioxide injection,J9017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.08,,,,,,,fee schedule,6.08,6.99,
Arsenic trioxide injection,J9017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.08,,,,,,,fee schedule,6.08,6.99,
Arsenic trioxide injection,J9017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.99,,,,,,,fee schedule,6.08,6.99,
Erwinaze injection,J9019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,411.15,,,,,,,fee schedule,411.15,472.82,
Erwinaze injection,J9019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,411.15,,,,,,,fee schedule,411.15,472.82,
Erwinaze injection,J9019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,411.15,,,,,,,fee schedule,411.15,472.82,
Erwinaze injection,J9019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,472.82,,,,,,,fee schedule,411.15,472.82,
"Asparaginase, nos",J9020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.13,,,,,,,fee schedule,62.13,71.45,
"Asparaginase, nos",J9020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.13,,,,,,,fee schedule,62.13,71.45,
"Asparaginase, nos",J9020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.13,,,,,,,fee schedule,62.13,71.45,
"Asparaginase, nos",J9020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.45,,,,,,,fee schedule,62.13,71.45,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.39,,,,,,,fee schedule,57.39,105.66,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.39,,,,,,,fee schedule,57.39,105.66,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.39,,,,,,,fee schedule,57.39,105.66,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66,,,,,,,fee schedule,57.39,105.66,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.63,,,,,,,fee schedule,57.39,105.66,APC
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.7,,,,,,,fee schedule,57.39,105.66,APC
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.66,,,,,,,fee schedule,57.39,105.66,APC
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.46,,,,,,,fee schedule,94.46,173.78,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.46,,,,,,,fee schedule,94.46,173.78,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.46,,,,,,,fee schedule,94.46,173.78,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.63,,,,,,,fee schedule,94.46,173.78,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.37,,,,,,,fee schedule,94.46,173.78,APC
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.55,,,,,,,fee schedule,94.46,173.78,APC
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.78,,,,,,,fee schedule,94.46,173.78,APC
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.08,,,,,,,fee schedule,104.08,195.54,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.08,,,,,,,fee schedule,104.08,195.54,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.08,,,,,,,fee schedule,104.08,195.54,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.69,,,,,,,fee schedule,104.08,195.54,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.07,,,,,,,fee schedule,104.08,195.54,APC
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,108.64,,,,,,,fee schedule,104.08,195.54,APC
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,195.54,,,,,,,fee schedule,104.08,195.54,APC
Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.83,,,,,,,fee schedule,32.55,58.6,
Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.83,,,,,,,fee schedule,32.55,58.6,
Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.83,,,,,,,fee schedule,32.55,58.6,
Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.75,,,,,,,fee schedule,32.55,58.6,
Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.18,,,,,,,fee schedule,32.55,58.6,APC
Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.55,,,,,,,fee schedule,32.55,58.6,APC
Inj atezolizumb 5mg hya-tqjs,J9024,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.6,,,,,,,fee schedule,32.55,58.6,APC
Azacitidine injection,J9025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
Azacitidine injection,J9025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
Azacitidine injection,J9025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.22,,,,,,,fee schedule,0.22,0.25,
Azacitidine injection,J9025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.25,,,,,,,fee schedule,0.22,0.25,
"Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1626.64,,,,,,,fee schedule,1612.42,2902.36,
"Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1626.64,,,,,,,fee schedule,1612.42,2902.36,
"Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1626.64,,,,,,,fee schedule,1612.42,2902.36,
"Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1870.64,,,,,,,fee schedule,1612.42,2902.36,
"Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1693.04,,,,,,,fee schedule,1612.42,2902.36,APC
"Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1612.42,,,,,,,fee schedule,1612.42,2902.36,APC
"Inj, tarlatamab-dlle, 1 mg",J9026,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2902.36,,,,,,,fee schedule,1612.42,2902.36,APC
Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.27,,,,,,,fee schedule,15.27,29.24,
Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.27,,,,,,,fee schedule,15.27,29.24,
Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.27,,,,,,,fee schedule,15.27,29.24,
Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.56,,,,,,,fee schedule,15.27,29.24,
Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.06,,,,,,,fee schedule,15.27,29.24,APC
Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.24,,,,,,,fee schedule,15.27,29.24,APC
Clofarabine injection,J9027,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.24,,,,,,,fee schedule,15.27,29.24,APC
"Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.67,,,,,,,fee schedule,94.31,169.75,
"Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,97.67,,,,,,,fee schedule,94.31,169.75,
"Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.67,,,,,,,fee schedule,94.31,169.75,
"Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.32,,,,,,,fee schedule,94.31,169.75,
"Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.02,,,,,,,fee schedule,94.31,169.75,APC
"Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.31,,,,,,,fee schedule,94.31,169.75,APC
"Inj, nogapendekin pmln, 1mcg",J9028,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,169.75,,,,,,,fee schedule,94.31,169.75,APC
Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.24,,,,,,,fee schedule,3.24,6.08,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.24,,,,,,,fee schedule,3.24,6.08,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.24,,,,,,,fee schedule,3.24,6.08,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.73,,,,,,,fee schedule,3.24,6.08,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.54,,,,,,,fee schedule,3.24,6.08,APC
Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.38,,,,,,,fee schedule,3.24,6.08,APC
Bcg live intravesical 1mg,J9030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.08,,,,,,,fee schedule,3.24,6.08,APC
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54,,,,,,,fee schedule,54,98,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54,,,,,,,fee schedule,54,98,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54,,,,,,,fee schedule,54,98,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.1,,,,,,,fee schedule,54,98,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.17,,,,,,,fee schedule,54,98,APC
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.45,,,,,,,fee schedule,54,98,APC
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,98,,,,,,,fee schedule,54,98,APC
"Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.92,,,,,,,fee schedule,1.92,5.33,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.92,,,,,,,fee schedule,1.92,5.33,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.92,,,,,,,fee schedule,1.92,5.33,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.21,,,,,,,fee schedule,1.92,5.33,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.11,,,,,,,fee schedule,1.92,5.33,APC
"Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.96,,,,,,,fee schedule,1.92,5.33,APC
"Inj., treanda 1 mg",J9033,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.33,,,,,,,fee schedule,1.92,5.33,APC
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.62,,,,,,,fee schedule,12.53,22.56,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.62,,,,,,,fee schedule,12.53,22.56,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.62,,,,,,,fee schedule,12.53,22.56,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.66,,,,,,,fee schedule,12.53,22.56,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.16,,,,,,,fee schedule,12.53,22.56,APC
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.53,,,,,,,fee schedule,12.53,22.56,APC
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.56,,,,,,,fee schedule,12.53,22.56,APC
Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.81,,,,,,,fee schedule,74.82,134.68,
Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.81,,,,,,,fee schedule,74.82,134.68,
Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.81,,,,,,,fee schedule,74.82,134.68,
Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.18,,,,,,,fee schedule,74.82,134.68,
Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.56,,,,,,,fee schedule,74.82,134.68,APC
Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.82,,,,,,,fee schedule,74.82,134.68,APC
Bevacizumab injection,J9035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,134.68,,,,,,,fee schedule,74.82,134.68,APC
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.45,,,,,,,fee schedule,11.6,20.88,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.45,,,,,,,fee schedule,11.6,20.88,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.45,,,,,,,fee schedule,11.6,20.88,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.32,,,,,,,fee schedule,11.6,20.88,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.18,,,,,,,fee schedule,11.6,20.88,APC
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.6,,,,,,,fee schedule,11.6,20.88,APC
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.88,,,,,,,fee schedule,11.6,20.88,APC
Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,53.55,,,,,,,fee schedule,53.55,101.63,
Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.55,,,,,,,fee schedule,53.55,101.63,
Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.55,,,,,,,fee schedule,53.55,101.63,
Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,61.58,,,,,,,fee schedule,53.55,101.63,
Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.28,,,,,,,fee schedule,53.55,101.63,APC
Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,56.46,,,,,,,fee schedule,53.55,101.63,APC
Inj axatilimab-csfr 0.1 mg,J9038,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,101.63,,,,,,,fee schedule,53.55,101.63,APC
"Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.36,,,,,,,fee schedule,169.36,311.22,
"Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.36,,,,,,,fee schedule,169.36,311.22,
"Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,169.36,,,,,,,fee schedule,169.36,311.22,
"Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.76,,,,,,,fee schedule,169.36,311.22,
"Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.54,,,,,,,fee schedule,169.36,311.22,APC
"Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,172.9,,,,,,,fee schedule,169.36,311.22,APC
"Injection, blinatumomab",J9039,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,311.22,,,,,,,fee schedule,169.36,311.22,APC
Bleomycin sulfate injection,J9040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.69,,,,,,,fee schedule,21.69,24.94,
Bleomycin sulfate injection,J9040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,21.69,24.94,
Bleomycin sulfate injection,J9040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.69,,,,,,,fee schedule,21.69,24.94,
Bleomycin sulfate injection,J9040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.94,,,,,,,fee schedule,21.69,24.94,
Bortezomib injection,J9041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.65,,,,,,,fee schedule,1.65,1.9,
Bortezomib injection,J9041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.65,,,,,,,fee schedule,1.65,1.9,
Bortezomib injection,J9041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.65,,,,,,,fee schedule,1.65,1.9,
Bortezomib injection,J9041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.9,,,,,,,fee schedule,1.65,1.9,
Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.27,,,,,,,fee schedule,268.27,502.57,
Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.27,,,,,,,fee schedule,268.27,502.57,
Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,268.27,,,,,,,fee schedule,268.27,502.57,
Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.51,,,,,,,fee schedule,268.27,502.57,
Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,293.17,,,,,,,fee schedule,268.27,502.57,APC
Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,279.21,,,,,,,fee schedule,268.27,502.57,APC
Brentuximab vedotin inj,J9042,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,502.57,,,,,,,fee schedule,268.27,502.57,APC
Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,235.67,,,,,,,fee schedule,233.73,420.71,
Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,235.67,,,,,,,fee schedule,233.73,420.71,
Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,235.67,,,,,,,fee schedule,233.73,420.71,
Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,271.02,,,,,,,fee schedule,233.73,420.71,
Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,245.42,,,,,,,fee schedule,233.73,420.71,APC
Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,233.73,,,,,,,fee schedule,233.73,420.71,APC
Cabazitaxel injection,J9043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,420.71,,,,,,,fee schedule,233.73,420.71,APC
Carboplatin injection,J9045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.19,,,,,,,fee schedule,2.19,2.52,
Carboplatin injection,J9045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.19,,,,,,,fee schedule,2.19,2.52,
Carboplatin injection,J9045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.19,,,,,,,fee schedule,2.19,2.52,
Carboplatin injection,J9045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.52,,,,,,,fee schedule,2.19,2.52,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.72,,,,,,,fee schedule,3.46,53.73,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.72,,,,,,,fee schedule,3.46,53.73,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.72,,,,,,,fee schedule,3.46,53.73,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.73,,,,,,,fee schedule,3.46,53.73,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.63,,,,,,,fee schedule,3.46,53.73,APC
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.46,,,,,,,fee schedule,3.46,53.73,APC
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.23,,,,,,,fee schedule,3.46,53.73,APC
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.17,,,,,,,fee schedule,57.17,108.52,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.17,,,,,,,fee schedule,57.17,108.52,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.17,,,,,,,fee schedule,57.17,108.52,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.75,,,,,,,fee schedule,57.17,108.52,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.31,,,,,,,fee schedule,57.17,108.52,APC
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.29,,,,,,,fee schedule,57.17,108.52,APC
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,108.52,,,,,,,fee schedule,57.17,108.52,APC
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.72,,,,,,,fee schedule,6.97,53.73,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.72,,,,,,,fee schedule,6.97,53.73,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.72,,,,,,,fee schedule,6.97,53.73,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.73,,,,,,,fee schedule,6.97,53.73,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.32,,,,,,,fee schedule,6.97,53.73,APC
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.97,,,,,,,fee schedule,6.97,53.73,APC
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.55,,,,,,,fee schedule,6.97,53.73,APC
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.6,,,,,,,fee schedule,1.6,1.84,
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.6,1.84,
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.6,,,,,,,fee schedule,1.6,1.84,
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.84,,,,,,,fee schedule,1.6,1.84,
Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,180.2,,,,,,,fee schedule,180.2,432.02,
Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.2,,,,,,,fee schedule,180.2,432.02,
Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,180.2,,,,,,,fee schedule,180.2,432.02,
Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,207.23,,,,,,,fee schedule,180.2,432.02,
Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,252.01,,,,,,,fee schedule,180.2,432.02,APC
Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,240.01,,,,,,,fee schedule,180.2,432.02,APC
Carmustine injection,J9050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,432.02,,,,,,,fee schedule,180.2,432.02,APC
"Inj, bortezomib (maia)",J9051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.49,,,,,,,fee schedule,3.49,4.01,
"Inj, bortezomib (maia)",J9051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.49,,,,,,,fee schedule,3.49,4.01,
"Inj, bortezomib (maia)",J9051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.49,,,,,,,fee schedule,3.49,4.01,
"Inj, bortezomib (maia)",J9051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.01,,,,,,,fee schedule,3.49,4.01,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,249.9,,,,,,,fee schedule,249.9,287.39,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,249.9,,,,,,,fee schedule,249.9,287.39,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,249.9,,,,,,,fee schedule,249.9,287.39,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,287.39,,,,,,,fee schedule,249.9,287.39,
Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.01,,,,,,,fee schedule,24.75,44.54,
Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.01,,,,,,,fee schedule,24.75,44.54,
Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.01,,,,,,,fee schedule,24.75,44.54,
Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.91,,,,,,,fee schedule,24.75,44.54,
Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.98,,,,,,,fee schedule,24.75,44.54,APC
Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.75,,,,,,,fee schedule,24.75,44.54,APC
Inj bortezomib boruzu 0.1 mg,J9054,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.54,,,,,,,fee schedule,24.75,44.54,APC
Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.43,,,,,,,fee schedule,81.43,147,
Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.43,,,,,,,fee schedule,81.43,147,
Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.43,,,,,,,fee schedule,81.43,147,
Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.64,,,,,,,fee schedule,81.43,147,
Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.75,,,,,,,fee schedule,81.43,147,APC
Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,81.67,,,,,,,fee schedule,81.43,147,APC
Cetuximab injection,J9055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,147,,,,,,,fee schedule,81.43,147,APC
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.12,,,,,,,fee schedule,29.12,53.84,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.12,,,,,,,fee schedule,29.12,53.84,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.12,,,,,,,fee schedule,29.12,53.84,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.49,,,,,,,fee schedule,29.12,53.84,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.41,,,,,,,fee schedule,29.12,53.84,APC
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.91,,,,,,,fee schedule,29.12,53.84,APC
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.84,,,,,,,fee schedule,29.12,53.84,APC
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.31,,,,,,,fee schedule,89.31,102.71,
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.31,,,,,,,fee schedule,89.31,102.71,
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.31,,,,,,,fee schedule,89.31,102.71,
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.71,,,,,,,fee schedule,89.31,102.71,
Cisplatin 10 mg injection,J9060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.02,,,,,,,fee schedule,2.02,2.32,
Cisplatin 10 mg injection,J9060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.02,,,,,,,fee schedule,2.02,2.32,
Cisplatin 10 mg injection,J9060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.02,,,,,,,fee schedule,2.02,2.32,
Cisplatin 10 mg injection,J9060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.32,,,,,,,fee schedule,2.02,2.32,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.05,,,,,,,fee schedule,23.05,41.79,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.05,,,,,,,fee schedule,23.05,41.79,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.05,,,,,,,fee schedule,23.05,41.79,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.51,,,,,,,fee schedule,23.05,41.79,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.38,,,,,,,fee schedule,23.05,41.79,APC
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.22,,,,,,,fee schedule,23.05,41.79,APC
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41.79,,,,,,,fee schedule,23.05,41.79,APC
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.14,,,,,,,fee schedule,71.99,129.58,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.14,,,,,,,fee schedule,71.99,129.58,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.14,,,,,,,fee schedule,71.99,129.58,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.96,,,,,,,fee schedule,71.99,129.58,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.59,,,,,,,fee schedule,71.99,129.58,APC
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.99,,,,,,,fee schedule,71.99,129.58,APC
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.58,,,,,,,fee schedule,71.99,129.58,APC
Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.09,,,,,,,fee schedule,8.19,14.74,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.09,,,,,,,fee schedule,8.19,14.74,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.09,,,,,,,fee schedule,8.19,14.74,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.6,,,,,,,fee schedule,8.19,14.74,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.6,,,,,,,fee schedule,8.19,14.74,APC
Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.19,,,,,,,fee schedule,8.19,14.74,APC
Inj cladribine per 1 mg,J9065,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.74,,,,,,,fee schedule,8.19,14.74,APC
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.81,,,,,,,fee schedule,0.49,0.93,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.81,,,,,,,fee schedule,0.49,0.93,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.81,,,,,,,fee schedule,0.49,0.93,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.93,,,,,,,fee schedule,0.49,0.93,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.51,,,,,,,fee schedule,0.49,0.93,APC
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.49,,,,,,,fee schedule,0.49,0.93,APC
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.88,,,,,,,fee schedule,0.49,0.93,APC
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.34,,,,,,,fee schedule,8.92,16.06,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.34,,,,,,,fee schedule,8.92,16.06,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.34,,,,,,,fee schedule,8.92,16.06,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.74,,,,,,,fee schedule,8.92,16.06,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.37,,,,,,,fee schedule,8.92,16.06,APC
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.92,,,,,,,fee schedule,8.92,16.06,APC
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.06,,,,,,,fee schedule,8.92,16.06,APC
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.2,,,,,,,fee schedule,0.5,1.38,
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.2,,,,,,,fee schedule,0.5,1.38,
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.2,,,,,,,fee schedule,0.5,1.38,
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.38,,,,,,,fee schedule,0.5,1.38,
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.52,,,,,,,fee schedule,0.5,1.38,APC
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.5,,,,,,,fee schedule,0.5,1.38,APC
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.9,,,,,,,fee schedule,0.5,1.38,APC
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.37,,,,,,,fee schedule,3.44,6.19,
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.37,,,,,,,fee schedule,3.44,6.19,
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.37,,,,,,,fee schedule,3.44,6.19,
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.03,,,,,,,fee schedule,3.44,6.19,
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.61,,,,,,,fee schedule,3.44,6.19,APC
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.44,,,,,,,fee schedule,3.44,6.19,APC
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6.19,,,,,,,fee schedule,3.44,6.19,APC
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.65,,,,,,,fee schedule,0.58,1.04,
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.65,,,,,,,fee schedule,0.58,1.04,
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.65,,,,,,,fee schedule,0.58,1.04,
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.75,,,,,,,fee schedule,0.58,1.04,
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.6,,,,,,,fee schedule,0.58,1.04,APC
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.58,,,,,,,fee schedule,0.58,1.04,APC
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.04,,,,,,,fee schedule,0.58,1.04,APC
"Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.22,,,,,,,fee schedule,4.39,7.9,
"Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.22,,,,,,,fee schedule,4.39,7.9,
"Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.22,,,,,,,fee schedule,4.39,7.9,
"Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6,,,,,,,fee schedule,4.39,7.9,
"Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.61,,,,,,,fee schedule,4.39,7.9,APC
"Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.39,,,,,,,fee schedule,4.39,7.9,APC
"Inj, cyclophos (baxter) 5mg",J9076,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.9,,,,,,,fee schedule,4.39,7.9,APC
Cytarabine liposome inj,J9098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,604.66,,,,,,,fee schedule,604.66,695.36,
Cytarabine liposome inj,J9098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,604.66,,,,,,,fee schedule,604.66,695.36,
Cytarabine liposome inj,J9098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,604.66,,,,,,,fee schedule,604.66,695.36,
Cytarabine liposome inj,J9098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,695.36,,,,,,,fee schedule,604.66,695.36,
Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.84,,,,,,,fee schedule,0.84,0.97,
Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.84,,,,,,,fee schedule,0.84,0.97,
Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.84,,,,,,,fee schedule,0.84,0.97,
Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.97,,,,,,,fee schedule,0.84,0.97,
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85,,,,,,,fee schedule,85,154.42,
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85,,,,,,,fee schedule,85,154.42,
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85,,,,,,,fee schedule,85,154.42,
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.75,,,,,,,fee schedule,85,154.42,
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.08,,,,,,,fee schedule,85,154.42,APC
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,85.79,,,,,,,fee schedule,85,154.42,APC
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,154.42,,,,,,,fee schedule,85,154.42,APC
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.78,,,,,,,fee schedule,29.67,53.4,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.78,,,,,,,fee schedule,29.67,53.4,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.78,,,,,,,fee schedule,29.67,53.4,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.25,,,,,,,fee schedule,29.67,53.4,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.15,,,,,,,fee schedule,29.67,53.4,APC
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.67,,,,,,,fee schedule,29.67,53.4,APC
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.4,,,,,,,fee schedule,29.67,53.4,APC
Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,314.35,,,,,,,fee schedule,307.41,553.34,
Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,314.35,,,,,,,fee schedule,307.41,553.34,
Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,314.35,,,,,,,fee schedule,307.41,553.34,
Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,361.5,,,,,,,fee schedule,307.41,553.34,
Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,322.78,,,,,,,fee schedule,307.41,553.34,APC
Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,307.41,,,,,,,fee schedule,307.41,553.34,APC
Dactinomycin injection,J9120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,553.34,,,,,,,fee schedule,307.41,553.34,APC
Dacarbazine 100 mg inj,J9130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.96,,,,,,,fee schedule,3.96,4.55,
Dacarbazine 100 mg inj,J9130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.96,,,,,,,fee schedule,3.96,4.55,
Dacarbazine 100 mg inj,J9130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.96,,,,,,,fee schedule,3.96,4.55,
Dacarbazine 100 mg inj,J9130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.55,,,,,,,fee schedule,3.96,4.55,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.73,,,,,,,fee schedule,56.73,102.69,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.73,,,,,,,fee schedule,56.73,102.69,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,56.73,,,,,,,fee schedule,56.73,102.69,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,65.24,,,,,,,fee schedule,56.73,102.69,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.9,,,,,,,fee schedule,56.73,102.69,APC
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57.05,,,,,,,fee schedule,56.73,102.69,APC
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,102.69,,,,,,,fee schedule,56.73,102.69,APC
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.47,,,,,,,fee schedule,72.47,132.79,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.47,,,,,,,fee schedule,72.47,132.79,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.47,,,,,,,fee schedule,72.47,132.79,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.34,,,,,,,fee schedule,72.47,132.79,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.46,,,,,,,fee schedule,72.47,132.79,APC
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.77,,,,,,,fee schedule,72.47,132.79,APC
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.79,,,,,,,fee schedule,72.47,132.79,APC
Daunorubicin injection,J9150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.51,,,,,,,fee schedule,20.51,23.59,
Daunorubicin injection,J9150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.51,,,,,,,fee schedule,20.51,23.59,
Daunorubicin injection,J9150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.51,,,,,,,fee schedule,20.51,23.59,
Daunorubicin injection,J9150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.59,,,,,,,fee schedule,20.51,23.59,
Daunorubicin citrate inj,J9151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,234.6,,,,,,,fee schedule,234.6,269.79,
Daunorubicin citrate inj,J9151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.6,,,,,,,fee schedule,234.6,269.79,
Daunorubicin citrate inj,J9151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,234.6,,,,,,,fee schedule,234.6,269.79,
Daunorubicin citrate inj,J9151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,269.79,,,,,,,fee schedule,234.6,269.79,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,264.72,,,,,,,fee schedule,264.72,491.19,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,264.72,,,,,,,fee schedule,264.72,491.19,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.72,,,,,,,fee schedule,264.72,491.19,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,304.43,,,,,,,fee schedule,264.72,491.19,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,286.53,,,,,,,fee schedule,264.72,491.19,APC
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,272.89,,,,,,,fee schedule,264.72,491.19,APC
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,491.19,,,,,,,fee schedule,264.72,491.19,APC
Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.52,,,,,,,fee schedule,4.48,8.07,
Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.52,,,,,,,fee schedule,4.48,8.07,
Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.52,,,,,,,fee schedule,4.48,8.07,
Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.2,,,,,,,fee schedule,4.48,8.07,
Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.71,,,,,,,fee schedule,4.48,8.07,APC
Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.48,8.07,APC
Degarelix injection,J9155,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.07,,,,,,,fee schedule,4.48,8.07,APC
Diethylstilbestrol injection,J9165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.89,,,,,,,fee schedule,12.89,14.82,
Diethylstilbestrol injection,J9165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.89,,,,,,,fee schedule,12.89,14.82,
Diethylstilbestrol injection,J9165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.89,,,,,,,fee schedule,12.89,14.82,
Diethylstilbestrol injection,J9165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.82,,,,,,,fee schedule,12.89,14.82,
Docetaxel injection,J9171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.39,,,,,,,fee schedule,0.39,0.45,
Docetaxel injection,J9171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.39,,,,,,,fee schedule,0.39,0.45,
Docetaxel injection,J9171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.39,,,,,,,fee schedule,0.39,0.45,
Docetaxel injection,J9171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.45,,,,,,,fee schedule,0.39,0.45,
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.93,,,,,,,fee schedule,46.29,83.32,
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.93,,,,,,,fee schedule,46.29,83.32,
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.93,,,,,,,fee schedule,46.29,83.32,
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.57,,,,,,,fee schedule,46.29,83.32,
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.6,,,,,,,fee schedule,46.29,83.32,APC
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.29,,,,,,,fee schedule,46.29,83.32,APC
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83.32,,,,,,,fee schedule,46.29,83.32,APC
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.47,,,,,,,fee schedule,87.95,158.31,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.47,,,,,,,fee schedule,87.95,158.31,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.47,,,,,,,fee schedule,87.95,158.31,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.74,,,,,,,fee schedule,87.95,158.31,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.35,,,,,,,fee schedule,87.95,158.31,APC
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,87.95,,,,,,,fee schedule,87.95,158.31,APC
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,158.31,,,,,,,fee schedule,87.95,158.31,APC
"Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.49,,,,,,,fee schedule,46.81,84.25,
"Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.49,,,,,,,fee schedule,46.81,84.25,
"Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.49,,,,,,,fee schedule,46.81,84.25,
"Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.06,,,,,,,fee schedule,46.81,84.25,
"Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.15,,,,,,,fee schedule,46.81,84.25,APC
"Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.81,,,,,,,fee schedule,46.81,84.25,APC
"Inj, docetaxel (beizray) 1mg",J9174,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84.25,,,,,,,fee schedule,46.81,84.25,APC
Elliotts b solution per ml,J9175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.4,,,,,,,fee schedule,10.4,11.96,
Elliotts b solution per ml,J9175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.4,,,,,,,fee schedule,10.4,11.96,
Elliotts b solution per ml,J9175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.4,,,,,,,fee schedule,10.4,11.96,
Elliotts b solution per ml,J9175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.96,,,,,,,fee schedule,10.4,11.96,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.17,,,,,,,fee schedule,8.17,14.74,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.17,,,,,,,fee schedule,8.17,14.74,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.17,,,,,,,fee schedule,8.17,14.74,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.4,,,,,,,fee schedule,8.17,14.74,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.6,,,,,,,fee schedule,8.17,14.74,APC
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.19,,,,,,,fee schedule,8.17,14.74,APC
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.74,,,,,,,fee schedule,8.17,14.74,APC
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.05,,,,,,,fee schedule,36.66,65.98,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.05,,,,,,,fee schedule,36.66,65.98,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.05,,,,,,,fee schedule,36.66,65.98,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.76,,,,,,,fee schedule,36.66,65.98,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.49,,,,,,,fee schedule,36.66,65.98,APC
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.66,,,,,,,fee schedule,36.66,65.98,APC
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.98,,,,,,,fee schedule,36.66,65.98,APC
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.65,,,,,,,fee schedule,1.65,1.9,
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.65,,,,,,,fee schedule,1.65,1.9,
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.65,,,,,,,fee schedule,1.65,1.9,
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.9,,,,,,,fee schedule,1.65,1.9,
Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.53,,,,,,,fee schedule,59.98,124.81,
Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.53,,,,,,,fee schedule,59.98,124.81,
Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.53,,,,,,,fee schedule,59.98,124.81,
Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.81,,,,,,,fee schedule,59.98,124.81,
Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,62.98,,,,,,,fee schedule,59.98,124.81,APC
Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,59.98,,,,,,,fee schedule,59.98,124.81,APC
Eribulin mesylate injection,J9179,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,107.96,,,,,,,fee schedule,59.98,124.81,APC
Etoposide injection,J9181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.35,,,,,,,fee schedule,1.35,1.55,
Etoposide injection,J9181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.35,,,,,,,fee schedule,1.35,1.55,
Etoposide injection,J9181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.35,,,,,,,fee schedule,1.35,1.55,
Etoposide injection,J9181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.55,,,,,,,fee schedule,1.35,1.55,
Fludarabine phosphate inj,J9185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,74.35,,,,,,,fee schedule,74.35,85.5,
Fludarabine phosphate inj,J9185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.35,,,,,,,fee schedule,74.35,85.5,
Fludarabine phosphate inj,J9185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.35,,,,,,,fee schedule,74.35,85.5,
Fludarabine phosphate inj,J9185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,85.5,,,,,,,fee schedule,74.35,85.5,
Fluorouracil injection,J9190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.78,,,,,,,fee schedule,1.78,2.05,
Fluorouracil injection,J9190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.78,,,,,,,fee schedule,1.78,2.05,
Fluorouracil injection,J9190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.78,,,,,,,fee schedule,1.78,2.05,
Fluorouracil injection,J9190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.05,,,,,,,fee schedule,1.78,2.05,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.49,,,,,,,fee schedule,5.49,6.31,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.49,,,,,,,fee schedule,5.49,6.31,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.49,,,,,,,fee schedule,5.49,6.31,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.31,,,,,,,fee schedule,5.49,6.31,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.76,,,,,,,fee schedule,38.76,44.57,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.76,,,,,,,fee schedule,38.76,44.57,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.76,,,,,,,fee schedule,38.76,44.57,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.57,,,,,,,fee schedule,38.76,44.57,
Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4281.23,,,,,,,fee schedule,4281.23,7913.69,
Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4281.23,,,,,,,fee schedule,4281.23,7913.69,
Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4281.23,,,,,,,fee schedule,4281.23,7913.69,
Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4923.41,,,,,,,fee schedule,4281.23,7913.69,
Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4616.32,,,,,,,fee schedule,4281.23,7913.69,APC
Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4396.49,,,,,,,fee schedule,4281.23,7913.69,APC
Floxuridine injection,J9200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7913.69,,,,,,,fee schedule,4281.23,7913.69,APC
Gemcitabine hcl injection,J9201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.07,,,,,,,fee schedule,3.07,3.53,
Gemcitabine hcl injection,J9201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.07,,,,,,,fee schedule,3.07,3.53,
Gemcitabine hcl injection,J9201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.07,,,,,,,fee schedule,3.07,3.53,
Gemcitabine hcl injection,J9201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.53,,,,,,,fee schedule,3.07,3.53,
Goserelin acetate implant,J9202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,761.85,,,,,,,fee schedule,761.85,876.13,
Goserelin acetate implant,J9202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,761.85,,,,,,,fee schedule,761.85,876.13,
Goserelin acetate implant,J9202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,761.85,,,,,,,fee schedule,761.85,876.13,
Goserelin acetate implant,J9202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,876.13,,,,,,,fee schedule,761.85,876.13,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,245.54,,,,,,,fee schedule,245.54,445.27,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,245.54,,,,,,,fee schedule,245.54,445.27,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,245.54,,,,,,,fee schedule,245.54,445.27,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,282.37,,,,,,,fee schedule,245.54,445.27,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.74,,,,,,,fee schedule,245.54,445.27,APC
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,247.37,,,,,,,fee schedule,245.54,445.27,APC
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,445.27,,,,,,,fee schedule,245.54,445.27,APC
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,257.87,,,,,,,fee schedule,257.87,465.36,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,257.87,,,,,,,fee schedule,257.87,465.36,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,257.87,,,,,,,fee schedule,257.87,465.36,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,296.55,,,,,,,fee schedule,257.87,465.36,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,271.46,,,,,,,fee schedule,257.87,465.36,APC
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,258.54,,,,,,,fee schedule,257.87,465.36,APC
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,465.36,,,,,,,fee schedule,257.87,465.36,APC
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.72,,,,,,,fee schedule,65.86,118.55,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.72,,,,,,,fee schedule,65.86,118.55,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.72,,,,,,,fee schedule,65.86,118.55,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.88,,,,,,,fee schedule,65.86,118.55,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.15,,,,,,,fee schedule,65.86,118.55,APC
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.86,,,,,,,fee schedule,65.86,118.55,APC
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,118.55,,,,,,,fee schedule,65.86,118.55,APC
Irinotecan injection,J9206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.45,,,,,,,fee schedule,1.45,1.67,
Irinotecan injection,J9206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.45,,,,,,,fee schedule,1.45,1.67,
Irinotecan injection,J9206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.45,,,,,,,fee schedule,1.45,1.67,
Irinotecan injection,J9206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.67,,,,,,,fee schedule,1.45,1.67,
Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.9,,,,,,,fee schedule,139.75,251.56,
Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,143.9,,,,,,,fee schedule,139.75,251.56,
Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.9,,,,,,,fee schedule,139.75,251.56,
Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.49,,,,,,,fee schedule,139.75,251.56,
Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,146.74,,,,,,,fee schedule,139.75,251.56,APC
Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,139.75,,,,,,,fee schedule,139.75,251.56,APC
Ixabepilone injection,J9207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,251.56,,,,,,,fee schedule,139.75,251.56,APC
Ifosfamide injection,J9208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.38,,,,,,,fee schedule,24.38,28.04,
Ifosfamide injection,J9208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.38,,,,,,,fee schedule,24.38,28.04,
Ifosfamide injection,J9208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.38,,,,,,,fee schedule,24.38,28.04,
Ifosfamide injection,J9208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.04,,,,,,,fee schedule,24.38,28.04,
Mesna injection,J9209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.38,,,,,,,fee schedule,1.38,1.59,
Mesna injection,J9209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.38,,,,,,,fee schedule,1.38,1.59,
Mesna injection,J9209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.38,,,,,,,fee schedule,1.38,1.59,
Mesna injection,J9209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.59,,,,,,,fee schedule,1.38,1.59,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,396.04,,,,,,,fee schedule,392.78,707,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,396.04,,,,,,,fee schedule,392.78,707,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,396.04,,,,,,,fee schedule,392.78,707,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,455.45,,,,,,,fee schedule,392.78,707,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,412.42,,,,,,,fee schedule,392.78,707,APC
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,392.78,,,,,,,fee schedule,392.78,707,APC
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,707,,,,,,,fee schedule,392.78,707,APC
Idarubicin hcl injection,J9211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.45,,,,,,,fee schedule,38.45,44.22,
Idarubicin hcl injection,J9211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.45,,,,,,,fee schedule,38.45,44.22,
Idarubicin hcl injection,J9211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.45,,,,,,,fee schedule,38.45,44.22,
Idarubicin hcl injection,J9211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.22,,,,,,,fee schedule,38.45,44.22,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.85,,,,,,,fee schedule,9.85,11.33,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.85,,,,,,,fee schedule,9.85,11.33,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.85,,,,,,,fee schedule,9.85,11.33,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.33,,,,,,,fee schedule,9.85,11.33,
Interferon alfa-2a inj,J9213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.82,,,,,,,fee schedule,42.82,49.24,
Interferon alfa-2a inj,J9213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.82,,,,,,,fee schedule,42.82,49.24,
Interferon alfa-2a inj,J9213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.82,,,,,,,fee schedule,42.82,49.24,
Interferon alfa-2a inj,J9213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.24,,,,,,,fee schedule,42.82,49.24,
Interferon alfa-2b inj,J9214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.35,,,,,,,fee schedule,31.35,36.05,
Interferon alfa-2b inj,J9214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.35,,,,,,,fee schedule,31.35,36.05,
Interferon alfa-2b inj,J9214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.35,,,,,,,fee schedule,31.35,36.05,
Interferon alfa-2b inj,J9214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.05,,,,,,,fee schedule,31.35,36.05,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.72,,,,,,,fee schedule,30.72,35.33,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.72,,,,,,,fee schedule,30.72,35.33,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.72,,,,,,,fee schedule,30.72,35.33,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.33,,,,,,,fee schedule,30.72,35.33,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8628.84,,,,,,,fee schedule,8628.84,9923.17,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8628.84,,,,,,,fee schedule,8628.84,9923.17,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8628.84,,,,,,,fee schedule,8628.84,9923.17,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9923.17,,,,,,,fee schedule,8628.84,9923.17,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.28,,,,,,,fee schedule,160.34,288.62,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.28,,,,,,,fee schedule,160.34,288.62,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.28,,,,,,,fee schedule,160.34,288.62,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.47,,,,,,,fee schedule,160.34,288.62,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.36,,,,,,,fee schedule,160.34,288.62,APC
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,160.34,,,,,,,fee schedule,160.34,288.62,APC
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,288.62,,,,,,,fee schedule,160.34,288.62,APC
Leuprolide acetate injeciton,J9218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.42,,,,,,,fee schedule,51.42,59.13,
Leuprolide acetate injeciton,J9218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.42,,,,,,,fee schedule,51.42,59.13,
Leuprolide acetate injeciton,J9218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.42,,,,,,,fee schedule,51.42,59.13,
Leuprolide acetate injeciton,J9218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.13,,,,,,,fee schedule,51.42,59.13,
Leuprolide acetate implant,J9219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5001.7,,,,,,,fee schedule,5001.7,5751.96,
Leuprolide acetate implant,J9219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5001.7,,,,,,,fee schedule,5001.7,5751.96,
Leuprolide acetate implant,J9219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5001.7,,,,,,,fee schedule,5001.7,5751.96,
Leuprolide acetate implant,J9219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5751.96,,,,,,,fee schedule,5001.7,5751.96,
Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.2,,,,,,,fee schedule,9.3,16.74,
Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.2,,,,,,,fee schedule,9.3,16.74,
Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.2,,,,,,,fee schedule,9.3,16.74,
Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.73,,,,,,,fee schedule,9.3,16.74,
Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.77,,,,,,,fee schedule,9.3,16.74,APC
Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.3,,,,,,,fee schedule,9.3,16.74,APC
Indigotindisulfonate sod 1mg,J9220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.74,,,,,,,fee schedule,9.3,16.74,APC
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,213.9,,,,,,,fee schedule,213.9,388.71,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.9,,,,,,,fee schedule,213.9,388.71,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,213.9,,,,,,,fee schedule,213.9,388.71,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,245.99,,,,,,,fee schedule,213.9,388.71,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,226.75,,,,,,,fee schedule,213.9,388.71,APC
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.95,,,,,,,fee schedule,213.9,388.71,APC
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,388.71,,,,,,,fee schedule,213.9,388.71,APC
Vantas implant,J9225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4971.34,,,,,,,fee schedule,4971.34,5717.04,
Vantas implant,J9225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4971.34,,,,,,,fee schedule,4971.34,5717.04,
Vantas implant,J9225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4971.34,,,,,,,fee schedule,4971.34,5717.04,
Vantas implant,J9225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5717.04,,,,,,,fee schedule,4971.34,5717.04,
Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47279.65,,,,,,,fee schedule,37491.97,67485.55,
Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47279.65,,,,,,,fee schedule,37491.97,67485.55,
Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47279.65,,,,,,,fee schedule,37491.97,67485.55,
Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54371.6,,,,,,,fee schedule,37491.97,67485.55,
Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39366.57,,,,,,,fee schedule,37491.97,67485.55,APC
Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37491.97,,,,,,,fee schedule,37491.97,67485.55,APC
Supprelin LA implant,J9226,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67485.55,,,,,,,fee schedule,37491.97,67485.55,APC
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.99,,,,,,,fee schedule,85.99,158.69,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.99,,,,,,,fee schedule,85.99,158.69,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.99,,,,,,,fee schedule,85.99,158.69,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,98.89,,,,,,,fee schedule,85.99,158.69,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.57,,,,,,,fee schedule,85.99,158.69,APC
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,88.16,,,,,,,fee schedule,85.99,158.69,APC
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,158.69,,,,,,,fee schedule,85.99,158.69,APC
Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.34,,,,,,,fee schedule,190.34,342.78,
Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.34,,,,,,,fee schedule,190.34,342.78,
Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,190.34,,,,,,,fee schedule,190.34,342.78,
Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,218.89,,,,,,,fee schedule,190.34,342.78,
Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,199.95,,,,,,,fee schedule,190.34,342.78,APC
Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,190.43,,,,,,,fee schedule,190.34,342.78,APC
Ipilimumab injection,J9228,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,342.78,,,,,,,fee schedule,190.34,342.78,APC
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2799.87,,,,,,,fee schedule,2799.87,5171.59,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2799.87,,,,,,,fee schedule,2799.87,5171.59,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2799.87,,,,,,,fee schedule,2799.87,5171.59,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3219.85,,,,,,,fee schedule,2799.87,5171.59,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3016.76,,,,,,,fee schedule,2799.87,5171.59,APC
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2873.1,,,,,,,fee schedule,2799.87,5171.59,APC
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5171.59,,,,,,,fee schedule,2799.87,5171.59,APC
Mechlorethamine hcl inj,J9230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.9,,,,,,,fee schedule,315.9,363.29,
Mechlorethamine hcl inj,J9230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,315.9,,,,,,,fee schedule,315.9,363.29,
Mechlorethamine hcl inj,J9230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,315.9,,,,,,,fee schedule,315.9,363.29,
Mechlorethamine hcl inj,J9230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,363.29,,,,,,,fee schedule,315.9,363.29,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.11,,,,,,,fee schedule,104.9,188.82,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112.11,,,,,,,fee schedule,104.9,188.82,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.11,,,,,,,fee schedule,104.9,188.82,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.93,,,,,,,fee schedule,104.9,188.82,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.14,,,,,,,fee schedule,104.9,188.82,APC
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.9,,,,,,,fee schedule,104.9,188.82,APC
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,188.82,,,,,,,fee schedule,104.9,188.82,APC
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.03,,,,,,,fee schedule,18.03,32.48,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.03,,,,,,,fee schedule,18.03,32.48,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.03,,,,,,,fee schedule,18.03,32.48,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.73,,,,,,,fee schedule,18.03,32.48,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.95,,,,,,,fee schedule,18.03,32.48,APC
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.04,,,,,,,fee schedule,18.03,32.48,APC
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32.48,,,,,,,fee schedule,18.03,32.48,APC
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,817.52,,,,,,,fee schedule,801.48,1442.66,
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,817.52,,,,,,,fee schedule,801.48,1442.66,
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,817.52,,,,,,,fee schedule,801.48,1442.66,
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,940.15,,,,,,,fee schedule,801.48,1442.66,
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,841.55,,,,,,,fee schedule,801.48,1442.66,APC
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,801.48,,,,,,,fee schedule,801.48,1442.66,APC
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1442.66,,,,,,,fee schedule,801.48,1442.66,APC
"Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.33,,,,,,,fee schedule,62.33,116.6,
"Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.33,,,,,,,fee schedule,62.33,116.6,
"Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.33,,,,,,,fee schedule,62.33,116.6,
"Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.68,,,,,,,fee schedule,62.33,116.6,
"Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.02,,,,,,,fee schedule,62.33,116.6,APC
"Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.78,,,,,,,fee schedule,62.33,116.6,APC
"Inj, melphalan (apotex) 1 mg",J9249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,116.6,,,,,,,fee schedule,62.33,116.6,APC
Methotrexate sodium inj,J9260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.35,,,,,,,fee schedule,2.35,2.7,
Methotrexate sodium inj,J9260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.35,,,,,,,fee schedule,2.35,2.7,
Methotrexate sodium inj,J9260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.35,,,,,,,fee schedule,2.35,2.7,
Methotrexate sodium inj,J9260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.7,,,,,,,fee schedule,2.35,2.7,
Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.77,,,,,,,fee schedule,65.41,117.73,
Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.77,,,,,,,fee schedule,65.41,117.73,
Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.77,,,,,,,fee schedule,65.41,117.73,
Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.64,,,,,,,fee schedule,65.41,117.73,
Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.68,,,,,,,fee schedule,65.41,117.73,APC
Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.41,,,,,,,fee schedule,65.41,117.73,APC
Nelarabine injection,J9261,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,117.73,,,,,,,fee schedule,65.41,117.73,APC
"Inj, omacetaxine mep, 0.01mg",J9262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.88,,,,,,,fee schedule,3.88,4.46,
"Inj, omacetaxine mep, 0.01mg",J9262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.88,,,,,,,fee schedule,3.88,4.46,
"Inj, omacetaxine mep, 0.01mg",J9262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.88,,,,,,,fee schedule,3.88,4.46,
"Inj, omacetaxine mep, 0.01mg",J9262,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.46,,,,,,,fee schedule,3.88,4.46,
Oxaliplatin,J9263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
Oxaliplatin,J9263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.09,,,,,,,fee schedule,0.09,0.1,
Oxaliplatin,J9263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.09,,,,,,,fee schedule,0.09,0.1,
Oxaliplatin,J9263,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.1,,,,,,,fee schedule,0.09,0.1,
Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.58,,,,,,,fee schedule,6.59,14.47,
Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.58,,,,,,,fee schedule,6.59,14.47,
Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.58,,,,,,,fee schedule,6.59,14.47,
Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.47,,,,,,,fee schedule,6.59,14.47,
Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.92,,,,,,,fee schedule,6.59,14.47,APC
Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.59,,,,,,,fee schedule,6.59,14.47,APC
Paclitaxel protein bound,J9264,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.85,,,,,,,fee schedule,6.59,14.47,APC
Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29496.67,,,,,,,fee schedule,29496.67,53395.14,
Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29496.67,,,,,,,fee schedule,29496.67,53395.14,
Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29496.67,,,,,,,fee schedule,29496.67,53395.14,
Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33921.17,,,,,,,fee schedule,29496.67,53395.14,
Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31147.16,,,,,,,fee schedule,29496.67,53395.14,APC
Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29663.96,,,,,,,fee schedule,29496.67,53395.14,APC
Pegaspargase injection,J9266,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53395.14,,,,,,,fee schedule,29496.67,53395.14,APC
Paclitaxel injection,J9267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.11,,,,,,,fee schedule,0.11,0.13,
Paclitaxel injection,J9267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.11,,,,,,,fee schedule,0.11,0.13,
Paclitaxel injection,J9267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.11,,,,,,,fee schedule,0.11,0.13,
Paclitaxel injection,J9267,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.13,,,,,,,fee schedule,0.11,0.13,
Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2639.89,,,,,,,fee schedule,2639.89,4856.38,
Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2639.89,,,,,,,fee schedule,2639.89,4856.38,
Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2639.89,,,,,,,fee schedule,2639.89,4856.38,
Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3035.87,,,,,,,fee schedule,2639.89,4856.38,
Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2832.89,,,,,,,fee schedule,2639.89,4856.38,APC
Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2697.99,,,,,,,fee schedule,2639.89,4856.38,APC
Pentostatin injection,J9268,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4856.38,,,,,,,fee schedule,2639.89,4856.38,APC
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,361.77,,,,,,,fee schedule,357.52,643.54,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,361.77,,,,,,,fee schedule,357.52,643.54,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,361.77,,,,,,,fee schedule,357.52,643.54,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,416.04,,,,,,,fee schedule,357.52,643.54,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.4,,,,,,,fee schedule,357.52,643.54,APC
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,357.52,,,,,,,fee schedule,357.52,643.54,APC
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,643.54,,,,,,,fee schedule,357.52,643.54,APC
Plicamycin (mithramycin) inj,J9270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.93,,,,,,,fee schedule,83.93,96.52,
Plicamycin (mithramycin) inj,J9270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.93,,,,,,,fee schedule,83.93,96.52,
Plicamycin (mithramycin) inj,J9270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.93,,,,,,,fee schedule,83.93,96.52,
Plicamycin (mithramycin) inj,J9270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.52,,,,,,,fee schedule,83.93,96.52,
Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.77,,,,,,,fee schedule,60.64,109.16,
Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.77,,,,,,,fee schedule,60.64,109.16,
Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.77,,,,,,,fee schedule,60.64,109.16,
Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.89,,,,,,,fee schedule,60.64,109.16,
Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.68,,,,,,,fee schedule,60.64,109.16,APC
Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.64,,,,,,,fee schedule,60.64,109.16,APC
Inj pembrolizumab,J9271,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,109.16,,,,,,,fee schedule,60.64,109.16,APC
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,253.02,,,,,,,fee schedule,251.3,452.34,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,253.02,,,,,,,fee schedule,251.3,452.34,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,253.02,,,,,,,fee schedule,251.3,452.34,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.97,,,,,,,fee schedule,251.3,452.34,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,263.86,,,,,,,fee schedule,251.3,452.34,APC
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,251.3,,,,,,,fee schedule,251.3,452.34,APC
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,452.34,,,,,,,fee schedule,251.3,452.34,APC
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.77,,,,,,,fee schedule,195.77,353.02,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.77,,,,,,,fee schedule,195.77,353.02,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,195.77,,,,,,,fee schedule,195.77,353.02,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.14,,,,,,,fee schedule,195.77,353.02,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,205.93,,,,,,,fee schedule,195.77,353.02,APC
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,196.12,,,,,,,fee schedule,195.77,353.02,APC
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,353.02,,,,,,,fee schedule,195.77,353.02,APC
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,225.28,,,,,,,fee schedule,225.28,410.41,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,225.28,,,,,,,fee schedule,225.28,410.41,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,225.28,,,,,,,fee schedule,225.28,410.41,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.07,,,,,,,fee schedule,225.28,410.41,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,239.41,,,,,,,fee schedule,225.28,410.41,APC
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,228.01,,,,,,,fee schedule,225.28,410.41,APC
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,410.41,,,,,,,fee schedule,225.28,410.41,APC
"Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.03,,,,,,,fee schedule,25.66,46.19,
"Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.03,,,,,,,fee schedule,25.66,46.19,
"Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.03,,,,,,,fee schedule,25.66,46.19,
"Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.93,,,,,,,fee schedule,25.66,46.19,
"Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.95,,,,,,,fee schedule,25.66,46.19,APC
"Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.66,,,,,,,fee schedule,25.66,46.19,APC
"Inj zanidatamab-hrii, 2 mg",J9276,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.19,,,,,,,fee schedule,25.66,46.19,APC
Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.34,,,,,,,fee schedule,29.34,61.39,
Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.34,,,,,,,fee schedule,29.34,61.39,
Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.34,,,,,,,fee schedule,29.34,61.39,
Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33.74,,,,,,,fee schedule,29.34,61.39,
Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.81,,,,,,,fee schedule,29.34,61.39,APC
Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.11,,,,,,,fee schedule,29.34,61.39,APC
Mitomycin injection,J9280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.39,,,,,,,fee schedule,29.34,61.39,APC
Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,329.4,,,,,,,fee schedule,329.4,593.89,
Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,329.4,,,,,,,fee schedule,329.4,593.89,
Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,329.4,,,,,,,fee schedule,329.4,593.89,
Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,378.81,,,,,,,fee schedule,329.4,593.89,
Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,346.43,,,,,,,fee schedule,329.4,593.89,APC
Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,329.94,,,,,,,fee schedule,329.4,593.89,APC
Mitomycin instillation,J9281,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,593.89,,,,,,,fee schedule,329.4,593.89,APC
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.1,,,,,,,fee schedule,50.1,57.62,
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.1,,,,,,,fee schedule,50.1,57.62,
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.1,,,,,,,fee schedule,50.1,57.62,
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,57.62,,,,,,,fee schedule,50.1,57.62,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2875.12,,,,,,,fee schedule,2864.68,5156.42,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2875.12,,,,,,,fee schedule,2864.68,5156.42,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2875.12,,,,,,,fee schedule,2864.68,5156.42,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3306.39,,,,,,,fee schedule,2864.68,5156.42,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3007.91,,,,,,,fee schedule,2864.68,5156.42,APC
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2864.68,,,,,,,fee schedule,2864.68,5156.42,APC
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5156.42,,,,,,,fee schedule,2864.68,5156.42,APC
Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.48,,,,,,,fee schedule,26.48,50.65,
Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.48,,,,,,,fee schedule,26.48,50.65,
Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.48,,,,,,,fee schedule,26.48,50.65,
Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.45,,,,,,,fee schedule,26.48,50.65,
Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.55,,,,,,,fee schedule,26.48,50.65,APC
Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.14,,,,,,,fee schedule,26.48,50.65,APC
Inj nivolumab 2 mg hyaluron,J9289,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.65,,,,,,,fee schedule,26.48,50.65,APC
"Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,86.43,,,,,,,fee schedule,73.67,132.61,
"Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.43,,,,,,,fee schedule,73.67,132.61,
"Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.43,,,,,,,fee schedule,73.67,132.61,
"Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,99.39,,,,,,,fee schedule,73.67,132.61,
"Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.35,,,,,,,fee schedule,73.67,132.61,APC
"Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.67,,,,,,,fee schedule,73.67,132.61,APC
"Inj, pemetrexed (avyxa) 10mg",J9292,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.61,,,,,,,fee schedule,73.67,132.61,APC
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30.72,,,,,,,fee schedule,29.7,53.46,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.72,,,,,,,fee schedule,29.7,53.46,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.72,,,,,,,fee schedule,29.7,53.46,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.33,,,,,,,fee schedule,29.7,53.46,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.19,,,,,,,fee schedule,29.7,53.46,APC
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.7,,,,,,,fee schedule,29.7,53.46,APC
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.46,,,,,,,fee schedule,29.7,53.46,APC
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.11,,,,,,,fee schedule,2.94,5.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.11,,,,,,,fee schedule,2.94,5.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.11,,,,,,,fee schedule,2.94,5.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.88,,,,,,,fee schedule,2.94,5.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.09,,,,,,,fee schedule,2.94,5.88,APC
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.94,,,,,,,fee schedule,2.94,5.88,APC
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.3,,,,,,,fee schedule,2.94,5.88,APC
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.95,,,,,,,fee schedule,5.73,10.32,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.95,,,,,,,fee schedule,5.73,10.32,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.95,,,,,,,fee schedule,5.73,10.32,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.84,,,,,,,fee schedule,5.73,10.32,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.02,,,,,,,fee schedule,5.73,10.32,APC
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.73,,,,,,,fee schedule,5.73,10.32,APC
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.32,,,,,,,fee schedule,5.73,10.32,APC
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.1,,,,,,,fee schedule,9.74,17.52,
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.1,,,,,,,fee schedule,9.74,17.52,
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.1,,,,,,,fee schedule,9.74,17.52,
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.62,,,,,,,fee schedule,9.74,17.52,
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.22,,,,,,,fee schedule,9.74,17.52,APC
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.74,,,,,,,fee schedule,9.74,17.52,APC
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.52,,,,,,,fee schedule,9.74,17.52,APC
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.25,,,,,,,fee schedule,1.25,1.44,
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.25,,,,,,,fee schedule,1.25,1.44,
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.25,,,,,,,fee schedule,1.25,1.44,
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.44,,,,,,,fee schedule,1.25,1.44,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,205.11,,,,,,,fee schedule,205.11,369.92,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,205.11,,,,,,,fee schedule,205.11,369.92,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,205.11,,,,,,,fee schedule,205.11,369.92,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.88,,,,,,,fee schedule,205.11,369.92,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,215.79,,,,,,,fee schedule,205.11,369.92,APC
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,205.51,,,,,,,fee schedule,205.11,369.92,APC
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,369.92,,,,,,,fee schedule,205.11,369.92,APC
"Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.25,,,,,,,fee schedule,34.22,61.6,
"Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.25,,,,,,,fee schedule,34.22,61.6,
"Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.25,,,,,,,fee schedule,34.22,61.6,
"Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.39,,,,,,,fee schedule,34.22,61.6,
"Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.93,,,,,,,fee schedule,34.22,61.6,APC
"Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.22,,,,,,,fee schedule,34.22,61.6,APC
"Injection, nivolumab",J9299,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.6,,,,,,,fee schedule,34.22,61.6,APC
Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.42,,,,,,,fee schedule,81.42,152.03,
Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.42,,,,,,,fee schedule,81.42,152.03,
Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.42,,,,,,,fee schedule,81.42,152.03,
Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.63,,,,,,,fee schedule,81.42,152.03,
Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,88.69,,,,,,,fee schedule,81.42,152.03,APC
Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,84.46,,,,,,,fee schedule,81.42,152.03,APC
Obinutuzumab inj,J9301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,152.03,,,,,,,fee schedule,81.42,152.03,APC
Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.54,,,,,,,fee schedule,61.54,112.02,
Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61.54,,,,,,,fee schedule,61.54,112.02,
Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.54,,,,,,,fee schedule,61.54,112.02,
Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.77,,,,,,,fee schedule,61.54,112.02,
Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.35,,,,,,,fee schedule,61.54,112.02,APC
Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.23,,,,,,,fee schedule,61.54,112.02,APC
Ofatumumab injection,J9302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,112.02,,,,,,,fee schedule,61.54,112.02,APC
Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,179.06,,,,,,,fee schedule,179.06,327.94,
Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,179.06,,,,,,,fee schedule,179.06,327.94,
Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.06,,,,,,,fee schedule,179.06,327.94,
Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,205.92,,,,,,,fee schedule,179.06,327.94,
Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,191.3,,,,,,,fee schedule,179.06,327.94,APC
Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,182.19,,,,,,,fee schedule,179.06,327.94,APC
Panitumumab injection,J9303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,327.94,,,,,,,fee schedule,179.06,327.94,APC
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.73,,,,,,,fee schedule,7.99,62.94,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.73,,,,,,,fee schedule,7.99,62.94,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.73,,,,,,,fee schedule,7.99,62.94,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.94,,,,,,,fee schedule,7.99,62.94,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.39,,,,,,,fee schedule,7.99,62.94,APC
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.99,,,,,,,fee schedule,7.99,62.94,APC
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.39,,,,,,,fee schedule,7.99,62.94,APC
Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.87,,,,,,,fee schedule,3.87,12.51,
Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.87,,,,,,,fee schedule,3.87,12.51,
Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.87,,,,,,,fee schedule,3.87,12.51,
Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.45,,,,,,,fee schedule,3.87,12.51,
Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.3,,,,,,,fee schedule,3.87,12.51,APC
Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.95,,,,,,,fee schedule,3.87,12.51,APC
Pemetrexed injection,J9305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12.51,,,,,,,fee schedule,3.87,12.51,APC
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.53,,,,,,,fee schedule,17.2,30.96,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.53,,,,,,,fee schedule,17.2,30.96,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.53,,,,,,,fee schedule,17.2,30.96,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.16,,,,,,,fee schedule,17.2,30.96,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.06,,,,,,,fee schedule,17.2,30.96,APC
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.2,,,,,,,fee schedule,17.2,30.96,APC
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30.96,,,,,,,fee schedule,17.2,30.96,APC
Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,403.5,,,,,,,fee schedule,386.12,695.02,
Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,403.5,,,,,,,fee schedule,386.12,695.02,
Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,403.5,,,,,,,fee schedule,386.12,695.02,
Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,464.03,,,,,,,fee schedule,386.12,695.02,
Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,405.43,,,,,,,fee schedule,386.12,695.02,APC
Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,386.12,,,,,,,fee schedule,386.12,695.02,APC
Pralatrexate injection,J9307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,695.02,,,,,,,fee schedule,386.12,695.02,APC
"Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.26,,,,,,,fee schedule,76.56,137.82,
"Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.26,,,,,,,fee schedule,76.56,137.82,
"Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.26,,,,,,,fee schedule,76.56,137.82,
"Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.85,,,,,,,fee schedule,76.56,137.82,
"Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.39,,,,,,,fee schedule,76.56,137.82,APC
"Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,76.56,,,,,,,fee schedule,76.56,137.82,APC
"Injection, ramucirumab",J9308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,137.82,,,,,,,fee schedule,76.56,137.82,APC
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.37,,,,,,,fee schedule,141.37,258.5,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.37,,,,,,,fee schedule,141.37,258.5,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.37,,,,,,,fee schedule,141.37,258.5,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.58,,,,,,,fee schedule,141.37,258.5,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,150.79,,,,,,,fee schedule,141.37,258.5,APC
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,143.61,,,,,,,fee schedule,141.37,258.5,APC
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,258.5,,,,,,,fee schedule,141.37,258.5,APC
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38.36,,,,,,,fee schedule,36.39,65.5,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.36,,,,,,,fee schedule,36.39,65.5,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.36,,,,,,,fee schedule,36.39,65.5,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.11,,,,,,,fee schedule,36.39,65.5,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.21,,,,,,,fee schedule,36.39,65.5,APC
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.39,,,,,,,fee schedule,36.39,65.5,APC
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.5,,,,,,,fee schedule,36.39,65.5,APC
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.8,,,,,,,fee schedule,73.28,131.9,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.8,,,,,,,fee schedule,73.28,131.9,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.8,,,,,,,fee schedule,73.28,131.9,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.62,,,,,,,fee schedule,73.28,131.9,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,76.94,,,,,,,fee schedule,73.28,131.9,APC
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.28,,,,,,,fee schedule,73.28,131.9,APC
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,131.9,,,,,,,fee schedule,73.28,131.9,APC
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.51,,,,,,,fee schedule,22.51,42.11,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.51,,,,,,,fee schedule,22.51,42.11,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.51,,,,,,,fee schedule,22.51,42.11,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.89,,,,,,,fee schedule,22.51,42.11,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.56,,,,,,,fee schedule,22.51,42.11,APC
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.39,,,,,,,fee schedule,22.51,42.11,APC
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42.11,,,,,,,fee schedule,22.51,42.11,APC
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.93,,,,,,,fee schedule,3.93,19.77,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.93,,,,,,,fee schedule,3.93,19.77,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.93,,,,,,,fee schedule,3.93,19.77,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.52,,,,,,,fee schedule,3.93,19.77,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.54,,,,,,,fee schedule,3.93,19.77,APC
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.99,,,,,,,fee schedule,3.93,19.77,APC
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.77,,,,,,,fee schedule,3.93,19.77,APC
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.78,,,,,,,fee schedule,59.9,107.81,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.78,,,,,,,fee schedule,59.9,107.81,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.78,,,,,,,fee schedule,59.9,107.81,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.65,,,,,,,fee schedule,59.9,107.81,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,62.89,,,,,,,fee schedule,59.9,107.81,APC
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,59.9,,,,,,,fee schedule,59.9,107.81,APC
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,107.81,,,,,,,fee schedule,59.9,107.81,APC
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.63,,,,,,,fee schedule,37.63,67.75,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.63,,,,,,,fee schedule,37.63,67.75,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.63,,,,,,,fee schedule,37.63,67.75,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.27,,,,,,,fee schedule,37.63,67.75,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.52,,,,,,,fee schedule,37.63,67.75,APC
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.64,,,,,,,fee schedule,37.63,67.75,APC
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.75,,,,,,,fee schedule,37.63,67.75,APC
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29.59,,,,,,,fee schedule,29.59,60.46,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.59,,,,,,,fee schedule,29.59,60.46,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.59,,,,,,,fee schedule,29.59,60.46,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,34.03,,,,,,,fee schedule,29.59,60.46,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.27,,,,,,,fee schedule,29.59,60.46,APC
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.59,,,,,,,fee schedule,29.59,60.46,APC
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,60.46,,,,,,,fee schedule,29.59,60.46,APC
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.25,,,,,,,fee schedule,30.71,55.28,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.25,,,,,,,fee schedule,30.71,55.28,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.25,,,,,,,fee schedule,30.71,55.28,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.09,,,,,,,fee schedule,30.71,55.28,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.25,,,,,,,fee schedule,30.71,55.28,APC
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.71,,,,,,,fee schedule,30.71,55.28,APC
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55.28,,,,,,,fee schedule,30.71,55.28,APC
Streptozocin injection,J9320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1326,,,,,,,fee schedule,1326,1524.9,
Streptozocin injection,J9320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1326,,,,,,,fee schedule,1326,1524.9,
Streptozocin injection,J9320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1326,,,,,,,fee schedule,1326,1524.9,
Streptozocin injection,J9320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1524.9,,,,,,,fee schedule,1326,1524.9,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,57.76,,,,,,,fee schedule,57.76,104.39,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57.76,,,,,,,fee schedule,57.76,104.39,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.76,,,,,,,fee schedule,57.76,104.39,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,66.42,,,,,,,fee schedule,57.76,104.39,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.89,,,,,,,fee schedule,57.76,104.39,APC
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57.99,,,,,,,fee schedule,57.76,104.39,APC
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.39,,,,,,,fee schedule,57.76,104.39,APC
Inj pemetrexed (bluepoint),J9322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.29,,,,,,,fee schedule,9.29,19.08,
Inj pemetrexed (bluepoint),J9322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.29,,,,,,,fee schedule,9.29,19.08,
Inj pemetrexed (bluepoint),J9322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.29,,,,,,,fee schedule,9.29,19.08,
Inj pemetrexed (bluepoint),J9322,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.68,,,,,,,fee schedule,9.29,19.08,
Inj pemetrexed (bluepoint),J9322,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.13,,,,,,,fee schedule,9.29,19.08,APC
Inj pemetrexed (bluepoint),J9322,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.6,,,,,,,fee schedule,9.29,19.08,APC
Inj pemetrexed (bluepoint),J9322,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.08,,,,,,,fee schedule,9.29,19.08,APC
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.73,,,,,,,fee schedule,10.73,12.34,
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.73,,,,,,,fee schedule,10.73,12.34,
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.73,,,,,,,fee schedule,10.73,12.34,
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.34,,,,,,,fee schedule,10.73,12.34,
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.12,,,,,,,fee schedule,67.94,122.28,
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.12,,,,,,,fee schedule,67.94,122.28,
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.12,,,,,,,fee schedule,67.94,122.28,
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.59,,,,,,,fee schedule,67.94,122.28,
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,71.33,,,,,,,fee schedule,67.94,122.28,APC
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67.94,,,,,,,fee schedule,67.94,122.28,APC
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,122.28,,,,,,,fee schedule,67.94,122.28,APC
Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.02,,,,,,,fee schedule,73.02,139.21,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.02,,,,,,,fee schedule,73.02,139.21,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.02,,,,,,,fee schedule,73.02,139.21,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,83.97,,,,,,,fee schedule,73.02,139.21,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.21,,,,,,,fee schedule,73.02,139.21,APC
Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,77.34,,,,,,,fee schedule,73.02,139.21,APC
Inj talimogene laherparepvec,J9325,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,139.21,,,,,,,fee schedule,73.02,139.21,APC
Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.79,,,,,,,fee schedule,10.41,18.73,
Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.79,,,,,,,fee schedule,10.41,18.73,
Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.79,,,,,,,fee schedule,10.41,18.73,
Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.41,,,,,,,fee schedule,10.41,18.73,
Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.93,,,,,,,fee schedule,10.41,18.73,APC
Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.41,,,,,,,fee schedule,10.41,18.73,APC
Temozolomide injection,J9328,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.73,,,,,,,fee schedule,10.41,18.73,APC
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.58,,,,,,,fee schedule,58.17,104.7,
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.58,,,,,,,fee schedule,58.17,104.7,
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.58,,,,,,,fee schedule,58.17,104.7,
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.52,,,,,,,fee schedule,58.17,104.7,
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.08,,,,,,,fee schedule,58.17,104.7,APC
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.17,,,,,,,fee schedule,58.17,104.7,APC
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.7,,,,,,,fee schedule,58.17,104.7,APC
Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.5,,,,,,,fee schedule,32.68,58.83,
Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.5,,,,,,,fee schedule,32.68,58.83,
Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.5,,,,,,,fee schedule,32.68,58.83,
Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.53,,,,,,,fee schedule,32.68,58.83,
Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.32,,,,,,,fee schedule,32.68,58.83,APC
Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.68,,,,,,,fee schedule,32.68,58.83,APC
Temsirolimus injection,J9330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.83,,,,,,,fee schedule,32.68,58.83,APC
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.72,,,,,,,fee schedule,87.72,163.85,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.72,,,,,,,fee schedule,87.72,163.85,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.72,,,,,,,fee schedule,87.72,163.85,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.88,,,,,,,fee schedule,87.72,163.85,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.58,,,,,,,fee schedule,87.72,163.85,APC
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,91.03,,,,,,,fee schedule,87.72,163.85,APC
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,163.85,,,,,,,fee schedule,87.72,163.85,APC
Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.62,,,,,,,fee schedule,32.55,58.6,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.62,,,,,,,fee schedule,32.55,58.6,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.62,,,,,,,fee schedule,32.55,58.6,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.66,,,,,,,fee schedule,32.55,58.6,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.18,,,,,,,fee schedule,32.55,58.6,APC
Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.55,,,,,,,fee schedule,32.55,58.6,APC
Inj efgartigimod 2mg,J9332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.6,,,,,,,fee schedule,32.55,58.6,APC
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.04,,,,,,,fee schedule,23.59,42.46,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.04,,,,,,,fee schedule,23.59,42.46,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.04,,,,,,,fee schedule,23.59,42.46,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.65,,,,,,,fee schedule,23.59,42.46,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.77,,,,,,,fee schedule,23.59,42.46,APC
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.59,,,,,,,fee schedule,23.59,42.46,APC
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42.46,,,,,,,fee schedule,23.59,42.46,APC
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.01,,,,,,,fee schedule,34.26,61.66,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.01,,,,,,,fee schedule,34.26,61.66,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.01,,,,,,,fee schedule,34.26,61.66,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.26,,,,,,,fee schedule,34.26,61.66,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.97,,,,,,,fee schedule,34.26,61.66,APC
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.26,,,,,,,fee schedule,34.26,61.66,APC
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61.66,,,,,,,fee schedule,34.26,61.66,APC
Inj thiotepa (tepylute) 1 mg,J9341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.88,,,,,,,fee schedule,37.88,43.56,
Inj thiotepa (tepylute) 1 mg,J9341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.88,,,,,,,fee schedule,37.88,43.56,
Inj thiotepa (tepylute) 1 mg,J9341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,37.88,,,,,,,fee schedule,37.88,43.56,
Inj thiotepa (tepylute) 1 mg,J9341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.56,,,,,,,fee schedule,37.88,43.56,
Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.7,,,,,,,fee schedule,4.93,14.61,
Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.7,,,,,,,fee schedule,4.93,14.61,
Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.7,,,,,,,fee schedule,4.93,14.61,
Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.61,,,,,,,fee schedule,4.93,14.61,
Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.18,,,,,,,fee schedule,4.93,14.61,APC
Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.93,,,,,,,fee schedule,4.93,14.61,APC
Inj thiotepa nos 1 mg,J9342,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.88,,,,,,,fee schedule,4.93,14.61,APC
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.11,,,,,,,fee schedule,30.98,55.77,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.11,,,,,,,fee schedule,30.98,55.77,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.11,,,,,,,fee schedule,30.98,55.77,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.78,,,,,,,fee schedule,30.98,55.77,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.53,,,,,,,fee schedule,30.98,55.77,APC
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.98,,,,,,,fee schedule,30.98,55.77,APC
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55.77,,,,,,,fee schedule,30.98,55.77,APC
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.49,,,,,,,fee schedule,146.49,264.41,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146.49,,,,,,,fee schedule,146.49,264.41,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.49,,,,,,,fee schedule,146.49,264.41,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,168.46,,,,,,,fee schedule,146.49,264.41,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,154.24,,,,,,,fee schedule,146.49,264.41,APC
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,146.89,,,,,,,fee schedule,146.49,264.41,APC
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,264.41,,,,,,,fee schedule,146.49,264.41,APC
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,711.79,,,,,,,fee schedule,684.9,1232.82,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,711.79,,,,,,,fee schedule,684.9,1232.82,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,711.79,,,,,,,fee schedule,684.9,1232.82,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,818.56,,,,,,,fee schedule,684.9,1232.82,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,719.14,,,,,,,fee schedule,684.9,1232.82,APC
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,684.9,,,,,,,fee schedule,684.9,1232.82,APC
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1232.82,,,,,,,fee schedule,684.9,1232.82,APC
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.61,,,,,,,fee schedule,14.43,25.97,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.61,,,,,,,fee schedule,14.43,25.97,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.61,,,,,,,fee schedule,14.43,25.97,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16.8,,,,,,,fee schedule,14.43,25.97,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.15,,,,,,,fee schedule,14.43,25.97,APC
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14.43,,,,,,,fee schedule,14.43,25.97,APC
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25.97,,,,,,,fee schedule,14.43,25.97,APC
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,677.38,,,,,,,fee schedule,674.5,1214.09,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,677.38,,,,,,,fee schedule,674.5,1214.09,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.38,,,,,,,fee schedule,674.5,1214.09,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,778.99,,,,,,,fee schedule,674.5,1214.09,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,708.22,,,,,,,fee schedule,674.5,1214.09,APC
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,674.5,,,,,,,fee schedule,674.5,1214.09,APC
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1214.09,,,,,,,fee schedule,674.5,1214.09,APC
Topotecan injection,J9351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.39,,,,,,,fee schedule,1.39,1.6,
Topotecan injection,J9351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.39,,,,,,,fee schedule,1.39,1.6,
Topotecan injection,J9351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.39,,,,,,,fee schedule,1.39,1.6,
Topotecan injection,J9351,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.6,,,,,,,fee schedule,1.39,1.6,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,397.52,,,,,,,fee schedule,397.52,738.86,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.52,,,,,,,fee schedule,397.52,738.86,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,397.52,,,,,,,fee schedule,397.52,738.86,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,457.15,,,,,,,fee schedule,397.52,738.86,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,431,,,,,,,fee schedule,397.52,738.86,APC
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,410.48,,,,,,,fee schedule,397.52,738.86,APC
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,738.86,,,,,,,fee schedule,397.52,738.86,APC
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.35,,,,,,,fee schedule,52.35,101.6,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.35,,,,,,,fee schedule,52.35,101.6,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.35,,,,,,,fee schedule,52.35,101.6,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.2,,,,,,,fee schedule,52.35,101.6,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.26,,,,,,,fee schedule,52.35,101.6,APC
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,56.44,,,,,,,fee schedule,52.35,101.6,APC
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,101.6,,,,,,,fee schedule,52.35,101.6,APC
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.43,,,,,,,fee schedule,43.43,78.53,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.43,,,,,,,fee schedule,43.43,78.53,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.43,,,,,,,fee schedule,43.43,78.53,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.94,,,,,,,fee schedule,43.43,78.53,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.81,,,,,,,fee schedule,43.43,78.53,APC
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.63,,,,,,,fee schedule,43.43,78.53,APC
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78.53,,,,,,,fee schedule,43.43,78.53,APC
Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.06,,,,,,,fee schedule,70.24,126.44,
Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.06,,,,,,,fee schedule,70.24,126.44,
Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.06,,,,,,,fee schedule,70.24,126.44,
Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.92,,,,,,,fee schedule,70.24,126.44,
Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.76,,,,,,,fee schedule,70.24,126.44,APC
Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.24,,,,,,,fee schedule,70.24,126.44,APC
Trastuzumab injection,J9355,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,126.44,,,,,,,fee schedule,70.24,126.44,APC
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.35,,,,,,,fee schedule,58.34,105.02,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.35,,,,,,,fee schedule,58.34,105.02,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.35,,,,,,,fee schedule,58.34,105.02,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.15,,,,,,,fee schedule,58.34,105.02,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.26,,,,,,,fee schedule,58.34,105.02,APC
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.34,,,,,,,fee schedule,58.34,105.02,APC
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.02,,,,,,,fee schedule,58.34,105.02,APC
Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1428.74,,,,,,,fee schedule,1247.05,2244.68,
Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1428.74,,,,,,,fee schedule,1247.05,2244.68,
Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1428.74,,,,,,,fee schedule,1247.05,2244.68,
Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1643.05,,,,,,,fee schedule,1247.05,2244.68,
Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1309.4,,,,,,,fee schedule,1247.05,2244.68,APC
Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1247.05,,,,,,,fee schedule,1247.05,2244.68,APC
Valrubicin injection,J9357,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2244.68,,,,,,,fee schedule,1247.05,2244.68,APC
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.13,,,,,,,fee schedule,31.13,59.17,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.13,,,,,,,fee schedule,31.13,59.17,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.13,,,,,,,fee schedule,31.13,59.17,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.8,,,,,,,fee schedule,31.13,59.17,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.52,,,,,,,fee schedule,31.13,59.17,APC
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.87,,,,,,,fee schedule,31.13,59.17,APC
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59.17,,,,,,,fee schedule,31.13,59.17,APC
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.92,,,,,,,fee schedule,224.92,407.89,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.92,,,,,,,fee schedule,224.92,407.89,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.92,,,,,,,fee schedule,224.92,407.89,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.66,,,,,,,fee schedule,224.92,407.89,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,237.94,,,,,,,fee schedule,224.92,407.89,APC
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,226.61,,,,,,,fee schedule,224.92,407.89,APC
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,407.89,,,,,,,fee schedule,224.92,407.89,APC
Vinblastine sulfate inj,J9360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.49,,,,,,,fee schedule,5.49,6.31,
Vinblastine sulfate inj,J9360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.49,,,,,,,fee schedule,5.49,6.31,
Vinblastine sulfate inj,J9360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.49,,,,,,,fee schedule,5.49,6.31,
Vinblastine sulfate inj,J9360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.31,,,,,,,fee schedule,5.49,6.31,
"Inj, efbemalenograstim alfa-",J9361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.3,,,,,,,fee schedule,117.3,134.9,
"Inj, efbemalenograstim alfa-",J9361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.3,,,,,,,fee schedule,117.3,134.9,
"Inj, efbemalenograstim alfa-",J9361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.3,,,,,,,fee schedule,117.3,134.9,
"Inj, efbemalenograstim alfa-",J9361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,134.9,,,,,,,fee schedule,117.3,134.9,
Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.16,,,,,,,fee schedule,8.16,9.38,
Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.16,,,,,,,fee schedule,8.16,9.38,
Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.16,,,,,,,fee schedule,8.16,9.38,
Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.38,,,,,,,fee schedule,8.16,9.38,
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.27,,,,,,,fee schedule,88.27,165.11,
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.27,,,,,,,fee schedule,88.27,165.11,
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.27,,,,,,,fee schedule,88.27,165.11,
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.51,,,,,,,fee schedule,88.27,165.11,
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.32,,,,,,,fee schedule,88.27,165.11,APC
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,91.73,,,,,,,fee schedule,88.27,165.11,APC
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,165.11,,,,,,,fee schedule,88.27,165.11,APC
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,34.52,,,,,,,fee schedule,34.52,63.58,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.52,,,,,,,fee schedule,34.52,63.58,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.52,,,,,,,fee schedule,34.52,63.58,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,39.7,,,,,,,fee schedule,34.52,63.58,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.09,,,,,,,fee schedule,34.52,63.58,APC
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.32,,,,,,,fee schedule,34.52,63.58,APC
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.58,,,,,,,fee schedule,34.52,63.58,APC
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.07,,,,,,,fee schedule,39.07,70.59,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.07,,,,,,,fee schedule,39.07,70.59,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.07,,,,,,,fee schedule,39.07,70.59,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,44.93,,,,,,,fee schedule,39.07,70.59,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.18,,,,,,,fee schedule,39.07,70.59,APC
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.22,,,,,,,fee schedule,39.07,70.59,APC
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.59,,,,,,,fee schedule,39.07,70.59,APC
Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.3,,,,,,,fee schedule,32.3,60.95,
Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.3,,,,,,,fee schedule,32.3,60.95,
Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.3,,,,,,,fee schedule,32.3,60.95,
Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.15,,,,,,,fee schedule,32.3,60.95,
Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.56,,,,,,,fee schedule,32.3,60.95,APC
Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33.86,,,,,,,fee schedule,32.3,60.95,APC
Inj zenocutuzumab-zbco 1 mg,J9382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,60.95,,,,,,,fee schedule,32.3,60.95,APC
Vinorelbine tartrate inj,J9390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.03,,,,,,,fee schedule,2.03,2.33,
Vinorelbine tartrate inj,J9390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.03,,,,,,,fee schedule,2.03,2.33,
Vinorelbine tartrate inj,J9390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.03,,,,,,,fee schedule,2.03,2.33,
Vinorelbine tartrate inj,J9390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.33,,,,,,,fee schedule,2.03,2.33,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.4,,,,,,,fee schedule,20.4,75.01,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.4,,,,,,,fee schedule,20.4,75.01,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.4,,,,,,,fee schedule,20.4,75.01,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.46,,,,,,,fee schedule,20.4,75.01,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.75,,,,,,,fee schedule,20.4,75.01,APC
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.67,,,,,,,fee schedule,20.4,75.01,APC
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75.01,,,,,,,fee schedule,20.4,75.01,APC
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.45,,,,,,,fee schedule,3.45,48.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.45,,,,,,,fee schedule,3.45,48.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.45,,,,,,,fee schedule,3.45,48.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.97,,,,,,,fee schedule,3.45,48.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,3.45,48.8,APC
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.11,,,,,,,fee schedule,3.45,48.8,APC
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48.8,,,,,,,fee schedule,3.45,48.8,APC
"Injection, Fulvestrant",J9395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.24,,,,,,,fee schedule,7.24,8.33,
"Injection, Fulvestrant",J9395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.24,,,,,,,fee schedule,7.24,8.33,
"Injection, Fulvestrant",J9395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.24,,,,,,,fee schedule,7.24,8.33,
"Injection, Fulvestrant",J9395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.33,,,,,,,fee schedule,7.24,8.33,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.28,,,,,,,fee schedule,8.28,15.61,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.28,,,,,,,fee schedule,8.28,15.61,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.28,,,,,,,fee schedule,8.28,15.61,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.52,,,,,,,fee schedule,8.28,15.61,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.11,,,,,,,fee schedule,8.28,15.61,APC
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.67,,,,,,,fee schedule,8.28,15.61,APC
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.61,,,,,,,fee schedule,8.28,15.61,APC
Porfimer sodium injection,J9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23789.46,,,,,,,fee schedule,23789.46,27357.88,
Porfimer sodium injection,J9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23789.46,,,,,,,fee schedule,23789.46,27357.88,
Porfimer sodium injection,J9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23789.46,,,,,,,fee schedule,23789.46,27357.88,
Porfimer sodium injection,J9600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27357.88,,,,,,,fee schedule,23789.46,27357.88,
Standard wheelchair,K0001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.08,,,,,,,fee schedule,41.36,72.54,
Standard wheelchair,K0001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51.63,,,,,,,fee schedule,41.36,72.54,
Standard wheelchair,K0001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.36,,,,,,,fee schedule,41.36,72.54,
Standard wheelchair,K0001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.54,,,,,,,fee schedule,41.36,72.54,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.58,,,,,,,fee schedule,69.87,122.57,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.24,,,,,,,fee schedule,69.87,122.57,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.87,,,,,,,fee schedule,69.87,122.57,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.57,,,,,,,fee schedule,69.87,122.57,
Lightweight wheelchair,K0003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.67,,,,,,,fee schedule,60.75,106.57,
Lightweight wheelchair,K0003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.85,,,,,,,fee schedule,60.75,106.57,
Lightweight wheelchair,K0003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.75,,,,,,,fee schedule,60.75,106.57,
Lightweight wheelchair,K0003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.57,,,,,,,fee schedule,60.75,106.57,
High strength ltwt whlchr,K0004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.32,,,,,,,fee schedule,72.98,128.02,
High strength ltwt whlchr,K0004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.12,,,,,,,fee schedule,72.98,128.02,
High strength ltwt whlchr,K0004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.98,,,,,,,fee schedule,72.98,128.02,
High strength ltwt whlchr,K0004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.02,,,,,,,fee schedule,72.98,128.02,
Ultralightweight wheelchair,K0005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5619.26,,,,,,,fee schedule,3683.99,6462.15,
Ultralightweight wheelchair,K0005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4599.36,,,,,,,fee schedule,3683.99,6462.15,
Ultralightweight wheelchair,K0005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3683.99,,,,,,,fee schedule,3683.99,6462.15,
Ultralightweight wheelchair,K0005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6462.15,,,,,,,fee schedule,3683.99,6462.15,
Heavy duty wheelchair,K0006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164,,,,,,,fee schedule,107.52,188.6,
Heavy duty wheelchair,K0006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.23,,,,,,,fee schedule,107.52,188.6,
Heavy duty wheelchair,K0006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.52,,,,,,,fee schedule,107.52,188.6,
Heavy duty wheelchair,K0006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,188.6,,,,,,,fee schedule,107.52,188.6,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,233.31,,,,,,,fee schedule,152.96,268.31,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.96,,,,,,,fee schedule,152.96,268.31,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.96,,,,,,,fee schedule,152.96,268.31,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,268.31,,,,,,,fee schedule,152.96,268.31,
Other manual wheelchair/base,K0009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226,,,,,,,fee schedule,148.17,259.9,
Other manual wheelchair/base,K0009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,184.98,,,,,,,fee schedule,148.17,259.9,
Other manual wheelchair/base,K0009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.17,,,,,,,fee schedule,148.17,259.9,
Other manual wheelchair/base,K0009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.9,,,,,,,fee schedule,148.17,259.9,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1294.77,,,,,,,fee schedule,848.85,1488.99,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1059.77,,,,,,,fee schedule,848.85,1488.99,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,848.85,,,,,,,fee schedule,848.85,1488.99,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1488.99,,,,,,,fee schedule,848.85,1488.99,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1539.63,,,,,,,fee schedule,1009.38,1770.57,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1260.19,,,,,,,fee schedule,1009.38,1770.57,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1009.38,,,,,,,fee schedule,1009.38,1770.57,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1770.57,,,,,,,fee schedule,1009.38,1770.57,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,944.44,,,,,,,fee schedule,619.17,1086.11,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,773.02,,,,,,,fee schedule,619.17,1086.11,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,619.17,,,,,,,fee schedule,619.17,1086.11,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086.11,,,,,,,fee schedule,619.17,1086.11,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.69,,,,,,,fee schedule,26.02,45.64,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.49,,,,,,,fee schedule,26.02,45.64,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.02,,,,,,,fee schedule,26.02,45.64,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.64,,,,,,,fee schedule,26.02,45.64,
Detach adjust armrest base,K0017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.31,,,,,,,fee schedule,78.88,138.36,
Detach adjust armrest base,K0017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.47,,,,,,,fee schedule,78.88,138.36,
Detach adjust armrest base,K0017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.88,,,,,,,fee schedule,78.88,138.36,
Detach adjust armrest base,K0017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.36,,,,,,,fee schedule,78.88,138.36,
Detach adjust armrst upper,K0018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.99,,,,,,,fee schedule,44.57,78.19,
Detach adjust armrst upper,K0018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.65,,,,,,,fee schedule,44.57,78.19,
Detach adjust armrst upper,K0018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.57,,,,,,,fee schedule,44.57,78.19,
Detach adjust armrst upper,K0018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.19,,,,,,,fee schedule,44.57,78.19,
"Arm pad repl, each",K0019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.18,,,,,,,fee schedule,23.72,41.61,
"Arm pad repl, each",K0019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.61,,,,,,,fee schedule,23.72,41.61,
"Arm pad repl, each",K0019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.72,,,,,,,fee schedule,23.72,41.61,
"Arm pad repl, each",K0019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.61,,,,,,,fee schedule,23.72,41.61,
Fixed adjust armrest pair,K0020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.88,,,,,,,fee schedule,77.28,135.56,
Fixed adjust armrest pair,K0020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.48,,,,,,,fee schedule,77.28,135.56,
Fixed adjust armrest pair,K0020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.28,,,,,,,fee schedule,77.28,135.56,
Fixed adjust armrest pair,K0020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.56,,,,,,,fee schedule,77.28,135.56,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.26,,,,,,,fee schedule,70.32,123.35,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.79,,,,,,,fee schedule,70.32,123.35,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.32,,,,,,,fee schedule,70.32,123.35,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.35,,,,,,,fee schedule,70.32,123.35,
Leg strap each,K0038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.1,,,,,,,fee schedule,39.4,69.12,
Leg strap each,K0038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.19,,,,,,,fee schedule,39.4,69.12,
Leg strap each,K0038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.4,,,,,,,fee schedule,39.4,69.12,
Leg strap each,K0038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.12,,,,,,,fee schedule,39.4,69.12,
Leg strap h style each,K0039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,129.09,,,,,,,fee schedule,84.63,148.45,
Leg strap h style each,K0039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.66,,,,,,,fee schedule,84.63,148.45,
Leg strap h style each,K0039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.63,,,,,,,fee schedule,84.63,148.45,
Leg strap h style each,K0039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.45,,,,,,,fee schedule,84.63,148.45,
Adjustable angle footplate,K0040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.26,,,,,,,fee schedule,91.3,160.15,
Adjustable angle footplate,K0040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.98,,,,,,,fee schedule,91.3,160.15,
Adjustable angle footplate,K0040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.3,,,,,,,fee schedule,91.3,160.15,
Adjustable angle footplate,K0040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.15,,,,,,,fee schedule,91.3,160.15,
Large size footplate each,K0041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.39,,,,,,,fee schedule,80.89,141.9,
Large size footplate each,K0041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.99,,,,,,,fee schedule,80.89,141.9,
Large size footplate each,K0041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.89,,,,,,,fee schedule,80.89,141.9,
Large size footplate each,K0041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.9,,,,,,,fee schedule,80.89,141.9,
Standard size ftplate rep ea,K0042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.24,,,,,,,fee schedule,51.95,91.13,
Standard size ftplate rep ea,K0042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.86,,,,,,,fee schedule,51.95,91.13,
Standard size ftplate rep ea,K0042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.95,,,,,,,fee schedule,51.95,91.13,
Standard size ftplate rep ea,K0042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.13,,,,,,,fee schedule,51.95,91.13,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.93,,,,,,,fee schedule,32.08,56.27,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.05,,,,,,,fee schedule,32.08,56.27,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.08,,,,,,,fee schedule,32.08,56.27,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.27,,,,,,,fee schedule,32.08,56.27,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.55,,,,,,,fee schedule,27.9,48.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.83,,,,,,,fee schedule,27.9,48.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.9,,,,,,,fee schedule,27.9,48.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.93,,,,,,,fee schedule,27.9,48.93,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.98,,,,,,,fee schedule,91.77,160.98,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.57,,,,,,,fee schedule,91.77,160.98,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.77,,,,,,,fee schedule,91.77,160.98,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.98,,,,,,,fee schedule,91.77,160.98,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49.25,,,,,,,fee schedule,32.29,56.64,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.31,,,,,,,fee schedule,32.29,56.64,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.29,,,,,,,fee schedule,32.29,56.64,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56.64,,,,,,,fee schedule,32.29,56.64,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,174.02,,,,,,,fee schedule,114.09,200.12,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.44,,,,,,,fee schedule,114.09,200.12,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.09,,,,,,,fee schedule,114.09,200.12,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,200.12,,,,,,,fee schedule,114.09,200.12,
Ratchet assembly replacement,K0050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.75,,,,,,,fee schedule,52.94,92.86,
Ratchet assembly replacement,K0050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.09,,,,,,,fee schedule,52.94,92.86,
Ratchet assembly replacement,K0050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.94,,,,,,,fee schedule,52.94,92.86,
Ratchet assembly replacement,K0050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.86,,,,,,,fee schedule,52.94,92.86,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.72,,,,,,,fee schedule,83.73,146.88,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.54,,,,,,,fee schedule,83.73,146.88,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.73,,,,,,,fee schedule,83.73,146.88,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.88,,,,,,,fee schedule,83.73,146.88,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.85,,,,,,,fee schedule,131.02,229.83,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.58,,,,,,,fee schedule,131.02,229.83,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.02,,,,,,,fee schedule,131.02,229.83,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.83,,,,,,,fee schedule,131.02,229.83,
Elevate footrest articulate,K0053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.77,,,,,,,fee schedule,147.36,258.49,
Elevate footrest articulate,K0053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,183.97,,,,,,,fee schedule,147.36,258.49,
Elevate footrest articulate,K0053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.36,,,,,,,fee schedule,147.36,258.49,
Elevate footrest articulate,K0053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.49,,,,,,,fee schedule,147.36,258.49,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,252.5,,,,,,,fee schedule,165.54,290.38,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.67,,,,,,,fee schedule,165.54,290.38,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.54,,,,,,,fee schedule,165.54,290.38,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,290.38,,,,,,,fee schedule,165.54,290.38,
Spoke protectors,K0065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.22,,,,,,,fee schedule,83.41,146.3,
Spoke protectors,K0065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.13,,,,,,,fee schedule,83.41,146.3,
Spoke protectors,K0065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.41,,,,,,,fee schedule,83.41,146.3,
Spoke protectors,K0065,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.3,,,,,,,fee schedule,83.41,146.3,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,257.48,,,,,,,fee schedule,168.8,296.1,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210.75,,,,,,,fee schedule,168.8,296.1,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.8,,,,,,,fee schedule,168.8,296.1,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,296.1,,,,,,,fee schedule,168.8,296.1,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.55,,,,,,,fee schedule,27.9,48.93,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.83,,,,,,,fee schedule,27.9,48.93,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.9,,,,,,,fee schedule,27.9,48.93,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.93,,,,,,,fee schedule,27.9,48.93,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,296.92,,,,,,,fee schedule,194.66,341.46,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,243.03,,,,,,,fee schedule,194.66,341.46,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,194.66,,,,,,,fee schedule,194.66,341.46,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,341.46,,,,,,,fee schedule,194.66,341.46,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.68,,,,,,,fee schedule,119.77,210.08,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.52,,,,,,,fee schedule,119.77,210.08,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.77,,,,,,,fee schedule,119.77,210.08,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,210.08,,,,,,,fee schedule,119.77,210.08,
Caster pin lock each,K0073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.47,,,,,,,fee schedule,63.25,110.94,
Caster pin lock each,K0073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.96,,,,,,,fee schedule,63.25,110.94,
Caster pin lock each,K0073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.25,,,,,,,fee schedule,63.25,110.94,
Caster pin lock each,K0073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,110.94,,,,,,,fee schedule,63.25,110.94,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.87,,,,,,,fee schedule,95.63,167.75,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.39,,,,,,,fee schedule,95.63,167.75,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.63,,,,,,,fee schedule,95.63,167.75,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,167.75,,,,,,,fee schedule,95.63,167.75,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.67,,,,,,,fee schedule,43.05,75.52,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53.75,,,,,,,fee schedule,43.05,75.52,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.05,,,,,,,fee schedule,43.05,75.52,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.52,,,,,,,fee schedule,43.05,75.52,
Iv hanger,K0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.57,,,,,,,fee schedule,178.04,312.31,
Iv hanger,K0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.28,,,,,,,fee schedule,178.04,312.31,
Iv hanger,K0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,178.04,,,,,,,fee schedule,178.04,312.31,
Iv hanger,K0105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.31,,,,,,,fee schedule,178.04,312.31,
Elevating whlchair leg rests,K0195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.13,,,,,,,fee schedule,18.44,32.35,
Elevating whlchair leg rests,K0195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.02,,,,,,,fee schedule,18.44,32.35,
Elevating whlchair leg rests,K0195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.44,,,,,,,fee schedule,18.44,32.35,
Elevating whlchair leg rests,K0195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.35,,,,,,,fee schedule,18.44,32.35,
Pump uninterrupted infusion,K0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,794.62,,,,,,,fee schedule,520.95,913.81,
Pump uninterrupted infusion,K0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,650.4,,,,,,,fee schedule,520.95,913.81,
Pump uninterrupted infusion,K0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,520.95,,,,,,,fee schedule,520.95,913.81,
Pump uninterrupted infusion,K0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,913.81,,,,,,,fee schedule,520.95,913.81,
Sup/ext non-ins inf pump syr,K0552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.1,,,,,,,fee schedule,4.65,8.17,
Sup/ext non-ins inf pump syr,K0552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.81,,,,,,,fee schedule,4.65,8.17,
Sup/ext non-ins inf pump syr,K0552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.65,,,,,,,fee schedule,4.65,8.17,
Sup/ext non-ins inf pump syr,K0552,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.17,,,,,,,fee schedule,4.65,8.17,
Repl batt silver oxide 1.5 v,K0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.22,,,,,,,fee schedule,2.11,3.7,
Repl batt silver oxide 1.5 v,K0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.64,,,,,,,fee schedule,2.11,3.7,
Repl batt silver oxide 1.5 v,K0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.11,,,,,,,fee schedule,2.11,3.7,
Repl batt silver oxide 1.5 v,K0601,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.7,,,,,,,fee schedule,2.11,3.7,
Repl batt silver oxide 3 v,K0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.17,,,,,,,fee schedule,11.91,20.9,
Repl batt silver oxide 3 v,K0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.87,,,,,,,fee schedule,11.91,20.9,
Repl batt silver oxide 3 v,K0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.91,,,,,,,fee schedule,11.91,20.9,
Repl batt silver oxide 3 v,K0602,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.9,,,,,,,fee schedule,11.91,20.9,
Repl batt alkaline 1.5 v,K0603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.64,,,,,,,fee schedule,1.08,1.89,
Repl batt alkaline 1.5 v,K0603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.34,,,,,,,fee schedule,1.08,1.89,
Repl batt alkaline 1.5 v,K0603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.08,,,,,,,fee schedule,1.08,1.89,
Repl batt alkaline 1.5 v,K0603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.89,,,,,,,fee schedule,1.08,1.89,
Repl batt lithium 3.6 v,K0604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.52,,,,,,,fee schedule,11.49,20.15,
Repl batt lithium 3.6 v,K0604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.34,,,,,,,fee schedule,11.49,20.15,
Repl batt lithium 3.6 v,K0604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.49,,,,,,,fee schedule,11.49,20.15,
Repl batt lithium 3.6 v,K0604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.15,,,,,,,fee schedule,11.49,20.15,
Repl batt lithium 4.5 v,K0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.88,,,,,,,fee schedule,27.46,48.16,
Repl batt lithium 4.5 v,K0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34.28,,,,,,,fee schedule,27.46,48.16,
Repl batt lithium 4.5 v,K0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.46,,,,,,,fee schedule,27.46,48.16,
Repl batt lithium 4.5 v,K0605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.16,,,,,,,fee schedule,27.46,48.16,
Repl batt for aed,K0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.05,,,,,,,fee schedule,38.71,67.91,
Repl batt for aed,K0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.33,,,,,,,fee schedule,38.71,67.91,
Repl batt for aed,K0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.71,,,,,,,fee schedule,38.71,67.91,
Repl batt for aed,K0607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.91,,,,,,,fee schedule,38.71,67.91,
Repl garment for AED,K0608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,368.38,,,,,,,fee schedule,241.51,423.64,
Repl garment for AED,K0608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,301.52,,,,,,,fee schedule,241.51,423.64,
Repl garment for AED,K0608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,241.51,,,,,,,fee schedule,241.51,423.64,
Repl garment for AED,K0608,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,423.64,,,,,,,fee schedule,241.51,423.64,
Repl electrode for AED,K0609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2450.04,,,,,,,fee schedule,1606.25,2817.55,
Repl electrode for AED,K0609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2005.36,,,,,,,fee schedule,1606.25,2817.55,
Repl electrode for AED,K0609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1606.25,,,,,,,fee schedule,1606.25,2817.55,
Repl electrode for AED,K0609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2817.55,,,,,,,fee schedule,1606.25,2817.55,
Removable soft interface le,K0672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,222.28,,,,,,,fee schedule,104.22,255.62,
Removable soft interface le,K0672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.94,,,,,,,fee schedule,104.22,255.62,
Removable soft interface le,K0672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.73,,,,,,,fee schedule,104.22,255.62,
Removable soft interface le,K0672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.62,,,,,,,fee schedule,104.22,255.62,
Removable soft interface le,K0672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.43,,,,,,,fee schedule,104.22,255.62,APC
Removable soft interface le,K0672,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.22,,,,,,,fee schedule,104.22,255.62,APC
Removable soft interface le,K0672,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.6,,,,,,,fee schedule,104.22,255.62,APC
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,523.97,,,,,,,fee schedule,343.51,602.57,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,428.87,,,,,,,fee schedule,343.51,602.57,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.51,,,,,,,fee schedule,343.51,602.57,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,602.57,,,,,,,fee schedule,343.51,602.57,
12-24hr sealed lead acid,K0733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,75.79,,,,,,,fee schedule,49.69,87.16,
12-24hr sealed lead acid,K0733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.03,,,,,,,fee schedule,49.69,87.16,
12-24hr sealed lead acid,K0733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,49.69,,,,,,,fee schedule,49.69,87.16,
12-24hr sealed lead acid,K0733,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,87.16,,,,,,,fee schedule,49.69,87.16,
Portable gas oxygen system,K0738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.67,,,,,,,fee schedule,64.69,113.47,
Portable gas oxygen system,K0738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.76,,,,,,,fee schedule,64.69,113.47,
Portable gas oxygen system,K0738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.69,,,,,,,fee schedule,64.69,113.47,
Portable gas oxygen system,K0738,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.47,,,,,,,fee schedule,64.69,113.47,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2177.49,,,,,,,fee schedule,1427.56,2504.11,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1782.28,,,,,,,fee schedule,1427.56,2504.11,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1427.56,,,,,,,fee schedule,1427.56,2504.11,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2504.11,,,,,,,fee schedule,1427.56,2504.11,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3952.89,,,,,,,fee schedule,2591.51,4545.82,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3235.44,,,,,,,fee schedule,2591.51,4545.82,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2591.51,,,,,,,fee schedule,2591.51,4545.82,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4545.82,,,,,,,fee schedule,2591.51,4545.82,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5428.64,,,,,,,fee schedule,3559.02,6242.94,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4443.34,,,,,,,fee schedule,3559.02,6242.94,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3559.02,,,,,,,fee schedule,3559.02,6242.94,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6242.94,,,,,,,fee schedule,3559.02,6242.94,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3566.5,,,,,,,fee schedule,2338.2,4101.48,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2919.18,,,,,,,fee schedule,2338.2,4101.48,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2338.2,,,,,,,fee schedule,2338.2,4101.48,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4101.48,,,,,,,fee schedule,2338.2,4101.48,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5527.17,,,,,,,fee schedule,3623.61,6356.25,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4523.99,,,,,,,fee schedule,3623.61,6356.25,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3623.61,,,,,,,fee schedule,3623.61,6356.25,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6356.25,,,,,,,fee schedule,3623.61,6356.25,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8544.08,,,,,,,fee schedule,5601.5,9825.69,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6993.33,,,,,,,fee schedule,5601.5,9825.69,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5601.5,,,,,,,fee schedule,5601.5,9825.69,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9825.69,,,,,,,fee schedule,5601.5,9825.69,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,698.12,,,,,,,fee schedule,457.69,802.84,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,571.41,,,,,,,fee schedule,457.69,802.84,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,457.69,,,,,,,fee schedule,457.69,802.84,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,802.84,,,,,,,fee schedule,457.69,802.84,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,693.08,,,,,,,fee schedule,454.38,797.04,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,567.29,,,,,,,fee schedule,454.38,797.04,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,454.38,,,,,,,fee schedule,454.38,797.04,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,797.04,,,,,,,fee schedule,454.38,797.04,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,765.86,,,,,,,fee schedule,502.1,880.74,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,626.86,,,,,,,fee schedule,502.1,880.74,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,502.1,,,,,,,fee schedule,502.1,880.74,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,880.74,,,,,,,fee schedule,502.1,880.74,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,724.9,,,,,,,fee schedule,475.24,833.64,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,593.33,,,,,,,fee schedule,475.24,833.64,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,475.24,,,,,,,fee schedule,475.24,833.64,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,833.64,,,,,,,fee schedule,475.24,833.64,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,706.8,,,,,,,fee schedule,463.38,812.82,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,578.52,,,,,,,fee schedule,463.38,812.82,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,463.38,,,,,,,fee schedule,463.38,812.82,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,812.82,,,,,,,fee schedule,463.38,812.82,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,732.13,,,,,,,fee schedule,479.98,841.95,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,599.25,,,,,,,fee schedule,479.98,841.95,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,479.98,,,,,,,fee schedule,479.98,841.95,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,841.95,,,,,,,fee schedule,479.98,841.95,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,773.21,,,,,,,fee schedule,506.92,889.19,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,632.87,,,,,,,fee schedule,506.92,889.19,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,506.92,,,,,,,fee schedule,506.92,889.19,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,889.19,,,,,,,fee schedule,506.92,889.19,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,732.98,,,,,,,fee schedule,480.54,842.93,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,599.94,,,,,,,fee schedule,480.54,842.93,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,480.54,,,,,,,fee schedule,480.54,842.93,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,842.93,,,,,,,fee schedule,480.54,842.93,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1104.15,,,,,,,fee schedule,723.88,1269.77,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,903.75,,,,,,,fee schedule,723.88,1269.77,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,723.88,,,,,,,fee schedule,723.88,1269.77,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1269.77,,,,,,,fee schedule,723.88,1269.77,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1007.74,,,,,,,fee schedule,660.67,1158.9,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,824.84,,,,,,,fee schedule,660.67,1158.9,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,660.67,,,,,,,fee schedule,660.67,1158.9,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1158.9,,,,,,,fee schedule,660.67,1158.9,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2043.47,,,,,,,fee schedule,1339.7,2349.99,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1672.58,,,,,,,fee schedule,1339.7,2349.99,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1339.7,,,,,,,fee schedule,1339.7,2349.99,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2349.99,,,,,,,fee schedule,1339.7,2349.99,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1761.44,,,,,,,fee schedule,1154.8,2025.66,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1441.74,,,,,,,fee schedule,1154.8,2025.66,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1154.8,,,,,,,fee schedule,1154.8,2025.66,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2025.66,,,,,,,fee schedule,1154.8,2025.66,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2501.22,,,,,,,fee schedule,1639.8,2876.4,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2047.25,,,,,,,fee schedule,1639.8,2876.4,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1639.8,,,,,,,fee schedule,1639.8,2876.4,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2876.4,,,,,,,fee schedule,1639.8,2876.4,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2363.64,,,,,,,fee schedule,1549.6,2718.19,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1934.64,,,,,,,fee schedule,1549.6,2718.19,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1549.6,,,,,,,fee schedule,1549.6,2718.19,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2718.19,,,,,,,fee schedule,1549.6,2718.19,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,916.36,,,,,,,fee schedule,600.77,1053.81,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,750.04,,,,,,,fee schedule,600.77,1053.81,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,600.77,,,,,,,fee schedule,600.77,1053.81,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1053.81,,,,,,,fee schedule,600.77,1053.81,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,950.48,,,,,,,fee schedule,623.13,1093.05,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,777.97,,,,,,,fee schedule,623.13,1093.05,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,623.13,,,,,,,fee schedule,623.13,1093.05,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1093.05,,,,,,,fee schedule,623.13,1093.05,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1175.36,,,,,,,fee schedule,770.57,1351.66,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,962.03,,,,,,,fee schedule,770.57,1351.66,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,770.57,,,,,,,fee schedule,770.57,1351.66,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1351.66,,,,,,,fee schedule,770.57,1351.66,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1041.75,,,,,,,fee schedule,682.97,1198.01,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,852.67,,,,,,,fee schedule,682.97,1198.01,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,682.97,,,,,,,fee schedule,682.97,1198.01,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1198.01,,,,,,,fee schedule,682.97,1198.01,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1561.29,,,,,,,fee schedule,1023.58,1795.48,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1277.92,,,,,,,fee schedule,1023.58,1795.48,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1023.58,,,,,,,fee schedule,1023.58,1795.48,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1795.48,,,,,,,fee schedule,1023.58,1795.48,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2397.07,,,,,,,fee schedule,1571.52,2756.63,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1962,,,,,,,fee schedule,1571.52,2756.63,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1571.52,,,,,,,fee schedule,1571.52,2756.63,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2756.63,,,,,,,fee schedule,1571.52,2756.63,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1032.7,,,,,,,fee schedule,677.04,1187.61,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,845.26,,,,,,,fee schedule,677.04,1187.61,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,677.04,,,,,,,fee schedule,677.04,1187.61,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1187.61,,,,,,,fee schedule,677.04,1187.61,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1031.19,,,,,,,fee schedule,676.05,1185.87,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,844.03,,,,,,,fee schedule,676.05,1185.87,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,676.05,,,,,,,fee schedule,676.05,1185.87,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1185.87,,,,,,,fee schedule,676.05,1185.87,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1224.12,,,,,,,fee schedule,802.53,1407.74,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1001.94,,,,,,,fee schedule,802.53,1407.74,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,802.53,,,,,,,fee schedule,802.53,1407.74,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1407.74,,,,,,,fee schedule,802.53,1407.74,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2076.54,,,,,,,fee schedule,1361.38,2388.02,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1699.65,,,,,,,fee schedule,1361.38,2388.02,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1361.38,,,,,,,fee schedule,1361.38,2388.02,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2388.02,,,,,,,fee schedule,1361.38,2388.02,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1996.47,,,,,,,fee schedule,1308.89,2295.94,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1634.11,,,,,,,fee schedule,1308.89,2295.94,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1308.89,,,,,,,fee schedule,1308.89,2295.94,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2295.94,,,,,,,fee schedule,1308.89,2295.94,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2408.7,,,,,,,fee schedule,1579.14,2770.01,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1971.52,,,,,,,fee schedule,1579.14,2770.01,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1579.14,,,,,,,fee schedule,1579.14,2770.01,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2770.01,,,,,,,fee schedule,1579.14,2770.01,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2315.98,,,,,,,fee schedule,1518.36,2663.38,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1895.63,,,,,,,fee schedule,1518.36,2663.38,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1518.36,,,,,,,fee schedule,1518.36,2663.38,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2663.38,,,,,,,fee schedule,1518.36,2663.38,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2783.11,,,,,,,fee schedule,1824.61,3200.58,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2277.98,,,,,,,fee schedule,1824.61,3200.58,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1824.61,,,,,,,fee schedule,1824.61,3200.58,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3200.58,,,,,,,fee schedule,1824.61,3200.58,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2858.96,,,,,,,fee schedule,1874.33,3287.8,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2340.06,,,,,,,fee schedule,1874.33,3287.8,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1874.33,,,,,,,fee schedule,1874.33,3287.8,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3287.8,,,,,,,fee schedule,1874.33,3287.8,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3787.5,,,,,,,fee schedule,2483.09,4355.63,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3100.07,,,,,,,fee schedule,2483.09,4355.63,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2483.09,,,,,,,fee schedule,2483.09,4355.63,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4355.63,,,,,,,fee schedule,2483.09,4355.63,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3577.86,,,,,,,fee schedule,2345.65,4114.54,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2928.48,,,,,,,fee schedule,2345.65,4114.54,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2345.65,,,,,,,fee schedule,2345.65,4114.54,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4114.54,,,,,,,fee schedule,2345.65,4114.54,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2228.91,,,,,,,fee schedule,1461.27,2563.25,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1824.36,,,,,,,fee schedule,1461.27,2563.25,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1461.27,,,,,,,fee schedule,1461.27,2563.25,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2563.25,,,,,,,fee schedule,1461.27,2563.25,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2273.61,,,,,,,fee schedule,1490.58,2614.65,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1860.95,,,,,,,fee schedule,1490.58,2614.65,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1490.58,,,,,,,fee schedule,1490.58,2614.65,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2614.65,,,,,,,fee schedule,1490.58,2614.65,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2765.48,,,,,,,fee schedule,1813.05,3180.3,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2263.55,,,,,,,fee schedule,1813.05,3180.3,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1813.05,,,,,,,fee schedule,1813.05,3180.3,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3180.3,,,,,,,fee schedule,1813.05,3180.3,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2637.4,,,,,,,fee schedule,1729.08,3033.01,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2158.71,,,,,,,fee schedule,1729.08,3033.01,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1729.08,,,,,,,fee schedule,1729.08,3033.01,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3033.01,,,,,,,fee schedule,1729.08,3033.01,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3950.8,,,,,,,fee schedule,2590.14,4543.42,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3233.73,,,,,,,fee schedule,2590.14,4543.42,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2590.14,,,,,,,fee schedule,2590.14,4543.42,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4543.42,,,,,,,fee schedule,2590.14,4543.42,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2232.52,,,,,,,fee schedule,1463.64,2567.4,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1827.32,,,,,,,fee schedule,1463.64,2567.4,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1463.64,,,,,,,fee schedule,1463.64,2567.4,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2567.4,,,,,,,fee schedule,1463.64,2567.4,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2765.48,,,,,,,fee schedule,1813.05,3180.3,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2263.55,,,,,,,fee schedule,1813.05,3180.3,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1813.05,,,,,,,fee schedule,1813.05,3180.3,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3180.3,,,,,,,fee schedule,1813.05,3180.3,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3950.8,,,,,,,fee schedule,2590.14,4543.42,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3233.73,,,,,,,fee schedule,2590.14,4543.42,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2590.14,,,,,,,fee schedule,2590.14,4543.42,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4543.42,,,,,,,fee schedule,2590.14,4543.42,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4701.5,,,,,,,fee schedule,3082.3,5406.73,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3848.18,,,,,,,fee schedule,3082.3,5406.73,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3082.3,,,,,,,fee schedule,3082.3,5406.73,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5406.73,,,,,,,fee schedule,3082.3,5406.73,
Cranial cervical orthosis,L0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3668.45,,,,,,,fee schedule,1720.06,4218.72,
Cranial cervical orthosis,L0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3002.63,,,,,,,fee schedule,1720.06,4218.72,
Cranial cervical orthosis,L0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2405.04,,,,,,,fee schedule,1720.06,4218.72,
Cranial cervical orthosis,L0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4218.72,,,,,,,fee schedule,1720.06,4218.72,
Cranial cervical orthosis,L0112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1806.06,,,,,,,fee schedule,1720.06,4218.72,APC
Cranial cervical orthosis,L0112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1720.06,,,,,,,fee schedule,1720.06,4218.72,APC
Cranial cervical orthosis,L0112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3096.11,,,,,,,fee schedule,1720.06,4218.72,APC
Cranial cervical torticollis,L0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,747.45,,,,,,,fee schedule,350.47,859.57,
Cranial cervical torticollis,L0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,611.79,,,,,,,fee schedule,350.47,859.57,
Cranial cervical torticollis,L0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.03,,,,,,,fee schedule,350.47,859.57,
Cranial cervical torticollis,L0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,859.57,,,,,,,fee schedule,350.47,859.57,
Cranial cervical torticollis,L0113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,367.99,,,,,,,fee schedule,350.47,859.57,APC
Cranial cervical torticollis,L0113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,350.47,,,,,,,fee schedule,350.47,859.57,APC
Cranial cervical torticollis,L0113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,630.85,,,,,,,fee schedule,350.47,859.57,APC
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.31,,,,,,,fee schedule,32.51,79.71,
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.73,,,,,,,fee schedule,32.51,79.71,
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.44,,,,,,,fee schedule,32.51,79.71,
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.71,,,,,,,fee schedule,32.51,79.71,
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.14,,,,,,,fee schedule,32.51,79.71,APC
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.51,,,,,,,fee schedule,32.51,79.71,APC
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.52,,,,,,,fee schedule,32.51,79.71,APC
Flex thermoplastic collar mo,L0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,400.08,,,,,,,fee schedule,187.59,460.09,
Flex thermoplastic collar mo,L0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,327.47,,,,,,,fee schedule,187.59,460.09,
Flex thermoplastic collar mo,L0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,262.29,,,,,,,fee schedule,187.59,460.09,
Flex thermoplastic collar mo,L0130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,460.09,,,,,,,fee schedule,187.59,460.09,
Flex thermoplastic collar mo,L0130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,196.97,,,,,,,fee schedule,187.59,460.09,APC
Flex thermoplastic collar mo,L0130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,187.59,,,,,,,fee schedule,187.59,460.09,APC
Flex thermoplastic collar mo,L0130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,337.66,,,,,,,fee schedule,187.59,460.09,APC
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.87,,,,,,,fee schedule,73.56,180.4,
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.4,,,,,,,fee schedule,73.56,180.4,
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.84,,,,,,,fee schedule,73.56,180.4,
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.4,,,,,,,fee schedule,73.56,180.4,
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.24,,,,,,,fee schedule,73.56,180.4,APC
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.56,,,,,,,fee schedule,73.56,180.4,APC
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.41,,,,,,,fee schedule,73.56,180.4,APC
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,280.54,,,,,,,fee schedule,131.54,322.62,
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,229.62,,,,,,,fee schedule,131.54,322.62,
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,183.92,,,,,,,fee schedule,131.54,322.62,
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,322.62,,,,,,,fee schedule,131.54,322.62,
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.12,,,,,,,fee schedule,131.54,322.62,APC
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,131.54,,,,,,,fee schedule,131.54,322.62,APC
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,236.77,,,,,,,fee schedule,131.54,322.62,APC
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,409.64,,,,,,,fee schedule,192.08,471.09,
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,335.29,,,,,,,fee schedule,192.08,471.09,
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,268.56,,,,,,,fee schedule,192.08,471.09,
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,471.09,,,,,,,fee schedule,192.08,471.09,
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.68,,,,,,,fee schedule,192.08,471.09,APC
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,192.08,,,,,,,fee schedule,192.08,471.09,APC
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,345.74,,,,,,,fee schedule,192.08,471.09,APC
Cervical collar molded to pt,L0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2107.41,,,,,,,fee schedule,988.11,2423.52,
Cervical collar molded to pt,L0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1724.92,,,,,,,fee schedule,988.11,2423.52,
Cervical collar molded to pt,L0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1381.62,,,,,,,fee schedule,988.11,2423.52,
Cervical collar molded to pt,L0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2423.52,,,,,,,fee schedule,988.11,2423.52,
Cervical collar molded to pt,L0170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1037.52,,,,,,,fee schedule,988.11,2423.52,APC
Cervical collar molded to pt,L0170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,988.11,,,,,,,fee schedule,988.11,2423.52,APC
Cervical collar molded to pt,L0170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1778.6,,,,,,,fee schedule,988.11,2423.52,APC
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,132.53,,,,,,,fee schedule,86.89,313.29,
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.48,,,,,,,fee schedule,86.89,313.29,
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.89,,,,,,,fee schedule,86.89,313.29,
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,152.41,,,,,,,fee schedule,86.89,313.29,
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.75,,,,,,,fee schedule,86.89,313.29,APC
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.05,,,,,,,fee schedule,86.89,313.29,APC
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,313.29,,,,,,,fee schedule,86.89,313.29,APC
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,729.91,,,,,,,fee schedule,342.24,839.4,
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,597.43,,,,,,,fee schedule,342.24,839.4,
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,478.53,,,,,,,fee schedule,342.24,839.4,
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,839.4,,,,,,,fee schedule,342.24,839.4,
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,359.35,,,,,,,fee schedule,342.24,839.4,APC
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,342.24,,,,,,,fee schedule,342.24,839.4,APC
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,616.03,,,,,,,fee schedule,342.24,839.4,APC
Cer post col occ/man sup adj,L0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1182.52,,,,,,,fee schedule,554.45,1359.9,
Cer post col occ/man sup adj,L0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,967.89,,,,,,,fee schedule,554.45,1359.9,
Cer post col occ/man sup adj,L0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,775.26,,,,,,,fee schedule,554.45,1359.9,
Cer post col occ/man sup adj,L0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1359.9,,,,,,,fee schedule,554.45,1359.9,
Cer post col occ/man sup adj,L0180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,582.17,,,,,,,fee schedule,554.45,1359.9,APC
Cer post col occ/man sup adj,L0180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,554.45,,,,,,,fee schedule,554.45,1359.9,APC
Cer post col occ/man sup adj,L0180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,998.01,,,,,,,fee schedule,554.45,1359.9,APC
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1394.6,,,,,,,fee schedule,653.92,1603.79,
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1141.48,,,,,,,fee schedule,653.92,1603.79,
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,914.3,,,,,,,fee schedule,653.92,1603.79,
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1603.79,,,,,,,fee schedule,653.92,1603.79,
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,686.62,,,,,,,fee schedule,653.92,1603.79,APC
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,653.92,,,,,,,fee schedule,653.92,1603.79,APC
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1177.06,,,,,,,fee schedule,653.92,1603.79,APC
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1617.61,,,,,,,fee schedule,758.49,1860.25,
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1324.01,,,,,,,fee schedule,758.49,1860.25,
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1060.51,,,,,,,fee schedule,758.49,1860.25,
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1860.25,,,,,,,fee schedule,758.49,1860.25,
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,796.41,,,,,,,fee schedule,758.49,1860.25,APC
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,758.49,,,,,,,fee schedule,758.49,1860.25,APC
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1365.28,,,,,,,fee schedule,758.49,1860.25,APC
Thor rib belt custom fabrica,L0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,338.63,,,,,,,fee schedule,158.76,389.42,
Thor rib belt custom fabrica,L0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,277.17,,,,,,,fee schedule,158.76,389.42,
Thor rib belt custom fabrica,L0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,222.01,,,,,,,fee schedule,158.76,389.42,
Thor rib belt custom fabrica,L0220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,389.42,,,,,,,fee schedule,158.76,389.42,
Thor rib belt custom fabrica,L0220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,166.7,,,,,,,fee schedule,158.76,389.42,APC
Thor rib belt custom fabrica,L0220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,158.76,,,,,,,fee schedule,158.76,389.42,APC
Thor rib belt custom fabrica,L0220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,285.77,,,,,,,fee schedule,158.76,389.42,APC
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,425.92,,,,,,,fee schedule,123.17,489.81,
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,348.62,,,,,,,fee schedule,123.17,489.81,
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,279.23,,,,,,,fee schedule,123.17,489.81,
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,489.81,,,,,,,fee schedule,123.17,489.81,
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.33,,,,,,,fee schedule,123.17,489.81,APC
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,123.17,,,,,,,fee schedule,123.17,489.81,APC
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,221.71,,,,,,,fee schedule,123.17,489.81,APC
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,909.03,,,,,,,fee schedule,426.22,1045.38,
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,744.04,,,,,,,fee schedule,426.22,1045.38,
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,595.96,,,,,,,fee schedule,426.22,1045.38,
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1045.38,,,,,,,fee schedule,426.22,1045.38,
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,447.53,,,,,,,fee schedule,426.22,1045.38,APC
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,426.22,,,,,,,fee schedule,426.22,1045.38,APC
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,767.2,,,,,,,fee schedule,426.22,1045.38,APC
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,909.03,,,,,,,fee schedule,228.66,1045.38,
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,744.04,,,,,,,fee schedule,228.66,1045.38,
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,595.96,,,,,,,fee schedule,228.66,1045.38,
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1045.38,,,,,,,fee schedule,228.66,1045.38,
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,240.09,,,,,,,fee schedule,228.66,1045.38,APC
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,228.66,,,,,,,fee schedule,228.66,1045.38,APC
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,411.59,,,,,,,fee schedule,228.66,1045.38,APC
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2606.84,,,,,,,fee schedule,1222.31,2997.87,
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2133.7,,,,,,,fee schedule,1222.31,2997.87,
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1709.04,,,,,,,fee schedule,1222.31,2997.87,
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2997.87,,,,,,,fee schedule,1222.31,2997.87,
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1283.43,,,,,,,fee schedule,1222.31,2997.87,APC
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1222.31,,,,,,,fee schedule,1222.31,2997.87,APC
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2200.16,,,,,,,fee schedule,1222.31,2997.87,APC
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2606.84,,,,,,,fee schedule,655.74,2997.87,
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2133.7,,,,,,,fee schedule,655.74,2997.87,
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1709.04,,,,,,,fee schedule,655.74,2997.87,
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2997.87,,,,,,,fee schedule,655.74,2997.87,
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,688.53,,,,,,,fee schedule,655.74,2997.87,APC
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,655.74,,,,,,,fee schedule,655.74,2997.87,APC
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1180.33,,,,,,,fee schedule,655.74,2997.87,APC
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2337.58,,,,,,,fee schedule,1096.06,2688.22,
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1913.31,,,,,,,fee schedule,1096.06,2688.22,
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1532.52,,,,,,,fee schedule,1096.06,2688.22,
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2688.22,,,,,,,fee schedule,1096.06,2688.22,
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1150.86,,,,,,,fee schedule,1096.06,2688.22,APC
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1096.06,,,,,,,fee schedule,1096.06,2688.22,APC
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1972.91,,,,,,,fee schedule,1096.06,2688.22,APC
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2631.13,,,,,,,fee schedule,1233.68,3025.8,
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2153.58,,,,,,,fee schedule,1233.68,3025.8,
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1724.97,,,,,,,fee schedule,1233.68,3025.8,
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3025.8,,,,,,,fee schedule,1233.68,3025.8,
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1295.36,,,,,,,fee schedule,1233.68,3025.8,APC
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1233.68,,,,,,,fee schedule,1233.68,3025.8,APC
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2220.62,,,,,,,fee schedule,1233.68,3025.8,APC
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3272.61,,,,,,,fee schedule,1534.47,3763.5,
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2678.63,,,,,,,fee schedule,1534.47,3763.5,
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2145.52,,,,,,,fee schedule,1534.47,3763.5,
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3763.5,,,,,,,fee schedule,1534.47,3763.5,
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1611.19,,,,,,,fee schedule,1534.47,3763.5,APC
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1534.47,,,,,,,fee schedule,1534.47,3763.5,APC
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2762.05,,,,,,,fee schedule,1534.47,3763.5,APC
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3896.02,,,,,,,fee schedule,1826.79,4480.42,
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3188.89,,,,,,,fee schedule,1826.79,4480.42,
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2554.23,,,,,,,fee schedule,1826.79,4480.42,
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4480.42,,,,,,,fee schedule,1826.79,4480.42,
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1918.13,,,,,,,fee schedule,1826.79,4480.42,APC
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1826.79,,,,,,,fee schedule,1826.79,4480.42,APC
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3288.22,,,,,,,fee schedule,1826.79,4480.42,APC
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,994.43,,,,,,,fee schedule,466.26,1143.59,
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,813.94,,,,,,,fee schedule,466.26,1143.59,
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,651.95,,,,,,,fee schedule,466.26,1143.59,
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1143.59,,,,,,,fee schedule,466.26,1143.59,
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,489.57,,,,,,,fee schedule,466.26,1143.59,APC
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,466.26,,,,,,,fee schedule,466.26,1143.59,APC
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,839.27,,,,,,,fee schedule,466.26,1143.59,APC
Tlso r fram soft pre ots,L0467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,994.43,,,,,,,fee schedule,256.45,1143.59,
Tlso r fram soft pre ots,L0467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,813.94,,,,,,,fee schedule,256.45,1143.59,
Tlso r fram soft pre ots,L0467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,651.95,,,,,,,fee schedule,256.45,1143.59,
Tlso r fram soft pre ots,L0467,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1143.59,,,,,,,fee schedule,256.45,1143.59,
Tlso r fram soft pre ots,L0467,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,269.27,,,,,,,fee schedule,256.45,1143.59,APC
Tlso r fram soft pre ots,L0467,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,256.45,,,,,,,fee schedule,256.45,1143.59,APC
Tlso r fram soft pre ots,L0467,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,461.61,,,,,,,fee schedule,256.45,1143.59,APC
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1246.25,,,,,,,fee schedule,584.34,1433.19,
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1020.06,,,,,,,fee schedule,584.34,1433.19,
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,817.04,,,,,,,fee schedule,584.34,1433.19,
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1433.19,,,,,,,fee schedule,584.34,1433.19,
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,613.56,,,,,,,fee schedule,584.34,1433.19,APC
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,584.34,,,,,,,fee schedule,584.34,1433.19,APC
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1051.81,,,,,,,fee schedule,584.34,1433.19,APC
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1246.25,,,,,,,fee schedule,326.76,1433.19,
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1020.06,,,,,,,fee schedule,326.76,1433.19,
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,817.04,,,,,,,fee schedule,326.76,1433.19,
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1433.19,,,,,,,fee schedule,326.76,1433.19,
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.1,,,,,,,fee schedule,326.76,1433.19,APC
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,326.76,,,,,,,fee schedule,326.76,1433.19,APC
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,588.17,,,,,,,fee schedule,326.76,1433.19,APC
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1724.5,,,,,,,fee schedule,808.59,1983.18,
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1411.5,,,,,,,fee schedule,808.59,1983.18,
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1130.58,,,,,,,fee schedule,808.59,1983.18,
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1983.18,,,,,,,fee schedule,808.59,1983.18,
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,849.02,,,,,,,fee schedule,808.59,1983.18,APC
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,808.59,,,,,,,fee schedule,808.59,1983.18,APC
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1455.46,,,,,,,fee schedule,808.59,1983.18,APC
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1061.14,,,,,,,fee schedule,497.56,1220.31,
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,868.54,,,,,,,fee schedule,497.56,1220.31,
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,695.68,,,,,,,fee schedule,497.56,1220.31,
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1220.31,,,,,,,fee schedule,497.56,1220.31,
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,522.44,,,,,,,fee schedule,497.56,1220.31,APC
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,497.56,,,,,,,fee schedule,497.56,1220.31,APC
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,895.61,,,,,,,fee schedule,497.56,1220.31,APC
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3958.95,,,,,,,fee schedule,1856.29,4552.79,
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3240.4,,,,,,,fee schedule,1856.29,4552.79,
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2595.49,,,,,,,fee schedule,1856.29,4552.79,
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4552.79,,,,,,,fee schedule,1856.29,4552.79,
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1949.1,,,,,,,fee schedule,1856.29,4552.79,APC
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1856.29,,,,,,,fee schedule,1856.29,4552.79,APC
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3341.32,,,,,,,fee schedule,1856.29,4552.79,APC
TLSO rigid lined custom fab,L0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4422.2,,,,,,,fee schedule,2073.49,5085.53,
TLSO rigid lined custom fab,L0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3619.57,,,,,,,fee schedule,2073.49,5085.53,
TLSO rigid lined custom fab,L0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2899.19,,,,,,,fee schedule,2073.49,5085.53,
TLSO rigid lined custom fab,L0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5085.53,,,,,,,fee schedule,2073.49,5085.53,
TLSO rigid lined custom fab,L0482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2177.16,,,,,,,fee schedule,2073.49,5085.53,APC
TLSO rigid lined custom fab,L0482,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2073.49,,,,,,,fee schedule,2073.49,5085.53,APC
TLSO rigid lined custom fab,L0482,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3732.28,,,,,,,fee schedule,2073.49,5085.53,APC
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4775.8,,,,,,,fee schedule,2239.27,5492.17,
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3908.99,,,,,,,fee schedule,2239.27,5492.17,
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3131.01,,,,,,,fee schedule,2239.27,5492.17,
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5492.17,,,,,,,fee schedule,2239.27,5492.17,
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2351.23,,,,,,,fee schedule,2239.27,5492.17,APC
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2239.27,,,,,,,fee schedule,2239.27,5492.17,APC
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4030.69,,,,,,,fee schedule,2239.27,5492.17,APC
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5363.4,,,,,,,fee schedule,2514.79,6167.91,
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4389.94,,,,,,,fee schedule,2514.79,6167.91,
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3516.25,,,,,,,fee schedule,2514.79,6167.91,
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6167.91,,,,,,,fee schedule,2514.79,6167.91,
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2640.53,,,,,,,fee schedule,2514.79,6167.91,APC
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2514.79,,,,,,,fee schedule,2514.79,6167.91,APC
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4526.62,,,,,,,fee schedule,2514.79,6167.91,APC
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2631.13,,,,,,,fee schedule,1233.68,3025.8,
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2153.58,,,,,,,fee schedule,1233.68,3025.8,
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1724.97,,,,,,,fee schedule,1233.68,3025.8,
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3025.8,,,,,,,fee schedule,1233.68,3025.8,
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1295.36,,,,,,,fee schedule,1233.68,3025.8,APC
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1233.68,,,,,,,fee schedule,1233.68,3025.8,APC
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2220.62,,,,,,,fee schedule,1233.68,3025.8,APC
TLSO rigid plastic pre one,L0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,741.42,,,,,,,fee schedule,347.64,852.63,
TLSO rigid plastic pre one,L0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,606.85,,,,,,,fee schedule,347.64,852.63,
TLSO rigid plastic pre one,L0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,486.07,,,,,,,fee schedule,347.64,852.63,
TLSO rigid plastic pre one,L0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,852.63,,,,,,,fee schedule,347.64,852.63,
TLSO rigid plastic pre one,L0490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365.02,,,,,,,fee schedule,347.64,852.63,APC
TLSO rigid plastic pre one,L0490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.64,,,,,,,fee schedule,347.64,852.63,APC
TLSO rigid plastic pre one,L0490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.75,,,,,,,fee schedule,347.64,852.63,APC
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2012.95,,,,,,,fee schedule,943.84,2314.89,
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1647.6,,,,,,,fee schedule,943.84,2314.89,
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1319.69,,,,,,,fee schedule,943.84,2314.89,
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2314.89,,,,,,,fee schedule,943.84,2314.89,
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,991.03,,,,,,,fee schedule,943.84,2314.89,APC
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,943.84,,,,,,,fee schedule,943.84,2314.89,APC
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1698.91,,,,,,,fee schedule,943.84,2314.89,APC
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1310.79,,,,,,,fee schedule,614.59,1507.41,
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1072.88,,,,,,,fee schedule,614.59,1507.41,
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,859.35,,,,,,,fee schedule,614.59,1507.41,
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1507.41,,,,,,,fee schedule,614.59,1507.41,
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,645.32,,,,,,,fee schedule,614.59,1507.41,APC
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,614.59,,,,,,,fee schedule,614.59,1507.41,APC
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1106.26,,,,,,,fee schedule,614.59,1507.41,APC
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226,,,,,,,fee schedule,64.94,259.9,
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,184.98,,,,,,,fee schedule,64.94,259.9,
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.17,,,,,,,fee schedule,64.94,259.9,
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,259.9,,,,,,,fee schedule,64.94,259.9,
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.19,,,,,,,fee schedule,64.94,259.9,APC
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.94,,,,,,,fee schedule,64.94,259.9,APC
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,116.89,,,,,,,fee schedule,64.94,259.9,APC
Sio flex pelvisacral custom,L0622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,700.55,,,,,,,fee schedule,328.48,805.63,
Sio flex pelvisacral custom,L0622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,573.4,,,,,,,fee schedule,328.48,805.63,
Sio flex pelvisacral custom,L0622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,459.28,,,,,,,fee schedule,328.48,805.63,
Sio flex pelvisacral custom,L0622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,805.63,,,,,,,fee schedule,328.48,805.63,
Sio flex pelvisacral custom,L0622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,344.9,,,,,,,fee schedule,328.48,805.63,APC
Sio flex pelvisacral custom,L0622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,328.48,,,,,,,fee schedule,328.48,805.63,APC
Sio flex pelvisacral custom,L0622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,591.26,,,,,,,fee schedule,328.48,805.63,APC
Sio rig pnl pelv/sac pre ots,L0623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.23,,,,,,,fee schedule,116.41,209.54,APC
Sio rig pnl pelv/sac pre ots,L0623,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.41,,,,,,,fee schedule,116.41,209.54,APC
Sio rig pnl pelv/sac pre ots,L0623,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,209.54,,,,,,,fee schedule,116.41,209.54,APC
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.4,,,,,,,fee schedule,36.33,166.06,
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.19,,,,,,,fee schedule,36.33,166.06,
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.67,,,,,,,fee schedule,36.33,166.06,
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,166.06,,,,,,,fee schedule,36.33,166.06,
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.15,,,,,,,fee schedule,36.33,166.06,APC
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.33,,,,,,,fee schedule,36.33,166.06,APC
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.39,,,,,,,fee schedule,36.33,166.06,APC
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.31,,,,,,,fee schedule,95.79,234.96,
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.23,,,,,,,fee schedule,95.79,234.96,
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.95,,,,,,,fee schedule,95.79,234.96,
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,234.96,,,,,,,fee schedule,95.79,234.96,
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.58,,,,,,,fee schedule,95.79,234.96,APC
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,95.79,,,,,,,fee schedule,95.79,234.96,APC
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,172.42,,,,,,,fee schedule,95.79,234.96,APC
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1077.29,,,,,,,fee schedule,505.13,1238.88,
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,881.76,,,,,,,fee schedule,505.13,1238.88,
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,706.27,,,,,,,fee schedule,505.13,1238.88,
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1238.88,,,,,,,fee schedule,505.13,1238.88,
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,530.39,,,,,,,fee schedule,505.13,1238.88,APC
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,505.13,,,,,,,fee schedule,505.13,1238.88,APC
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,909.23,,,,,,,fee schedule,505.13,1238.88,APC
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,219.83,,,,,,,fee schedule,55.32,252.8,
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,179.93,,,,,,,fee schedule,55.32,252.8,
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,144.12,,,,,,,fee schedule,55.32,252.8,
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,252.8,,,,,,,fee schedule,55.32,252.8,
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.09,,,,,,,fee schedule,55.32,252.8,APC
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55.32,,,,,,,fee schedule,55.32,252.8,APC
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,99.58,,,,,,,fee schedule,55.32,252.8,APC
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,424.53,,,,,,,fee schedule,199.05,488.21,
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,347.48,,,,,,,fee schedule,199.05,488.21,
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,278.32,,,,,,,fee schedule,199.05,488.21,
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,488.21,,,,,,,fee schedule,199.05,488.21,
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209,,,,,,,fee schedule,199.05,488.21,APC
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.05,,,,,,,fee schedule,199.05,488.21,APC
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,358.29,,,,,,,fee schedule,199.05,488.21,APC
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2690.65,,,,,,,fee schedule,1261.6,3094.25,
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2202.3,,,,,,,fee schedule,1261.6,3094.25,
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1763.99,,,,,,,fee schedule,1261.6,3094.25,
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3094.25,,,,,,,fee schedule,1261.6,3094.25,
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1324.68,,,,,,,fee schedule,1261.6,3094.25,APC
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1261.6,,,,,,,fee schedule,1261.6,3094.25,APC
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2270.88,,,,,,,fee schedule,1261.6,3094.25,APC
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,751.61,,,,,,,fee schedule,352.41,864.35,
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,615.19,,,,,,,fee schedule,352.41,864.35,
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,492.76,,,,,,,fee schedule,352.41,864.35,
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,864.35,,,,,,,fee schedule,352.41,864.35,
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,370.03,,,,,,,fee schedule,352.41,864.35,APC
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,352.41,,,,,,,fee schedule,352.41,864.35,APC
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,634.34,,,,,,,fee schedule,352.41,864.35,APC
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2619.02,,,,,,,fee schedule,1228.02,3011.87,
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2143.67,,,,,,,fee schedule,1228.02,3011.87,
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1717.03,,,,,,,fee schedule,1228.02,3011.87,
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3011.87,,,,,,,fee schedule,1228.02,3011.87,
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1289.42,,,,,,,fee schedule,1228.02,3011.87,APC
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1228.02,,,,,,,fee schedule,1228.02,3011.87,APC
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2210.44,,,,,,,fee schedule,1228.02,3011.87,APC
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3553.55,,,,,,,fee schedule,1666.22,4086.58,
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2908.58,,,,,,,fee schedule,1666.22,4086.58,
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2329.71,,,,,,,fee schedule,1666.22,4086.58,
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4086.58,,,,,,,fee schedule,1666.22,4086.58,
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1749.53,,,,,,,fee schedule,1666.22,4086.58,APC
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1666.22,,,,,,,fee schedule,1666.22,4086.58,APC
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2999.2,,,,,,,fee schedule,1666.22,4086.58,APC
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3395.59,,,,,,,fee schedule,1592.13,3904.93,
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2779.29,,,,,,,fee schedule,1592.13,3904.93,
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2226.15,,,,,,,fee schedule,1592.13,3904.93,
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3904.93,,,,,,,fee schedule,1592.13,3904.93,
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.74,,,,,,,fee schedule,1592.13,3904.93,APC
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1592.13,,,,,,,fee schedule,1592.13,3904.93,APC
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2865.83,,,,,,,fee schedule,1592.13,3904.93,APC
Lso sag-coronal panel custom,L0638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3456.96,,,,,,,fee schedule,1620.91,3975.5,
Lso sag-coronal panel custom,L0638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2829.52,,,,,,,fee schedule,1620.91,3975.5,
Lso sag-coronal panel custom,L0638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2266.38,,,,,,,fee schedule,1620.91,3975.5,
Lso sag-coronal panel custom,L0638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3975.5,,,,,,,fee schedule,1620.91,3975.5,
Lso sag-coronal panel custom,L0638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1701.96,,,,,,,fee schedule,1620.91,3975.5,APC
Lso sag-coronal panel custom,L0638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1620.91,,,,,,,fee schedule,1620.91,3975.5,APC
Lso sag-coronal panel custom,L0638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2917.64,,,,,,,fee schedule,1620.91,3975.5,APC
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3395.59,,,,,,,fee schedule,1592.13,3904.93,
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2779.29,,,,,,,fee schedule,1592.13,3904.93,
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2226.15,,,,,,,fee schedule,1592.13,3904.93,
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3904.93,,,,,,,fee schedule,1592.13,3904.93,
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.74,,,,,,,fee schedule,1592.13,3904.93,APC
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1592.13,,,,,,,fee schedule,1592.13,3904.93,APC
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2865.83,,,,,,,fee schedule,1592.13,3904.93,APC
Lso s/c shell/panel custom,L0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2742.61,,,,,,,fee schedule,1285.97,3154,
Lso s/c shell/panel custom,L0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2244.83,,,,,,,fee schedule,1285.97,3154,
Lso s/c shell/panel custom,L0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1798.06,,,,,,,fee schedule,1285.97,3154,
Lso s/c shell/panel custom,L0640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3154,,,,,,,fee schedule,1285.97,3154,
Lso s/c shell/panel custom,L0640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1350.27,,,,,,,fee schedule,1285.97,3154,APC
Lso s/c shell/panel custom,L0640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1285.97,,,,,,,fee schedule,1285.97,3154,APC
Lso s/c shell/panel custom,L0640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2314.75,,,,,,,fee schedule,1285.97,3154,APC
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.31,,,,,,,fee schedule,51.4,234.96,
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.23,,,,,,,fee schedule,51.4,234.96,
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.95,,,,,,,fee schedule,51.4,234.96,
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,234.96,,,,,,,fee schedule,51.4,234.96,
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.97,,,,,,,fee schedule,51.4,234.96,APC
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.4,,,,,,,fee schedule,51.4,234.96,APC
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.52,,,,,,,fee schedule,51.4,234.96,APC
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1077.29,,,,,,,fee schedule,271.08,1238.88,
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,881.76,,,,,,,fee schedule,271.08,1238.88,
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,706.27,,,,,,,fee schedule,271.08,1238.88,
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1238.88,,,,,,,fee schedule,271.08,1238.88,
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,284.63,,,,,,,fee schedule,271.08,1238.88,APC
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,271.08,,,,,,,fee schedule,271.08,1238.88,APC
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,487.94,,,,,,,fee schedule,271.08,1238.88,APC
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,424.53,,,,,,,fee schedule,106.8,488.21,
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,347.48,,,,,,,fee schedule,106.8,488.21,
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,278.32,,,,,,,fee schedule,106.8,488.21,
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,488.21,,,,,,,fee schedule,106.8,488.21,
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.14,,,,,,,fee schedule,106.8,488.21,APC
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,106.8,,,,,,,fee schedule,106.8,488.21,APC
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,192.24,,,,,,,fee schedule,106.8,488.21,APC
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2690.65,,,,,,,fee schedule,676.99,3094.25,
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2202.3,,,,,,,fee schedule,676.99,3094.25,
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1763.99,,,,,,,fee schedule,676.99,3094.25,
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3094.25,,,,,,,fee schedule,676.99,3094.25,
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.84,,,,,,,fee schedule,676.99,3094.25,APC
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,676.99,,,,,,,fee schedule,676.99,3094.25,APC
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1218.58,,,,,,,fee schedule,676.99,3094.25,APC
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,751.61,,,,,,,fee schedule,189.11,864.35,
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,615.19,,,,,,,fee schedule,189.11,864.35,
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,492.76,,,,,,,fee schedule,189.11,864.35,
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,864.35,,,,,,,fee schedule,189.11,864.35,
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,198.57,,,,,,,fee schedule,189.11,864.35,APC
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,189.11,,,,,,,fee schedule,189.11,864.35,APC
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,340.4,,,,,,,fee schedule,189.11,864.35,APC
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3395.59,,,,,,,fee schedule,783.31,3904.93,
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2779.29,,,,,,,fee schedule,783.31,3904.93,
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2226.15,,,,,,,fee schedule,783.31,3904.93,
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3904.93,,,,,,,fee schedule,783.31,3904.93,
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,822.48,,,,,,,fee schedule,783.31,3904.93,APC
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,783.31,,,,,,,fee schedule,783.31,3904.93,APC
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1409.96,,,,,,,fee schedule,783.31,3904.93,APC
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3395.59,,,,,,,fee schedule,783.31,3904.93,
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2779.29,,,,,,,fee schedule,783.31,3904.93,
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2226.15,,,,,,,fee schedule,783.31,3904.93,
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3904.93,,,,,,,fee schedule,783.31,3904.93,
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,822.48,,,,,,,fee schedule,783.31,3904.93,APC
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,783.31,,,,,,,fee schedule,783.31,3904.93,APC
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1409.96,,,,,,,fee schedule,783.31,3904.93,APC
Ctlso a-p-l control molded,L0700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5217.87,,,,,,,fee schedule,2446.57,6000.55,
Ctlso a-p-l control molded,L0700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4270.83,,,,,,,fee schedule,2446.57,6000.55,
Ctlso a-p-l control molded,L0700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3420.84,,,,,,,fee schedule,2446.57,6000.55,
Ctlso a-p-l control molded,L0700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6000.55,,,,,,,fee schedule,2446.57,6000.55,
Ctlso a-p-l control molded,L0700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2568.9,,,,,,,fee schedule,2446.57,6000.55,APC
Ctlso a-p-l control molded,L0700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2446.57,,,,,,,fee schedule,2446.57,6000.55,APC
Ctlso a-p-l control molded,L0700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4403.83,,,,,,,fee schedule,2446.57,6000.55,APC
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5735.85,,,,,,,fee schedule,2689.42,6596.23,
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4694.79,,,,,,,fee schedule,2689.42,6596.23,
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3760.42,,,,,,,fee schedule,2689.42,6596.23,
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6596.23,,,,,,,fee schedule,2689.42,6596.23,
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2823.89,,,,,,,fee schedule,2689.42,6596.23,APC
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2689.42,,,,,,,fee schedule,2689.42,6596.23,APC
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4840.96,,,,,,,fee schedule,2689.42,6596.23,APC
Ctlso a-p-l control custom,L0720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2500.3,,,,,,,fee schedule,2381.24,4286.23,APC
Ctlso a-p-l control custom,L0720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2381.24,,,,,,,fee schedule,2381.24,4286.23,APC
Ctlso a-p-l control custom,L0720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4286.23,,,,,,,fee schedule,2381.24,4286.23,APC
Halo cervical into jckt vest,L0810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7005.79,,,,,,,fee schedule,3284.91,8056.66,
Halo cervical into jckt vest,L0810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5734.24,,,,,,,fee schedule,3284.91,8056.66,
Halo cervical into jckt vest,L0810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4593,,,,,,,fee schedule,3284.91,8056.66,
Halo cervical into jckt vest,L0810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8056.66,,,,,,,fee schedule,3284.91,8056.66,
Halo cervical into jckt vest,L0810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3449.16,,,,,,,fee schedule,3284.91,8056.66,APC
Halo cervical into jckt vest,L0810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3284.91,,,,,,,fee schedule,3284.91,8056.66,APC
Halo cervical into jckt vest,L0810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5912.84,,,,,,,fee schedule,3284.91,8056.66,APC
Halo cervical into body jack,L0820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5511.03,,,,,,,fee schedule,2584.02,6337.68,
Halo cervical into body jack,L0820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4510.78,,,,,,,fee schedule,2584.02,6337.68,
Halo cervical into body jack,L0820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3613.03,,,,,,,fee schedule,2584.02,6337.68,
Halo cervical into body jack,L0820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6337.68,,,,,,,fee schedule,2584.02,6337.68,
Halo cervical into body jack,L0820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2713.22,,,,,,,fee schedule,2584.02,6337.68,APC
Halo cervical into body jack,L0820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2584.02,,,,,,,fee schedule,2584.02,6337.68,APC
Halo cervical into body jack,L0820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4651.24,,,,,,,fee schedule,2584.02,6337.68,APC
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8432.69,,,,,,,fee schedule,3953.92,9697.59,
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6902.16,,,,,,,fee schedule,3953.92,9697.59,
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5528.47,,,,,,,fee schedule,3953.92,9697.59,
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9697.59,,,,,,,fee schedule,3953.92,9697.59,
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4151.62,,,,,,,fee schedule,3953.92,9697.59,APC
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3953.92,,,,,,,fee schedule,3953.92,9697.59,APC
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7117.06,,,,,,,fee schedule,3953.92,9697.59,APC
MRI compatible system,L0859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2985.62,,,,,,,fee schedule,1399.89,3433.46,
MRI compatible system,L0859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2443.73,,,,,,,fee schedule,1399.89,3433.46,
MRI compatible system,L0859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1957.37,,,,,,,fee schedule,1399.89,3433.46,
MRI compatible system,L0859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3433.46,,,,,,,fee schedule,1399.89,3433.46,
MRI compatible system,L0859,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1469.88,,,,,,,fee schedule,1399.89,3433.46,APC
MRI compatible system,L0859,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1399.89,,,,,,,fee schedule,1399.89,3433.46,APC
MRI compatible system,L0859,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2519.8,,,,,,,fee schedule,1399.89,3433.46,APC
Halo repl liner/interface,L0861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,564.94,,,,,,,fee schedule,264.89,649.68,
Halo repl liner/interface,L0861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,462.4,,,,,,,fee schedule,264.89,649.68,
Halo repl liner/interface,L0861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,370.37,,,,,,,fee schedule,264.89,649.68,
Halo repl liner/interface,L0861,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,649.68,,,,,,,fee schedule,264.89,649.68,
Halo repl liner/interface,L0861,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,278.13,,,,,,,fee schedule,264.89,649.68,APC
Halo repl liner/interface,L0861,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,264.89,,,,,,,fee schedule,264.89,649.68,APC
Halo repl liner/interface,L0861,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,476.8,,,,,,,fee schedule,264.89,649.68,APC
Tlso corset front,L0970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,280.11,,,,,,,fee schedule,131.34,322.13,
Tlso corset front,L0970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,229.27,,,,,,,fee schedule,131.34,322.13,
Tlso corset front,L0970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,183.64,,,,,,,fee schedule,131.34,322.13,
Tlso corset front,L0970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,322.13,,,,,,,fee schedule,131.34,322.13,
Tlso corset front,L0970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,137.91,,,,,,,fee schedule,131.34,322.13,APC
Tlso corset front,L0970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,131.34,,,,,,,fee schedule,131.34,322.13,APC
Tlso corset front,L0970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,236.41,,,,,,,fee schedule,131.34,322.13,APC
Lso corset front,L0972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.94,,,,,,,fee schedule,119.54,293.18,
Lso corset front,L0972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.67,,,,,,,fee schedule,119.54,293.18,
Lso corset front,L0972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.14,,,,,,,fee schedule,119.54,293.18,
Lso corset front,L0972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,293.18,,,,,,,fee schedule,119.54,293.18,
Lso corset front,L0972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,125.52,,,,,,,fee schedule,119.54,293.18,APC
Lso corset front,L0972,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,119.54,,,,,,,fee schedule,119.54,293.18,APC
Lso corset front,L0972,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,215.17,,,,,,,fee schedule,119.54,293.18,APC
Tlso full corset,L0974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,458.03,,,,,,,fee schedule,214.76,526.73,
Tlso full corset,L0974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,374.9,,,,,,,fee schedule,214.76,526.73,
Tlso full corset,L0974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.28,,,,,,,fee schedule,214.76,526.73,
Tlso full corset,L0974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,526.73,,,,,,,fee schedule,214.76,526.73,
Tlso full corset,L0974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.5,,,,,,,fee schedule,214.76,526.73,APC
Tlso full corset,L0974,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,214.76,,,,,,,fee schedule,214.76,526.73,APC
Tlso full corset,L0974,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,386.57,,,,,,,fee schedule,214.76,526.73,APC
Lso full corset,L0976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,391.87,,,,,,,fee schedule,183.75,450.65,
Lso full corset,L0976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,320.75,,,,,,,fee schedule,183.75,450.65,
Lso full corset,L0976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,256.91,,,,,,,fee schedule,183.75,450.65,
Lso full corset,L0976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,450.65,,,,,,,fee schedule,183.75,450.65,
Lso full corset,L0976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,192.94,,,,,,,fee schedule,183.75,450.65,APC
Lso full corset,L0976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,183.75,,,,,,,fee schedule,183.75,450.65,APC
Lso full corset,L0976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,330.75,,,,,,,fee schedule,183.75,450.65,APC
Axillary crutch extension,L0978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,493.23,,,,,,,fee schedule,231.25,567.21,
Axillary crutch extension,L0978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,403.71,,,,,,,fee schedule,231.25,567.21,
Axillary crutch extension,L0978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,323.36,,,,,,,fee schedule,231.25,567.21,
Axillary crutch extension,L0978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,567.21,,,,,,,fee schedule,231.25,567.21,
Axillary crutch extension,L0978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.81,,,,,,,fee schedule,231.25,567.21,APC
Axillary crutch extension,L0978,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,231.25,,,,,,,fee schedule,231.25,567.21,APC
Axillary crutch extension,L0978,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,416.25,,,,,,,fee schedule,231.25,567.21,APC
Peroneal straps pair pre ots,L0980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.8,,,,,,,fee schedule,20.99,51.52,
Peroneal straps pair pre ots,L0980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.67,,,,,,,fee schedule,20.99,51.52,
Peroneal straps pair pre ots,L0980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.37,,,,,,,fee schedule,20.99,51.52,
Peroneal straps pair pre ots,L0980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.52,,,,,,,fee schedule,20.99,51.52,
Peroneal straps pair pre ots,L0980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.04,,,,,,,fee schedule,20.99,51.52,APC
Peroneal straps pair pre ots,L0980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.99,,,,,,,fee schedule,20.99,51.52,APC
Peroneal straps pair pre ots,L0980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.78,,,,,,,fee schedule,20.99,51.52,APC
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.98,,,,,,,fee schedule,19.23,47.13,
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.54,,,,,,,fee schedule,19.23,47.13,
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.87,,,,,,,fee schedule,19.23,47.13,
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.13,,,,,,,fee schedule,19.23,47.13,
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.19,,,,,,,fee schedule,19.23,47.13,APC
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.23,,,,,,,fee schedule,19.23,47.13,APC
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.61,,,,,,,fee schedule,19.23,47.13,APC
Protect body sock ea pre ots,L0984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.39,,,,,,,fee schedule,83.16,204,
Protect body sock ea pre ots,L0984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145.19,,,,,,,fee schedule,83.16,204,
Protect body sock ea pre ots,L0984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.3,,,,,,,fee schedule,83.16,204,
Protect body sock ea pre ots,L0984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,204,,,,,,,fee schedule,83.16,204,
Protect body sock ea pre ots,L0984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.32,,,,,,,fee schedule,83.16,204,APC
Protect body sock ea pre ots,L0984,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,83.16,,,,,,,fee schedule,83.16,204,APC
Protect body sock ea pre ots,L0984,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,149.69,,,,,,,fee schedule,83.16,204,APC
Ctlso milwauke initial model,L1000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5314.89,,,,,,,fee schedule,2492.04,6112.12,
Ctlso milwauke initial model,L1000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4350.24,,,,,,,fee schedule,2492.04,6112.12,
Ctlso milwauke initial model,L1000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3484.44,,,,,,,fee schedule,2492.04,6112.12,
Ctlso milwauke initial model,L1000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6112.12,,,,,,,fee schedule,2492.04,6112.12,
Ctlso milwauke initial model,L1000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2616.64,,,,,,,fee schedule,2492.04,6112.12,APC
Ctlso milwauke initial model,L1000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2492.04,,,,,,,fee schedule,2492.04,6112.12,APC
Ctlso milwauke initial model,L1000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4485.67,,,,,,,fee schedule,2492.04,6112.12,APC
Tension based scoliosis orth,L1005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8389.03,,,,,,,fee schedule,3933.46,9647.38,
Tension based scoliosis orth,L1005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6866.42,,,,,,,fee schedule,3933.46,9647.38,
Tension based scoliosis orth,L1005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5499.85,,,,,,,fee schedule,3933.46,9647.38,
Tension based scoliosis orth,L1005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9647.38,,,,,,,fee schedule,3933.46,9647.38,
Tension based scoliosis orth,L1005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4130.13,,,,,,,fee schedule,3933.46,9647.38,APC
Tension based scoliosis orth,L1005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3933.46,,,,,,,fee schedule,3933.46,9647.38,APC
Tension based scoliosis orth,L1005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7080.23,,,,,,,fee schedule,3933.46,9647.38,APC
Ctlso axilla sling,L1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,219.3,,,,,,,fee schedule,102.83,252.2,
Ctlso axilla sling,L1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,179.5,,,,,,,fee schedule,102.83,252.2,
Ctlso axilla sling,L1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,143.77,,,,,,,fee schedule,102.83,252.2,
Ctlso axilla sling,L1010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,252.2,,,,,,,fee schedule,102.83,252.2,
Ctlso axilla sling,L1010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.97,,,,,,,fee schedule,102.83,252.2,APC
Ctlso axilla sling,L1010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,102.83,,,,,,,fee schedule,102.83,252.2,APC
Ctlso axilla sling,L1010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,185.09,,,,,,,fee schedule,102.83,252.2,APC
Kyphosis pad,L1020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,282.45,,,,,,,fee schedule,132.43,324.82,
Kyphosis pad,L1020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,231.19,,,,,,,fee schedule,132.43,324.82,
Kyphosis pad,L1020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.17,,,,,,,fee schedule,132.43,324.82,
Kyphosis pad,L1020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,324.82,,,,,,,fee schedule,132.43,324.82,
Kyphosis pad,L1020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.05,,,,,,,fee schedule,132.43,324.82,APC
Kyphosis pad,L1020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.43,,,,,,,fee schedule,132.43,324.82,APC
Kyphosis pad,L1020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.37,,,,,,,fee schedule,132.43,324.82,APC
Kyphosis pad floating,L1025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,407.46,,,,,,,fee schedule,191.06,468.58,
Kyphosis pad floating,L1025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,333.51,,,,,,,fee schedule,191.06,468.58,
Kyphosis pad floating,L1025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,267.13,,,,,,,fee schedule,191.06,468.58,
Kyphosis pad floating,L1025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,468.58,,,,,,,fee schedule,191.06,468.58,
Kyphosis pad floating,L1025,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,200.61,,,,,,,fee schedule,191.06,468.58,APC
Kyphosis pad floating,L1025,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,191.06,,,,,,,fee schedule,191.06,468.58,APC
Kyphosis pad floating,L1025,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,343.91,,,,,,,fee schedule,191.06,468.58,APC
Lumbar bolster pad,L1030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,205.2,,,,,,,fee schedule,96.23,235.98,
Lumbar bolster pad,L1030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.96,,,,,,,fee schedule,96.23,235.98,
Lumbar bolster pad,L1030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.53,,,,,,,fee schedule,96.23,235.98,
Lumbar bolster pad,L1030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.98,,,,,,,fee schedule,96.23,235.98,
Lumbar bolster pad,L1030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.04,,,,,,,fee schedule,96.23,235.98,APC
Lumbar bolster pad,L1030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.23,,,,,,,fee schedule,96.23,235.98,APC
Lumbar bolster pad,L1030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,173.21,,,,,,,fee schedule,96.23,235.98,APC
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,232.36,,,,,,,fee schedule,108.96,267.21,
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.19,,,,,,,fee schedule,108.96,267.21,
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.34,,,,,,,fee schedule,108.96,267.21,
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,267.21,,,,,,,fee schedule,108.96,267.21,
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.41,,,,,,,fee schedule,108.96,267.21,APC
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,108.96,,,,,,,fee schedule,108.96,267.21,APC
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,196.13,,,,,,,fee schedule,108.96,267.21,APC
Sternal pad,L1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,262.97,,,,,,,fee schedule,123.31,302.42,
Sternal pad,L1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,215.24,,,,,,,fee schedule,123.31,302.42,
Sternal pad,L1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.4,,,,,,,fee schedule,123.31,302.42,
Sternal pad,L1050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,302.42,,,,,,,fee schedule,123.31,302.42,
Sternal pad,L1050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.48,,,,,,,fee schedule,123.31,302.42,APC
Sternal pad,L1050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,123.31,,,,,,,fee schedule,123.31,302.42,APC
Sternal pad,L1050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,221.96,,,,,,,fee schedule,123.31,302.42,APC
Thoracic pad,L1060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,283.85,,,,,,,fee schedule,133.1,326.43,
Thoracic pad,L1060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.33,,,,,,,fee schedule,133.1,326.43,
Thoracic pad,L1060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.09,,,,,,,fee schedule,133.1,326.43,
Thoracic pad,L1060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.43,,,,,,,fee schedule,133.1,326.43,
Thoracic pad,L1060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.76,,,,,,,fee schedule,133.1,326.43,APC
Thoracic pad,L1060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.1,,,,,,,fee schedule,133.1,326.43,APC
Thoracic pad,L1060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,239.58,,,,,,,fee schedule,133.1,326.43,APC
Trapezius sling,L1070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,294.04,,,,,,,fee schedule,137.88,338.15,
Trapezius sling,L1070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,240.67,,,,,,,fee schedule,137.88,338.15,
Trapezius sling,L1070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,192.77,,,,,,,fee schedule,137.88,338.15,
Trapezius sling,L1070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,338.15,,,,,,,fee schedule,137.88,338.15,
Trapezius sling,L1070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,144.77,,,,,,,fee schedule,137.88,338.15,APC
Trapezius sling,L1070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,137.88,,,,,,,fee schedule,137.88,338.15,APC
Trapezius sling,L1070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,248.18,,,,,,,fee schedule,137.88,338.15,APC
Outrigger,L1080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.15,,,,,,,fee schedule,64.3,157.72,
Outrigger,L1080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112.26,,,,,,,fee schedule,64.3,157.72,
Outrigger,L1080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.92,,,,,,,fee schedule,64.3,157.72,
Outrigger,L1080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.72,,,,,,,fee schedule,64.3,157.72,
Outrigger,L1080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.52,,,,,,,fee schedule,64.3,157.72,APC
Outrigger,L1080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.3,,,,,,,fee schedule,64.3,157.72,APC
Outrigger,L1080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.74,,,,,,,fee schedule,64.3,157.72,APC
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,459.09,,,,,,,fee schedule,215.27,527.95,
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,375.77,,,,,,,fee schedule,215.27,527.95,
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,300.98,,,,,,,fee schedule,215.27,527.95,
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,527.95,,,,,,,fee schedule,215.27,527.95,
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,226.03,,,,,,,fee schedule,215.27,527.95,APC
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,215.27,,,,,,,fee schedule,215.27,527.95,APC
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,387.49,,,,,,,fee schedule,215.27,527.95,APC
Lumbar sling,L1090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,263.75,,,,,,,fee schedule,123.66,303.31,
Lumbar sling,L1090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,215.88,,,,,,,fee schedule,123.66,303.31,
Lumbar sling,L1090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.91,,,,,,,fee schedule,123.66,303.31,
Lumbar sling,L1090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,303.31,,,,,,,fee schedule,123.66,303.31,
Lumbar sling,L1090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.84,,,,,,,fee schedule,123.66,303.31,APC
Lumbar sling,L1090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,123.66,,,,,,,fee schedule,123.66,303.31,APC
Lumbar sling,L1090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,222.59,,,,,,,fee schedule,123.66,303.31,APC
Ring flange plastic/leather,L1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,497.74,,,,,,,fee schedule,233.39,572.4,
Ring flange plastic/leather,L1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,407.4,,,,,,,fee schedule,233.39,572.4,
Ring flange plastic/leather,L1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.32,,,,,,,fee schedule,233.39,572.4,
Ring flange plastic/leather,L1100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,572.4,,,,,,,fee schedule,233.39,572.4,
Ring flange plastic/leather,L1100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,245.06,,,,,,,fee schedule,233.39,572.4,APC
Ring flange plastic/leather,L1100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,233.39,,,,,,,fee schedule,233.39,572.4,APC
Ring flange plastic/leather,L1100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,420.1,,,,,,,fee schedule,233.39,572.4,APC
Ring flange plas/leather mol,L1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,834.56,,,,,,,fee schedule,391.31,959.74,
Ring flange plas/leather mol,L1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,683.09,,,,,,,fee schedule,391.31,959.74,
Ring flange plas/leather mol,L1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,547.14,,,,,,,fee schedule,391.31,959.74,
Ring flange plas/leather mol,L1110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,959.74,,,,,,,fee schedule,391.31,959.74,
Ring flange plas/leather mol,L1110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.88,,,,,,,fee schedule,391.31,959.74,APC
Ring flange plas/leather mol,L1110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,391.31,,,,,,,fee schedule,391.31,959.74,APC
Ring flange plas/leather mol,L1110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,704.36,,,,,,,fee schedule,391.31,959.74,APC
Covers for upright each,L1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.67,,,,,,,fee schedule,46.74,114.62,
Covers for upright each,L1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.58,,,,,,,fee schedule,46.74,114.62,
Covers for upright each,L1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.34,,,,,,,fee schedule,46.74,114.62,
Covers for upright each,L1120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.62,,,,,,,fee schedule,46.74,114.62,
Covers for upright each,L1120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.08,,,,,,,fee schedule,46.74,114.62,APC
Covers for upright each,L1120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.74,,,,,,,fee schedule,46.74,114.62,APC
Covers for upright each,L1120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84.13,,,,,,,fee schedule,46.74,114.62,APC
Furnsh initial orthosis only,L1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4690.41,,,,,,,fee schedule,2199.24,5393.97,
Furnsh initial orthosis only,L1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3839.1,,,,,,,fee schedule,2199.24,5393.97,
Furnsh initial orthosis only,L1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3075.03,,,,,,,fee schedule,2199.24,5393.97,
Furnsh initial orthosis only,L1200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5393.97,,,,,,,fee schedule,2199.24,5393.97,
Furnsh initial orthosis only,L1200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2309.2,,,,,,,fee schedule,2199.24,5393.97,APC
Furnsh initial orthosis only,L1200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2199.24,,,,,,,fee schedule,2199.24,5393.97,APC
Furnsh initial orthosis only,L1200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3958.63,,,,,,,fee schedule,2199.24,5393.97,APC
Lateral thoracic extension,L1210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,641.28,,,,,,,fee schedule,300.68,737.47,
Lateral thoracic extension,L1210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,524.89,,,,,,,fee schedule,300.68,737.47,
Lateral thoracic extension,L1210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,420.42,,,,,,,fee schedule,300.68,737.47,
Lateral thoracic extension,L1210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,737.47,,,,,,,fee schedule,300.68,737.47,
Lateral thoracic extension,L1210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315.71,,,,,,,fee schedule,300.68,737.47,APC
Lateral thoracic extension,L1210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,300.68,,,,,,,fee schedule,300.68,737.47,APC
Lateral thoracic extension,L1210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,541.22,,,,,,,fee schedule,300.68,737.47,APC
Anterior thoracic extension,L1220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,624.16,,,,,,,fee schedule,292.66,717.78,
Anterior thoracic extension,L1220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,510.87,,,,,,,fee schedule,292.66,717.78,
Anterior thoracic extension,L1220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,409.2,,,,,,,fee schedule,292.66,717.78,
Anterior thoracic extension,L1220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,717.78,,,,,,,fee schedule,292.66,717.78,
Anterior thoracic extension,L1220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,307.29,,,,,,,fee schedule,292.66,717.78,APC
Anterior thoracic extension,L1220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,292.66,,,,,,,fee schedule,292.66,717.78,APC
Anterior thoracic extension,L1220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,526.79,,,,,,,fee schedule,292.66,717.78,APC
Milwaukee type superstructur,L1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1748.57,,,,,,,fee schedule,819.86,2010.86,
Milwaukee type superstructur,L1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1431.2,,,,,,,fee schedule,819.86,2010.86,
Milwaukee type superstructur,L1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1146.36,,,,,,,fee schedule,819.86,2010.86,
Milwaukee type superstructur,L1230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2010.86,,,,,,,fee schedule,819.86,2010.86,
Milwaukee type superstructur,L1230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,860.85,,,,,,,fee schedule,819.86,2010.86,APC
Milwaukee type superstructur,L1230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,819.86,,,,,,,fee schedule,819.86,2010.86,APC
Milwaukee type superstructur,L1230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1475.75,,,,,,,fee schedule,819.86,2010.86,APC
Lumbar derotation pad,L1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,238.37,,,,,,,fee schedule,111.77,274.13,
Lumbar derotation pad,L1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.11,,,,,,,fee schedule,111.77,274.13,
Lumbar derotation pad,L1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.28,,,,,,,fee schedule,111.77,274.13,
Lumbar derotation pad,L1240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,274.13,,,,,,,fee schedule,111.77,274.13,
Lumbar derotation pad,L1240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,117.36,,,,,,,fee schedule,111.77,274.13,APC
Lumbar derotation pad,L1240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,111.77,,,,,,,fee schedule,111.77,274.13,APC
Lumbar derotation pad,L1240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,201.19,,,,,,,fee schedule,111.77,274.13,APC
Anterior asis pad,L1250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,207.24,,,,,,,fee schedule,97.2,238.33,
Anterior asis pad,L1250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.63,,,,,,,fee schedule,97.2,238.33,
Anterior asis pad,L1250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.87,,,,,,,fee schedule,97.2,238.33,
Anterior asis pad,L1250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,238.33,,,,,,,fee schedule,97.2,238.33,
Anterior asis pad,L1250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.06,,,,,,,fee schedule,97.2,238.33,APC
Anterior asis pad,L1250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,97.2,,,,,,,fee schedule,97.2,238.33,APC
Anterior asis pad,L1250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,174.96,,,,,,,fee schedule,97.2,238.33,APC
Anterior thoracic derotation,L1260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,247.2,,,,,,,fee schedule,115.91,284.28,
Anterior thoracic derotation,L1260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.33,,,,,,,fee schedule,115.91,284.28,
Anterior thoracic derotation,L1260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,162.06,,,,,,,fee schedule,115.91,284.28,
Anterior thoracic derotation,L1260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,284.28,,,,,,,fee schedule,115.91,284.28,
Anterior thoracic derotation,L1260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,121.71,,,,,,,fee schedule,115.91,284.28,APC
Anterior thoracic derotation,L1260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,115.91,,,,,,,fee schedule,115.91,284.28,APC
Anterior thoracic derotation,L1260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,208.64,,,,,,,fee schedule,115.91,284.28,APC
Abdominal pad,L1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.2,,,,,,,fee schedule,101.86,249.78,
Abdominal pad,L1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.78,,,,,,,fee schedule,101.86,249.78,
Abdominal pad,L1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.4,,,,,,,fee schedule,101.86,249.78,
Abdominal pad,L1270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,249.78,,,,,,,fee schedule,101.86,249.78,
Abdominal pad,L1270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.95,,,,,,,fee schedule,101.86,249.78,APC
Abdominal pad,L1270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.86,,,,,,,fee schedule,101.86,249.78,APC
Abdominal pad,L1270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,183.35,,,,,,,fee schedule,101.86,249.78,APC
Rib gusset (elastic) each,L1280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.01,,,,,,,fee schedule,107.39,263.36,
Rib gusset (elastic) each,L1280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.44,,,,,,,fee schedule,107.39,263.36,
Rib gusset (elastic) each,L1280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.14,,,,,,,fee schedule,107.39,263.36,
Rib gusset (elastic) each,L1280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.36,,,,,,,fee schedule,107.39,263.36,
Rib gusset (elastic) each,L1280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.76,,,,,,,fee schedule,107.39,263.36,APC
Rib gusset (elastic) each,L1280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,107.39,,,,,,,fee schedule,107.39,263.36,APC
Rib gusset (elastic) each,L1280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,193.3,,,,,,,fee schedule,107.39,263.36,APC
Lateral trochanteric pad,L1290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.67,,,,,,,fee schedule,95.49,234.22,
Lateral trochanteric pad,L1290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.7,,,,,,,fee schedule,95.49,234.22,
Lateral trochanteric pad,L1290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.53,,,,,,,fee schedule,95.49,234.22,
Lateral trochanteric pad,L1290,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,234.22,,,,,,,fee schedule,95.49,234.22,
Lateral trochanteric pad,L1290,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.26,,,,,,,fee schedule,95.49,234.22,APC
Lateral trochanteric pad,L1290,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,95.49,,,,,,,fee schedule,95.49,234.22,APC
Lateral trochanteric pad,L1290,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,171.88,,,,,,,fee schedule,95.49,234.22,APC
Body jacket mold to patient,L1300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4517.3,,,,,,,fee schedule,2118.07,5194.9,
Body jacket mold to patient,L1300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3697.41,,,,,,,fee schedule,2118.07,5194.9,
Body jacket mold to patient,L1300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2961.54,,,,,,,fee schedule,2118.07,5194.9,
Body jacket mold to patient,L1300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5194.9,,,,,,,fee schedule,2118.07,5194.9,
Body jacket mold to patient,L1300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2223.97,,,,,,,fee schedule,2118.07,5194.9,APC
Body jacket mold to patient,L1300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2118.07,,,,,,,fee schedule,2118.07,5194.9,APC
Body jacket mold to patient,L1300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3812.53,,,,,,,fee schedule,2118.07,5194.9,APC
Post-operative body jacket,L1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4705.14,,,,,,,fee schedule,2206.15,5410.91,
Post-operative body jacket,L1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3851.16,,,,,,,fee schedule,2206.15,5410.91,
Post-operative body jacket,L1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3084.69,,,,,,,fee schedule,2206.15,5410.91,
Post-operative body jacket,L1310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5410.91,,,,,,,fee schedule,2206.15,5410.91,
Post-operative body jacket,L1310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2316.46,,,,,,,fee schedule,2206.15,5410.91,APC
Post-operative body jacket,L1310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2206.15,,,,,,,fee schedule,2206.15,5410.91,APC
Post-operative body jacket,L1310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3971.07,,,,,,,fee schedule,2206.15,5410.91,APC
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,337.74,,,,,,,fee schedule,158.37,388.4,
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,276.44,,,,,,,fee schedule,158.37,388.4,
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,221.42,,,,,,,fee schedule,158.37,388.4,
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,388.4,,,,,,,fee schedule,158.37,388.4,
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,166.29,,,,,,,fee schedule,158.37,388.4,APC
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,158.37,,,,,,,fee schedule,158.37,388.4,APC
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,285.07,,,,,,,fee schedule,158.37,388.4,APC
Ho frejka cov only pre cst,L1610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.44,,,,,,,fee schedule,67.26,164.96,
Ho frejka cov only pre cst,L1610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.41,,,,,,,fee schedule,67.26,164.96,
Ho frejka cov only pre cst,L1610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.04,,,,,,,fee schedule,67.26,164.96,
Ho frejka cov only pre cst,L1610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.96,,,,,,,fee schedule,67.26,164.96,
Ho frejka cov only pre cst,L1610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.62,,,,,,,fee schedule,67.26,164.96,APC
Ho frejka cov only pre cst,L1610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67.26,,,,,,,fee schedule,67.26,164.96,APC
Ho frejka cov only pre cst,L1610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,121.07,,,,,,,fee schedule,67.26,164.96,APC
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,411.86,,,,,,,fee schedule,193.1,473.64,
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,337.11,,,,,,,fee schedule,193.1,473.64,
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,270.02,,,,,,,fee schedule,193.1,473.64,
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,473.64,,,,,,,fee schedule,193.1,473.64,
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.76,,,,,,,fee schedule,193.1,473.64,APC
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,193.1,,,,,,,fee schedule,193.1,473.64,APC
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,347.58,,,,,,,fee schedule,193.1,473.64,APC
Abduct control hip semi-flex,L1630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,553.71,,,,,,,fee schedule,259.63,636.77,
Abduct control hip semi-flex,L1630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,453.21,,,,,,,fee schedule,259.63,636.77,
Abduct control hip semi-flex,L1630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,363.01,,,,,,,fee schedule,259.63,636.77,
Abduct control hip semi-flex,L1630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,636.77,,,,,,,fee schedule,259.63,636.77,
Abduct control hip semi-flex,L1630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,272.61,,,,,,,fee schedule,259.63,636.77,APC
Abduct control hip semi-flex,L1630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,259.63,,,,,,,fee schedule,259.63,636.77,APC
Abduct control hip semi-flex,L1630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,467.33,,,,,,,fee schedule,259.63,636.77,APC
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1240.77,,,,,,,fee schedule,581.79,1426.89,
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1015.57,,,,,,,fee schedule,581.79,1426.89,
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,813.45,,,,,,,fee schedule,581.79,1426.89,
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1426.89,,,,,,,fee schedule,581.79,1426.89,
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,610.88,,,,,,,fee schedule,581.79,1426.89,APC
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,581.79,,,,,,,fee schedule,581.79,1426.89,APC
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1047.22,,,,,,,fee schedule,581.79,1426.89,APC
HO abduction hip adjustable,L1650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.37,,,,,,,fee schedule,303.07,743.33,
HO abduction hip adjustable,L1650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,529.05,,,,,,,fee schedule,303.07,743.33,
HO abduction hip adjustable,L1650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,423.76,,,,,,,fee schedule,303.07,743.33,
HO abduction hip adjustable,L1650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,743.33,,,,,,,fee schedule,303.07,743.33,
HO abduction hip adjustable,L1650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.22,,,,,,,fee schedule,303.07,743.33,APC
HO abduction hip adjustable,L1650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,303.07,,,,,,,fee schedule,303.07,743.33,APC
HO abduction hip adjustable,L1650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,545.53,,,,,,,fee schedule,303.07,743.33,APC
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,934.32,,,,,,,fee schedule,438.09,1074.47,
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,764.74,,,,,,,fee schedule,438.09,1074.47,
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,612.54,,,,,,,fee schedule,438.09,1074.47,
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1074.47,,,,,,,fee schedule,438.09,1074.47,
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,459.99,,,,,,,fee schedule,438.09,1074.47,APC
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,438.09,,,,,,,fee schedule,438.09,1074.47,APC
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,788.56,,,,,,,fee schedule,438.09,1074.47,APC
HO abduction static plastic,L1660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,473.67,,,,,,,fee schedule,222.08,544.72,
HO abduction static plastic,L1660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,387.7,,,,,,,fee schedule,222.08,544.72,
HO abduction static plastic,L1660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.54,,,,,,,fee schedule,222.08,544.72,
HO abduction static plastic,L1660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,544.72,,,,,,,fee schedule,222.08,544.72,
HO abduction static plastic,L1660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,233.18,,,,,,,fee schedule,222.08,544.72,APC
HO abduction static plastic,L1660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,222.08,,,,,,,fee schedule,222.08,544.72,APC
HO abduction static plastic,L1660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,399.74,,,,,,,fee schedule,222.08,544.72,APC
Pelvic & hip control thigh c,L1680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2986.08,,,,,,,fee schedule,1400.11,3433.99,
Pelvic & hip control thigh c,L1680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2444.11,,,,,,,fee schedule,1400.11,3433.99,
Pelvic & hip control thigh c,L1680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1957.67,,,,,,,fee schedule,1400.11,3433.99,
Pelvic & hip control thigh c,L1680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3433.99,,,,,,,fee schedule,1400.11,3433.99,
Pelvic & hip control thigh c,L1680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1470.12,,,,,,,fee schedule,1400.11,3433.99,APC
Pelvic & hip control thigh c,L1680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1400.11,,,,,,,fee schedule,1400.11,3433.99,APC
Pelvic & hip control thigh c,L1680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2520.2,,,,,,,fee schedule,1400.11,3433.99,APC
Ho bilateral hip abduction,L1681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2418.28,,,,,,,fee schedule,2303.12,4145.62,APC
Ho bilateral hip abduction,L1681,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2303.12,,,,,,,fee schedule,2303.12,4145.62,APC
Ho bilateral hip abduction,L1681,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4145.62,,,,,,,fee schedule,2303.12,4145.62,APC
Post-op hip abduct custom fa,L1685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2915.17,,,,,,,fee schedule,1366.86,3352.45,
Post-op hip abduct custom fa,L1685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2386.07,,,,,,,fee schedule,1366.86,3352.45,
Post-op hip abduct custom fa,L1685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1911.19,,,,,,,fee schedule,1366.86,3352.45,
Post-op hip abduct custom fa,L1685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3352.45,,,,,,,fee schedule,1366.86,3352.45,
Post-op hip abduct custom fa,L1685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1435.2,,,,,,,fee schedule,1366.86,3352.45,APC
Post-op hip abduct custom fa,L1685,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1366.86,,,,,,,fee schedule,1366.86,3352.45,APC
Post-op hip abduct custom fa,L1685,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2460.35,,,,,,,fee schedule,1366.86,3352.45,APC
HO post-op hip abduction,L1686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2455.97,,,,,,,fee schedule,1151.56,2824.37,
HO post-op hip abduction,L1686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2010.21,,,,,,,fee schedule,1151.56,2824.37,
HO post-op hip abduction,L1686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1610.13,,,,,,,fee schedule,1151.56,2824.37,
HO post-op hip abduction,L1686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2824.37,,,,,,,fee schedule,1151.56,2824.37,
HO post-op hip abduction,L1686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1209.14,,,,,,,fee schedule,1151.56,2824.37,APC
HO post-op hip abduction,L1686,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1151.56,,,,,,,fee schedule,1151.56,2824.37,APC
HO post-op hip abduction,L1686,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2072.81,,,,,,,fee schedule,1151.56,2824.37,APC
Combination bilateral HO,L1690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5068.46,,,,,,,fee schedule,2376.51,5828.73,
Combination bilateral HO,L1690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4148.53,,,,,,,fee schedule,2376.51,5828.73,
Combination bilateral HO,L1690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3322.88,,,,,,,fee schedule,2376.51,5828.73,
Combination bilateral HO,L1690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5828.73,,,,,,,fee schedule,2376.51,5828.73,
Combination bilateral HO,L1690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2495.34,,,,,,,fee schedule,2376.51,5828.73,APC
Combination bilateral HO,L1690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2376.51,,,,,,,fee schedule,2376.51,5828.73,APC
Combination bilateral HO,L1690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4277.72,,,,,,,fee schedule,2376.51,5828.73,APC
Leg perthes orth toronto typ,L1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4077.92,,,,,,,fee schedule,1912.04,4689.61,
Leg perthes orth toronto typ,L1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3337.78,,,,,,,fee schedule,1912.04,4689.61,
Leg perthes orth toronto typ,L1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2673.48,,,,,,,fee schedule,1912.04,4689.61,
Leg perthes orth toronto typ,L1700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4689.61,,,,,,,fee schedule,1912.04,4689.61,
Leg perthes orth toronto typ,L1700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2007.64,,,,,,,fee schedule,1912.04,4689.61,APC
Leg perthes orth toronto typ,L1700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1912.04,,,,,,,fee schedule,1912.04,4689.61,APC
Leg perthes orth toronto typ,L1700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3441.67,,,,,,,fee schedule,1912.04,4689.61,APC
Legg perthes orth newington,L1710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5192.73,,,,,,,fee schedule,2434.79,5971.64,
Legg perthes orth newington,L1710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4250.25,,,,,,,fee schedule,2434.79,5971.64,
Legg perthes orth newington,L1710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3404.35,,,,,,,fee schedule,2434.79,5971.64,
Legg perthes orth newington,L1710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5971.64,,,,,,,fee schedule,2434.79,5971.64,
Legg perthes orth newington,L1710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.53,,,,,,,fee schedule,2434.79,5971.64,APC
Legg perthes orth newington,L1710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2434.79,,,,,,,fee schedule,2434.79,5971.64,APC
Legg perthes orth newington,L1710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4382.62,,,,,,,fee schedule,2434.79,5971.64,APC
Legg perthes orthosis trilat,L1720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3866.49,,,,,,,fee schedule,1812.94,4446.46,
Legg perthes orthosis trilat,L1720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3164.72,,,,,,,fee schedule,1812.94,4446.46,
Legg perthes orthosis trilat,L1720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2534.87,,,,,,,fee schedule,1812.94,4446.46,
Legg perthes orthosis trilat,L1720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4446.46,,,,,,,fee schedule,1812.94,4446.46,
Legg perthes orthosis trilat,L1720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1903.59,,,,,,,fee schedule,1812.94,4446.46,APC
Legg perthes orthosis trilat,L1720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1812.94,,,,,,,fee schedule,1812.94,4446.46,APC
Legg perthes orthosis trilat,L1720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3263.29,,,,,,,fee schedule,1812.94,4446.46,APC
Legg perthes orth scottish r,L1730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3264.18,,,,,,,fee schedule,1530.52,3753.81,
Legg perthes orth scottish r,L1730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2671.73,,,,,,,fee schedule,1530.52,3753.81,
Legg perthes orth scottish r,L1730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2140,,,,,,,fee schedule,1530.52,3753.81,
Legg perthes orth scottish r,L1730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3753.81,,,,,,,fee schedule,1530.52,3753.81,
Legg perthes orth scottish r,L1730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1607.05,,,,,,,fee schedule,1530.52,3753.81,APC
Legg perthes orth scottish r,L1730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1530.52,,,,,,,fee schedule,1530.52,3753.81,APC
Legg perthes orth scottish r,L1730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2754.94,,,,,,,fee schedule,1530.52,3753.81,APC
Legg perthes patten bottom t,L1755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4692.97,,,,,,,fee schedule,2200.45,5396.92,
Legg perthes patten bottom t,L1755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3841.2,,,,,,,fee schedule,2200.45,5396.92,
Legg perthes patten bottom t,L1755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3076.71,,,,,,,fee schedule,2200.45,5396.92,
Legg perthes patten bottom t,L1755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5396.92,,,,,,,fee schedule,2200.45,5396.92,
Legg perthes patten bottom t,L1755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2310.47,,,,,,,fee schedule,2200.45,5396.92,APC
Legg perthes patten bottom t,L1755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2200.45,,,,,,,fee schedule,2200.45,5396.92,APC
Legg perthes patten bottom t,L1755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3960.81,,,,,,,fee schedule,2200.45,5396.92,APC
Ko elastic with joints,L1810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,269.81,,,,,,,fee schedule,126.52,310.28,
Ko elastic with joints,L1810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.84,,,,,,,fee schedule,126.52,310.28,
Ko elastic with joints,L1810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.89,,,,,,,fee schedule,126.52,310.28,
Ko elastic with joints,L1810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,310.28,,,,,,,fee schedule,126.52,310.28,
Ko elastic with joints,L1810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.85,,,,,,,fee schedule,126.52,310.28,APC
Ko elastic with joints,L1810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,126.52,,,,,,,fee schedule,126.52,310.28,APC
Ko elastic with joints,L1810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,227.74,,,,,,,fee schedule,126.52,310.28,APC
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,269.81,,,,,,,fee schedule,78.51,310.28,
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.84,,,,,,,fee schedule,78.51,310.28,
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.89,,,,,,,fee schedule,78.51,310.28,
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,310.28,,,,,,,fee schedule,78.51,310.28,
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.44,,,,,,,fee schedule,78.51,310.28,APC
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,78.51,,,,,,,fee schedule,78.51,310.28,APC
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,141.32,,,,,,,fee schedule,78.51,310.28,APC
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,372.53,,,,,,,fee schedule,174.65,428.41,
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,304.92,,,,,,,fee schedule,174.65,428.41,
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,244.23,,,,,,,fee schedule,174.65,428.41,
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,428.41,,,,,,,fee schedule,174.65,428.41,
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.38,,,,,,,fee schedule,174.65,428.41,APC
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,174.65,,,,,,,fee schedule,174.65,428.41,APC
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,314.37,,,,,,,fee schedule,174.65,428.41,APC
Ko immob canvas long pre ots,L1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.59,,,,,,,fee schedule,48.25,127.35,
Ko immob canvas long pre ots,L1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.23,,,,,,,fee schedule,48.25,127.35,
Ko immob canvas long pre ots,L1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.25,,,,,,,fee schedule,48.25,127.35,
Ko immob canvas long pre ots,L1830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.63,,,,,,,fee schedule,48.25,127.35,
Ko immob canvas long pre ots,L1830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.29,,,,,,,fee schedule,48.25,127.35,APC
Ko immob canvas long pre ots,L1830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.75,,,,,,,fee schedule,48.25,127.35,APC
Ko immob canvas long pre ots,L1830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,127.35,,,,,,,fee schedule,48.25,127.35,APC
Knee orth pos locking joint,L1831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,771.4,,,,,,,fee schedule,361.7,887.11,
Knee orth pos locking joint,L1831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,631.39,,,,,,,fee schedule,361.7,887.11,
Knee orth pos locking joint,L1831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,505.73,,,,,,,fee schedule,361.7,887.11,
Knee orth pos locking joint,L1831,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,887.11,,,,,,,fee schedule,361.7,887.11,
Knee orth pos locking joint,L1831,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,379.78,,,,,,,fee schedule,361.7,887.11,APC
Knee orth pos locking joint,L1831,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,361.7,,,,,,,fee schedule,361.7,887.11,APC
Knee orth pos locking joint,L1831,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,651.06,,,,,,,fee schedule,361.7,887.11,APC
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1805.37,,,,,,,fee schedule,846.51,2076.18,
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1477.7,,,,,,,fee schedule,846.51,2076.18,
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1183.6,,,,,,,fee schedule,846.51,2076.18,
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2076.18,,,,,,,fee schedule,846.51,2076.18,
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,888.84,,,,,,,fee schedule,846.51,2076.18,APC
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,846.51,,,,,,,fee schedule,846.51,2076.18,APC
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1523.72,,,,,,,fee schedule,846.51,2076.18,APC
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1805.37,,,,,,,fee schedule,509.63,2076.18,
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1477.7,,,,,,,fee schedule,509.63,2076.18,
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1183.6,,,,,,,fee schedule,509.63,2076.18,
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2076.18,,,,,,,fee schedule,509.63,2076.18,
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,535.11,,,,,,,fee schedule,509.63,2076.18,APC
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,509.63,,,,,,,fee schedule,509.63,2076.18,APC
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,917.33,,,,,,,fee schedule,509.63,2076.18,APC
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1902.43,,,,,,,fee schedule,892.02,2187.79,
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1557.14,,,,,,,fee schedule,892.02,2187.79,
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1247.23,,,,,,,fee schedule,892.02,2187.79,
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2187.79,,,,,,,fee schedule,892.02,2187.79,
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,936.62,,,,,,,fee schedule,892.02,2187.79,APC
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,892.02,,,,,,,fee schedule,892.02,2187.79,APC
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1605.64,,,,,,,fee schedule,892.02,2187.79,APC
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,349.69,,,,,,,fee schedule,100.03,402.14,
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,286.22,,,,,,,fee schedule,100.03,402.14,
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,229.26,,,,,,,fee schedule,100.03,402.14,
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,402.14,,,,,,,fee schedule,100.03,402.14,
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.03,,,,,,,fee schedule,100.03,402.14,APC
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,100.03,,,,,,,fee schedule,100.03,402.14,APC
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,180.05,,,,,,,fee schedule,100.03,402.14,APC
Ko derot ant cruciate custom,L1840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2464.87,,,,,,,fee schedule,1155.72,2834.6,
Ko derot ant cruciate custom,L1840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2017.5,,,,,,,fee schedule,1155.72,2834.6,
Ko derot ant cruciate custom,L1840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1615.97,,,,,,,fee schedule,1155.72,2834.6,
Ko derot ant cruciate custom,L1840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2834.6,,,,,,,fee schedule,1155.72,2834.6,
Ko derot ant cruciate custom,L1840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1213.51,,,,,,,fee schedule,1155.72,2834.6,APC
Ko derot ant cruciate custom,L1840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1155.72,,,,,,,fee schedule,1155.72,2834.6,APC
Ko derot ant cruciate custom,L1840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2080.3,,,,,,,fee schedule,1155.72,2834.6,APC
Ko single upright pre cst,L1843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2351.75,,,,,,,fee schedule,1102.71,2704.51,
Ko single upright pre cst,L1843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1924.91,,,,,,,fee schedule,1102.71,2704.51,
Ko single upright pre cst,L1843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1541.81,,,,,,,fee schedule,1102.71,2704.51,
Ko single upright pre cst,L1843,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2704.51,,,,,,,fee schedule,1102.71,2704.51,
Ko single upright pre cst,L1843,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1157.85,,,,,,,fee schedule,1102.71,2704.51,APC
Ko single upright pre cst,L1843,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1102.71,,,,,,,fee schedule,1102.71,2704.51,APC
Ko single upright pre cst,L1843,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1984.88,,,,,,,fee schedule,1102.71,2704.51,APC
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3991.43,,,,,,,fee schedule,1871.51,4590.14,
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3266.99,,,,,,,fee schedule,1871.51,4590.14,
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2616.78,,,,,,,fee schedule,1871.51,4590.14,
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4590.14,,,,,,,fee schedule,1871.51,4590.14,
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1965.09,,,,,,,fee schedule,1871.51,4590.14,APC
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1871.51,,,,,,,fee schedule,1871.51,4590.14,APC
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3368.72,,,,,,,fee schedule,1871.51,4590.14,APC
Ko double upright pre cst,L1845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1797.06,,,,,,,fee schedule,1029.48,2524.88,
Ko double upright pre cst,L1845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1439.4,,,,,,,fee schedule,1029.48,2524.88,
Ko double upright pre cst,L1845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2524.88,,,,,,,fee schedule,1029.48,2524.88,
Ko double upright pre cst,L1845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2195.55,,,,,,,fee schedule,1029.48,2524.88,
Ko double upright pre cst,L1845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1080.95,,,,,,,fee schedule,1029.48,2524.88,APC
Ko double upright pre cst,L1845,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1029.48,,,,,,,fee schedule,1029.48,2524.88,APC
Ko double upright pre cst,L1845,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1853.06,,,,,,,fee schedule,1029.48,2524.88,APC
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2510.09,,,,,,,fee schedule,1437.92,3526.69,
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2010.52,,,,,,,fee schedule,1437.92,3526.69,
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3526.69,,,,,,,fee schedule,1437.92,3526.69,
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3066.69,,,,,,,fee schedule,1437.92,3526.69,
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1509.82,,,,,,,fee schedule,1437.92,3526.69,APC
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1437.92,,,,,,,fee schedule,1437.92,3526.69,APC
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2588.26,,,,,,,fee schedule,1437.92,3526.69,APC
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1233.94,,,,,,,fee schedule,706.86,1733.69,
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.36,,,,,,,fee schedule,706.86,1733.69,
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1733.69,,,,,,,fee schedule,706.86,1733.69,
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1507.56,,,,,,,fee schedule,706.86,1733.69,
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,742.2,,,,,,,fee schedule,706.86,1733.69,APC
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.86,,,,,,,fee schedule,706.86,1733.69,APC
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1272.35,,,,,,,fee schedule,706.86,1733.69,APC
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1233.94,,,,,,,fee schedule,706.86,1733.69,
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,988.36,,,,,,,fee schedule,706.86,1733.69,
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1733.69,,,,,,,fee schedule,706.86,1733.69,
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1507.56,,,,,,,fee schedule,706.86,1733.69,
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,742.2,,,,,,,fee schedule,706.86,1733.69,APC
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.86,,,,,,,fee schedule,706.86,1733.69,APC
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1272.35,,,,,,,fee schedule,706.86,1733.69,APC
Ko swedish type pre ots,L1850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,611.17,,,,,,,fee schedule,230.4,858.69,
Ko swedish type pre ots,L1850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,489.53,,,,,,,fee schedule,230.4,858.69,
Ko swedish type pre ots,L1850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,858.69,,,,,,,fee schedule,230.4,858.69,
Ko swedish type pre ots,L1850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,746.69,,,,,,,fee schedule,230.4,858.69,
Ko swedish type pre ots,L1850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,241.92,,,,,,,fee schedule,230.4,858.69,APC
Ko swedish type pre ots,L1850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,230.4,,,,,,,fee schedule,230.4,858.69,APC
Ko swedish type pre ots,L1850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,414.72,,,,,,,fee schedule,230.4,858.69,APC
Ko single upright prefab ots,L1851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1924.91,,,,,,,fee schedule,672.67,2704.51,
Ko single upright prefab ots,L1851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1541.81,,,,,,,fee schedule,672.67,2704.51,
Ko single upright prefab ots,L1851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2704.51,,,,,,,fee schedule,672.67,2704.51,
Ko single upright prefab ots,L1851,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2351.75,,,,,,,fee schedule,672.67,2704.51,
Ko single upright prefab ots,L1851,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,706.3,,,,,,,fee schedule,672.67,2704.51,APC
Ko single upright prefab ots,L1851,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,672.67,,,,,,,fee schedule,672.67,2704.51,APC
Ko single upright prefab ots,L1851,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1210.81,,,,,,,fee schedule,672.67,2704.51,APC
Ko double upright prefab ots,L1852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1797.06,,,,,,,fee schedule,641.72,2524.88,
Ko double upright prefab ots,L1852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1439.4,,,,,,,fee schedule,641.72,2524.88,
Ko double upright prefab ots,L1852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2524.88,,,,,,,fee schedule,641.72,2524.88,
Ko double upright prefab ots,L1852,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2195.55,,,,,,,fee schedule,641.72,2524.88,
Ko double upright prefab ots,L1852,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,673.81,,,,,,,fee schedule,641.72,2524.88,APC
Ko double upright prefab ots,L1852,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,641.72,,,,,,,fee schedule,641.72,2524.88,APC
Ko double upright prefab ots,L1852,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1155.1,,,,,,,fee schedule,641.72,2524.88,APC
Ko supracondylar socket mold,L1860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2675.18,,,,,,,fee schedule,1532.49,3758.65,
Ko supracondylar socket mold,L1860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2142.76,,,,,,,fee schedule,1532.49,3758.65,
Ko supracondylar socket mold,L1860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3758.65,,,,,,,fee schedule,1532.49,3758.65,
Ko supracondylar socket mold,L1860,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3268.39,,,,,,,fee schedule,1532.49,3758.65,
Ko supracondylar socket mold,L1860,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1609.11,,,,,,,fee schedule,1532.49,3758.65,APC
Ko supracondylar socket mold,L1860,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1532.49,,,,,,,fee schedule,1532.49,3758.65,APC
Ko supracondylar socket mold,L1860,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2758.48,,,,,,,fee schedule,1532.49,3758.65,APC
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,612.06,,,,,,,fee schedule,350.64,859.95,
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,490.24,,,,,,,fee schedule,350.64,859.95,
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,859.95,,,,,,,fee schedule,350.64,859.95,
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,747.78,,,,,,,fee schedule,350.64,859.95,
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,368.17,,,,,,,fee schedule,350.64,859.95,APC
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,350.64,,,,,,,fee schedule,350.64,859.95,APC
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,631.15,,,,,,,fee schedule,350.64,859.95,APC
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.13,,,,,,,fee schedule,91.73,224.99,
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.26,,,,,,,fee schedule,91.73,224.99,
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,224.99,,,,,,,fee schedule,91.73,224.99,
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,195.64,,,,,,,fee schedule,91.73,224.99,
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.32,,,,,,,fee schedule,91.73,224.99,APC
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,91.73,,,,,,,fee schedule,91.73,224.99,APC
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,165.11,,,,,,,fee schedule,91.73,224.99,APC
Afo molded ankle gauntlet,L1904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,968.31,,,,,,,fee schedule,554.72,1360.48,
Afo molded ankle gauntlet,L1904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,775.59,,,,,,,fee schedule,554.72,1360.48,
Afo molded ankle gauntlet,L1904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1360.48,,,,,,,fee schedule,554.72,1360.48,
Afo molded ankle gauntlet,L1904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1183.03,,,,,,,fee schedule,554.72,1360.48,
Afo molded ankle gauntlet,L1904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,582.46,,,,,,,fee schedule,554.72,1360.48,APC
Afo molded ankle gauntlet,L1904,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,554.72,,,,,,,fee schedule,554.72,1360.48,APC
Afo molded ankle gauntlet,L1904,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,998.5,,,,,,,fee schedule,554.72,1360.48,APC
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,241.24,,,,,,,fee schedule,138.2,338.95,
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,193.23,,,,,,,fee schedule,138.2,338.95,
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,338.95,,,,,,,fee schedule,138.2,338.95,
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,294.74,,,,,,,fee schedule,138.2,338.95,
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,145.11,,,,,,,fee schedule,138.2,338.95,APC
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,138.2,,,,,,,fee schedule,138.2,338.95,APC
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,248.76,,,,,,,fee schedule,138.2,338.95,APC
AFO supramalleolar custom,L1907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1207.19,,,,,,,fee schedule,691.55,1696.11,
AFO supramalleolar custom,L1907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,966.93,,,,,,,fee schedule,691.55,1696.11,
AFO supramalleolar custom,L1907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1696.11,,,,,,,fee schedule,691.55,1696.11,
AFO supramalleolar custom,L1907,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1474.88,,,,,,,fee schedule,691.55,1696.11,
AFO supramalleolar custom,L1907,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,726.13,,,,,,,fee schedule,691.55,1696.11,APC
AFO supramalleolar custom,L1907,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,691.55,,,,,,,fee schedule,691.55,1696.11,APC
AFO supramalleolar custom,L1907,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1244.79,,,,,,,fee schedule,691.55,1696.11,APC
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,601.61,,,,,,,fee schedule,344.65,845.27,
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.88,,,,,,,fee schedule,344.65,845.27,
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,845.27,,,,,,,fee schedule,344.65,845.27,
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,735.02,,,,,,,fee schedule,344.65,845.27,
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,361.88,,,,,,,fee schedule,344.65,845.27,APC
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,344.65,,,,,,,fee schedule,344.65,845.27,APC
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,620.37,,,,,,,fee schedule,344.65,845.27,APC
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,881.29,,,,,,,fee schedule,504.86,1238.22,
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,705.89,,,,,,,fee schedule,504.86,1238.22,
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1238.22,,,,,,,fee schedule,504.86,1238.22,
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1076.71,,,,,,,fee schedule,504.86,1238.22,
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,530.1,,,,,,,fee schedule,504.86,1238.22,APC
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,504.86,,,,,,,fee schedule,504.86,1238.22,APC
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,908.75,,,,,,,fee schedule,504.86,1238.22,APC
Afo plastic,L1930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,540.48,,,,,,,fee schedule,309.6,759.38,
Afo plastic,L1930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,432.91,,,,,,,fee schedule,309.6,759.38,
Afo plastic,L1930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,759.38,,,,,,,fee schedule,309.6,759.38,
Afo plastic,L1930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,660.33,,,,,,,fee schedule,309.6,759.38,
Afo plastic,L1930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,325.08,,,,,,,fee schedule,309.6,759.38,APC
Afo plastic,L1930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,309.6,,,,,,,fee schedule,309.6,759.38,APC
Afo plastic,L1930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,557.28,,,,,,,fee schedule,309.6,759.38,APC
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1914.37,,,,,,,fee schedule,1096.64,2689.7,
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1533.36,,,,,,,fee schedule,1096.64,2689.7,
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2689.7,,,,,,,fee schedule,1096.64,2689.7,
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2338.87,,,,,,,fee schedule,1096.64,2689.7,
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1151.47,,,,,,,fee schedule,1096.64,2689.7,APC
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1096.64,,,,,,,fee schedule,1096.64,2689.7,APC
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1973.95,,,,,,,fee schedule,1096.64,2689.7,APC
Afo rig ant tib tcf/= ots,L1933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1151.47,,,,,,,fee schedule,1096.64,1973.95,APC
Afo rig ant tib tcf/= ots,L1933,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1096.64,,,,,,,fee schedule,1096.64,1973.95,APC
Afo rig ant tib tcf/= ots,L1933,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1973.95,,,,,,,fee schedule,1096.64,1973.95,APC
Afo molded to patient plasti,L1940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1044.72,,,,,,,fee schedule,598.47,1467.84,
Afo molded to patient plasti,L1940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,836.79,,,,,,,fee schedule,598.47,1467.84,
Afo molded to patient plasti,L1940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1467.84,,,,,,,fee schedule,598.47,1467.84,
Afo molded to patient plasti,L1940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1276.38,,,,,,,fee schedule,598.47,1467.84,
Afo molded to patient plasti,L1940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,628.39,,,,,,,fee schedule,598.47,1467.84,APC
Afo molded to patient plasti,L1940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,598.47,,,,,,,fee schedule,598.47,1467.84,APC
Afo molded to patient plasti,L1940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1077.25,,,,,,,fee schedule,598.47,1467.84,APC
Afo molded plas rig ant tib,L1945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2408.07,,,,,,,fee schedule,1379.49,3383.36,
Afo molded plas rig ant tib,L1945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1928.81,,,,,,,fee schedule,1379.49,3383.36,
Afo molded plas rig ant tib,L1945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3383.36,,,,,,,fee schedule,1379.49,3383.36,
Afo molded plas rig ant tib,L1945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2942.05,,,,,,,fee schedule,1379.49,3383.36,
Afo molded plas rig ant tib,L1945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1448.46,,,,,,,fee schedule,1379.49,3383.36,APC
Afo molded plas rig ant tib,L1945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1379.49,,,,,,,fee schedule,1379.49,3383.36,APC
Afo molded plas rig ant tib,L1945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2483.08,,,,,,,fee schedule,1379.49,3383.36,APC
Afo spiral molded to pt plas,L1950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1649.88,,,,,,,fee schedule,945.14,2318.1,
Afo spiral molded to pt plas,L1950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1321.52,,,,,,,fee schedule,945.14,2318.1,
Afo spiral molded to pt plas,L1950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2318.1,,,,,,,fee schedule,945.14,2318.1,
Afo spiral molded to pt plas,L1950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2015.74,,,,,,,fee schedule,945.14,2318.1,
Afo spiral molded to pt plas,L1950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,992.4,,,,,,,fee schedule,945.14,2318.1,APC
Afo spiral molded to pt plas,L1950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,945.14,,,,,,,fee schedule,945.14,2318.1,APC
Afo spiral molded to pt plas,L1950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1701.25,,,,,,,fee schedule,945.14,2318.1,APC
AFO spiral prefabricated,L1951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1801.66,,,,,,,fee schedule,1032.09,2531.35,
AFO spiral prefabricated,L1951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1443.09,,,,,,,fee schedule,1032.09,2531.35,
AFO spiral prefabricated,L1951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2531.35,,,,,,,fee schedule,1032.09,2531.35,
AFO spiral prefabricated,L1951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2201.17,,,,,,,fee schedule,1032.09,2531.35,
AFO spiral prefabricated,L1951,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1083.69,,,,,,,fee schedule,1032.09,2531.35,APC
AFO spiral prefabricated,L1951,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1032.09,,,,,,,fee schedule,1032.09,2531.35,APC
AFO spiral prefabricated,L1951,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1857.76,,,,,,,fee schedule,1032.09,2531.35,APC
Afo spiral prefab ots,L1952,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1083.69,,,,,,,fee schedule,1032.09,1857.76,APC
Afo spiral prefab ots,L1952,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1032.09,,,,,,,fee schedule,1032.09,1857.76,APC
Afo spiral prefab ots,L1952,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1857.76,,,,,,,fee schedule,1032.09,1857.76,APC
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1329.83,,,,,,,fee schedule,761.8,1868.42,
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1065.16,,,,,,,fee schedule,761.8,1868.42,
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1868.42,,,,,,,fee schedule,761.8,1868.42,
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1624.71,,,,,,,fee schedule,761.8,1868.42,
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,799.89,,,,,,,fee schedule,761.8,1868.42,APC
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,761.8,,,,,,,fee schedule,761.8,1868.42,APC
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1371.24,,,,,,,fee schedule,761.8,1868.42,APC
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1484.86,,,,,,,fee schedule,850.61,2086.24,
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1189.34,,,,,,,fee schedule,850.61,2086.24,
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2086.24,,,,,,,fee schedule,850.61,2086.24,
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1814.12,,,,,,,fee schedule,850.61,2086.24,
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,893.14,,,,,,,fee schedule,850.61,2086.24,APC
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,850.61,,,,,,,fee schedule,850.61,2086.24,APC
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1531.1,,,,,,,fee schedule,850.61,2086.24,APC
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1005.64,,,,,,,fee schedule,576.1,1412.94,
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,805.5,,,,,,,fee schedule,576.1,1412.94,
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1412.94,,,,,,,fee schedule,576.1,1412.94,
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1228.64,,,,,,,fee schedule,576.1,1412.94,
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,604.9,,,,,,,fee schedule,576.1,1412.94,APC
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,576.1,,,,,,,fee schedule,576.1,1412.94,APC
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1036.98,,,,,,,fee schedule,576.1,1412.94,APC
Afo sing solid stirrup calf,L1980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,866.22,,,,,,,fee schedule,496.21,1217.05,
Afo sing solid stirrup calf,L1980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,693.82,,,,,,,fee schedule,496.21,1217.05,
Afo sing solid stirrup calf,L1980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1217.05,,,,,,,fee schedule,496.21,1217.05,
Afo sing solid stirrup calf,L1980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1058.3,,,,,,,fee schedule,496.21,1217.05,
Afo sing solid stirrup calf,L1980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,521.02,,,,,,,fee schedule,496.21,1217.05,APC
Afo sing solid stirrup calf,L1980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,496.21,,,,,,,fee schedule,496.21,1217.05,APC
Afo sing solid stirrup calf,L1980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,893.18,,,,,,,fee schedule,496.21,1217.05,APC
Afo doub solid stirrup calf,L1990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1002.52,,,,,,,fee schedule,574.3,1408.55,
Afo doub solid stirrup calf,L1990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,803,,,,,,,fee schedule,574.3,1408.55,
Afo doub solid stirrup calf,L1990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1408.55,,,,,,,fee schedule,574.3,1408.55,
Afo doub solid stirrup calf,L1990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1224.83,,,,,,,fee schedule,574.3,1408.55,
Afo doub solid stirrup calf,L1990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,603.02,,,,,,,fee schedule,574.3,1408.55,APC
Afo doub solid stirrup calf,L1990,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,574.3,,,,,,,fee schedule,574.3,1408.55,APC
Afo doub solid stirrup calf,L1990,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1033.74,,,,,,,fee schedule,574.3,1408.55,APC
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2399.92,,,,,,,fee schedule,1374.81,3371.9,
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1922.28,,,,,,,fee schedule,1374.81,3371.9,
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3371.9,,,,,,,fee schedule,1374.81,3371.9,
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2932.09,,,,,,,fee schedule,1374.81,3371.9,
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1443.55,,,,,,,fee schedule,1374.81,3371.9,APC
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1374.81,,,,,,,fee schedule,1374.81,3371.9,APC
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2474.66,,,,,,,fee schedule,1374.81,3371.9,APC
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8790.97,,,,,,,fee schedule,5035.93,12351.39,
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7041.37,,,,,,,fee schedule,5035.93,12351.39,
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12351.39,,,,,,,fee schedule,5035.93,12351.39,
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10740.34,,,,,,,fee schedule,5035.93,12351.39,
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5287.73,,,,,,,fee schedule,5035.93,12351.39,APC
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5035.93,,,,,,,fee schedule,5035.93,12351.39,APC
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9064.67,,,,,,,fee schedule,5035.93,12351.39,APC
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1871.9,,,,,,,fee schedule,1072.34,2630.04,
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1499.35,,,,,,,fee schedule,1072.34,2630.04,
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2630.04,,,,,,,fee schedule,1072.34,2630.04,
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2286.99,,,,,,,fee schedule,1072.34,2630.04,
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1125.96,,,,,,,fee schedule,1072.34,2630.04,APC
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1072.34,,,,,,,fee schedule,1072.34,2630.04,APC
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1930.21,,,,,,,fee schedule,1072.34,2630.04,APC
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2364.13,,,,,,,fee schedule,1354.33,3321.63,
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1893.62,,,,,,,fee schedule,1354.33,3321.63,
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3321.63,,,,,,,fee schedule,1354.33,3321.63,
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2888.37,,,,,,,fee schedule,1354.33,3321.63,
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1422.05,,,,,,,fee schedule,1354.33,3321.63,APC
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1354.33,,,,,,,fee schedule,1354.33,3321.63,APC
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2437.79,,,,,,,fee schedule,1354.33,3321.63,APC
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2323.78,,,,,,,fee schedule,1331.19,3264.93,
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1861.29,,,,,,,fee schedule,1331.19,3264.93,
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3264.93,,,,,,,fee schedule,1331.19,3264.93,
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2839.07,,,,,,,fee schedule,1331.19,3264.93,
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1397.75,,,,,,,fee schedule,1331.19,3264.93,APC
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1331.19,,,,,,,fee schedule,1331.19,3264.93,APC
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2396.14,,,,,,,fee schedule,1331.19,3264.93,APC
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.19,,,,,,,fee schedule,2496.59,6123.29,
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3490.81,,,,,,,fee schedule,2496.59,6123.29,
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6123.29,,,,,,,fee schedule,2496.59,6123.29,
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5324.6,,,,,,,fee schedule,2496.59,6123.29,
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2621.42,,,,,,,fee schedule,2496.59,6123.29,APC
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2496.59,,,,,,,fee schedule,2496.59,6123.29,APC
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4493.86,,,,,,,fee schedule,2496.59,6123.29,APC
KAFO plastic pediatric size,L2035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,371.64,,,,,,,fee schedule,212.91,522.16,
KAFO plastic pediatric size,L2035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,297.68,,,,,,,fee schedule,212.91,522.16,
KAFO plastic pediatric size,L2035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,522.16,,,,,,,fee schedule,212.91,522.16,
KAFO plastic pediatric size,L2035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,454.05,,,,,,,fee schedule,212.91,522.16,
KAFO plastic pediatric size,L2035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,223.56,,,,,,,fee schedule,212.91,522.16,APC
KAFO plastic pediatric size,L2035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,212.91,,,,,,,fee schedule,212.91,522.16,APC
KAFO plastic pediatric size,L2035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,383.24,,,,,,,fee schedule,212.91,522.16,APC
Kafo plas doub free knee mol,L2036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3977.3,,,,,,,fee schedule,2278.43,5588.15,
Kafo plas doub free knee mol,L2036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3185.73,,,,,,,fee schedule,2278.43,5588.15,
Kafo plas doub free knee mol,L2036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5588.15,,,,,,,fee schedule,2278.43,5588.15,
Kafo plas doub free knee mol,L2036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4859.26,,,,,,,fee schedule,2278.43,5588.15,
Kafo plas doub free knee mol,L2036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2392.35,,,,,,,fee schedule,2278.43,5588.15,APC
Kafo plas doub free knee mol,L2036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2278.43,,,,,,,fee schedule,2278.43,5588.15,APC
Kafo plas doub free knee mol,L2036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4101.17,,,,,,,fee schedule,2278.43,5588.15,APC
Kafo plas sing free knee mol,L2037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3557.65,,,,,,,fee schedule,2038.02,4998.53,
Kafo plas sing free knee mol,L2037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2849.6,,,,,,,fee schedule,2038.02,4998.53,
Kafo plas sing free knee mol,L2037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4998.53,,,,,,,fee schedule,2038.02,4998.53,
Kafo plas sing free knee mol,L2037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4346.55,,,,,,,fee schedule,2038.02,4998.53,
Kafo plas sing free knee mol,L2037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2139.92,,,,,,,fee schedule,2038.02,4998.53,APC
Kafo plas sing free knee mol,L2037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2038.02,,,,,,,fee schedule,2038.02,4998.53,APC
Kafo plas sing free knee mol,L2037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3668.44,,,,,,,fee schedule,2038.02,4998.53,APC
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2867.98,,,,,,,fee schedule,1642.94,4029.54,
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2297.19,,,,,,,fee schedule,1642.94,4029.54,
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4029.54,,,,,,,fee schedule,1642.94,4029.54,
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3503.95,,,,,,,fee schedule,1642.94,4029.54,
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1725.09,,,,,,,fee schedule,1642.94,4029.54,APC
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1642.94,,,,,,,fee schedule,1642.94,4029.54,APC
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2957.29,,,,,,,fee schedule,1642.94,4029.54,APC
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,433.98,,,,,,,fee schedule,248.63,609.74,
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,347.61,,,,,,,fee schedule,248.63,609.74,
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,609.74,,,,,,,fee schedule,248.63,609.74,
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,530.21,,,,,,,fee schedule,248.63,609.74,
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.06,,,,,,,fee schedule,248.63,609.74,APC
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,248.63,,,,,,,fee schedule,248.63,609.74,APC
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,447.53,,,,,,,fee schedule,248.63,609.74,APC
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1045.41,,,,,,,fee schedule,598.88,1468.81,
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,837.35,,,,,,,fee schedule,598.88,1468.81,
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1468.81,,,,,,,fee schedule,598.88,1468.81,
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1277.23,,,,,,,fee schedule,598.88,1468.81,
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,628.82,,,,,,,fee schedule,598.88,1468.81,APC
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,598.88,,,,,,,fee schedule,598.88,1468.81,APC
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1077.98,,,,,,,fee schedule,598.88,1468.81,APC
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1307.61,,,,,,,fee schedule,749.08,1837.21,
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1047.37,,,,,,,fee schedule,749.08,1837.21,
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1837.21,,,,,,,fee schedule,749.08,1837.21,
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1597.57,,,,,,,fee schedule,749.08,1837.21,
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,786.53,,,,,,,fee schedule,749.08,1837.21,APC
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,749.08,,,,,,,fee schedule,749.08,1837.21,APC
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1348.34,,,,,,,fee schedule,749.08,1837.21,APC
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,332.97,,,,,,,fee schedule,190.75,467.82,
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,266.7,,,,,,,fee schedule,190.75,467.82,
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,467.82,,,,,,,fee schedule,190.75,467.82,
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,406.8,,,,,,,fee schedule,190.75,467.82,
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,200.29,,,,,,,fee schedule,190.75,467.82,APC
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,190.75,,,,,,,fee schedule,190.75,467.82,APC
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,343.35,,,,,,,fee schedule,190.75,467.82,APC
Hkafo unilat torsion cable,L2080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,800.6,,,,,,,fee schedule,458.63,1124.85,
Hkafo unilat torsion cable,L2080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,641.26,,,,,,,fee schedule,458.63,1124.85,
Hkafo unilat torsion cable,L2080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1124.85,,,,,,,fee schedule,458.63,1124.85,
Hkafo unilat torsion cable,L2080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,978.13,,,,,,,fee schedule,458.63,1124.85,
Hkafo unilat torsion cable,L2080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,481.56,,,,,,,fee schedule,458.63,1124.85,APC
Hkafo unilat torsion cable,L2080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,458.63,,,,,,,fee schedule,458.63,1124.85,APC
Hkafo unilat torsion cable,L2080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,825.53,,,,,,,fee schedule,458.63,1124.85,APC
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1066.69,,,,,,,fee schedule,611.07,1498.71,
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,854.4,,,,,,,fee schedule,611.07,1498.71,
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1498.71,,,,,,,fee schedule,611.07,1498.71,
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1303.23,,,,,,,fee schedule,611.07,1498.71,
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,641.62,,,,,,,fee schedule,611.07,1498.71,APC
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,611.07,,,,,,,fee schedule,611.07,1498.71,APC
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1099.93,,,,,,,fee schedule,611.07,1498.71,APC
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1690.98,,,,,,,fee schedule,968.68,2375.84,
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1354.44,,,,,,,fee schedule,968.68,2375.84,
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2375.84,,,,,,,fee schedule,968.68,2375.84,
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2065.95,,,,,,,fee schedule,968.68,2375.84,
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1017.11,,,,,,,fee schedule,968.68,2375.84,APC
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,968.68,,,,,,,fee schedule,968.68,2375.84,APC
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1743.62,,,,,,,fee schedule,968.68,2375.84,APC
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2466.36,,,,,,,fee schedule,1412.85,3465.26,
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1975.5,,,,,,,fee schedule,1412.85,3465.26,
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3465.26,,,,,,,fee schedule,1412.85,3465.26,
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3013.27,,,,,,,fee schedule,1412.85,3465.26,
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1483.49,,,,,,,fee schedule,1412.85,3465.26,APC
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1412.85,,,,,,,fee schedule,1412.85,3465.26,APC
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2543.13,,,,,,,fee schedule,1412.85,3465.26,APC
Afo tibial fracture soft,L2112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1082.31,,,,,,,fee schedule,620.02,1520.66,
Afo tibial fracture soft,L2112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,866.91,,,,,,,fee schedule,620.02,1520.66,
Afo tibial fracture soft,L2112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1520.66,,,,,,,fee schedule,620.02,1520.66,
Afo tibial fracture soft,L2112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1322.31,,,,,,,fee schedule,620.02,1520.66,
Afo tibial fracture soft,L2112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,651.02,,,,,,,fee schedule,620.02,1520.66,APC
Afo tibial fracture soft,L2112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,620.02,,,,,,,fee schedule,620.02,1520.66,APC
Afo tibial fracture soft,L2112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1116.04,,,,,,,fee schedule,620.02,1520.66,APC
Afo tib fx semi-rigid,L2114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1355.63,,,,,,,fee schedule,776.59,1904.68,
Afo tib fx semi-rigid,L2114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1085.83,,,,,,,fee schedule,776.59,1904.68,
Afo tib fx semi-rigid,L2114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1904.68,,,,,,,fee schedule,776.59,1904.68,
Afo tib fx semi-rigid,L2114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1656.24,,,,,,,fee schedule,776.59,1904.68,
Afo tib fx semi-rigid,L2114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,815.42,,,,,,,fee schedule,776.59,1904.68,APC
Afo tib fx semi-rigid,L2114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,776.59,,,,,,,fee schedule,776.59,1904.68,APC
Afo tib fx semi-rigid,L2114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1397.86,,,,,,,fee schedule,776.59,1904.68,APC
Afo tibial fracture rigid,L2116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1653.48,,,,,,,fee schedule,947.2,2323.15,
Afo tibial fracture rigid,L2116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1324.4,,,,,,,fee schedule,947.2,2323.15,
Afo tibial fracture rigid,L2116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2323.15,,,,,,,fee schedule,947.2,2323.15,
Afo tibial fracture rigid,L2116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2020.13,,,,,,,fee schedule,947.2,2323.15,
Afo tibial fracture rigid,L2116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,994.56,,,,,,,fee schedule,947.2,2323.15,APC
Afo tibial fracture rigid,L2116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,947.2,,,,,,,fee schedule,947.2,2323.15,APC
Afo tibial fracture rigid,L2116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1704.96,,,,,,,fee schedule,947.2,2323.15,APC
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2739.36,,,,,,,fee schedule,1569.24,3848.82,
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2194.16,,,,,,,fee schedule,1569.24,3848.82,
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3848.82,,,,,,,fee schedule,1569.24,3848.82,
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3346.8,,,,,,,fee schedule,1569.24,3848.82,
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1647.7,,,,,,,fee schedule,1569.24,3848.82,APC
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1569.24,,,,,,,fee schedule,1569.24,3848.82,APC
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2824.63,,,,,,,fee schedule,1569.24,3848.82,APC
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3439.69,,,,,,,fee schedule,1970.44,4832.79,
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2755.11,,,,,,,fee schedule,1970.44,4832.79,
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4832.79,,,,,,,fee schedule,1970.44,4832.79,
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4202.43,,,,,,,fee schedule,1970.44,4832.79,
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2068.96,,,,,,,fee schedule,1970.44,4832.79,APC
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1970.44,,,,,,,fee schedule,1970.44,4832.79,APC
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3546.79,,,,,,,fee schedule,1970.44,4832.79,APC
Kafo femoral fx cast soft,L2132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2087.83,,,,,,,fee schedule,1196.02,2933.42,
Kafo femoral fx cast soft,L2132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1672.3,,,,,,,fee schedule,1196.02,2933.42,
Kafo femoral fx cast soft,L2132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2933.42,,,,,,,fee schedule,1196.02,2933.42,
Kafo femoral fx cast soft,L2132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2550.8,,,,,,,fee schedule,1196.02,2933.42,
Kafo femoral fx cast soft,L2132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1255.82,,,,,,,fee schedule,1196.02,2933.42,APC
Kafo femoral fx cast soft,L2132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1196.02,,,,,,,fee schedule,1196.02,2933.42,APC
Kafo femoral fx cast soft,L2132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2152.84,,,,,,,fee schedule,1196.02,2933.42,APC
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2472.25,,,,,,,fee schedule,1416.24,3473.54,
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1980.22,,,,,,,fee schedule,1416.24,3473.54,
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3473.54,,,,,,,fee schedule,1416.24,3473.54,
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3020.47,,,,,,,fee schedule,1416.24,3473.54,
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1487.05,,,,,,,fee schedule,1416.24,3473.54,APC
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1416.24,,,,,,,fee schedule,1416.24,3473.54,APC
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2549.23,,,,,,,fee schedule,1416.24,3473.54,APC
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2705.52,,,,,,,fee schedule,1549.86,3801.28,
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.06,,,,,,,fee schedule,1549.86,3801.28,
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3801.28,,,,,,,fee schedule,1549.86,3801.28,
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3305.46,,,,,,,fee schedule,1549.86,3801.28,
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1627.35,,,,,,,fee schedule,1549.86,3801.28,APC
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1549.86,,,,,,,fee schedule,1549.86,3801.28,APC
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2789.75,,,,,,,fee schedule,1549.86,3801.28,APC
Plas shoe insert w ank joint,L2180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,284.4,,,,,,,fee schedule,162.92,399.59,
Plas shoe insert w ank joint,L2180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.8,,,,,,,fee schedule,162.92,399.59,
Plas shoe insert w ank joint,L2180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,399.59,,,,,,,fee schedule,162.92,399.59,
Plas shoe insert w ank joint,L2180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,347.47,,,,,,,fee schedule,162.92,399.59,
Plas shoe insert w ank joint,L2180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,171.07,,,,,,,fee schedule,162.92,399.59,APC
Plas shoe insert w ank joint,L2180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,162.92,,,,,,,fee schedule,162.92,399.59,APC
Plas shoe insert w ank joint,L2180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,293.26,,,,,,,fee schedule,162.92,399.59,APC
Drop lock knee,L2182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,245.16,,,,,,,fee schedule,140.43,344.45,
Drop lock knee,L2182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,196.37,,,,,,,fee schedule,140.43,344.45,
Drop lock knee,L2182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.45,,,,,,,fee schedule,140.43,344.45,
Drop lock knee,L2182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.52,,,,,,,fee schedule,140.43,344.45,
Drop lock knee,L2182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,147.45,,,,,,,fee schedule,140.43,344.45,APC
Drop lock knee,L2182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,140.43,,,,,,,fee schedule,140.43,344.45,APC
Drop lock knee,L2182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,252.77,,,,,,,fee schedule,140.43,344.45,APC
Limited motion knee joint,L2184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,248.5,,,,,,,fee schedule,142.35,349.15,
Limited motion knee joint,L2184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,199.05,,,,,,,fee schedule,142.35,349.15,
Limited motion knee joint,L2184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,349.15,,,,,,,fee schedule,142.35,349.15,
Limited motion knee joint,L2184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,303.61,,,,,,,fee schedule,142.35,349.15,
Limited motion knee joint,L2184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.47,,,,,,,fee schedule,142.35,349.15,APC
Limited motion knee joint,L2184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,142.35,,,,,,,fee schedule,142.35,349.15,APC
Limited motion knee joint,L2184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,256.23,,,,,,,fee schedule,142.35,349.15,APC
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,330.44,,,,,,,fee schedule,189.31,464.27,
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,264.67,,,,,,,fee schedule,189.31,464.27,
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,464.27,,,,,,,fee schedule,189.31,464.27,
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,403.71,,,,,,,fee schedule,189.31,464.27,
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,198.78,,,,,,,fee schedule,189.31,464.27,APC
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,189.31,,,,,,,fee schedule,189.31,464.27,APC
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,340.76,,,,,,,fee schedule,189.31,464.27,APC
Quadrilateral brim,L2188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,600.74,,,,,,,fee schedule,344.15,844.04,
Quadrilateral brim,L2188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,481.18,,,,,,,fee schedule,344.15,844.04,
Quadrilateral brim,L2188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,844.04,,,,,,,fee schedule,344.15,844.04,
Quadrilateral brim,L2188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,733.95,,,,,,,fee schedule,344.15,844.04,
Quadrilateral brim,L2188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,361.36,,,,,,,fee schedule,344.15,844.04,APC
Quadrilateral brim,L2188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,344.15,,,,,,,fee schedule,344.15,844.04,APC
Quadrilateral brim,L2188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,619.47,,,,,,,fee schedule,344.15,844.04,APC
Waist belt,L2190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.98,,,,,,,fee schedule,104.83,257.09,
Waist belt,L2190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.57,,,,,,,fee schedule,104.83,257.09,
Waist belt,L2190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,257.09,,,,,,,fee schedule,104.83,257.09,
Waist belt,L2190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,223.56,,,,,,,fee schedule,104.83,257.09,
Waist belt,L2190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.07,,,,,,,fee schedule,104.83,257.09,APC
Waist belt,L2190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.83,,,,,,,fee schedule,104.83,257.09,APC
Waist belt,L2190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,188.69,,,,,,,fee schedule,104.83,257.09,APC
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,715.23,,,,,,,fee schedule,409.73,1004.9,
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,572.88,,,,,,,fee schedule,409.73,1004.9,
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1004.9,,,,,,,fee schedule,409.73,1004.9,
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,873.83,,,,,,,fee schedule,409.73,1004.9,
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,430.22,,,,,,,fee schedule,409.73,1004.9,APC
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,409.73,,,,,,,fee schedule,409.73,1004.9,APC
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,737.51,,,,,,,fee schedule,409.73,1004.9,APC
Limited ankle motion ea jnt,L2200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.8,,,,,,,fee schedule,61.75,151.46,
Limited ankle motion ea jnt,L2200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,86.34,,,,,,,fee schedule,61.75,151.46,
Limited ankle motion ea jnt,L2200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,151.46,,,,,,,fee schedule,61.75,151.46,
Limited ankle motion ea jnt,L2200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,131.7,,,,,,,fee schedule,61.75,151.46,
Limited ankle motion ea jnt,L2200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.84,,,,,,,fee schedule,61.75,151.46,APC
Limited ankle motion ea jnt,L2200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,61.75,,,,,,,fee schedule,61.75,151.46,APC
Limited ankle motion ea jnt,L2200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,111.15,,,,,,,fee schedule,61.75,151.46,APC
Dorsiflexion assist each joi,L2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.85,,,,,,,fee schedule,77.24,189.46,
Dorsiflexion assist each joi,L2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.01,,,,,,,fee schedule,77.24,189.46,
Dorsiflexion assist each joi,L2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.46,,,,,,,fee schedule,77.24,189.46,
Dorsiflexion assist each joi,L2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.75,,,,,,,fee schedule,77.24,189.46,
Dorsiflexion assist each joi,L2210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.1,,,,,,,fee schedule,77.24,189.46,APC
Dorsiflexion assist each joi,L2210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,77.24,,,,,,,fee schedule,77.24,189.46,APC
Dorsiflexion assist each joi,L2210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,139.03,,,,,,,fee schedule,77.24,189.46,APC
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.6,,,,,,,fee schedule,99.43,243.9,
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.05,,,,,,,fee schedule,99.43,243.9,
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,243.9,,,,,,,fee schedule,99.43,243.9,
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.09,,,,,,,fee schedule,99.43,243.9,
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.4,,,,,,,fee schedule,99.43,243.9,APC
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,99.43,,,,,,,fee schedule,99.43,243.9,APC
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,178.97,,,,,,,fee schedule,99.43,243.9,APC
Ank mcrop plant & dorsi flex,L2221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1845.58,,,,,,,fee schedule,1757.7,3163.86,APC
Ank mcrop plant & dorsi flex,L2221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1757.7,,,,,,,fee schedule,1757.7,3163.86,APC
Ank mcrop plant & dorsi flex,L2221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3163.86,,,,,,,fee schedule,1757.7,3163.86,APC
Split flat caliper stirr & p,L2230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,205.21,,,,,,,fee schedule,117.56,288.32,
Split flat caliper stirr & p,L2230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.37,,,,,,,fee schedule,117.56,288.32,
Split flat caliper stirr & p,L2230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,288.32,,,,,,,fee schedule,117.56,288.32,
Split flat caliper stirr & p,L2230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,250.71,,,,,,,fee schedule,117.56,288.32,
Split flat caliper stirr & p,L2230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,123.44,,,,,,,fee schedule,117.56,288.32,APC
Split flat caliper stirr & p,L2230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,117.56,,,,,,,fee schedule,117.56,288.32,APC
Split flat caliper stirr & p,L2230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,211.61,,,,,,,fee schedule,117.56,288.32,APC
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.37,,,,,,,fee schedule,119.38,292.77,
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,166.9,,,,,,,fee schedule,119.38,292.77,
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.77,,,,,,,fee schedule,119.38,292.77,
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.58,,,,,,,fee schedule,119.38,292.77,
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,125.35,,,,,,,fee schedule,119.38,292.77,APC
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,119.38,,,,,,,fee schedule,119.38,292.77,APC
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,214.88,,,,,,,fee schedule,119.38,292.77,APC
Round caliper and plate atta,L2240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,204.24,,,,,,,fee schedule,117.01,286.96,
Round caliper and plate atta,L2240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,163.59,,,,,,,fee schedule,117.01,286.96,
Round caliper and plate atta,L2240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,286.96,,,,,,,fee schedule,117.01,286.96,
Round caliper and plate atta,L2240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,249.53,,,,,,,fee schedule,117.01,286.96,
Round caliper and plate atta,L2240,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.86,,,,,,,fee schedule,117.01,286.96,APC
Round caliper and plate atta,L2240,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,117.01,,,,,,,fee schedule,117.01,286.96,APC
Round caliper and plate atta,L2240,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,210.62,,,,,,,fee schedule,117.01,286.96,APC
Foot plate molded stirrup at,L2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,716.59,,,,,,,fee schedule,410.5,1006.81,
Foot plate molded stirrup at,L2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,573.97,,,,,,,fee schedule,410.5,1006.81,
Foot plate molded stirrup at,L2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1006.81,,,,,,,fee schedule,410.5,1006.81,
Foot plate molded stirrup at,L2250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,875.49,,,,,,,fee schedule,410.5,1006.81,
Foot plate molded stirrup at,L2250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,431.02,,,,,,,fee schedule,410.5,1006.81,APC
Foot plate molded stirrup at,L2250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,410.5,,,,,,,fee schedule,410.5,1006.81,APC
Foot plate molded stirrup at,L2250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,738.9,,,,,,,fee schedule,410.5,1006.81,APC
Reinforced solid stirrup,L2260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,402.11,,,,,,,fee schedule,230.35,564.97,
Reinforced solid stirrup,L2260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,322.08,,,,,,,fee schedule,230.35,564.97,
Reinforced solid stirrup,L2260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,564.97,,,,,,,fee schedule,230.35,564.97,
Reinforced solid stirrup,L2260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,491.28,,,,,,,fee schedule,230.35,564.97,
Reinforced solid stirrup,L2260,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,241.87,,,,,,,fee schedule,230.35,564.97,APC
Reinforced solid stirrup,L2260,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,230.35,,,,,,,fee schedule,230.35,564.97,APC
Reinforced solid stirrup,L2260,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,414.63,,,,,,,fee schedule,230.35,564.97,APC
Long tongue stirrup,L2265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,288.37,,,,,,,fee schedule,165.21,405.17,
Long tongue stirrup,L2265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,230.98,,,,,,,fee schedule,165.21,405.17,
Long tongue stirrup,L2265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,405.17,,,,,,,fee schedule,165.21,405.17,
Long tongue stirrup,L2265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,352.32,,,,,,,fee schedule,165.21,405.17,
Long tongue stirrup,L2265,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.47,,,,,,,fee schedule,165.21,405.17,APC
Long tongue stirrup,L2265,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,165.21,,,,,,,fee schedule,165.21,405.17,APC
Long tongue stirrup,L2265,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,297.38,,,,,,,fee schedule,165.21,405.17,APC
Varus/valgus strap padded/li,L2270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.23,,,,,,,fee schedule,75.76,185.78,
Varus/valgus strap padded/li,L2270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.91,,,,,,,fee schedule,75.76,185.78,
Varus/valgus strap padded/li,L2270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.78,,,,,,,fee schedule,75.76,185.78,
Varus/valgus strap padded/li,L2270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.55,,,,,,,fee schedule,75.76,185.78,
Varus/valgus strap padded/li,L2270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.55,,,,,,,fee schedule,75.76,185.78,APC
Varus/valgus strap padded/li,L2270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,75.76,,,,,,,fee schedule,75.76,185.78,APC
Varus/valgus strap padded/li,L2270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,136.37,,,,,,,fee schedule,75.76,185.78,APC
Plastic mod low ext pad/line,L2275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.66,,,,,,,fee schedule,160.19,392.92,
Plastic mod low ext pad/line,L2275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224,,,,,,,fee schedule,160.19,392.92,
Plastic mod low ext pad/line,L2275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.92,,,,,,,fee schedule,160.19,392.92,
Plastic mod low ext pad/line,L2275,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,341.67,,,,,,,fee schedule,160.19,392.92,
Plastic mod low ext pad/line,L2275,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.2,,,,,,,fee schedule,160.19,392.92,APC
Plastic mod low ext pad/line,L2275,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,160.19,,,,,,,fee schedule,160.19,392.92,APC
Plastic mod low ext pad/line,L2275,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,288.34,,,,,,,fee schedule,160.19,392.92,APC
Molded inner boot,L2280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1211.1,,,,,,,fee schedule,693.78,1701.61,
Molded inner boot,L2280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,970.07,,,,,,,fee schedule,693.78,1701.61,
Molded inner boot,L2280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1701.61,,,,,,,fee schedule,693.78,1701.61,
Molded inner boot,L2280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1479.66,,,,,,,fee schedule,693.78,1701.61,
Molded inner boot,L2280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.47,,,,,,,fee schedule,693.78,1701.61,APC
Molded inner boot,L2280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,693.78,,,,,,,fee schedule,693.78,1701.61,APC
Molded inner boot,L2280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1248.8,,,,,,,fee schedule,693.78,1701.61,APC
Abduction bar jointed adjust,L2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,540.08,,,,,,,fee schedule,309.39,758.82,
Abduction bar jointed adjust,L2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,432.59,,,,,,,fee schedule,309.39,758.82,
Abduction bar jointed adjust,L2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,758.82,,,,,,,fee schedule,309.39,758.82,
Abduction bar jointed adjust,L2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,659.84,,,,,,,fee schedule,309.39,758.82,
Abduction bar jointed adjust,L2300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,324.86,,,,,,,fee schedule,309.39,758.82,APC
Abduction bar jointed adjust,L2300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,309.39,,,,,,,fee schedule,309.39,758.82,APC
Abduction bar jointed adjust,L2300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,556.9,,,,,,,fee schedule,309.39,758.82,APC
Abduction bar-straight,L2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,246.78,,,,,,,fee schedule,141.37,346.73,
Abduction bar-straight,L2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,197.66,,,,,,,fee schedule,141.37,346.73,
Abduction bar-straight,L2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,346.73,,,,,,,fee schedule,141.37,346.73,
Abduction bar-straight,L2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,301.5,,,,,,,fee schedule,141.37,346.73,
Abduction bar-straight,L2310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,148.44,,,,,,,fee schedule,141.37,346.73,APC
Abduction bar-straight,L2310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,141.37,,,,,,,fee schedule,141.37,346.73,APC
Abduction bar-straight,L2310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,254.47,,,,,,,fee schedule,141.37,346.73,APC
Non-molded lacer,L2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,413.8,,,,,,,fee schedule,237.08,581.39,
Non-molded lacer,L2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,331.45,,,,,,,fee schedule,237.08,581.39,
Non-molded lacer,L2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,581.39,,,,,,,fee schedule,237.08,581.39,
Non-molded lacer,L2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,505.56,,,,,,,fee schedule,237.08,581.39,
Non-molded lacer,L2320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.93,,,,,,,fee schedule,237.08,581.39,APC
Non-molded lacer,L2320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,237.08,,,,,,,fee schedule,237.08,581.39,APC
Non-molded lacer,L2320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,426.74,,,,,,,fee schedule,237.08,581.39,APC
Lacer molded to patient mode,L2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,787.65,,,,,,,fee schedule,451.21,1106.66,
Lacer molded to patient mode,L2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,630.89,,,,,,,fee schedule,451.21,1106.66,
Lacer molded to patient mode,L2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1106.66,,,,,,,fee schedule,451.21,1106.66,
Lacer molded to patient mode,L2330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,962.31,,,,,,,fee schedule,451.21,1106.66,
Lacer molded to patient mode,L2330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.77,,,,,,,fee schedule,451.21,1106.66,APC
Lacer molded to patient mode,L2330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,451.21,,,,,,,fee schedule,451.21,1106.66,APC
Lacer molded to patient mode,L2330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,812.18,,,,,,,fee schedule,451.21,1106.66,APC
Anterior swing band,L2335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,603.05,,,,,,,fee schedule,345.46,847.29,
Anterior swing band,L2335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,483.03,,,,,,,fee schedule,345.46,847.29,
Anterior swing band,L2335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,847.29,,,,,,,fee schedule,345.46,847.29,
Anterior swing band,L2335,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,736.77,,,,,,,fee schedule,345.46,847.29,
Anterior swing band,L2335,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.73,,,,,,,fee schedule,345.46,847.29,APC
Anterior swing band,L2335,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,345.46,,,,,,,fee schedule,345.46,847.29,APC
Anterior swing band,L2335,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,621.83,,,,,,,fee schedule,345.46,847.29,APC
Pre-tibial shell molded to p,L2340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,896.52,,,,,,,fee schedule,513.58,1259.62,
Pre-tibial shell molded to p,L2340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,718.09,,,,,,,fee schedule,513.58,1259.62,
Pre-tibial shell molded to p,L2340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1259.62,,,,,,,fee schedule,513.58,1259.62,
Pre-tibial shell molded to p,L2340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1095.32,,,,,,,fee schedule,513.58,1259.62,
Pre-tibial shell molded to p,L2340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,539.26,,,,,,,fee schedule,513.58,1259.62,APC
Pre-tibial shell molded to p,L2340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,513.58,,,,,,,fee schedule,513.58,1259.62,APC
Pre-tibial shell molded to p,L2340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,924.44,,,,,,,fee schedule,513.58,1259.62,APC
Prosthetic type socket molde,L2350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1787.41,,,,,,,fee schedule,1023.92,2511.32,
Prosthetic type socket molde,L2350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1431.67,,,,,,,fee schedule,1023.92,2511.32,
Prosthetic type socket molde,L2350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2511.32,,,,,,,fee schedule,1023.92,2511.32,
Prosthetic type socket molde,L2350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2183.76,,,,,,,fee schedule,1023.92,2511.32,
Prosthetic type socket molde,L2350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1075.12,,,,,,,fee schedule,1023.92,2511.32,APC
Prosthetic type socket molde,L2350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1023.92,,,,,,,fee schedule,1023.92,2511.32,APC
Prosthetic type socket molde,L2350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1843.06,,,,,,,fee schedule,1023.92,2511.32,APC
Extended steel shank,L2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.64,,,,,,,fee schedule,63.37,155.45,
Extended steel shank,L2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.62,,,,,,,fee schedule,63.37,155.45,
Extended steel shank,L2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.45,,,,,,,fee schedule,63.37,155.45,
Extended steel shank,L2360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,135.17,,,,,,,fee schedule,63.37,155.45,
Extended steel shank,L2360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,66.54,,,,,,,fee schedule,63.37,155.45,APC
Extended steel shank,L2360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,63.37,,,,,,,fee schedule,63.37,155.45,APC
Extended steel shank,L2360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,114.07,,,,,,,fee schedule,63.37,155.45,APC
Patten bottom,L2370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,686.59,,,,,,,fee schedule,393.31,964.67,
Patten bottom,L2370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,549.94,,,,,,,fee schedule,393.31,964.67,
Patten bottom,L2370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,964.67,,,,,,,fee schedule,393.31,964.67,
Patten bottom,L2370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,838.84,,,,,,,fee schedule,393.31,964.67,
Patten bottom,L2370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,412.98,,,,,,,fee schedule,393.31,964.67,APC
Patten bottom,L2370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,393.31,,,,,,,fee schedule,393.31,964.67,APC
Patten bottom,L2370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,707.96,,,,,,,fee schedule,393.31,964.67,APC
Torsion ank & half solid sti,L2375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,263.96,,,,,,,fee schedule,151.22,370.86,
Torsion ank & half solid sti,L2375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,211.42,,,,,,,fee schedule,151.22,370.86,
Torsion ank & half solid sti,L2375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,370.86,,,,,,,fee schedule,151.22,370.86,
Torsion ank & half solid sti,L2375,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,322.49,,,,,,,fee schedule,151.22,370.86,
Torsion ank & half solid sti,L2375,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,158.78,,,,,,,fee schedule,151.22,370.86,APC
Torsion ank & half solid sti,L2375,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,151.22,,,,,,,fee schedule,151.22,370.86,APC
Torsion ank & half solid sti,L2375,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,272.2,,,,,,,fee schedule,151.22,370.86,APC
Torsion straight knee joint,L2380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,276.84,,,,,,,fee schedule,158.6,388.96,
Torsion straight knee joint,L2380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,221.74,,,,,,,fee schedule,158.6,388.96,
Torsion straight knee joint,L2380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,388.96,,,,,,,fee schedule,158.6,388.96,
Torsion straight knee joint,L2380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,338.23,,,,,,,fee schedule,158.6,388.96,
Torsion straight knee joint,L2380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,166.53,,,,,,,fee schedule,158.6,388.96,APC
Torsion straight knee joint,L2380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,158.6,,,,,,,fee schedule,158.6,388.96,APC
Torsion straight knee joint,L2380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,285.48,,,,,,,fee schedule,158.6,388.96,APC
Straight knee joint heavy du,L2385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,315.25,,,,,,,fee schedule,180.58,442.93,
Straight knee joint heavy du,L2385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,252.51,,,,,,,fee schedule,180.58,442.93,
Straight knee joint heavy du,L2385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,442.93,,,,,,,fee schedule,180.58,442.93,
Straight knee joint heavy du,L2385,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,385.16,,,,,,,fee schedule,180.58,442.93,
Straight knee joint heavy du,L2385,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,189.61,,,,,,,fee schedule,180.58,442.93,APC
Straight knee joint heavy du,L2385,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,180.58,,,,,,,fee schedule,180.58,442.93,APC
Straight knee joint heavy du,L2385,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,325.04,,,,,,,fee schedule,180.58,442.93,APC
Add le poly knee custom kafo,L2387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,409.53,,,,,,,fee schedule,234.6,575.39,
Add le poly knee custom kafo,L2387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,328.02,,,,,,,fee schedule,234.6,575.39,
Add le poly knee custom kafo,L2387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,575.39,,,,,,,fee schedule,234.6,575.39,
Add le poly knee custom kafo,L2387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,500.34,,,,,,,fee schedule,234.6,575.39,
Add le poly knee custom kafo,L2387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.33,,,,,,,fee schedule,234.6,575.39,APC
Add le poly knee custom kafo,L2387,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,234.6,,,,,,,fee schedule,234.6,575.39,APC
Add le poly knee custom kafo,L2387,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,422.28,,,,,,,fee schedule,234.6,575.39,APC
Offset knee joint each,L2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,219.57,,,,,,,fee schedule,125.79,308.5,
Offset knee joint each,L2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.87,,,,,,,fee schedule,125.79,308.5,
Offset knee joint each,L2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.5,,,,,,,fee schedule,125.79,308.5,
Offset knee joint each,L2390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.26,,,,,,,fee schedule,125.79,308.5,
Offset knee joint each,L2390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.08,,,,,,,fee schedule,125.79,308.5,APC
Offset knee joint each,L2390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,125.79,,,,,,,fee schedule,125.79,308.5,APC
Offset knee joint each,L2390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,226.42,,,,,,,fee schedule,125.79,308.5,APC
Offset knee joint heavy duty,L2395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,313.87,,,,,,,fee schedule,179.8,440.99,
Offset knee joint heavy duty,L2395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.4,,,,,,,fee schedule,179.8,440.99,
Offset knee joint heavy duty,L2395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,440.99,,,,,,,fee schedule,179.8,440.99,
Offset knee joint heavy duty,L2395,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,383.47,,,,,,,fee schedule,179.8,440.99,
Offset knee joint heavy duty,L2395,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,188.79,,,,,,,fee schedule,179.8,440.99,APC
Offset knee joint heavy duty,L2395,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,179.8,,,,,,,fee schedule,179.8,440.99,APC
Offset knee joint heavy duty,L2395,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,323.64,,,,,,,fee schedule,179.8,440.99,APC
Suspension sleeve lower ext,L2397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.85,,,,,,,fee schedule,150,367.91,
Suspension sleeve lower ext,L2397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,209.74,,,,,,,fee schedule,150,367.91,
Suspension sleeve lower ext,L2397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,367.91,,,,,,,fee schedule,150,367.91,
Suspension sleeve lower ext,L2397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,319.92,,,,,,,fee schedule,150,367.91,
Suspension sleeve lower ext,L2397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.5,,,,,,,fee schedule,150,367.91,APC
Suspension sleeve lower ext,L2397,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150,,,,,,,fee schedule,150,367.91,APC
Suspension sleeve lower ext,L2397,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270,,,,,,,fee schedule,150,367.91,APC
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.04,,,,,,,fee schedule,107.14,262.8,
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.82,,,,,,,fee schedule,107.14,262.8,
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,262.8,,,,,,,fee schedule,107.14,262.8,
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.52,,,,,,,fee schedule,107.14,262.8,
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.5,,,,,,,fee schedule,107.14,262.8,APC
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,107.14,,,,,,,fee schedule,107.14,262.8,APC
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,192.85,,,,,,,fee schedule,107.14,262.8,APC
Knee joint cam lock each joi,L2415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,260.63,,,,,,,fee schedule,149.3,366.18,
Knee joint cam lock each joi,L2415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,208.76,,,,,,,fee schedule,149.3,366.18,
Knee joint cam lock each joi,L2415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,366.18,,,,,,,fee schedule,149.3,366.18,
Knee joint cam lock each joi,L2415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,318.42,,,,,,,fee schedule,149.3,366.18,
Knee joint cam lock each joi,L2415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,156.76,,,,,,,fee schedule,149.3,366.18,APC
Knee joint cam lock each joi,L2415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,149.3,,,,,,,fee schedule,149.3,366.18,APC
Knee joint cam lock each joi,L2415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,268.74,,,,,,,fee schedule,149.3,366.18,APC
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.54,,,,,,,fee schedule,176.17,432.09,
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.33,,,,,,,fee schedule,176.17,432.09,
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,432.09,,,,,,,fee schedule,176.17,432.09,
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.73,,,,,,,fee schedule,176.17,432.09,
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.98,,,,,,,fee schedule,176.17,432.09,APC
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.17,,,,,,,fee schedule,176.17,432.09,APC
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,317.11,,,,,,,fee schedule,176.17,432.09,APC
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,307.54,,,,,,,fee schedule,176.17,432.09,
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.33,,,,,,,fee schedule,176.17,432.09,
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,432.09,,,,,,,fee schedule,176.17,432.09,
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,375.73,,,,,,,fee schedule,176.17,432.09,
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.98,,,,,,,fee schedule,176.17,432.09,APC
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,176.17,,,,,,,fee schedule,176.17,432.09,APC
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,317.11,,,,,,,fee schedule,176.17,432.09,APC
Knee lift loop drop lock rin,L2492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.6,,,,,,,fee schedule,144.15,353.5,
Knee lift loop drop lock rin,L2492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.52,,,,,,,fee schedule,144.15,353.5,
Knee lift loop drop lock rin,L2492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,353.5,,,,,,,fee schedule,144.15,353.5,
Knee lift loop drop lock rin,L2492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,307.39,,,,,,,fee schedule,144.15,353.5,
Knee lift loop drop lock rin,L2492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,151.36,,,,,,,fee schedule,144.15,353.5,APC
Knee lift loop drop lock rin,L2492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,144.15,,,,,,,fee schedule,144.15,353.5,APC
Knee lift loop drop lock rin,L2492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,259.47,,,,,,,fee schedule,144.15,353.5,APC
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,671.33,,,,,,,fee schedule,384.58,943.22,
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,537.72,,,,,,,fee schedule,384.58,943.22,
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,943.22,,,,,,,fee schedule,384.58,943.22,
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,820.19,,,,,,,fee schedule,384.58,943.22,
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.81,,,,,,,fee schedule,384.58,943.22,APC
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,384.58,,,,,,,fee schedule,384.58,943.22,APC
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,692.24,,,,,,,fee schedule,384.58,943.22,APC
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1730.23,,,,,,,fee schedule,991.19,2430.99,
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1385.87,,,,,,,fee schedule,991.19,2430.99,
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2430.99,,,,,,,fee schedule,991.19,2430.99,
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2113.9,,,,,,,fee schedule,991.19,2430.99,
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1040.75,,,,,,,fee schedule,991.19,2430.99,APC
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,991.19,,,,,,,fee schedule,991.19,2430.99,APC
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1784.14,,,,,,,fee schedule,991.19,2430.99,APC
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1153.1,,,,,,,fee schedule,660.58,1620.12,
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,923.61,,,,,,,fee schedule,660.58,1620.12,
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1620.12,,,,,,,fee schedule,660.58,1620.12,
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1408.8,,,,,,,fee schedule,660.58,1620.12,
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,693.61,,,,,,,fee schedule,660.58,1620.12,APC
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,660.58,,,,,,,fee schedule,660.58,1620.12,APC
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1189.04,,,,,,,fee schedule,660.58,1620.12,APC
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2445.24,,,,,,,fee schedule,1400.77,3435.59,
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1958.59,,,,,,,fee schedule,1400.77,3435.59,
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3435.59,,,,,,,fee schedule,1400.77,3435.59,
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2987.47,,,,,,,fee schedule,1400.77,3435.59,
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1470.81,,,,,,,fee schedule,1400.77,3435.59,APC
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1400.77,,,,,,,fee schedule,1400.77,3435.59,APC
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2521.39,,,,,,,fee schedule,1400.77,3435.59,APC
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1373.97,,,,,,,fee schedule,787.09,1930.44,
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1100.52,,,,,,,fee schedule,787.09,1930.44,
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1930.44,,,,,,,fee schedule,787.09,1930.44,
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1678.64,,,,,,,fee schedule,787.09,1930.44,
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,826.44,,,,,,,fee schedule,787.09,1930.44,APC
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,787.09,,,,,,,fee schedule,787.09,1930.44,APC
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1416.76,,,,,,,fee schedule,787.09,1930.44,APC
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,514.52,,,,,,,fee schedule,294.73,722.9,
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,412.12,,,,,,,fee schedule,294.73,722.9,
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,722.9,,,,,,,fee schedule,294.73,722.9,
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,628.61,,,,,,,fee schedule,294.73,722.9,
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,309.47,,,,,,,fee schedule,294.73,722.9,APC
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,294.73,,,,,,,fee schedule,294.73,722.9,APC
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,530.51,,,,,,,fee schedule,294.73,722.9,APC
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,973.54,,,,,,,fee schedule,557.7,1367.83,
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,779.78,,,,,,,fee schedule,557.7,1367.83,
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1367.83,,,,,,,fee schedule,557.7,1367.83,
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1189.42,,,,,,,fee schedule,557.7,1367.83,
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,585.58,,,,,,,fee schedule,557.7,1367.83,APC
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,557.7,,,,,,,fee schedule,557.7,1367.83,APC
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1003.86,,,,,,,fee schedule,557.7,1367.83,APC
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,729.93,,,,,,,fee schedule,418.16,1025.56,
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,584.66,,,,,,,fee schedule,418.16,1025.56,
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1025.56,,,,,,,fee schedule,418.16,1025.56,
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,891.79,,,,,,,fee schedule,418.16,1025.56,
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,439.07,,,,,,,fee schedule,418.16,1025.56,APC
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,418.16,,,,,,,fee schedule,418.16,1025.56,APC
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,752.69,,,,,,,fee schedule,418.16,1025.56,APC
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,955.44,,,,,,,fee schedule,547.34,1342.4,
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,765.28,,,,,,,fee schedule,547.34,1342.4,
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1342.4,,,,,,,fee schedule,547.34,1342.4,
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1167.3,,,,,,,fee schedule,547.34,1342.4,
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.71,,,,,,,fee schedule,547.34,1342.4,APC
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,547.34,,,,,,,fee schedule,547.34,1342.4,APC
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,985.21,,,,,,,fee schedule,547.34,1342.4,APC
Pelvic control pelvic sling,L2580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,930.96,,,,,,,fee schedule,533.32,1308.01,
Pelvic control pelvic sling,L2580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,745.68,,,,,,,fee schedule,533.32,1308.01,
Pelvic control pelvic sling,L2580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1308.01,,,,,,,fee schedule,533.32,1308.01,
Pelvic control pelvic sling,L2580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1137.4,,,,,,,fee schedule,533.32,1308.01,
Pelvic control pelvic sling,L2580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,559.99,,,,,,,fee schedule,533.32,1308.01,APC
Pelvic control pelvic sling,L2580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,533.32,,,,,,,fee schedule,533.32,1308.01,APC
Pelvic control pelvic sling,L2580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,959.98,,,,,,,fee schedule,533.32,1308.01,APC
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,457.55,,,,,,,fee schedule,262.12,642.86,
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,366.49,,,,,,,fee schedule,262.12,642.86,
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,642.86,,,,,,,fee schedule,262.12,642.86,
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,559.01,,,,,,,fee schedule,262.12,642.86,
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,275.23,,,,,,,fee schedule,262.12,642.86,APC
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,262.12,,,,,,,fee schedule,262.12,642.86,APC
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,471.82,,,,,,,fee schedule,262.12,642.86,APC
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,505.59,,,,,,,fee schedule,289.65,710.36,
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,404.96,,,,,,,fee schedule,289.65,710.36,
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,710.36,,,,,,,fee schedule,289.65,710.36,
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,617.7,,,,,,,fee schedule,289.65,710.36,
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,304.13,,,,,,,fee schedule,289.65,710.36,APC
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,289.65,,,,,,,fee schedule,289.65,710.36,APC
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,521.37,,,,,,,fee schedule,289.65,710.36,APC
Pelvic control hip heavy dut,L2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,536.35,,,,,,,fee schedule,307.25,753.57,
Pelvic control hip heavy dut,L2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,429.6,,,,,,,fee schedule,307.25,753.57,
Pelvic control hip heavy dut,L2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,753.57,,,,,,,fee schedule,307.25,753.57,
Pelvic control hip heavy dut,L2620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,655.28,,,,,,,fee schedule,307.25,753.57,
Pelvic control hip heavy dut,L2620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,322.61,,,,,,,fee schedule,307.25,753.57,APC
Pelvic control hip heavy dut,L2620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,307.25,,,,,,,fee schedule,307.25,753.57,APC
Pelvic control hip heavy dut,L2620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,553.05,,,,,,,fee schedule,307.25,753.57,APC
Hip joint adjustable flexion,L2622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,682.66,,,,,,,fee schedule,391.07,959.15,
Hip joint adjustable flexion,L2622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,546.8,,,,,,,fee schedule,391.07,959.15,
Hip joint adjustable flexion,L2622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,959.15,,,,,,,fee schedule,391.07,959.15,
Hip joint adjustable flexion,L2622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,834.04,,,,,,,fee schedule,391.07,959.15,
Hip joint adjustable flexion,L2622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.62,,,,,,,fee schedule,391.07,959.15,APC
Hip joint adjustable flexion,L2622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,391.07,,,,,,,fee schedule,391.07,959.15,APC
Hip joint adjustable flexion,L2622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,703.93,,,,,,,fee schedule,391.07,959.15,APC
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,837.07,,,,,,,fee schedule,479.52,1176.09,
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.48,,,,,,,fee schedule,479.52,1176.09,
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1176.09,,,,,,,fee schedule,479.52,1176.09,
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1022.69,,,,,,,fee schedule,479.52,1176.09,
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,503.5,,,,,,,fee schedule,479.52,1176.09,APC
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,479.52,,,,,,,fee schedule,479.52,1176.09,APC
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,863.14,,,,,,,fee schedule,479.52,1176.09,APC
Plastic mold recipro hip & c,L2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4585.07,,,,,,,fee schedule,2626.58,6442.06,
Plastic mold recipro hip & c,L2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3672.53,,,,,,,fee schedule,2626.58,6442.06,
Plastic mold recipro hip & c,L2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6442.06,,,,,,,fee schedule,2626.58,6442.06,
Plastic mold recipro hip & c,L2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5601.79,,,,,,,fee schedule,2626.58,6442.06,
Plastic mold recipro hip & c,L2627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2757.91,,,,,,,fee schedule,2626.58,6442.06,APC
Plastic mold recipro hip & c,L2627,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2626.58,,,,,,,fee schedule,2626.58,6442.06,APC
Plastic mold recipro hip & c,L2627,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4727.84,,,,,,,fee schedule,2626.58,6442.06,APC
Metal frame recipro hip & ca,L2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3360.76,,,,,,,fee schedule,1925.23,4721.9,
Metal frame recipro hip & ca,L2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2691.89,,,,,,,fee schedule,1925.23,4721.9,
Metal frame recipro hip & ca,L2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4721.9,,,,,,,fee schedule,1925.23,4721.9,
Metal frame recipro hip & ca,L2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4106,,,,,,,fee schedule,1925.23,4721.9,
Metal frame recipro hip & ca,L2628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2021.49,,,,,,,fee schedule,1925.23,4721.9,APC
Metal frame recipro hip & ca,L2628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1925.23,,,,,,,fee schedule,1925.23,4721.9,APC
Metal frame recipro hip & ca,L2628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3465.41,,,,,,,fee schedule,1925.23,4721.9,APC
Pelvic control band & belt u,L2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,496.72,,,,,,,fee schedule,284.55,697.9,
Pelvic control band & belt u,L2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,397.86,,,,,,,fee schedule,284.55,697.9,
Pelvic control band & belt u,L2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,697.9,,,,,,,fee schedule,284.55,697.9,
Pelvic control band & belt u,L2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,606.87,,,,,,,fee schedule,284.55,697.9,
Pelvic control band & belt u,L2630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,298.78,,,,,,,fee schedule,284.55,697.9,APC
Pelvic control band & belt u,L2630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,284.55,,,,,,,fee schedule,284.55,697.9,APC
Pelvic control band & belt u,L2630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,512.19,,,,,,,fee schedule,284.55,697.9,APC
Pelvic control band & belt b,L2640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,674.12,,,,,,,fee schedule,386.17,947.14,
Pelvic control band & belt b,L2640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,539.95,,,,,,,fee schedule,386.17,947.14,
Pelvic control band & belt b,L2640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,947.14,,,,,,,fee schedule,386.17,947.14,
Pelvic control band & belt b,L2640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,823.6,,,,,,,fee schedule,386.17,947.14,
Pelvic control band & belt b,L2640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,405.48,,,,,,,fee schedule,386.17,947.14,APC
Pelvic control band & belt b,L2640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,386.17,,,,,,,fee schedule,386.17,947.14,APC
Pelvic control band & belt b,L2640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,695.11,,,,,,,fee schedule,386.17,947.14,APC
Pelv & thor control gluteal,L2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,296.86,,,,,,,fee schedule,170.06,417.09,
Pelv & thor control gluteal,L2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,237.78,,,,,,,fee schedule,170.06,417.09,
Pelv & thor control gluteal,L2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,417.09,,,,,,,fee schedule,170.06,417.09,
Pelv & thor control gluteal,L2650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,362.69,,,,,,,fee schedule,170.06,417.09,
Pelv & thor control gluteal,L2650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.56,,,,,,,fee schedule,170.06,417.09,APC
Pelv & thor control gluteal,L2650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,170.06,,,,,,,fee schedule,170.06,417.09,APC
Pelv & thor control gluteal,L2650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,306.11,,,,,,,fee schedule,170.06,417.09,APC
Thoracic control thoracic ba,L2660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,384.4,,,,,,,fee schedule,220.2,540.09,
Thoracic control thoracic ba,L2660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,307.9,,,,,,,fee schedule,220.2,540.09,
Thoracic control thoracic ba,L2660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,540.09,,,,,,,fee schedule,220.2,540.09,
Thoracic control thoracic ba,L2660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,469.64,,,,,,,fee schedule,220.2,540.09,
Thoracic control thoracic ba,L2660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,231.21,,,,,,,fee schedule,220.2,540.09,APC
Thoracic control thoracic ba,L2660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,220.2,,,,,,,fee schedule,220.2,540.09,APC
Thoracic control thoracic ba,L2660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,396.36,,,,,,,fee schedule,220.2,540.09,APC
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.17,,,,,,,fee schedule,196.02,480.76,
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,274.07,,,,,,,fee schedule,196.02,480.76,
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,480.76,,,,,,,fee schedule,196.02,480.76,
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,418.05,,,,,,,fee schedule,196.02,480.76,
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,205.82,,,,,,,fee schedule,196.02,480.76,APC
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,196.02,,,,,,,fee schedule,196.02,480.76,APC
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,352.84,,,,,,,fee schedule,196.02,480.76,APC
Thorac cont lat support upri,L2680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,313.92,,,,,,,fee schedule,179.82,441.06,
Thorac cont lat support upri,L2680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.44,,,,,,,fee schedule,179.82,441.06,
Thorac cont lat support upri,L2680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,441.06,,,,,,,fee schedule,179.82,441.06,
Thorac cont lat support upri,L2680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,383.53,,,,,,,fee schedule,179.82,441.06,
Thorac cont lat support upri,L2680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,188.81,,,,,,,fee schedule,179.82,441.06,APC
Thorac cont lat support upri,L2680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,179.82,,,,,,,fee schedule,179.82,441.06,APC
Thorac cont lat support upri,L2680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,323.68,,,,,,,fee schedule,179.82,441.06,APC
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,167.65,,,,,,,fee schedule,96.05,235.55,
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.29,,,,,,,fee schedule,96.05,235.55,
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,235.55,,,,,,,fee schedule,96.05,235.55,
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,204.83,,,,,,,fee schedule,96.05,235.55,
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.85,,,,,,,fee schedule,96.05,235.55,APC
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96.05,,,,,,,fee schedule,96.05,235.55,APC
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,172.89,,,,,,,fee schedule,96.05,235.55,APC
Carbon graphite lamination,L2755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,280.3,,,,,,,fee schedule,160.58,393.83,
Carbon graphite lamination,L2755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,224.52,,,,,,,fee schedule,160.58,393.83,
Carbon graphite lamination,L2755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,393.83,,,,,,,fee schedule,160.58,393.83,
Carbon graphite lamination,L2755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,342.46,,,,,,,fee schedule,160.58,393.83,
Carbon graphite lamination,L2755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.61,,,,,,,fee schedule,160.58,393.83,APC
Carbon graphite lamination,L2755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,160.58,,,,,,,fee schedule,160.58,393.83,APC
Carbon graphite lamination,L2755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,289.04,,,,,,,fee schedule,160.58,393.83,APC
Extension per extension per,L2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.87,,,,,,,fee schedule,69.82,171.24,
Extension per extension per,L2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.62,,,,,,,fee schedule,69.82,171.24,
Extension per extension per,L2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.24,,,,,,,fee schedule,69.82,171.24,
Extension per extension per,L2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.9,,,,,,,fee schedule,69.82,171.24,
Extension per extension per,L2760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.31,,,,,,,fee schedule,69.82,171.24,APC
Extension per extension per,L2760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,69.82,,,,,,,fee schedule,69.82,171.24,APC
Extension per extension per,L2760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,125.68,,,,,,,fee schedule,69.82,171.24,APC
Ortho sidebar disconnect,L2768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.49,,,,,,,fee schedule,160.11,392.68,
Ortho sidebar disconnect,L2768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.86,,,,,,,fee schedule,160.11,392.68,
Ortho sidebar disconnect,L2768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.68,,,,,,,fee schedule,160.11,392.68,
Ortho sidebar disconnect,L2768,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,341.46,,,,,,,fee schedule,160.11,392.68,
Ortho sidebar disconnect,L2768,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.12,,,,,,,fee schedule,160.11,392.68,APC
Ortho sidebar disconnect,L2768,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,160.11,,,,,,,fee schedule,160.11,392.68,APC
Ortho sidebar disconnect,L2768,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,288.2,,,,,,,fee schedule,160.11,392.68,APC
Non-corrosive finish,L2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.75,,,,,,,fee schedule,77.77,190.73,
Non-corrosive finish,L2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.73,,,,,,,fee schedule,77.77,190.73,
Non-corrosive finish,L2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.73,,,,,,,fee schedule,77.77,190.73,
Non-corrosive finish,L2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.85,,,,,,,fee schedule,77.77,190.73,
Non-corrosive finish,L2780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.66,,,,,,,fee schedule,77.77,190.73,APC
Non-corrosive finish,L2780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,77.77,,,,,,,fee schedule,77.77,190.73,APC
Non-corrosive finish,L2780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,139.99,,,,,,,fee schedule,77.77,190.73,APC
Drop lock retainer each,L2785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.56,,,,,,,fee schedule,36.42,89.31,
Drop lock retainer each,L2785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.91,,,,,,,fee schedule,36.42,89.31,
Drop lock retainer each,L2785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,89.31,,,,,,,fee schedule,36.42,89.31,
Drop lock retainer each,L2785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,77.66,,,,,,,fee schedule,36.42,89.31,
Drop lock retainer each,L2785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.24,,,,,,,fee schedule,36.42,89.31,APC
Drop lock retainer each,L2785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36.42,,,,,,,fee schedule,36.42,89.31,APC
Drop lock retainer each,L2785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65.56,,,,,,,fee schedule,36.42,89.31,APC
Knee control full kneecap,L2795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.94,,,,,,,fee schedule,100.8,247.19,
Knee control full kneecap,L2795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.92,,,,,,,fee schedule,100.8,247.19,
Knee control full kneecap,L2795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,247.19,,,,,,,fee schedule,100.8,247.19,
Knee control full kneecap,L2795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.95,,,,,,,fee schedule,100.8,247.19,
Knee control full kneecap,L2795,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.84,,,,,,,fee schedule,100.8,247.19,APC
Knee control full kneecap,L2795,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,100.8,,,,,,,fee schedule,100.8,247.19,APC
Knee control full kneecap,L2795,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,181.44,,,,,,,fee schedule,100.8,247.19,APC
Knee cap medial or lateral p,L2800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,216.03,,,,,,,fee schedule,123.76,303.53,
Knee cap medial or lateral p,L2800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,173.04,,,,,,,fee schedule,123.76,303.53,
Knee cap medial or lateral p,L2800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,303.53,,,,,,,fee schedule,123.76,303.53,
Knee cap medial or lateral p,L2800,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,263.94,,,,,,,fee schedule,123.76,303.53,
Knee cap medial or lateral p,L2800,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.95,,,,,,,fee schedule,123.76,303.53,APC
Knee cap medial or lateral p,L2800,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,123.76,,,,,,,fee schedule,123.76,303.53,APC
Knee cap medial or lateral p,L2800,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,222.77,,,,,,,fee schedule,123.76,303.53,APC
Knee control condylar pad,L2810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.22,,,,,,,fee schedule,100.38,246.19,
Knee control condylar pad,L2810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.35,,,,,,,fee schedule,100.38,246.19,
Knee control condylar pad,L2810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.19,,,,,,,fee schedule,100.38,246.19,
Knee control condylar pad,L2810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.08,,,,,,,fee schedule,100.38,246.19,
Knee control condylar pad,L2810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.4,,,,,,,fee schedule,100.38,246.19,APC
Knee control condylar pad,L2810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,100.38,,,,,,,fee schedule,100.38,246.19,APC
Knee control condylar pad,L2810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,180.68,,,,,,,fee schedule,100.38,246.19,APC
Soft interface below knee se,L2820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.18,,,,,,,fee schedule,99.79,244.73,
Soft interface below knee se,L2820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.52,,,,,,,fee schedule,99.79,244.73,
Soft interface below knee se,L2820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.73,,,,,,,fee schedule,99.79,244.73,
Soft interface below knee se,L2820,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.81,,,,,,,fee schedule,99.79,244.73,
Soft interface below knee se,L2820,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.78,,,,,,,fee schedule,99.79,244.73,APC
Soft interface below knee se,L2820,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,99.79,,,,,,,fee schedule,99.79,244.73,APC
Soft interface below knee se,L2820,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,179.62,,,,,,,fee schedule,99.79,244.73,APC
Soft interface above knee se,L2830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,188.46,,,,,,,fee schedule,107.96,264.79,
Soft interface above knee se,L2830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.95,,,,,,,fee schedule,107.96,264.79,
Soft interface above knee se,L2830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,264.79,,,,,,,fee schedule,107.96,264.79,
Soft interface above knee se,L2830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,230.25,,,,,,,fee schedule,107.96,264.79,
Soft interface above knee se,L2830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.36,,,,,,,fee schedule,107.96,264.79,APC
Soft interface above knee se,L2830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,107.96,,,,,,,fee schedule,107.96,264.79,APC
Soft interface above knee se,L2830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,194.33,,,,,,,fee schedule,107.96,264.79,APC
Tibial length sock fx or equ,L2840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.51,,,,,,,fee schedule,53.02,129.97,
Tibial length sock fx or equ,L2840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.1,,,,,,,fee schedule,53.02,129.97,
Tibial length sock fx or equ,L2840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.97,,,,,,,fee schedule,53.02,129.97,
Tibial length sock fx or equ,L2840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.02,,,,,,,fee schedule,53.02,129.97,
Tibial length sock fx or equ,L2840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.67,,,,,,,fee schedule,53.02,129.97,APC
Tibial length sock fx or equ,L2840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.02,,,,,,,fee schedule,53.02,129.97,APC
Tibial length sock fx or equ,L2840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95.44,,,,,,,fee schedule,53.02,129.97,APC
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,129.77,,,,,,,fee schedule,74.34,182.33,
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.95,,,,,,,fee schedule,74.34,182.33,
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.33,,,,,,,fee schedule,74.34,182.33,
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.55,,,,,,,fee schedule,74.34,182.33,
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.06,,,,,,,fee schedule,74.34,182.33,APC
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.34,,,,,,,fee schedule,74.34,182.33,APC
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,133.81,,,,,,,fee schedule,74.34,182.33,APC
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,673.92,,,,,,,fee schedule,386.06,946.86,
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,539.79,,,,,,,fee schedule,386.06,946.86,
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,946.86,,,,,,,fee schedule,386.06,946.86,
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,823.36,,,,,,,fee schedule,386.06,946.86,
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,405.36,,,,,,,fee schedule,386.06,946.86,APC
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,386.06,,,,,,,fee schedule,386.06,946.86,APC
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,694.91,,,,,,,fee schedule,386.06,946.86,APC
Foot insert remov molded spe,L3001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.77,,,,,,,fee schedule,162.56,398.69,
Foot insert remov molded spe,L3001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.29,,,,,,,fee schedule,162.56,398.69,
Foot insert remov molded spe,L3001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,398.69,,,,,,,fee schedule,162.56,398.69,
Foot insert remov molded spe,L3001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,346.69,,,,,,,fee schedule,162.56,398.69,
Foot insert remov molded spe,L3001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.69,,,,,,,fee schedule,162.56,398.69,APC
Foot insert remov molded spe,L3001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,162.56,,,,,,,fee schedule,162.56,398.69,APC
Foot insert remov molded spe,L3001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,292.61,,,,,,,fee schedule,162.56,398.69,APC
Foot insert plastazote or eq,L3002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.46,,,,,,,fee schedule,198.48,486.78,
Foot insert plastazote or eq,L3002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.51,,,,,,,fee schedule,198.48,486.78,
Foot insert plastazote or eq,L3002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,486.78,,,,,,,fee schedule,198.48,486.78,
Foot insert plastazote or eq,L3002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.29,,,,,,,fee schedule,198.48,486.78,
Foot insert plastazote or eq,L3002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.4,,,,,,,fee schedule,198.48,486.78,APC
Foot insert plastazote or eq,L3002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.48,,,,,,,fee schedule,198.48,486.78,APC
Foot insert plastazote or eq,L3002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,357.26,,,,,,,fee schedule,198.48,486.78,APC
Foot insert silicone gel eac,L3003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,373.74,,,,,,,fee schedule,214.11,525.1,
Foot insert silicone gel eac,L3003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.35,,,,,,,fee schedule,214.11,525.1,
Foot insert silicone gel eac,L3003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,525.1,,,,,,,fee schedule,214.11,525.1,
Foot insert silicone gel eac,L3003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,456.61,,,,,,,fee schedule,214.11,525.1,
Foot insert silicone gel eac,L3003,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.82,,,,,,,fee schedule,214.11,525.1,APC
Foot insert silicone gel eac,L3003,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,214.11,,,,,,,fee schedule,214.11,525.1,APC
Foot insert silicone gel eac,L3003,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,385.4,,,,,,,fee schedule,214.11,525.1,APC
Foot longitudinal arch suppo,L3010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,373.74,,,,,,,fee schedule,214.11,525.1,
Foot longitudinal arch suppo,L3010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,299.35,,,,,,,fee schedule,214.11,525.1,
Foot longitudinal arch suppo,L3010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,525.1,,,,,,,fee schedule,214.11,525.1,
Foot longitudinal arch suppo,L3010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,456.61,,,,,,,fee schedule,214.11,525.1,
Foot longitudinal arch suppo,L3010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.82,,,,,,,fee schedule,214.11,525.1,APC
Foot longitudinal arch suppo,L3010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,214.11,,,,,,,fee schedule,214.11,525.1,APC
Foot longitudinal arch suppo,L3010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,385.4,,,,,,,fee schedule,214.11,525.1,APC
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,425.62,,,,,,,fee schedule,243.83,598,
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,340.91,,,,,,,fee schedule,243.83,598,
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,598,,,,,,,fee schedule,243.83,598,
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,520,,,,,,,fee schedule,243.83,598,
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.02,,,,,,,fee schedule,243.83,598,APC
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,243.83,,,,,,,fee schedule,243.83,598,APC
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,438.89,,,,,,,fee schedule,243.83,598,APC
Foot arch support remov prem,L3030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.68,,,,,,,fee schedule,93.77,229.98,
Foot arch support remov prem,L3030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.11,,,,,,,fee schedule,93.77,229.98,
Foot arch support remov prem,L3030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.98,,,,,,,fee schedule,93.77,229.98,
Foot arch support remov prem,L3030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.98,,,,,,,fee schedule,93.77,229.98,
Foot arch support remov prem,L3030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.46,,,,,,,fee schedule,93.77,229.98,APC
Foot arch support remov prem,L3030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,93.77,,,,,,,fee schedule,93.77,229.98,APC
Foot arch support remov prem,L3030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,168.79,,,,,,,fee schedule,93.77,229.98,APC
Foot lamin/prepreg composite,L3031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.76,,,,,,,fee schedule,150.51,369.18,
Foot lamin/prepreg composite,L3031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,210.47,,,,,,,fee schedule,150.51,369.18,
Foot lamin/prepreg composite,L3031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,369.18,,,,,,,fee schedule,150.51,369.18,
Foot lamin/prepreg composite,L3031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,321.03,,,,,,,fee schedule,150.51,369.18,
Foot lamin/prepreg composite,L3031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,158.04,,,,,,,fee schedule,150.51,369.18,APC
Foot lamin/prepreg composite,L3031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150.51,,,,,,,fee schedule,150.51,369.18,APC
Foot lamin/prepreg composite,L3031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270.92,,,,,,,fee schedule,150.51,369.18,APC
Ft arch suprt premold longit,L3040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.98,,,,,,,fee schedule,57.84,141.88,
Ft arch suprt premold longit,L3040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.88,,,,,,,fee schedule,57.84,141.88,
Ft arch suprt premold longit,L3040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.88,,,,,,,fee schedule,57.84,141.88,
Ft arch suprt premold longit,L3040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.37,,,,,,,fee schedule,57.84,141.88,
Ft arch suprt premold longit,L3040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.73,,,,,,,fee schedule,57.84,141.88,APC
Ft arch suprt premold longit,L3040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57.84,,,,,,,fee schedule,57.84,141.88,APC
Ft arch suprt premold longit,L3040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.11,,,,,,,fee schedule,57.84,141.88,APC
Foot arch supp premold metat,L3050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.98,,,,,,,fee schedule,57.84,141.88,
Foot arch supp premold metat,L3050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.88,,,,,,,fee schedule,57.84,141.88,
Foot arch supp premold metat,L3050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.88,,,,,,,fee schedule,57.84,141.88,
Foot arch supp premold metat,L3050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.37,,,,,,,fee schedule,57.84,141.88,
Foot arch supp premold metat,L3050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.73,,,,,,,fee schedule,57.84,141.88,APC
Foot arch supp premold metat,L3050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57.84,,,,,,,fee schedule,57.84,141.88,APC
Foot arch supp premold metat,L3050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.11,,,,,,,fee schedule,57.84,141.88,APC
Foot arch supp longitud/meta,L3060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.21,,,,,,,fee schedule,90.65,222.28,
Foot arch supp longitud/meta,L3060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.72,,,,,,,fee schedule,90.65,222.28,
Foot arch supp longitud/meta,L3060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.28,,,,,,,fee schedule,90.65,222.28,
Foot arch supp longitud/meta,L3060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.29,,,,,,,fee schedule,90.65,222.28,
Foot arch supp longitud/meta,L3060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.18,,,,,,,fee schedule,90.65,222.28,APC
Foot arch supp longitud/meta,L3060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,90.65,,,,,,,fee schedule,90.65,222.28,APC
Foot arch supp longitud/meta,L3060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,163.17,,,,,,,fee schedule,90.65,222.28,APC
Arch suprt att to sho longit,L3070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.2,,,,,,,fee schedule,39.08,95.82,
Arch suprt att to sho longit,L3070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.62,,,,,,,fee schedule,39.08,95.82,
Arch suprt att to sho longit,L3070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.82,,,,,,,fee schedule,39.08,95.82,
Arch suprt att to sho longit,L3070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.32,,,,,,,fee schedule,39.08,95.82,
Arch suprt att to sho longit,L3070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.03,,,,,,,fee schedule,39.08,95.82,APC
Arch suprt att to sho longit,L3070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.08,,,,,,,fee schedule,39.08,95.82,APC
Arch suprt att to sho longit,L3070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.34,,,,,,,fee schedule,39.08,95.82,APC
Arch supp att to shoe metata,L3080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.2,,,,,,,fee schedule,39.08,95.82,
Arch supp att to shoe metata,L3080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.62,,,,,,,fee schedule,39.08,95.82,
Arch supp att to shoe metata,L3080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.82,,,,,,,fee schedule,39.08,95.82,
Arch supp att to shoe metata,L3080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.32,,,,,,,fee schedule,39.08,95.82,
Arch supp att to shoe metata,L3080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.03,,,,,,,fee schedule,39.08,95.82,APC
Arch supp att to shoe metata,L3080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.08,,,,,,,fee schedule,39.08,95.82,APC
Arch supp att to shoe metata,L3080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.34,,,,,,,fee schedule,39.08,95.82,APC
Arch supp att to shoe long/m,L3090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.33,,,,,,,fee schedule,50.02,122.69,
Arch supp att to shoe long/m,L3090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.95,,,,,,,fee schedule,50.02,122.69,
Arch supp att to shoe long/m,L3090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.69,,,,,,,fee schedule,50.02,122.69,
Arch supp att to shoe long/m,L3090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.69,,,,,,,fee schedule,50.02,122.69,
Arch supp att to shoe long/m,L3090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.52,,,,,,,fee schedule,50.02,122.69,APC
Arch supp att to shoe long/m,L3090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50.02,,,,,,,fee schedule,50.02,122.69,APC
Arch supp att to shoe long/m,L3090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,90.04,,,,,,,fee schedule,50.02,122.69,APC
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.79,,,,,,,fee schedule,53.16,130.36,
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.32,,,,,,,fee schedule,53.16,130.36,
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.36,,,,,,,fee schedule,53.16,130.36,
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.36,,,,,,,fee schedule,53.16,130.36,
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.82,,,,,,,fee schedule,53.16,130.36,APC
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.16,,,,,,,fee schedule,53.16,130.36,APC
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95.69,,,,,,,fee schedule,53.16,130.36,APC
Abduction rotation bar shoe,L3140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.96,,,,,,,fee schedule,109.41,268.31,
Abduction rotation bar shoe,L3140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.96,,,,,,,fee schedule,109.41,268.31,
Abduction rotation bar shoe,L3140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,268.31,,,,,,,fee schedule,109.41,268.31,
Abduction rotation bar shoe,L3140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,233.31,,,,,,,fee schedule,109.41,268.31,
Abduction rotation bar shoe,L3140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.88,,,,,,,fee schedule,109.41,268.31,APC
Abduction rotation bar shoe,L3140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,109.41,,,,,,,fee schedule,109.41,268.31,APC
Abduction rotation bar shoe,L3140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,196.94,,,,,,,fee schedule,109.41,268.31,APC
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.64,,,,,,,fee schedule,100.05,245.38,
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.89,,,,,,,fee schedule,100.05,245.38,
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,245.38,,,,,,,fee schedule,100.05,245.38,
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,213.37,,,,,,,fee schedule,100.05,245.38,
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.05,,,,,,,fee schedule,100.05,245.38,APC
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,100.05,,,,,,,fee schedule,100.05,245.38,APC
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,180.09,,,,,,,fee schedule,100.05,245.38,APC
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.12,,,,,,,fee schedule,62.52,153.32,
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.4,,,,,,,fee schedule,62.52,153.32,
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.32,,,,,,,fee schedule,62.52,153.32,
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.32,,,,,,,fee schedule,62.52,153.32,
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.65,,,,,,,fee schedule,62.52,153.32,APC
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.52,,,,,,,fee schedule,62.52,153.32,APC
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,112.54,,,,,,,fee schedule,62.52,153.32,APC
Oxford w supinat/pronat inf,L3201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.83,,,,,,,fee schedule,68.07,119.4,
Oxford w supinat/pronat inf,L3201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.98,,,,,,,fee schedule,68.07,119.4,
Oxford w supinat/pronat inf,L3201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.07,,,,,,,fee schedule,68.07,119.4,
Oxford w supinat/pronat inf,L3201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.4,,,,,,,fee schedule,68.07,119.4,
Oxford w/ supinat/pronator c,L3202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,101.88,,,,,,,fee schedule,66.79,117.16,
Oxford w/ supinat/pronator c,L3202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.39,,,,,,,fee schedule,66.79,117.16,
Oxford w/ supinat/pronator c,L3202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.79,,,,,,,fee schedule,66.79,117.16,
Oxford w/ supinat/pronator c,L3202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.16,,,,,,,fee schedule,66.79,117.16,
Oxford w/ supinator/pronator,L3203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.96,,,,,,,fee schedule,64.88,113.8,
Oxford w/ supinator/pronator,L3203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81,,,,,,,fee schedule,64.88,113.8,
Oxford w/ supinator/pronator,L3203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.88,,,,,,,fee schedule,64.88,113.8,
Oxford w/ supinator/pronator,L3203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.8,,,,,,,fee schedule,64.88,113.8,
Hightop w/ supp/pronator inf,L3204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,98.96,,,,,,,fee schedule,64.88,113.8,
Hightop w/ supp/pronator inf,L3204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81,,,,,,,fee schedule,64.88,113.8,
Hightop w/ supp/pronator inf,L3204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.88,,,,,,,fee schedule,64.88,113.8,
Hightop w/ supp/pronator inf,L3204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,113.8,,,,,,,fee schedule,64.88,113.8,
Hightop w/ supp/pronator chi,L3206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.85,,,,,,,fee schedule,67.43,118.28,
Hightop w/ supp/pronator chi,L3206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.18,,,,,,,fee schedule,67.43,118.28,
Hightop w/ supp/pronator chi,L3206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.43,,,,,,,fee schedule,67.43,118.28,
Hightop w/ supp/pronator chi,L3206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.28,,,,,,,fee schedule,67.43,118.28,
Hightop w/ supp/pronator jun,L3207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.83,,,,,,,fee schedule,68.73,120.55,
Hightop w/ supp/pronator jun,L3207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.8,,,,,,,fee schedule,68.73,120.55,
Hightop w/ supp/pronator jun,L3207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.73,,,,,,,fee schedule,68.73,120.55,
Hightop w/ supp/pronator jun,L3207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.55,,,,,,,fee schedule,68.73,120.55,
Surgical boot each infant,L3208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.87,,,,,,,fee schedule,35.97,63.1,
Surgical boot each infant,L3208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.91,,,,,,,fee schedule,35.97,63.1,
Surgical boot each infant,L3208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.97,,,,,,,fee schedule,35.97,63.1,
Surgical boot each infant,L3208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,63.1,,,,,,,fee schedule,35.97,63.1,
Surgical boot each child,L3209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.37,,,,,,,fee schedule,51.38,90.13,
Surgical boot each child,L3209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.15,,,,,,,fee schedule,51.38,90.13,
Surgical boot each child,L3209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.38,,,,,,,fee schedule,51.38,90.13,
Surgical boot each child,L3209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.13,,,,,,,fee schedule,51.38,90.13,
Surgical boot each junior,L3211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.29,,,,,,,fee schedule,54.6,95.78,
Surgical boot each junior,L3211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.17,,,,,,,fee schedule,54.6,95.78,
Surgical boot each junior,L3211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.6,,,,,,,fee schedule,54.6,95.78,
Surgical boot each junior,L3211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.78,,,,,,,fee schedule,54.6,95.78,
Benesch boot pair infant,L3212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.62,,,,,,,fee schedule,75.8,132.96,
Benesch boot pair infant,L3212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.63,,,,,,,fee schedule,75.8,132.96,
Benesch boot pair infant,L3212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.8,,,,,,,fee schedule,75.8,132.96,
Benesch boot pair infant,L3212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.96,,,,,,,fee schedule,75.8,132.96,
Benesch boot pair child,L3213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.12,,,,,,,fee schedule,91.86,161.14,
Benesch boot pair child,L3213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.69,,,,,,,fee schedule,91.86,161.14,
Benesch boot pair child,L3213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.86,,,,,,,fee schedule,91.86,161.14,
Benesch boot pair child,L3213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.14,,,,,,,fee schedule,91.86,161.14,
Benesch boot pair junior,L3214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.94,,,,,,,fee schedule,97.65,171.28,
Benesch boot pair junior,L3214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,121.91,,,,,,,fee schedule,97.65,171.28,
Benesch boot pair junior,L3214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,97.65,,,,,,,fee schedule,97.65,171.28,
Benesch boot pair junior,L3214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,171.28,,,,,,,fee schedule,97.65,171.28,
Orthopedic ftwear ladies oxf,L3215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.1,,,,,,,fee schedule,123.97,217.47,
Orthopedic ftwear ladies oxf,L3215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.78,,,,,,,fee schedule,123.97,217.47,
Orthopedic ftwear ladies oxf,L3215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.97,,,,,,,fee schedule,123.97,217.47,
Orthopedic ftwear ladies oxf,L3215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.47,,,,,,,fee schedule,123.97,217.47,
Orthoped ladies shoes dpth i,L3216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.28,,,,,,,fee schedule,150.32,263.67,
Orthoped ladies shoes dpth i,L3216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.67,,,,,,,fee schedule,150.32,263.67,
Orthoped ladies shoes dpth i,L3216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.32,,,,,,,fee schedule,150.32,263.67,
Orthoped ladies shoes dpth i,L3216,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.67,,,,,,,fee schedule,150.32,263.67,
Ladies shoes hightop depth i,L3217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,247.9,,,,,,,fee schedule,162.52,285.09,
Ladies shoes hightop depth i,L3217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.91,,,,,,,fee schedule,162.52,285.09,
Ladies shoes hightop depth i,L3217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,162.52,,,,,,,fee schedule,162.52,285.09,
Ladies shoes hightop depth i,L3217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,285.09,,,,,,,fee schedule,162.52,285.09,
Orthopedic mens shoes oxford,L3219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.6,,,,,,,fee schedule,139.38,244.49,
Orthopedic mens shoes oxford,L3219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.01,,,,,,,fee schedule,139.38,244.49,
Orthopedic mens shoes oxford,L3219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.38,,,,,,,fee schedule,139.38,244.49,
Orthopedic mens shoes oxford,L3219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.49,,,,,,,fee schedule,139.38,244.49,
Orthopedic mens shoes dpth i,L3221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,254.77,,,,,,,fee schedule,167.03,292.99,
Orthopedic mens shoes dpth i,L3221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,208.53,,,,,,,fee schedule,167.03,292.99,
Orthopedic mens shoes dpth i,L3221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,167.03,,,,,,,fee schedule,167.03,292.99,
Orthopedic mens shoes dpth i,L3221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,292.99,,,,,,,fee schedule,167.03,292.99,
Mens shoes hightop depth inl,L3222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,282.19,,,,,,,fee schedule,185,324.52,
Mens shoes hightop depth inl,L3222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,230.97,,,,,,,fee schedule,185,324.52,
Mens shoes hightop depth inl,L3222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185,,,,,,,fee schedule,185,324.52,
Mens shoes hightop depth inl,L3222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,324.52,,,,,,,fee schedule,185,324.52,
Woman's shoe oxford brace,L3224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,177.1,,,,,,,fee schedule,83.04,203.67,
Woman's shoe oxford brace,L3224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,144.96,,,,,,,fee schedule,83.04,203.67,
Woman's shoe oxford brace,L3224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,116.11,,,,,,,fee schedule,83.04,203.67,
Woman's shoe oxford brace,L3224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,203.67,,,,,,,fee schedule,83.04,203.67,
Woman's shoe oxford brace,L3224,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.19,,,,,,,fee schedule,83.04,203.67,APC
Woman's shoe oxford brace,L3224,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,83.04,,,,,,,fee schedule,83.04,203.67,APC
Woman's shoe oxford brace,L3224,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,149.47,,,,,,,fee schedule,83.04,203.67,APC
Man's shoe oxford brace,L3225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.44,,,,,,,fee schedule,90.7,222.46,
Man's shoe oxford brace,L3225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.33,,,,,,,fee schedule,90.7,222.46,
Man's shoe oxford brace,L3225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.82,,,,,,,fee schedule,90.7,222.46,
Man's shoe oxford brace,L3225,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.46,,,,,,,fee schedule,90.7,222.46,
Man's shoe oxford brace,L3225,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.24,,,,,,,fee schedule,90.7,222.46,APC
Man's shoe oxford brace,L3225,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,90.7,,,,,,,fee schedule,90.7,222.46,APC
Man's shoe oxford brace,L3225,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,163.26,,,,,,,fee schedule,90.7,222.46,APC
Custom shoes depth inlay,L3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,332.16,,,,,,,fee schedule,217.76,381.98,
Custom shoes depth inlay,L3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,271.87,,,,,,,fee schedule,217.76,381.98,
Custom shoes depth inlay,L3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,217.76,,,,,,,fee schedule,217.76,381.98,
Custom shoes depth inlay,L3230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,381.98,,,,,,,fee schedule,217.76,381.98,
Custom mold shoe remov prost,L3250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,645.74,,,,,,,fee schedule,423.35,742.6,
Custom mold shoe remov prost,L3250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,528.54,,,,,,,fee schedule,423.35,742.6,
Custom mold shoe remov prost,L3250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,423.35,,,,,,,fee schedule,423.35,742.6,
Custom mold shoe remov prost,L3250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.6,,,,,,,fee schedule,423.35,742.6,
Shoe molded to pt silicone s,L3251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,89.16,,,,,,,fee schedule,58.45,102.53,
Shoe molded to pt silicone s,L3251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.98,,,,,,,fee schedule,58.45,102.53,
Shoe molded to pt silicone s,L3251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.45,,,,,,,fee schedule,58.45,102.53,
Shoe molded to pt silicone s,L3251,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,102.53,,,,,,,fee schedule,58.45,102.53,
Shoe molded plastazote cust,L3252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,353.72,,,,,,,fee schedule,231.9,406.78,
Shoe molded plastazote cust,L3252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,289.52,,,,,,,fee schedule,231.9,406.78,
Shoe molded plastazote cust,L3252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,231.9,,,,,,,fee schedule,231.9,406.78,
Shoe molded plastazote cust,L3252,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,406.78,,,,,,,fee schedule,231.9,406.78,
Shoe molded plastazote cust,L3253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.17,,,,,,,fee schedule,57.8,101.4,
Shoe molded plastazote cust,L3253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,72.17,,,,,,,fee schedule,57.8,101.4,
Shoe molded plastazote cust,L3253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.8,,,,,,,fee schedule,57.8,101.4,
Shoe molded plastazote cust,L3253,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.4,,,,,,,fee schedule,57.8,101.4,
Orth foot add charge split s,L3257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.7,,,,,,,fee schedule,41.76,73.26,
Orth foot add charge split s,L3257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52.14,,,,,,,fee schedule,41.76,73.26,
Orth foot add charge split s,L3257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.76,,,,,,,fee schedule,41.76,73.26,
Orth foot add charge split s,L3257,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,73.26,,,,,,,fee schedule,41.76,73.26,
Ambulatory surgical boot eac,L3260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Ambulatory surgical boot eac,L3260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Ambulatory surgical boot eac,L3260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Ambulatory surgical boot eac,L3260,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Plastazote sandal each,L3265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.21,,,,,,,fee schedule,25.71,45.09,
Plastazote sandal each,L3265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.09,,,,,,,fee schedule,25.71,45.09,
Plastazote sandal each,L3265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.71,,,,,,,fee schedule,25.71,45.09,
Plastazote sandal each,L3265,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.09,,,,,,,fee schedule,25.71,45.09,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.7,,,,,,,fee schedule,64.1,157.21,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,111.89,,,,,,,fee schedule,64.1,157.21,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.62,,,,,,,fee schedule,64.1,157.21,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.21,,,,,,,fee schedule,64.1,157.21,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.3,,,,,,,fee schedule,64.1,157.21,APC
Sho lift taper to metatarsal,L3300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.1,,,,,,,fee schedule,64.1,157.21,APC
Sho lift taper to metatarsal,L3300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.38,,,,,,,fee schedule,64.1,157.21,APC
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,213.37,,,,,,,fee schedule,100.05,245.38,
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.64,,,,,,,fee schedule,100.05,245.38,
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.89,,,,,,,fee schedule,100.05,245.38,
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,245.38,,,,,,,fee schedule,100.05,245.38,
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.05,,,,,,,fee schedule,100.05,245.38,APC
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,100.05,,,,,,,fee schedule,100.05,245.38,APC
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,180.09,,,,,,,fee schedule,100.05,245.38,APC
Shoe lift elev heel/sole cor,L3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,239.08,,,,,,,fee schedule,156.74,274.94,
Shoe lift elev heel/sole cor,L3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,195.69,,,,,,,fee schedule,156.74,274.94,
Shoe lift elev heel/sole cor,L3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156.74,,,,,,,fee schedule,156.74,274.94,
Shoe lift elev heel/sole cor,L3320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,274.94,,,,,,,fee schedule,156.74,274.94,
Lifts elevation metal extens,L3330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1483.34,,,,,,,fee schedule,695.51,1705.84,
Lifts elevation metal extens,L3330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1214.11,,,,,,,fee schedule,695.51,1705.84,
Lifts elevation metal extens,L3330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,972.48,,,,,,,fee schedule,695.51,1705.84,
Lifts elevation metal extens,L3330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1705.84,,,,,,,fee schedule,695.51,1705.84,
Lifts elevation metal extens,L3330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,730.29,,,,,,,fee schedule,695.51,1705.84,APC
Lifts elevation metal extens,L3330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,695.51,,,,,,,fee schedule,695.51,1705.84,APC
Lifts elevation metal extens,L3330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1251.92,,,,,,,fee schedule,695.51,1705.84,APC
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,193.29,,,,,,,fee schedule,90.65,222.28,
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,158.21,,,,,,,fee schedule,90.65,222.28,
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.72,,,,,,,fee schedule,90.65,222.28,
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,222.28,,,,,,,fee schedule,90.65,222.28,
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.18,,,,,,,fee schedule,90.65,222.28,APC
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,90.65,,,,,,,fee schedule,90.65,222.28,APC
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,163.17,,,,,,,fee schedule,90.65,222.28,APC
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.96,,,,,,,fee schedule,46.87,114.95,
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81.82,,,,,,,fee schedule,46.87,114.95,
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.53,,,,,,,fee schedule,46.87,114.95,
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.95,,,,,,,fee schedule,46.87,114.95,
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.21,,,,,,,fee schedule,46.87,114.95,APC
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46.87,,,,,,,fee schedule,46.87,114.95,APC
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84.37,,,,,,,fee schedule,46.87,114.95,APC
Shoe wedge sach,L3340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,223.41,,,,,,,fee schedule,104.74,256.92,
Shoe wedge sach,L3340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.86,,,,,,,fee schedule,104.74,256.92,
Shoe wedge sach,L3340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.47,,,,,,,fee schedule,104.74,256.92,
Shoe wedge sach,L3340,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,256.92,,,,,,,fee schedule,104.74,256.92,
Shoe wedge sach,L3340,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.98,,,,,,,fee schedule,104.74,256.92,APC
Shoe wedge sach,L3340,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.74,,,,,,,fee schedule,104.74,256.92,APC
Shoe wedge sach,L3340,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,188.53,,,,,,,fee schedule,104.74,256.92,APC
Shoe heel wedge,L3350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.96,,,,,,,fee schedule,28.11,68.95,
Shoe heel wedge,L3350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.08,,,,,,,fee schedule,28.11,68.95,
Shoe heel wedge,L3350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.31,,,,,,,fee schedule,28.11,68.95,
Shoe heel wedge,L3350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.95,,,,,,,fee schedule,28.11,68.95,
Shoe heel wedge,L3350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.52,,,,,,,fee schedule,28.11,68.95,APC
Shoe heel wedge,L3350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.11,,,,,,,fee schedule,28.11,68.95,APC
Shoe heel wedge,L3350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.6,,,,,,,fee schedule,28.11,68.95,APC
Shoe sole wedge outside sole,L3360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,93.29,,,,,,,fee schedule,43.76,107.28,
Shoe sole wedge outside sole,L3360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76.36,,,,,,,fee schedule,43.76,107.28,
Shoe sole wedge outside sole,L3360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,61.16,,,,,,,fee schedule,43.76,107.28,
Shoe sole wedge outside sole,L3360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,107.28,,,,,,,fee schedule,43.76,107.28,
Shoe sole wedge outside sole,L3360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.95,,,,,,,fee schedule,43.76,107.28,APC
Shoe sole wedge outside sole,L3360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43.76,,,,,,,fee schedule,43.76,107.28,APC
Shoe sole wedge outside sole,L3360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78.77,,,,,,,fee schedule,43.76,107.28,APC
Shoe sole wedge between sole,L3370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130,,,,,,,fee schedule,60.96,149.5,
Shoe sole wedge between sole,L3370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.41,,,,,,,fee schedule,60.96,149.5,
Shoe sole wedge between sole,L3370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.23,,,,,,,fee schedule,60.96,149.5,
Shoe sole wedge between sole,L3370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.5,,,,,,,fee schedule,60.96,149.5,
Shoe sole wedge between sole,L3370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.01,,,,,,,fee schedule,60.96,149.5,APC
Shoe sole wedge between sole,L3370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.96,,,,,,,fee schedule,60.96,149.5,APC
Shoe sole wedge between sole,L3370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,109.73,,,,,,,fee schedule,60.96,149.5,APC
Shoe clubfoot wedge,L3380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130,,,,,,,fee schedule,60.96,149.5,
Shoe clubfoot wedge,L3380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.41,,,,,,,fee schedule,60.96,149.5,
Shoe clubfoot wedge,L3380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.23,,,,,,,fee schedule,60.96,149.5,
Shoe clubfoot wedge,L3380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.5,,,,,,,fee schedule,60.96,149.5,
Shoe clubfoot wedge,L3380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.01,,,,,,,fee schedule,60.96,149.5,APC
Shoe clubfoot wedge,L3380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.96,,,,,,,fee schedule,60.96,149.5,APC
Shoe clubfoot wedge,L3380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,109.73,,,,,,,fee schedule,60.96,149.5,APC
Shoe outflare wedge,L3390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130,,,,,,,fee schedule,60.96,149.5,
Shoe outflare wedge,L3390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.41,,,,,,,fee schedule,60.96,149.5,
Shoe outflare wedge,L3390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.23,,,,,,,fee schedule,60.96,149.5,
Shoe outflare wedge,L3390,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.5,,,,,,,fee schedule,60.96,149.5,
Shoe outflare wedge,L3390,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.01,,,,,,,fee schedule,60.96,149.5,APC
Shoe outflare wedge,L3390,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.96,,,,,,,fee schedule,60.96,149.5,APC
Shoe outflare wedge,L3390,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,109.73,,,,,,,fee schedule,60.96,149.5,APC
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.33,,,,,,,fee schedule,50.02,122.69,
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.95,,,,,,,fee schedule,50.02,122.69,
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.69,,,,,,,fee schedule,50.02,122.69,
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.69,,,,,,,fee schedule,50.02,122.69,
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.52,,,,,,,fee schedule,50.02,122.69,APC
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50.02,,,,,,,fee schedule,50.02,122.69,APC
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,90.04,,,,,,,fee schedule,50.02,122.69,APC
Shoe metatarsal bar between,L3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.16,,,,,,,fee schedule,114.09,279.82,
Shoe metatarsal bar between,L3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,159.52,,,,,,,fee schedule,114.09,279.82,
Shoe metatarsal bar between,L3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,279.82,,,,,,,fee schedule,114.09,279.82,
Shoe metatarsal bar between,L3410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,243.32,,,,,,,fee schedule,114.09,279.82,
Shoe metatarsal bar between,L3410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,119.79,,,,,,,fee schedule,114.09,279.82,APC
Shoe metatarsal bar between,L3410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,114.09,,,,,,,fee schedule,114.09,279.82,APC
Shoe metatarsal bar between,L3410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,205.36,,,,,,,fee schedule,114.09,279.82,APC
Full sole/heel wedge btween,L3420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117.31,,,,,,,fee schedule,67.21,164.82,
Full sole/heel wedge btween,L3420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,93.96,,,,,,,fee schedule,67.21,164.82,
Full sole/heel wedge btween,L3420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,164.82,,,,,,,fee schedule,67.21,164.82,
Full sole/heel wedge btween,L3420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,143.32,,,,,,,fee schedule,67.21,164.82,
Full sole/heel wedge btween,L3420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.57,,,,,,,fee schedule,67.21,164.82,APC
Full sole/heel wedge btween,L3420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67.21,,,,,,,fee schedule,67.21,164.82,APC
Full sole/heel wedge btween,L3420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120.98,,,,,,,fee schedule,67.21,164.82,APC
Sho heel count plast reinfor,L3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,343.79,,,,,,,fee schedule,196.94,483.02,
Sho heel count plast reinfor,L3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,275.37,,,,,,,fee schedule,196.94,483.02,
Sho heel count plast reinfor,L3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,483.02,,,,,,,fee schedule,196.94,483.02,
Sho heel count plast reinfor,L3430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,420.02,,,,,,,fee schedule,196.94,483.02,
Sho heel count plast reinfor,L3430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,206.79,,,,,,,fee schedule,196.94,483.02,APC
Sho heel count plast reinfor,L3430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,196.94,,,,,,,fee schedule,196.94,483.02,APC
Sho heel count plast reinfor,L3430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,354.49,,,,,,,fee schedule,196.94,483.02,APC
Heel leather reinforced,L3440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.68,,,,,,,fee schedule,93.77,229.98,
Heel leather reinforced,L3440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.11,,,,,,,fee schedule,93.77,229.98,
Heel leather reinforced,L3440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.98,,,,,,,fee schedule,93.77,229.98,
Heel leather reinforced,L3440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.98,,,,,,,fee schedule,93.77,229.98,
Heel leather reinforced,L3440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.46,,,,,,,fee schedule,93.77,229.98,APC
Heel leather reinforced,L3440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,93.77,,,,,,,fee schedule,93.77,229.98,APC
Heel leather reinforced,L3440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,168.79,,,,,,,fee schedule,93.77,229.98,APC
Shoe heel sach cushion type,L3450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,226.39,,,,,,,fee schedule,129.69,318.08,
Shoe heel sach cushion type,L3450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,181.33,,,,,,,fee schedule,129.69,318.08,
Shoe heel sach cushion type,L3450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,318.08,,,,,,,fee schedule,129.69,318.08,
Shoe heel sach cushion type,L3450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,276.59,,,,,,,fee schedule,129.69,318.08,
Shoe heel sach cushion type,L3450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,136.17,,,,,,,fee schedule,129.69,318.08,APC
Shoe heel sach cushion type,L3450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,129.69,,,,,,,fee schedule,129.69,318.08,APC
Shoe heel sach cushion type,L3450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,233.44,,,,,,,fee schedule,129.69,318.08,APC
Shoe heel new leather standa,L3455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.33,,,,,,,fee schedule,50.02,122.69,
Shoe heel new leather standa,L3455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.95,,,,,,,fee schedule,50.02,122.69,
Shoe heel new leather standa,L3455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,122.69,,,,,,,fee schedule,50.02,122.69,
Shoe heel new leather standa,L3455,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,106.69,,,,,,,fee schedule,50.02,122.69,
Shoe heel new leather standa,L3455,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.52,,,,,,,fee schedule,50.02,122.69,APC
Shoe heel new leather standa,L3455,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50.02,,,,,,,fee schedule,50.02,122.69,APC
Shoe heel new leather standa,L3455,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,90.04,,,,,,,fee schedule,50.02,122.69,APC
Shoe heel new rubber standar,L3460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.7,,,,,,,fee schedule,42.22,103.55,
Shoe heel new rubber standar,L3460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.03,,,,,,,fee schedule,42.22,103.55,
Shoe heel new rubber standar,L3460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.55,,,,,,,fee schedule,42.22,103.55,
Shoe heel new rubber standar,L3460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.04,,,,,,,fee schedule,42.22,103.55,
Shoe heel new rubber standar,L3460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.33,,,,,,,fee schedule,42.22,103.55,APC
Shoe heel new rubber standar,L3460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42.22,,,,,,,fee schedule,42.22,103.55,APC
Shoe heel new rubber standar,L3460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,76,,,,,,,fee schedule,42.22,103.55,APC
Shoe heel thomas with wedge,L3465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125.57,,,,,,,fee schedule,71.94,176.42,
Shoe heel thomas with wedge,L3465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,100.58,,,,,,,fee schedule,71.94,176.42,
Shoe heel thomas with wedge,L3465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,176.42,,,,,,,fee schedule,71.94,176.42,
Shoe heel thomas with wedge,L3465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153.41,,,,,,,fee schedule,71.94,176.42,
Shoe heel thomas with wedge,L3465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.54,,,,,,,fee schedule,71.94,176.42,APC
Shoe heel thomas with wedge,L3465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.94,,,,,,,fee schedule,71.94,176.42,APC
Shoe heel thomas with wedge,L3465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.49,,,,,,,fee schedule,71.94,176.42,APC
Shoe heel thomas extend to b,L3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.64,,,,,,,fee schedule,76.57,187.77,
Shoe heel thomas extend to b,L3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.05,,,,,,,fee schedule,76.57,187.77,
Shoe heel thomas extend to b,L3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.77,,,,,,,fee schedule,76.57,187.77,
Shoe heel thomas extend to b,L3470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.28,,,,,,,fee schedule,76.57,187.77,
Shoe heel thomas extend to b,L3470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.4,,,,,,,fee schedule,76.57,187.77,APC
Shoe heel thomas extend to b,L3470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,76.57,,,,,,,fee schedule,76.57,187.77,APC
Shoe heel thomas extend to b,L3470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,137.83,,,,,,,fee schedule,76.57,187.77,APC
Shoe heel pad & depress for,L3480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,133.64,,,,,,,fee schedule,76.57,187.77,
Shoe heel pad & depress for,L3480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.05,,,,,,,fee schedule,76.57,187.77,
Shoe heel pad & depress for,L3480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,187.77,,,,,,,fee schedule,76.57,187.77,
Shoe heel pad & depress for,L3480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,163.28,,,,,,,fee schedule,76.57,187.77,
Shoe heel pad & depress for,L3480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.4,,,,,,,fee schedule,76.57,187.77,APC
Shoe heel pad & depress for,L3480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,76.57,,,,,,,fee schedule,76.57,187.77,APC
Shoe heel pad & depress for,L3480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,137.83,,,,,,,fee schedule,76.57,187.77,APC
Shoe heel pad removable for,L3485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.67,,,,,,,fee schedule,23.77,41.69,
Shoe heel pad removable for,L3485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.77,,,,,,,fee schedule,23.77,41.69,
Shoe heel pad removable for,L3485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.69,,,,,,,fee schedule,23.77,41.69,
Shoe heel pad removable for,L3485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.25,,,,,,,fee schedule,23.77,41.69,
Ortho shoe add leather insol,L3500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.73,,,,,,,fee schedule,35.93,88.14,
Ortho shoe add leather insol,L3500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.25,,,,,,,fee schedule,35.93,88.14,
Ortho shoe add leather insol,L3500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.14,,,,,,,fee schedule,35.93,88.14,
Ortho shoe add leather insol,L3500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.64,,,,,,,fee schedule,35.93,88.14,
Ortho shoe add leather insol,L3500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.73,,,,,,,fee schedule,35.93,88.14,APC
Ortho shoe add leather insol,L3500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.93,,,,,,,fee schedule,35.93,88.14,APC
Ortho shoe add leather insol,L3500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,64.67,,,,,,,fee schedule,35.93,88.14,APC
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62.73,,,,,,,fee schedule,35.93,88.14,
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.25,,,,,,,fee schedule,35.93,88.14,
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,88.14,,,,,,,fee schedule,35.93,88.14,
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,76.64,,,,,,,fee schedule,35.93,88.14,
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.73,,,,,,,fee schedule,35.93,88.14,APC
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.93,,,,,,,fee schedule,35.93,88.14,APC
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,64.67,,,,,,,fee schedule,35.93,88.14,APC
O shoe add felt w leath insl,L3520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.2,,,,,,,fee schedule,39.08,95.82,
O shoe add felt w leath insl,L3520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.62,,,,,,,fee schedule,39.08,95.82,
O shoe add felt w leath insl,L3520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.82,,,,,,,fee schedule,39.08,95.82,
O shoe add felt w leath insl,L3520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.32,,,,,,,fee schedule,39.08,95.82,
O shoe add felt w leath insl,L3520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.03,,,,,,,fee schedule,39.08,95.82,APC
O shoe add felt w leath insl,L3520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.08,,,,,,,fee schedule,39.08,95.82,APC
O shoe add felt w leath insl,L3520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.34,,,,,,,fee schedule,39.08,95.82,APC
Ortho shoe add half sole,L3530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.2,,,,,,,fee schedule,39.08,95.82,
Ortho shoe add half sole,L3530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.62,,,,,,,fee schedule,39.08,95.82,
Ortho shoe add half sole,L3530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.82,,,,,,,fee schedule,39.08,95.82,
Ortho shoe add half sole,L3530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.32,,,,,,,fee schedule,39.08,95.82,
Ortho shoe add half sole,L3530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.03,,,,,,,fee schedule,39.08,95.82,APC
Ortho shoe add half sole,L3530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.08,,,,,,,fee schedule,39.08,95.82,APC
Ortho shoe add half sole,L3530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.34,,,,,,,fee schedule,39.08,95.82,APC
Ortho shoe add full sole,L3540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109.12,,,,,,,fee schedule,62.52,153.32,
Ortho shoe add full sole,L3540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.4,,,,,,,fee schedule,62.52,153.32,
Ortho shoe add full sole,L3540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,153.32,,,,,,,fee schedule,62.52,153.32,
Ortho shoe add full sole,L3540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133.32,,,,,,,fee schedule,62.52,153.32,
Ortho shoe add full sole,L3540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.65,,,,,,,fee schedule,62.52,153.32,APC
Ortho shoe add full sole,L3540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62.52,,,,,,,fee schedule,62.52,153.32,APC
Ortho shoe add full sole,L3540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,112.54,,,,,,,fee schedule,62.52,153.32,APC
O shoe add standard toe tap,L3550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.19,,,,,,,fee schedule,10.99,26.97,
O shoe add standard toe tap,L3550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.37,,,,,,,fee schedule,10.99,26.97,
O shoe add standard toe tap,L3550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.97,,,,,,,fee schedule,10.99,26.97,
O shoe add standard toe tap,L3550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.45,,,,,,,fee schedule,10.99,26.97,
O shoe add standard toe tap,L3550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.54,,,,,,,fee schedule,10.99,26.97,APC
O shoe add standard toe tap,L3550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.99,,,,,,,fee schedule,10.99,26.97,APC
O shoe add standard toe tap,L3550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.78,,,,,,,fee schedule,10.99,26.97,APC
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49.08,,,,,,,fee schedule,28.11,68.95,
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.31,,,,,,,fee schedule,28.11,68.95,
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68.95,,,,,,,fee schedule,28.11,68.95,
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59.96,,,,,,,fee schedule,28.11,68.95,
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.52,,,,,,,fee schedule,28.11,68.95,APC
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.11,,,,,,,fee schedule,28.11,68.95,APC
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50.6,,,,,,,fee schedule,28.11,68.95,APC
O shoe add instep extension,L3570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,182.86,,,,,,,fee schedule,104.74,256.92,
O shoe add instep extension,L3570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,146.47,,,,,,,fee schedule,104.74,256.92,
O shoe add instep extension,L3570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,256.92,,,,,,,fee schedule,104.74,256.92,
O shoe add instep extension,L3570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,223.41,,,,,,,fee schedule,104.74,256.92,
O shoe add instep extension,L3570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.98,,,,,,,fee schedule,104.74,256.92,APC
O shoe add instep extension,L3570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104.74,,,,,,,fee schedule,104.74,256.92,APC
O shoe add instep extension,L3570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,188.53,,,,,,,fee schedule,104.74,256.92,APC
O shoe add instep velcro clo,L3580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.15,,,,,,,fee schedule,79.7,195.5,
O shoe add instep velcro clo,L3580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.45,,,,,,,fee schedule,79.7,195.5,
O shoe add instep velcro clo,L3580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.5,,,,,,,fee schedule,79.7,195.5,
O shoe add instep velcro clo,L3580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,170,,,,,,,fee schedule,79.7,195.5,
O shoe add instep velcro clo,L3580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.68,,,,,,,fee schedule,79.7,195.5,APC
O shoe add instep velcro clo,L3580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.7,,,,,,,fee schedule,79.7,195.5,APC
O shoe add instep velcro clo,L3580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,143.46,,,,,,,fee schedule,79.7,195.5,APC
O shoe convert to sof counte,L3590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.61,,,,,,,fee schedule,65.66,161.02,
O shoe convert to sof counte,L3590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.8,,,,,,,fee schedule,65.66,161.02,
O shoe convert to sof counte,L3590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.02,,,,,,,fee schedule,65.66,161.02,
O shoe convert to sof counte,L3590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.02,,,,,,,fee schedule,65.66,161.02,
O shoe convert to sof counte,L3590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.94,,,,,,,fee schedule,65.66,161.02,APC
O shoe convert to sof counte,L3590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.66,,,,,,,fee schedule,65.66,161.02,APC
O shoe convert to sof counte,L3590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,118.19,,,,,,,fee schedule,65.66,161.02,APC
Ortho shoe add march bar,L3595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89.99,,,,,,,fee schedule,51.54,126.44,
Ortho shoe add march bar,L3595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.08,,,,,,,fee schedule,51.54,126.44,
Ortho shoe add march bar,L3595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.44,,,,,,,fee schedule,51.54,126.44,
Ortho shoe add march bar,L3595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.95,,,,,,,fee schedule,51.54,126.44,
Ortho shoe add march bar,L3595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.12,,,,,,,fee schedule,51.54,126.44,APC
Ortho shoe add march bar,L3595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.54,,,,,,,fee schedule,51.54,126.44,APC
Ortho shoe add march bar,L3595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.77,,,,,,,fee schedule,51.54,126.44,APC
Trans shoe calip plate exist,L3600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.68,,,,,,,fee schedule,93.77,229.98,
Trans shoe calip plate exist,L3600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.11,,,,,,,fee schedule,93.77,229.98,
Trans shoe calip plate exist,L3600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.98,,,,,,,fee schedule,93.77,229.98,
Trans shoe calip plate exist,L3600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.98,,,,,,,fee schedule,93.77,229.98,
Trans shoe calip plate exist,L3600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.46,,,,,,,fee schedule,93.77,229.98,APC
Trans shoe calip plate exist,L3600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,93.77,,,,,,,fee schedule,93.77,229.98,APC
Trans shoe calip plate exist,L3600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,168.79,,,,,,,fee schedule,93.77,229.98,APC
Trans shoe caliper plate new,L3610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,215.54,,,,,,,fee schedule,123.48,302.83,
Trans shoe caliper plate new,L3610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.64,,,,,,,fee schedule,123.48,302.83,
Trans shoe caliper plate new,L3610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,302.83,,,,,,,fee schedule,123.48,302.83,
Trans shoe caliper plate new,L3610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,263.33,,,,,,,fee schedule,123.48,302.83,
Trans shoe caliper plate new,L3610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.65,,,,,,,fee schedule,123.48,302.83,APC
Trans shoe caliper plate new,L3610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,123.48,,,,,,,fee schedule,123.48,302.83,APC
Trans shoe caliper plate new,L3610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,222.26,,,,,,,fee schedule,123.48,302.83,APC
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.68,,,,,,,fee schedule,93.77,229.98,
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.11,,,,,,,fee schedule,93.77,229.98,
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.98,,,,,,,fee schedule,93.77,229.98,
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.98,,,,,,,fee schedule,93.77,229.98,
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.46,,,,,,,fee schedule,93.77,229.98,APC
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,93.77,,,,,,,fee schedule,93.77,229.98,APC
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,168.79,,,,,,,fee schedule,93.77,229.98,APC
Trans shoe solid stirrup new,L3630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,215.54,,,,,,,fee schedule,123.48,302.83,
Trans shoe solid stirrup new,L3630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.64,,,,,,,fee schedule,123.48,302.83,
Trans shoe solid stirrup new,L3630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,302.83,,,,,,,fee schedule,123.48,302.83,
Trans shoe solid stirrup new,L3630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,263.33,,,,,,,fee schedule,123.48,302.83,
Trans shoe solid stirrup new,L3630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.65,,,,,,,fee schedule,123.48,302.83,APC
Trans shoe solid stirrup new,L3630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,123.48,,,,,,,fee schedule,123.48,302.83,APC
Trans shoe solid stirrup new,L3630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,222.26,,,,,,,fee schedule,123.48,302.83,APC
Shoe dennis browne splint bo,L3640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.79,,,,,,,fee schedule,53.16,130.36,
Shoe dennis browne splint bo,L3640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,74.32,,,,,,,fee schedule,53.16,130.36,
Shoe dennis browne splint bo,L3640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.36,,,,,,,fee schedule,53.16,130.36,
Shoe dennis browne splint bo,L3640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.36,,,,,,,fee schedule,53.16,130.36,
Shoe dennis browne splint bo,L3640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.82,,,,,,,fee schedule,53.16,130.36,APC
Shoe dennis browne splint bo,L3640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.16,,,,,,,fee schedule,53.16,130.36,APC
Shoe dennis browne splint bo,L3640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95.69,,,,,,,fee schedule,53.16,130.36,APC
So 8 abd restraint pre ots,L3650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,140.7,,,,,,,fee schedule,80.6,197.69,
So 8 abd restraint pre ots,L3650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.7,,,,,,,fee schedule,80.6,197.69,
So 8 abd restraint pre ots,L3650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,197.69,,,,,,,fee schedule,80.6,197.69,
So 8 abd restraint pre ots,L3650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.9,,,,,,,fee schedule,80.6,197.69,
So 8 abd restraint pre ots,L3650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.63,,,,,,,fee schedule,80.6,197.69,APC
So 8 abd restraint pre ots,L3650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,80.6,,,,,,,fee schedule,80.6,197.69,APC
So 8 abd restraint pre ots,L3650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,145.08,,,,,,,fee schedule,80.6,197.69,APC
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.74,,,,,,,fee schedule,115.57,283.45,
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.59,,,,,,,fee schedule,115.57,283.45,
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.45,,,,,,,fee schedule,115.57,283.45,
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.48,,,,,,,fee schedule,115.57,283.45,
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,121.35,,,,,,,fee schedule,115.57,283.45,APC
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,115.57,,,,,,,fee schedule,115.57,283.45,APC
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,208.03,,,,,,,fee schedule,115.57,283.45,APC
So acro/clav can web pre ots,L3670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,221.97,,,,,,,fee schedule,127.15,311.87,
So acro/clav can web pre ots,L3670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,177.79,,,,,,,fee schedule,127.15,311.87,
So acro/clav can web pre ots,L3670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,311.87,,,,,,,fee schedule,127.15,311.87,
So acro/clav can web pre ots,L3670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.19,,,,,,,fee schedule,127.15,311.87,
So acro/clav can web pre ots,L3670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.51,,,,,,,fee schedule,127.15,311.87,APC
So acro/clav can web pre ots,L3670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,127.15,,,,,,,fee schedule,127.15,311.87,APC
So acro/clav can web pre ots,L3670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,228.87,,,,,,,fee schedule,127.15,311.87,APC
SO cap design w/o jnts CF,L3671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1759.23,,,,,,,fee schedule,1007.79,2471.74,
SO cap design w/o jnts CF,L3671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1409.11,,,,,,,fee schedule,1007.79,2471.74,
SO cap design w/o jnts CF,L3671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2471.74,,,,,,,fee schedule,1007.79,2471.74,
SO cap design w/o jnts CF,L3671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2149.34,,,,,,,fee schedule,1007.79,2471.74,
SO cap design w/o jnts CF,L3671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1058.18,,,,,,,fee schedule,1007.79,2471.74,APC
SO cap design w/o jnts CF,L3671,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1007.79,,,,,,,fee schedule,1007.79,2471.74,APC
SO cap design w/o jnts CF,L3671,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1814.02,,,,,,,fee schedule,1007.79,2471.74,APC
SO airplane w/wo joint CF,L3674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2307.84,,,,,,,fee schedule,1322.06,3242.54,
SO airplane w/wo joint CF,L3674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1848.53,,,,,,,fee schedule,1322.06,3242.54,
SO airplane w/wo joint CF,L3674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3242.54,,,,,,,fee schedule,1322.06,3242.54,
SO airplane w/wo joint CF,L3674,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2819.6,,,,,,,fee schedule,1322.06,3242.54,
SO airplane w/wo joint CF,L3674,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1388.16,,,,,,,fee schedule,1322.06,3242.54,APC
SO airplane w/wo joint CF,L3674,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1322.06,,,,,,,fee schedule,1322.06,3242.54,APC
SO airplane w/wo joint CF,L3674,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2379.71,,,,,,,fee schedule,1322.06,3242.54,APC
So vest canvas/web pre ots,L3675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.67,,,,,,,fee schedule,196.31,481.45,
So vest canvas/web pre ots,L3675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,274.47,,,,,,,fee schedule,196.31,481.45,
So vest canvas/web pre ots,L3675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,481.45,,,,,,,fee schedule,196.31,481.45,
So vest canvas/web pre ots,L3675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,418.65,,,,,,,fee schedule,196.31,481.45,
So vest canvas/web pre ots,L3675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,206.13,,,,,,,fee schedule,196.31,481.45,APC
So vest canvas/web pre ots,L3675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,196.31,,,,,,,fee schedule,196.31,481.45,APC
So vest canvas/web pre ots,L3675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,353.36,,,,,,,fee schedule,196.31,481.45,APC
So hard plas stabili pre cst,L3677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,214.13,,,,,,,fee schedule,171.51,300.85,
So hard plas stabili pre cst,L3677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.51,,,,,,,fee schedule,171.51,300.85,
So hard plas stabili pre cst,L3677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,300.85,,,,,,,fee schedule,171.51,300.85,
So hard plas stabili pre cst,L3677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,261.61,,,,,,,fee schedule,171.51,300.85,
EO w/o joints CF,L3702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,302.85,,,,,,,fee schedule,242.58,581.35,
EO w/o joints CF,L3702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,242.58,,,,,,,fee schedule,242.58,581.35,
EO w/o joints CF,L3702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,425.51,,,,,,,fee schedule,242.58,581.35,
EO w/o joints CF,L3702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,370.01,,,,,,,fee schedule,242.58,581.35,
EO w/o joints CF,L3702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.12,,,,,,,fee schedule,242.58,581.35,APC
EO w/o joints CF,L3702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,322.97,,,,,,,fee schedule,242.58,581.35,APC
EO w/o joints CF,L3702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,581.35,,,,,,,fee schedule,242.58,581.35,APC
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,278.81,,,,,,,fee schedule,159.7,391.72,
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.32,,,,,,,fee schedule,159.7,391.72,
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,391.72,,,,,,,fee schedule,159.7,391.72,
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,340.63,,,,,,,fee schedule,159.7,391.72,
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,167.68,,,,,,,fee schedule,159.7,391.72,APC
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,159.7,,,,,,,fee schedule,159.7,391.72,APC
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,287.46,,,,,,,fee schedule,159.7,391.72,APC
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1334.05,,,,,,,fee schedule,764.22,1874.35,
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1068.54,,,,,,,fee schedule,764.22,1874.35,
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1874.35,,,,,,,fee schedule,764.22,1874.35,
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1629.87,,,,,,,fee schedule,764.22,1874.35,
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,802.43,,,,,,,fee schedule,764.22,1874.35,APC
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,764.22,,,,,,,fee schedule,764.22,1874.35,APC
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1375.6,,,,,,,fee schedule,764.22,1874.35,APC
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1769.46,,,,,,,fee schedule,1013.66,2486.1,
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1417.3,,,,,,,fee schedule,1013.66,2486.1,
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2486.1,,,,,,,fee schedule,1013.66,2486.1,
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2161.83,,,,,,,fee schedule,1013.66,2486.1,
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1064.34,,,,,,,fee schedule,1013.66,2486.1,APC
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1013.66,,,,,,,fee schedule,1013.66,2486.1,APC
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1824.59,,,,,,,fee schedule,1013.66,2486.1,APC
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2097.86,,,,,,,fee schedule,1201.78,2947.52,
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1680.34,,,,,,,fee schedule,1201.78,2947.52,
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2947.52,,,,,,,fee schedule,1201.78,2947.52,
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2563.06,,,,,,,fee schedule,1201.78,2947.52,
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1261.87,,,,,,,fee schedule,1201.78,2947.52,APC
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1201.78,,,,,,,fee schedule,1201.78,2947.52,APC
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2163.2,,,,,,,fee schedule,1201.78,2947.52,APC
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,524.52,,,,,,,fee schedule,420.13,1006.85,
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,420.13,,,,,,,fee schedule,420.13,1006.85,
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,736.95,,,,,,,fee schedule,420.13,1006.85,
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,640.83,,,,,,,fee schedule,420.13,1006.85,
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,587.33,,,,,,,fee schedule,420.13,1006.85,APC
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,559.36,,,,,,,fee schedule,420.13,1006.85,APC
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1006.85,,,,,,,fee schedule,420.13,1006.85,APC
"Eo, adj lock joint prefab ot",L3761,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,587.33,,,,,,,fee schedule,559.36,1006.85,APC
"Eo, adj lock joint prefab ot",L3761,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,559.36,,,,,,,fee schedule,559.36,1006.85,APC
"Eo, adj lock joint prefab ot",L3761,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1006.85,,,,,,,fee schedule,559.36,1006.85,APC
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,209.94,,,,,,,fee schedule,120.25,294.96,
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,168.15,,,,,,,fee schedule,120.25,294.96,
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,294.96,,,,,,,fee schedule,120.25,294.96,
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,256.49,,,,,,,fee schedule,120.25,294.96,
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,126.26,,,,,,,fee schedule,120.25,294.96,APC
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,120.25,,,,,,,fee schedule,120.25,294.96,APC
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,216.45,,,,,,,fee schedule,120.25,294.96,APC
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1723.29,,,,,,,fee schedule,836.99,2421.24,
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1380.32,,,,,,,fee schedule,836.99,2421.24,
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2421.24,,,,,,,fee schedule,836.99,2421.24,
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2105.43,,,,,,,fee schedule,836.99,2421.24,
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,878.84,,,,,,,fee schedule,836.99,2421.24,APC
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,836.99,,,,,,,fee schedule,836.99,2421.24,APC
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1506.58,,,,,,,fee schedule,836.99,2421.24,APC
EWHO w/joint(s) CF,L3764,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1529.06,,,,,,,fee schedule,875.94,2148.35,
EWHO w/joint(s) CF,L3764,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1224.75,,,,,,,fee schedule,875.94,2148.35,
EWHO w/joint(s) CF,L3764,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2148.35,,,,,,,fee schedule,875.94,2148.35,
EWHO w/joint(s) CF,L3764,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1868.13,,,,,,,fee schedule,875.94,2148.35,
EWHO w/joint(s) CF,L3764,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.74,,,,,,,fee schedule,875.94,2148.35,APC
EWHO w/joint(s) CF,L3764,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,875.94,,,,,,,fee schedule,875.94,2148.35,APC
EWHO w/joint(s) CF,L3764,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1576.69,,,,,,,fee schedule,875.94,2148.35,APC
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2952.77,,,,,,,fee schedule,1434.15,4148.67,
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2365.1,,,,,,,fee schedule,1434.15,4148.67,
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4148.67,,,,,,,fee schedule,1434.15,4148.67,
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3607.54,,,,,,,fee schedule,1434.15,4148.67,
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1505.86,,,,,,,fee schedule,1434.15,4148.67,APC
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1434.15,,,,,,,fee schedule,1434.15,4148.67,APC
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2581.47,,,,,,,fee schedule,1434.15,4148.67,APC
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2651.06,,,,,,,fee schedule,1518.68,3724.76,
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2123.44,,,,,,,fee schedule,1518.68,3724.76,
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3724.76,,,,,,,fee schedule,1518.68,3724.76,
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3238.92,,,,,,,fee schedule,1518.68,3724.76,
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1594.61,,,,,,,fee schedule,1518.68,3724.76,APC
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1518.68,,,,,,,fee schedule,1518.68,3724.76,APC
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2733.62,,,,,,,fee schedule,1518.68,3724.76,APC
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1045.95,,,,,,,fee schedule,508.03,1469.57,
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,837.78,,,,,,,fee schedule,508.03,1469.57,
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1469.57,,,,,,,fee schedule,508.03,1469.57,
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1277.89,,,,,,,fee schedule,508.03,1469.57,
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,533.43,,,,,,,fee schedule,508.03,1469.57,APC
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,508.03,,,,,,,fee schedule,508.03,1469.57,APC
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,914.45,,,,,,,fee schedule,508.03,1469.57,APC
Whfo w/o joints pre cst,L3807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,488.19,,,,,,,fee schedule,279.67,685.92,
Whfo w/o joints pre cst,L3807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,391.03,,,,,,,fee schedule,279.67,685.92,
Whfo w/o joints pre cst,L3807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,685.92,,,,,,,fee schedule,279.67,685.92,
Whfo w/o joints pre cst,L3807,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,596.45,,,,,,,fee schedule,279.67,685.92,
Whfo w/o joints pre cst,L3807,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,293.65,,,,,,,fee schedule,279.67,685.92,APC
Whfo w/o joints pre cst,L3807,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,279.67,,,,,,,fee schedule,279.67,685.92,APC
Whfo w/o joints pre cst,L3807,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,503.41,,,,,,,fee schedule,279.67,685.92,APC
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,820.28,,,,,,,fee schedule,398.43,1152.5,
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,657.02,,,,,,,fee schedule,398.43,1152.5,
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1152.5,,,,,,,fee schedule,398.43,1152.5,
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1002.17,,,,,,,fee schedule,398.43,1152.5,
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,418.35,,,,,,,fee schedule,398.43,1152.5,APC
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,398.43,,,,,,,fee schedule,398.43,1152.5,APC
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,717.17,,,,,,,fee schedule,398.43,1152.5,APC
Whfo w/o joints pre ots,L3809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,488.19,,,,,,,fee schedule,279.67,685.92,
Whfo w/o joints pre ots,L3809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,391.03,,,,,,,fee schedule,279.67,685.92,
Whfo w/o joints pre ots,L3809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,685.92,,,,,,,fee schedule,279.67,685.92,
Whfo w/o joints pre ots,L3809,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,596.45,,,,,,,fee schedule,279.67,685.92,
Whfo w/o joints pre ots,L3809,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,293.65,,,,,,,fee schedule,279.67,685.92,APC
Whfo w/o joints pre ots,L3809,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,279.67,,,,,,,fee schedule,279.67,685.92,APC
Whfo w/o joints pre ots,L3809,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,503.41,,,,,,,fee schedule,279.67,685.92,APC
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1715.07,,,,,,,fee schedule,1373.73,3261.33,
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1373.73,,,,,,,fee schedule,1373.73,3261.33,
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2409.69,,,,,,,fee schedule,1373.73,3261.33,
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2095.38,,,,,,,fee schedule,1373.73,3261.33,
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1902.44,,,,,,,fee schedule,1373.73,3261.33,APC
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1811.85,,,,,,,fee schedule,1373.73,3261.33,APC
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3261.33,,,,,,,fee schedule,1373.73,3261.33,APC
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4145.07,,,,,,,fee schedule,2374.53,5823.86,
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3320.11,,,,,,,fee schedule,2374.53,5823.86,
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5823.86,,,,,,,fee schedule,2374.53,5823.86,
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5064.23,,,,,,,fee schedule,2374.53,5823.86,
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2493.26,,,,,,,fee schedule,2374.53,5823.86,APC
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2374.53,,,,,,,fee schedule,2374.53,5823.86,APC
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4274.15,,,,,,,fee schedule,2374.53,5823.86,APC
Whfo electric custom fitted,L3904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6590.23,,,,,,,fee schedule,3775.23,9259.34,
Whfo electric custom fitted,L3904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5278.63,,,,,,,fee schedule,3775.23,9259.34,
Whfo electric custom fitted,L3904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9259.34,,,,,,,fee schedule,3775.23,9259.34,
Whfo electric custom fitted,L3904,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8051.6,,,,,,,fee schedule,3775.23,9259.34,
Whfo electric custom fitted,L3904,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3963.99,,,,,,,fee schedule,3775.23,9259.34,APC
Whfo electric custom fitted,L3904,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3775.23,,,,,,,fee schedule,3775.23,9259.34,APC
Whfo electric custom fitted,L3904,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6795.41,,,,,,,fee schedule,3775.23,9259.34,APC
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1049.94,,,,,,,fee schedule,840.98,1996.49,
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,840.98,,,,,,,fee schedule,840.98,1996.49,
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1475.17,,,,,,,fee schedule,840.98,1996.49,
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1282.76,,,,,,,fee schedule,840.98,1996.49,
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1164.62,,,,,,,fee schedule,840.98,1996.49,APC
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1109.16,,,,,,,fee schedule,840.98,1996.49,APC
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1996.49,,,,,,,fee schedule,840.98,1996.49,APC
Who w/o joints cf,L3906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1166.99,,,,,,,fee schedule,566.79,1639.64,
Who w/o joints cf,L3906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,934.73,,,,,,,fee schedule,566.79,1639.64,
Who w/o joints cf,L3906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1639.64,,,,,,,fee schedule,566.79,1639.64,
Who w/o joints cf,L3906,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1425.77,,,,,,,fee schedule,566.79,1639.64,
Who w/o joints cf,L3906,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,595.13,,,,,,,fee schedule,566.79,1639.64,APC
Who w/o joints cf,L3906,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,566.79,,,,,,,fee schedule,566.79,1639.64,APC
Who w/o joints cf,L3906,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1020.22,,,,,,,fee schedule,566.79,1639.64,APC
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,168.83,,,,,,,fee schedule,82,237.21,
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.23,,,,,,,fee schedule,82,237.21,
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,237.21,,,,,,,fee schedule,82,237.21,
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,206.27,,,,,,,fee schedule,82,237.21,
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,86.1,,,,,,,fee schedule,82,237.21,APC
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,82,,,,,,,fee schedule,82,237.21,APC
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,147.6,,,,,,,fee schedule,82,237.21,APC
Hfo flexion glove pre ots,L3912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,205.7,,,,,,,fee schedule,117.84,289.01,
Hfo flexion glove pre ots,L3912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.76,,,,,,,fee schedule,117.84,289.01,
Hfo flexion glove pre ots,L3912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,289.01,,,,,,,fee schedule,117.84,289.01,
Hfo flexion glove pre ots,L3912,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,251.31,,,,,,,fee schedule,117.84,289.01,
Hfo flexion glove pre ots,L3912,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,123.73,,,,,,,fee schedule,117.84,289.01,APC
Hfo flexion glove pre ots,L3912,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,117.84,,,,,,,fee schedule,117.84,289.01,APC
Hfo flexion glove pre ots,L3912,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,212.11,,,,,,,fee schedule,117.84,289.01,APC
HFO w/o joints CF,L3913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,623.66,,,,,,,fee schedule,302.9,876.25,
HFO w/o joints CF,L3913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,499.54,,,,,,,fee schedule,302.9,876.25,
HFO w/o joints CF,L3913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,876.25,,,,,,,fee schedule,302.9,876.25,
HFO w/o joints CF,L3913,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,761.96,,,,,,,fee schedule,302.9,876.25,
HFO w/o joints CF,L3913,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.04,,,,,,,fee schedule,302.9,876.25,APC
HFO w/o joints CF,L3913,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,302.9,,,,,,,fee schedule,302.9,876.25,APC
HFO w/o joints CF,L3913,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,545.22,,,,,,,fee schedule,302.9,876.25,APC
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1037.87,,,,,,,fee schedule,594.54,1458.21,
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,831.31,,,,,,,fee schedule,594.54,1458.21,
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1458.21,,,,,,,fee schedule,594.54,1458.21,
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1268.01,,,,,,,fee schedule,594.54,1458.21,
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,624.27,,,,,,,fee schedule,594.54,1458.21,APC
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,594.54,,,,,,,fee schedule,594.54,1458.21,APC
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1070.17,,,,,,,fee schedule,594.54,1458.21,APC
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1037.87,,,,,,,fee schedule,594.54,1458.21,
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,831.31,,,,,,,fee schedule,594.54,1458.21,
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1458.21,,,,,,,fee schedule,594.54,1458.21,
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1268.01,,,,,,,fee schedule,594.54,1458.21,
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,624.27,,,,,,,fee schedule,594.54,1458.21,APC
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,594.54,,,,,,,fee schedule,594.54,1458.21,APC
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1070.17,,,,,,,fee schedule,594.54,1458.21,APC
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.17,,,,,,,fee schedule,118.11,289.67,
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.14,,,,,,,fee schedule,118.11,289.67,
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,289.67,,,,,,,fee schedule,118.11,289.67,
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,251.89,,,,,,,fee schedule,118.11,289.67,
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,124.02,,,,,,,fee schedule,118.11,289.67,APC
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,118.11,,,,,,,fee schedule,118.11,289.67,APC
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,212.6,,,,,,,fee schedule,118.11,289.67,APC
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,206.17,,,,,,,fee schedule,118.11,289.67,
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,165.14,,,,,,,fee schedule,118.11,289.67,
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,289.67,,,,,,,fee schedule,118.11,289.67,
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,251.89,,,,,,,fee schedule,118.11,289.67,
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,124.02,,,,,,,fee schedule,118.11,289.67,APC
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,118.11,,,,,,,fee schedule,118.11,289.67,APC
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,212.6,,,,,,,fee schedule,118.11,289.67,APC
HO w/o joints CF,L3919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,528.77,,,,,,,fee schedule,302.9,742.92,
HO w/o joints CF,L3919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,423.53,,,,,,,fee schedule,302.9,742.92,
HO w/o joints CF,L3919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,742.92,,,,,,,fee schedule,302.9,742.92,
HO w/o joints CF,L3919,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,646.02,,,,,,,fee schedule,302.9,742.92,
HO w/o joints CF,L3919,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,318.04,,,,,,,fee schedule,302.9,742.92,APC
HO w/o joints CF,L3919,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,302.9,,,,,,,fee schedule,302.9,742.92,APC
HO w/o joints CF,L3919,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,545.22,,,,,,,fee schedule,302.9,742.92,APC
HFO w/joint(s) CF,L3921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,627.15,,,,,,,fee schedule,359.28,881.15,
HFO w/joint(s) CF,L3921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,502.33,,,,,,,fee schedule,359.28,881.15,
HFO w/joint(s) CF,L3921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,881.15,,,,,,,fee schedule,359.28,881.15,
HFO w/joint(s) CF,L3921,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,766.22,,,,,,,fee schedule,359.28,881.15,
HFO w/joint(s) CF,L3921,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,377.24,,,,,,,fee schedule,359.28,881.15,APC
HFO w/joint(s) CF,L3921,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,359.28,,,,,,,fee schedule,359.28,881.15,APC
HFO w/joint(s) CF,L3921,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,646.7,,,,,,,fee schedule,359.28,881.15,APC
Hfo without joints pre cst,L3923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,188.57,,,,,,,fee schedule,108.04,264.95,
Hfo without joints pre cst,L3923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.04,,,,,,,fee schedule,108.04,264.95,
Hfo without joints pre cst,L3923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,264.95,,,,,,,fee schedule,108.04,264.95,
Hfo without joints pre cst,L3923,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,230.39,,,,,,,fee schedule,108.04,264.95,
Hfo without joints pre cst,L3923,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.44,,,,,,,fee schedule,108.04,264.95,APC
Hfo without joints pre cst,L3923,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,108.04,,,,,,,fee schedule,108.04,264.95,APC
Hfo without joints pre cst,L3923,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,194.47,,,,,,,fee schedule,108.04,264.95,APC
Hfo without joints pre ots,L3924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,222.43,,,,,,,fee schedule,108.04,312.51,
Hfo without joints pre ots,L3924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,178.16,,,,,,,fee schedule,108.04,312.51,
Hfo without joints pre ots,L3924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,312.51,,,,,,,fee schedule,108.04,312.51,
Hfo without joints pre ots,L3924,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,271.75,,,,,,,fee schedule,108.04,312.51,
Hfo without joints pre ots,L3924,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.44,,,,,,,fee schedule,108.04,312.51,APC
Hfo without joints pre ots,L3924,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,108.04,,,,,,,fee schedule,108.04,312.51,APC
Hfo without joints pre ots,L3924,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,194.47,,,,,,,fee schedule,108.04,312.51,APC
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110.42,,,,,,,fee schedule,73.47,155.14,
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.44,,,,,,,fee schedule,73.47,155.14,
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,155.14,,,,,,,fee schedule,73.47,155.14,
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.9,,,,,,,fee schedule,73.47,155.14,
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.14,,,,,,,fee schedule,73.47,155.14,APC
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.47,,,,,,,fee schedule,73.47,155.14,APC
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.25,,,,,,,fee schedule,73.47,155.14,APC
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.36,,,,,,,fee schedule,39.15,96.05,
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,54.76,,,,,,,fee schedule,39.15,96.05,
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,96.05,,,,,,,fee schedule,39.15,96.05,
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.52,,,,,,,fee schedule,39.15,96.05,
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.11,,,,,,,fee schedule,39.15,96.05,APC
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39.15,,,,,,,fee schedule,39.15,96.05,APC
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70.47,,,,,,,fee schedule,39.15,96.05,APC
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.31,,,,,,,fee schedule,102.16,250.53,
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.82,,,,,,,fee schedule,102.16,250.53,
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.53,,,,,,,fee schedule,102.16,250.53,
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.85,,,,,,,fee schedule,102.16,250.53,
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.27,,,,,,,fee schedule,102.16,250.53,APC
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,102.16,,,,,,,fee schedule,102.16,250.53,APC
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,183.89,,,,,,,fee schedule,102.16,250.53,APC
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.31,,,,,,,fee schedule,102.16,250.53,
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.82,,,,,,,fee schedule,102.16,250.53,
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,250.53,,,,,,,fee schedule,102.16,250.53,
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.85,,,,,,,fee schedule,102.16,250.53,
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.27,,,,,,,fee schedule,102.16,250.53,APC
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,102.16,,,,,,,fee schedule,102.16,250.53,APC
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,183.89,,,,,,,fee schedule,102.16,250.53,APC
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,407.06,,,,,,,fee schedule,233.2,571.93,
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,326.05,,,,,,,fee schedule,233.2,571.93,
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,571.93,,,,,,,fee schedule,233.2,571.93,
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,497.33,,,,,,,fee schedule,233.2,571.93,
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.86,,,,,,,fee schedule,233.2,571.93,APC
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,233.2,,,,,,,fee schedule,233.2,571.93,APC
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,419.76,,,,,,,fee schedule,233.2,571.93,APC
FO w/o joints CF,L3933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,491.32,,,,,,,fee schedule,238.64,690.31,
FO w/o joints CF,L3933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,393.54,,,,,,,fee schedule,238.64,690.31,
FO w/o joints CF,L3933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,690.31,,,,,,,fee schedule,238.64,690.31,
FO w/o joints CF,L3933,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,600.27,,,,,,,fee schedule,238.64,690.31,
FO w/o joints CF,L3933,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,250.57,,,,,,,fee schedule,238.64,690.31,APC
FO w/o joints CF,L3933,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,238.64,,,,,,,fee schedule,238.64,690.31,APC
FO w/o joints CF,L3933,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,429.55,,,,,,,fee schedule,238.64,690.31,APC
FO nontorsion joint CF,L3935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,431.31,,,,,,,fee schedule,247.07,605.99,
FO nontorsion joint CF,L3935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,345.47,,,,,,,fee schedule,247.07,605.99,
FO nontorsion joint CF,L3935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,605.99,,,,,,,fee schedule,247.07,605.99,
FO nontorsion joint CF,L3935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,526.95,,,,,,,fee schedule,247.07,605.99,
FO nontorsion joint CF,L3935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.42,,,,,,,fee schedule,247.07,605.99,APC
FO nontorsion joint CF,L3935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,247.07,,,,,,,fee schedule,247.07,605.99,APC
FO nontorsion joint CF,L3935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,444.73,,,,,,,fee schedule,247.07,605.99,APC
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1557.21,,,,,,,fee schedule,892.05,2187.9,
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1247.29,,,,,,,fee schedule,892.05,2187.9,
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2187.9,,,,,,,fee schedule,892.05,2187.9,
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1902.52,,,,,,,fee schedule,892.05,2187.9,
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,936.65,,,,,,,fee schedule,892.05,2187.9,APC
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,892.05,,,,,,,fee schedule,892.05,2187.9,APC
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1605.69,,,,,,,fee schedule,892.05,2187.9,APC
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3280.37,,,,,,,fee schedule,1879.17,4608.95,
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2627.5,,,,,,,fee schedule,1879.17,4608.95,
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4608.95,,,,,,,fee schedule,1879.17,4608.95,
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4007.78,,,,,,,fee schedule,1879.17,4608.95,
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1973.13,,,,,,,fee schedule,1879.17,4608.95,APC
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1879.17,,,,,,,fee schedule,1879.17,4608.95,APC
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3382.51,,,,,,,fee schedule,1879.17,4608.95,APC
Sewho erbs palsey design abd,L3962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1408.4,,,,,,,fee schedule,806.8,1978.82,
Sewho erbs palsey design abd,L3962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1128.1,,,,,,,fee schedule,806.8,1978.82,
Sewho erbs palsey design abd,L3962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1978.82,,,,,,,fee schedule,806.8,1978.82,
Sewho erbs palsey design abd,L3962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1720.71,,,,,,,fee schedule,806.8,1978.82,
Sewho erbs palsey design abd,L3962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,847.14,,,,,,,fee schedule,806.8,1978.82,APC
Sewho erbs palsey design abd,L3962,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,806.8,,,,,,,fee schedule,806.8,1978.82,APC
Sewho erbs palsey design abd,L3962,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1452.24,,,,,,,fee schedule,806.8,1978.82,APC
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3872.96,,,,,,,fee schedule,2218.63,5441.55,
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3102.15,,,,,,,fee schedule,2218.63,5441.55,
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5441.55,,,,,,,fee schedule,2218.63,5441.55,
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4731.78,,,,,,,fee schedule,2218.63,5441.55,
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2329.56,,,,,,,fee schedule,2218.63,5441.55,APC
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2218.63,,,,,,,fee schedule,2218.63,5441.55,APC
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3993.53,,,,,,,fee schedule,2218.63,5441.55,APC
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3676.35,,,,,,,fee schedule,2106,5165.31,
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2944.67,,,,,,,fee schedule,2106,5165.31,
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5165.31,,,,,,,fee schedule,2106,5165.31,
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4491.57,,,,,,,fee schedule,2106,5165.31,
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2211.3,,,,,,,fee schedule,2106,5165.31,APC
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2106,,,,,,,fee schedule,2106,5165.31,APC
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3790.8,,,,,,,fee schedule,2106,5165.31,APC
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3872.96,,,,,,,fee schedule,2218.63,5441.55,
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3102.15,,,,,,,fee schedule,2218.63,5441.55,
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5441.55,,,,,,,fee schedule,2218.63,5441.55,
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4731.78,,,,,,,fee schedule,2218.63,5441.55,
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2329.56,,,,,,,fee schedule,2218.63,5441.55,APC
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2218.63,,,,,,,fee schedule,2218.63,5441.55,APC
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3993.53,,,,,,,fee schedule,2218.63,5441.55,APC
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3280.37,,,,,,,fee schedule,1879.17,4608.95,
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2627.5,,,,,,,fee schedule,1879.17,4608.95,
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4608.95,,,,,,,fee schedule,1879.17,4608.95,
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4007.78,,,,,,,fee schedule,1879.17,4608.95,
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1973.13,,,,,,,fee schedule,1879.17,4608.95,APC
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1879.17,,,,,,,fee schedule,1879.17,4608.95,APC
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3382.51,,,,,,,fee schedule,1879.17,4608.95,APC
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3280.37,,,,,,,fee schedule,1879.17,4608.95,
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2627.5,,,,,,,fee schedule,1879.17,4608.95,
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4608.95,,,,,,,fee schedule,1879.17,4608.95,
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4007.78,,,,,,,fee schedule,1879.17,4608.95,
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1973.13,,,,,,,fee schedule,1879.17,4608.95,APC
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1879.17,,,,,,,fee schedule,1879.17,4608.95,APC
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3382.51,,,,,,,fee schedule,1879.17,4608.95,APC
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3676.35,,,,,,,fee schedule,2106,5165.31,
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2944.67,,,,,,,fee schedule,2106,5165.31,
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5165.31,,,,,,,fee schedule,2106,5165.31,
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4491.57,,,,,,,fee schedule,2106,5165.31,
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2211.3,,,,,,,fee schedule,2106,5165.31,APC
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2106,,,,,,,fee schedule,2106,5165.31,APC
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3790.8,,,,,,,fee schedule,2106,5165.31,APC
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3872.96,,,,,,,fee schedule,2218.63,5441.55,
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3102.15,,,,,,,fee schedule,2218.63,5441.55,
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5441.55,,,,,,,fee schedule,2218.63,5441.55,
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4731.78,,,,,,,fee schedule,2218.63,5441.55,
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2329.56,,,,,,,fee schedule,2218.63,5441.55,APC
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2218.63,,,,,,,fee schedule,2218.63,5441.55,APC
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3993.53,,,,,,,fee schedule,2218.63,5441.55,APC
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,755.31,,,,,,,fee schedule,432.69,1061.22,
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,604.99,,,,,,,fee schedule,432.69,1061.22,
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1061.22,,,,,,,fee schedule,432.69,1061.22,
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,922.8,,,,,,,fee schedule,432.69,1061.22,
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,454.32,,,,,,,fee schedule,432.69,1061.22,APC
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,432.69,,,,,,,fee schedule,432.69,1061.22,APC
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,778.84,,,,,,,fee schedule,432.69,1061.22,APC
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1965.23,,,,,,,fee schedule,1125.8,2761.17,
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1574.11,,,,,,,fee schedule,1125.8,2761.17,
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2761.17,,,,,,,fee schedule,1125.8,2761.17,
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2401.02,,,,,,,fee schedule,1125.8,2761.17,
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1182.09,,,,,,,fee schedule,1125.8,2761.17,APC
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1125.8,,,,,,,fee schedule,1125.8,2761.17,APC
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2026.44,,,,,,,fee schedule,1125.8,2761.17,APC
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,766.96,,,,,,,fee schedule,439.35,1077.58,
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,614.32,,,,,,,fee schedule,439.35,1077.58,
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1077.58,,,,,,,fee schedule,439.35,1077.58,
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,937.03,,,,,,,fee schedule,439.35,1077.58,
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.32,,,,,,,fee schedule,439.35,1077.58,APC
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.35,,,,,,,fee schedule,439.35,1077.58,APC
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,790.83,,,,,,,fee schedule,439.35,1077.58,APC
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,675.61,,,,,,,fee schedule,387.03,949.23,
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,541.15,,,,,,,fee schedule,387.03,949.23,
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,949.23,,,,,,,fee schedule,387.03,949.23,
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,825.42,,,,,,,fee schedule,387.03,949.23,
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.38,,,,,,,fee schedule,387.03,949.23,APC
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,387.03,,,,,,,fee schedule,387.03,949.23,APC
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,696.65,,,,,,,fee schedule,387.03,949.23,APC
Sock fracture or equal each,L3995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80.2,,,,,,,fee schedule,45.92,112.68,
Sock fracture or equal each,L3995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,64.24,,,,,,,fee schedule,45.92,112.68,
Sock fracture or equal each,L3995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,112.68,,,,,,,fee schedule,45.92,112.68,
Sock fracture or equal each,L3995,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,97.98,,,,,,,fee schedule,45.92,112.68,
Sock fracture or equal each,L3995,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.22,,,,,,,fee schedule,45.92,112.68,APC
Sock fracture or equal each,L3995,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,45.92,,,,,,,fee schedule,45.92,112.68,APC
Sock fracture or equal each,L3995,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,82.66,,,,,,,fee schedule,45.92,112.68,APC
Repl girdle milwaukee orth,L4000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2834.87,,,,,,,fee schedule,1623.97,3983.01,
Repl girdle milwaukee orth,L4000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2270.66,,,,,,,fee schedule,1623.97,3983.01,
Repl girdle milwaukee orth,L4000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3983.01,,,,,,,fee schedule,1623.97,3983.01,
Repl girdle milwaukee orth,L4000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3463.49,,,,,,,fee schedule,1623.97,3983.01,
Repl girdle milwaukee orth,L4000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1705.17,,,,,,,fee schedule,1623.97,3983.01,APC
Repl girdle milwaukee orth,L4000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1623.97,,,,,,,fee schedule,1623.97,3983.01,APC
Repl girdle milwaukee orth,L4000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2923.15,,,,,,,fee schedule,1623.97,3983.01,APC
Replace trilateral socket br,L4010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1723.07,,,,,,,fee schedule,987.07,2420.93,
Replace trilateral socket br,L4010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1380.14,,,,,,,fee schedule,987.07,2420.93,
Replace trilateral socket br,L4010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2420.93,,,,,,,fee schedule,987.07,2420.93,
Replace trilateral socket br,L4010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2105.16,,,,,,,fee schedule,987.07,2420.93,
Replace trilateral socket br,L4010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.42,,,,,,,fee schedule,987.07,2420.93,APC
Replace trilateral socket br,L4010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,987.07,,,,,,,fee schedule,987.07,2420.93,APC
Replace trilateral socket br,L4010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1776.73,,,,,,,fee schedule,987.07,2420.93,APC
Replace quadlat socket brim,L4020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2069.86,,,,,,,fee schedule,1185.74,2908.18,
Replace quadlat socket brim,L4020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1657.91,,,,,,,fee schedule,1185.74,2908.18,
Replace quadlat socket brim,L4020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2908.18,,,,,,,fee schedule,1185.74,2908.18,
Replace quadlat socket brim,L4020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2528.85,,,,,,,fee schedule,1185.74,2908.18,
Replace quadlat socket brim,L4020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1245.03,,,,,,,fee schedule,1185.74,2908.18,APC
Replace quadlat socket brim,L4020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1185.74,,,,,,,fee schedule,1185.74,2908.18,APC
Replace quadlat socket brim,L4020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2134.33,,,,,,,fee schedule,1185.74,2908.18,APC
Replace socket brim cust fit,L4030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1315.35,,,,,,,fee schedule,753.5,1848.07,
Replace socket brim cust fit,L4030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1053.56,,,,,,,fee schedule,753.5,1848.07,
Replace socket brim cust fit,L4030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1848.07,,,,,,,fee schedule,753.5,1848.07,
Replace socket brim cust fit,L4030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1607.02,,,,,,,fee schedule,753.5,1848.07,
Replace socket brim cust fit,L4030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,791.18,,,,,,,fee schedule,753.5,1848.07,APC
Replace socket brim cust fit,L4030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,753.5,,,,,,,fee schedule,753.5,1848.07,APC
Replace socket brim cust fit,L4030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1356.3,,,,,,,fee schedule,753.5,1848.07,APC
Replace molded thigh lacer,L4040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,890.77,,,,,,,fee schedule,510.29,1251.55,
Replace molded thigh lacer,L4040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,713.49,,,,,,,fee schedule,510.29,1251.55,
Replace molded thigh lacer,L4040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1251.55,,,,,,,fee schedule,510.29,1251.55,
Replace molded thigh lacer,L4040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1088.3,,,,,,,fee schedule,510.29,1251.55,
Replace molded thigh lacer,L4040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,535.8,,,,,,,fee schedule,510.29,1251.55,APC
Replace molded thigh lacer,L4040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,510.29,,,,,,,fee schedule,510.29,1251.55,APC
Replace molded thigh lacer,L4040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,918.52,,,,,,,fee schedule,510.29,1251.55,APC
Replace non-molded thigh lac,L4045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,658,,,,,,,fee schedule,376.94,924.5,
Replace non-molded thigh lac,L4045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,527.04,,,,,,,fee schedule,376.94,924.5,
Replace non-molded thigh lac,L4045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,924.5,,,,,,,fee schedule,376.94,924.5,
Replace non-molded thigh lac,L4045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,803.91,,,,,,,fee schedule,376.94,924.5,
Replace non-molded thigh lac,L4045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,395.79,,,,,,,fee schedule,376.94,924.5,APC
Replace non-molded thigh lac,L4045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,376.94,,,,,,,fee schedule,376.94,924.5,APC
Replace non-molded thigh lac,L4045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,678.49,,,,,,,fee schedule,376.94,924.5,APC
Replace molded calf lacer,L4050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,882.24,,,,,,,fee schedule,505.37,1239.56,
Replace molded calf lacer,L4050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,706.66,,,,,,,fee schedule,505.37,1239.56,
Replace molded calf lacer,L4050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1239.56,,,,,,,fee schedule,505.37,1239.56,
Replace molded calf lacer,L4050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1077.88,,,,,,,fee schedule,505.37,1239.56,
Replace molded calf lacer,L4050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,530.64,,,,,,,fee schedule,505.37,1239.56,APC
Replace molded calf lacer,L4050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,505.37,,,,,,,fee schedule,505.37,1239.56,APC
Replace molded calf lacer,L4050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,909.67,,,,,,,fee schedule,505.37,1239.56,APC
Replace non-molded calf lace,L4055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,536.26,,,,,,,fee schedule,307.2,753.46,
Replace non-molded calf lace,L4055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,429.54,,,,,,,fee schedule,307.2,753.46,
Replace non-molded calf lace,L4055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,753.46,,,,,,,fee schedule,307.2,753.46,
Replace non-molded calf lace,L4055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,655.18,,,,,,,fee schedule,307.2,753.46,
Replace non-molded calf lace,L4055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,322.56,,,,,,,fee schedule,307.2,753.46,APC
Replace non-molded calf lace,L4055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,307.2,,,,,,,fee schedule,307.2,753.46,APC
Replace non-molded calf lace,L4055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,552.96,,,,,,,fee schedule,307.2,753.46,APC
Replace high roll cuff,L4060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,697.08,,,,,,,fee schedule,399.32,979.41,
Replace high roll cuff,L4060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,558.35,,,,,,,fee schedule,399.32,979.41,
Replace high roll cuff,L4060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,979.41,,,,,,,fee schedule,399.32,979.41,
Replace high roll cuff,L4060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,851.66,,,,,,,fee schedule,399.32,979.41,
Replace high roll cuff,L4060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,419.29,,,,,,,fee schedule,399.32,979.41,APC
Replace high roll cuff,L4060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,399.32,,,,,,,fee schedule,399.32,979.41,APC
Replace high roll cuff,L4060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,718.78,,,,,,,fee schedule,399.32,979.41,APC
Replace prox & dist upright,L4070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,564.53,,,,,,,fee schedule,323.39,793.17,
Replace prox & dist upright,L4070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,452.17,,,,,,,fee schedule,323.39,793.17,
Replace prox & dist upright,L4070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,793.17,,,,,,,fee schedule,323.39,793.17,
Replace prox & dist upright,L4070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,689.71,,,,,,,fee schedule,323.39,793.17,
Replace prox & dist upright,L4070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.56,,,,,,,fee schedule,323.39,793.17,APC
Replace prox & dist upright,L4070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,323.39,,,,,,,fee schedule,323.39,793.17,APC
Replace prox & dist upright,L4070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,582.1,,,,,,,fee schedule,323.39,793.17,APC
Repl met band kafo-afo prox,L4080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,213.1,,,,,,,fee schedule,122.09,299.4,
Repl met band kafo-afo prox,L4080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,170.69,,,,,,,fee schedule,122.09,299.4,
Repl met band kafo-afo prox,L4080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,299.4,,,,,,,fee schedule,122.09,299.4,
Repl met band kafo-afo prox,L4080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,260.35,,,,,,,fee schedule,122.09,299.4,
Repl met band kafo-afo prox,L4080,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.19,,,,,,,fee schedule,122.09,299.4,APC
Repl met band kafo-afo prox,L4080,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,122.09,,,,,,,fee schedule,122.09,299.4,APC
Repl met band kafo-afo prox,L4080,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,219.76,,,,,,,fee schedule,122.09,299.4,APC
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.29,,,,,,,fee schedule,103.88,254.71,
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.21,,,,,,,fee schedule,103.88,254.71,
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,254.71,,,,,,,fee schedule,103.88,254.71,
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.49,,,,,,,fee schedule,103.88,254.71,
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.07,,,,,,,fee schedule,103.88,254.71,APC
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,103.88,,,,,,,fee schedule,103.88,254.71,APC
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,186.98,,,,,,,fee schedule,103.88,254.71,APC
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,217.85,,,,,,,fee schedule,124.81,306.08,
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,174.49,,,,,,,fee schedule,124.81,306.08,
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,306.08,,,,,,,fee schedule,124.81,306.08,
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,266.16,,,,,,,fee schedule,124.81,306.08,
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.05,,,,,,,fee schedule,124.81,306.08,APC
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124.81,,,,,,,fee schedule,124.81,306.08,APC
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,224.66,,,,,,,fee schedule,124.81,306.08,APC
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,170.1,,,,,,,fee schedule,97.45,238.99,
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.25,,,,,,,fee schedule,97.45,238.99,
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,238.99,,,,,,,fee schedule,97.45,238.99,
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,207.82,,,,,,,fee schedule,97.45,238.99,
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.32,,,,,,,fee schedule,97.45,238.99,APC
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,97.45,,,,,,,fee schedule,97.45,238.99,APC
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,175.41,,,,,,,fee schedule,97.45,238.99,APC
Replace pretibial shell,L4130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1028.28,,,,,,,fee schedule,589.05,1444.75,
Replace pretibial shell,L4130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,823.63,,,,,,,fee schedule,589.05,1444.75,
Replace pretibial shell,L4130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1444.75,,,,,,,fee schedule,589.05,1444.75,
Replace pretibial shell,L4130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1256.3,,,,,,,fee schedule,589.05,1444.75,
Replace pretibial shell,L4130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,618.5,,,,,,,fee schedule,589.05,1444.75,APC
Replace pretibial shell,L4130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,589.05,,,,,,,fee schedule,589.05,1444.75,APC
Replace pretibial shell,L4130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1060.29,,,,,,,fee schedule,589.05,1444.75,APC
Ortho dvc repair per 15 min,L4205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.42,,,,,,,fee schedule,29.92,53.86,APC
Ortho dvc repair per 15 min,L4205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.92,,,,,,,fee schedule,29.92,53.86,APC
Ortho dvc repair per 15 min,L4205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53.86,,,,,,,fee schedule,29.92,53.86,APC
Ankle control ortho pre ots,L4350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.92,,,,,,,fee schedule,36.78,214.02,
Ankle control ortho pre ots,L4350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.78,,,,,,,fee schedule,36.78,214.02,
Ankle control ortho pre ots,L4350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.52,,,,,,,fee schedule,36.78,214.02,
Ankle control ortho pre ots,L4350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,56.1,,,,,,,fee schedule,36.78,214.02,
Ankle control ortho pre ots,L4350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,124.84,,,,,,,fee schedule,36.78,214.02,APC
Ankle control ortho pre ots,L4350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,118.9,,,,,,,fee schedule,36.78,214.02,APC
Ankle control ortho pre ots,L4350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,214.02,,,,,,,fee schedule,36.78,214.02,APC
Pneumat walking boot pre cst,L4360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,555.42,,,,,,,fee schedule,318.18,780.37,
Pneumat walking boot pre cst,L4360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,444.88,,,,,,,fee schedule,318.18,780.37,
Pneumat walking boot pre cst,L4360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,780.37,,,,,,,fee schedule,318.18,780.37,
Pneumat walking boot pre cst,L4360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,678.58,,,,,,,fee schedule,318.18,780.37,
Pneumat walking boot pre cst,L4360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,334.09,,,,,,,fee schedule,318.18,780.37,APC
Pneumat walking boot pre cst,L4360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,318.18,,,,,,,fee schedule,318.18,780.37,APC
Pneumat walking boot pre cst,L4360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,572.72,,,,,,,fee schedule,318.18,780.37,APC
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,555.42,,,,,,,fee schedule,318.18,780.37,
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,444.88,,,,,,,fee schedule,318.18,780.37,
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,780.37,,,,,,,fee schedule,318.18,780.37,
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,678.58,,,,,,,fee schedule,318.18,780.37,
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,334.09,,,,,,,fee schedule,318.18,780.37,APC
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,318.18,,,,,,,fee schedule,318.18,780.37,APC
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,572.72,,,,,,,fee schedule,318.18,780.37,APC
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,504.93,,,,,,,fee schedule,289.25,709.44,
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,404.44,,,,,,,fee schedule,289.25,709.44,
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,709.44,,,,,,,fee schedule,289.25,709.44,
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,616.9,,,,,,,fee schedule,289.25,709.44,
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,303.71,,,,,,,fee schedule,289.25,709.44,APC
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,289.25,,,,,,,fee schedule,289.25,709.44,APC
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,520.65,,,,,,,fee schedule,289.25,709.44,APC
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,340.14,,,,,,,fee schedule,194.86,477.91,
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,272.45,,,,,,,fee schedule,194.86,477.91,
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,477.91,,,,,,,fee schedule,194.86,477.91,
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,415.57,,,,,,,fee schedule,194.86,477.91,
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,204.6,,,,,,,fee schedule,194.86,477.91,APC
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,194.86,,,,,,,fee schedule,194.86,477.91,APC
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,350.75,,,,,,,fee schedule,194.86,477.91,APC
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,340.14,,,,,,,fee schedule,194.86,477.91,
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,272.45,,,,,,,fee schedule,194.86,477.91,
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,477.91,,,,,,,fee schedule,194.86,477.91,
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,415.57,,,,,,,fee schedule,194.86,477.91,
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,204.6,,,,,,,fee schedule,194.86,477.91,APC
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,194.86,,,,,,,fee schedule,194.86,477.91,APC
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,350.75,,,,,,,fee schedule,194.86,477.91,APC
Replace AFO soft interface,L4392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.45,,,,,,,fee schedule,28.91,70.89,
Replace AFO soft interface,L4392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.41,,,,,,,fee schedule,28.91,70.89,
Replace AFO soft interface,L4392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,70.89,,,,,,,fee schedule,28.91,70.89,
Replace AFO soft interface,L4392,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,61.64,,,,,,,fee schedule,28.91,70.89,
Replace AFO soft interface,L4392,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.36,,,,,,,fee schedule,28.91,70.89,APC
Replace AFO soft interface,L4392,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.91,,,,,,,fee schedule,28.91,70.89,APC
Replace AFO soft interface,L4392,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.04,,,,,,,fee schedule,28.91,70.89,APC
Replace foot drop spint,L4394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.85,,,,,,,fee schedule,21.09,51.77,
Replace foot drop spint,L4394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.52,,,,,,,fee schedule,21.09,51.77,
Replace foot drop spint,L4394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.77,,,,,,,fee schedule,21.09,51.77,
Replace foot drop spint,L4394,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.02,,,,,,,fee schedule,21.09,51.77,
Replace foot drop spint,L4394,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.14,,,,,,,fee schedule,21.09,51.77,APC
Replace foot drop spint,L4394,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.09,,,,,,,fee schedule,21.09,51.77,APC
Replace foot drop spint,L4394,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.96,,,,,,,fee schedule,21.09,51.77,APC
Static or dynami afo pre cst,L4396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,360.02,,,,,,,fee schedule,206.23,505.83,
Static or dynami afo pre cst,L4396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,288.37,,,,,,,fee schedule,206.23,505.83,
Static or dynami afo pre cst,L4396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,505.83,,,,,,,fee schedule,206.23,505.83,
Static or dynami afo pre cst,L4396,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,439.85,,,,,,,fee schedule,206.23,505.83,
Static or dynami afo pre cst,L4396,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,216.54,,,,,,,fee schedule,206.23,505.83,APC
Static or dynami afo pre cst,L4396,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,206.23,,,,,,,fee schedule,206.23,505.83,APC
Static or dynami afo pre cst,L4396,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,371.21,,,,,,,fee schedule,206.23,505.83,APC
Static or dynami afo pre ots,L4397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,360.02,,,,,,,fee schedule,206.23,505.83,
Static or dynami afo pre ots,L4397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,288.37,,,,,,,fee schedule,206.23,505.83,
Static or dynami afo pre ots,L4397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,505.83,,,,,,,fee schedule,206.23,505.83,
Static or dynami afo pre ots,L4397,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,439.85,,,,,,,fee schedule,206.23,505.83,
Static or dynami afo pre ots,L4397,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,216.54,,,,,,,fee schedule,206.23,505.83,APC
Static or dynami afo pre ots,L4397,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,206.23,,,,,,,fee schedule,206.23,505.83,APC
Static or dynami afo pre ots,L4397,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,371.21,,,,,,,fee schedule,206.23,505.83,APC
Foot drop splint pre ots,L4398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,165.71,,,,,,,fee schedule,94.92,232.83,
Foot drop splint pre ots,L4398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.73,,,,,,,fee schedule,94.92,232.83,
Foot drop splint pre ots,L4398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,232.83,,,,,,,fee schedule,94.92,232.83,
Foot drop splint pre ots,L4398,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,202.46,,,,,,,fee schedule,94.92,232.83,
Foot drop splint pre ots,L4398,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.67,,,,,,,fee schedule,94.92,232.83,APC
Foot drop splint pre ots,L4398,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.92,,,,,,,fee schedule,94.92,232.83,APC
Foot drop splint pre ots,L4398,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.86,,,,,,,fee schedule,94.92,232.83,APC
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3162.54,,,,,,,fee schedule,1811.67,4443.39,
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2533.12,,,,,,,fee schedule,1811.67,4443.39,
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4443.39,,,,,,,fee schedule,1811.67,4443.39,
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3863.82,,,,,,,fee schedule,1811.67,4443.39,
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1902.25,,,,,,,fee schedule,1811.67,4443.39,APC
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1811.67,,,,,,,fee schedule,1811.67,4443.39,APC
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3261.01,,,,,,,fee schedule,1811.67,4443.39,APC
Sho insert w arch toe filler,L5000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1231.9,,,,,,,fee schedule,705.71,1730.83,
Sho insert w arch toe filler,L5000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,986.72,,,,,,,fee schedule,705.71,1730.83,
Sho insert w arch toe filler,L5000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1730.83,,,,,,,fee schedule,705.71,1730.83,
Sho insert w arch toe filler,L5000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1505.07,,,,,,,fee schedule,705.71,1730.83,
Sho insert w arch toe filler,L5000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741,,,,,,,fee schedule,705.71,1730.83,APC
Sho insert w arch toe filler,L5000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,705.71,,,,,,,fee schedule,705.71,1730.83,APC
Sho insert w arch toe filler,L5000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1270.28,,,,,,,fee schedule,705.71,1730.83,APC
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3442.1,,,,,,,fee schedule,1971.82,4836.18,
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2757.04,,,,,,,fee schedule,1971.82,4836.18,
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4836.18,,,,,,,fee schedule,1971.82,4836.18,
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4205.37,,,,,,,fee schedule,1971.82,4836.18,
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2070.41,,,,,,,fee schedule,1971.82,4836.18,APC
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1971.82,,,,,,,fee schedule,1971.82,4836.18,APC
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3549.28,,,,,,,fee schedule,1971.82,4836.18,APC
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5392.67,,,,,,,fee schedule,3089.2,7576.75,
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4319.41,,,,,,,fee schedule,3089.2,7576.75,
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7576.75,,,,,,,fee schedule,3089.2,7576.75,
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6588.48,,,,,,,fee schedule,3089.2,7576.75,
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3243.66,,,,,,,fee schedule,3089.2,7576.75,APC
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3089.2,,,,,,,fee schedule,3089.2,7576.75,APC
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5560.56,,,,,,,fee schedule,3089.2,7576.75,APC
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5889.8,,,,,,,fee schedule,3374,8275.23,
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4717.6,,,,,,,fee schedule,3374,8275.23,
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8275.23,,,,,,,fee schedule,3374,8275.23,
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7195.85,,,,,,,fee schedule,3374,8275.23,
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3542.7,,,,,,,fee schedule,3374,8275.23,APC
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3374,,,,,,,fee schedule,3374,8275.23,APC
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6073.2,,,,,,,fee schedule,3374,8275.23,APC
Symes met fr leath socket ar,L5060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7260.41,,,,,,,fee schedule,4159.16,10200.95,
Symes met fr leath socket ar,L5060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5815.43,,,,,,,fee schedule,4159.16,10200.95,
Symes met fr leath socket ar,L5060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10200.95,,,,,,,fee schedule,4159.16,10200.95,
Symes met fr leath socket ar,L5060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8870.39,,,,,,,fee schedule,4159.16,10200.95,
Symes met fr leath socket ar,L5060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4367.12,,,,,,,fee schedule,4159.16,10200.95,APC
Symes met fr leath socket ar,L5060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4159.16,,,,,,,fee schedule,4159.16,10200.95,APC
Symes met fr leath socket ar,L5060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7486.49,,,,,,,fee schedule,4159.16,10200.95,APC
Molded socket shin sach foot,L5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5864.61,,,,,,,fee schedule,3359.56,8239.83,
Molded socket shin sach foot,L5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4697.42,,,,,,,fee schedule,3359.56,8239.83,
Molded socket shin sach foot,L5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8239.83,,,,,,,fee schedule,3359.56,8239.83,
Molded socket shin sach foot,L5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7165.07,,,,,,,fee schedule,3359.56,8239.83,
Molded socket shin sach foot,L5100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3527.54,,,,,,,fee schedule,3359.56,8239.83,APC
Molded socket shin sach foot,L5100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3359.56,,,,,,,fee schedule,3359.56,8239.83,APC
Molded socket shin sach foot,L5100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6047.21,,,,,,,fee schedule,3359.56,8239.83,APC
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8276.23,,,,,,,fee schedule,4741.07,11628.18,
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6629.07,,,,,,,fee schedule,4741.07,11628.18,
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11628.18,,,,,,,fee schedule,4741.07,11628.18,
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10111.46,,,,,,,fee schedule,4741.07,11628.18,
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4978.12,,,,,,,fee schedule,4741.07,11628.18,APC
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4741.07,,,,,,,fee schedule,4741.07,11628.18,APC
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8533.93,,,,,,,fee schedule,4741.07,11628.18,APC
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9201.2,,,,,,,fee schedule,5270.94,12927.77,
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7369.95,,,,,,,fee schedule,5270.94,12927.77,
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12927.77,,,,,,,fee schedule,5270.94,12927.77,
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11241.54,,,,,,,fee schedule,5270.94,12927.77,
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5534.49,,,,,,,fee schedule,5270.94,12927.77,APC
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5270.94,,,,,,,fee schedule,5270.94,12927.77,APC
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9487.69,,,,,,,fee schedule,5270.94,12927.77,APC
Mold socket bent knee shin s,L5160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10102.48,,,,,,,fee schedule,5787.25,14194.07,
Mold socket bent knee shin s,L5160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8091.85,,,,,,,fee schedule,5787.25,14194.07,
Mold socket bent knee shin s,L5160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14194.07,,,,,,,fee schedule,5787.25,14194.07,
Mold socket bent knee shin s,L5160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12342.67,,,,,,,fee schedule,5787.25,14194.07,
Mold socket bent knee shin s,L5160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6076.61,,,,,,,fee schedule,5787.25,14194.07,APC
Mold socket bent knee shin s,L5160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5787.25,,,,,,,fee schedule,5787.25,14194.07,APC
Mold socket bent knee shin s,L5160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10417.05,,,,,,,fee schedule,5787.25,14194.07,APC
Kne sing axis fric shin sach,L5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7813.51,,,,,,,fee schedule,4476.02,10978.05,
Kne sing axis fric shin sach,L5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6258.44,,,,,,,fee schedule,4476.02,10978.05,
Kne sing axis fric shin sach,L5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10978.05,,,,,,,fee schedule,4476.02,10978.05,
Kne sing axis fric shin sach,L5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9546.13,,,,,,,fee schedule,4476.02,10978.05,
Kne sing axis fric shin sach,L5200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4699.82,,,,,,,fee schedule,4476.02,10978.05,APC
Kne sing axis fric shin sach,L5200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4476.02,,,,,,,fee schedule,4476.02,10978.05,APC
Kne sing axis fric shin sach,L5200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8056.84,,,,,,,fee schedule,4476.02,10978.05,APC
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6203.93,,,,,,,fee schedule,3553.95,8716.57,
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4969.21,,,,,,,fee schedule,3553.95,8716.57,
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8716.57,,,,,,,fee schedule,3553.95,8716.57,
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7579.63,,,,,,,fee schedule,3553.95,8716.57,
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3731.65,,,,,,,fee schedule,3553.95,8716.57,APC
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3553.95,,,,,,,fee schedule,3553.95,8716.57,APC
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6397.11,,,,,,,fee schedule,3553.95,8716.57,APC
No knee joint with artic ali,L5220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6834.07,,,,,,,fee schedule,3914.91,9601.94,
No knee joint with artic ali,L5220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5473.94,,,,,,,fee schedule,3914.91,9601.94,
No knee joint with artic ali,L5220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9601.94,,,,,,,fee schedule,3914.91,9601.94,
No knee joint with artic ali,L5220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8349.51,,,,,,,fee schedule,3914.91,9601.94,
No knee joint with artic ali,L5220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4110.66,,,,,,,fee schedule,3914.91,9601.94,APC
No knee joint with artic ali,L5220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3914.91,,,,,,,fee schedule,3914.91,9601.94,APC
No knee joint with artic ali,L5220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7046.84,,,,,,,fee schedule,3914.91,9601.94,APC
Fem focal defic constant fri,L5230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10250.06,,,,,,,fee schedule,5871.76,14401.43,
Fem focal defic constant fri,L5230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8210.07,,,,,,,fee schedule,5871.76,14401.43,
Fem focal defic constant fri,L5230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14401.43,,,,,,,fee schedule,5871.76,14401.43,
Fem focal defic constant fri,L5230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12522.98,,,,,,,fee schedule,5871.76,14401.43,
Fem focal defic constant fri,L5230,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6165.35,,,,,,,fee schedule,5871.76,14401.43,APC
Fem focal defic constant fri,L5230,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5871.76,,,,,,,fee schedule,5871.76,14401.43,APC
Fem focal defic constant fri,L5230,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10569.17,,,,,,,fee schedule,5871.76,14401.43,APC
Hip canad sing axi cons fric,L5250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12018.45,,,,,,,fee schedule,6884.81,16886.04,
Hip canad sing axi cons fric,L5250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9626.51,,,,,,,fee schedule,6884.81,16886.04,
Hip canad sing axi cons fric,L5250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16886.04,,,,,,,fee schedule,6884.81,16886.04,
Hip canad sing axi cons fric,L5250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14683.51,,,,,,,fee schedule,6884.81,16886.04,
Hip canad sing axi cons fric,L5250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7229.05,,,,,,,fee schedule,6884.81,16886.04,APC
Hip canad sing axi cons fric,L5250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6884.81,,,,,,,fee schedule,6884.81,16886.04,APC
Hip canad sing axi cons fric,L5250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12392.66,,,,,,,fee schedule,6884.81,16886.04,APC
Tilt table locking hip sing,L5270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13390.91,,,,,,,fee schedule,7671.01,18814.35,
Tilt table locking hip sing,L5270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10725.81,,,,,,,fee schedule,7671.01,18814.35,
Tilt table locking hip sing,L5270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18814.35,,,,,,,fee schedule,7671.01,18814.35,
Tilt table locking hip sing,L5270,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16360.3,,,,,,,fee schedule,7671.01,18814.35,
Tilt table locking hip sing,L5270,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8054.56,,,,,,,fee schedule,7671.01,18814.35,APC
Tilt table locking hip sing,L5270,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7671.01,,,,,,,fee schedule,7671.01,18814.35,APC
Tilt table locking hip sing,L5270,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13807.82,,,,,,,fee schedule,7671.01,18814.35,APC
Hemipelvect canad sing axis,L5280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13016.43,,,,,,,fee schedule,7456.53,18288.21,
Hemipelvect canad sing axis,L5280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10425.87,,,,,,,fee schedule,7456.53,18288.21,
Hemipelvect canad sing axis,L5280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18288.21,,,,,,,fee schedule,7456.53,18288.21,
Hemipelvect canad sing axis,L5280,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15902.79,,,,,,,fee schedule,7456.53,18288.21,
Hemipelvect canad sing axis,L5280,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7829.36,,,,,,,fee schedule,7456.53,18288.21,APC
Hemipelvect canad sing axis,L5280,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7456.53,,,,,,,fee schedule,7456.53,18288.21,APC
Hemipelvect canad sing axis,L5280,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13421.75,,,,,,,fee schedule,7456.53,18288.21,APC
Bk mold socket sach ft endo,L5301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5758.9,,,,,,,fee schedule,3299.01,8091.31,
Bk mold socket sach ft endo,L5301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4612.75,,,,,,,fee schedule,3299.01,8091.31,
Bk mold socket sach ft endo,L5301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8091.31,,,,,,,fee schedule,3299.01,8091.31,
Bk mold socket sach ft endo,L5301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7035.92,,,,,,,fee schedule,3299.01,8091.31,
Bk mold socket sach ft endo,L5301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3463.96,,,,,,,fee schedule,3299.01,8091.31,APC
Bk mold socket sach ft endo,L5301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3299.01,,,,,,,fee schedule,3299.01,8091.31,APC
Bk mold socket sach ft endo,L5301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5938.22,,,,,,,fee schedule,3299.01,8091.31,APC
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9073.58,,,,,,,fee schedule,5197.83,12748.46,
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7267.73,,,,,,,fee schedule,5197.83,12748.46,
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12748.46,,,,,,,fee schedule,5197.83,12748.46,
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11085.62,,,,,,,fee schedule,5197.83,12748.46,
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5457.72,,,,,,,fee schedule,5197.83,12748.46,APC
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5197.83,,,,,,,fee schedule,5197.83,12748.46,APC
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9356.09,,,,,,,fee schedule,5197.83,12748.46,APC
Ak open end sach,L5321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7679.29,,,,,,,fee schedule,4399.13,10789.47,
Ak open end sach,L5321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6150.94,,,,,,,fee schedule,4399.13,10789.47,
Ak open end sach,L5321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10789.47,,,,,,,fee schedule,4399.13,10789.47,
Ak open end sach,L5321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9382.15,,,,,,,fee schedule,4399.13,10789.47,
Ak open end sach,L5321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4619.09,,,,,,,fee schedule,4399.13,10789.47,APC
Ak open end sach,L5321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4399.13,,,,,,,fee schedule,4399.13,10789.47,APC
Ak open end sach,L5321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7918.43,,,,,,,fee schedule,4399.13,10789.47,APC
Hip disart canadian sach ft,L5331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11247.44,,,,,,,fee schedule,6443.12,15802.76,
Hip disart canadian sach ft,L5331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9008.95,,,,,,,fee schedule,6443.12,15802.76,
Hip disart canadian sach ft,L5331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15802.76,,,,,,,fee schedule,6443.12,15802.76,
Hip disart canadian sach ft,L5331,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13741.53,,,,,,,fee schedule,6443.12,15802.76,
Hip disart canadian sach ft,L5331,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6765.28,,,,,,,fee schedule,6443.12,15802.76,APC
Hip disart canadian sach ft,L5331,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6443.12,,,,,,,fee schedule,6443.12,15802.76,APC
Hip disart canadian sach ft,L5331,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11597.62,,,,,,,fee schedule,6443.12,15802.76,APC
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11955.83,,,,,,,fee schedule,6848.94,16798.05,
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9576.35,,,,,,,fee schedule,6848.94,16798.05,
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16798.05,,,,,,,fee schedule,6848.94,16798.05,
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14607,,,,,,,fee schedule,6848.94,16798.05,
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7191.39,,,,,,,fee schedule,6848.94,16798.05,APC
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6848.94,,,,,,,fee schedule,6848.94,16798.05,APC
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12328.09,,,,,,,fee schedule,6848.94,16798.05,APC
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3429.44,,,,,,,fee schedule,1964.57,4818.4,
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2746.9,,,,,,,fee schedule,1964.57,4818.4,
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4818.4,,,,,,,fee schedule,1964.57,4818.4,
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4189.91,,,,,,,fee schedule,1964.57,4818.4,
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2062.8,,,,,,,fee schedule,1964.57,4818.4,APC
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1964.57,,,,,,,fee schedule,1964.57,4818.4,APC
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3536.23,,,,,,,fee schedule,1964.57,4818.4,APC
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,947.45,,,,,,,fee schedule,542.75,1331.18,
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,758.89,,,,,,,fee schedule,542.75,1331.18,
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1331.18,,,,,,,fee schedule,542.75,1331.18,
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1157.55,,,,,,,fee schedule,542.75,1331.18,
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,569.89,,,,,,,fee schedule,542.75,1331.18,APC
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,542.75,,,,,,,fee schedule,542.75,1331.18,APC
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,976.95,,,,,,,fee schedule,542.75,1331.18,APC
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4331.25,,,,,,,fee schedule,2481.17,6085.44,
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3469.23,,,,,,,fee schedule,2481.17,6085.44,
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6085.44,,,,,,,fee schedule,2481.17,6085.44,
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5291.69,,,,,,,fee schedule,2481.17,6085.44,
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2605.23,,,,,,,fee schedule,2481.17,6085.44,APC
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2481.17,,,,,,,fee schedule,2481.17,6085.44,APC
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4466.11,,,,,,,fee schedule,2481.17,6085.44,APC
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1175.69,,,,,,,fee schedule,673.51,1651.85,
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,941.7,,,,,,,fee schedule,673.51,1651.85,
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1651.85,,,,,,,fee schedule,673.51,1651.85,
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1436.39,,,,,,,fee schedule,673.51,1651.85,
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,707.19,,,,,,,fee schedule,673.51,1651.85,APC
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,673.51,,,,,,,fee schedule,673.51,1651.85,APC
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1212.32,,,,,,,fee schedule,673.51,1651.85,APC
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1016.59,,,,,,,fee schedule,582.35,1428.32,
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,814.27,,,,,,,fee schedule,582.35,1428.32,
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1428.32,,,,,,,fee schedule,582.35,1428.32,
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1242.02,,,,,,,fee schedule,582.35,1428.32,
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,611.47,,,,,,,fee schedule,582.35,1428.32,APC
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,582.35,,,,,,,fee schedule,582.35,1428.32,APC
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1048.23,,,,,,,fee schedule,582.35,1428.32,APC
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1333.36,,,,,,,fee schedule,763.82,1873.38,
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1067.99,,,,,,,fee schedule,763.82,1873.38,
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1873.38,,,,,,,fee schedule,763.82,1873.38,
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1629.03,,,,,,,fee schedule,763.82,1873.38,
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,802.01,,,,,,,fee schedule,763.82,1873.38,APC
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,763.82,,,,,,,fee schedule,763.82,1873.38,APC
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1374.88,,,,,,,fee schedule,763.82,1873.38,APC
Init bk ptb plaster direct,L5500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3169.85,,,,,,,fee schedule,1815.83,4453.66,
Init bk ptb plaster direct,L5500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2538.97,,,,,,,fee schedule,1815.83,4453.66,
Init bk ptb plaster direct,L5500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4453.66,,,,,,,fee schedule,1815.83,4453.66,
Init bk ptb plaster direct,L5500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3872.75,,,,,,,fee schedule,1815.83,4453.66,
Init bk ptb plaster direct,L5500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1906.62,,,,,,,fee schedule,1815.83,4453.66,APC
Init bk ptb plaster direct,L5500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1815.83,,,,,,,fee schedule,1815.83,4453.66,APC
Init bk ptb plaster direct,L5500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3268.49,,,,,,,fee schedule,1815.83,4453.66,APC
Init ak ischal plstr direct,L5505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4459.05,,,,,,,fee schedule,2554.38,6265,
Init ak ischal plstr direct,L5505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3571.6,,,,,,,fee schedule,2554.38,6265,
Init ak ischal plstr direct,L5505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6265,,,,,,,fee schedule,2554.38,6265,
Init ak ischal plstr direct,L5505,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5447.83,,,,,,,fee schedule,2554.38,6265,
Init ak ischal plstr direct,L5505,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2682.1,,,,,,,fee schedule,2554.38,6265,APC
Init ak ischal plstr direct,L5505,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2554.38,,,,,,,fee schedule,2554.38,6265,APC
Init ak ischal plstr direct,L5505,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4597.88,,,,,,,fee schedule,2554.38,6265,APC
Prep BK ptb plaster molded,L5510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3785.27,,,,,,,fee schedule,2168.42,5318.34,
Prep BK ptb plaster molded,L5510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3031.91,,,,,,,fee schedule,2168.42,5318.34,
Prep BK ptb plaster molded,L5510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5318.34,,,,,,,fee schedule,2168.42,5318.34,
Prep BK ptb plaster molded,L5510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4624.64,,,,,,,fee schedule,2168.42,5318.34,
Prep BK ptb plaster molded,L5510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2276.84,,,,,,,fee schedule,2168.42,5318.34,APC
Prep BK ptb plaster molded,L5510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2168.42,,,,,,,fee schedule,2168.42,5318.34,APC
Prep BK ptb plaster molded,L5510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3903.16,,,,,,,fee schedule,2168.42,5318.34,APC
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3393.06,,,,,,,fee schedule,1943.72,4767.28,
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2717.76,,,,,,,fee schedule,1943.72,4767.28,
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4767.28,,,,,,,fee schedule,1943.72,4767.28,
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4145.46,,,,,,,fee schedule,1943.72,4767.28,
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2040.91,,,,,,,fee schedule,1943.72,4767.28,APC
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1943.72,,,,,,,fee schedule,1943.72,4767.28,APC
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3498.7,,,,,,,fee schedule,1943.72,4767.28,APC
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4460.37,,,,,,,fee schedule,2555.15,6266.86,
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3572.65,,,,,,,fee schedule,2555.15,6266.86,
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6266.86,,,,,,,fee schedule,2555.15,6266.86,
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5449.44,,,,,,,fee schedule,2555.15,6266.86,
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2682.91,,,,,,,fee schedule,2555.15,6266.86,APC
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2555.15,,,,,,,fee schedule,2555.15,6266.86,APC
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4599.27,,,,,,,fee schedule,2555.15,6266.86,APC
Prep BK ptb open end socket,L5535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4158.01,,,,,,,fee schedule,2381.94,5842.05,
Prep BK ptb open end socket,L5535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3330.47,,,,,,,fee schedule,2381.94,5842.05,
Prep BK ptb open end socket,L5535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5842.05,,,,,,,fee schedule,2381.94,5842.05,
Prep BK ptb open end socket,L5535,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5080.04,,,,,,,fee schedule,2381.94,5842.05,
Prep BK ptb open end socket,L5535,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2501.04,,,,,,,fee schedule,2381.94,5842.05,APC
Prep BK ptb open end socket,L5535,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2381.94,,,,,,,fee schedule,2381.94,5842.05,APC
Prep BK ptb open end socket,L5535,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4287.49,,,,,,,fee schedule,2381.94,5842.05,APC
Prep BK ptb laminated socket,L5540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4403.96,,,,,,,fee schedule,2522.82,6187.6,
Prep BK ptb laminated socket,L5540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3527.47,,,,,,,fee schedule,2522.82,6187.6,
Prep BK ptb laminated socket,L5540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6187.6,,,,,,,fee schedule,2522.82,6187.6,
Prep BK ptb laminated socket,L5540,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5380.52,,,,,,,fee schedule,2522.82,6187.6,
Prep BK ptb laminated socket,L5540,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2648.96,,,,,,,fee schedule,2522.82,6187.6,APC
Prep BK ptb laminated socket,L5540,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2522.82,,,,,,,fee schedule,2522.82,6187.6,APC
Prep BK ptb laminated socket,L5540,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4541.08,,,,,,,fee schedule,2522.82,6187.6,APC
Prep AK ischial plast molded,L5560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5018.07,,,,,,,fee schedule,2874.62,7050.43,
Prep AK ischial plast molded,L5560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4019.36,,,,,,,fee schedule,2874.62,7050.43,
Prep AK ischial plast molded,L5560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7050.43,,,,,,,fee schedule,2874.62,7050.43,
Prep AK ischial plast molded,L5560,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6130.81,,,,,,,fee schedule,2874.62,7050.43,
Prep AK ischial plast molded,L5560,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3018.35,,,,,,,fee schedule,2874.62,7050.43,APC
Prep AK ischial plast molded,L5560,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2874.62,,,,,,,fee schedule,2874.62,7050.43,APC
Prep AK ischial plast molded,L5560,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5174.32,,,,,,,fee schedule,2874.62,7050.43,APC
Prep AK ischial direct form,L5570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4870.21,,,,,,,fee schedule,2789.92,6842.68,
Prep AK ischial direct form,L5570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3900.92,,,,,,,fee schedule,2789.92,6842.68,
Prep AK ischial direct form,L5570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6842.68,,,,,,,fee schedule,2789.92,6842.68,
Prep AK ischial direct form,L5570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5950.16,,,,,,,fee schedule,2789.92,6842.68,
Prep AK ischial direct form,L5570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2929.42,,,,,,,fee schedule,2789.92,6842.68,APC
Prep AK ischial direct form,L5570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2789.92,,,,,,,fee schedule,2789.92,6842.68,APC
Prep AK ischial direct form,L5570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5021.86,,,,,,,fee schedule,2789.92,6842.68,APC
Prep AK ischial thermo mold,L5580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6044.62,,,,,,,fee schedule,3462.71,8492.75,
Prep AK ischial thermo mold,L5580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4841.61,,,,,,,fee schedule,3462.71,8492.75,
Prep AK ischial thermo mold,L5580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8492.75,,,,,,,fee schedule,3462.71,8492.75,
Prep AK ischial thermo mold,L5580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7385,,,,,,,fee schedule,3462.71,8492.75,
Prep AK ischial thermo mold,L5580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3635.85,,,,,,,fee schedule,3462.71,8492.75,APC
Prep AK ischial thermo mold,L5580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3462.71,,,,,,,fee schedule,3462.71,8492.75,APC
Prep AK ischial thermo mold,L5580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6232.88,,,,,,,fee schedule,3462.71,8492.75,APC
Prep AK ischial open end,L5585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7078.76,,,,,,,fee schedule,4055.09,9945.72,
Prep AK ischial open end,L5585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5669.92,,,,,,,fee schedule,4055.09,9945.72,
Prep AK ischial open end,L5585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9945.72,,,,,,,fee schedule,4055.09,9945.72,
Prep AK ischial open end,L5585,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8648.45,,,,,,,fee schedule,4055.09,9945.72,
Prep AK ischial open end,L5585,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4257.84,,,,,,,fee schedule,4055.09,9945.72,APC
Prep AK ischial open end,L5585,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4055.09,,,,,,,fee schedule,4055.09,9945.72,APC
Prep AK ischial open end,L5585,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7299.16,,,,,,,fee schedule,4055.09,9945.72,APC
Prep AK ischial laminated,L5590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6302.13,,,,,,,fee schedule,3610.21,8854.55,
Prep AK ischial laminated,L5590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5047.86,,,,,,,fee schedule,3610.21,8854.55,
Prep AK ischial laminated,L5590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8854.55,,,,,,,fee schedule,3610.21,8854.55,
Prep AK ischial laminated,L5590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7699.61,,,,,,,fee schedule,3610.21,8854.55,
Prep AK ischial laminated,L5590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3790.72,,,,,,,fee schedule,3610.21,8854.55,APC
Prep AK ischial laminated,L5590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3610.21,,,,,,,fee schedule,3610.21,8854.55,APC
Prep AK ischial laminated,L5590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6498.38,,,,,,,fee schedule,3610.21,8854.55,APC
Hip disartic sach thermopls,L5595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9848.63,,,,,,,fee schedule,5641.82,13837.41,
Hip disartic sach thermopls,L5595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7888.53,,,,,,,fee schedule,5641.82,13837.41,
Hip disartic sach thermopls,L5595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13837.41,,,,,,,fee schedule,5641.82,13837.41,
Hip disartic sach thermopls,L5595,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12032.53,,,,,,,fee schedule,5641.82,13837.41,
Hip disartic sach thermopls,L5595,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5923.91,,,,,,,fee schedule,5641.82,13837.41,APC
Hip disartic sach thermopls,L5595,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5641.82,,,,,,,fee schedule,5641.82,13837.41,APC
Hip disartic sach thermopls,L5595,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10155.28,,,,,,,fee schedule,5641.82,13837.41,APC
Hip disart sach laminat mold,L5600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11209.16,,,,,,,fee schedule,6421.23,15748.97,
Hip disart sach laminat mold,L5600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8978.28,,,,,,,fee schedule,6421.23,15748.97,
Hip disart sach laminat mold,L5600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15748.97,,,,,,,fee schedule,6421.23,15748.97,
Hip disart sach laminat mold,L5600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13694.76,,,,,,,fee schedule,6421.23,15748.97,
Hip disart sach laminat mold,L5600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6742.29,,,,,,,fee schedule,6421.23,15748.97,APC
Hip disart sach laminat mold,L5600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6421.23,,,,,,,fee schedule,6421.23,15748.97,APC
Hip disart sach laminat mold,L5600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11558.21,,,,,,,fee schedule,6421.23,15748.97,APC
Above knee hydracadence,L5610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5406.12,,,,,,,fee schedule,3096.92,7595.65,
Above knee hydracadence,L5610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4330.18,,,,,,,fee schedule,3096.92,7595.65,
Above knee hydracadence,L5610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7595.65,,,,,,,fee schedule,3096.92,7595.65,
Above knee hydracadence,L5610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6604.91,,,,,,,fee schedule,3096.92,7595.65,
Above knee hydracadence,L5610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3251.77,,,,,,,fee schedule,3096.92,7595.65,APC
Above knee hydracadence,L5610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3096.92,,,,,,,fee schedule,3096.92,7595.65,APC
Above knee hydracadence,L5610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5574.46,,,,,,,fee schedule,3096.92,7595.65,APC
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3443.24,,,,,,,fee schedule,1972.47,4837.79,
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2757.96,,,,,,,fee schedule,1972.47,4837.79,
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4837.79,,,,,,,fee schedule,1972.47,4837.79,
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4206.77,,,,,,,fee schedule,1972.47,4837.79,
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2071.09,,,,,,,fee schedule,1972.47,4837.79,APC
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1972.47,,,,,,,fee schedule,1972.47,4837.79,APC
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3550.45,,,,,,,fee schedule,1972.47,4837.79,APC
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5237.39,,,,,,,fee schedule,3000.26,7358.57,
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4195.03,,,,,,,fee schedule,3000.26,7358.57,
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7358.57,,,,,,,fee schedule,3000.26,7358.57,
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6398.76,,,,,,,fee schedule,3000.26,7358.57,
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3150.27,,,,,,,fee schedule,3000.26,7358.57,APC
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3000.26,,,,,,,fee schedule,3000.26,7358.57,APC
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5400.47,,,,,,,fee schedule,3000.26,7358.57,APC
4-bar link above knee w/swng,L5614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3627.25,,,,,,,fee schedule,2077.88,5096.32,
4-bar link above knee w/swng,L5614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2905.34,,,,,,,fee schedule,2077.88,5096.32,
4-bar link above knee w/swng,L5614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5096.32,,,,,,,fee schedule,2077.88,5096.32,
4-bar link above knee w/swng,L5614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4431.58,,,,,,,fee schedule,2077.88,5096.32,
4-bar link above knee w/swng,L5614,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2181.77,,,,,,,fee schedule,2077.88,5096.32,APC
4-bar link above knee w/swng,L5614,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2077.88,,,,,,,fee schedule,2077.88,5096.32,APC
4-bar link above knee w/swng,L5614,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3740.18,,,,,,,fee schedule,2077.88,5096.32,APC
Ak 4 bar link hydl swg/stanc,L5615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7274.39,,,,,,,fee schedule,6927.99,12470.38,APC
Ak 4 bar link hydl swg/stanc,L5615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6927.99,,,,,,,fee schedule,6927.99,12470.38,APC
Ak 4 bar link hydl swg/stanc,L5615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12470.38,,,,,,,fee schedule,6927.99,12470.38,APC
Ak univ multiplex sys frict,L5616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3158,,,,,,,fee schedule,1809.06,4437.02,
Ak univ multiplex sys frict,L5616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2529.49,,,,,,,fee schedule,1809.06,4437.02,
Ak univ multiplex sys frict,L5616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4437.02,,,,,,,fee schedule,1809.06,4437.02,
Ak univ multiplex sys frict,L5616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3858.28,,,,,,,fee schedule,1809.06,4437.02,
Ak univ multiplex sys frict,L5616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1899.51,,,,,,,fee schedule,1809.06,4437.02,APC
Ak univ multiplex sys frict,L5616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1809.06,,,,,,,fee schedule,1809.06,4437.02,APC
Ak univ multiplex sys frict,L5616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3256.31,,,,,,,fee schedule,1809.06,4437.02,APC
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1202.67,,,,,,,fee schedule,688.96,1689.76,
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,963.31,,,,,,,fee schedule,688.96,1689.76,
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1689.76,,,,,,,fee schedule,688.96,1689.76,
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1469.36,,,,,,,fee schedule,688.96,1689.76,
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,723.41,,,,,,,fee schedule,688.96,1689.76,APC
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,688.96,,,,,,,fee schedule,688.96,1689.76,APC
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1240.13,,,,,,,fee schedule,688.96,1689.76,APC
Test socket symes,L5618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,718.21,,,,,,,fee schedule,411.43,1009.09,
Test socket symes,L5618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,575.27,,,,,,,fee schedule,411.43,1009.09,
Test socket symes,L5618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1009.09,,,,,,,fee schedule,411.43,1009.09,
Test socket symes,L5618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,877.47,,,,,,,fee schedule,411.43,1009.09,
Test socket symes,L5618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,432,,,,,,,fee schedule,411.43,1009.09,APC
Test socket symes,L5618,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,411.43,,,,,,,fee schedule,411.43,1009.09,APC
Test socket symes,L5618,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,740.57,,,,,,,fee schedule,411.43,1009.09,APC
Test socket below knee,L5620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,637.21,,,,,,,fee schedule,365.04,895.29,
Test socket below knee,L5620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,510.39,,,,,,,fee schedule,365.04,895.29,
Test socket below knee,L5620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,895.29,,,,,,,fee schedule,365.04,895.29,
Test socket below knee,L5620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,778.51,,,,,,,fee schedule,365.04,895.29,
Test socket below knee,L5620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,383.29,,,,,,,fee schedule,365.04,895.29,APC
Test socket below knee,L5620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,365.04,,,,,,,fee schedule,365.04,895.29,APC
Test socket below knee,L5620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,657.07,,,,,,,fee schedule,365.04,895.29,APC
Test socket knee disarticula,L5622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,858.47,,,,,,,fee schedule,491.79,1206.15,
Test socket knee disarticula,L5622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,687.61,,,,,,,fee schedule,491.79,1206.15,
Test socket knee disarticula,L5622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1206.15,,,,,,,fee schedule,491.79,1206.15,
Test socket knee disarticula,L5622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1048.83,,,,,,,fee schedule,491.79,1206.15,
Test socket knee disarticula,L5622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,516.38,,,,,,,fee schedule,491.79,1206.15,APC
Test socket knee disarticula,L5622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,491.79,,,,,,,fee schedule,491.79,1206.15,APC
Test socket knee disarticula,L5622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,885.22,,,,,,,fee schedule,491.79,1206.15,APC
Test socket above knee,L5624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,858.17,,,,,,,fee schedule,491.61,1205.74,
Test socket above knee,L5624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,687.38,,,,,,,fee schedule,491.61,1205.74,
Test socket above knee,L5624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1205.74,,,,,,,fee schedule,491.61,1205.74,
Test socket above knee,L5624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1048.47,,,,,,,fee schedule,491.61,1205.74,
Test socket above knee,L5624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,516.19,,,,,,,fee schedule,491.61,1205.74,APC
Test socket above knee,L5624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,491.61,,,,,,,fee schedule,491.61,1205.74,APC
Test socket above knee,L5624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,884.9,,,,,,,fee schedule,491.61,1205.74,APC
Test socket hip disarticulat,L5626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1358.6,,,,,,,fee schedule,778.27,1908.84,
Test socket hip disarticulat,L5626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1088.2,,,,,,,fee schedule,778.27,1908.84,
Test socket hip disarticulat,L5626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1908.84,,,,,,,fee schedule,778.27,1908.84,
Test socket hip disarticulat,L5626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1659.86,,,,,,,fee schedule,778.27,1908.84,
Test socket hip disarticulat,L5626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,817.18,,,,,,,fee schedule,778.27,1908.84,APC
Test socket hip disarticulat,L5626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,778.27,,,,,,,fee schedule,778.27,1908.84,APC
Test socket hip disarticulat,L5626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1400.89,,,,,,,fee schedule,778.27,1908.84,APC
Test socket hemipelvectomy,L5628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1375.75,,,,,,,fee schedule,788.11,1932.94,
Test socket hemipelvectomy,L5628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1101.95,,,,,,,fee schedule,788.11,1932.94,
Test socket hemipelvectomy,L5628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1932.94,,,,,,,fee schedule,788.11,1932.94,
Test socket hemipelvectomy,L5628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1680.82,,,,,,,fee schedule,788.11,1932.94,
Test socket hemipelvectomy,L5628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,827.52,,,,,,,fee schedule,788.11,1932.94,APC
Test socket hemipelvectomy,L5628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,788.11,,,,,,,fee schedule,788.11,1932.94,APC
Test socket hemipelvectomy,L5628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1418.6,,,,,,,fee schedule,788.11,1932.94,APC
Below knee acrylic socket,L5629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,679.17,,,,,,,fee schedule,389.06,954.24,
Below knee acrylic socket,L5629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,544,,,,,,,fee schedule,389.06,954.24,
Below knee acrylic socket,L5629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,954.24,,,,,,,fee schedule,389.06,954.24,
Below knee acrylic socket,L5629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,829.77,,,,,,,fee schedule,389.06,954.24,
Below knee acrylic socket,L5629,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,408.51,,,,,,,fee schedule,389.06,954.24,APC
Below knee acrylic socket,L5629,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,389.06,,,,,,,fee schedule,389.06,954.24,APC
Below knee acrylic socket,L5629,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,700.31,,,,,,,fee schedule,389.06,954.24,APC
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1180.05,,,,,,,fee schedule,676.01,1657.98,
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,945.19,,,,,,,fee schedule,676.01,1657.98,
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1657.98,,,,,,,fee schedule,676.01,1657.98,
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1441.72,,,,,,,fee schedule,676.01,1657.98,
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,709.81,,,,,,,fee schedule,676.01,1657.98,APC
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,676.01,,,,,,,fee schedule,676.01,1657.98,APC
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1216.82,,,,,,,fee schedule,676.01,1657.98,APC
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,939.01,,,,,,,fee schedule,537.91,1319.31,
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,752.12,,,,,,,fee schedule,537.91,1319.31,
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1319.31,,,,,,,fee schedule,537.91,1319.31,
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1147.23,,,,,,,fee schedule,537.91,1319.31,
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.81,,,,,,,fee schedule,537.91,1319.31,APC
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,537.91,,,,,,,fee schedule,537.91,1319.31,APC
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,968.24,,,,,,,fee schedule,537.91,1319.31,APC
Symes type ptb brim design s,L5632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,578.76,,,,,,,fee schedule,331.54,813.17,
Symes type ptb brim design s,L5632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,463.57,,,,,,,fee schedule,331.54,813.17,
Symes type ptb brim design s,L5632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,813.17,,,,,,,fee schedule,331.54,813.17,
Symes type ptb brim design s,L5632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,707.1,,,,,,,fee schedule,331.54,813.17,
Symes type ptb brim design s,L5632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,348.12,,,,,,,fee schedule,331.54,813.17,APC
Symes type ptb brim design s,L5632,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,331.54,,,,,,,fee schedule,331.54,813.17,APC
Symes type ptb brim design s,L5632,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,596.77,,,,,,,fee schedule,331.54,813.17,APC
Symes type poster opening so,L5634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,723.77,,,,,,,fee schedule,414.62,1016.91,
Symes type poster opening so,L5634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,579.73,,,,,,,fee schedule,414.62,1016.91,
Symes type poster opening so,L5634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1016.91,,,,,,,fee schedule,414.62,1016.91,
Symes type poster opening so,L5634,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,884.27,,,,,,,fee schedule,414.62,1016.91,
Symes type poster opening so,L5634,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,435.35,,,,,,,fee schedule,414.62,1016.91,APC
Symes type poster opening so,L5634,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,414.62,,,,,,,fee schedule,414.62,1016.91,APC
Symes type poster opening so,L5634,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,746.32,,,,,,,fee schedule,414.62,1016.91,APC
Symes type medial opening so,L5636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,553.22,,,,,,,fee schedule,316.91,777.29,
Symes type medial opening so,L5636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,443.12,,,,,,,fee schedule,316.91,777.29,
Symes type medial opening so,L5636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,777.29,,,,,,,fee schedule,316.91,777.29,
Symes type medial opening so,L5636,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,675.9,,,,,,,fee schedule,316.91,777.29,
Symes type medial opening so,L5636,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,332.76,,,,,,,fee schedule,316.91,777.29,APC
Symes type medial opening so,L5636,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,316.91,,,,,,,fee schedule,316.91,777.29,APC
Symes type medial opening so,L5636,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,570.44,,,,,,,fee schedule,316.91,777.29,APC
Below knee total contact,L5637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,823.18,,,,,,,fee schedule,471.56,1156.58,
Below knee total contact,L5637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,659.35,,,,,,,fee schedule,471.56,1156.58,
Below knee total contact,L5637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1156.58,,,,,,,fee schedule,471.56,1156.58,
Below knee total contact,L5637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1005.72,,,,,,,fee schedule,471.56,1156.58,
Below knee total contact,L5637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,495.14,,,,,,,fee schedule,471.56,1156.58,APC
Below knee total contact,L5637,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,471.56,,,,,,,fee schedule,471.56,1156.58,APC
Below knee total contact,L5637,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,848.81,,,,,,,fee schedule,471.56,1156.58,APC
Below knee leather socket,L5638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1386.72,,,,,,,fee schedule,794.39,1948.35,
Below knee leather socket,L5638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1110.73,,,,,,,fee schedule,794.39,1948.35,
Below knee leather socket,L5638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1948.35,,,,,,,fee schedule,794.39,1948.35,
Below knee leather socket,L5638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1694.22,,,,,,,fee schedule,794.39,1948.35,
Below knee leather socket,L5638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.11,,,,,,,fee schedule,794.39,1948.35,APC
Below knee leather socket,L5638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,794.39,,,,,,,fee schedule,794.39,1948.35,APC
Below knee leather socket,L5638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1429.9,,,,,,,fee schedule,794.39,1948.35,APC
Below knee wood socket,L5639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2396.07,,,,,,,fee schedule,1372.6,3366.5,
Below knee wood socket,L5639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1919.2,,,,,,,fee schedule,1372.6,3366.5,
Below knee wood socket,L5639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3366.5,,,,,,,fee schedule,1372.6,3366.5,
Below knee wood socket,L5639,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2927.39,,,,,,,fee schedule,1372.6,3366.5,
Below knee wood socket,L5639,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1441.23,,,,,,,fee schedule,1372.6,3366.5,APC
Below knee wood socket,L5639,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1372.6,,,,,,,fee schedule,1372.6,3366.5,APC
Below knee wood socket,L5639,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2470.68,,,,,,,fee schedule,1372.6,3366.5,APC
Knee disarticulat leather so,L5640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1574.95,,,,,,,fee schedule,902.21,2212.82,
Knee disarticulat leather so,L5640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1261.5,,,,,,,fee schedule,902.21,2212.82,
Knee disarticulat leather so,L5640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2212.82,,,,,,,fee schedule,902.21,2212.82,
Knee disarticulat leather so,L5640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1924.19,,,,,,,fee schedule,902.21,2212.82,
Knee disarticulat leather so,L5640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,947.32,,,,,,,fee schedule,902.21,2212.82,APC
Knee disarticulat leather so,L5640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,902.21,,,,,,,fee schedule,902.21,2212.82,APC
Knee disarticulat leather so,L5640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1623.98,,,,,,,fee schedule,902.21,2212.82,APC
Above knee leather socket,L5642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1459.92,,,,,,,fee schedule,836.32,2051.2,
Above knee leather socket,L5642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1169.36,,,,,,,fee schedule,836.32,2051.2,
Above knee leather socket,L5642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2051.2,,,,,,,fee schedule,836.32,2051.2,
Above knee leather socket,L5642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1783.65,,,,,,,fee schedule,836.32,2051.2,
Above knee leather socket,L5642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,878.14,,,,,,,fee schedule,836.32,2051.2,APC
Above knee leather socket,L5642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,836.32,,,,,,,fee schedule,836.32,2051.2,APC
Above knee leather socket,L5642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1505.38,,,,,,,fee schedule,836.32,2051.2,APC
Hip flex inner socket ext fr,L5643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4306,,,,,,,fee schedule,2466.73,6049.97,
Hip flex inner socket ext fr,L5643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3449.01,,,,,,,fee schedule,2466.73,6049.97,
Hip flex inner socket ext fr,L5643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6049.97,,,,,,,fee schedule,2466.73,6049.97,
Hip flex inner socket ext fr,L5643,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5260.84,,,,,,,fee schedule,2466.73,6049.97,
Hip flex inner socket ext fr,L5643,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2590.07,,,,,,,fee schedule,2466.73,6049.97,APC
Hip flex inner socket ext fr,L5643,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2466.73,,,,,,,fee schedule,2466.73,6049.97,APC
Hip flex inner socket ext fr,L5643,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4440.11,,,,,,,fee schedule,2466.73,6049.97,APC
Above knee wood socket,L5644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1262.26,,,,,,,fee schedule,723.09,1773.48,
Above knee wood socket,L5644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1011.04,,,,,,,fee schedule,723.09,1773.48,
Above knee wood socket,L5644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1773.48,,,,,,,fee schedule,723.09,1773.48,
Above knee wood socket,L5644,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1542.16,,,,,,,fee schedule,723.09,1773.48,
Above knee wood socket,L5644,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,759.24,,,,,,,fee schedule,723.09,1773.48,APC
Above knee wood socket,L5644,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,723.09,,,,,,,fee schedule,723.09,1773.48,APC
Above knee wood socket,L5644,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1301.56,,,,,,,fee schedule,723.09,1773.48,APC
Bk flex inner socket ext fra,L5645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2094.02,,,,,,,fee schedule,1199.56,2942.11,
Bk flex inner socket ext fra,L5645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1677.26,,,,,,,fee schedule,1199.56,2942.11,
Bk flex inner socket ext fra,L5645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2942.11,,,,,,,fee schedule,1199.56,2942.11,
Bk flex inner socket ext fra,L5645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2558.36,,,,,,,fee schedule,1199.56,2942.11,
Bk flex inner socket ext fra,L5645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1259.54,,,,,,,fee schedule,1199.56,2942.11,APC
Bk flex inner socket ext fra,L5645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1199.56,,,,,,,fee schedule,1199.56,2942.11,APC
Bk flex inner socket ext fra,L5645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2159.21,,,,,,,fee schedule,1199.56,2942.11,APC
Below knee cushion socket,L5646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1327.03,,,,,,,fee schedule,760.2,1864.48,
Below knee cushion socket,L5646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1062.92,,,,,,,fee schedule,760.2,1864.48,
Below knee cushion socket,L5646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1864.48,,,,,,,fee schedule,760.2,1864.48,
Below knee cushion socket,L5646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1621.29,,,,,,,fee schedule,760.2,1864.48,
Below knee cushion socket,L5646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798.21,,,,,,,fee schedule,760.2,1864.48,APC
Below knee cushion socket,L5646,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,760.2,,,,,,,fee schedule,760.2,1864.48,APC
Below knee cushion socket,L5646,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1368.36,,,,,,,fee schedule,760.2,1864.48,APC
Below knee suction socket,L5647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1699.98,,,,,,,fee schedule,973.84,2388.49,
Below knee suction socket,L5647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1361.65,,,,,,,fee schedule,973.84,2388.49,
Below knee suction socket,L5647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2388.49,,,,,,,fee schedule,973.84,2388.49,
Below knee suction socket,L5647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2076.95,,,,,,,fee schedule,973.84,2388.49,
Below knee suction socket,L5647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1022.53,,,,,,,fee schedule,973.84,2388.49,APC
Below knee suction socket,L5647,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,973.84,,,,,,,fee schedule,973.84,2388.49,APC
Below knee suction socket,L5647,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1752.91,,,,,,,fee schedule,973.84,2388.49,APC
Above knee cushion socket,L5648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1567.99,,,,,,,fee schedule,898.23,2203.04,
Above knee cushion socket,L5648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1255.93,,,,,,,fee schedule,898.23,2203.04,
Above knee cushion socket,L5648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2203.04,,,,,,,fee schedule,898.23,2203.04,
Above knee cushion socket,L5648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1915.69,,,,,,,fee schedule,898.23,2203.04,
Above knee cushion socket,L5648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,943.14,,,,,,,fee schedule,898.23,2203.04,APC
Above knee cushion socket,L5648,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,898.23,,,,,,,fee schedule,898.23,2203.04,APC
Above knee cushion socket,L5648,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1616.81,,,,,,,fee schedule,898.23,2203.04,APC
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5268.6,,,,,,,fee schedule,3018.14,7402.44,
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4220.03,,,,,,,fee schedule,3018.14,7402.44,
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7402.44,,,,,,,fee schedule,3018.14,7402.44,
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6436.9,,,,,,,fee schedule,3018.14,7402.44,
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3169.05,,,,,,,fee schedule,3018.14,7402.44,APC
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3018.14,,,,,,,fee schedule,3018.14,7402.44,APC
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5432.65,,,,,,,fee schedule,3018.14,7402.44,APC
Tot contact ak/knee disart s,L5650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1043.29,,,,,,,fee schedule,597.66,1465.84,
Tot contact ak/knee disart s,L5650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,835.65,,,,,,,fee schedule,597.66,1465.84,
Tot contact ak/knee disart s,L5650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1465.84,,,,,,,fee schedule,597.66,1465.84,
Tot contact ak/knee disart s,L5650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1274.64,,,,,,,fee schedule,597.66,1465.84,
Tot contact ak/knee disart s,L5650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.54,,,,,,,fee schedule,597.66,1465.84,APC
Tot contact ak/knee disart s,L5650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,597.66,,,,,,,fee schedule,597.66,1465.84,APC
Tot contact ak/knee disart s,L5650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1075.79,,,,,,,fee schedule,597.66,1465.84,APC
Ak flex inner socket ext fra,L5651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3056.75,,,,,,,fee schedule,1751.06,4294.76,
Ak flex inner socket ext fra,L5651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2448.38,,,,,,,fee schedule,1751.06,4294.76,
Ak flex inner socket ext fra,L5651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4294.76,,,,,,,fee schedule,1751.06,4294.76,
Ak flex inner socket ext fra,L5651,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3734.57,,,,,,,fee schedule,1751.06,4294.76,
Ak flex inner socket ext fra,L5651,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1838.61,,,,,,,fee schedule,1751.06,4294.76,APC
Ak flex inner socket ext fra,L5651,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1751.06,,,,,,,fee schedule,1751.06,4294.76,APC
Ak flex inner socket ext fra,L5651,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3151.91,,,,,,,fee schedule,1751.06,4294.76,APC
Suction susp ak/knee disart,L5652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,931.73,,,,,,,fee schedule,533.75,1309.09,
Suction susp ak/knee disart,L5652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,746.3,,,,,,,fee schedule,533.75,1309.09,
Suction susp ak/knee disart,L5652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1309.09,,,,,,,fee schedule,533.75,1309.09,
Suction susp ak/knee disart,L5652,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1138.34,,,,,,,fee schedule,533.75,1309.09,
Suction susp ak/knee disart,L5652,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.44,,,,,,,fee schedule,533.75,1309.09,APC
Suction susp ak/knee disart,L5652,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,533.75,,,,,,,fee schedule,533.75,1309.09,APC
Suction susp ak/knee disart,L5652,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,960.75,,,,,,,fee schedule,533.75,1309.09,APC
Knee disart expand wall sock,L5653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1453.74,,,,,,,fee schedule,832.81,2042.52,
Knee disart expand wall sock,L5653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1164.41,,,,,,,fee schedule,832.81,2042.52,
Knee disart expand wall sock,L5653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2042.52,,,,,,,fee schedule,832.81,2042.52,
Knee disart expand wall sock,L5653,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1776.1,,,,,,,fee schedule,832.81,2042.52,
Knee disart expand wall sock,L5653,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,874.45,,,,,,,fee schedule,832.81,2042.52,APC
Knee disart expand wall sock,L5653,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,832.81,,,,,,,fee schedule,832.81,2042.52,APC
Knee disart expand wall sock,L5653,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1499.06,,,,,,,fee schedule,832.81,2042.52,APC
Socket insert symes,L5654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,842.72,,,,,,,fee schedule,482.77,1184.03,
Socket insert symes,L5654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,675,,,,,,,fee schedule,482.77,1184.03,
Socket insert symes,L5654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1184.03,,,,,,,fee schedule,482.77,1184.03,
Socket insert symes,L5654,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1029.59,,,,,,,fee schedule,482.77,1184.03,
Socket insert symes,L5654,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,506.91,,,,,,,fee schedule,482.77,1184.03,APC
Socket insert symes,L5654,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,482.77,,,,,,,fee schedule,482.77,1184.03,APC
Socket insert symes,L5654,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,868.99,,,,,,,fee schedule,482.77,1184.03,APC
Socket insert below knee,L5655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,608.46,,,,,,,fee schedule,348.56,854.89,
Socket insert below knee,L5655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,487.36,,,,,,,fee schedule,348.56,854.89,
Socket insert below knee,L5655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,854.89,,,,,,,fee schedule,348.56,854.89,
Socket insert below knee,L5655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,743.38,,,,,,,fee schedule,348.56,854.89,
Socket insert below knee,L5655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365.99,,,,,,,fee schedule,348.56,854.89,APC
Socket insert below knee,L5655,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,348.56,,,,,,,fee schedule,348.56,854.89,APC
Socket insert below knee,L5655,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,627.41,,,,,,,fee schedule,348.56,854.89,APC
Socket insert knee articulat,L5656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,924.38,,,,,,,fee schedule,529.54,1298.76,
Socket insert knee articulat,L5656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,740.41,,,,,,,fee schedule,529.54,1298.76,
Socket insert knee articulat,L5656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1298.76,,,,,,,fee schedule,529.54,1298.76,
Socket insert knee articulat,L5656,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1129.36,,,,,,,fee schedule,529.54,1298.76,
Socket insert knee articulat,L5656,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,556.02,,,,,,,fee schedule,529.54,1298.76,APC
Socket insert knee articulat,L5656,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,529.54,,,,,,,fee schedule,529.54,1298.76,APC
Socket insert knee articulat,L5656,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,953.17,,,,,,,fee schedule,529.54,1298.76,APC
Add low ext man aut vol any,L5657,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.64,,,,,,,fee schedule,306.32,551.38,APC
Add low ext man aut vol any,L5657,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,306.32,,,,,,,fee schedule,306.32,551.38,APC
Add low ext man aut vol any,L5657,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,551.38,,,,,,,fee schedule,306.32,551.38,APC
Socket insert above knee,L5658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,975.74,,,,,,,fee schedule,558.94,1370.93,
Socket insert above knee,L5658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,781.55,,,,,,,fee schedule,558.94,1370.93,
Socket insert above knee,L5658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1370.93,,,,,,,fee schedule,558.94,1370.93,
Socket insert above knee,L5658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1192.11,,,,,,,fee schedule,558.94,1370.93,
Socket insert above knee,L5658,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,586.89,,,,,,,fee schedule,558.94,1370.93,APC
Socket insert above knee,L5658,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,558.94,,,,,,,fee schedule,558.94,1370.93,APC
Socket insert above knee,L5658,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1006.09,,,,,,,fee schedule,558.94,1370.93,APC
Multi-durometer symes,L5661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1399.92,,,,,,,fee schedule,801.96,1966.9,
Multi-durometer symes,L5661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1121.31,,,,,,,fee schedule,801.96,1966.9,
Multi-durometer symes,L5661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1966.9,,,,,,,fee schedule,801.96,1966.9,
Multi-durometer symes,L5661,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1710.35,,,,,,,fee schedule,801.96,1966.9,
Multi-durometer symes,L5661,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,842.06,,,,,,,fee schedule,801.96,1966.9,APC
Multi-durometer symes,L5661,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,801.96,,,,,,,fee schedule,801.96,1966.9,APC
Multi-durometer symes,L5661,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1443.53,,,,,,,fee schedule,801.96,1966.9,APC
Multi-durometer below knee,L5665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1244.59,,,,,,,fee schedule,712.97,1748.67,
Multi-durometer below knee,L5665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,996.89,,,,,,,fee schedule,712.97,1748.67,
Multi-durometer below knee,L5665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1748.67,,,,,,,fee schedule,712.97,1748.67,
Multi-durometer below knee,L5665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1520.58,,,,,,,fee schedule,712.97,1748.67,
Multi-durometer below knee,L5665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,748.62,,,,,,,fee schedule,712.97,1748.67,APC
Multi-durometer below knee,L5665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,712.97,,,,,,,fee schedule,712.97,1748.67,APC
Multi-durometer below knee,L5665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1283.35,,,,,,,fee schedule,712.97,1748.67,APC
Below knee cuff suspension,L5666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.8,,,,,,,fee schedule,94.4,231.54,
Below knee cuff suspension,L5666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132,,,,,,,fee schedule,94.4,231.54,
Below knee cuff suspension,L5666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.54,,,,,,,fee schedule,94.4,231.54,
Below knee cuff suspension,L5666,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.34,,,,,,,fee schedule,94.4,231.54,
Below knee cuff suspension,L5666,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.12,,,,,,,fee schedule,94.4,231.54,APC
Below knee cuff suspension,L5666,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.4,,,,,,,fee schedule,94.4,231.54,APC
Below knee cuff suspension,L5666,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,169.92,,,,,,,fee schedule,94.4,231.54,APC
Bk molded distal cushion,L5668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,245.48,,,,,,,fee schedule,140.62,344.91,
Bk molded distal cushion,L5668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,196.63,,,,,,,fee schedule,140.62,344.91,
Bk molded distal cushion,L5668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,344.91,,,,,,,fee schedule,140.62,344.91,
Bk molded distal cushion,L5668,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,299.92,,,,,,,fee schedule,140.62,344.91,
Bk molded distal cushion,L5668,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,147.65,,,,,,,fee schedule,140.62,344.91,APC
Bk molded distal cushion,L5668,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,140.62,,,,,,,fee schedule,140.62,344.91,APC
Bk molded distal cushion,L5668,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,253.12,,,,,,,fee schedule,140.62,344.91,APC
Bk molded supracondylar susp,L5670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,579.89,,,,,,,fee schedule,332.2,814.75,
Bk molded supracondylar susp,L5670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,464.48,,,,,,,fee schedule,332.2,814.75,
Bk molded supracondylar susp,L5670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,814.75,,,,,,,fee schedule,332.2,814.75,
Bk molded supracondylar susp,L5670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,708.48,,,,,,,fee schedule,332.2,814.75,
Bk molded supracondylar susp,L5670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,348.81,,,,,,,fee schedule,332.2,814.75,APC
Bk molded supracondylar susp,L5670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,332.2,,,,,,,fee schedule,332.2,814.75,APC
Bk molded supracondylar susp,L5670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,597.96,,,,,,,fee schedule,332.2,814.75,APC
Bk/ak locking mechanism,L5671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1062.99,,,,,,,fee schedule,608.96,1493.52,
Bk/ak locking mechanism,L5671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,851.43,,,,,,,fee schedule,608.96,1493.52,
Bk/ak locking mechanism,L5671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1493.52,,,,,,,fee schedule,608.96,1493.52,
Bk/ak locking mechanism,L5671,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1298.71,,,,,,,fee schedule,608.96,1493.52,
Bk/ak locking mechanism,L5671,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,639.41,,,,,,,fee schedule,608.96,1493.52,APC
Bk/ak locking mechanism,L5671,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.96,,,,,,,fee schedule,608.96,1493.52,APC
Bk/ak locking mechanism,L5671,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1096.13,,,,,,,fee schedule,608.96,1493.52,APC
Bk removable medial brim sus,L5672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,767.37,,,,,,,fee schedule,439.6,1078.16,
Bk removable medial brim sus,L5672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,614.64,,,,,,,fee schedule,439.6,1078.16,
Bk removable medial brim sus,L5672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1078.16,,,,,,,fee schedule,439.6,1078.16,
Bk removable medial brim sus,L5672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,937.53,,,,,,,fee schedule,439.6,1078.16,
Bk removable medial brim sus,L5672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.58,,,,,,,fee schedule,439.6,1078.16,APC
Bk removable medial brim sus,L5672,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.6,,,,,,,fee schedule,439.6,1078.16,APC
Bk removable medial brim sus,L5672,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,791.28,,,,,,,fee schedule,439.6,1078.16,APC
Socket insert w lock mech,L5673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1689.44,,,,,,,fee schedule,967.82,2373.68,
Socket insert w lock mech,L5673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1353.2,,,,,,,fee schedule,967.82,2373.68,
Socket insert w lock mech,L5673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2373.68,,,,,,,fee schedule,967.82,2373.68,
Socket insert w lock mech,L5673,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2064.07,,,,,,,fee schedule,967.82,2373.68,
Socket insert w lock mech,L5673,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1016.21,,,,,,,fee schedule,967.82,2373.68,APC
Socket insert w lock mech,L5673,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,967.82,,,,,,,fee schedule,967.82,2373.68,APC
Socket insert w lock mech,L5673,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1742.08,,,,,,,fee schedule,967.82,2373.68,APC
Bk knee joints single axis p,L5676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,774.42,,,,,,,fee schedule,443.63,1088.06,
Bk knee joints single axis p,L5676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,620.29,,,,,,,fee schedule,443.63,1088.06,
Bk knee joints single axis p,L5676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1088.06,,,,,,,fee schedule,443.63,1088.06,
Bk knee joints single axis p,L5676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,946.14,,,,,,,fee schedule,443.63,1088.06,
Bk knee joints single axis p,L5676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,465.81,,,,,,,fee schedule,443.63,1088.06,APC
Bk knee joints single axis p,L5676,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,443.63,,,,,,,fee schedule,443.63,1088.06,APC
Bk knee joints single axis p,L5676,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,798.53,,,,,,,fee schedule,443.63,1088.06,APC
Bk knee joints polycentric p,L5677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1186.05,,,,,,,fee schedule,679.42,1666.41,
Bk knee joints polycentric p,L5677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,950,,,,,,,fee schedule,679.42,1666.41,
Bk knee joints polycentric p,L5677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1666.41,,,,,,,fee schedule,679.42,1666.41,
Bk knee joints polycentric p,L5677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1449.05,,,,,,,fee schedule,679.42,1666.41,
Bk knee joints polycentric p,L5677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.39,,,,,,,fee schedule,679.42,1666.41,APC
Bk knee joints polycentric p,L5677,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,679.42,,,,,,,fee schedule,679.42,1666.41,APC
Bk knee joints polycentric p,L5677,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1222.96,,,,,,,fee schedule,679.42,1666.41,APC
Bk joint covers pair,L5678,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.85,,,,,,,fee schedule,48.61,119.21,
Bk joint covers pair,L5678,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.96,,,,,,,fee schedule,48.61,119.21,
Bk joint covers pair,L5678,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.21,,,,,,,fee schedule,48.61,119.21,
Bk joint covers pair,L5678,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.66,,,,,,,fee schedule,48.61,119.21,
Bk joint covers pair,L5678,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.04,,,,,,,fee schedule,48.61,119.21,APC
Bk joint covers pair,L5678,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48.61,,,,,,,fee schedule,48.61,119.21,APC
Bk joint covers pair,L5678,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,87.5,,,,,,,fee schedule,48.61,119.21,APC
Socket insert w/o lock mech,L5679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1407.86,,,,,,,fee schedule,806.49,1978.06,
Socket insert w/o lock mech,L5679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1127.66,,,,,,,fee schedule,806.49,1978.06,
Socket insert w/o lock mech,L5679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1978.06,,,,,,,fee schedule,806.49,1978.06,
Socket insert w/o lock mech,L5679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1720.05,,,,,,,fee schedule,806.49,1978.06,
Socket insert w/o lock mech,L5679,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,846.81,,,,,,,fee schedule,806.49,1978.06,APC
Socket insert w/o lock mech,L5679,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,806.49,,,,,,,fee schedule,806.49,1978.06,APC
Socket insert w/o lock mech,L5679,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1451.68,,,,,,,fee schedule,806.49,1978.06,APC
Bk thigh lacer non-molded,L5680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,650.48,,,,,,,fee schedule,372.63,913.93,
Bk thigh lacer non-molded,L5680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,521.02,,,,,,,fee schedule,372.63,913.93,
Bk thigh lacer non-molded,L5680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,913.93,,,,,,,fee schedule,372.63,913.93,
Bk thigh lacer non-molded,L5680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,794.72,,,,,,,fee schedule,372.63,913.93,
Bk thigh lacer non-molded,L5680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.26,,,,,,,fee schedule,372.63,913.93,APC
Bk thigh lacer non-molded,L5680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,372.63,,,,,,,fee schedule,372.63,913.93,APC
Bk thigh lacer non-molded,L5680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,670.73,,,,,,,fee schedule,372.63,913.93,APC
Intl custm cong/latyp insert,L5681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2827.48,,,,,,,fee schedule,1619.74,3972.64,
Intl custm cong/latyp insert,L5681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2264.75,,,,,,,fee schedule,1619.74,3972.64,
Intl custm cong/latyp insert,L5681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3972.64,,,,,,,fee schedule,1619.74,3972.64,
Intl custm cong/latyp insert,L5681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3454.47,,,,,,,fee schedule,1619.74,3972.64,
Intl custm cong/latyp insert,L5681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1700.73,,,,,,,fee schedule,1619.74,3972.64,APC
Intl custm cong/latyp insert,L5681,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1619.74,,,,,,,fee schedule,1619.74,3972.64,APC
Intl custm cong/latyp insert,L5681,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2915.53,,,,,,,fee schedule,1619.74,3972.64,APC
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1336.53,,,,,,,fee schedule,765.63,1877.84,
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1070.53,,,,,,,fee schedule,765.63,1877.84,
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1877.84,,,,,,,fee schedule,765.63,1877.84,
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1632.9,,,,,,,fee schedule,765.63,1877.84,
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,803.91,,,,,,,fee schedule,765.63,1877.84,APC
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,765.63,,,,,,,fee schedule,765.63,1877.84,APC
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1378.13,,,,,,,fee schedule,765.63,1877.84,APC
Initial custom socket insert,L5683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2827.48,,,,,,,fee schedule,1619.74,3972.64,
Initial custom socket insert,L5683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2264.75,,,,,,,fee schedule,1619.74,3972.64,
Initial custom socket insert,L5683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3972.64,,,,,,,fee schedule,1619.74,3972.64,
Initial custom socket insert,L5683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3454.47,,,,,,,fee schedule,1619.74,3972.64,
Initial custom socket insert,L5683,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1700.73,,,,,,,fee schedule,1619.74,3972.64,APC
Initial custom socket insert,L5683,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1619.74,,,,,,,fee schedule,1619.74,3972.64,APC
Initial custom socket insert,L5683,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2915.53,,,,,,,fee schedule,1619.74,3972.64,APC
Bk fork strap,L5684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.86,,,,,,,fee schedule,58.93,144.52,
Bk fork strap,L5684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.39,,,,,,,fee schedule,58.93,144.52,
Bk fork strap,L5684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,144.52,,,,,,,fee schedule,58.93,144.52,
Bk fork strap,L5684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.67,,,,,,,fee schedule,58.93,144.52,
Bk fork strap,L5684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.88,,,,,,,fee schedule,58.93,144.52,APC
Bk fork strap,L5684,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.93,,,,,,,fee schedule,58.93,144.52,APC
Bk fork strap,L5684,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,106.07,,,,,,,fee schedule,58.93,144.52,APC
Below knee sus/seal sleeve,L5685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,275.34,,,,,,,fee schedule,157.74,386.86,
Below knee sus/seal sleeve,L5685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,220.54,,,,,,,fee schedule,157.74,386.86,
Below knee sus/seal sleeve,L5685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,386.86,,,,,,,fee schedule,157.74,386.86,
Below knee sus/seal sleeve,L5685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,336.4,,,,,,,fee schedule,157.74,386.86,
Below knee sus/seal sleeve,L5685,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,165.63,,,,,,,fee schedule,157.74,386.86,APC
Below knee sus/seal sleeve,L5685,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,157.74,,,,,,,fee schedule,157.74,386.86,APC
Below knee sus/seal sleeve,L5685,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,283.93,,,,,,,fee schedule,157.74,386.86,APC
Bk back check,L5686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,123.69,,,,,,,fee schedule,70.87,173.79,
Bk back check,L5686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.07,,,,,,,fee schedule,70.87,173.79,
Bk back check,L5686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,173.79,,,,,,,fee schedule,70.87,173.79,
Bk back check,L5686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,151.12,,,,,,,fee schedule,70.87,173.79,
Bk back check,L5686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.41,,,,,,,fee schedule,70.87,173.79,APC
Bk back check,L5686,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,70.87,,,,,,,fee schedule,70.87,173.79,APC
Bk back check,L5686,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,127.57,,,,,,,fee schedule,70.87,173.79,APC
Bk waist belt webbing,L5688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.37,,,,,,,fee schedule,75.28,184.58,
Bk waist belt webbing,L5688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.22,,,,,,,fee schedule,75.28,184.58,
Bk waist belt webbing,L5688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.58,,,,,,,fee schedule,75.28,184.58,
Bk waist belt webbing,L5688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.5,,,,,,,fee schedule,75.28,184.58,
Bk waist belt webbing,L5688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.04,,,,,,,fee schedule,75.28,184.58,APC
Bk waist belt webbing,L5688,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,75.28,,,,,,,fee schedule,75.28,184.58,APC
Bk waist belt webbing,L5688,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,135.5,,,,,,,fee schedule,75.28,184.58,APC
Bk waist belt padded and lin,L5690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.21,,,,,,,fee schedule,153.65,376.84,
Bk waist belt padded and lin,L5690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.83,,,,,,,fee schedule,153.65,376.84,
Bk waist belt padded and lin,L5690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,376.84,,,,,,,fee schedule,153.65,376.84,
Bk waist belt padded and lin,L5690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,327.69,,,,,,,fee schedule,153.65,376.84,
Bk waist belt padded and lin,L5690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,161.33,,,,,,,fee schedule,153.65,376.84,APC
Bk waist belt padded and lin,L5690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,153.65,,,,,,,fee schedule,153.65,376.84,APC
Bk waist belt padded and lin,L5690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,276.57,,,,,,,fee schedule,153.65,376.84,APC
Ak pelvic control belt light,L5692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,283.98,,,,,,,fee schedule,162.67,398.99,
Ak pelvic control belt light,L5692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,227.46,,,,,,,fee schedule,162.67,398.99,
Ak pelvic control belt light,L5692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,398.99,,,,,,,fee schedule,162.67,398.99,
Ak pelvic control belt light,L5692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,346.95,,,,,,,fee schedule,162.67,398.99,
Ak pelvic control belt light,L5692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.8,,,,,,,fee schedule,162.67,398.99,APC
Ak pelvic control belt light,L5692,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,162.67,,,,,,,fee schedule,162.67,398.99,APC
Ak pelvic control belt light,L5692,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,292.81,,,,,,,fee schedule,162.67,398.99,APC
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,387.7,,,,,,,fee schedule,222.1,544.72,
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,310.54,,,,,,,fee schedule,222.1,544.72,
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,544.72,,,,,,,fee schedule,222.1,544.72,
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,473.67,,,,,,,fee schedule,222.1,544.72,
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,233.2,,,,,,,fee schedule,222.1,544.72,APC
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,222.1,,,,,,,fee schedule,222.1,544.72,APC
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,399.78,,,,,,,fee schedule,222.1,544.72,APC
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,348.53,,,,,,,fee schedule,199.65,489.68,
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,279.16,,,,,,,fee schedule,199.65,489.68,
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,489.68,,,,,,,fee schedule,199.65,489.68,
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,425.81,,,,,,,fee schedule,199.65,489.68,
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.63,,,,,,,fee schedule,199.65,489.68,APC
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,199.65,,,,,,,fee schedule,199.65,489.68,APC
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,359.37,,,,,,,fee schedule,199.65,489.68,APC
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,421.02,,,,,,,fee schedule,241.17,591.54,
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,337.23,,,,,,,fee schedule,241.17,591.54,
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,591.54,,,,,,,fee schedule,241.17,591.54,
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,514.38,,,,,,,fee schedule,241.17,591.54,
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,253.23,,,,,,,fee schedule,241.17,591.54,APC
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,241.17,,,,,,,fee schedule,241.17,591.54,APC
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,434.11,,,,,,,fee schedule,241.17,591.54,APC
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,199.93,,,,,,,fee schedule,114.53,280.91,
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,160.14,,,,,,,fee schedule,114.53,280.91,
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,280.91,,,,,,,fee schedule,114.53,280.91,
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,244.27,,,,,,,fee schedule,114.53,280.91,
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.26,,,,,,,fee schedule,114.53,280.91,APC
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,114.53,,,,,,,fee schedule,114.53,280.91,APC
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,206.15,,,,,,,fee schedule,114.53,280.91,APC
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,256.47,,,,,,,fee schedule,146.92,360.34,
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,205.43,,,,,,,fee schedule,146.92,360.34,
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,360.34,,,,,,,fee schedule,146.92,360.34,
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,313.34,,,,,,,fee schedule,146.92,360.34,
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,154.27,,,,,,,fee schedule,146.92,360.34,APC
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,146.92,,,,,,,fee schedule,146.92,360.34,APC
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,264.46,,,,,,,fee schedule,146.92,360.34,APC
Shoulder harness,L5699,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,438.34,,,,,,,fee schedule,251.1,615.87,
Shoulder harness,L5699,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,351.1,,,,,,,fee schedule,251.1,615.87,
Shoulder harness,L5699,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,615.87,,,,,,,fee schedule,251.1,615.87,
Shoulder harness,L5699,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,535.54,,,,,,,fee schedule,251.1,615.87,
Shoulder harness,L5699,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,263.66,,,,,,,fee schedule,251.1,615.87,APC
Shoulder harness,L5699,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,251.1,,,,,,,fee schedule,251.1,615.87,APC
Shoulder harness,L5699,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,451.98,,,,,,,fee schedule,251.1,615.87,APC
Replace socket below knee,L5700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6593.27,,,,,,,fee schedule,3776.99,9263.61,
Replace socket below knee,L5700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5281.06,,,,,,,fee schedule,3776.99,9263.61,
Replace socket below knee,L5700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9263.61,,,,,,,fee schedule,3776.99,9263.61,
Replace socket below knee,L5700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8055.31,,,,,,,fee schedule,3776.99,9263.61,
Replace socket below knee,L5700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3965.84,,,,,,,fee schedule,3776.99,9263.61,APC
Replace socket below knee,L5700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3776.99,,,,,,,fee schedule,3776.99,9263.61,APC
Replace socket below knee,L5700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6798.58,,,,,,,fee schedule,3776.99,9263.61,APC
Replace socket above knee,L5701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8179.57,,,,,,,fee schedule,4685.7,11492.38,
Replace socket above knee,L5701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6551.65,,,,,,,fee schedule,4685.7,11492.38,
Replace socket above knee,L5701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11492.38,,,,,,,fee schedule,4685.7,11492.38,
Replace socket above knee,L5701,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9993.37,,,,,,,fee schedule,4685.7,11492.38,
Replace socket above knee,L5701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4919.98,,,,,,,fee schedule,4685.7,11492.38,APC
Replace socket above knee,L5701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4685.7,,,,,,,fee schedule,4685.7,11492.38,APC
Replace socket above knee,L5701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8434.26,,,,,,,fee schedule,4685.7,11492.38,APC
Replace socket hip,L5702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10309.11,,,,,,,fee schedule,5905.61,14484.39,
Replace socket hip,L5702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8257.36,,,,,,,fee schedule,5905.61,14484.39,
Replace socket hip,L5702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14484.39,,,,,,,fee schedule,5905.61,14484.39,
Replace socket hip,L5702,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12595.12,,,,,,,fee schedule,5905.61,14484.39,
Replace socket hip,L5702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6200.89,,,,,,,fee schedule,5905.61,14484.39,APC
Replace socket hip,L5702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5905.61,,,,,,,fee schedule,5905.61,14484.39,APC
Replace socket hip,L5702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10630.1,,,,,,,fee schedule,5905.61,14484.39,APC
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5422.89,,,,,,,fee schedule,3106.52,7619.21,
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4343.61,,,,,,,fee schedule,3106.52,7619.21,
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7619.21,,,,,,,fee schedule,3106.52,7619.21,
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6625.4,,,,,,,fee schedule,3106.52,7619.21,
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3261.85,,,,,,,fee schedule,3106.52,7619.21,APC
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3106.52,,,,,,,fee schedule,3106.52,7619.21,APC
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5591.74,,,,,,,fee schedule,3106.52,7619.21,APC
Custom shape cover bk,L5704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1344.31,,,,,,,fee schedule,770.11,1888.77,
Custom shape cover bk,L5704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1076.76,,,,,,,fee schedule,770.11,1888.77,
Custom shape cover bk,L5704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1888.77,,,,,,,fee schedule,770.11,1888.77,
Custom shape cover bk,L5704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1642.41,,,,,,,fee schedule,770.11,1888.77,
Custom shape cover bk,L5704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,808.62,,,,,,,fee schedule,770.11,1888.77,APC
Custom shape cover bk,L5704,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,770.11,,,,,,,fee schedule,770.11,1888.77,APC
Custom shape cover bk,L5704,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1386.2,,,,,,,fee schedule,770.11,1888.77,APC
Custom shape cover ak,L5705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2464.65,,,,,,,fee schedule,1411.9,3462.86,
Custom shape cover ak,L5705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1974.13,,,,,,,fee schedule,1411.9,3462.86,
Custom shape cover ak,L5705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3462.86,,,,,,,fee schedule,1411.9,3462.86,
Custom shape cover ak,L5705,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3011.18,,,,,,,fee schedule,1411.9,3462.86,
Custom shape cover ak,L5705,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1482.5,,,,,,,fee schedule,1411.9,3462.86,APC
Custom shape cover ak,L5705,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1411.9,,,,,,,fee schedule,1411.9,3462.86,APC
Custom shape cover ak,L5705,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2541.42,,,,,,,fee schedule,1411.9,3462.86,APC
Custom shape cvr knee disart,L5706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2403.98,,,,,,,fee schedule,1377.12,3377.62,
Custom shape cvr knee disart,L5706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1925.54,,,,,,,fee schedule,1377.12,3377.62,
Custom shape cvr knee disart,L5706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3377.62,,,,,,,fee schedule,1377.12,3377.62,
Custom shape cvr knee disart,L5706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2937.06,,,,,,,fee schedule,1377.12,3377.62,
Custom shape cvr knee disart,L5706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1445.98,,,,,,,fee schedule,1377.12,3377.62,APC
Custom shape cvr knee disart,L5706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1377.12,,,,,,,fee schedule,1377.12,3377.62,APC
Custom shape cvr knee disart,L5706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2478.82,,,,,,,fee schedule,1377.12,3377.62,APC
Custom shape cvr hip disart,L5707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3229.81,,,,,,,fee schedule,1850.21,4537.91,
Custom shape cvr hip disart,L5707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2587,,,,,,,fee schedule,1850.21,4537.91,
Custom shape cvr hip disart,L5707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4537.91,,,,,,,fee schedule,1850.21,4537.91,
Custom shape cvr hip disart,L5707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3946.01,,,,,,,fee schedule,1850.21,4537.91,
Custom shape cvr hip disart,L5707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1942.72,,,,,,,fee schedule,1850.21,4537.91,APC
Custom shape cvr hip disart,L5707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1850.21,,,,,,,fee schedule,1850.21,4537.91,APC
Custom shape cvr hip disart,L5707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3330.38,,,,,,,fee schedule,1850.21,4537.91,APC
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,768.63,,,,,,,fee schedule,440.31,1079.93,
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,615.65,,,,,,,fee schedule,440.31,1079.93,
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1079.93,,,,,,,fee schedule,440.31,1079.93,
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,939.07,,,,,,,fee schedule,440.31,1079.93,
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,462.33,,,,,,,fee schedule,440.31,1079.93,APC
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,440.31,,,,,,,fee schedule,440.31,1079.93,APC
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,792.56,,,,,,,fee schedule,440.31,1079.93,APC
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1289.99,,,,,,,fee schedule,738.97,1812.45,
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1033.25,,,,,,,fee schedule,738.97,1812.45,
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1812.45,,,,,,,fee schedule,738.97,1812.45,
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1576.04,,,,,,,fee schedule,738.97,1812.45,
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,775.92,,,,,,,fee schedule,738.97,1812.45,APC
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,738.97,,,,,,,fee schedule,738.97,1812.45,APC
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1330.15,,,,,,,fee schedule,738.97,1812.45,APC
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,920.87,,,,,,,fee schedule,527.52,1293.83,
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,737.6,,,,,,,fee schedule,527.52,1293.83,
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1293.83,,,,,,,fee schedule,527.52,1293.83,
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1125.07,,,,,,,fee schedule,527.52,1293.83,
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,553.9,,,,,,,fee schedule,527.52,1293.83,APC
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,527.52,,,,,,,fee schedule,527.52,1293.83,APC
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,949.54,,,,,,,fee schedule,527.52,1293.83,APC
Knee-shin exo variable frict,L5714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,936.99,,,,,,,fee schedule,536.75,1316.47,
Knee-shin exo variable frict,L5714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,750.5,,,,,,,fee schedule,536.75,1316.47,
Knee-shin exo variable frict,L5714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1316.47,,,,,,,fee schedule,536.75,1316.47,
Knee-shin exo variable frict,L5714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1144.76,,,,,,,fee schedule,536.75,1316.47,
Knee-shin exo variable frict,L5714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,563.59,,,,,,,fee schedule,536.75,1316.47,APC
Knee-shin exo variable frict,L5714,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,536.75,,,,,,,fee schedule,536.75,1316.47,APC
Knee-shin exo variable frict,L5714,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,966.15,,,,,,,fee schedule,536.75,1316.47,APC
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1852.76,,,,,,,fee schedule,1061.36,2603.14,
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1484.02,,,,,,,fee schedule,1061.36,2603.14,
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2603.14,,,,,,,fee schedule,1061.36,2603.14,
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2263.6,,,,,,,fee schedule,1061.36,2603.14,
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1114.43,,,,,,,fee schedule,1061.36,2603.14,APC
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1061.36,,,,,,,fee schedule,1061.36,2603.14,APC
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1910.45,,,,,,,fee schedule,1061.36,2603.14,APC
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1981.18,,,,,,,fee schedule,1134.92,2783.58,
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1586.88,,,,,,,fee schedule,1134.92,2783.58,
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2783.58,,,,,,,fee schedule,1134.92,2783.58,
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2420.5,,,,,,,fee schedule,1134.92,2783.58,
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1191.67,,,,,,,fee schedule,1134.92,2783.58,APC
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1134.92,,,,,,,fee schedule,1134.92,2783.58,APC
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2042.86,,,,,,,fee schedule,1134.92,2783.58,APC
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2409.25,,,,,,,fee schedule,1380.15,3385.01,
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1929.75,,,,,,,fee schedule,1380.15,3385.01,
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3385.01,,,,,,,fee schedule,1380.15,3385.01,
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2943.49,,,,,,,fee schedule,1380.15,3385.01,
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1449.16,,,,,,,fee schedule,1380.15,3385.01,APC
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1380.15,,,,,,,fee schedule,1380.15,3385.01,APC
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2484.27,,,,,,,fee schedule,1380.15,3385.01,APC
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3713.45,,,,,,,fee schedule,2127.27,5217.44,
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2974.39,,,,,,,fee schedule,2127.27,5217.44,
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5217.44,,,,,,,fee schedule,2127.27,5217.44,
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4536.9,,,,,,,fee schedule,2127.27,5217.44,
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2233.63,,,,,,,fee schedule,2127.27,5217.44,APC
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2127.27,,,,,,,fee schedule,2127.27,5217.44,APC
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3829.09,,,,,,,fee schedule,2127.27,5217.44,APC
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4421.05,,,,,,,fee schedule,2532.6,6211.62,
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3541.16,,,,,,,fee schedule,2532.6,6211.62,
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6211.62,,,,,,,fee schedule,2532.6,6211.62,
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5401.41,,,,,,,fee schedule,2532.6,6211.62,
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2659.23,,,,,,,fee schedule,2532.6,6211.62,APC
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2532.6,,,,,,,fee schedule,2532.6,6211.62,APC
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4558.68,,,,,,,fee schedule,2532.6,6211.62,APC
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5180.96,,,,,,,fee schedule,2967.93,7279.29,
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4149.83,,,,,,,fee schedule,2967.93,7279.29,
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7279.29,,,,,,,fee schedule,2967.93,7279.29,
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6329.82,,,,,,,fee schedule,2967.93,7279.29,
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3116.33,,,,,,,fee schedule,2967.93,7279.29,APC
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2967.93,,,,,,,fee schedule,2967.93,7279.29,APC
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5342.27,,,,,,,fee schedule,2967.93,7279.29,APC
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2852.53,,,,,,,fee schedule,1634.07,4007.83,
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2284.81,,,,,,,fee schedule,1634.07,4007.83,
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4007.83,,,,,,,fee schedule,1634.07,4007.83,
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3485.07,,,,,,,fee schedule,1634.07,4007.83,
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1715.77,,,,,,,fee schedule,1634.07,4007.83,APC
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1634.07,,,,,,,fee schedule,1634.07,4007.83,APC
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2941.33,,,,,,,fee schedule,1634.07,4007.83,APC
Lower limb pros vacuum pump,L5781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8600.63,,,,,,,fee schedule,4926.9,12083.97,
Lower limb pros vacuum pump,L5781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6888.91,,,,,,,fee schedule,4926.9,12083.97,
Lower limb pros vacuum pump,L5781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12083.97,,,,,,,fee schedule,4926.9,12083.97,
Lower limb pros vacuum pump,L5781,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10507.8,,,,,,,fee schedule,4926.9,12083.97,
Lower limb pros vacuum pump,L5781,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5173.24,,,,,,,fee schedule,4926.9,12083.97,APC
Lower limb pros vacuum pump,L5781,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4926.9,,,,,,,fee schedule,4926.9,12083.97,APC
Lower limb pros vacuum pump,L5781,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8868.42,,,,,,,fee schedule,4926.9,12083.97,APC
HD low limb pros vacuum pump,L5782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9066.97,,,,,,,fee schedule,5194.06,12739.17,
HD low limb pros vacuum pump,L5782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7262.44,,,,,,,fee schedule,5194.06,12739.17,
HD low limb pros vacuum pump,L5782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12739.17,,,,,,,fee schedule,5194.06,12739.17,
HD low limb pros vacuum pump,L5782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11077.54,,,,,,,fee schedule,5194.06,12739.17,
HD low limb pros vacuum pump,L5782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5453.76,,,,,,,fee schedule,5194.06,12739.17,APC
HD low limb pros vacuum pump,L5782,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5194.06,,,,,,,fee schedule,5194.06,12739.17,APC
HD low limb pros vacuum pump,L5782,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9349.31,,,,,,,fee schedule,5194.06,12739.17,APC
Add low ext mec limb vol sys,L5783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3307.57,,,,,,,fee schedule,3150.07,5670.13,APC
Add low ext mec limb vol sys,L5783,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3150.07,,,,,,,fee schedule,3150.07,5670.13,APC
Add low ext mec limb vol sys,L5783,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5670.13,,,,,,,fee schedule,3150.07,5670.13,APC
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1110.34,,,,,,,fee schedule,636.06,1560.03,
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,889.35,,,,,,,fee schedule,636.06,1560.03,
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1560.03,,,,,,,fee schedule,636.06,1560.03,
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1356.55,,,,,,,fee schedule,636.06,1560.03,
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,667.86,,,,,,,fee schedule,636.06,1560.03,APC
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,636.06,,,,,,,fee schedule,636.06,1560.03,APC
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1144.91,,,,,,,fee schedule,636.06,1560.03,APC
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1602.5,,,,,,,fee schedule,917.99,2251.53,
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1283.57,,,,,,,fee schedule,917.99,2251.53,
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2251.53,,,,,,,fee schedule,917.99,2251.53,
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1957.85,,,,,,,fee schedule,917.99,2251.53,
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,963.89,,,,,,,fee schedule,917.99,2251.53,APC
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,917.99,,,,,,,fee schedule,917.99,2251.53,APC
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1652.38,,,,,,,fee schedule,917.99,2251.53,APC
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2294.57,,,,,,,fee schedule,1314.46,3223.9,
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1837.9,,,,,,,fee schedule,1314.46,3223.9,
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3223.9,,,,,,,fee schedule,1314.46,3223.9,
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2803.39,,,,,,,fee schedule,1314.46,3223.9,
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1380.18,,,,,,,fee schedule,1314.46,3223.9,APC
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1314.46,,,,,,,fee schedule,1314.46,3223.9,APC
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2366.03,,,,,,,fee schedule,1314.46,3223.9,APC
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1222.54,,,,,,,fee schedule,700.33,1717.69,
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,979.23,,,,,,,fee schedule,700.33,1717.69,
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1717.69,,,,,,,fee schedule,700.33,1717.69,
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1493.64,,,,,,,fee schedule,700.33,1717.69,
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,735.35,,,,,,,fee schedule,700.33,1717.69,APC
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,700.33,,,,,,,fee schedule,700.33,1717.69,APC
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1260.59,,,,,,,fee schedule,700.33,1717.69,APC
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1687.11,,,,,,,fee schedule,966.47,2370.4,
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1351.34,,,,,,,fee schedule,966.47,2370.4,
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2370.4,,,,,,,fee schedule,966.47,2370.4,
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2061.22,,,,,,,fee schedule,966.47,2370.4,
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1014.79,,,,,,,fee schedule,966.47,2370.4,APC
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,966.47,,,,,,,fee schedule,966.47,2370.4,APC
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1739.65,,,,,,,fee schedule,966.47,2370.4,APC
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1269.59,,,,,,,fee schedule,727.31,1783.79,
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1016.91,,,,,,,fee schedule,727.31,1783.79,
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1783.79,,,,,,,fee schedule,727.31,1783.79,
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1551.12,,,,,,,fee schedule,727.31,1783.79,
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,763.68,,,,,,,fee schedule,727.31,1783.79,APC
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,727.31,,,,,,,fee schedule,727.31,1783.79,APC
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1309.16,,,,,,,fee schedule,727.31,1783.79,APC
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7983.04,,,,,,,fee schedule,4573.12,11216.24,
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6394.23,,,,,,,fee schedule,4573.12,11216.24,
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11216.24,,,,,,,fee schedule,4573.12,11216.24,
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9753.25,,,,,,,fee schedule,4573.12,11216.24,
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4801.78,,,,,,,fee schedule,4573.12,11216.24,APC
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4573.12,,,,,,,fee schedule,4573.12,11216.24,APC
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8231.62,,,,,,,fee schedule,4573.12,11216.24,APC
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1817.48,,,,,,,fee schedule,1041.16,2553.58,
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1455.76,,,,,,,fee schedule,1041.16,2553.58,
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2553.58,,,,,,,fee schedule,1041.16,2553.58,
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2220.5,,,,,,,fee schedule,1041.16,2553.58,
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1093.22,,,,,,,fee schedule,1041.16,2553.58,APC
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1041.16,,,,,,,fee schedule,1041.16,2553.58,APC
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1874.09,,,,,,,fee schedule,1041.16,2553.58,APC
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2052.29,,,,,,,fee schedule,1175.67,2883.49,
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1643.84,,,,,,,fee schedule,1175.67,2883.49,
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2883.49,,,,,,,fee schedule,1175.67,2883.49,
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2507.38,,,,,,,fee schedule,1175.67,2883.49,
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1234.45,,,,,,,fee schedule,1175.67,2883.49,APC
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1175.67,,,,,,,fee schedule,1175.67,2883.49,APC
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2116.21,,,,,,,fee schedule,1175.67,2883.49,APC
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3764.91,,,,,,,fee schedule,2156.75,5289.74,
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3015.61,,,,,,,fee schedule,2156.75,5289.74,
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5289.74,,,,,,,fee schedule,2156.75,5289.74,
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4599.77,,,,,,,fee schedule,2156.75,5289.74,
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2264.59,,,,,,,fee schedule,2156.75,5289.74,APC
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2156.75,,,,,,,fee schedule,2156.75,5289.74,APC
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3882.15,,,,,,,fee schedule,2156.75,5289.74,APC
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3558.95,,,,,,,fee schedule,2038.76,5000.36,
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2850.64,,,,,,,fee schedule,2038.76,5000.36,
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5000.36,,,,,,,fee schedule,2038.76,5000.36,
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4348.14,,,,,,,fee schedule,2038.76,5000.36,
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2140.7,,,,,,,fee schedule,2038.76,5000.36,APC
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2038.76,,,,,,,fee schedule,2038.76,5000.36,APC
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3669.77,,,,,,,fee schedule,2038.76,5000.36,APC
Miniature knee joint,L5826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6712.75,,,,,,,fee schedule,3845.42,9431.47,
Miniature knee joint,L5826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5376.76,,,,,,,fee schedule,3845.42,9431.47,
Miniature knee joint,L5826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9431.47,,,,,,,fee schedule,3845.42,9431.47,
Miniature knee joint,L5826,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8201.28,,,,,,,fee schedule,3845.42,9431.47,
Miniature knee joint,L5826,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4037.69,,,,,,,fee schedule,3845.42,9431.47,APC
Miniature knee joint,L5826,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3845.42,,,,,,,fee schedule,3845.42,9431.47,APC
Miniature knee joint,L5826,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6921.76,,,,,,,fee schedule,3845.42,9431.47,APC
Endo knee shin single axis,L5827,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7517.64,,,,,,,fee schedule,7159.66,12887.39,APC
Endo knee shin single axis,L5827,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7159.66,,,,,,,fee schedule,7159.66,12887.39,APC
Endo knee shin single axis,L5827,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12887.39,,,,,,,fee schedule,7159.66,12887.39,APC
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6334.04,,,,,,,fee schedule,3628.49,8899.38,
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5073.42,,,,,,,fee schedule,3628.49,8899.38,
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8899.38,,,,,,,fee schedule,3628.49,8899.38,
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7738.59,,,,,,,fee schedule,3628.49,8899.38,
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3809.91,,,,,,,fee schedule,3628.49,8899.38,APC
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3628.49,,,,,,,fee schedule,3628.49,8899.38,APC
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6531.28,,,,,,,fee schedule,3628.49,8899.38,APC
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4270.83,,,,,,,fee schedule,2446.57,6000.55,
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3420.84,,,,,,,fee schedule,2446.57,6000.55,
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6000.55,,,,,,,fee schedule,2446.57,6000.55,
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5217.87,,,,,,,fee schedule,2446.57,6000.55,
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2568.9,,,,,,,fee schedule,2446.57,6000.55,APC
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2446.57,,,,,,,fee schedule,2446.57,6000.55,APC
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4403.83,,,,,,,fee schedule,2446.57,6000.55,APC
Multi-axial knee/shin system,L5840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8382.5,,,,,,,fee schedule,4801.96,11777.5,
Multi-axial knee/shin system,L5840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6714.2,,,,,,,fee schedule,4801.96,11777.5,
Multi-axial knee/shin system,L5840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11777.5,,,,,,,fee schedule,4801.96,11777.5,
Multi-axial knee/shin system,L5840,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10241.3,,,,,,,fee schedule,4801.96,11777.5,
Multi-axial knee/shin system,L5840,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5042.06,,,,,,,fee schedule,4801.96,11777.5,APC
Multi-axial knee/shin system,L5840,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4801.96,,,,,,,fee schedule,4801.96,11777.5,APC
Multi-axial knee/shin system,L5840,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8643.53,,,,,,,fee schedule,4801.96,11777.5,APC
Addition endoskletl knee-shi,L5841,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2955.1,,,,,,,fee schedule,2814.38,5065.88,APC
Addition endoskletl knee-shi,L5841,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2814.38,,,,,,,fee schedule,2814.38,5065.88,APC
Addition endoskletl knee-shi,L5841,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5065.88,,,,,,,fee schedule,2814.38,5065.88,APC
Knee-shin sys stance flexion,L5845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3852.72,,,,,,,fee schedule,2207.05,5413.11,
Knee-shin sys stance flexion,L5845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3085.94,,,,,,,fee schedule,2207.05,5413.11,
Knee-shin sys stance flexion,L5845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5413.11,,,,,,,fee schedule,2207.05,5413.11,
Knee-shin sys stance flexion,L5845,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4707.05,,,,,,,fee schedule,2207.05,5413.11,
Knee-shin sys stance flexion,L5845,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2317.4,,,,,,,fee schedule,2207.05,5413.11,APC
Knee-shin sys stance flexion,L5845,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2207.05,,,,,,,fee schedule,2207.05,5413.11,APC
Knee-shin sys stance flexion,L5845,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3972.69,,,,,,,fee schedule,2207.05,5413.11,APC
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2311.44,,,,,,,fee schedule,1324.12,3247.59,
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1851.41,,,,,,,fee schedule,1324.12,3247.59,
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3247.59,,,,,,,fee schedule,1324.12,3247.59,
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2823.99,,,,,,,fee schedule,1324.12,3247.59,
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1390.33,,,,,,,fee schedule,1324.12,3247.59,APC
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1324.12,,,,,,,fee schedule,1324.12,3247.59,APC
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2383.42,,,,,,,fee schedule,1324.12,3247.59,APC
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,273.4,,,,,,,fee schedule,156.61,384.13,
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,218.99,,,,,,,fee schedule,156.61,384.13,
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,384.13,,,,,,,fee schedule,156.61,384.13,
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,334.03,,,,,,,fee schedule,156.61,384.13,
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.44,,,,,,,fee schedule,156.61,384.13,APC
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,156.61,,,,,,,fee schedule,156.61,384.13,APC
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,281.9,,,,,,,fee schedule,156.61,384.13,APC
Mech hip extension assist,L5855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,660.01,,,,,,,fee schedule,378.09,927.31,
Mech hip extension assist,L5855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,528.65,,,,,,,fee schedule,378.09,927.31,
Mech hip extension assist,L5855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,927.31,,,,,,,fee schedule,378.09,927.31,
Mech hip extension assist,L5855,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,806.36,,,,,,,fee schedule,378.09,927.31,
Mech hip extension assist,L5855,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,396.99,,,,,,,fee schedule,378.09,927.31,APC
Mech hip extension assist,L5855,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,378.09,,,,,,,fee schedule,378.09,927.31,APC
Mech hip extension assist,L5855,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,680.56,,,,,,,fee schedule,378.09,927.31,APC
Elec knee-shin swing/stance,L5856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51600.96,,,,,,,fee schedule,29559.78,72499.82,
Elec knee-shin swing/stance,L5856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41331.2,,,,,,,fee schedule,29559.78,72499.82,
Elec knee-shin swing/stance,L5856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72499.82,,,,,,,fee schedule,29559.78,72499.82,
Elec knee-shin swing/stance,L5856,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63043.32,,,,,,,fee schedule,29559.78,72499.82,
Elec knee-shin swing/stance,L5856,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31037.77,,,,,,,fee schedule,29559.78,72499.82,APC
Elec knee-shin swing/stance,L5856,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29559.78,,,,,,,fee schedule,29559.78,72499.82,APC
Elec knee-shin swing/stance,L5856,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53207.6,,,,,,,fee schedule,29559.78,72499.82,APC
Elec knee-shin swing only,L5857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18309.94,,,,,,,fee schedule,10488.92,25725.64,
Elec knee-shin swing only,L5857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14665.85,,,,,,,fee schedule,10488.92,25725.64,
Elec knee-shin swing only,L5857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25725.64,,,,,,,fee schedule,10488.92,25725.64,
Elec knee-shin swing only,L5857,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22370.12,,,,,,,fee schedule,10488.92,25725.64,
Elec knee-shin swing only,L5857,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11013.37,,,,,,,fee schedule,10488.92,25725.64,APC
Elec knee-shin swing only,L5857,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10488.92,,,,,,,fee schedule,10488.92,25725.64,APC
Elec knee-shin swing only,L5857,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18880.06,,,,,,,fee schedule,10488.92,25725.64,APC
Stance phase only,L5858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39949.2,,,,,,,fee schedule,22885.05,56128.99,
Stance phase only,L5858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31998.41,,,,,,,fee schedule,22885.05,56128.99,
Stance phase only,L5858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56128.99,,,,,,,fee schedule,22885.05,56128.99,
Stance phase only,L5858,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48807.82,,,,,,,fee schedule,22885.05,56128.99,
Stance phase only,L5858,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24029.3,,,,,,,fee schedule,22885.05,56128.99,APC
Stance phase only,L5858,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22885.05,,,,,,,fee schedule,22885.05,56128.99,APC
Stance phase only,L5858,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41193.09,,,,,,,fee schedule,22885.05,56128.99,APC
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31187.95,,,,,,,fee schedule,17866.14,43819.36,
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24980.84,,,,,,,fee schedule,17866.14,43819.36,
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43819.36,,,,,,,fee schedule,17866.14,43819.36,
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,38103.79,,,,,,,fee schedule,17866.14,43819.36,
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18759.45,,,,,,,fee schedule,17866.14,43819.36,APC
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17866.14,,,,,,,fee schedule,17866.14,43819.36,APC
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32159.05,,,,,,,fee schedule,17866.14,43819.36,APC
Endo below knee alignable sy,L5910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,773.99,,,,,,,fee schedule,443.39,1087.46,
Endo below knee alignable sy,L5910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,619.95,,,,,,,fee schedule,443.39,1087.46,
Endo below knee alignable sy,L5910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1087.46,,,,,,,fee schedule,443.39,1087.46,
Endo below knee alignable sy,L5910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,945.62,,,,,,,fee schedule,443.39,1087.46,
Endo below knee alignable sy,L5910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,465.56,,,,,,,fee schedule,443.39,1087.46,APC
Endo below knee alignable sy,L5910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,443.39,,,,,,,fee schedule,443.39,1087.46,APC
Endo below knee alignable sy,L5910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,798.1,,,,,,,fee schedule,443.39,1087.46,APC
Endo ak/hip alignable system,L5920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1133.93,,,,,,,fee schedule,649.58,1593.18,
Endo ak/hip alignable system,L5920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,908.25,,,,,,,fee schedule,649.58,1593.18,
Endo ak/hip alignable system,L5920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1593.18,,,,,,,fee schedule,649.58,1593.18,
Endo ak/hip alignable system,L5920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1385.37,,,,,,,fee schedule,649.58,1593.18,
Endo ak/hip alignable system,L5920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,682.06,,,,,,,fee schedule,649.58,1593.18,APC
Endo ak/hip alignable system,L5920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,649.58,,,,,,,fee schedule,649.58,1593.18,APC
Endo ak/hip alignable system,L5920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1169.24,,,,,,,fee schedule,649.58,1593.18,APC
Above knee manual lock,L5925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,718.09,,,,,,,fee schedule,411.36,1008.92,
Above knee manual lock,L5925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,575.17,,,,,,,fee schedule,411.36,1008.92,
Above knee manual lock,L5925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1008.92,,,,,,,fee schedule,411.36,1008.92,
Above knee manual lock,L5925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,877.32,,,,,,,fee schedule,411.36,1008.92,
Above knee manual lock,L5925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,431.93,,,,,,,fee schedule,411.36,1008.92,APC
Above knee manual lock,L5925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,411.36,,,,,,,fee schedule,411.36,1008.92,APC
Above knee manual lock,L5925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,740.45,,,,,,,fee schedule,411.36,1008.92,APC
Endoskel posit rotat unit,L5926,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,831.33,,,,,,,fee schedule,791.74,1425.13,APC
Endoskel posit rotat unit,L5926,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,791.74,,,,,,,fee schedule,791.74,1425.13,APC
Endoskel posit rotat unit,L5926,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1425.13,,,,,,,fee schedule,791.74,1425.13,APC
High activity knee frame,L5930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7235.11,,,,,,,fee schedule,4144.66,10165.39,
High activity knee frame,L5930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5795.16,,,,,,,fee schedule,4144.66,10165.39,
High activity knee frame,L5930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10165.39,,,,,,,fee schedule,4144.66,10165.39,
High activity knee frame,L5930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8839.47,,,,,,,fee schedule,4144.66,10165.39,
High activity knee frame,L5930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4351.89,,,,,,,fee schedule,4144.66,10165.39,APC
High activity knee frame,L5930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4144.66,,,,,,,fee schedule,4144.66,10165.39,APC
High activity knee frame,L5930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7460.39,,,,,,,fee schedule,4144.66,10165.39,APC
Endo bk ultra-light material,L5940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1071.99,,,,,,,fee schedule,614.1,1506.16,
Endo bk ultra-light material,L5940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,858.64,,,,,,,fee schedule,614.1,1506.16,
Endo bk ultra-light material,L5940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1506.16,,,,,,,fee schedule,614.1,1506.16,
Endo bk ultra-light material,L5940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1309.7,,,,,,,fee schedule,614.1,1506.16,
Endo bk ultra-light material,L5940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,644.8,,,,,,,fee schedule,614.1,1506.16,APC
Endo bk ultra-light material,L5940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,614.1,,,,,,,fee schedule,614.1,1506.16,APC
Endo bk ultra-light material,L5940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1105.38,,,,,,,fee schedule,614.1,1506.16,APC
Endo ak ultra-light material,L5950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1662.69,,,,,,,fee schedule,952.47,2336.1,
Endo ak ultra-light material,L5950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1331.78,,,,,,,fee schedule,952.47,2336.1,
Endo ak ultra-light material,L5950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2336.1,,,,,,,fee schedule,952.47,2336.1,
Endo ak ultra-light material,L5950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2031.39,,,,,,,fee schedule,952.47,2336.1,
Endo ak ultra-light material,L5950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1000.09,,,,,,,fee schedule,952.47,2336.1,APC
Endo ak ultra-light material,L5950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,952.47,,,,,,,fee schedule,952.47,2336.1,APC
Endo ak ultra-light material,L5950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1714.45,,,,,,,fee schedule,952.47,2336.1,APC
Endo hip ultra-light materia,L5960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2486.1,,,,,,,fee schedule,1424.19,3493,
Endo hip ultra-light materia,L5960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1991.31,,,,,,,fee schedule,1424.19,3493,
Endo hip ultra-light materia,L5960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3493,,,,,,,fee schedule,1424.19,3493,
Endo hip ultra-light materia,L5960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3037.39,,,,,,,fee schedule,1424.19,3493,
Endo hip ultra-light materia,L5960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1495.4,,,,,,,fee schedule,1424.19,3493,APC
Endo hip ultra-light materia,L5960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1424.19,,,,,,,fee schedule,1424.19,3493,APC
Endo hip ultra-light materia,L5960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2563.54,,,,,,,fee schedule,1424.19,3493,APC
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10260.23,,,,,,,fee schedule,5877.61,14415.72,
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8218.21,,,,,,,fee schedule,5877.61,14415.72,
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14415.72,,,,,,,fee schedule,5877.61,14415.72,
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12535.41,,,,,,,fee schedule,5877.61,14415.72,
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6171.49,,,,,,,fee schedule,5877.61,14415.72,APC
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5877.61,,,,,,,fee schedule,5877.61,14415.72,APC
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10579.7,,,,,,,fee schedule,5877.61,14415.72,APC
Below knee flex cover system,L5962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1256.17,,,,,,,fee schedule,719.6,1764.93,
Below knee flex cover system,L5962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1006.16,,,,,,,fee schedule,719.6,1764.93,
Below knee flex cover system,L5962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1764.93,,,,,,,fee schedule,719.6,1764.93,
Below knee flex cover system,L5962,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1534.72,,,,,,,fee schedule,719.6,1764.93,
Below knee flex cover system,L5962,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,755.58,,,,,,,fee schedule,719.6,1764.93,APC
Below knee flex cover system,L5962,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,719.6,,,,,,,fee schedule,719.6,1764.93,APC
Below knee flex cover system,L5962,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1295.28,,,,,,,fee schedule,719.6,1764.93,APC
Above knee flex cover system,L5964,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2409.57,,,,,,,fee schedule,1380.34,3385.47,
Above knee flex cover system,L5964,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1930.01,,,,,,,fee schedule,1380.34,3385.47,
Above knee flex cover system,L5964,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3385.47,,,,,,,fee schedule,1380.34,3385.47,
Above knee flex cover system,L5964,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2943.89,,,,,,,fee schedule,1380.34,3385.47,
Above knee flex cover system,L5964,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1449.36,,,,,,,fee schedule,1380.34,3385.47,APC
Above knee flex cover system,L5964,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1380.34,,,,,,,fee schedule,1380.34,3385.47,APC
Above knee flex cover system,L5964,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2484.61,,,,,,,fee schedule,1380.34,3385.47,APC
Hip flexible cover system,L5966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3103.95,,,,,,,fee schedule,1778.12,4361.08,
Hip flexible cover system,L5966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2486.19,,,,,,,fee schedule,1778.12,4361.08,
Hip flexible cover system,L5966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4361.08,,,,,,,fee schedule,1778.12,4361.08,
Hip flexible cover system,L5966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3792.24,,,,,,,fee schedule,1778.12,4361.08,
Hip flexible cover system,L5966,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1867.03,,,,,,,fee schedule,1778.12,4361.08,APC
Hip flexible cover system,L5966,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1778.12,,,,,,,fee schedule,1778.12,4361.08,APC
Hip flexible cover system,L5966,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3200.62,,,,,,,fee schedule,1778.12,4361.08,APC
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7811.08,,,,,,,fee schedule,4474.62,10974.65,
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6256.5,,,,,,,fee schedule,4474.62,10974.65,
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10974.65,,,,,,,fee schedule,4474.62,10974.65,
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9543.17,,,,,,,fee schedule,4474.62,10974.65,
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4698.35,,,,,,,fee schedule,4474.62,10974.65,APC
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4474.62,,,,,,,fee schedule,4474.62,10974.65,APC
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8054.32,,,,,,,fee schedule,4474.62,10974.65,APC
Foot external keel sach foot,L5970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,466.89,,,,,,,fee schedule,267.47,655.98,
Foot external keel sach foot,L5970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,373.97,,,,,,,fee schedule,267.47,655.98,
Foot external keel sach foot,L5970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.98,,,,,,,fee schedule,267.47,655.98,
Foot external keel sach foot,L5970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,570.42,,,,,,,fee schedule,267.47,655.98,
Foot external keel sach foot,L5970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,280.84,,,,,,,fee schedule,267.47,655.98,APC
Foot external keel sach foot,L5970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,267.47,,,,,,,fee schedule,267.47,655.98,APC
Foot external keel sach foot,L5970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,481.45,,,,,,,fee schedule,267.47,655.98,APC
"SACH foot, replacement",L5971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,466.89,,,,,,,fee schedule,267.47,655.98,
"SACH foot, replacement",L5971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,373.97,,,,,,,fee schedule,267.47,655.98,
"SACH foot, replacement",L5971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,655.98,,,,,,,fee schedule,267.47,655.98,
"SACH foot, replacement",L5971,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,570.42,,,,,,,fee schedule,267.47,655.98,
"SACH foot, replacement",L5971,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,280.84,,,,,,,fee schedule,267.47,655.98,APC
"SACH foot, replacement",L5971,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,267.47,,,,,,,fee schedule,267.47,655.98,APC
"SACH foot, replacement",L5971,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,481.45,,,,,,,fee schedule,267.47,655.98,APC
Flexible keel foot,L5972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,850.53,,,,,,,fee schedule,487.23,1195,
Flexible keel foot,L5972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,681.25,,,,,,,fee schedule,487.23,1195,
Flexible keel foot,L5972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1195,,,,,,,fee schedule,487.23,1195,
Flexible keel foot,L5972,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1039.13,,,,,,,fee schedule,487.23,1195,
Flexible keel foot,L5972,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,511.59,,,,,,,fee schedule,487.23,1195,APC
Flexible keel foot,L5972,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,487.23,,,,,,,fee schedule,487.23,1195,APC
Flexible keel foot,L5972,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,877.01,,,,,,,fee schedule,487.23,1195,APC
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37949.52,,,,,,,fee schedule,21739.52,53319.43,
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30396.71,,,,,,,fee schedule,21739.52,53319.43,
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53319.43,,,,,,,fee schedule,21739.52,53319.43,
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46364.72,,,,,,,fee schedule,21739.52,53319.43,
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22826.5,,,,,,,fee schedule,21739.52,53319.43,APC
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21739.52,,,,,,,fee schedule,21739.52,53319.43,APC
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39131.14,,,,,,,fee schedule,21739.52,53319.43,APC
Foot single axis ankle/foot,L5974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,497.99,,,,,,,fee schedule,285.29,699.68,
Foot single axis ankle/foot,L5974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,398.88,,,,,,,fee schedule,285.29,699.68,
Foot single axis ankle/foot,L5974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,699.68,,,,,,,fee schedule,285.29,699.68,
Foot single axis ankle/foot,L5974,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,608.42,,,,,,,fee schedule,285.29,699.68,
Foot single axis ankle/foot,L5974,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,299.55,,,,,,,fee schedule,285.29,699.68,APC
Foot single axis ankle/foot,L5974,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,285.29,,,,,,,fee schedule,285.29,699.68,APC
Foot single axis ankle/foot,L5974,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,513.52,,,,,,,fee schedule,285.29,699.68,APC
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,996.51,,,,,,,fee schedule,570.86,1400.1,
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,798.18,,,,,,,fee schedule,570.86,1400.1,
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1400.1,,,,,,,fee schedule,570.86,1400.1,
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1217.48,,,,,,,fee schedule,570.86,1400.1,
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,599.4,,,,,,,fee schedule,570.86,1400.1,APC
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,570.86,,,,,,,fee schedule,570.86,1400.1,APC
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1027.55,,,,,,,fee schedule,570.86,1400.1,APC
Energy storing foot,L5976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1263.22,,,,,,,fee schedule,723.64,1774.83,
Energy storing foot,L5976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1011.81,,,,,,,fee schedule,723.64,1774.83,
Energy storing foot,L5976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1774.83,,,,,,,fee schedule,723.64,1774.83,
Energy storing foot,L5976,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1543.33,,,,,,,fee schedule,723.64,1774.83,
Energy storing foot,L5976,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,759.82,,,,,,,fee schedule,723.64,1774.83,APC
Energy storing foot,L5976,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,723.64,,,,,,,fee schedule,723.64,1774.83,APC
Energy storing foot,L5976,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1302.55,,,,,,,fee schedule,723.64,1774.83,APC
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,669.38,,,,,,,fee schedule,383.44,940.48,
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,536.16,,,,,,,fee schedule,383.44,940.48,
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,940.48,,,,,,,fee schedule,383.44,940.48,
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,817.81,,,,,,,fee schedule,383.44,940.48,
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,402.61,,,,,,,fee schedule,383.44,940.48,APC
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,383.44,,,,,,,fee schedule,383.44,940.48,APC
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,690.19,,,,,,,fee schedule,383.44,940.48,APC
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5359.32,,,,,,,fee schedule,3070.11,7529.89,
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4292.69,,,,,,,fee schedule,3070.11,7529.89,
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7529.89,,,,,,,fee schedule,3070.11,7529.89,
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6547.73,,,,,,,fee schedule,3070.11,7529.89,
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3223.62,,,,,,,fee schedule,3070.11,7529.89,APC
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3070.11,,,,,,,fee schedule,3070.11,7529.89,APC
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5526.2,,,,,,,fee schedule,3070.11,7529.89,APC
Flex foot system,L5980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8165.41,,,,,,,fee schedule,4677.59,11472.48,
Flex foot system,L5980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6540.31,,,,,,,fee schedule,4677.59,11472.48,
Flex foot system,L5980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11472.48,,,,,,,fee schedule,4677.59,11472.48,
Flex foot system,L5980,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9976.07,,,,,,,fee schedule,4677.59,11472.48,
Flex foot system,L5980,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4911.47,,,,,,,fee schedule,4677.59,11472.48,APC
Flex foot system,L5980,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4677.59,,,,,,,fee schedule,4677.59,11472.48,APC
Flex foot system,L5980,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8419.66,,,,,,,fee schedule,4677.59,11472.48,APC
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7334.53,,,,,,,fee schedule,4201.6,10305.08,
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5874.79,,,,,,,fee schedule,4201.6,10305.08,
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10305.08,,,,,,,fee schedule,4201.6,10305.08,
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8960.94,,,,,,,fee schedule,4201.6,10305.08,
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4411.68,,,,,,,fee schedule,4201.6,10305.08,APC
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4201.6,,,,,,,fee schedule,4201.6,10305.08,APC
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7562.88,,,,,,,fee schedule,4201.6,10305.08,APC
Exoskeletal axial rotation u,L5982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1377.82,,,,,,,fee schedule,789.31,1935.85,
Exoskeletal axial rotation u,L5982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1103.6,,,,,,,fee schedule,789.31,1935.85,
Exoskeletal axial rotation u,L5982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1935.85,,,,,,,fee schedule,789.31,1935.85,
Exoskeletal axial rotation u,L5982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1683.35,,,,,,,fee schedule,789.31,1935.85,
Exoskeletal axial rotation u,L5982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,828.78,,,,,,,fee schedule,789.31,1935.85,APC
Exoskeletal axial rotation u,L5982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,789.31,,,,,,,fee schedule,789.31,1935.85,APC
Exoskeletal axial rotation u,L5982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1420.76,,,,,,,fee schedule,789.31,1935.85,APC
Endoskeletal axial rotation,L5984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1382.13,,,,,,,fee schedule,791.74,1941.9,
Endoskeletal axial rotation,L5984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1107.05,,,,,,,fee schedule,791.74,1941.9,
Endoskeletal axial rotation,L5984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1941.9,,,,,,,fee schedule,791.74,1941.9,
Endoskeletal axial rotation,L5984,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1688.61,,,,,,,fee schedule,791.74,1941.9,
Endoskeletal axial rotation,L5984,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,831.33,,,,,,,fee schedule,791.74,1941.9,APC
Endoskeletal axial rotation,L5984,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,791.74,,,,,,,fee schedule,791.74,1941.9,APC
Endoskeletal axial rotation,L5984,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1425.13,,,,,,,fee schedule,791.74,1941.9,APC
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,606.97,,,,,,,fee schedule,347.73,852.79,
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,486.17,,,,,,,fee schedule,347.73,852.79,
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,852.79,,,,,,,fee schedule,347.73,852.79,
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,741.56,,,,,,,fee schedule,347.73,852.79,
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365.12,,,,,,,fee schedule,347.73,852.79,APC
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,347.73,,,,,,,fee schedule,347.73,852.79,APC
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,625.91,,,,,,,fee schedule,347.73,852.79,APC
Multi-axial rotation unit,L5986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1667.19,,,,,,,fee schedule,955.08,2342.41,
Multi-axial rotation unit,L5986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1335.38,,,,,,,fee schedule,955.08,2342.41,
Multi-axial rotation unit,L5986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2342.41,,,,,,,fee schedule,955.08,2342.41,
Multi-axial rotation unit,L5986,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2036.88,,,,,,,fee schedule,955.08,2342.41,
Multi-axial rotation unit,L5986,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1002.83,,,,,,,fee schedule,955.08,2342.41,APC
Multi-axial rotation unit,L5986,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,955.08,,,,,,,fee schedule,955.08,2342.41,APC
Multi-axial rotation unit,L5986,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1719.14,,,,,,,fee schedule,955.08,2342.41,APC
Shank ft w vert load pylon,L5987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15463.16,,,,,,,fee schedule,8858.1,21725.88,
Shank ft w vert load pylon,L5987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12385.64,,,,,,,fee schedule,8858.1,21725.88,
Shank ft w vert load pylon,L5987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21725.88,,,,,,,fee schedule,8858.1,21725.88,
Shank ft w vert load pylon,L5987,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18892.07,,,,,,,fee schedule,8858.1,21725.88,
Shank ft w vert load pylon,L5987,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9301,,,,,,,fee schedule,8858.1,21725.88,APC
Shank ft w vert load pylon,L5987,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8858.1,,,,,,,fee schedule,8858.1,21725.88,APC
Shank ft w vert load pylon,L5987,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15944.58,,,,,,,fee schedule,8858.1,21725.88,APC
Vertical shock reducing pylo,L5988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4294.06,,,,,,,fee schedule,2459.87,6033.19,
Vertical shock reducing pylo,L5988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3439.44,,,,,,,fee schedule,2459.87,6033.19,
Vertical shock reducing pylo,L5988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6033.19,,,,,,,fee schedule,2459.87,6033.19,
Vertical shock reducing pylo,L5988,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5246.25,,,,,,,fee schedule,2459.87,6033.19,
Vertical shock reducing pylo,L5988,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2582.86,,,,,,,fee schedule,2459.87,6033.19,APC
Vertical shock reducing pylo,L5988,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2459.87,,,,,,,fee schedule,2459.87,6033.19,APC
Vertical shock reducing pylo,L5988,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4427.77,,,,,,,fee schedule,2459.87,6033.19,APC
User adjustable heel height,L5990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3899.55,,,,,,,fee schedule,2233.87,5478.9,
User adjustable heel height,L5990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3123.45,,,,,,,fee schedule,2233.87,5478.9,
User adjustable heel height,L5990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5478.9,,,,,,,fee schedule,2233.87,5478.9,
User adjustable heel height,L5990,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4764.26,,,,,,,fee schedule,2233.87,5478.9,
User adjustable heel height,L5990,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2345.56,,,,,,,fee schedule,2233.87,5478.9,APC
User adjustable heel height,L5990,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2233.87,,,,,,,fee schedule,2233.87,5478.9,APC
User adjustable heel height,L5990,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4020.97,,,,,,,fee schedule,2233.87,5478.9,APC
Low pros ext osseo connector,L5991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12342.79,,,,,,,fee schedule,11755.04,21159.07,APC
Low pros ext osseo connector,L5991,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11755.04,,,,,,,fee schedule,11755.04,21159.07,APC
Low pros ext osseo connector,L5991,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21159.07,,,,,,,fee schedule,11755.04,21159.07,APC
Low prosth foot shell repl,L5992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.47,,,,,,,fee schedule,127.11,228.8,APC
Low prosth foot shell repl,L5992,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,127.11,,,,,,,fee schedule,127.11,228.8,APC
Low prosth foot shell repl,L5992,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,228.8,,,,,,,fee schedule,127.11,228.8,APC
Part hand thumb rem,L6000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3786.07,,,,,,,fee schedule,3032.56,5319.46,
Part hand thumb rem,L6000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3032.56,,,,,,,fee schedule,3032.56,5319.46,
Part hand thumb rem,L6000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5319.46,,,,,,,fee schedule,3032.56,5319.46,
Part hand thumb rem,L6000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4625.62,,,,,,,fee schedule,3032.56,5319.46,
Part hand little/ring,L6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4213.26,,,,,,,fee schedule,3374.73,5919.67,
Part hand little/ring,L6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3374.73,,,,,,,fee schedule,3374.73,5919.67,
Part hand little/ring,L6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5919.67,,,,,,,fee schedule,3374.73,5919.67,
Part hand little/ring,L6010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5147.54,,,,,,,fee schedule,3374.73,5919.67,
Part hand no fingers,L6020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3928.19,,,,,,,fee schedule,3146.39,5519.15,
Part hand no fingers,L6020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3146.39,,,,,,,fee schedule,3146.39,5519.15,
Part hand no fingers,L6020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5519.15,,,,,,,fee schedule,3146.39,5519.15,
Part hand no fingers,L6020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4799.26,,,,,,,fee schedule,3146.39,5519.15,
Part hand myo exclu term dev,L6026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9350.11,,,,,,,fee schedule,5356.25,13136.99,
Part hand myo exclu term dev,L6026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7489.23,,,,,,,fee schedule,5356.25,13136.99,
Part hand myo exclu term dev,L6026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13136.99,,,,,,,fee schedule,5356.25,13136.99,
Part hand myo exclu term dev,L6026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11423.47,,,,,,,fee schedule,5356.25,13136.99,
Part hand myo exclu term dev,L6026,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5624.06,,,,,,,fee schedule,5356.25,13136.99,APC
Part hand myo exclu term dev,L6026,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5356.25,,,,,,,fee schedule,5356.25,13136.99,APC
Part hand myo exclu term dev,L6026,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9641.25,,,,,,,fee schedule,5356.25,13136.99,APC
Part handfng endoskel molded,L6028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2401.86,,,,,,,fee schedule,2287.49,4117.48,APC
Part handfng endoskel molded,L6028,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2287.49,,,,,,,fee schedule,2287.49,4117.48,APC
Part handfng endoskel molded,L6028,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4117.48,,,,,,,fee schedule,2287.49,4117.48,APC
Test interface part handfing,L6029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,397.65,,,,,,,fee schedule,378.71,681.68,APC
Test interface part handfing,L6029,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,378.71,,,,,,,fee schedule,378.71,681.68,APC
Test interface part handfing,L6029,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,681.68,,,,,,,fee schedule,378.71,681.68,APC
External frame part handfing,L6030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.47,,,,,,,fee schedule,706.16,1271.09,APC
External frame part handfing,L6030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.16,,,,,,,fee schedule,706.16,1271.09,APC
External frame part handfing,L6030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1271.09,,,,,,,fee schedule,706.16,1271.09,APC
Rep interface handfng molded,L6031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1611.96,,,,,,,fee schedule,1535.2,2763.36,APC
Rep interface handfng molded,L6031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1535.2,,,,,,,fee schedule,1535.2,2763.36,APC
Rep interface handfng molded,L6031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2763.36,,,,,,,fee schedule,1535.2,2763.36,APC
Part handfng ultralite tcf/=,L6032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,396.26,,,,,,,fee schedule,377.39,679.3,APC
Part handfng ultralite tcf/=,L6032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,377.39,,,,,,,fee schedule,377.39,679.3,APC
Part handfng ultralite tcf/=,L6032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,679.3,,,,,,,fee schedule,377.39,679.3,APC
Part handfing acrylic,L6033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,476.15,,,,,,,fee schedule,453.48,816.26,APC
Part handfing acrylic,L6033,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,453.48,,,,,,,fee schedule,453.48,816.26,APC
Part handfing acrylic,L6033,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,816.26,,,,,,,fee schedule,453.48,816.26,APC
Part hand finger distal amp,L6034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,480.38,,,,,,,fee schedule,457.5,823.5,APC
Part hand finger distal amp,L6034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,457.5,,,,,,,fee schedule,457.5,823.5,APC
Part hand finger distal amp,L6034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,823.5,,,,,,,fee schedule,457.5,823.5,APC
Prosthetic digit mechanical,L6035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1694.83,,,,,,,fee schedule,1614.12,2905.42,APC
Prosthetic digit mechanical,L6035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1614.12,,,,,,,fee schedule,1614.12,2905.42,APC
Prosthetic digit mechanical,L6035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2905.42,,,,,,,fee schedule,1614.12,2905.42,APC
Prosthetic thumb mechanical,L6036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1694.83,,,,,,,fee schedule,1614.12,2905.42,APC
Prosthetic thumb mechanical,L6036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1614.12,,,,,,,fee schedule,1614.12,2905.42,APC
Prosthetic thumb mechanical,L6036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2905.42,,,,,,,fee schedule,1614.12,2905.42,APC
Postop dsg cast chg handfing,L6037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1831.11,,,,,,,fee schedule,1743.91,3139.04,APC
Postop dsg cast chg handfing,L6037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1743.91,,,,,,,fee schedule,1743.91,3139.04,APC
Postop dsg cast chg handfing,L6037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3139.04,,,,,,,fee schedule,1743.91,3139.04,APC
Multiax rotation attachment,L6038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,388.2,,,,,,,fee schedule,369.71,665.48,APC
Multiax rotation attachment,L6038,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,369.71,,,,,,,fee schedule,369.71,665.48,APC
Multiax rotation attachment,L6038,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,665.48,,,,,,,fee schedule,369.71,665.48,APC
Passive custom digit/thumb,L6039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2494.5,,,,,,,fee schedule,2375.71,4276.28,APC
Passive custom digit/thumb,L6039,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2375.71,,,,,,,fee schedule,2375.71,4276.28,APC
Passive custom digit/thumb,L6039,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4276.28,,,,,,,fee schedule,2375.71,4276.28,APC
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5343.14,,,,,,,fee schedule,3060.84,7507.15,
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4279.73,,,,,,,fee schedule,3060.84,7507.15,
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7507.15,,,,,,,fee schedule,3060.84,7507.15,
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6527.96,,,,,,,fee schedule,3060.84,7507.15,
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3213.88,,,,,,,fee schedule,3060.84,7507.15,APC
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3060.84,,,,,,,fee schedule,3060.84,7507.15,APC
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5509.51,,,,,,,fee schedule,3060.84,7507.15,APC
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6815.44,,,,,,,fee schedule,3904.27,9575.76,
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5459.02,,,,,,,fee schedule,3904.27,9575.76,
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9575.76,,,,,,,fee schedule,3904.27,9575.76,
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8326.75,,,,,,,fee schedule,3904.27,9575.76,
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4099.48,,,,,,,fee schedule,3904.27,9575.76,APC
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3904.27,,,,,,,fee schedule,3904.27,9575.76,APC
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7027.69,,,,,,,fee schedule,3904.27,9575.76,APC
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5407.1,,,,,,,fee schedule,3097.46,7597.03,
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4330.97,,,,,,,fee schedule,3097.46,7597.03,
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7597.03,,,,,,,fee schedule,3097.46,7597.03,
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6606.11,,,,,,,fee schedule,3097.46,7597.03,
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3252.33,,,,,,,fee schedule,3097.46,7597.03,APC
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3097.46,,,,,,,fee schedule,3097.46,7597.03,APC
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5575.43,,,,,,,fee schedule,3097.46,7597.03,APC
Elbow mold sock suspension t,L6110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5720.33,,,,,,,fee schedule,3276.91,8037.12,
Elbow mold sock suspension t,L6110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4581.86,,,,,,,fee schedule,3276.91,8037.12,
Elbow mold sock suspension t,L6110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8037.12,,,,,,,fee schedule,3276.91,8037.12,
Elbow mold sock suspension t,L6110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6988.8,,,,,,,fee schedule,3276.91,8037.12,
Elbow mold sock suspension t,L6110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3440.76,,,,,,,fee schedule,3276.91,8037.12,APC
Elbow mold sock suspension t,L6110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3276.91,,,,,,,fee schedule,3276.91,8037.12,APC
Elbow mold sock suspension t,L6110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5898.44,,,,,,,fee schedule,3276.91,8037.12,APC
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6469.72,,,,,,,fee schedule,3706.2,9090.01,
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5182.1,,,,,,,fee schedule,3706.2,9090.01,
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9090.01,,,,,,,fee schedule,3706.2,9090.01,
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7904.36,,,,,,,fee schedule,3706.2,9090.01,
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3891.51,,,,,,,fee schedule,3706.2,9090.01,APC
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3706.2,,,,,,,fee schedule,3706.2,9090.01,APC
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6671.16,,,,,,,fee schedule,3706.2,9090.01,APC
Elbow stump activated lock h,L6130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6825.7,,,,,,,fee schedule,3910.12,9590.17,
Elbow stump activated lock h,L6130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5467.23,,,,,,,fee schedule,3910.12,9590.17,
Elbow stump activated lock h,L6130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9590.17,,,,,,,fee schedule,3910.12,9590.17,
Elbow stump activated lock h,L6130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8339.28,,,,,,,fee schedule,3910.12,9590.17,
Elbow stump activated lock h,L6130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4105.63,,,,,,,fee schedule,3910.12,9590.17,APC
Elbow stump activated lock h,L6130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3910.12,,,,,,,fee schedule,3910.12,9590.17,APC
Elbow stump activated lock h,L6130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7038.22,,,,,,,fee schedule,3910.12,9590.17,APC
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7031.26,,,,,,,fee schedule,4027.88,9878.98,
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5631.88,,,,,,,fee schedule,4027.88,9878.98,
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9878.98,,,,,,,fee schedule,4027.88,9878.98,
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8590.42,,,,,,,fee schedule,4027.88,9878.98,
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4229.27,,,,,,,fee schedule,4027.88,9878.98,APC
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4027.88,,,,,,,fee schedule,4027.88,9878.98,APC
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7250.18,,,,,,,fee schedule,4027.88,9878.98,APC
Elbow molded w/ expand inter,L6205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9699.48,,,,,,,fee schedule,5556.38,13627.86,
Elbow molded w/ expand inter,L6205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7769.06,,,,,,,fee schedule,5556.38,13627.86,
Elbow molded w/ expand inter,L6205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13627.86,,,,,,,fee schedule,5556.38,13627.86,
Elbow molded w/ expand inter,L6205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11850.31,,,,,,,fee schedule,5556.38,13627.86,
Elbow molded w/ expand inter,L6205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5834.2,,,,,,,fee schedule,5556.38,13627.86,APC
Elbow molded w/ expand inter,L6205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5556.38,,,,,,,fee schedule,5556.38,13627.86,APC
Elbow molded w/ expand inter,L6205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10001.48,,,,,,,fee schedule,5556.38,13627.86,APC
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6917.54,,,,,,,fee schedule,3962.73,9719.2,
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5540.79,,,,,,,fee schedule,3962.73,9719.2,
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9719.2,,,,,,,fee schedule,3962.73,9719.2,
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8451.48,,,,,,,fee schedule,3962.73,9719.2,
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4160.87,,,,,,,fee schedule,3962.73,9719.2,APC
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3962.73,,,,,,,fee schedule,3962.73,9719.2,APC
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7132.91,,,,,,,fee schedule,3962.73,9719.2,APC
Shlder disart int lock elbow,L6300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9541.19,,,,,,,fee schedule,5465.7,13405.46,
Shlder disart int lock elbow,L6300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7642.28,,,,,,,fee schedule,5465.7,13405.46,
Shlder disart int lock elbow,L6300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13405.46,,,,,,,fee schedule,5465.7,13405.46,
Shlder disart int lock elbow,L6300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11656.92,,,,,,,fee schedule,5465.7,13405.46,
Shlder disart int lock elbow,L6300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5738.98,,,,,,,fee schedule,5465.7,13405.46,APC
Shlder disart int lock elbow,L6300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5465.7,,,,,,,fee schedule,5465.7,13405.46,APC
Shlder disart int lock elbow,L6300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9838.26,,,,,,,fee schedule,5465.7,13405.46,APC
Shoulder passive restor comp,L6310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8646.99,,,,,,,fee schedule,4953.47,12149.11,
Shoulder passive restor comp,L6310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6926.05,,,,,,,fee schedule,4953.47,12149.11,
Shoulder passive restor comp,L6310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12149.11,,,,,,,fee schedule,4953.47,12149.11,
Shoulder passive restor comp,L6310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10564.44,,,,,,,fee schedule,4953.47,12149.11,
Shoulder passive restor comp,L6310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5201.14,,,,,,,fee schedule,4953.47,12149.11,APC
Shoulder passive restor comp,L6310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4953.47,,,,,,,fee schedule,4953.47,12149.11,APC
Shoulder passive restor comp,L6310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8916.25,,,,,,,fee schedule,4953.47,12149.11,APC
Shoulder passive restor cap,L6320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4506.56,,,,,,,fee schedule,2581.59,6331.76,
Shoulder passive restor cap,L6320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3609.65,,,,,,,fee schedule,2581.59,6331.76,
Shoulder passive restor cap,L6320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6331.76,,,,,,,fee schedule,2581.59,6331.76,
Shoulder passive restor cap,L6320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5505.88,,,,,,,fee schedule,2581.59,6331.76,
Shoulder passive restor cap,L6320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2710.67,,,,,,,fee schedule,2581.59,6331.76,APC
Shoulder passive restor cap,L6320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2581.59,,,,,,,fee schedule,2581.59,6331.76,APC
Shoulder passive restor cap,L6320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4646.86,,,,,,,fee schedule,2581.59,6331.76,APC
Thoracic intern lock elbow,L6350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10454.19,,,,,,,fee schedule,5988.72,14688.24,
Thoracic intern lock elbow,L6350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8373.57,,,,,,,fee schedule,5988.72,14688.24,
Thoracic intern lock elbow,L6350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14688.24,,,,,,,fee schedule,5988.72,14688.24,
Thoracic intern lock elbow,L6350,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12772.38,,,,,,,fee schedule,5988.72,14688.24,
Thoracic intern lock elbow,L6350,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6288.16,,,,,,,fee schedule,5988.72,14688.24,APC
Thoracic intern lock elbow,L6350,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5988.72,,,,,,,fee schedule,5988.72,14688.24,APC
Thoracic intern lock elbow,L6350,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10779.7,,,,,,,fee schedule,5988.72,14688.24,APC
Thoracic passive restor comp,L6360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9076.06,,,,,,,fee schedule,5199.26,12751.95,
Thoracic passive restor comp,L6360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7269.72,,,,,,,fee schedule,5199.26,12751.95,
Thoracic passive restor comp,L6360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12751.95,,,,,,,fee schedule,5199.26,12751.95,
Thoracic passive restor comp,L6360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11088.65,,,,,,,fee schedule,5199.26,12751.95,
Thoracic passive restor comp,L6360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5459.22,,,,,,,fee schedule,5199.26,12751.95,APC
Thoracic passive restor comp,L6360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5199.26,,,,,,,fee schedule,5199.26,12751.95,APC
Thoracic passive restor comp,L6360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9358.67,,,,,,,fee schedule,5199.26,12751.95,APC
Thoracic passive restor cap,L6370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5263.48,,,,,,,fee schedule,3015.22,7395.24,
Thoracic passive restor cap,L6370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4215.93,,,,,,,fee schedule,3015.22,7395.24,
Thoracic passive restor cap,L6370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7395.24,,,,,,,fee schedule,3015.22,7395.24,
Thoracic passive restor cap,L6370,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6430.64,,,,,,,fee schedule,3015.22,7395.24,
Thoracic passive restor cap,L6370,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3165.98,,,,,,,fee schedule,3015.22,7395.24,APC
Thoracic passive restor cap,L6370,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3015.22,,,,,,,fee schedule,3015.22,7395.24,APC
Thoracic passive restor cap,L6370,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5427.4,,,,,,,fee schedule,3015.22,7395.24,APC
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3044.26,,,,,,,fee schedule,1743.91,4277.22,
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2438.39,,,,,,,fee schedule,1743.91,4277.22,
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4277.22,,,,,,,fee schedule,1743.91,4277.22,
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3719.32,,,,,,,fee schedule,1743.91,4277.22,
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1831.11,,,,,,,fee schedule,1743.91,4277.22,APC
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1743.91,,,,,,,fee schedule,1743.91,4277.22,APC
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3139.04,,,,,,,fee schedule,1743.91,4277.22,APC
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3624.06,,,,,,,fee schedule,2076.05,5091.83,
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2902.79,,,,,,,fee schedule,2076.05,5091.83,
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5091.83,,,,,,,fee schedule,2076.05,5091.83,
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4427.68,,,,,,,fee schedule,2076.05,5091.83,
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2179.85,,,,,,,fee schedule,2076.05,5091.83,APC
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2076.05,,,,,,,fee schedule,2076.05,5091.83,APC
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3736.89,,,,,,,fee schedule,2076.05,5091.83,APC
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4584.61,,,,,,,fee schedule,2626.33,6441.43,
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3672.17,,,,,,,fee schedule,2626.33,6441.43,
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6441.43,,,,,,,fee schedule,2626.33,6441.43,
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5601.24,,,,,,,fee schedule,2626.33,6441.43,
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2757.65,,,,,,,fee schedule,2626.33,6441.43,APC
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2626.33,,,,,,,fee schedule,2626.33,6441.43,APC
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4727.39,,,,,,,fee schedule,2626.33,6441.43,APC
Postop ea cast chg & realign,L6386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1004.95,,,,,,,fee schedule,575.71,1411.97,
Postop ea cast chg & realign,L6386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,804.95,,,,,,,fee schedule,575.71,1411.97,
Postop ea cast chg & realign,L6386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1411.97,,,,,,,fee schedule,575.71,1411.97,
Postop ea cast chg & realign,L6386,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1227.8,,,,,,,fee schedule,575.71,1411.97,
Postop ea cast chg & realign,L6386,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,604.5,,,,,,,fee schedule,575.71,1411.97,APC
Postop ea cast chg & realign,L6386,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,575.71,,,,,,,fee schedule,575.71,1411.97,APC
Postop ea cast chg & realign,L6386,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1036.28,,,,,,,fee schedule,575.71,1411.97,APC
Postop applicat rigid dsg on,L6388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1106.71,,,,,,,fee schedule,633.99,1554.94,
Postop applicat rigid dsg on,L6388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,886.45,,,,,,,fee schedule,633.99,1554.94,
Postop applicat rigid dsg on,L6388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1554.94,,,,,,,fee schedule,633.99,1554.94,
Postop applicat rigid dsg on,L6388,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1352.12,,,,,,,fee schedule,633.99,1554.94,
Postop applicat rigid dsg on,L6388,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,665.69,,,,,,,fee schedule,633.99,1554.94,APC
Postop applicat rigid dsg on,L6388,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,633.99,,,,,,,fee schedule,633.99,1554.94,APC
Postop applicat rigid dsg on,L6388,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1141.18,,,,,,,fee schedule,633.99,1554.94,APC
Below elbow prosth tiss shap,L6400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5849.12,,,,,,,fee schedule,3350.67,8218.06,
Below elbow prosth tiss shap,L6400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4685.01,,,,,,,fee schedule,3350.67,8218.06,
Below elbow prosth tiss shap,L6400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8218.06,,,,,,,fee schedule,3350.67,8218.06,
Below elbow prosth tiss shap,L6400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7146.14,,,,,,,fee schedule,3350.67,8218.06,
Below elbow prosth tiss shap,L6400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3518.2,,,,,,,fee schedule,3350.67,8218.06,APC
Below elbow prosth tiss shap,L6400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3350.67,,,,,,,fee schedule,3350.67,8218.06,APC
Below elbow prosth tiss shap,L6400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6031.21,,,,,,,fee schedule,3350.67,8218.06,APC
Elb disart prosth tiss shap,L6450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7644.48,,,,,,,fee schedule,4379.16,10740.56,
Elb disart prosth tiss shap,L6450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6123.05,,,,,,,fee schedule,4379.16,10740.56,
Elb disart prosth tiss shap,L6450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10740.56,,,,,,,fee schedule,4379.16,10740.56,
Elb disart prosth tiss shap,L6450,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9339.62,,,,,,,fee schedule,4379.16,10740.56,
Elb disart prosth tiss shap,L6450,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4598.12,,,,,,,fee schedule,4379.16,10740.56,APC
Elb disart prosth tiss shap,L6450,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4379.16,,,,,,,fee schedule,4379.16,10740.56,APC
Elb disart prosth tiss shap,L6450,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7882.49,,,,,,,fee schedule,4379.16,10740.56,APC
Above elbow prosth tiss shap,L6500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7506.7,,,,,,,fee schedule,4300.25,10546.98,
Above elbow prosth tiss shap,L6500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6012.7,,,,,,,fee schedule,4300.25,10546.98,
Above elbow prosth tiss shap,L6500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10546.98,,,,,,,fee schedule,4300.25,10546.98,
Above elbow prosth tiss shap,L6500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9171.29,,,,,,,fee schedule,4300.25,10546.98,
Above elbow prosth tiss shap,L6500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4515.26,,,,,,,fee schedule,4300.25,10546.98,APC
Above elbow prosth tiss shap,L6500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4300.25,,,,,,,fee schedule,4300.25,10546.98,APC
Above elbow prosth tiss shap,L6500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7740.45,,,,,,,fee schedule,4300.25,10546.98,APC
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9722.74,,,,,,,fee schedule,5569.71,13660.54,
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7787.7,,,,,,,fee schedule,5569.71,13660.54,
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13660.54,,,,,,,fee schedule,5569.71,13660.54,
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11878.73,,,,,,,fee schedule,5569.71,13660.54,
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5848.2,,,,,,,fee schedule,5569.71,13660.54,APC
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5569.71,,,,,,,fee schedule,5569.71,13660.54,APC
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10025.48,,,,,,,fee schedule,5569.71,13660.54,APC
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10854.16,,,,,,,fee schedule,6217.85,15250.2,
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8693.94,,,,,,,fee schedule,6217.85,15250.2,
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15250.2,,,,,,,fee schedule,6217.85,15250.2,
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13261.04,,,,,,,fee schedule,6217.85,15250.2,
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6528.74,,,,,,,fee schedule,6217.85,15250.2,APC
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6217.85,,,,,,,fee schedule,6217.85,15250.2,APC
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11192.13,,,,,,,fee schedule,6217.85,15250.2,APC
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4339.76,,,,,,,fee schedule,2486.04,6097.4,
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3476.05,,,,,,,fee schedule,2486.04,6097.4,
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6097.4,,,,,,,fee schedule,2486.04,6097.4,
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5302.09,,,,,,,fee schedule,2486.04,6097.4,
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2610.34,,,,,,,fee schedule,2486.04,6097.4,APC
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2486.04,,,,,,,fee schedule,2486.04,6097.4,APC
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4474.87,,,,,,,fee schedule,2486.04,6097.4,APC
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3644.79,,,,,,,fee schedule,2087.94,5120.96,
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2919.39,,,,,,,fee schedule,2087.94,5120.96,
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5120.96,,,,,,,fee schedule,2087.94,5120.96,
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4453.01,,,,,,,fee schedule,2087.94,5120.96,
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2192.34,,,,,,,fee schedule,2087.94,5120.96,APC
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2087.94,,,,,,,fee schedule,2087.94,5120.96,APC
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3758.29,,,,,,,fee schedule,2087.94,5120.96,APC
Elbow fair lead cable molded,L6584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5396.93,,,,,,,fee schedule,3091.67,7582.73,
Elbow fair lead cable molded,L6584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4322.82,,,,,,,fee schedule,3091.67,7582.73,
Elbow fair lead cable molded,L6584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7582.73,,,,,,,fee schedule,3091.67,7582.73,
Elbow fair lead cable molded,L6584,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6593.68,,,,,,,fee schedule,3091.67,7582.73,
Elbow fair lead cable molded,L6584,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3246.25,,,,,,,fee schedule,3091.67,7582.73,APC
Elbow fair lead cable molded,L6584,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3091.67,,,,,,,fee schedule,3091.67,7582.73,APC
Elbow fair lead cable molded,L6584,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5565.01,,,,,,,fee schedule,3091.67,7582.73,APC
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4809.03,,,,,,,fee schedule,2754.87,6756.73,
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3851.93,,,,,,,fee schedule,2754.87,6756.73,
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6756.73,,,,,,,fee schedule,2754.87,6756.73,
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5875.42,,,,,,,fee schedule,2754.87,6756.73,
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2892.61,,,,,,,fee schedule,2754.87,6756.73,APC
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2754.87,,,,,,,fee schedule,2754.87,6756.73,APC
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4958.77,,,,,,,fee schedule,2754.87,6756.73,APC
Shdr fair lead cable molded,L6588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7659.01,,,,,,,fee schedule,4387.49,10760.98,
Shdr fair lead cable molded,L6588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6134.69,,,,,,,fee schedule,4387.49,10760.98,
Shdr fair lead cable molded,L6588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10760.98,,,,,,,fee schedule,4387.49,10760.98,
Shdr fair lead cable molded,L6588,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9357.37,,,,,,,fee schedule,4387.49,10760.98,
Shdr fair lead cable molded,L6588,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4606.86,,,,,,,fee schedule,4387.49,10760.98,APC
Shdr fair lead cable molded,L6588,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4387.49,,,,,,,fee schedule,4387.49,10760.98,APC
Shdr fair lead cable molded,L6588,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7897.48,,,,,,,fee schedule,4387.49,10760.98,APC
Shdr fair lead cable direct,L6590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6675.1,,,,,,,fee schedule,3823.85,9378.58,
Shdr fair lead cable direct,L6590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5346.61,,,,,,,fee schedule,3823.85,9378.58,
Shdr fair lead cable direct,L6590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9378.58,,,,,,,fee schedule,3823.85,9378.58,
Shdr fair lead cable direct,L6590,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8155.29,,,,,,,fee schedule,3823.85,9378.58,
Shdr fair lead cable direct,L6590,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4015.04,,,,,,,fee schedule,3823.85,9378.58,APC
Shdr fair lead cable direct,L6590,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3823.85,,,,,,,fee schedule,3823.85,9378.58,APC
Shdr fair lead cable direct,L6590,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6882.93,,,,,,,fee schedule,3823.85,9378.58,APC
Polycentric hinge pair,L6600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,487.53,,,,,,,fee schedule,279.3,684.99,
Polycentric hinge pair,L6600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,390.5,,,,,,,fee schedule,279.3,684.99,
Polycentric hinge pair,L6600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,684.99,,,,,,,fee schedule,279.3,684.99,
Polycentric hinge pair,L6600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,595.64,,,,,,,fee schedule,279.3,684.99,
Polycentric hinge pair,L6600,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,293.26,,,,,,,fee schedule,279.3,684.99,APC
Polycentric hinge pair,L6600,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,279.3,,,,,,,fee schedule,279.3,684.99,APC
Polycentric hinge pair,L6600,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,502.74,,,,,,,fee schedule,279.3,684.99,APC
Single pivot hinge pair,L6605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,501.81,,,,,,,fee schedule,287.48,705.04,
Single pivot hinge pair,L6605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,401.94,,,,,,,fee schedule,287.48,705.04,
Single pivot hinge pair,L6605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,705.04,,,,,,,fee schedule,287.48,705.04,
Single pivot hinge pair,L6605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,613.08,,,,,,,fee schedule,287.48,705.04,
Single pivot hinge pair,L6605,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,301.85,,,,,,,fee schedule,287.48,705.04,APC
Single pivot hinge pair,L6605,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,287.48,,,,,,,fee schedule,287.48,705.04,APC
Single pivot hinge pair,L6605,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,517.46,,,,,,,fee schedule,287.48,705.04,APC
Flexible metal hinge pair,L6610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,474.4,,,,,,,fee schedule,271.77,666.54,
Flexible metal hinge pair,L6610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,379.99,,,,,,,fee schedule,271.77,666.54,
Flexible metal hinge pair,L6610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,666.54,,,,,,,fee schedule,271.77,666.54,
Flexible metal hinge pair,L6610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,579.6,,,,,,,fee schedule,271.77,666.54,
Flexible metal hinge pair,L6610,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,285.36,,,,,,,fee schedule,271.77,666.54,APC
Flexible metal hinge pair,L6610,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,271.77,,,,,,,fee schedule,271.77,666.54,APC
Flexible metal hinge pair,L6610,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,489.19,,,,,,,fee schedule,271.77,666.54,APC
"Additional switch, ext power",L6611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,884.95,,,,,,,fee schedule,506.97,1243.37,
"Additional switch, ext power",L6611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,708.83,,,,,,,fee schedule,506.97,1243.37,
"Additional switch, ext power",L6611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1243.37,,,,,,,fee schedule,506.97,1243.37,
"Additional switch, ext power",L6611,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1081.19,,,,,,,fee schedule,506.97,1243.37,
"Additional switch, ext power",L6611,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,532.32,,,,,,,fee schedule,506.97,1243.37,APC
"Additional switch, ext power",L6611,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,506.97,,,,,,,fee schedule,506.97,1243.37,APC
"Additional switch, ext power",L6611,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,912.55,,,,,,,fee schedule,506.97,1243.37,APC
Disconnect locking wrist uni,L6615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,460.5,,,,,,,fee schedule,263.8,647,
Disconnect locking wrist uni,L6615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,368.85,,,,,,,fee schedule,263.8,647,
Disconnect locking wrist uni,L6615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,647,,,,,,,fee schedule,263.8,647,
Disconnect locking wrist uni,L6615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,562.61,,,,,,,fee schedule,263.8,647,
Disconnect locking wrist uni,L6615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.99,,,,,,,fee schedule,263.8,647,APC
Disconnect locking wrist uni,L6615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,263.8,,,,,,,fee schedule,263.8,647,APC
Disconnect locking wrist uni,L6615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,474.84,,,,,,,fee schedule,263.8,647,APC
Disconnect insert locking wr,L6616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.6,,,,,,,fee schedule,79.41,194.74,
Disconnect insert locking wr,L6616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.02,,,,,,,fee schedule,79.41,194.74,
Disconnect insert locking wr,L6616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.74,,,,,,,fee schedule,79.41,194.74,
Disconnect insert locking wr,L6616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.34,,,,,,,fee schedule,79.41,194.74,
Disconnect insert locking wr,L6616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.38,,,,,,,fee schedule,79.41,194.74,APC
Disconnect insert locking wr,L6616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.41,,,,,,,fee schedule,79.41,194.74,APC
Disconnect insert locking wr,L6616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,142.94,,,,,,,fee schedule,79.41,194.74,APC
Flexion/extension wrist unit,L6620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,805.04,,,,,,,fee schedule,461.17,1131.09,
Flexion/extension wrist unit,L6620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,644.82,,,,,,,fee schedule,461.17,1131.09,
Flexion/extension wrist unit,L6620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1131.09,,,,,,,fee schedule,461.17,1131.09,
Flexion/extension wrist unit,L6620,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,983.56,,,,,,,fee schedule,461.17,1131.09,
Flexion/extension wrist unit,L6620,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,484.23,,,,,,,fee schedule,461.17,1131.09,APC
Flexion/extension wrist unit,L6620,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,461.17,,,,,,,fee schedule,461.17,1131.09,APC
Flexion/extension wrist unit,L6620,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,830.11,,,,,,,fee schedule,461.17,1131.09,APC
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4916.61,,,,,,,fee schedule,2816.5,6907.88,
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3938.09,,,,,,,fee schedule,2816.5,6907.88,
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6907.88,,,,,,,fee schedule,2816.5,6907.88,
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6006.85,,,,,,,fee schedule,2816.5,6907.88,
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2957.32,,,,,,,fee schedule,2816.5,6907.88,APC
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2816.5,,,,,,,fee schedule,2816.5,6907.88,APC
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5069.7,,,,,,,fee schedule,2816.5,6907.88,APC
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1533.59,,,,,,,fee schedule,878.53,2154.71,
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1228.37,,,,,,,fee schedule,878.53,2154.71,
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2154.71,,,,,,,fee schedule,878.53,2154.71,
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1873.66,,,,,,,fee schedule,878.53,2154.71,
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,922.46,,,,,,,fee schedule,878.53,2154.71,APC
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,878.53,,,,,,,fee schedule,878.53,2154.71,APC
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1581.35,,,,,,,fee schedule,878.53,2154.71,APC
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8095.24,,,,,,,fee schedule,4637.39,11373.88,
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6484.1,,,,,,,fee schedule,4637.39,11373.88,
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11373.88,,,,,,,fee schedule,4637.39,11373.88,
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9890.33,,,,,,,fee schedule,4637.39,11373.88,
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4869.26,,,,,,,fee schedule,4637.39,11373.88,APC
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4637.39,,,,,,,fee schedule,4637.39,11373.88,APC
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8347.3,,,,,,,fee schedule,4637.39,11373.88,APC
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1136.62,,,,,,,fee schedule,651.11,1596.96,
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,910.41,,,,,,,fee schedule,651.11,1596.96,
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1596.96,,,,,,,fee schedule,651.11,1596.96,
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1388.66,,,,,,,fee schedule,651.11,1596.96,
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,683.67,,,,,,,fee schedule,651.11,1596.96,APC
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,651.11,,,,,,,fee schedule,651.11,1596.96,APC
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1172,,,,,,,fee schedule,651.11,1596.96,APC
Quick disconn hook adapter o,L6628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1223.46,,,,,,,fee schedule,700.86,1718.97,
Quick disconn hook adapter o,L6628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,979.96,,,,,,,fee schedule,700.86,1718.97,
Quick disconn hook adapter o,L6628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1718.97,,,,,,,fee schedule,700.86,1718.97,
Quick disconn hook adapter o,L6628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1494.76,,,,,,,fee schedule,700.86,1718.97,
Quick disconn hook adapter o,L6628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,735.9,,,,,,,fee schedule,700.86,1718.97,APC
Quick disconn hook adapter o,L6628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,700.86,,,,,,,fee schedule,700.86,1718.97,APC
Quick disconn hook adapter o,L6628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1261.55,,,,,,,fee schedule,700.86,1718.97,APC
Lamination collar w/ couplin,L6629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,416.86,,,,,,,fee schedule,238.81,585.7,
Lamination collar w/ couplin,L6629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,333.9,,,,,,,fee schedule,238.81,585.7,
Lamination collar w/ couplin,L6629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,585.7,,,,,,,fee schedule,238.81,585.7,
Lamination collar w/ couplin,L6629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,509.3,,,,,,,fee schedule,238.81,585.7,
Lamination collar w/ couplin,L6629,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,250.75,,,,,,,fee schedule,238.81,585.7,APC
Lamination collar w/ couplin,L6629,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,238.81,,,,,,,fee schedule,238.81,585.7,APC
Lamination collar w/ couplin,L6629,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,429.86,,,,,,,fee schedule,238.81,585.7,APC
Stainless steel any wrist,L6630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,614.1,,,,,,,fee schedule,351.8,862.82,
Stainless steel any wrist,L6630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,491.88,,,,,,,fee schedule,351.8,862.82,
Stainless steel any wrist,L6630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,862.82,,,,,,,fee schedule,351.8,862.82,
Stainless steel any wrist,L6630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,750.28,,,,,,,fee schedule,351.8,862.82,
Stainless steel any wrist,L6630,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,369.39,,,,,,,fee schedule,351.8,862.82,APC
Stainless steel any wrist,L6630,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,351.8,,,,,,,fee schedule,351.8,862.82,APC
Stainless steel any wrist,L6630,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,633.24,,,,,,,fee schedule,351.8,862.82,APC
Latex suspension sleeve each,L6632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.84,,,,,,,fee schedule,79.54,195.07,
Latex suspension sleeve each,L6632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.21,,,,,,,fee schedule,79.54,195.07,
Latex suspension sleeve each,L6632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.07,,,,,,,fee schedule,79.54,195.07,
Latex suspension sleeve each,L6632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.63,,,,,,,fee schedule,79.54,195.07,
Latex suspension sleeve each,L6632,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.52,,,,,,,fee schedule,79.54,195.07,APC
Latex suspension sleeve each,L6632,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.54,,,,,,,fee schedule,79.54,195.07,APC
Latex suspension sleeve each,L6632,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,143.17,,,,,,,fee schedule,79.54,195.07,APC
Lift assist for elbow,L6635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,443.86,,,,,,,fee schedule,254.26,623.63,
Lift assist for elbow,L6635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,355.53,,,,,,,fee schedule,254.26,623.63,
Lift assist for elbow,L6635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,623.63,,,,,,,fee schedule,254.26,623.63,
Lift assist for elbow,L6635,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,542.29,,,,,,,fee schedule,254.26,623.63,
Lift assist for elbow,L6635,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,266.97,,,,,,,fee schedule,254.26,623.63,APC
Lift assist for elbow,L6635,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,254.26,,,,,,,fee schedule,254.26,623.63,APC
Lift assist for elbow,L6635,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,457.67,,,,,,,fee schedule,254.26,623.63,APC
Nudge control elbow lock,L6637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,868.96,,,,,,,fee schedule,497.8,1220.9,
Nudge control elbow lock,L6637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,696.02,,,,,,,fee schedule,497.8,1220.9,
Nudge control elbow lock,L6637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1220.9,,,,,,,fee schedule,497.8,1220.9,
Nudge control elbow lock,L6637,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1061.65,,,,,,,fee schedule,497.8,1220.9,
Nudge control elbow lock,L6637,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,522.69,,,,,,,fee schedule,497.8,1220.9,APC
Nudge control elbow lock,L6637,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,497.8,,,,,,,fee schedule,497.8,1220.9,APC
Nudge control elbow lock,L6637,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,896.04,,,,,,,fee schedule,497.8,1220.9,APC
Elec lock on manual pw elbow,L6638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5375.38,,,,,,,fee schedule,3079.31,7552.45,
Elec lock on manual pw elbow,L6638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4305.55,,,,,,,fee schedule,3079.31,7552.45,
Elec lock on manual pw elbow,L6638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7552.45,,,,,,,fee schedule,3079.31,7552.45,
Elec lock on manual pw elbow,L6638,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6567.35,,,,,,,fee schedule,3079.31,7552.45,
Elec lock on manual pw elbow,L6638,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3233.28,,,,,,,fee schedule,3079.31,7552.45,APC
Elec lock on manual pw elbow,L6638,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3079.31,,,,,,,fee schedule,3079.31,7552.45,APC
Elec lock on manual pw elbow,L6638,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5542.76,,,,,,,fee schedule,3079.31,7552.45,APC
Shoulder abduction joint pai,L6640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,723.72,,,,,,,fee schedule,414.58,1016.83,
Shoulder abduction joint pai,L6640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,579.68,,,,,,,fee schedule,414.58,1016.83,
Shoulder abduction joint pai,L6640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1016.83,,,,,,,fee schedule,414.58,1016.83,
Shoulder abduction joint pai,L6640,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,884.2,,,,,,,fee schedule,414.58,1016.83,
Shoulder abduction joint pai,L6640,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,435.31,,,,,,,fee schedule,414.58,1016.83,APC
Shoulder abduction joint pai,L6640,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,414.58,,,,,,,fee schedule,414.58,1016.83,APC
Shoulder abduction joint pai,L6640,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,746.24,,,,,,,fee schedule,414.58,1016.83,APC
Excursion amplifier pulley t,L6641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,421.42,,,,,,,fee schedule,241.41,592.1,
Excursion amplifier pulley t,L6641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,337.55,,,,,,,fee schedule,241.41,592.1,
Excursion amplifier pulley t,L6641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,592.1,,,,,,,fee schedule,241.41,592.1,
Excursion amplifier pulley t,L6641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,514.87,,,,,,,fee schedule,241.41,592.1,
Excursion amplifier pulley t,L6641,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,253.48,,,,,,,fee schedule,241.41,592.1,APC
Excursion amplifier pulley t,L6641,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,241.41,,,,,,,fee schedule,241.41,592.1,APC
Excursion amplifier pulley t,L6641,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,434.54,,,,,,,fee schedule,241.41,592.1,APC
Excursion amplifier lever ty,L6642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,619.62,,,,,,,fee schedule,354.94,870.57,
Excursion amplifier lever ty,L6642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,496.3,,,,,,,fee schedule,354.94,870.57,
Excursion amplifier lever ty,L6642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,870.57,,,,,,,fee schedule,354.94,870.57,
Excursion amplifier lever ty,L6642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,757.02,,,,,,,fee schedule,354.94,870.57,
Excursion amplifier lever ty,L6642,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.69,,,,,,,fee schedule,354.94,870.57,APC
Excursion amplifier lever ty,L6642,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,354.94,,,,,,,fee schedule,354.94,870.57,APC
Excursion amplifier lever ty,L6642,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,638.89,,,,,,,fee schedule,354.94,870.57,APC
Shoulder flexion-abduction j,L6645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,782.66,,,,,,,fee schedule,448.35,1099.64,
Shoulder flexion-abduction j,L6645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,626.89,,,,,,,fee schedule,448.35,1099.64,
Shoulder flexion-abduction j,L6645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1099.64,,,,,,,fee schedule,448.35,1099.64,
Shoulder flexion-abduction j,L6645,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,956.21,,,,,,,fee schedule,448.35,1099.64,
Shoulder flexion-abduction j,L6645,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,470.77,,,,,,,fee schedule,448.35,1099.64,APC
Shoulder flexion-abduction j,L6645,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,448.35,,,,,,,fee schedule,448.35,1099.64,APC
Shoulder flexion-abduction j,L6645,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,807.03,,,,,,,fee schedule,448.35,1099.64,APC
Multipo locking shoulder jnt,L6646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6779.57,,,,,,,fee schedule,3883.7,9525.36,
Multipo locking shoulder jnt,L6646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5430.28,,,,,,,fee schedule,3883.7,9525.36,
Multipo locking shoulder jnt,L6646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9525.36,,,,,,,fee schedule,3883.7,9525.36,
Multipo locking shoulder jnt,L6646,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8282.92,,,,,,,fee schedule,3883.7,9525.36,
Multipo locking shoulder jnt,L6646,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4077.88,,,,,,,fee schedule,3883.7,9525.36,APC
Multipo locking shoulder jnt,L6646,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3883.7,,,,,,,fee schedule,3883.7,9525.36,APC
Multipo locking shoulder jnt,L6646,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6990.66,,,,,,,fee schedule,3883.7,9525.36,APC
Shoulder lock actuator,L6647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1116.17,,,,,,,fee schedule,639.39,1568.23,
Shoulder lock actuator,L6647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,894.03,,,,,,,fee schedule,639.39,1568.23,
Shoulder lock actuator,L6647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1568.23,,,,,,,fee schedule,639.39,1568.23,
Shoulder lock actuator,L6647,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1363.68,,,,,,,fee schedule,639.39,1568.23,
Shoulder lock actuator,L6647,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,671.36,,,,,,,fee schedule,639.39,1568.23,APC
Shoulder lock actuator,L6647,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,639.39,,,,,,,fee schedule,639.39,1568.23,APC
Shoulder lock actuator,L6647,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1150.9,,,,,,,fee schedule,639.39,1568.23,APC
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6992.13,,,,,,,fee schedule,4005.49,9824.01,
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5600.54,,,,,,,fee schedule,4005.49,9824.01,
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9824.01,,,,,,,fee schedule,4005.49,9824.01,
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8542.62,,,,,,,fee schedule,4005.49,9824.01,
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4205.76,,,,,,,fee schedule,4005.49,9824.01,APC
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4005.49,,,,,,,fee schedule,4005.49,9824.01,APC
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7209.88,,,,,,,fee schedule,4005.49,9824.01,APC
Shoulder universal joint,L6650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,848.87,,,,,,,fee schedule,486.29,1192.68,
Shoulder universal joint,L6650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,679.93,,,,,,,fee schedule,486.29,1192.68,
Shoulder universal joint,L6650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1192.68,,,,,,,fee schedule,486.29,1192.68,
Shoulder universal joint,L6650,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1037.11,,,,,,,fee schedule,486.29,1192.68,
Shoulder universal joint,L6650,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,510.6,,,,,,,fee schedule,486.29,1192.68,APC
Shoulder universal joint,L6650,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,486.29,,,,,,,fee schedule,486.29,1192.68,APC
Shoulder universal joint,L6650,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,875.32,,,,,,,fee schedule,486.29,1192.68,APC
Standard control cable extra,L6655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.67,,,,,,,fee schedule,94.34,231.37,
Standard control cable extra,L6655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,131.9,,,,,,,fee schedule,94.34,231.37,
Standard control cable extra,L6655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.37,,,,,,,fee schedule,94.34,231.37,
Standard control cable extra,L6655,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.19,,,,,,,fee schedule,94.34,231.37,
Standard control cable extra,L6655,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.06,,,,,,,fee schedule,94.34,231.37,APC
Standard control cable extra,L6655,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.34,,,,,,,fee schedule,94.34,231.37,APC
Standard control cable extra,L6655,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,169.81,,,,,,,fee schedule,94.34,231.37,APC
Heavy duty control cable,L6660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,220.36,,,,,,,fee schedule,126.24,309.61,
Heavy duty control cable,L6660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.51,,,,,,,fee schedule,126.24,309.61,
Heavy duty control cable,L6660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,309.61,,,,,,,fee schedule,126.24,309.61,
Heavy duty control cable,L6660,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,269.23,,,,,,,fee schedule,126.24,309.61,
Heavy duty control cable,L6660,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.55,,,,,,,fee schedule,126.24,309.61,APC
Heavy duty control cable,L6660,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,126.24,,,,,,,fee schedule,126.24,309.61,APC
Heavy duty control cable,L6660,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,227.23,,,,,,,fee schedule,126.24,309.61,APC
Teflon or equal cable lining,L6665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,98.41,,,,,,,fee schedule,56.38,138.26,
Teflon or equal cable lining,L6665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.82,,,,,,,fee schedule,56.38,138.26,
Teflon or equal cable lining,L6665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,138.26,,,,,,,fee schedule,56.38,138.26,
Teflon or equal cable lining,L6665,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,120.23,,,,,,,fee schedule,56.38,138.26,
Teflon or equal cable lining,L6665,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.2,,,,,,,fee schedule,56.38,138.26,APC
Teflon or equal cable lining,L6665,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,56.38,,,,,,,fee schedule,56.38,138.26,APC
Teflon or equal cable lining,L6665,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,101.48,,,,,,,fee schedule,56.38,138.26,APC
Hook to hand cable adapter,L6670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.48,,,,,,,fee schedule,58.71,143.99,
Hook to hand cable adapter,L6670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.09,,,,,,,fee schedule,58.71,143.99,
Hook to hand cable adapter,L6670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,143.99,,,,,,,fee schedule,58.71,143.99,
Hook to hand cable adapter,L6670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.21,,,,,,,fee schedule,58.71,143.99,
Hook to hand cable adapter,L6670,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.65,,,,,,,fee schedule,58.71,143.99,APC
Hook to hand cable adapter,L6670,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.71,,,,,,,fee schedule,58.71,143.99,APC
Hook to hand cable adapter,L6670,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.68,,,,,,,fee schedule,58.71,143.99,APC
Harness chest/shlder saddle,L6672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,470.35,,,,,,,fee schedule,269.43,660.85,
Harness chest/shlder saddle,L6672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,376.74,,,,,,,fee schedule,269.43,660.85,
Harness chest/shlder saddle,L6672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,660.85,,,,,,,fee schedule,269.43,660.85,
Harness chest/shlder saddle,L6672,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,574.65,,,,,,,fee schedule,269.43,660.85,
Harness chest/shlder saddle,L6672,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,282.9,,,,,,,fee schedule,269.43,660.85,APC
Harness chest/shlder saddle,L6672,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,269.43,,,,,,,fee schedule,269.43,660.85,APC
Harness chest/shlder saddle,L6672,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,484.97,,,,,,,fee schedule,269.43,660.85,APC
Harness figure of 8 sing con,L6675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,256.66,,,,,,,fee schedule,147.02,360.61,
Harness figure of 8 sing con,L6675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,205.58,,,,,,,fee schedule,147.02,360.61,
Harness figure of 8 sing con,L6675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,360.61,,,,,,,fee schedule,147.02,360.61,
Harness figure of 8 sing con,L6675,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,313.57,,,,,,,fee schedule,147.02,360.61,
Harness figure of 8 sing con,L6675,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,154.37,,,,,,,fee schedule,147.02,360.61,APC
Harness figure of 8 sing con,L6675,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,147.02,,,,,,,fee schedule,147.02,360.61,APC
Harness figure of 8 sing con,L6675,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,264.64,,,,,,,fee schedule,147.02,360.61,APC
Harness figure of 8 dual con,L6676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.52,,,,,,,fee schedule,153.82,377.27,
Harness figure of 8 dual con,L6676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,215.08,,,,,,,fee schedule,153.82,377.27,
Harness figure of 8 dual con,L6676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,377.27,,,,,,,fee schedule,153.82,377.27,
Harness figure of 8 dual con,L6676,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,328.06,,,,,,,fee schedule,153.82,377.27,
Harness figure of 8 dual con,L6676,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,161.51,,,,,,,fee schedule,153.82,377.27,APC
Harness figure of 8 dual con,L6676,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,153.82,,,,,,,fee schedule,153.82,377.27,APC
Harness figure of 8 dual con,L6676,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,276.88,,,,,,,fee schedule,153.82,377.27,APC
UE triple control harness,L6677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,637.6,,,,,,,fee schedule,365.26,895.84,
UE triple control harness,L6677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,510.71,,,,,,,fee schedule,365.26,895.84,
UE triple control harness,L6677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,895.84,,,,,,,fee schedule,365.26,895.84,
UE triple control harness,L6677,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,778.99,,,,,,,fee schedule,365.26,895.84,
UE triple control harness,L6677,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,383.52,,,,,,,fee schedule,365.26,895.84,APC
UE triple control harness,L6677,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,365.26,,,,,,,fee schedule,365.26,895.84,APC
UE triple control harness,L6677,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,657.47,,,,,,,fee schedule,365.26,895.84,APC
Test sock wrist disart/bel e,L6680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,661.1,,,,,,,fee schedule,378.71,928.86,
Test sock wrist disart/bel e,L6680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,529.53,,,,,,,fee schedule,378.71,928.86,
Test sock wrist disart/bel e,L6680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,928.86,,,,,,,fee schedule,378.71,928.86,
Test sock wrist disart/bel e,L6680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,807.7,,,,,,,fee schedule,378.71,928.86,
Test sock wrist disart/bel e,L6680,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,397.65,,,,,,,fee schedule,378.71,928.86,APC
Test sock wrist disart/bel e,L6680,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,378.71,,,,,,,fee schedule,378.71,928.86,APC
Test sock wrist disart/bel e,L6680,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,681.68,,,,,,,fee schedule,378.71,928.86,APC
Test sock elbw disart/above,L6682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,730.94,,,,,,,fee schedule,418.71,1026.97,
Test sock elbw disart/above,L6682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,585.46,,,,,,,fee schedule,418.71,1026.97,
Test sock elbw disart/above,L6682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1026.97,,,,,,,fee schedule,418.71,1026.97,
Test sock elbw disart/above,L6682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,893.02,,,,,,,fee schedule,418.71,1026.97,
Test sock elbw disart/above,L6682,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,439.65,,,,,,,fee schedule,418.71,1026.97,APC
Test sock elbw disart/above,L6682,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,418.71,,,,,,,fee schedule,418.71,1026.97,APC
Test sock elbw disart/above,L6682,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,753.68,,,,,,,fee schedule,418.71,1026.97,APC
Test socket shldr disart/tho,L6684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,993.26,,,,,,,fee schedule,568.98,1395.54,
Test socket shldr disart/tho,L6684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,795.58,,,,,,,fee schedule,568.98,1395.54,
Test socket shldr disart/tho,L6684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1395.54,,,,,,,fee schedule,568.98,1395.54,
Test socket shldr disart/tho,L6684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1213.51,,,,,,,fee schedule,568.98,1395.54,
Test socket shldr disart/tho,L6684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,597.43,,,,,,,fee schedule,568.98,1395.54,APC
Test socket shldr disart/tho,L6684,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,568.98,,,,,,,fee schedule,568.98,1395.54,APC
Test socket shldr disart/tho,L6684,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1024.16,,,,,,,fee schedule,568.98,1395.54,APC
Suction socket,L6686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1473.82,,,,,,,fee schedule,844.29,2070.74,
Suction socket,L6686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1180.5,,,,,,,fee schedule,844.29,2070.74,
Suction socket,L6686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2070.74,,,,,,,fee schedule,844.29,2070.74,
Suction socket,L6686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1800.64,,,,,,,fee schedule,844.29,2070.74,
Suction socket,L6686,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,886.5,,,,,,,fee schedule,844.29,2070.74,APC
Suction socket,L6686,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,844.29,,,,,,,fee schedule,844.29,2070.74,APC
Suction socket,L6686,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1519.72,,,,,,,fee schedule,844.29,2070.74,APC
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1232.69,,,,,,,fee schedule,706.16,1731.95,
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,987.36,,,,,,,fee schedule,706.16,1731.95,
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1731.95,,,,,,,fee schedule,706.16,1731.95,
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1506.04,,,,,,,fee schedule,706.16,1731.95,
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.47,,,,,,,fee schedule,706.16,1731.95,APC
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,706.16,,,,,,,fee schedule,706.16,1731.95,APC
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1271.09,,,,,,,fee schedule,706.16,1731.95,APC
Frame typ sock above elb/dis,L6688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1364.28,,,,,,,fee schedule,781.53,1916.82,
Frame typ sock above elb/dis,L6688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1092.75,,,,,,,fee schedule,781.53,1916.82,
Frame typ sock above elb/dis,L6688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1916.82,,,,,,,fee schedule,781.53,1916.82,
Frame typ sock above elb/dis,L6688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1666.8,,,,,,,fee schedule,781.53,1916.82,
Frame typ sock above elb/dis,L6688,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.61,,,,,,,fee schedule,781.53,1916.82,APC
Frame typ sock above elb/dis,L6688,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,781.53,,,,,,,fee schedule,781.53,1916.82,APC
Frame typ sock above elb/dis,L6688,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1406.75,,,,,,,fee schedule,781.53,1916.82,APC
Frame typ socket shoulder di,L6689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1625.98,,,,,,,fee schedule,931.44,2284.52,
Frame typ socket shoulder di,L6689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1302.38,,,,,,,fee schedule,931.44,2284.52,
Frame typ socket shoulder di,L6689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2284.52,,,,,,,fee schedule,931.44,2284.52,
Frame typ socket shoulder di,L6689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1986.54,,,,,,,fee schedule,931.44,2284.52,
Frame typ socket shoulder di,L6689,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,978.01,,,,,,,fee schedule,931.44,2284.52,APC
Frame typ socket shoulder di,L6689,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,931.44,,,,,,,fee schedule,931.44,2284.52,APC
Frame typ socket shoulder di,L6689,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1676.59,,,,,,,fee schedule,931.44,2284.52,APC
Frame typ sock interscap-tho,L6690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1914.35,,,,,,,fee schedule,1096.63,2689.68,
Frame typ sock interscap-tho,L6690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1533.35,,,,,,,fee schedule,1096.63,2689.68,
Frame typ sock interscap-tho,L6690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2689.68,,,,,,,fee schedule,1096.63,2689.68,
Frame typ sock interscap-tho,L6690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2338.85,,,,,,,fee schedule,1096.63,2689.68,
Frame typ sock interscap-tho,L6690,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1151.46,,,,,,,fee schedule,1096.63,2689.68,APC
Frame typ sock interscap-tho,L6690,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1096.63,,,,,,,fee schedule,1096.63,2689.68,APC
Frame typ sock interscap-tho,L6690,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1973.93,,,,,,,fee schedule,1096.63,2689.68,APC
Removable insert each,L6691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,755.65,,,,,,,fee schedule,432.88,1061.69,
Removable insert each,L6691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,605.26,,,,,,,fee schedule,432.88,1061.69,
Removable insert each,L6691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1061.69,,,,,,,fee schedule,432.88,1061.69,
Removable insert each,L6691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,923.21,,,,,,,fee schedule,432.88,1061.69,
Removable insert each,L6691,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,454.52,,,,,,,fee schedule,432.88,1061.69,APC
Removable insert each,L6691,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,432.88,,,,,,,fee schedule,432.88,1061.69,APC
Removable insert each,L6691,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,779.18,,,,,,,fee schedule,432.88,1061.69,APC
Silicone gel insert or equal,L6692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1374.73,,,,,,,fee schedule,787.53,1931.51,
Silicone gel insert or equal,L6692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1101.13,,,,,,,fee schedule,787.53,1931.51,
Silicone gel insert or equal,L6692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1931.51,,,,,,,fee schedule,787.53,1931.51,
Silicone gel insert or equal,L6692,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1679.57,,,,,,,fee schedule,787.53,1931.51,
Silicone gel insert or equal,L6692,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,826.91,,,,,,,fee schedule,787.53,1931.51,APC
Silicone gel insert or equal,L6692,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,787.53,,,,,,,fee schedule,787.53,1931.51,APC
Silicone gel insert or equal,L6692,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1417.55,,,,,,,fee schedule,787.53,1931.51,APC
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6102.49,,,,,,,fee schedule,3495.85,8574.06,
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4887.96,,,,,,,fee schedule,3495.85,8574.06,
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8574.06,,,,,,,fee schedule,3495.85,8574.06,
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7455.7,,,,,,,fee schedule,3495.85,8574.06,
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3670.64,,,,,,,fee schedule,3495.85,8574.06,APC
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3495.85,,,,,,,fee schedule,3495.85,8574.06,APC
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6292.53,,,,,,,fee schedule,3495.85,8574.06,APC
Elbow socket ins use w/lock,L6694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1689.44,,,,,,,fee schedule,967.82,2373.68,
Elbow socket ins use w/lock,L6694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1353.2,,,,,,,fee schedule,967.82,2373.68,
Elbow socket ins use w/lock,L6694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2373.68,,,,,,,fee schedule,967.82,2373.68,
Elbow socket ins use w/lock,L6694,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2064.07,,,,,,,fee schedule,967.82,2373.68,
Elbow socket ins use w/lock,L6694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1016.21,,,,,,,fee schedule,967.82,2373.68,APC
Elbow socket ins use w/lock,L6694,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,967.82,,,,,,,fee schedule,967.82,2373.68,APC
Elbow socket ins use w/lock,L6694,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1742.08,,,,,,,fee schedule,967.82,2373.68,APC
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1407.86,,,,,,,fee schedule,806.49,1978.06,
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1127.66,,,,,,,fee schedule,806.49,1978.06,
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1978.06,,,,,,,fee schedule,806.49,1978.06,
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1720.05,,,,,,,fee schedule,806.49,1978.06,
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,846.81,,,,,,,fee schedule,806.49,1978.06,APC
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,806.49,,,,,,,fee schedule,806.49,1978.06,APC
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1451.68,,,,,,,fee schedule,806.49,1978.06,APC
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2827.48,,,,,,,fee schedule,1619.74,3972.64,
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2264.75,,,,,,,fee schedule,1619.74,3972.64,
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3972.64,,,,,,,fee schedule,1619.74,3972.64,
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3454.47,,,,,,,fee schedule,1619.74,3972.64,
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1700.73,,,,,,,fee schedule,1619.74,3972.64,APC
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1619.74,,,,,,,fee schedule,1619.74,3972.64,APC
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2915.53,,,,,,,fee schedule,1619.74,3972.64,APC
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2827.48,,,,,,,fee schedule,1619.74,3972.64,
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2264.75,,,,,,,fee schedule,1619.74,3972.64,
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3972.64,,,,,,,fee schedule,1619.74,3972.64,
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3454.47,,,,,,,fee schedule,1619.74,3972.64,
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1700.73,,,,,,,fee schedule,1619.74,3972.64,APC
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1619.74,,,,,,,fee schedule,1619.74,3972.64,APC
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2915.53,,,,,,,fee schedule,1619.74,3972.64,APC
Below/above elbow lock mech,L6698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1062.99,,,,,,,fee schedule,608.96,1493.52,
Below/above elbow lock mech,L6698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,851.43,,,,,,,fee schedule,608.96,1493.52,
Below/above elbow lock mech,L6698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1493.52,,,,,,,fee schedule,608.96,1493.52,
Below/above elbow lock mech,L6698,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1298.71,,,,,,,fee schedule,608.96,1493.52,
Below/above elbow lock mech,L6698,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,639.41,,,,,,,fee schedule,608.96,1493.52,APC
Below/above elbow lock mech,L6698,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,608.96,,,,,,,fee schedule,608.96,1493.52,APC
Below/above elbow lock mech,L6698,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1096.13,,,,,,,fee schedule,608.96,1493.52,APC
Ue add ext power myoel,L6700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30985.7,,,,,,,fee schedule,29510.19,53118.34,APC
Ue add ext power myoel,L6700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29510.19,,,,,,,fee schedule,29510.19,53118.34,APC
Ue add ext power myoel,L6700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53118.34,,,,,,,fee schedule,29510.19,53118.34,APC
"Term dev, passive hand mitt",L6703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,751.84,,,,,,,fee schedule,430.7,1056.34,
"Term dev, passive hand mitt",L6703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,602.21,,,,,,,fee schedule,430.7,1056.34,
"Term dev, passive hand mitt",L6703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1056.34,,,,,,,fee schedule,430.7,1056.34,
"Term dev, passive hand mitt",L6703,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,918.56,,,,,,,fee schedule,430.7,1056.34,
"Term dev, passive hand mitt",L6703,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,452.24,,,,,,,fee schedule,430.7,1056.34,APC
"Term dev, passive hand mitt",L6703,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,430.7,,,,,,,fee schedule,430.7,1056.34,APC
"Term dev, passive hand mitt",L6703,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,775.26,,,,,,,fee schedule,430.7,1056.34,APC
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1451.26,,,,,,,fee schedule,831.35,2039.03,
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1162.42,,,,,,,fee schedule,831.35,2039.03,
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2039.03,,,,,,,fee schedule,831.35,2039.03,
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1773.07,,,,,,,fee schedule,831.35,2039.03,
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,872.92,,,,,,,fee schedule,831.35,2039.03,APC
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,831.35,,,,,,,fee schedule,831.35,2039.03,APC
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1496.43,,,,,,,fee schedule,831.35,2039.03,APC
Term dev mech hook vol open,L6706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,900.6,,,,,,,fee schedule,515.91,1265.36,
Term dev mech hook vol open,L6706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,721.36,,,,,,,fee schedule,515.91,1265.36,
Term dev mech hook vol open,L6706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1265.36,,,,,,,fee schedule,515.91,1265.36,
Term dev mech hook vol open,L6706,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1100.31,,,,,,,fee schedule,515.91,1265.36,
Term dev mech hook vol open,L6706,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,541.71,,,,,,,fee schedule,515.91,1265.36,APC
Term dev mech hook vol open,L6706,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,515.91,,,,,,,fee schedule,515.91,1265.36,APC
Term dev mech hook vol open,L6706,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,928.64,,,,,,,fee schedule,515.91,1265.36,APC
Term dev mech hook vol close,L6707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3185.85,,,,,,,fee schedule,1825.05,4476.15,
Term dev mech hook vol close,L6707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2551.79,,,,,,,fee schedule,1825.05,4476.15,
Term dev mech hook vol close,L6707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4476.15,,,,,,,fee schedule,1825.05,4476.15,
Term dev mech hook vol close,L6707,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3892.3,,,,,,,fee schedule,1825.05,4476.15,
Term dev mech hook vol close,L6707,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1916.3,,,,,,,fee schedule,1825.05,4476.15,APC
Term dev mech hook vol close,L6707,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1825.05,,,,,,,fee schedule,1825.05,4476.15,APC
Term dev mech hook vol close,L6707,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3285.09,,,,,,,fee schedule,1825.05,4476.15,APC
Term dev mech hand vol open,L6708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2105.97,,,,,,,fee schedule,1206.42,2958.9,
Term dev mech hand vol open,L6708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1686.83,,,,,,,fee schedule,1206.42,2958.9,
Term dev mech hand vol open,L6708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2958.9,,,,,,,fee schedule,1206.42,2958.9,
Term dev mech hand vol open,L6708,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2572.96,,,,,,,fee schedule,1206.42,2958.9,
Term dev mech hand vol open,L6708,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1266.74,,,,,,,fee schedule,1206.42,2958.9,APC
Term dev mech hand vol open,L6708,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1206.42,,,,,,,fee schedule,1206.42,2958.9,APC
Term dev mech hand vol open,L6708,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2171.56,,,,,,,fee schedule,1206.42,2958.9,APC
Term dev mech hand vol close,L6709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2988.92,,,,,,,fee schedule,1712.21,4199.47,
Term dev mech hand vol close,L6709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2394.06,,,,,,,fee schedule,1712.21,4199.47,
Term dev mech hand vol close,L6709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4199.47,,,,,,,fee schedule,1712.21,4199.47,
Term dev mech hand vol close,L6709,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3651.71,,,,,,,fee schedule,1712.21,4199.47,
Term dev mech hand vol close,L6709,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1797.82,,,,,,,fee schedule,1712.21,4199.47,APC
Term dev mech hand vol close,L6709,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1712.21,,,,,,,fee schedule,1712.21,4199.47,APC
Term dev mech hand vol close,L6709,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3081.98,,,,,,,fee schedule,1712.21,4199.47,APC
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1445.11,,,,,,,fee schedule,827.85,2030.39,
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1157.5,,,,,,,fee schedule,827.85,2030.39,
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2030.39,,,,,,,fee schedule,827.85,2030.39,
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1765.56,,,,,,,fee schedule,827.85,2030.39,
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,869.24,,,,,,,fee schedule,827.85,2030.39,APC
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,827.85,,,,,,,fee schedule,827.85,2030.39,APC
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1490.13,,,,,,,fee schedule,827.85,2030.39,APC
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2660.85,,,,,,,fee schedule,1524.28,3738.52,
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2131.28,,,,,,,fee schedule,1524.28,3738.52,
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3738.52,,,,,,,fee schedule,1524.28,3738.52,
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3250.89,,,,,,,fee schedule,1524.28,3738.52,
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1600.49,,,,,,,fee schedule,1524.28,3738.52,APC
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1524.28,,,,,,,fee schedule,1524.28,3738.52,APC
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2743.7,,,,,,,fee schedule,1524.28,3738.52,APC
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3358.17,,,,,,,fee schedule,1923.74,4718.25,
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2689.82,,,,,,,fee schedule,1923.74,4718.25,
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4718.25,,,,,,,fee schedule,1923.74,4718.25,
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4102.83,,,,,,,fee schedule,1923.74,4718.25,
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2019.93,,,,,,,fee schedule,1923.74,4718.25,APC
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1923.74,,,,,,,fee schedule,1923.74,4718.25,APC
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3462.73,,,,,,,fee schedule,1923.74,4718.25,APC
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2844.33,,,,,,,fee schedule,1629.4,3996.31,
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2278.24,,,,,,,fee schedule,1629.4,3996.31,
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3996.31,,,,,,,fee schedule,1629.4,3996.31,
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3475.05,,,,,,,fee schedule,1629.4,3996.31,
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1710.87,,,,,,,fee schedule,1629.4,3996.31,APC
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1629.4,,,,,,,fee schedule,1629.4,3996.31,APC
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2932.92,,,,,,,fee schedule,1629.4,3996.31,APC
"Term device, multi art digit",L6715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6786.37,,,,,,,fee schedule,3887.6,9534.91,
"Term device, multi art digit",L6715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5435.73,,,,,,,fee schedule,3887.6,9534.91,
"Term device, multi art digit",L6715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9534.91,,,,,,,fee schedule,3887.6,9534.91,
"Term device, multi art digit",L6715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8291.23,,,,,,,fee schedule,3887.6,9534.91,
"Term device, multi art digit",L6715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4081.98,,,,,,,fee schedule,3887.6,9534.91,APC
"Term device, multi art digit",L6715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3887.6,,,,,,,fee schedule,3887.6,9534.91,APC
"Term device, multi art digit",L6715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6997.68,,,,,,,fee schedule,3887.6,9534.91,APC
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5055.6,,,,,,,fee schedule,2896.15,7103.16,
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4049.42,,,,,,,fee schedule,2896.15,7103.16,
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7103.16,,,,,,,fee schedule,2896.15,7103.16,
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6176.66,,,,,,,fee schedule,2896.15,7103.16,
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3040.96,,,,,,,fee schedule,2896.15,7103.16,APC
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2896.15,,,,,,,fee schedule,2896.15,7103.16,APC
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5213.07,,,,,,,fee schedule,2896.15,7103.16,APC
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4358.28,,,,,,,fee schedule,2496.64,6123.43,
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3490.89,,,,,,,fee schedule,2496.64,6123.43,
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6123.43,,,,,,,fee schedule,2496.64,6123.43,
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5324.72,,,,,,,fee schedule,2496.64,6123.43,
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2621.47,,,,,,,fee schedule,2496.64,6123.43,APC
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2496.64,,,,,,,fee schedule,2496.64,6123.43,APC
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4493.95,,,,,,,fee schedule,2496.64,6123.43,APC
Term dev modifier wrist unit,L6805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,824.39,,,,,,,fee schedule,472.26,1158.28,
Term dev modifier wrist unit,L6805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,660.32,,,,,,,fee schedule,472.26,1158.28,
Term dev modifier wrist unit,L6805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1158.28,,,,,,,fee schedule,472.26,1158.28,
Term dev modifier wrist unit,L6805,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1007.2,,,,,,,fee schedule,472.26,1158.28,
Term dev modifier wrist unit,L6805,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,495.87,,,,,,,fee schedule,472.26,1158.28,APC
Term dev modifier wrist unit,L6805,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,472.26,,,,,,,fee schedule,472.26,1158.28,APC
Term dev modifier wrist unit,L6805,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,850.07,,,,,,,fee schedule,472.26,1158.28,APC
Term dev precision pinch dev,L6810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,438.24,,,,,,,fee schedule,251.06,615.73,
Term dev precision pinch dev,L6810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,351.02,,,,,,,fee schedule,251.06,615.73,
Term dev precision pinch dev,L6810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,615.73,,,,,,,fee schedule,251.06,615.73,
Term dev precision pinch dev,L6810,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,535.42,,,,,,,fee schedule,251.06,615.73,
Term dev precision pinch dev,L6810,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,263.61,,,,,,,fee schedule,251.06,615.73,APC
Term dev precision pinch dev,L6810,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,251.06,,,,,,,fee schedule,251.06,615.73,APC
Term dev precision pinch dev,L6810,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,451.91,,,,,,,fee schedule,251.06,615.73,APC
Elec hand ind art digits,L6880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51357.31,,,,,,,fee schedule,29420.21,72157.49,
Elec hand ind art digits,L6880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41136.04,,,,,,,fee schedule,29420.21,72157.49,
Elec hand ind art digits,L6880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72157.49,,,,,,,fee schedule,29420.21,72157.49,
Elec hand ind art digits,L6880,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62745.64,,,,,,,fee schedule,29420.21,72157.49,
Elec hand ind art digits,L6880,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30891.22,,,,,,,fee schedule,29420.21,72157.49,APC
Elec hand ind art digits,L6880,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29420.21,,,,,,,fee schedule,29420.21,72157.49,APC
Elec hand ind art digits,L6880,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52956.38,,,,,,,fee schedule,29420.21,72157.49,APC
Term dev auto grasp feature,L6881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8787.79,,,,,,,fee schedule,5034.12,12346.93,
Term dev auto grasp feature,L6881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7038.82,,,,,,,fee schedule,5034.12,12346.93,
Term dev auto grasp feature,L6881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12346.93,,,,,,,fee schedule,5034.12,12346.93,
Term dev auto grasp feature,L6881,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10736.46,,,,,,,fee schedule,5034.12,12346.93,
Term dev auto grasp feature,L6881,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5285.83,,,,,,,fee schedule,5034.12,12346.93,APC
Term dev auto grasp feature,L6881,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5034.12,,,,,,,fee schedule,5034.12,12346.93,APC
Term dev auto grasp feature,L6881,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9061.42,,,,,,,fee schedule,5034.12,12346.93,APC
Microprocessor control uplmb,L6882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6665.95,,,,,,,fee schedule,3818.61,9365.73,
Microprocessor control uplmb,L6882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5339.28,,,,,,,fee schedule,3818.61,9365.73,
Microprocessor control uplmb,L6882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9365.73,,,,,,,fee schedule,3818.61,9365.73,
Microprocessor control uplmb,L6882,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8144.11,,,,,,,fee schedule,3818.61,9365.73,
Microprocessor control uplmb,L6882,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4009.54,,,,,,,fee schedule,3818.61,9365.73,APC
Microprocessor control uplmb,L6882,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3818.61,,,,,,,fee schedule,3818.61,9365.73,APC
Microprocessor control uplmb,L6882,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6873.5,,,,,,,fee schedule,3818.61,9365.73,APC
Replc sockt below e/w disa,L6883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4269.93,,,,,,,fee schedule,2446.07,5999.3,
Replc sockt below e/w disa,L6883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3420.12,,,,,,,fee schedule,2446.07,5999.3,
Replc sockt below e/w disa,L6883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5999.3,,,,,,,fee schedule,2446.07,5999.3,
Replc sockt below e/w disa,L6883,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5216.78,,,,,,,fee schedule,2446.07,5999.3,
Replc sockt below e/w disa,L6883,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2568.37,,,,,,,fee schedule,2446.07,5999.3,APC
Replc sockt below e/w disa,L6883,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2446.07,,,,,,,fee schedule,2446.07,5999.3,APC
Replc sockt below e/w disa,L6883,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4402.93,,,,,,,fee schedule,2446.07,5999.3,APC
Replc sockt above elbow disa,L6884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5842.28,,,,,,,fee schedule,3346.77,8208.46,
Replc sockt above elbow disa,L6884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4679.54,,,,,,,fee schedule,3346.77,8208.46,
Replc sockt above elbow disa,L6884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8208.46,,,,,,,fee schedule,3346.77,8208.46,
Replc sockt above elbow disa,L6884,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7137.79,,,,,,,fee schedule,3346.77,8208.46,
Replc sockt above elbow disa,L6884,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3514.11,,,,,,,fee schedule,3346.77,8208.46,APC
Replc sockt above elbow disa,L6884,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3346.77,,,,,,,fee schedule,3346.77,8208.46,APC
Replc sockt above elbow disa,L6884,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6024.19,,,,,,,fee schedule,3346.77,8208.46,APC
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9076.06,,,,,,,fee schedule,5199.26,12751.95,
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7269.72,,,,,,,fee schedule,5199.26,12751.95,
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12751.95,,,,,,,fee schedule,5199.26,12751.95,
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11088.65,,,,,,,fee schedule,5199.26,12751.95,
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5459.22,,,,,,,fee schedule,5199.26,12751.95,APC
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5199.26,,,,,,,fee schedule,5199.26,12751.95,APC
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9358.67,,,,,,,fee schedule,5199.26,12751.95,APC
Prefab glove for term device,L6890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,429.31,,,,,,,fee schedule,245.93,603.19,
Prefab glove for term device,L6890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,343.87,,,,,,,fee schedule,245.93,603.19,
Prefab glove for term device,L6890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,603.19,,,,,,,fee schedule,245.93,603.19,
Prefab glove for term device,L6890,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,524.51,,,,,,,fee schedule,245.93,603.19,
Prefab glove for term device,L6890,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.23,,,,,,,fee schedule,245.93,603.19,APC
Prefab glove for term device,L6890,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,245.93,,,,,,,fee schedule,245.93,603.19,APC
Prefab glove for term device,L6890,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,442.67,,,,,,,fee schedule,245.93,603.19,APC
Custom glove for term device,L6895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1435.47,,,,,,,fee schedule,822.33,2016.85,
Custom glove for term device,L6895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1149.78,,,,,,,fee schedule,822.33,2016.85,
Custom glove for term device,L6895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2016.85,,,,,,,fee schedule,822.33,2016.85,
Custom glove for term device,L6895,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1753.78,,,,,,,fee schedule,822.33,2016.85,
Custom glove for term device,L6895,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,863.45,,,,,,,fee schedule,822.33,2016.85,APC
Custom glove for term device,L6895,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,822.33,,,,,,,fee schedule,822.33,2016.85,APC
Custom glove for term device,L6895,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1480.19,,,,,,,fee schedule,822.33,2016.85,APC
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4168.56,,,,,,,fee schedule,2387.98,5856.87,
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3338.92,,,,,,,fee schedule,2387.98,5856.87,
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5856.87,,,,,,,fee schedule,2387.98,5856.87,
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5092.93,,,,,,,fee schedule,2387.98,5856.87,
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2507.38,,,,,,,fee schedule,2387.98,5856.87,APC
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2387.98,,,,,,,fee schedule,2387.98,5856.87,APC
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4298.36,,,,,,,fee schedule,2387.98,5856.87,APC
Hand restoration multiple fi,L6905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4125.74,,,,,,,fee schedule,2363.43,5796.7,
Hand restoration multiple fi,L6905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3304.62,,,,,,,fee schedule,2363.43,5796.7,
Hand restoration multiple fi,L6905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5796.7,,,,,,,fee schedule,2363.43,5796.7,
Hand restoration multiple fi,L6905,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5040.61,,,,,,,fee schedule,2363.43,5796.7,
Hand restoration multiple fi,L6905,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2481.6,,,,,,,fee schedule,2363.43,5796.7,APC
Hand restoration multiple fi,L6905,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2363.43,,,,,,,fee schedule,2363.43,5796.7,APC
Hand restoration multiple fi,L6905,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4254.17,,,,,,,fee schedule,2363.43,5796.7,APC
Hand restoration no fingers,L6910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4055.88,,,,,,,fee schedule,2323.42,5698.55,
Hand restoration no fingers,L6910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3248.67,,,,,,,fee schedule,2323.42,5698.55,
Hand restoration no fingers,L6910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5698.55,,,,,,,fee schedule,2323.42,5698.55,
Hand restoration no fingers,L6910,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4955.26,,,,,,,fee schedule,2323.42,5698.55,
Hand restoration no fingers,L6910,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2439.59,,,,,,,fee schedule,2323.42,5698.55,APC
Hand restoration no fingers,L6910,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2323.42,,,,,,,fee schedule,2323.42,5698.55,APC
Hand restoration no fingers,L6910,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4182.16,,,,,,,fee schedule,2323.42,5698.55,APC
Hand restoration replacmnt g,L6915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1742.62,,,,,,,fee schedule,998.28,2448.4,
Hand restoration replacmnt g,L6915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1395.8,,,,,,,fee schedule,998.28,2448.4,
Hand restoration replacmnt g,L6915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2448.4,,,,,,,fee schedule,998.28,2448.4,
Hand restoration replacmnt g,L6915,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2129.04,,,,,,,fee schedule,998.28,2448.4,
Hand restoration replacmnt g,L6915,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1048.19,,,,,,,fee schedule,998.28,2448.4,APC
Hand restoration replacmnt g,L6915,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,998.28,,,,,,,fee schedule,998.28,2448.4,APC
Hand restoration replacmnt g,L6915,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1796.9,,,,,,,fee schedule,998.28,2448.4,APC
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18006.38,,,,,,,fee schedule,10315.01,25299.13,
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14422.7,,,,,,,fee schedule,10315.01,25299.13,
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25299.13,,,,,,,fee schedule,10315.01,25299.13,
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21999.24,,,,,,,fee schedule,10315.01,25299.13,
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10830.76,,,,,,,fee schedule,10315.01,25299.13,APC
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10315.01,,,,,,,fee schedule,10315.01,25299.13,APC
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18567.02,,,,,,,fee schedule,10315.01,25299.13,APC
Wrist disart myoelectronic c,L6925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19236.77,,,,,,,fee schedule,11019.87,27027.84,
Wrist disart myoelectronic c,L6925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15408.22,,,,,,,fee schedule,11019.87,27027.84,
Wrist disart myoelectronic c,L6925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27027.84,,,,,,,fee schedule,11019.87,27027.84,
Wrist disart myoelectronic c,L6925,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23502.47,,,,,,,fee schedule,11019.87,27027.84,
Wrist disart myoelectronic c,L6925,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11570.86,,,,,,,fee schedule,11019.87,27027.84,APC
Wrist disart myoelectronic c,L6925,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11019.87,,,,,,,fee schedule,11019.87,27027.84,APC
Wrist disart myoelectronic c,L6925,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19835.77,,,,,,,fee schedule,11019.87,27027.84,APC
Below elbow switch control,L6930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17342.6,,,,,,,fee schedule,9934.8,24366.51,
Below elbow switch control,L6930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13891.03,,,,,,,fee schedule,9934.8,24366.51,
Below elbow switch control,L6930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24366.51,,,,,,,fee schedule,9934.8,24366.51,
Below elbow switch control,L6930,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21188.27,,,,,,,fee schedule,9934.8,24366.51,
Below elbow switch control,L6930,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10431.54,,,,,,,fee schedule,9934.8,24366.51,APC
Below elbow switch control,L6930,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9934.8,,,,,,,fee schedule,9934.8,24366.51,APC
Below elbow switch control,L6930,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17882.64,,,,,,,fee schedule,9934.8,24366.51,APC
Below elbow myoelectronic ct,L6935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19146.4,,,,,,,fee schedule,10968.08,26900.87,
Below elbow myoelectronic ct,L6935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15335.83,,,,,,,fee schedule,10968.08,26900.87,
Below elbow myoelectronic ct,L6935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26900.87,,,,,,,fee schedule,10968.08,26900.87,
Below elbow myoelectronic ct,L6935,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23392.06,,,,,,,fee schedule,10968.08,26900.87,
Below elbow myoelectronic ct,L6935,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11516.48,,,,,,,fee schedule,10968.08,26900.87,APC
Below elbow myoelectronic ct,L6935,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10968.08,,,,,,,fee schedule,10968.08,26900.87,APC
Below elbow myoelectronic ct,L6935,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19742.54,,,,,,,fee schedule,10968.08,26900.87,APC
Elbow disarticulation switch,L6940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22395.03,,,,,,,fee schedule,12829.08,31465.22,
Elbow disarticulation switch,L6940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17937.91,,,,,,,fee schedule,12829.08,31465.22,
Elbow disarticulation switch,L6940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31465.22,,,,,,,fee schedule,12829.08,31465.22,
Elbow disarticulation switch,L6940,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27361.06,,,,,,,fee schedule,12829.08,31465.22,
Elbow disarticulation switch,L6940,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13470.53,,,,,,,fee schedule,12829.08,31465.22,APC
Elbow disarticulation switch,L6940,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12829.08,,,,,,,fee schedule,12829.08,31465.22,APC
Elbow disarticulation switch,L6940,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23092.34,,,,,,,fee schedule,12829.08,31465.22,APC
Elbow disart myoelectronic c,L6945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24984.59,,,,,,,fee schedule,14312.5,35103.58,
Elbow disart myoelectronic c,L6945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20012.09,,,,,,,fee schedule,14312.5,35103.58,
Elbow disart myoelectronic c,L6945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35103.58,,,,,,,fee schedule,14312.5,35103.58,
Elbow disart myoelectronic c,L6945,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,30524.85,,,,,,,fee schedule,14312.5,35103.58,
Elbow disart myoelectronic c,L6945,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15028.12,,,,,,,fee schedule,14312.5,35103.58,APC
Elbow disart myoelectronic c,L6945,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14312.5,,,,,,,fee schedule,14312.5,35103.58,APC
Elbow disart myoelectronic c,L6945,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25762.5,,,,,,,fee schedule,14312.5,35103.58,APC
Above elbow switch control,L6950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22353.51,,,,,,,fee schedule,12805.28,31406.89,
Above elbow switch control,L6950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17904.66,,,,,,,fee schedule,12805.28,31406.89,
Above elbow switch control,L6950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31406.89,,,,,,,fee schedule,12805.28,31406.89,
Above elbow switch control,L6950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27310.34,,,,,,,fee schedule,12805.28,31406.89,
Above elbow switch control,L6950,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13445.54,,,,,,,fee schedule,12805.28,31406.89,APC
Above elbow switch control,L6950,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12805.28,,,,,,,fee schedule,12805.28,31406.89,APC
Above elbow switch control,L6950,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23049.5,,,,,,,fee schedule,12805.28,31406.89,APC
Above elbow myoelectronic ct,L6955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25923.06,,,,,,,fee schedule,14850.1,36422.13,
Above elbow myoelectronic ct,L6955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20763.78,,,,,,,fee schedule,14850.1,36422.13,
Above elbow myoelectronic ct,L6955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36422.13,,,,,,,fee schedule,14850.1,36422.13,
Above elbow myoelectronic ct,L6955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31671.42,,,,,,,fee schedule,14850.1,36422.13,
Above elbow myoelectronic ct,L6955,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15592.6,,,,,,,fee schedule,14850.1,36422.13,APC
Above elbow myoelectronic ct,L6955,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14850.1,,,,,,,fee schedule,14850.1,36422.13,APC
Above elbow myoelectronic ct,L6955,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26730.18,,,,,,,fee schedule,14850.1,36422.13,APC
Shldr disartic switch contro,L6960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27270.05,,,,,,,fee schedule,15621.74,38314.68,
Shldr disartic switch contro,L6960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21842.7,,,,,,,fee schedule,15621.74,38314.68,
Shldr disartic switch contro,L6960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38314.68,,,,,,,fee schedule,15621.74,38314.68,
Shldr disartic switch contro,L6960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33317.11,,,,,,,fee schedule,15621.74,38314.68,
Shldr disartic switch contro,L6960,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16402.83,,,,,,,fee schedule,15621.74,38314.68,APC
Shldr disartic switch contro,L6960,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15621.74,,,,,,,fee schedule,15621.74,38314.68,APC
Shldr disartic switch contro,L6960,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28119.13,,,,,,,fee schedule,15621.74,38314.68,APC
Shldr disartic myoelectronic,L6965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32305.61,,,,,,,fee schedule,18506.37,45389.67,
Shldr disartic myoelectronic,L6965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25876.06,,,,,,,fee schedule,18506.37,45389.67,
Shldr disartic myoelectronic,L6965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45389.67,,,,,,,fee schedule,18506.37,45389.67,
Shldr disartic myoelectronic,L6965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39469.28,,,,,,,fee schedule,18506.37,45389.67,
Shldr disartic myoelectronic,L6965,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19431.69,,,,,,,fee schedule,18506.37,45389.67,APC
Shldr disartic myoelectronic,L6965,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18506.37,,,,,,,fee schedule,18506.37,45389.67,APC
Shldr disartic myoelectronic,L6965,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33311.47,,,,,,,fee schedule,18506.37,45389.67,APC
Interscapular-thor switch ct,L6970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34579.58,,,,,,,fee schedule,19809.02,48584.63,
Interscapular-thor switch ct,L6970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27697.46,,,,,,,fee schedule,19809.02,48584.63,
Interscapular-thor switch ct,L6970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48584.63,,,,,,,fee schedule,19809.02,48584.63,
Interscapular-thor switch ct,L6970,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42247.5,,,,,,,fee schedule,19809.02,48584.63,
Interscapular-thor switch ct,L6970,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20799.47,,,,,,,fee schedule,19809.02,48584.63,APC
Interscapular-thor switch ct,L6970,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19809.02,,,,,,,fee schedule,19809.02,48584.63,APC
Interscapular-thor switch ct,L6970,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35656.24,,,,,,,fee schedule,19809.02,48584.63,APC
Interscap-thor myoelectronic,L6975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38114.82,,,,,,,fee schedule,21834.21,53551.67,
Interscap-thor myoelectronic,L6975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30529.11,,,,,,,fee schedule,21834.21,53551.67,
Interscap-thor myoelectronic,L6975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53551.67,,,,,,,fee schedule,21834.21,53551.67,
Interscap-thor myoelectronic,L6975,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46566.67,,,,,,,fee schedule,21834.21,53551.67,
Interscap-thor myoelectronic,L6975,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22925.92,,,,,,,fee schedule,21834.21,53551.67,APC
Interscap-thor myoelectronic,L6975,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21834.21,,,,,,,fee schedule,21834.21,53551.67,APC
Interscap-thor myoelectronic,L6975,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39301.58,,,,,,,fee schedule,21834.21,53551.67,APC
Adult electric hand,L7007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7851.13,,,,,,,fee schedule,4497.55,11030.9,
Adult electric hand,L7007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6288.57,,,,,,,fee schedule,4497.55,11030.9,
Adult electric hand,L7007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11030.9,,,,,,,fee schedule,4497.55,11030.9,
Adult electric hand,L7007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9592.09,,,,,,,fee schedule,4497.55,11030.9,
Adult electric hand,L7007,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4722.43,,,,,,,fee schedule,4497.55,11030.9,APC
Adult electric hand,L7007,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4497.55,,,,,,,fee schedule,4497.55,11030.9,APC
Adult electric hand,L7007,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8095.59,,,,,,,fee schedule,4497.55,11030.9,APC
Pediatric electric hand,L7008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12174.77,,,,,,,fee schedule,6974.35,17105.66,
Pediatric electric hand,L7008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9751.72,,,,,,,fee schedule,6974.35,17105.66,
Pediatric electric hand,L7008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17105.66,,,,,,,fee schedule,6974.35,17105.66,
Pediatric electric hand,L7008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14874.49,,,,,,,fee schedule,6974.35,17105.66,
Pediatric electric hand,L7008,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7323.07,,,,,,,fee schedule,6974.35,17105.66,APC
Pediatric electric hand,L7008,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6974.35,,,,,,,fee schedule,6974.35,17105.66,APC
Pediatric electric hand,L7008,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12553.83,,,,,,,fee schedule,6974.35,17105.66,APC
Adult electric hook,L7009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8032.66,,,,,,,fee schedule,4601.53,11285.96,
Adult electric hook,L7009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6433.98,,,,,,,fee schedule,4601.53,11285.96,
Adult electric hook,L7009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11285.96,,,,,,,fee schedule,4601.53,11285.96,
Adult electric hook,L7009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9813.88,,,,,,,fee schedule,4601.53,11285.96,
Adult electric hook,L7009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4831.61,,,,,,,fee schedule,4601.53,11285.96,APC
Adult electric hook,L7009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4601.53,,,,,,,fee schedule,4601.53,11285.96,APC
Adult electric hook,L7009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8282.75,,,,,,,fee schedule,4601.53,11285.96,APC
Prehensile actuator,L7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6538.06,,,,,,,fee schedule,3745.35,9186.03,
Prehensile actuator,L7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5236.83,,,,,,,fee schedule,3745.35,9186.03,
Prehensile actuator,L7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9186.03,,,,,,,fee schedule,3745.35,9186.03,
Prehensile actuator,L7040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7987.85,,,,,,,fee schedule,3745.35,9186.03,
Prehensile actuator,L7040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3932.62,,,,,,,fee schedule,3745.35,9186.03,APC
Prehensile actuator,L7040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3745.35,,,,,,,fee schedule,3745.35,9186.03,APC
Prehensile actuator,L7040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6741.63,,,,,,,fee schedule,3745.35,9186.03,APC
Pediatric electric hook,L7045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3454.27,,,,,,,fee schedule,1978.79,4853.28,
Pediatric electric hook,L7045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2766.79,,,,,,,fee schedule,1978.79,4853.28,
Pediatric electric hook,L7045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4853.28,,,,,,,fee schedule,1978.79,4853.28,
Pediatric electric hook,L7045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4220.24,,,,,,,fee schedule,1978.79,4853.28,
Pediatric electric hook,L7045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2077.73,,,,,,,fee schedule,1978.79,4853.28,APC
Pediatric electric hook,L7045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1978.79,,,,,,,fee schedule,1978.79,4853.28,APC
Pediatric electric hook,L7045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3561.82,,,,,,,fee schedule,1978.79,4853.28,APC
Electronic elbow hosmer swit,L7170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12929.78,,,,,,,fee schedule,7406.87,18166.46,
Electronic elbow hosmer swit,L7170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10356.46,,,,,,,fee schedule,7406.87,18166.46,
Electronic elbow hosmer swit,L7170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18166.46,,,,,,,fee schedule,7406.87,18166.46,
Electronic elbow hosmer swit,L7170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15796.92,,,,,,,fee schedule,7406.87,18166.46,
Electronic elbow hosmer swit,L7170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7777.21,,,,,,,fee schedule,7406.87,18166.46,APC
Electronic elbow hosmer swit,L7170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7406.87,,,,,,,fee schedule,7406.87,18166.46,APC
Electronic elbow hosmer swit,L7170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13332.37,,,,,,,fee schedule,7406.87,18166.46,APC
Electronic elbow sequential,L7180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83651.43,,,,,,,fee schedule,47919.99,117531.02,
Electronic elbow sequential,L7180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67002.9,,,,,,,fee schedule,47919.99,117531.02,
Electronic elbow sequential,L7180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117531.02,,,,,,,fee schedule,47919.99,117531.02,
Electronic elbow sequential,L7180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102200.89,,,,,,,fee schedule,47919.99,117531.02,
Electronic elbow sequential,L7180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50315.99,,,,,,,fee schedule,47919.99,117531.02,APC
Electronic elbow sequential,L7180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47919.99,,,,,,,fee schedule,47919.99,117531.02,APC
Electronic elbow sequential,L7180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86255.98,,,,,,,fee schedule,47919.99,117531.02,APC
Electronic elbo simultaneous,L7181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86127.03,,,,,,,fee schedule,49338.18,121009.27,
Electronic elbo simultaneous,L7181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68985.81,,,,,,,fee schedule,49338.18,121009.27,
Electronic elbo simultaneous,L7181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121009.27,,,,,,,fee schedule,49338.18,121009.27,
Electronic elbo simultaneous,L7181,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105225.45,,,,,,,fee schedule,49338.18,121009.27,
Electronic elbo simultaneous,L7181,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51805.09,,,,,,,fee schedule,49338.18,121009.27,APC
Electronic elbo simultaneous,L7181,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49338.18,,,,,,,fee schedule,49338.18,121009.27,APC
Electronic elbo simultaneous,L7181,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88808.72,,,,,,,fee schedule,49338.18,121009.27,APC
Electron elbow adolescent sw,L7185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13593.4,,,,,,,fee schedule,7787.04,19098.86,
Electron elbow adolescent sw,L7185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10888.01,,,,,,,fee schedule,7787.04,19098.86,
Electron elbow adolescent sw,L7185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19098.86,,,,,,,fee schedule,7787.04,19098.86,
Electron elbow adolescent sw,L7185,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16607.7,,,,,,,fee schedule,7787.04,19098.86,
Electron elbow adolescent sw,L7185,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8176.39,,,,,,,fee schedule,7787.04,19098.86,APC
Electron elbow adolescent sw,L7185,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7787.04,,,,,,,fee schedule,7787.04,19098.86,APC
Electron elbow adolescent sw,L7185,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14016.67,,,,,,,fee schedule,7787.04,19098.86,APC
Electron elbow child switch,L7186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22852.42,,,,,,,fee schedule,13091.11,32107.86,
Electron elbow child switch,L7186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18304.27,,,,,,,fee schedule,13091.11,32107.86,
Electron elbow child switch,L7186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32107.86,,,,,,,fee schedule,13091.11,32107.86,
Electron elbow child switch,L7186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27919.88,,,,,,,fee schedule,13091.11,32107.86,
Electron elbow child switch,L7186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13745.67,,,,,,,fee schedule,13091.11,32107.86,APC
Electron elbow child switch,L7186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13091.11,,,,,,,fee schedule,13091.11,32107.86,APC
Electron elbow child switch,L7186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23564,,,,,,,fee schedule,13091.11,32107.86,APC
Elbow adolescent myoelectron,L7190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18037.19,,,,,,,fee schedule,10332.65,25342.41,
Elbow adolescent myoelectron,L7190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14447.38,,,,,,,fee schedule,10332.65,25342.41,
Elbow adolescent myoelectron,L7190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25342.41,,,,,,,fee schedule,10332.65,25342.41,
Elbow adolescent myoelectron,L7190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22036.88,,,,,,,fee schedule,10332.65,25342.41,
Elbow adolescent myoelectron,L7190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10849.28,,,,,,,fee schedule,10332.65,25342.41,APC
Elbow adolescent myoelectron,L7190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10332.65,,,,,,,fee schedule,10332.65,25342.41,APC
Elbow adolescent myoelectron,L7190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18598.77,,,,,,,fee schedule,10332.65,25342.41,APC
Elbow child myoelectronic ct,L7191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24037.14,,,,,,,fee schedule,13769.77,33772.4,
Elbow child myoelectronic ct,L7191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19253.2,,,,,,,fee schedule,13769.77,33772.4,
Elbow child myoelectronic ct,L7191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,33772.4,,,,,,,fee schedule,13769.77,33772.4,
Elbow child myoelectronic ct,L7191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,29367.3,,,,,,,fee schedule,13769.77,33772.4,
Elbow child myoelectronic ct,L7191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14458.26,,,,,,,fee schedule,13769.77,33772.4,APC
Elbow child myoelectronic ct,L7191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13769.77,,,,,,,fee schedule,13769.77,33772.4,APC
Elbow child myoelectronic ct,L7191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24785.59,,,,,,,fee schedule,13769.77,33772.4,APC
Electronic wrist rotator any,L7259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8809.24,,,,,,,fee schedule,5046.41,12377.06,
Electronic wrist rotator any,L7259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7056,,,,,,,fee schedule,5046.41,12377.06,
Electronic wrist rotator any,L7259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12377.06,,,,,,,fee schedule,5046.41,12377.06,
Electronic wrist rotator any,L7259,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10762.66,,,,,,,fee schedule,5046.41,12377.06,
Electronic wrist rotator any,L7259,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5298.73,,,,,,,fee schedule,5046.41,12377.06,APC
Electronic wrist rotator any,L7259,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5046.41,,,,,,,fee schedule,5046.41,12377.06,APC
Electronic wrist rotator any,L7259,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9083.54,,,,,,,fee schedule,5046.41,12377.06,APC
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,568.64,,,,,,,fee schedule,325.76,798.95,
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,455.47,,,,,,,fee schedule,325.76,798.95,
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,798.95,,,,,,,fee schedule,325.76,798.95,
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,694.74,,,,,,,fee schedule,325.76,798.95,
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,342.05,,,,,,,fee schedule,325.76,798.95,APC
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,325.76,,,,,,,fee schedule,325.76,798.95,APC
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,586.37,,,,,,,fee schedule,325.76,798.95,APC
Battery chrgr six volt otto,L7362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,621.23,,,,,,,fee schedule,355.87,872.83,
Battery chrgr six volt otto,L7362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,497.59,,,,,,,fee schedule,355.87,872.83,
Battery chrgr six volt otto,L7362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,872.83,,,,,,,fee schedule,355.87,872.83,
Battery chrgr six volt otto,L7362,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,758.98,,,,,,,fee schedule,355.87,872.83,
Battery chrgr six volt otto,L7362,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,373.66,,,,,,,fee schedule,355.87,872.83,APC
Battery chrgr six volt otto,L7362,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,355.87,,,,,,,fee schedule,355.87,872.83,APC
Battery chrgr six volt otto,L7362,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,640.57,,,,,,,fee schedule,355.87,872.83,APC
Twelve volt battery utah/equ,L7364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1099.19,,,,,,,fee schedule,629.69,1544.37,
Twelve volt battery utah/equ,L7364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,880.42,,,,,,,fee schedule,629.69,1544.37,
Twelve volt battery utah/equ,L7364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1544.37,,,,,,,fee schedule,629.69,1544.37,
Twelve volt battery utah/equ,L7364,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1342.93,,,,,,,fee schedule,629.69,1544.37,
Twelve volt battery utah/equ,L7364,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,661.17,,,,,,,fee schedule,629.69,1544.37,APC
Twelve volt battery utah/equ,L7364,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,629.69,,,,,,,fee schedule,629.69,1544.37,APC
Twelve volt battery utah/equ,L7364,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1133.44,,,,,,,fee schedule,629.69,1544.37,APC
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1511.7,,,,,,,fee schedule,865.98,2123.96,
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1210.84,,,,,,,fee schedule,865.98,2123.96,
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2123.96,,,,,,,fee schedule,865.98,2123.96,
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1846.92,,,,,,,fee schedule,865.98,2123.96,
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,909.28,,,,,,,fee schedule,865.98,2123.96,APC
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,865.98,,,,,,,fee schedule,865.98,2123.96,APC
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1558.76,,,,,,,fee schedule,865.98,2123.96,APC
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,836.87,,,,,,,fee schedule,479.42,1175.81,
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,670.31,,,,,,,fee schedule,479.42,1175.81,
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1175.81,,,,,,,fee schedule,479.42,1175.81,
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1022.44,,,,,,,fee schedule,479.42,1175.81,
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,503.39,,,,,,,fee schedule,479.42,1175.81,APC
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,479.42,,,,,,,fee schedule,479.42,1175.81,APC
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,862.96,,,,,,,fee schedule,479.42,1175.81,APC
Lithium ion battery charger,L7368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1084.84,,,,,,,fee schedule,621.46,1524.21,
Lithium ion battery charger,L7368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,868.93,,,,,,,fee schedule,621.46,1524.21,
Lithium ion battery charger,L7368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1524.21,,,,,,,fee schedule,621.46,1524.21,
Lithium ion battery charger,L7368,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1325.4,,,,,,,fee schedule,621.46,1524.21,
Lithium ion battery charger,L7368,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.53,,,,,,,fee schedule,621.46,1524.21,APC
Lithium ion battery charger,L7368,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,621.46,,,,,,,fee schedule,621.46,1524.21,APC
Lithium ion battery charger,L7368,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1118.63,,,,,,,fee schedule,621.46,1524.21,APC
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,658.79,,,,,,,fee schedule,377.39,925.6,
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,527.67,,,,,,,fee schedule,377.39,925.6,
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,925.6,,,,,,,fee schedule,377.39,925.6,
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,804.87,,,,,,,fee schedule,377.39,925.6,
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,396.26,,,,,,,fee schedule,377.39,925.6,APC
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,377.39,,,,,,,fee schedule,377.39,925.6,APC
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,679.3,,,,,,,fee schedule,377.39,925.6,APC
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,737.45,,,,,,,fee schedule,422.45,1036.13,
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,590.68,,,,,,,fee schedule,422.45,1036.13,
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1036.13,,,,,,,fee schedule,422.45,1036.13,
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,900.98,,,,,,,fee schedule,422.45,1036.13,
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,443.57,,,,,,,fee schedule,422.45,1036.13,APC
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,422.45,,,,,,,fee schedule,422.45,1036.13,APC
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,760.41,,,,,,,fee schedule,422.45,1036.13,APC
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,796.47,,,,,,,fee schedule,456.27,1119.04,
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,637.95,,,,,,,fee schedule,456.27,1119.04,
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1119.04,,,,,,,fee schedule,456.27,1119.04,
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,973.08,,,,,,,fee schedule,456.27,1119.04,
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,479.08,,,,,,,fee schedule,456.27,1119.04,APC
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,456.27,,,,,,,fee schedule,456.27,1119.04,APC
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,821.29,,,,,,,fee schedule,456.27,1119.04,APC
Add UE prost b/e acrylic,L7403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,791.6,,,,,,,fee schedule,453.48,1112.21,
Add UE prost b/e acrylic,L7403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,634.06,,,,,,,fee schedule,453.48,1112.21,
Add UE prost b/e acrylic,L7403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1112.21,,,,,,,fee schedule,453.48,1112.21,
Add UE prost b/e acrylic,L7403,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,967.14,,,,,,,fee schedule,453.48,1112.21,
Add UE prost b/e acrylic,L7403,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,476.15,,,,,,,fee schedule,453.48,1112.21,APC
Add UE prost b/e acrylic,L7403,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,453.48,,,,,,,fee schedule,453.48,1112.21,APC
Add UE prost b/e acrylic,L7403,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,816.26,,,,,,,fee schedule,453.48,1112.21,APC
Add UE prost a/e acrylic,L7404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1194.79,,,,,,,fee schedule,684.45,1678.69,
Add UE prost a/e acrylic,L7404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,957,,,,,,,fee schedule,684.45,1678.69,
Add UE prost a/e acrylic,L7404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1678.69,,,,,,,fee schedule,684.45,1678.69,
Add UE prost a/e acrylic,L7404,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1459.73,,,,,,,fee schedule,684.45,1678.69,
Add UE prost a/e acrylic,L7404,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,718.67,,,,,,,fee schedule,684.45,1678.69,APC
Add UE prost a/e acrylic,L7404,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,684.45,,,,,,,fee schedule,684.45,1678.69,APC
Add UE prost a/e acrylic,L7404,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1232.01,,,,,,,fee schedule,684.45,1678.69,APC
Add UE prost s/d acrylic,L7405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1562.47,,,,,,,fee schedule,895.08,2195.28,
Add UE prost s/d acrylic,L7405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1251.5,,,,,,,fee schedule,895.08,2195.28,
Add UE prost s/d acrylic,L7405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2195.28,,,,,,,fee schedule,895.08,2195.28,
Add UE prost s/d acrylic,L7405,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1908.94,,,,,,,fee schedule,895.08,2195.28,
Add UE prost s/d acrylic,L7405,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,939.83,,,,,,,fee schedule,895.08,2195.28,APC
Add UE prost s/d acrylic,L7405,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,895.08,,,,,,,fee schedule,895.08,2195.28,APC
Add UE prost s/d acrylic,L7405,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1611.14,,,,,,,fee schedule,895.08,2195.28,APC
Add to upp extr user adj mec,L7406,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3307.57,,,,,,,fee schedule,3150.07,5670.13,APC
Add to upp extr user adj mec,L7406,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3150.07,,,,,,,fee schedule,3150.07,5670.13,APC
Add to upp extr user adj mec,L7406,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5670.13,,,,,,,fee schedule,3150.07,5670.13,APC
Repair prosthesis per 15 min,L7520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.7,,,,,,,fee schedule,40.67,73.21,APC
Repair prosthesis per 15 min,L7520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40.67,,,,,,,fee schedule,40.67,73.21,APC
Repair prosthesis per 15 min,L7520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,73.21,,,,,,,fee schedule,40.67,73.21,APC
Pros soc insert gasket/seal,L7700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,193.43,,,,,,,fee schedule,184.22,331.6,APC
Pros soc insert gasket/seal,L7700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,184.22,,,,,,,fee schedule,184.22,331.6,APC
Pros soc insert gasket/seal,L7700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,331.6,,,,,,,fee schedule,184.22,331.6,APC
Male vacuum erection system,L7900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,641.62,,,,,,,fee schedule,513.92,901.49,
Male vacuum erection system,L7900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,513.92,,,,,,,fee schedule,513.92,901.49,
Male vacuum erection system,L7900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,901.49,,,,,,,fee schedule,513.92,901.49,
Male vacuum erection system,L7900,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,783.9,,,,,,,fee schedule,513.92,901.49,
Mastectomy bra,L8000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91,,,,,,,fee schedule,52.13,127.86,
Mastectomy bra,L8000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.89,,,,,,,fee schedule,52.13,127.86,
Mastectomy bra,L8000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.86,,,,,,,fee schedule,52.13,127.86,
Mastectomy bra,L8000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.18,,,,,,,fee schedule,52.13,127.86,
Mastectomy bra,L8000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.74,,,,,,,fee schedule,52.13,127.86,APC
Mastectomy bra,L8000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52.13,,,,,,,fee schedule,52.13,127.86,APC
Mastectomy bra,L8000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93.83,,,,,,,fee schedule,52.13,127.86,APC
Breast prosthesis bra & form,L8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,269.65,,,,,,,fee schedule,154.49,378.86,
Breast prosthesis bra & form,L8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,215.98,,,,,,,fee schedule,154.49,378.86,
Breast prosthesis bra & form,L8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,378.86,,,,,,,fee schedule,154.49,378.86,
Breast prosthesis bra & form,L8001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,329.44,,,,,,,fee schedule,154.49,378.86,
Breast prosthesis bra & form,L8001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,162.21,,,,,,,fee schedule,154.49,378.86,APC
Breast prosthesis bra & form,L8001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,154.49,,,,,,,fee schedule,154.49,378.86,APC
Breast prosthesis bra & form,L8001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,278.08,,,,,,,fee schedule,154.49,378.86,APC
Brst prsth bra & bilat form,L8002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,354.62,,,,,,,fee schedule,203.15,498.25,
Brst prsth bra & bilat form,L8002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,284.05,,,,,,,fee schedule,203.15,498.25,
Brst prsth bra & bilat form,L8002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,498.25,,,,,,,fee schedule,203.15,498.25,
Brst prsth bra & bilat form,L8002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,433.26,,,,,,,fee schedule,203.15,498.25,
Brst prsth bra & bilat form,L8002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,213.31,,,,,,,fee schedule,203.15,498.25,APC
Brst prsth bra & bilat form,L8002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,203.15,,,,,,,fee schedule,203.15,498.25,APC
Brst prsth bra & bilat form,L8002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,365.67,,,,,,,fee schedule,203.15,498.25,APC
Ext breastprosthesis garment,L8015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.84,,,,,,,fee schedule,73.81,181.02,
Ext breastprosthesis garment,L8015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,103.2,,,,,,,fee schedule,73.81,181.02,
Ext breastprosthesis garment,L8015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,181.02,,,,,,,fee schedule,73.81,181.02,
Ext breastprosthesis garment,L8015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,157.41,,,,,,,fee schedule,73.81,181.02,
Ext breastprosthesis garment,L8015,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.5,,,,,,,fee schedule,73.81,181.02,APC
Ext breastprosthesis garment,L8015,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.81,,,,,,,fee schedule,73.81,181.02,APC
Ext breastprosthesis garment,L8015,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.86,,,,,,,fee schedule,73.81,181.02,APC
Mastectomy form,L8020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,486,,,,,,,fee schedule,278.4,682.84,
Mastectomy form,L8020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,389.28,,,,,,,fee schedule,278.4,682.84,
Mastectomy form,L8020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,682.84,,,,,,,fee schedule,278.4,682.84,
Mastectomy form,L8020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,593.77,,,,,,,fee schedule,278.4,682.84,
Mastectomy form,L8020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.32,,,,,,,fee schedule,278.4,682.84,APC
Mastectomy form,L8020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,278.4,,,,,,,fee schedule,278.4,682.84,APC
Mastectomy form,L8020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,501.12,,,,,,,fee schedule,278.4,682.84,APC
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,751.31,,,,,,,fee schedule,430.39,1055.6,
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,601.78,,,,,,,fee schedule,430.39,1055.6,
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1055.6,,,,,,,fee schedule,430.39,1055.6,
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,917.91,,,,,,,fee schedule,430.39,1055.6,
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,451.91,,,,,,,fee schedule,430.39,1055.6,APC
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,430.39,,,,,,,fee schedule,430.39,1055.6,APC
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,774.7,,,,,,,fee schedule,430.39,1055.6,APC
Breast prosthesis w adhesive,L8031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,751.31,,,,,,,fee schedule,430.39,1055.6,
Breast prosthesis w adhesive,L8031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,601.78,,,,,,,fee schedule,430.39,1055.6,
Breast prosthesis w adhesive,L8031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1055.6,,,,,,,fee schedule,430.39,1055.6,
Breast prosthesis w adhesive,L8031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,917.91,,,,,,,fee schedule,430.39,1055.6,
Breast prosthesis w adhesive,L8031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,451.91,,,,,,,fee schedule,430.39,1055.6,APC
Breast prosthesis w adhesive,L8031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,430.39,,,,,,,fee schedule,430.39,1055.6,APC
Breast prosthesis w adhesive,L8031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,774.7,,,,,,,fee schedule,430.39,1055.6,APC
Reusable nipple prosthesis,L8032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.17,,,,,,,fee schedule,48.23,118.25,
Reusable nipple prosthesis,L8032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.42,,,,,,,fee schedule,48.23,118.25,
Reusable nipple prosthesis,L8032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.25,,,,,,,fee schedule,48.23,118.25,
Reusable nipple prosthesis,L8032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.83,,,,,,,fee schedule,48.23,118.25,
Reusable nipple prosthesis,L8032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.64,,,,,,,fee schedule,48.23,118.25,APC
Reusable nipple prosthesis,L8032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48.23,,,,,,,fee schedule,48.23,118.25,APC
Reusable nipple prosthesis,L8032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86.81,,,,,,,fee schedule,48.23,118.25,APC
Custom breast prosthesis,L8035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7874.98,,,,,,,fee schedule,4511.21,11064.43,
Custom breast prosthesis,L8035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6307.68,,,,,,,fee schedule,4511.21,11064.43,
Custom breast prosthesis,L8035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11064.43,,,,,,,fee schedule,4511.21,11064.43,
Custom breast prosthesis,L8035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9621.24,,,,,,,fee schedule,4511.21,11064.43,
Custom breast prosthesis,L8035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4736.77,,,,,,,fee schedule,4511.21,11064.43,APC
Custom breast prosthesis,L8035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4511.21,,,,,,,fee schedule,4511.21,11064.43,APC
Custom breast prosthesis,L8035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8120.18,,,,,,,fee schedule,4511.21,11064.43,APC
Nasal prosthesis,L8040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5328.99,,,,,,,fee schedule,3052.75,7487.28,
Nasal prosthesis,L8040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4268.4,,,,,,,fee schedule,3052.75,7487.28,
Nasal prosthesis,L8040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7487.28,,,,,,,fee schedule,3052.75,7487.28,
Nasal prosthesis,L8040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6510.68,,,,,,,fee schedule,3052.75,7487.28,
Nasal prosthesis,L8040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3205.39,,,,,,,fee schedule,3052.75,7487.28,APC
Nasal prosthesis,L8040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3052.75,,,,,,,fee schedule,3052.75,7487.28,APC
Nasal prosthesis,L8040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5494.95,,,,,,,fee schedule,3052.75,7487.28,APC
Midfacial prosthesis,L8041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6422.58,,,,,,,fee schedule,3679.2,9023.79,
Midfacial prosthesis,L8041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5144.34,,,,,,,fee schedule,3679.2,9023.79,
Midfacial prosthesis,L8041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9023.79,,,,,,,fee schedule,3679.2,9023.79,
Midfacial prosthesis,L8041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7846.77,,,,,,,fee schedule,3679.2,9023.79,
Midfacial prosthesis,L8041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3863.16,,,,,,,fee schedule,3679.2,9023.79,APC
Midfacial prosthesis,L8041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3679.2,,,,,,,fee schedule,3679.2,9023.79,APC
Midfacial prosthesis,L8041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,6622.56,,,,,,,fee schedule,3679.2,9023.79,APC
Orbital prosthesis,L8042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7216.36,,,,,,,fee schedule,4133.93,10139.06,
Orbital prosthesis,L8042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5780.14,,,,,,,fee schedule,4133.93,10139.06,
Orbital prosthesis,L8042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10139.06,,,,,,,fee schedule,4133.93,10139.06,
Orbital prosthesis,L8042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8816.57,,,,,,,fee schedule,4133.93,10139.06,
Orbital prosthesis,L8042,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4340.63,,,,,,,fee schedule,4133.93,10139.06,APC
Orbital prosthesis,L8042,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4133.93,,,,,,,fee schedule,4133.93,10139.06,APC
Orbital prosthesis,L8042,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7441.07,,,,,,,fee schedule,4133.93,10139.06,APC
Upper facial prosthesis,L8043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8082.38,,,,,,,fee schedule,4630.01,11355.82,
Upper facial prosthesis,L8043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6473.81,,,,,,,fee schedule,4630.01,11355.82,
Upper facial prosthesis,L8043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11355.82,,,,,,,fee schedule,4630.01,11355.82,
Upper facial prosthesis,L8043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9874.63,,,,,,,fee schedule,4630.01,11355.82,
Upper facial prosthesis,L8043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4861.51,,,,,,,fee schedule,4630.01,11355.82,APC
Upper facial prosthesis,L8043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4630.01,,,,,,,fee schedule,4630.01,11355.82,APC
Upper facial prosthesis,L8043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8334.02,,,,,,,fee schedule,4630.01,11355.82,APC
Hemi-facial prosthesis,L8044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8948.3,,,,,,,fee schedule,5126.08,12572.44,
Hemi-facial prosthesis,L8044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7167.39,,,,,,,fee schedule,5126.08,12572.44,
Hemi-facial prosthesis,L8044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12572.44,,,,,,,fee schedule,5126.08,12572.44,
Hemi-facial prosthesis,L8044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10932.56,,,,,,,fee schedule,5126.08,12572.44,
Hemi-facial prosthesis,L8044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5382.38,,,,,,,fee schedule,5126.08,12572.44,APC
Hemi-facial prosthesis,L8044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5126.08,,,,,,,fee schedule,5126.08,12572.44,APC
Hemi-facial prosthesis,L8044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9226.94,,,,,,,fee schedule,5126.08,12572.44,APC
Auricular prosthesis,L8045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7007.12,,,,,,,fee schedule,4014.06,9845.07,
Auricular prosthesis,L8045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5612.55,,,,,,,fee schedule,4014.06,9845.07,
Auricular prosthesis,L8045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9845.07,,,,,,,fee schedule,4014.06,9845.07,
Auricular prosthesis,L8045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8560.93,,,,,,,fee schedule,4014.06,9845.07,
Auricular prosthesis,L8045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4214.76,,,,,,,fee schedule,4014.06,9845.07,APC
Auricular prosthesis,L8045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4014.06,,,,,,,fee schedule,4014.06,9845.07,APC
Auricular prosthesis,L8045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7225.31,,,,,,,fee schedule,4014.06,9845.07,APC
Partial facial prosthesis,L8046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5773.14,,,,,,,fee schedule,3307.18,8111.32,
Partial facial prosthesis,L8046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4624.16,,,,,,,fee schedule,3307.18,8111.32,
Partial facial prosthesis,L8046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8111.32,,,,,,,fee schedule,3307.18,8111.32,
Partial facial prosthesis,L8046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7053.32,,,,,,,fee schedule,3307.18,8111.32,
Partial facial prosthesis,L8046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3472.54,,,,,,,fee schedule,3307.18,8111.32,APC
Partial facial prosthesis,L8046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3307.18,,,,,,,fee schedule,3307.18,8111.32,APC
Partial facial prosthesis,L8046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5952.92,,,,,,,fee schedule,3307.18,8111.32,APC
Nasal septal prosthesis,L8047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2958.72,,,,,,,fee schedule,1694.92,4157.03,
Nasal septal prosthesis,L8047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2369.87,,,,,,,fee schedule,1694.92,4157.03,
Nasal septal prosthesis,L8047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4157.03,,,,,,,fee schedule,1694.92,4157.03,
Nasal septal prosthesis,L8047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3614.81,,,,,,,fee schedule,1694.92,4157.03,
Nasal septal prosthesis,L8047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1779.67,,,,,,,fee schedule,1694.92,4157.03,APC
Nasal septal prosthesis,L8047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1694.92,,,,,,,fee schedule,1694.92,4157.03,APC
Nasal septal prosthesis,L8047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3050.86,,,,,,,fee schedule,1694.92,4157.03,APC
Truss single w/ standard pad,L8300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,180.26,,,,,,,fee schedule,103.28,253.26,
Truss single w/ standard pad,L8300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,144.38,,,,,,,fee schedule,103.28,253.26,
Truss single w/ standard pad,L8300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,253.26,,,,,,,fee schedule,103.28,253.26,
Truss single w/ standard pad,L8300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,220.23,,,,,,,fee schedule,103.28,253.26,
Truss single w/ standard pad,L8300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.44,,,,,,,fee schedule,103.28,253.26,APC
Truss single w/ standard pad,L8300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,103.28,,,,,,,fee schedule,103.28,253.26,APC
Truss single w/ standard pad,L8300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,185.9,,,,,,,fee schedule,103.28,253.26,APC
Truss double w/ standard pad,L8310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,319.38,,,,,,,fee schedule,182.95,448.73,
Truss double w/ standard pad,L8310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,255.82,,,,,,,fee schedule,182.95,448.73,
Truss double w/ standard pad,L8310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,448.73,,,,,,,fee schedule,182.95,448.73,
Truss double w/ standard pad,L8310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,390.2,,,,,,,fee schedule,182.95,448.73,
Truss double w/ standard pad,L8310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,192.1,,,,,,,fee schedule,182.95,448.73,APC
Truss double w/ standard pad,L8310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,182.95,,,,,,,fee schedule,182.95,448.73,APC
Truss double w/ standard pad,L8310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,329.31,,,,,,,fee schedule,182.95,448.73,APC
Truss addition to std pad wa,L8320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.52,,,,,,,fee schedule,75.9,186.19,
Truss addition to std pad wa,L8320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,106.14,,,,,,,fee schedule,75.9,186.19,
Truss addition to std pad wa,L8320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,186.19,,,,,,,fee schedule,75.9,186.19,
Truss addition to std pad wa,L8320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.9,,,,,,,fee schedule,75.9,186.19,
Truss addition to std pad wa,L8320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.7,,,,,,,fee schedule,75.9,186.19,APC
Truss addition to std pad wa,L8320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,75.9,,,,,,,fee schedule,75.9,186.19,APC
Truss addition to std pad wa,L8320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,136.62,,,,,,,fee schedule,75.9,186.19,APC
Truss add to std pad scrotal,L8330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105.5,,,,,,,fee schedule,60.44,148.22,
Truss add to std pad scrotal,L8330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,84.5,,,,,,,fee schedule,60.44,148.22,
Truss add to std pad scrotal,L8330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,148.22,,,,,,,fee schedule,60.44,148.22,
Truss add to std pad scrotal,L8330,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,128.89,,,,,,,fee schedule,60.44,148.22,
Truss add to std pad scrotal,L8330,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.46,,,,,,,fee schedule,60.44,148.22,APC
Truss add to std pad scrotal,L8330,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.44,,,,,,,fee schedule,60.44,148.22,APC
Truss add to std pad scrotal,L8330,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,108.79,,,,,,,fee schedule,60.44,148.22,APC
Sheath below knee,L8400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.62,,,,,,,fee schedule,19.27,47.24,
Sheath below knee,L8400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.93,,,,,,,fee schedule,19.27,47.24,
Sheath below knee,L8400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.24,,,,,,,fee schedule,19.27,47.24,
Sheath below knee,L8400,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.08,,,,,,,fee schedule,19.27,47.24,
Sheath below knee,L8400,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.23,,,,,,,fee schedule,19.27,47.24,APC
Sheath below knee,L8400,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19.27,,,,,,,fee schedule,19.27,47.24,APC
Sheath below knee,L8400,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34.69,,,,,,,fee schedule,19.27,47.24,APC
Sheath above knee,L8410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.25,,,,,,,fee schedule,25.36,62.17,
Sheath above knee,L8410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.44,,,,,,,fee schedule,25.36,62.17,
Sheath above knee,L8410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.17,,,,,,,fee schedule,25.36,62.17,
Sheath above knee,L8410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.06,,,,,,,fee schedule,25.36,62.17,
Sheath above knee,L8410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.63,,,,,,,fee schedule,25.36,62.17,APC
Sheath above knee,L8410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.36,,,,,,,fee schedule,25.36,62.17,APC
Sheath above knee,L8410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45.65,,,,,,,fee schedule,25.36,62.17,APC
Sheath upper limb,L8415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.8,,,,,,,fee schedule,26.24,64.35,
Sheath upper limb,L8415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.69,,,,,,,fee schedule,26.24,64.35,
Sheath upper limb,L8415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.35,,,,,,,fee schedule,26.24,64.35,
Sheath upper limb,L8415,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.96,,,,,,,fee schedule,26.24,64.35,
Sheath upper limb,L8415,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.55,,,,,,,fee schedule,26.24,64.35,APC
Sheath upper limb,L8415,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.24,,,,,,,fee schedule,26.24,64.35,APC
Sheath upper limb,L8415,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.23,,,,,,,fee schedule,26.24,64.35,APC
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.67,,,,,,,fee schedule,92.62,227.15,
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.49,,,,,,,fee schedule,92.62,227.15,
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227.15,,,,,,,fee schedule,92.62,227.15,
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,197.52,,,,,,,fee schedule,92.62,227.15,
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,97.25,,,,,,,fee schedule,92.62,227.15,APC
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,92.62,,,,,,,fee schedule,92.62,227.15,APC
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,166.72,,,,,,,fee schedule,92.62,227.15,APC
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.82,,,,,,,fee schedule,25.68,62.97,
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.9,,,,,,,fee schedule,25.68,62.97,
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.97,,,,,,,fee schedule,25.68,62.97,
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.76,,,,,,,fee schedule,25.68,62.97,
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.96,,,,,,,fee schedule,25.68,62.97,APC
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.68,,,,,,,fee schedule,25.68,62.97,APC
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.22,,,,,,,fee schedule,25.68,62.97,APC
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.76,,,,,,,fee schedule,29.09,71.32,
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.66,,,,,,,fee schedule,29.09,71.32,
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,71.32,,,,,,,fee schedule,29.09,71.32,
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,62.02,,,,,,,fee schedule,29.09,71.32,
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.54,,,,,,,fee schedule,29.09,71.32,APC
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29.09,,,,,,,fee schedule,29.09,71.32,APC
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52.36,,,,,,,fee schedule,29.09,71.32,APC
Pros sock multi ply upper lm,L8435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.25,,,,,,,fee schedule,27.64,67.79,
Pros sock multi ply upper lm,L8435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,38.65,,,,,,,fee schedule,27.64,67.79,
Pros sock multi ply upper lm,L8435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.79,,,,,,,fee schedule,27.64,67.79,
Pros sock multi ply upper lm,L8435,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.95,,,,,,,fee schedule,27.64,67.79,
Pros sock multi ply upper lm,L8435,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.02,,,,,,,fee schedule,27.64,67.79,APC
Pros sock multi ply upper lm,L8435,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.64,,,,,,,fee schedule,27.64,67.79,APC
Pros sock multi ply upper lm,L8435,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49.75,,,,,,,fee schedule,27.64,67.79,APC
Shrinker below knee,L8440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100.2,,,,,,,fee schedule,57.4,140.78,
Shrinker below knee,L8440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.26,,,,,,,fee schedule,57.4,140.78,
Shrinker below knee,L8440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,140.78,,,,,,,fee schedule,57.4,140.78,
Shrinker below knee,L8440,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,122.42,,,,,,,fee schedule,57.4,140.78,
Shrinker below knee,L8440,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.27,,,,,,,fee schedule,57.4,140.78,APC
Shrinker below knee,L8440,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57.4,,,,,,,fee schedule,57.4,140.78,APC
Shrinker below knee,L8440,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,103.32,,,,,,,fee schedule,57.4,140.78,APC
Shrinker above knee,L8460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.44,,,,,,,fee schedule,81.59,200.12,
Shrinker above knee,L8460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,114.09,,,,,,,fee schedule,81.59,200.12,
Shrinker above knee,L8460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,200.12,,,,,,,fee schedule,81.59,200.12,
Shrinker above knee,L8460,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,174.02,,,,,,,fee schedule,81.59,200.12,
Shrinker above knee,L8460,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.67,,,,,,,fee schedule,81.59,200.12,APC
Shrinker above knee,L8460,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,81.59,,,,,,,fee schedule,81.59,200.12,APC
Shrinker above knee,L8460,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,146.86,,,,,,,fee schedule,81.59,200.12,APC
Shrinker upper limb,L8465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.65,,,,,,,fee schedule,75.41,184.97,
Shrinker upper limb,L8465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.45,,,,,,,fee schedule,75.41,184.97,
Shrinker upper limb,L8465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.97,,,,,,,fee schedule,75.41,184.97,
Shrinker upper limb,L8465,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.84,,,,,,,fee schedule,75.41,184.97,
Shrinker upper limb,L8465,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.18,,,,,,,fee schedule,75.41,184.97,APC
Shrinker upper limb,L8465,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,75.41,,,,,,,fee schedule,75.41,184.97,APC
Shrinker upper limb,L8465,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,135.74,,,,,,,fee schedule,75.41,184.97,APC
Pros sock single ply BK,L8470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.26,,,,,,,fee schedule,8.17,20.03,
Pros sock single ply BK,L8470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.42,,,,,,,fee schedule,8.17,20.03,
Pros sock single ply BK,L8470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.03,,,,,,,fee schedule,8.17,20.03,
Pros sock single ply BK,L8470,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.42,,,,,,,fee schedule,8.17,20.03,
Pros sock single ply BK,L8470,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.58,,,,,,,fee schedule,8.17,20.03,APC
Pros sock single ply BK,L8470,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.17,,,,,,,fee schedule,8.17,20.03,APC
Pros sock single ply BK,L8470,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.71,,,,,,,fee schedule,8.17,20.03,APC
Pros sock single ply AK,L8480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.64,,,,,,,fee schedule,11.27,27.6,
Pros sock single ply AK,L8480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.73,,,,,,,fee schedule,11.27,27.6,
Pros sock single ply AK,L8480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.6,,,,,,,fee schedule,11.27,27.6,
Pros sock single ply AK,L8480,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24,,,,,,,fee schedule,11.27,27.6,
Pros sock single ply AK,L8480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.83,,,,,,,fee schedule,11.27,27.6,APC
Pros sock single ply AK,L8480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.27,,,,,,,fee schedule,11.27,27.6,APC
Pros sock single ply AK,L8480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.29,,,,,,,fee schedule,11.27,27.6,APC
Pros sock single ply upper l,L8485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.49,,,,,,,fee schedule,15.17,37.21,
Pros sock single ply upper l,L8485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.22,,,,,,,fee schedule,15.17,37.21,
Pros sock single ply upper l,L8485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.21,,,,,,,fee schedule,15.17,37.21,
Pros sock single ply upper l,L8485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.36,,,,,,,fee schedule,15.17,37.21,
Pros sock single ply upper l,L8485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.93,,,,,,,fee schedule,15.17,37.21,APC
Pros sock single ply upper l,L8485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.17,,,,,,,fee schedule,15.17,37.21,APC
Pros sock single ply upper l,L8485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.31,,,,,,,fee schedule,15.17,37.21,APC
Artificial larynx,L8500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1414.52,,,,,,,fee schedule,810.32,1987.41,
Artificial larynx,L8500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1132.99,,,,,,,fee schedule,810.32,1987.41,
Artificial larynx,L8500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1987.41,,,,,,,fee schedule,810.32,1987.41,
Artificial larynx,L8500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1728.18,,,,,,,fee schedule,810.32,1987.41,
Artificial larynx,L8500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,850.84,,,,,,,fee schedule,810.32,1987.41,APC
Artificial larynx,L8500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,810.32,,,,,,,fee schedule,810.32,1987.41,APC
Artificial larynx,L8500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1458.58,,,,,,,fee schedule,810.32,1987.41,APC
Tracheostomy speaking valve,L8501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,258.14,,,,,,,fee schedule,147.88,362.69,
Tracheostomy speaking valve,L8501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,206.76,,,,,,,fee schedule,147.88,362.69,
Tracheostomy speaking valve,L8501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,362.69,,,,,,,fee schedule,147.88,362.69,
Tracheostomy speaking valve,L8501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,315.38,,,,,,,fee schedule,147.88,362.69,
Tracheostomy speaking valve,L8501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,155.27,,,,,,,fee schedule,147.88,362.69,APC
Tracheostomy speaking valve,L8501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,147.88,,,,,,,fee schedule,147.88,362.69,APC
Tracheostomy speaking valve,L8501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,266.18,,,,,,,fee schedule,147.88,362.69,APC
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.01,,,,,,,fee schedule,51.55,126.47,
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.1,,,,,,,fee schedule,51.55,126.47,
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.47,,,,,,,fee schedule,51.55,126.47,
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,109.97,,,,,,,fee schedule,51.55,126.47,
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.13,,,,,,,fee schedule,51.55,126.47,APC
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.55,,,,,,,fee schedule,51.55,126.47,APC
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.79,,,,,,,fee schedule,51.55,126.47,APC
Trach-esoph voice pros md in,L8509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,234.74,,,,,,,fee schedule,134.48,329.81,
Trach-esoph voice pros md in,L8509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,188.02,,,,,,,fee schedule,134.48,329.81,
Trach-esoph voice pros md in,L8509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,329.81,,,,,,,fee schedule,134.48,329.81,
Trach-esoph voice pros md in,L8509,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,286.79,,,,,,,fee schedule,134.48,329.81,
Trach-esoph voice pros md in,L8509,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,141.2,,,,,,,fee schedule,134.48,329.81,APC
Trach-esoph voice pros md in,L8509,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,134.48,,,,,,,fee schedule,134.48,329.81,APC
Trach-esoph voice pros md in,L8509,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,242.06,,,,,,,fee schedule,134.48,329.81,APC
Voice amplifier,L8510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,543.21,,,,,,,fee schedule,311.17,763.22,
Voice amplifier,L8510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,435.1,,,,,,,fee schedule,311.17,763.22,
Voice amplifier,L8510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,763.22,,,,,,,fee schedule,311.17,763.22,
Voice amplifier,L8510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,663.67,,,,,,,fee schedule,311.17,763.22,
Voice amplifier,L8510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,326.73,,,,,,,fee schedule,311.17,763.22,APC
Voice amplifier,L8510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,311.17,,,,,,,fee schedule,311.17,763.22,APC
Voice amplifier,L8510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,560.11,,,,,,,fee schedule,311.17,763.22,APC
Indwelling trach insert,L8511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.3,,,,,,,fee schedule,89.55,219.6,
Indwelling trach insert,L8511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.19,,,,,,,fee schedule,89.55,219.6,
Indwelling trach insert,L8511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,219.6,,,,,,,fee schedule,89.55,219.6,
Indwelling trach insert,L8511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.96,,,,,,,fee schedule,89.55,219.6,
Indwelling trach insert,L8511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.03,,,,,,,fee schedule,89.55,219.6,APC
Indwelling trach insert,L8511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,89.55,,,,,,,fee schedule,89.55,219.6,APC
Indwelling trach insert,L8511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,161.19,,,,,,,fee schedule,89.55,219.6,APC
Gel cap for trach voice pros,L8512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.67,,,,,,,fee schedule,2.68,6.57,
Gel cap for trach voice pros,L8512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.74,,,,,,,fee schedule,2.68,6.57,
Gel cap for trach voice pros,L8512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.57,,,,,,,fee schedule,2.68,6.57,
Gel cap for trach voice pros,L8512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.71,,,,,,,fee schedule,2.68,6.57,
Gel cap for trach voice pros,L8512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.81,,,,,,,fee schedule,2.68,6.57,APC
Gel cap for trach voice pros,L8512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.68,,,,,,,fee schedule,2.68,6.57,APC
Gel cap for trach voice pros,L8512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.82,,,,,,,fee schedule,2.68,6.57,APC
Trach pros cleaning device,L8513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.16,,,,,,,fee schedule,6.41,15.67,
Trach pros cleaning device,L8513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.94,,,,,,,fee schedule,6.41,15.67,
Trach pros cleaning device,L8513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.67,,,,,,,fee schedule,6.41,15.67,
Trach pros cleaning device,L8513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.63,,,,,,,fee schedule,6.41,15.67,
Trach pros cleaning device,L8513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,6.41,15.67,APC
Trach pros cleaning device,L8513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6.41,,,,,,,fee schedule,6.41,15.67,APC
Trach pros cleaning device,L8513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11.54,,,,,,,fee schedule,6.41,15.67,APC
Repl trach puncture dilator,L8514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,202.71,,,,,,,fee schedule,116.13,284.81,
Repl trach puncture dilator,L8514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,162.37,,,,,,,fee schedule,116.13,284.81,
Repl trach puncture dilator,L8514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,284.81,,,,,,,fee schedule,116.13,284.81,
Repl trach puncture dilator,L8514,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,247.66,,,,,,,fee schedule,116.13,284.81,
Repl trach puncture dilator,L8514,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,121.94,,,,,,,fee schedule,116.13,284.81,APC
Repl trach puncture dilator,L8514,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.13,,,,,,,fee schedule,116.13,284.81,APC
Repl trach puncture dilator,L8514,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,209.03,,,,,,,fee schedule,116.13,284.81,APC
Gel cap app device for trach,L8515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,135.67,,,,,,,fee schedule,77.74,190.61,
Gel cap app device for trach,L8515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,108.67,,,,,,,fee schedule,77.74,190.61,
Gel cap app device for trach,L8515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,190.61,,,,,,,fee schedule,77.74,190.61,
Gel cap app device for trach,L8515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,165.75,,,,,,,fee schedule,77.74,190.61,
Gel cap app device for trach,L8515,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.63,,,,,,,fee schedule,77.74,190.61,APC
Gel cap app device for trach,L8515,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,77.74,,,,,,,fee schedule,77.74,190.61,APC
Gel cap app device for trach,L8515,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,139.93,,,,,,,fee schedule,77.74,190.61,APC
Implant breast silicone/eq,L8600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1779.35,,,,,,,fee schedule,1425.22,2500,
Implant breast silicone/eq,L8600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1425.22,,,,,,,fee schedule,1425.22,2500,
Implant breast silicone/eq,L8600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2500,,,,,,,fee schedule,1425.22,2500,
Implant breast silicone/eq,L8600,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2173.91,,,,,,,fee schedule,1425.22,2500,
Collagen imp urinary 2.5 ml,L8603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,935.8,,,,,,,fee schedule,749.55,1314.81,
Collagen imp urinary 2.5 ml,L8603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,749.55,,,,,,,fee schedule,749.55,1314.81,
Collagen imp urinary 2.5 ml,L8603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1314.81,,,,,,,fee schedule,749.55,1314.81,
Collagen imp urinary 2.5 ml,L8603,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1143.31,,,,,,,fee schedule,749.55,1314.81,
Inj bulking agent anal canal,L8605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3935.17,,,,,,,fee schedule,3151.98,5528.95,
Inj bulking agent anal canal,L8605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3151.98,,,,,,,fee schedule,3151.98,5528.95,
Inj bulking agent anal canal,L8605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5528.95,,,,,,,fee schedule,3151.98,5528.95,
Inj bulking agent anal canal,L8605,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4807.78,,,,,,,fee schedule,3151.98,5528.95,
Synthetic implnt urinary 1ml,L8606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4939.68,,,,,,,fee schedule,3956.57,6940.3,
Synthetic implnt urinary 1ml,L8606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3956.57,,,,,,,fee schedule,3956.57,6940.3,
Synthetic implnt urinary 1ml,L8606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6940.3,,,,,,,fee schedule,3956.57,6940.3,
Synthetic implnt urinary 1ml,L8606,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6035.04,,,,,,,fee schedule,3956.57,6940.3,
Inj vocal cord bulking agent,L8607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.2,,,,,,,fee schedule,73.85,129.55,
Inj vocal cord bulking agent,L8607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.85,,,,,,,fee schedule,73.85,129.55,
Inj vocal cord bulking agent,L8607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.55,,,,,,,fee schedule,73.85,129.55,
Inj vocal cord bulking agent,L8607,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.65,,,,,,,fee schedule,73.85,129.55,
Artificial cornea,L8609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14005.03,,,,,,,fee schedule,11217.72,19677.2,
Artificial cornea,L8609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11217.72,,,,,,,fee schedule,11217.72,19677.2,
Artificial cornea,L8609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19677.2,,,,,,,fee schedule,11217.72,19677.2,
Artificial cornea,L8609,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17110.61,,,,,,,fee schedule,11217.72,19677.2,
Ocular implant,L8610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1461.17,,,,,,,fee schedule,1170.36,2052.96,
Ocular implant,L8610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1170.36,,,,,,,fee schedule,1170.36,2052.96,
Ocular implant,L8610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2052.96,,,,,,,fee schedule,1170.36,2052.96,
Ocular implant,L8610,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1785.18,,,,,,,fee schedule,1170.36,2052.96,
Aqueous shunt prosthesis,L8612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1701.25,,,,,,,fee schedule,1362.66,2390.28,
Aqueous shunt prosthesis,L8612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1362.66,,,,,,,fee schedule,1362.66,2390.28,
Aqueous shunt prosthesis,L8612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2390.28,,,,,,,fee schedule,1362.66,2390.28,
Aqueous shunt prosthesis,L8612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2078.5,,,,,,,fee schedule,1362.66,2390.28,
Ossicular implant,L8613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,730.47,,,,,,,fee schedule,585.09,1026.32,
Ossicular implant,L8613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,585.09,,,,,,,fee schedule,585.09,1026.32,
Ossicular implant,L8613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1026.32,,,,,,,fee schedule,585.09,1026.32,
Ossicular implant,L8613,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,892.45,,,,,,,fee schedule,585.09,1026.32,
Cochlear device,L8614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54956.18,,,,,,,fee schedule,44018.66,77213.93,
Cochlear device,L8614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44018.66,,,,,,,fee schedule,44018.66,77213.93,
Cochlear device,L8614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77213.93,,,,,,,fee schedule,44018.66,77213.93,
Cochlear device,L8614,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67142.55,,,,,,,fee schedule,44018.66,77213.93,
Coch implant headset replace,L8615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,969.43,,,,,,,fee schedule,555.35,1362.06,
Coch implant headset replace,L8615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,776.49,,,,,,,fee schedule,555.35,1362.06,
Coch implant headset replace,L8615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1362.06,,,,,,,fee schedule,555.35,1362.06,
Coch implant headset replace,L8615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1184.4,,,,,,,fee schedule,555.35,1362.06,
Coch implant headset replace,L8615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,583.12,,,,,,,fee schedule,555.35,1362.06,APC
Coch implant headset replace,L8615,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,555.35,,,,,,,fee schedule,555.35,1362.06,APC
Coch implant headset replace,L8615,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,999.63,,,,,,,fee schedule,555.35,1362.06,APC
Coch implant microphone repl,L8616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,225.76,,,,,,,fee schedule,129.34,317.19,
Coch implant microphone repl,L8616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,180.83,,,,,,,fee schedule,129.34,317.19,
Coch implant microphone repl,L8616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,317.19,,,,,,,fee schedule,129.34,317.19,
Coch implant microphone repl,L8616,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,275.82,,,,,,,fee schedule,129.34,317.19,
Coch implant microphone repl,L8616,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.81,,,,,,,fee schedule,129.34,317.19,APC
Coch implant microphone repl,L8616,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,129.34,,,,,,,fee schedule,129.34,317.19,APC
Coch implant microphone repl,L8616,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,232.81,,,,,,,fee schedule,129.34,317.19,APC
Coch implant trans coil repl,L8617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,197.21,,,,,,,fee schedule,112.98,277.08,
Coch implant trans coil repl,L8617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,157.96,,,,,,,fee schedule,112.98,277.08,
Coch implant trans coil repl,L8617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,277.08,,,,,,,fee schedule,112.98,277.08,
Coch implant trans coil repl,L8617,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,240.94,,,,,,,fee schedule,112.98,277.08,
Coch implant trans coil repl,L8617,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,118.63,,,,,,,fee schedule,112.98,277.08,APC
Coch implant trans coil repl,L8617,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,112.98,,,,,,,fee schedule,112.98,277.08,APC
Coch implant trans coil repl,L8617,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,203.36,,,,,,,fee schedule,112.98,277.08,APC
Coch implant tran cable repl,L8618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.38,,,,,,,fee schedule,32.29,79.21,
Coch implant tran cable repl,L8618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.16,,,,,,,fee schedule,32.29,79.21,
Coch implant tran cable repl,L8618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.21,,,,,,,fee schedule,32.29,79.21,
Coch implant tran cable repl,L8618,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.88,,,,,,,fee schedule,32.29,79.21,
Coch implant tran cable repl,L8618,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.9,,,,,,,fee schedule,32.29,79.21,APC
Coch implant tran cable repl,L8618,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.29,,,,,,,fee schedule,32.29,79.21,APC
Coch implant tran cable repl,L8618,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.12,,,,,,,fee schedule,32.29,79.21,APC
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18067.57,,,,,,,fee schedule,10350.06,25385.1,
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14471.71,,,,,,,fee schedule,10350.06,25385.1,
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25385.1,,,,,,,fee schedule,10350.06,25385.1,
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22074,,,,,,,fee schedule,10350.06,25385.1,
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10867.56,,,,,,,fee schedule,10350.06,25385.1,APC
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10350.06,,,,,,,fee schedule,10350.06,25385.1,APC
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18630.11,,,,,,,fee schedule,10350.06,25385.1,APC
Repl zinc air battery,L8621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.31,,,,,,,fee schedule,0.77,1.84,
Repl zinc air battery,L8621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.05,,,,,,,fee schedule,0.77,1.84,
Repl zinc air battery,L8621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.84,,,,,,,fee schedule,0.77,1.84,
Repl zinc air battery,L8621,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.6,,,,,,,fee schedule,0.77,1.84,
Repl zinc air battery,L8621,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.81,,,,,,,fee schedule,0.77,1.84,APC
Repl zinc air battery,L8621,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.77,,,,,,,fee schedule,0.77,1.84,APC
Repl zinc air battery,L8621,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.39,,,,,,,fee schedule,0.77,1.84,APC
Repl alkaline battery,L8622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.69,,,,,,,fee schedule,0.4,0.97,
Repl alkaline battery,L8622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.55,,,,,,,fee schedule,0.4,0.97,
Repl alkaline battery,L8622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.97,,,,,,,fee schedule,0.4,0.97,
Repl alkaline battery,L8622,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.84,,,,,,,fee schedule,0.4,0.97,
Repl alkaline battery,L8622,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.42,,,,,,,fee schedule,0.4,0.97,APC
Repl alkaline battery,L8622,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.4,,,,,,,fee schedule,0.4,0.97,APC
Repl alkaline battery,L8622,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.72,,,,,,,fee schedule,0.4,0.97,APC
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,139.04,,,,,,,fee schedule,79.65,195.35,
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.37,,,,,,,fee schedule,79.65,195.35,
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,195.35,,,,,,,fee schedule,79.65,195.35,
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.87,,,,,,,fee schedule,79.65,195.35,
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.63,,,,,,,fee schedule,79.65,195.35,APC
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.65,,,,,,,fee schedule,79.65,195.35,APC
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,143.37,,,,,,,fee schedule,79.65,195.35,APC
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,346.64,,,,,,,fee schedule,198.57,487.04,
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,277.65,,,,,,,fee schedule,198.57,487.04,
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,487.04,,,,,,,fee schedule,198.57,487.04,
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,423.51,,,,,,,fee schedule,198.57,487.04,
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.5,,,,,,,fee schedule,198.57,487.04,APC
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,198.57,,,,,,,fee schedule,198.57,487.04,APC
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,357.43,,,,,,,fee schedule,198.57,487.04,APC
Charger coch impl/aoi battry,L8625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.2,,,,,,,fee schedule,232.57,418.63,APC
Charger coch impl/aoi battry,L8625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,232.57,,,,,,,fee schedule,232.57,418.63,APC
Charger coch impl/aoi battry,L8625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,418.63,,,,,,,fee schedule,232.57,418.63,APC
CID ext speech process repl,L8627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15335.35,,,,,,,fee schedule,8784.91,21546.31,
CID ext speech process repl,L8627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12283.27,,,,,,,fee schedule,8784.91,21546.31,
CID ext speech process repl,L8627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21546.31,,,,,,,fee schedule,8784.91,21546.31,
CID ext speech process repl,L8627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18735.92,,,,,,,fee schedule,8784.91,21546.31,
CID ext speech process repl,L8627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9224.16,,,,,,,fee schedule,8784.91,21546.31,APC
CID ext speech process repl,L8627,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8784.91,,,,,,,fee schedule,8784.91,21546.31,APC
CID ext speech process repl,L8627,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15812.84,,,,,,,fee schedule,8784.91,21546.31,APC
CID ext controller repl,L8628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2732.19,,,,,,,fee schedule,1565.13,3838.76,
CID ext controller repl,L8628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2188.43,,,,,,,fee schedule,1565.13,3838.76,
CID ext controller repl,L8628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3838.76,,,,,,,fee schedule,1565.13,3838.76,
CID ext controller repl,L8628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3338.05,,,,,,,fee schedule,1565.13,3838.76,
CID ext controller repl,L8628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1643.39,,,,,,,fee schedule,1565.13,3838.76,APC
CID ext controller repl,L8628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1565.13,,,,,,,fee schedule,1565.13,3838.76,APC
CID ext controller repl,L8628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2817.23,,,,,,,fee schedule,1565.13,3838.76,APC
CID transmit coil and cable,L8629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,384.9,,,,,,,fee schedule,220.48,540.79,
CID transmit coil and cable,L8629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,308.3,,,,,,,fee schedule,220.48,540.79,
CID transmit coil and cable,L8629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,540.79,,,,,,,fee schedule,220.48,540.79,
CID transmit coil and cable,L8629,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,470.25,,,,,,,fee schedule,220.48,540.79,
CID transmit coil and cable,L8629,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,231.5,,,,,,,fee schedule,220.48,540.79,APC
CID transmit coil and cable,L8629,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,220.48,,,,,,,fee schedule,220.48,540.79,APC
CID transmit coil and cable,L8629,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,396.86,,,,,,,fee schedule,220.48,540.79,APC
Metacarpophalangeal implant,L8630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,959.99,,,,,,,fee schedule,768.93,1348.79,
Metacarpophalangeal implant,L8630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,768.93,,,,,,,fee schedule,768.93,1348.79,
Metacarpophalangeal implant,L8630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1348.79,,,,,,,fee schedule,768.93,1348.79,
Metacarpophalangeal implant,L8630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1172.86,,,,,,,fee schedule,768.93,1348.79,
MCP joint repl 2 pc or more,L8631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4728.47,,,,,,,fee schedule,3787.39,6643.54,
MCP joint repl 2 pc or more,L8631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3787.39,,,,,,,fee schedule,3787.39,6643.54,
MCP joint repl 2 pc or more,L8631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6643.54,,,,,,,fee schedule,3787.39,6643.54,
MCP joint repl 2 pc or more,L8631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5776.99,,,,,,,fee schedule,3787.39,6643.54,
Metatarsal joint implant,L8641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,748.09,,,,,,,fee schedule,599.21,1051.08,
Metatarsal joint implant,L8641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,599.21,,,,,,,fee schedule,599.21,1051.08,
Metatarsal joint implant,L8641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1051.08,,,,,,,fee schedule,599.21,1051.08,
Metatarsal joint implant,L8641,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,913.98,,,,,,,fee schedule,599.21,1051.08,
Hallux implant,L8642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,668.91,,,,,,,fee schedule,535.78,939.83,
Hallux implant,L8642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,535.78,,,,,,,fee schedule,535.78,939.83,
Hallux implant,L8642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,939.83,,,,,,,fee schedule,535.78,939.83,
Hallux implant,L8642,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,817.24,,,,,,,fee schedule,535.78,939.83,
Interphalangeal joint spacer,L8658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,652.25,,,,,,,fee schedule,522.43,916.41,
Interphalangeal joint spacer,L8658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,522.43,,,,,,,fee schedule,522.43,916.41,
Interphalangeal joint spacer,L8658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,916.41,,,,,,,fee schedule,522.43,916.41,
Interphalangeal joint spacer,L8658,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,796.88,,,,,,,fee schedule,522.43,916.41,
Interphalangeal joint repl,L8659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4147.89,,,,,,,fee schedule,3322.36,5827.82,
Interphalangeal joint repl,L8659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3322.36,,,,,,,fee schedule,3322.36,5827.82,
Interphalangeal joint repl,L8659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5827.82,,,,,,,fee schedule,3322.36,5827.82,
Interphalangeal joint repl,L8659,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5067.67,,,,,,,fee schedule,3322.36,5827.82,
"Vascular graft, synthetic",L8670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1189.62,,,,,,,fee schedule,952.86,1671.43,
"Vascular graft, synthetic",L8670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,952.86,,,,,,,fee schedule,952.86,1671.43,
"Vascular graft, synthetic",L8670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1671.43,,,,,,,fee schedule,952.86,1671.43,
"Vascular graft, synthetic",L8670,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1453.42,,,,,,,fee schedule,952.86,1671.43,
Imp neurosti pls gn any type,L8679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18418.39,,,,,,,fee schedule,14752.72,25878.01,
Imp neurosti pls gn any type,L8679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14752.72,,,,,,,fee schedule,14752.72,25878.01,
Imp neurosti pls gn any type,L8679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25878.01,,,,,,,fee schedule,14752.72,25878.01,
Imp neurosti pls gn any type,L8679,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22502.62,,,,,,,fee schedule,14752.72,25878.01,
Implt neurostim elctr each,L8680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,555.79,,,,,,,fee schedule,445.18,780.9,
Implt neurostim elctr each,L8680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,445.18,,,,,,,fee schedule,445.18,780.9,
Implt neurostim elctr each,L8680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,780.9,,,,,,,fee schedule,445.18,780.9,
Implt neurostim elctr each,L8680,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,679.04,,,,,,,fee schedule,445.18,780.9,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2451.55,,,,,,,fee schedule,1404.38,3444.45,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1963.63,,,,,,,fee schedule,1404.38,3444.45,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3444.45,,,,,,,fee schedule,1404.38,3444.45,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2995.17,,,,,,,fee schedule,1404.38,3444.45,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1474.6,,,,,,,fee schedule,1404.38,3444.45,APC
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1404.38,,,,,,,fee schedule,1404.38,3444.45,APC
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2527.88,,,,,,,fee schedule,1404.38,3444.45,APC
Implt neurostim radiofq rec,L8682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13159.56,,,,,,,fee schedule,10540.51,18489.3,
Implt neurostim radiofq rec,L8682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10540.51,,,,,,,fee schedule,10540.51,18489.3,
Implt neurostim radiofq rec,L8682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18489.3,,,,,,,fee schedule,10540.51,18489.3,
Implt neurostim radiofq rec,L8682,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16077.65,,,,,,,fee schedule,10540.51,18489.3,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11583.44,,,,,,,fee schedule,6635.61,16274.83,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9278.07,,,,,,,fee schedule,6635.61,16274.83,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,16274.83,,,,,,,fee schedule,6635.61,16274.83,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14152.03,,,,,,,fee schedule,6635.61,16274.83,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6967.39,,,,,,,fee schedule,6635.61,16274.83,APC
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6635.61,,,,,,,fee schedule,6635.61,16274.83,APC
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11944.1,,,,,,,fee schedule,6635.61,16274.83,APC
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1817.6,,,,,,,fee schedule,1041.21,2553.75,
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1455.86,,,,,,,fee schedule,1041.21,2553.75,
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2553.75,,,,,,,fee schedule,1041.21,2553.75,
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2220.65,,,,,,,fee schedule,1041.21,2553.75,
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1093.27,,,,,,,fee schedule,1041.21,2553.75,APC
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1041.21,,,,,,,fee schedule,1041.21,2553.75,APC
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1874.18,,,,,,,fee schedule,1041.21,2553.75,APC
Implt nrostm pls gen sng rec,L8685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15820.41,,,,,,,fee schedule,12671.79,22227.82,
Implt nrostm pls gen sng rec,L8685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12671.79,,,,,,,fee schedule,12671.79,22227.82,
Implt nrostm pls gen sng rec,L8685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22227.82,,,,,,,fee schedule,12671.79,22227.82,
Implt nrostm pls gen sng rec,L8685,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19328.54,,,,,,,fee schedule,12671.79,22227.82,
Implt nrostm pls gen sng non,L8686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10094.87,,,,,,,fee schedule,8085.76,14183.39,
Implt nrostm pls gen sng non,L8686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8085.76,,,,,,,fee schedule,8085.76,14183.39,
Implt nrostm pls gen sng non,L8686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14183.39,,,,,,,fee schedule,8085.76,14183.39,
Implt nrostm pls gen sng non,L8686,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12333.38,,,,,,,fee schedule,8085.76,14183.39,
Implt nrostm pls gen dua rec,L8687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20589.2,,,,,,,fee schedule,16491.49,28928.02,
Implt nrostm pls gen dua rec,L8687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16491.49,,,,,,,fee schedule,16491.49,28928.02,
Implt nrostm pls gen dua rec,L8687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28928.02,,,,,,,fee schedule,16491.49,28928.02,
Implt nrostm pls gen dua rec,L8687,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25154.8,,,,,,,fee schedule,16491.49,28928.02,
Implt nrostm pls gen dua non,L8688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13137.72,,,,,,,fee schedule,10523.02,18458.62,
Implt nrostm pls gen dua non,L8688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10523.02,,,,,,,fee schedule,10523.02,18458.62,
Implt nrostm pls gen dua non,L8688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18458.62,,,,,,,fee schedule,10523.02,18458.62,
Implt nrostm pls gen dua non,L8688,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16050.97,,,,,,,fee schedule,10523.02,18458.62,
External recharg sys intern,L8689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3707.82,,,,,,,fee schedule,2124.03,5209.52,
External recharg sys intern,L8689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2969.88,,,,,,,fee schedule,2124.03,5209.52,
External recharg sys intern,L8689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5209.52,,,,,,,fee schedule,2124.03,5209.52,
External recharg sys intern,L8689,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4530.02,,,,,,,fee schedule,2124.03,5209.52,
External recharg sys intern,L8689,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2230.23,,,,,,,fee schedule,2124.03,5209.52,APC
External recharg sys intern,L8689,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2124.03,,,,,,,fee schedule,2124.03,5209.52,APC
External recharg sys intern,L8689,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3823.25,,,,,,,fee schedule,2124.03,5209.52,APC
"Aud osseo dev, int/ext comp",L8690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20290.14,,,,,,,fee schedule,16251.94,28507.83,
"Aud osseo dev, int/ext comp",L8690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16251.94,,,,,,,fee schedule,16251.94,28507.83,
"Aud osseo dev, int/ext comp",L8690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28507.83,,,,,,,fee schedule,16251.94,28507.83,
"Aud osseo dev, int/ext comp",L8690,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24789.42,,,,,,,fee schedule,16251.94,28507.83,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5731.78,,,,,,,fee schedule,2120.58,8053.21,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4591.03,,,,,,,fee schedule,2120.58,8053.21,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8053.21,,,,,,,fee schedule,2120.58,8053.21,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7002.79,,,,,,,fee schedule,2120.58,8053.21,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2226.61,,,,,,,fee schedule,2120.58,8053.21,APC
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2120.58,,,,,,,fee schedule,2120.58,8053.21,APC
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3817.04,,,,,,,fee schedule,2120.58,8053.21,APC
"Aud osseo dev, abutment",L8693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3259.37,,,,,,,fee schedule,1867.13,4579.44,
"Aud osseo dev, abutment",L8693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2610.68,,,,,,,fee schedule,1867.13,4579.44,
"Aud osseo dev, abutment",L8693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4579.44,,,,,,,fee schedule,1867.13,4579.44,
"Aud osseo dev, abutment",L8693,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3982.12,,,,,,,fee schedule,1867.13,4579.44,
"Aud osseo dev, abutment",L8693,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1960.49,,,,,,,fee schedule,1867.13,4579.44,APC
"Aud osseo dev, abutment",L8693,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1867.13,,,,,,,fee schedule,1867.13,4579.44,APC
"Aud osseo dev, abutment",L8693,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3360.83,,,,,,,fee schedule,1867.13,4579.44,APC
Aoi transducer/actuator repl,L8694,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1221.01,,,,,,,fee schedule,1162.87,2093.17,APC
Aoi transducer/actuator repl,L8694,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1162.87,,,,,,,fee schedule,1162.87,2093.17,APC
Aoi transducer/actuator repl,L8694,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2093.17,,,,,,,fee schedule,1162.87,2093.17,APC
External recharg sys extern,L8695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.84,,,,,,,fee schedule,20.53,50.36,
External recharg sys extern,L8695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.71,,,,,,,fee schedule,20.53,50.36,
External recharg sys extern,L8695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.36,,,,,,,fee schedule,20.53,50.36,
External recharg sys extern,L8695,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.79,,,,,,,fee schedule,20.53,50.36,
External recharg sys extern,L8695,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.56,,,,,,,fee schedule,20.53,50.36,APC
External recharg sys extern,L8695,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.53,,,,,,,fee schedule,20.53,50.36,APC
External recharg sys extern,L8695,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.95,,,,,,,fee schedule,20.53,50.36,APC
Ext antenna phren nerve stim,L8696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,465.85,,,,,,,fee schedule,266.86,654.52,
Ext antenna phren nerve stim,L8696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,373.13,,,,,,,fee schedule,266.86,654.52,
Ext antenna phren nerve stim,L8696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,654.52,,,,,,,fee schedule,266.86,654.52,
Ext antenna phren nerve stim,L8696,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,569.15,,,,,,,fee schedule,266.86,654.52,
Ext antenna phren nerve stim,L8696,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,280.2,,,,,,,fee schedule,266.86,654.52,APC
Ext antenna phren nerve stim,L8696,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,266.86,,,,,,,fee schedule,266.86,654.52,APC
Ext antenna phren nerve stim,L8696,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,480.35,,,,,,,fee schedule,266.86,654.52,APC
Pow ue rom dev ewh uprt cust,L8701,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36718.64,,,,,,,fee schedule,34970.13,62946.23,APC
Pow ue rom dev ewh uprt cust,L8701,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34970.13,,,,,,,fee schedule,34970.13,62946.23,APC
Pow ue rom dev ewh uprt cust,L8701,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,62946.23,,,,,,,fee schedule,34970.13,62946.23,APC
Pow ue rom dev ewhf uprt cus,L8702,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72241.8,,,,,,,fee schedule,68801.71,123843.08,APC
Pow ue rom dev ewhf uprt cus,L8702,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,68801.71,,,,,,,fee schedule,68801.71,123843.08,APC
Pow ue rom dev ewhf uprt cus,L8702,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,123843.08,,,,,,,fee schedule,68801.71,123843.08,APC
Covid-19 vaccine home admin,M0201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71.29,,,,,,,fee schedule,35.94,100.17,
Covid-19 vaccine home admin,M0201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,57.1,,,,,,,fee schedule,35.94,100.17,
Covid-19 vaccine home admin,M0201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.17,,,,,,,fee schedule,35.94,100.17,
Covid-19 vaccine home admin,M0201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.1,,,,,,,fee schedule,35.94,100.17,
Covid-19 vaccine home admin,M0201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.74,,,,,,,fee schedule,35.94,100.17,APC
Covid-19 vaccine home admin,M0201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.94,,,,,,,fee schedule,35.94,100.17,APC
Covid-19 vaccine home admin,M0201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,64.69,,,,,,,fee schedule,35.94,100.17,APC
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,876.92,,,,,,,fee schedule,439.36,1232.08,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,702.39,,,,,,,fee schedule,439.36,1232.08,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1232.08,,,,,,,fee schedule,439.36,1232.08,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1071.37,,,,,,,fee schedule,439.36,1232.08,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.33,,,,,,,fee schedule,439.36,1232.08,APC
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.36,,,,,,,fee schedule,439.36,1232.08,APC
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,790.85,,,,,,,fee schedule,439.36,1232.08,APC
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,876.92,,,,,,,fee schedule,439.36,1232.08,
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,702.39,,,,,,,fee schedule,439.36,1232.08,
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1232.08,,,,,,,fee schedule,439.36,1232.08,
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1071.37,,,,,,,fee schedule,439.36,1232.08,
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,461.33,,,,,,,fee schedule,439.36,1232.08,APC
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,439.36,,,,,,,fee schedule,439.36,1232.08,APC
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,790.85,,,,,,,fee schedule,439.36,1232.08,APC
Cephalin floculation test,P2028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.7,,,,,,,fee schedule,4.7,8.91,
Cephalin floculation test,P2028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.7,8.91,APC
Cephalin floculation test,P2028,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.95,,,,,,,fee schedule,4.7,8.91,APC
Cephalin floculation test,P2028,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.91,,,,,,,fee schedule,4.7,8.91,APC
Congo red blood test,P2029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.7,,,,,,,fee schedule,4.7,8.91,
Congo red blood test,P2029,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.7,8.91,APC
Congo red blood test,P2029,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.95,,,,,,,fee schedule,4.7,8.91,APC
Congo red blood test,P2029,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.91,,,,,,,fee schedule,4.7,8.91,APC
Hair analysis,P2031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.7,,,,,,,fee schedule,4.7,4.7,
Blood thymol turbidity,P2033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.7,,,,,,,fee schedule,4.7,8.91,
Blood thymol turbidity,P2033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.7,8.91,APC
Blood thymol turbidity,P2033,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.95,,,,,,,fee schedule,4.7,8.91,APC
Blood thymol turbidity,P2033,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.91,,,,,,,fee schedule,4.7,8.91,APC
Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,4.7,,,,,,,fee schedule,4.7,21.67,
Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.42,,,,,,,fee schedule,4.7,21.67,
Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.35,,,,,,,fee schedule,4.7,21.67,
Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.67,,,,,,,fee schedule,4.7,21.67,
Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.84,,,,,,,fee schedule,4.7,21.67,
Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.7,21.67,APC
Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.95,,,,,,,fee schedule,4.7,21.67,APC
Blood mucoprotein,P2038,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8.91,,,,,,,fee schedule,4.7,21.67,APC
Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,16.44,,,,,,,fee schedule,16.44,45.48,
Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.37,,,,,,,fee schedule,16.44,45.48,
Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.93,,,,,,,fee schedule,16.44,45.48,
Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.48,,,,,,,fee schedule,16.44,45.48,
Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.55,,,,,,,fee schedule,16.44,45.48,
Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.44,45.48,APC
Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,16.44,45.48,APC
Screen pap by tech w md supv,P3000,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,16.44,45.48,APC
Screening pap smear by phys,P3001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,20.74,,,,,,,fee schedule,20.74,54.1,
Screening pap smear by phys,P3001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.5,,,,,,,fee schedule,20.74,54.1,
Screening pap smear by phys,P3001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.84,,,,,,,fee schedule,20.74,54.1,
Screening pap smear by phys,P3001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.1,,,,,,,fee schedule,20.74,54.1,
Screening pap smear by phys,P3001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.04,,,,,,,fee schedule,20.74,54.1,
Culture bacterial urine,P7001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,15.84,,,,,,,fee schedule,15.84,60.85,
Culture bacterial urine,P7001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.31,,,,,,,fee schedule,15.84,60.85,
Culture bacterial urine,P7001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.69,,,,,,,fee schedule,15.84,60.85,
Culture bacterial urine,P7001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.85,,,,,,,fee schedule,15.84,60.85,
Culture bacterial urine,P7001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.91,,,,,,,fee schedule,15.84,60.85,
Whole blood for transfusion,P9010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,37.54,,,,,,,fee schedule,37.54,341.71,
Whole blood for transfusion,P9010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190.35,,,,,,,fee schedule,37.54,341.71,
Whole blood for transfusion,P9010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,152.47,,,,,,,fee schedule,37.54,341.71,
Whole blood for transfusion,P9010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,267.44,,,,,,,fee schedule,37.54,341.71,
Whole blood for transfusion,P9010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,232.56,,,,,,,fee schedule,37.54,341.71,
Whole blood for transfusion,P9010,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,199.33,,,,,,,fee schedule,37.54,341.71,APC
Whole blood for transfusion,P9010,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,189.84,,,,,,,fee schedule,37.54,341.71,APC
Whole blood for transfusion,P9010,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,341.71,,,,,,,fee schedule,37.54,341.71,APC
Blood split unit,P9011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,53.67,,,,,,,fee schedule,53.67,280.51,
Blood split unit,P9011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.56,,,,,,,fee schedule,53.67,280.51,
Blood split unit,P9011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.41,,,,,,,fee schedule,53.67,280.51,
Blood split unit,P9011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227,,,,,,,fee schedule,53.67,280.51,
Blood split unit,P9011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,197.39,,,,,,,fee schedule,53.67,280.51,
Blood split unit,P9011,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,163.63,,,,,,,fee schedule,53.67,280.51,APC
Blood split unit,P9011,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,155.84,,,,,,,fee schedule,53.67,280.51,APC
Blood split unit,P9011,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,280.51,,,,,,,fee schedule,53.67,280.51,APC
Cryoprecipitate each unit,P9012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,7.68,,,,,,,fee schedule,7.68,141.91,
Cryoprecipitate each unit,P9012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101,,,,,,,fee schedule,7.68,141.91,
Cryoprecipitate each unit,P9012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,80.9,,,,,,,fee schedule,7.68,141.91,
Cryoprecipitate each unit,P9012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,141.91,,,,,,,fee schedule,7.68,141.91,
Cryoprecipitate each unit,P9012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.4,,,,,,,fee schedule,7.68,141.91,
Cryoprecipitate each unit,P9012,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.55,,,,,,,fee schedule,7.68,141.91,APC
Cryoprecipitate each unit,P9012,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,71.95,,,,,,,fee schedule,7.68,141.91,APC
Cryoprecipitate each unit,P9012,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,129.51,,,,,,,fee schedule,7.68,141.91,APC
Rbc leukocytes reduced,P9016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,240.18,,,,,,,fee schedule,184.91,613.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,436.56,,,,,,,fee schedule,184.91,613.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,349.68,,,,,,,fee schedule,184.91,613.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,613.38,,,,,,,fee schedule,184.91,613.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,533.37,,,,,,,fee schedule,184.91,613.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.16,,,,,,,fee schedule,184.91,613.38,APC
Rbc leukocytes reduced,P9016,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,184.91,,,,,,,fee schedule,184.91,613.38,APC
Rbc leukocytes reduced,P9016,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,332.84,,,,,,,fee schedule,184.91,613.38,APC
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,64.95,,,,,,,fee schedule,64.95,154.76,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.35,,,,,,,fee schedule,64.95,154.76,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,77.17,,,,,,,fee schedule,64.95,154.76,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,135.37,,,,,,,fee schedule,64.95,154.76,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.71,,,,,,,fee schedule,64.95,154.76,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.28,,,,,,,fee schedule,64.95,154.76,APC
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,85.98,,,,,,,fee schedule,64.95,154.76,APC
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,154.76,,,,,,,fee schedule,64.95,154.76,APC
"Platelets, each unit",P9019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,157.95,,,,,,,fee schedule,53.17,165.93,
"Platelets, each unit",P9019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.1,,,,,,,fee schedule,53.17,165.93,
"Platelets, each unit",P9019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.6,,,,,,,fee schedule,53.17,165.93,
"Platelets, each unit",P9019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,165.93,,,,,,,fee schedule,53.17,165.93,
"Platelets, each unit",P9019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.29,,,,,,,fee schedule,53.17,165.93,
"Platelets, each unit",P9019,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.83,,,,,,,fee schedule,53.17,165.93,APC
"Platelets, each unit",P9019,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.17,,,,,,,fee schedule,53.17,165.93,APC
"Platelets, each unit",P9019,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95.71,,,,,,,fee schedule,53.17,165.93,APC
Plaelet rich plasma unit,P9020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,233.85,,,,,,,fee schedule,129.1,1007.62,
Plaelet rich plasma unit,P9020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.18,,,,,,,fee schedule,129.1,1007.62,
Plaelet rich plasma unit,P9020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.1,,,,,,,fee schedule,129.1,1007.62,
Plaelet rich plasma unit,P9020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,226.46,,,,,,,fee schedule,129.1,1007.62,
Plaelet rich plasma unit,P9020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.92,,,,,,,fee schedule,129.1,1007.62,
Plaelet rich plasma unit,P9020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,587.78,,,,,,,fee schedule,129.1,1007.62,APC
Plaelet rich plasma unit,P9020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,559.79,,,,,,,fee schedule,129.1,1007.62,APC
Plaelet rich plasma unit,P9020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1007.62,,,,,,,fee schedule,129.1,1007.62,APC
Red blood cells unit,P9021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,73.58,,,,,,,fee schedule,73.58,271.03,
Red blood cells unit,P9021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,174.26,,,,,,,fee schedule,73.58,271.03,
Red blood cells unit,P9021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.58,,,,,,,fee schedule,73.58,271.03,
Red blood cells unit,P9021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.84,,,,,,,fee schedule,73.58,271.03,
Red blood cells unit,P9021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.9,,,,,,,fee schedule,73.58,271.03,
Red blood cells unit,P9021,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,158.1,,,,,,,fee schedule,73.58,271.03,APC
Red blood cells unit,P9021,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150.57,,,,,,,fee schedule,73.58,271.03,APC
Red blood cells unit,P9021,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,271.03,,,,,,,fee schedule,73.58,271.03,APC
Washed red blood cells unit,P9022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,165.73,,,,,,,fee schedule,165.73,700.3,
Washed red blood cells unit,P9022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,498.43,,,,,,,fee schedule,165.73,700.3,
Washed red blood cells unit,P9022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,399.23,,,,,,,fee schedule,165.73,700.3,
Washed red blood cells unit,P9022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,700.3,,,,,,,fee schedule,165.73,700.3,
Washed red blood cells unit,P9022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,608.96,,,,,,,fee schedule,165.73,700.3,
Washed red blood cells unit,P9022,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.01,,,,,,,fee schedule,165.73,700.3,APC
Washed red blood cells unit,P9022,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,368.58,,,,,,,fee schedule,165.73,700.3,APC
Washed red blood cells unit,P9022,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,663.44,,,,,,,fee schedule,165.73,700.3,APC
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,0.82,,,,,,,fee schedule,0.82,100.73,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.28,,,,,,,fee schedule,0.82,100.73,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.82,,,,,,,fee schedule,0.82,100.73,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.2,,,,,,,fee schedule,0.82,100.73,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.78,,,,,,,fee schedule,0.82,100.73,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.76,,,,,,,fee schedule,0.82,100.73,APC
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55.96,,,,,,,fee schedule,0.82,100.73,APC
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,100.73,,,,,,,fee schedule,0.82,100.73,APC
Platelets leukocytes reduced,P9031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,140.22,,,,,,,fee schedule,136.58,259.67,
Platelets leukocytes reduced,P9031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,170.52,,,,,,,fee schedule,136.58,259.67,
Platelets leukocytes reduced,P9031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,136.58,,,,,,,fee schedule,136.58,259.67,
Platelets leukocytes reduced,P9031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,239.58,,,,,,,fee schedule,136.58,259.67,
Platelets leukocytes reduced,P9031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,208.33,,,,,,,fee schedule,136.58,259.67,
Platelets leukocytes reduced,P9031,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,151.47,,,,,,,fee schedule,136.58,259.67,APC
Platelets leukocytes reduced,P9031,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,144.26,,,,,,,fee schedule,136.58,259.67,APC
Platelets leukocytes reduced,P9031,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,259.67,,,,,,,fee schedule,136.58,259.67,APC
"Platelets, irradiated",P9032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,46.62,,,,,,,fee schedule,46.62,707.35,
"Platelets, irradiated",P9032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,204.92,,,,,,,fee schedule,46.62,707.35,
"Platelets, irradiated",P9032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.14,,,,,,,fee schedule,46.62,707.35,
"Platelets, irradiated",P9032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,287.91,,,,,,,fee schedule,46.62,707.35,
"Platelets, irradiated",P9032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,250.36,,,,,,,fee schedule,46.62,707.35,
"Platelets, irradiated",P9032,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,412.62,,,,,,,fee schedule,46.62,707.35,APC
"Platelets, irradiated",P9032,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,392.97,,,,,,,fee schedule,46.62,707.35,APC
"Platelets, irradiated",P9032,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,707.35,,,,,,,fee schedule,46.62,707.35,APC
Platelets leukoreduced irrad,P9033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,343.58,,,,,,,fee schedule,147.49,343.58,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,184.14,,,,,,,fee schedule,147.49,343.58,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.49,,,,,,,fee schedule,147.49,343.58,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,258.72,,,,,,,fee schedule,147.49,343.58,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,224.97,,,,,,,fee schedule,147.49,343.58,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,199.07,,,,,,,fee schedule,147.49,343.58,APC
Platelets leukoreduced irrad,P9033,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,189.59,,,,,,,fee schedule,147.49,343.58,APC
Platelets leukoreduced irrad,P9033,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,341.26,,,,,,,fee schedule,147.49,343.58,APC
"Platelets, pheresis",P9034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,455.42,,,,,,,fee schedule,308.96,708.73,
"Platelets, pheresis",P9034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,504.43,,,,,,,fee schedule,308.96,708.73,
"Platelets, pheresis",P9034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,404.04,,,,,,,fee schedule,308.96,708.73,
"Platelets, pheresis",P9034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,708.73,,,,,,,fee schedule,308.96,708.73,
"Platelets, pheresis",P9034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,616.29,,,,,,,fee schedule,308.96,708.73,
"Platelets, pheresis",P9034,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,324.41,,,,,,,fee schedule,308.96,708.73,APC
"Platelets, pheresis",P9034,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,308.96,,,,,,,fee schedule,308.96,708.73,APC
"Platelets, pheresis",P9034,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,556.13,,,,,,,fee schedule,308.96,708.73,APC
Platelet pheres leukoreduced,P9035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,553.76,,,,,,,fee schedule,511.59,1455.16,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1035.7,,,,,,,fee schedule,511.59,1455.16,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,829.57,,,,,,,fee schedule,511.59,1455.16,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1455.16,,,,,,,fee schedule,511.59,1455.16,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1265.36,,,,,,,fee schedule,511.59,1455.16,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,537.17,,,,,,,fee schedule,511.59,1455.16,APC
Platelet pheres leukoreduced,P9035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,511.59,,,,,,,fee schedule,511.59,1455.16,APC
Platelet pheres leukoreduced,P9035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,920.86,,,,,,,fee schedule,511.59,1455.16,APC
Platelet pheresis irradiated,P9036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,468.03,,,,,,,fee schedule,468.03,1708.43,
Platelet pheresis irradiated,P9036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,681.32,,,,,,,fee schedule,468.03,1708.43,
Platelet pheresis irradiated,P9036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,545.72,,,,,,,fee schedule,468.03,1708.43,
Platelet pheresis irradiated,P9036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,957.26,,,,,,,fee schedule,468.03,1708.43,
Platelet pheresis irradiated,P9036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,832.4,,,,,,,fee schedule,468.03,1708.43,
Platelet pheresis irradiated,P9036,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,996.59,,,,,,,fee schedule,468.03,1708.43,APC
Platelet pheresis irradiated,P9036,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,949.13,,,,,,,fee schedule,468.03,1708.43,APC
Platelet pheresis irradiated,P9036,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1708.43,,,,,,,fee schedule,468.03,1708.43,APC
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,808.34,,,,,,,fee schedule,680.61,1576.4,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1121.98,,,,,,,fee schedule,680.61,1576.4,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,898.68,,,,,,,fee schedule,680.61,1576.4,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1576.4,,,,,,,fee schedule,680.61,1576.4,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1370.78,,,,,,,fee schedule,680.61,1576.4,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,714.64,,,,,,,fee schedule,680.61,1576.4,APC
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,680.61,,,,,,,fee schedule,680.61,1576.4,APC
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1225.1,,,,,,,fee schedule,680.61,1576.4,APC
RBC irradiated,P9038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.03,,,,,,,fee schedule,13.03,376.56,
RBC irradiated,P9038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,268.01,,,,,,,fee schedule,13.03,376.56,
RBC irradiated,P9038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,214.67,,,,,,,fee schedule,13.03,376.56,
RBC irradiated,P9038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,376.56,,,,,,,fee schedule,13.03,376.56,
RBC irradiated,P9038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,327.44,,,,,,,fee schedule,13.03,376.56,
RBC irradiated,P9038,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,152.48,,,,,,,fee schedule,13.03,376.56,APC
RBC irradiated,P9038,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,145.22,,,,,,,fee schedule,13.03,376.56,APC
RBC irradiated,P9038,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,261.4,,,,,,,fee schedule,13.03,376.56,APC
RBC deglycerolized,P9039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,198.97,,,,,,,fee schedule,198.97,659.67,
RBC deglycerolized,P9039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,469.52,,,,,,,fee schedule,198.97,659.67,
RBC deglycerolized,P9039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,376.07,,,,,,,fee schedule,198.97,659.67,
RBC deglycerolized,P9039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,659.67,,,,,,,fee schedule,198.97,659.67,
RBC deglycerolized,P9039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,573.63,,,,,,,fee schedule,198.97,659.67,
RBC deglycerolized,P9039,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,328.65,,,,,,,fee schedule,198.97,659.67,APC
RBC deglycerolized,P9039,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,313,,,,,,,fee schedule,198.97,659.67,APC
RBC deglycerolized,P9039,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,563.4,,,,,,,fee schedule,198.97,659.67,APC
RBC leukoreduced irradiated,P9040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,270.3,,,,,,,fee schedule,265.41,611.39,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,435.15,,,,,,,fee schedule,265.41,611.39,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,348.54,,,,,,,fee schedule,265.41,611.39,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,611.39,,,,,,,fee schedule,265.41,611.39,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,531.64,,,,,,,fee schedule,265.41,611.39,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,278.68,,,,,,,fee schedule,265.41,611.39,APC
RBC leukoreduced irradiated,P9040,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,265.41,,,,,,,fee schedule,265.41,611.39,APC
RBC leukoreduced irradiated,P9040,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,477.74,,,,,,,fee schedule,265.41,611.39,APC
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.93,,,,,,,fee schedule,10.62,38.47,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.45,,,,,,,fee schedule,10.62,38.47,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33.45,,,,,,,fee schedule,10.62,38.47,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.45,,,,,,,fee schedule,10.62,38.47,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38.47,,,,,,,fee schedule,10.62,38.47,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.15,,,,,,,fee schedule,10.62,38.47,APC
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.62,,,,,,,fee schedule,10.62,38.47,APC
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.11,,,,,,,fee schedule,10.62,38.47,APC
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.62,,,,,,,fee schedule,8.11,84.8,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.36,,,,,,,fee schedule,8.11,84.8,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.34,,,,,,,fee schedule,8.11,84.8,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.8,,,,,,,fee schedule,8.11,84.8,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.74,,,,,,,fee schedule,8.11,84.8,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.52,,,,,,,fee schedule,8.11,84.8,APC
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.11,,,,,,,fee schedule,8.11,84.8,APC
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.6,,,,,,,fee schedule,8.11,84.8,APC
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,64.05,,,,,,,fee schedule,62.06,237.69,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77.48,,,,,,,fee schedule,62.06,237.69,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.06,,,,,,,fee schedule,62.06,237.69,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,108.86,,,,,,,fee schedule,62.06,237.69,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,94.66,,,,,,,fee schedule,62.06,237.69,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.65,,,,,,,fee schedule,62.06,237.69,APC
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.05,,,,,,,fee schedule,62.06,237.69,APC
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,237.69,,,,,,,fee schedule,62.06,237.69,APC
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,54.67,,,,,,,fee schedule,47.49,95.54,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.49,,,,,,,fee schedule,47.49,95.54,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.49,,,,,,,fee schedule,47.49,95.54,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.49,,,,,,,fee schedule,47.49,95.54,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.61,,,,,,,fee schedule,47.49,95.54,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.73,,,,,,,fee schedule,47.49,95.54,APC
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.08,,,,,,,fee schedule,47.49,95.54,APC
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95.54,,,,,,,fee schedule,47.49,95.54,APC
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,21.87,,,,,,,fee schedule,21.33,38.39,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.21,,,,,,,fee schedule,21.33,38.39,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.21,,,,,,,fee schedule,21.33,38.39,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.21,,,,,,,fee schedule,21.33,38.39,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.44,,,,,,,fee schedule,21.33,38.39,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.4,,,,,,,fee schedule,21.33,38.39,APC
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.33,,,,,,,fee schedule,21.33,38.39,APC
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38.39,,,,,,,fee schedule,21.33,38.39,APC
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,54.67,,,,,,,fee schedule,45.9,95.98,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.9,,,,,,,fee schedule,45.9,95.98,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.9,,,,,,,fee schedule,45.9,95.98,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.9,,,,,,,fee schedule,45.9,95.98,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.79,,,,,,,fee schedule,45.9,95.98,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.99,,,,,,,fee schedule,45.9,95.98,APC
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.32,,,,,,,fee schedule,45.9,95.98,APC
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95.98,,,,,,,fee schedule,45.9,95.98,APC
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,50.78,,,,,,,fee schedule,35.32,199.28,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.84,,,,,,,fee schedule,35.32,199.28,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.61,,,,,,,fee schedule,35.32,199.28,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,199.28,,,,,,,fee schedule,35.32,199.28,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,173.29,,,,,,,fee schedule,35.32,199.28,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.09,,,,,,,fee schedule,35.32,199.28,APC
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.32,,,,,,,fee schedule,35.32,199.28,APC
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63.58,,,,,,,fee schedule,35.32,199.28,APC
"Granulocytes, pheresis unit",P9050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,779.12,,,,,,,fee schedule,779.12,779.12,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,202.54,,,,,,,fee schedule,151.58,355.12,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,252.75,,,,,,,fee schedule,151.58,355.12,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,202.45,,,,,,,fee schedule,151.58,355.12,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,355.12,,,,,,,fee schedule,151.58,355.12,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,308.8,,,,,,,fee schedule,151.58,355.12,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,159.16,,,,,,,fee schedule,151.58,355.12,APC
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,151.58,,,,,,,fee schedule,151.58,355.12,APC
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,272.84,,,,,,,fee schedule,151.58,355.12,APC
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,493.94,,,,,,,fee schedule,493.94,1274.51,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,903.56,,,,,,,fee schedule,493.94,1274.51,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,723.73,,,,,,,fee schedule,493.94,1274.51,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1269.51,,,,,,,fee schedule,493.94,1274.51,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1103.92,,,,,,,fee schedule,493.94,1274.51,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,743.46,,,,,,,fee schedule,493.94,1274.51,APC
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,708.06,,,,,,,fee schedule,493.94,1274.51,APC
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1274.51,,,,,,,fee schedule,493.94,1274.51,APC
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,549.68,,,,,,,fee schedule,503.45,1064.41,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,757.58,,,,,,,fee schedule,503.45,1064.41,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,606.8,,,,,,,fee schedule,503.45,1064.41,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1064.41,,,,,,,fee schedule,503.45,1064.41,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,925.57,,,,,,,fee schedule,503.45,1064.41,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,528.62,,,,,,,fee schedule,503.45,1064.41,APC
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,503.45,,,,,,,fee schedule,503.45,1064.41,APC
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,906.21,,,,,,,fee schedule,503.45,1064.41,APC
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,137.57,,,,,,,fee schedule,137.57,477.34,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,337.32,,,,,,,fee schedule,137.57,477.34,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,270.19,,,,,,,fee schedule,137.57,477.34,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,473.94,,,,,,,fee schedule,137.57,477.34,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,412.12,,,,,,,fee schedule,137.57,477.34,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,278.45,,,,,,,fee schedule,137.57,477.34,APC
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,265.19,,,,,,,fee schedule,137.57,477.34,APC
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,477.34,,,,,,,fee schedule,137.57,477.34,APC
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,183.7,,,,,,,fee schedule,183.7,725.79,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,516.57,,,,,,,fee schedule,183.7,725.79,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,413.76,,,,,,,fee schedule,183.7,725.79,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,725.79,,,,,,,fee schedule,183.7,725.79,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,631.12,,,,,,,fee schedule,183.7,725.79,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,263.01,,,,,,,fee schedule,183.7,725.79,APC
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,250.49,,,,,,,fee schedule,183.7,725.79,APC
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,450.88,,,,,,,fee schedule,183.7,725.79,APC
"Blood, l/r, irradiated",P9056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,117.39,,,,,,,fee schedule,84.55,213.91,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,152.25,,,,,,,fee schedule,84.55,213.91,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,121.95,,,,,,,fee schedule,84.55,213.91,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,213.91,,,,,,,fee schedule,84.55,213.91,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,186.01,,,,,,,fee schedule,84.55,213.91,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,88.78,,,,,,,fee schedule,84.55,213.91,APC
"Blood, l/r, irradiated",P9056,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,84.55,,,,,,,fee schedule,84.55,213.91,APC
"Blood, l/r, irradiated",P9056,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,152.19,,,,,,,fee schedule,84.55,213.91,APC
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,542.08,,,,,,,fee schedule,203.41,760.84,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,253.96,,,,,,,fee schedule,203.41,760.84,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.41,,,,,,,fee schedule,203.41,760.84,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,356.81,,,,,,,fee schedule,203.41,760.84,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,310.27,,,,,,,fee schedule,203.41,760.84,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,443.82,,,,,,,fee schedule,203.41,760.84,APC
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,422.69,,,,,,,fee schedule,203.41,760.84,APC
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,760.84,,,,,,,fee schedule,203.41,760.84,APC
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,71.9,,,,,,,fee schedule,71.9,448.92,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,306.13,,,,,,,fee schedule,71.9,448.92,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,245.2,,,,,,,fee schedule,71.9,448.92,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,430.11,,,,,,,fee schedule,71.9,448.92,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,374.01,,,,,,,fee schedule,71.9,448.92,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.87,,,,,,,fee schedule,71.9,448.92,APC
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,249.4,,,,,,,fee schedule,71.9,448.92,APC
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,448.92,,,,,,,fee schedule,71.9,448.92,APC
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,55.84,,,,,,,fee schedule,55.84,132.79,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.58,,,,,,,fee schedule,55.84,132.79,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.56,,,,,,,fee schedule,55.84,132.79,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.27,,,,,,,fee schedule,55.84,132.79,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.67,,,,,,,fee schedule,55.84,132.79,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.46,,,,,,,fee schedule,55.84,132.79,APC
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.77,,,,,,,fee schedule,55.84,132.79,APC
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.79,,,,,,,fee schedule,55.84,132.79,APC
Fr frz plasma donor retested,P9060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,13.68,,,,,,,fee schedule,13.68,115.52,
Fr frz plasma donor retested,P9060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.22,,,,,,,fee schedule,13.68,115.52,
Fr frz plasma donor retested,P9060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.86,,,,,,,fee schedule,13.68,115.52,
Fr frz plasma donor retested,P9060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,115.52,,,,,,,fee schedule,13.68,115.52,
Fr frz plasma donor retested,P9060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,100.45,,,,,,,fee schedule,13.68,115.52,
Fr frz plasma donor retested,P9060,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.91,,,,,,,fee schedule,13.68,115.52,APC
Fr frz plasma donor retested,P9060,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53.25,,,,,,,fee schedule,13.68,115.52,APC
Fr frz plasma donor retested,P9060,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95.85,,,,,,,fee schedule,13.68,115.52,APC
Pathogen reduced plasma pool,P9070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,700,,,,,,,fee schedule,55.78,700,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.58,,,,,,,fee schedule,55.78,700,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.56,,,,,,,fee schedule,55.78,700,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.27,,,,,,,fee schedule,55.78,700,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.67,,,,,,,fee schedule,55.78,700,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.57,,,,,,,fee schedule,55.78,700,APC
Pathogen reduced plasma pool,P9070,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55.78,,,,,,,fee schedule,55.78,700,APC
Pathogen reduced plasma pool,P9070,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,100.4,,,,,,,fee schedule,55.78,700,APC
Pathogen reduced plasma sing,P9071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.27,,,,,,,fee schedule,72.31,530.06,
Pathogen reduced plasma sing,P9071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.31,,,,,,,fee schedule,72.31,530.06,
Pathogen reduced plasma sing,P9071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,126.83,,,,,,,fee schedule,72.31,530.06,
Pathogen reduced plasma sing,P9071,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.29,,,,,,,fee schedule,72.31,530.06,
Pathogen reduced plasma sing,P9071,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,309.2,,,,,,,fee schedule,72.31,530.06,APC
Pathogen reduced plasma sing,P9071,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,294.48,,,,,,,fee schedule,72.31,530.06,APC
Pathogen reduced plasma sing,P9071,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,530.06,,,,,,,fee schedule,72.31,530.06,APC
"Platelets, pathogen reduced",P9073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,836.47,,,,,,,fee schedule,607.43,1961.13,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1395.81,,,,,,,fee schedule,607.43,1961.13,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1118.01,,,,,,,fee schedule,607.43,1961.13,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1961.13,,,,,,,fee schedule,607.43,1961.13,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1705.33,,,,,,,fee schedule,607.43,1961.13,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,637.8,,,,,,,fee schedule,607.43,1961.13,APC
"Platelets, pathogen reduced",P9073,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,607.43,,,,,,,fee schedule,607.43,1961.13,APC
"Platelets, pathogen reduced",P9073,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1093.37,,,,,,,fee schedule,607.43,1961.13,APC
Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,50.38,,,,,,,fee schedule,45.64,105.8,
Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.98,,,,,,,fee schedule,45.64,105.8,
Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.64,,,,,,,fee schedule,45.64,105.8,
Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.05,,,,,,,fee schedule,45.64,105.8,
Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.61,,,,,,,fee schedule,45.64,105.8,
Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.72,,,,,,,fee schedule,45.64,105.8,APC
Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.78,,,,,,,fee schedule,45.64,105.8,APC
Pathogen test for platelets,P9100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.8,,,,,,,fee schedule,45.64,105.8,APC
One-way allow prorated miles,P9603,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,1.05,,,,,,,fee schedule,1.05,1.05,
One-way allow prorated trip,P9604,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,10.55,,,,,,,fee schedule,6.42,11.27,
One-way allow prorated trip,P9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.02,,,,,,,fee schedule,6.42,11.27,
One-way allow prorated trip,P9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.42,,,,,,,fee schedule,6.42,11.27,
One-way allow prorated trip,P9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,11.27,,,,,,,fee schedule,6.42,11.27,
One-way allow prorated trip,P9604,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.8,,,,,,,fee schedule,6.42,11.27,
Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.14,,,,,,,fee schedule,3.87,16.81,
Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.84,,,,,,,fee schedule,3.87,16.81,
Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.87,,,,,,,fee schedule,3.87,16.81,
Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.8,,,,,,,fee schedule,3.87,16.81,
Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.91,,,,,,,fee schedule,3.87,16.81,
Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.81,,,,,,,fee schedule,3.87,16.81,APC
Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.34,,,,,,,fee schedule,3.87,16.81,APC
Catheterize for urine spec,P9612,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16.81,,,,,,,fee schedule,3.87,16.81,APC
Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Existing Business All Commercial Plans,8.14,,,,,,,fee schedule,5.37,9.42,
Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.7,,,,,,,fee schedule,5.37,9.42,
Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.37,,,,,,,fee schedule,5.37,9.42,
Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.42,,,,,,,fee schedule,5.37,9.42,
Urine specimen collect mult,P9615,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.19,,,,,,,fee schedule,5.37,9.42,
Cardiokymography,Q0035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,66.99,
Cardiokymography,Q0035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,66.99,
Cardiokymography,Q0035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,66.99,
Cardiokymography,Q0035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,66.99,
Cardiokymography,Q0035,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.08,,,,,,,fee schedule,21.2,66.99,APC
Cardiokymography,Q0035,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.22,,,,,,,fee schedule,21.2,66.99,APC
Cardiokymography,Q0035,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66.99,,,,,,,fee schedule,21.2,66.99,APC
Chemotherapy by infusion,Q0084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,227.74,,,,,,,fee schedule,182.41,319.98,
Chemotherapy by infusion,Q0084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,182.41,,,,,,,fee schedule,182.41,319.98,
Chemotherapy by infusion,Q0084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,319.98,,,,,,,fee schedule,182.41,319.98,
Chemotherapy by infusion,Q0084,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,278.24,,,,,,,fee schedule,182.41,319.98,
Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.44,,,,,,,fee schedule,12.36,51.88,
Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.36,,,,,,,fee schedule,12.36,51.88,
Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.69,,,,,,,fee schedule,12.36,51.88,
Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.86,,,,,,,fee schedule,12.36,51.88,
Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,12.36,51.88,APC
Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28.82,,,,,,,fee schedule,12.36,51.88,APC
Obtaining screen pap smear,Q0091,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51.88,,,,,,,fee schedule,12.36,51.88,APC
Set up port xray equipment,Q0092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.93,,,,,,,fee schedule,45.6,79.99,
Set up port xray equipment,Q0092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.6,,,,,,,fee schedule,45.6,79.99,
Set up port xray equipment,Q0092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.99,,,,,,,fee schedule,45.6,79.99,
Set up port xray equipment,Q0092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.56,,,,,,,fee schedule,45.6,79.99,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.09,,,,,,,fee schedule,10.48,33.37,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.48,,,,,,,fee schedule,10.48,33.37,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.39,,,,,,,fee schedule,10.48,33.37,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.99,,,,,,,fee schedule,10.48,33.37,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,10.48,33.37,APC
Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.54,,,,,,,fee schedule,10.48,33.37,APC
Wet mounts/ w preparations,Q0111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.37,,,,,,,fee schedule,10.48,33.37,APC
Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.09,,,,,,,fee schedule,5.83,18.39,
Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.48,,,,,,,fee schedule,5.83,18.39,
Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.39,,,,,,,fee schedule,5.83,18.39,
Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.99,,,,,,,fee schedule,5.83,18.39,
Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.12,,,,,,,fee schedule,5.83,18.39,APC
Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.83,,,,,,,fee schedule,5.83,18.39,APC
Potassium hydroxide preps,Q0112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10.49,,,,,,,fee schedule,5.83,18.39,APC
Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.57,,,,,,,fee schedule,4.27,23.29,
Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.28,,,,,,,fee schedule,4.27,23.29,
Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.29,,,,,,,fee schedule,4.27,23.29,
Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.25,,,,,,,fee schedule,4.27,23.29,
Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,4.27,23.29,APC
Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.27,,,,,,,fee schedule,4.27,23.29,APC
Pinworm examinations,Q0113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.69,,,,,,,fee schedule,4.27,23.29,APC
Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.61,,,,,,,fee schedule,9.74,37.39,
Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.31,,,,,,,fee schedule,9.74,37.39,
Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.39,,,,,,,fee schedule,9.74,37.39,
Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.51,,,,,,,fee schedule,9.74,37.39,
Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.23,,,,,,,fee schedule,9.74,37.39,APC
Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9.74,,,,,,,fee schedule,9.74,37.39,APC
Fern test,Q0114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17.53,,,,,,,fee schedule,9.74,37.39,APC
Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.33,,,,,,,fee schedule,24.3,45,
Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.3,,,,,,,fee schedule,24.3,45,
Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.62,,,,,,,fee schedule,24.3,45,
Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.06,,,,,,,fee schedule,24.3,45,
Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.25,,,,,,,fee schedule,24.3,45,APC
Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25,,,,,,,fee schedule,24.3,45,APC
Post-coital mucous exam,Q0115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45,,,,,,,fee schedule,24.3,45,APC
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.32,,,,,,,fee schedule,0.32,0.67,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.32,,,,,,,fee schedule,0.32,0.67,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.32,,,,,,,fee schedule,0.32,0.67,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.37,,,,,,,fee schedule,0.32,0.67,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.39,,,,,,,fee schedule,0.32,0.67,APC
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.37,,,,,,,fee schedule,0.32,0.67,APC
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.67,,,,,,,fee schedule,0.32,0.67,APC
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.32,,,,,,,fee schedule,0.32,0.67,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.32,,,,,,,fee schedule,0.32,0.67,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.32,,,,,,,fee schedule,0.32,0.67,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.37,,,,,,,fee schedule,0.32,0.67,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.39,,,,,,,fee schedule,0.32,0.67,APC
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.37,,,,,,,fee schedule,0.32,0.67,APC
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.67,,,,,,,fee schedule,0.32,0.67,APC
"Azithromycin dihydrate, oral",Q0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.91,,,,,,,fee schedule,5.53,9.71,
"Azithromycin dihydrate, oral",Q0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.53,,,,,,,fee schedule,5.53,9.71,
"Azithromycin dihydrate, oral",Q0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.71,,,,,,,fee schedule,5.53,9.71,
"Azithromycin dihydrate, oral",Q0144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.44,,,,,,,fee schedule,5.53,9.71,
Dronabinol (syndros) 0.1 mg,Q0155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.31,,,,,,,fee schedule,3.31,3.81,
Dronabinol (syndros) 0.1 mg,Q0155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.31,,,,,,,fee schedule,3.31,3.81,
Dronabinol (syndros) 0.1 mg,Q0155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.31,,,,,,,fee schedule,3.31,3.81,
Dronabinol (syndros) 0.1 mg,Q0155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.81,,,,,,,fee schedule,3.31,3.81,
Chlorpromazine hcl 5mg oral,Q0161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.33,,,,,,,fee schedule,0.33,0.38,
Chlorpromazine hcl 5mg oral,Q0161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.33,,,,,,,fee schedule,0.33,0.38,
Chlorpromazine hcl 5mg oral,Q0161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.33,,,,,,,fee schedule,0.33,0.38,
Chlorpromazine hcl 5mg oral,Q0161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.38,,,,,,,fee schedule,0.33,0.38,
Ondansetron oral,Q0162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Ondansetron oral,Q0162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Ondansetron oral,Q0162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.01,,,,,,,fee schedule,0.01,0.01,
Ondansetron oral,Q0162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.01,,,,,,,fee schedule,0.01,0.01,
Diphenhydramine HCl 50mg,Q0163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.56,,,,,,,fee schedule,0.45,0.78,
Diphenhydramine HCl 50mg,Q0163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.45,,,,,,,fee schedule,0.45,0.78,
Diphenhydramine HCl 50mg,Q0163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.78,,,,,,,fee schedule,0.45,0.78,
Diphenhydramine HCl 50mg,Q0163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.68,,,,,,,fee schedule,0.45,0.78,
Prochlorperazine maleate 5mg,Q0164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.08,,,,,,,fee schedule,0.07,0.12,
Prochlorperazine maleate 5mg,Q0164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.07,,,,,,,fee schedule,0.07,0.12,
Prochlorperazine maleate 5mg,Q0164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.12,,,,,,,fee schedule,0.07,0.12,
Prochlorperazine maleate 5mg,Q0164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.1,,,,,,,fee schedule,0.07,0.12,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.39,,,,,,,fee schedule,5.92,10.38,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.92,,,,,,,fee schedule,5.92,10.38,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.38,,,,,,,fee schedule,5.92,10.38,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.03,,,,,,,fee schedule,5.92,10.38,
Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.96,,,,,,,fee schedule,7.18,12.59,
Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.18,,,,,,,fee schedule,7.18,12.59,
Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.59,,,,,,,fee schedule,7.18,12.59,
Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.95,,,,,,,fee schedule,7.18,12.59,
Promethazine HCl 12.5mg oral,Q0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.06,,,,,,,fee schedule,0.05,0.08,
Promethazine HCl 12.5mg oral,Q0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.05,,,,,,,fee schedule,0.05,0.08,
Promethazine HCl 12.5mg oral,Q0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.08,,,,,,,fee schedule,0.05,0.08,
Promethazine HCl 12.5mg oral,Q0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.07,,,,,,,fee schedule,0.05,0.08,
Trimethobenzamide HCl 250mg,Q0173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.28,2.25,
Trimethobenzamide HCl 250mg,Q0173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.28,,,,,,,fee schedule,1.28,2.25,
Trimethobenzamide HCl 250mg,Q0173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.25,,,,,,,fee schedule,1.28,2.25,
Trimethobenzamide HCl 250mg,Q0173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.96,,,,,,,fee schedule,1.28,2.25,
Thiethylperazine maleate10mg,Q0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.6,,,,,,,fee schedule,1.28,2.25,
Thiethylperazine maleate10mg,Q0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.28,,,,,,,fee schedule,1.28,2.25,
Thiethylperazine maleate10mg,Q0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.25,,,,,,,fee schedule,1.28,2.25,
Thiethylperazine maleate10mg,Q0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.96,,,,,,,fee schedule,1.28,2.25,
Perphenazine 4mg oral,Q0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,5.34,,,,,,,fee schedule,4.27,7.5,
Perphenazine 4mg oral,Q0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.27,,,,,,,fee schedule,4.27,7.5,
Perphenazine 4mg oral,Q0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.5,,,,,,,fee schedule,4.27,7.5,
Perphenazine 4mg oral,Q0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.52,,,,,,,fee schedule,4.27,7.5,
Hydroxyzine pamoate 25mg,Q0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.63,,,,,,,fee schedule,0.5,0.89,
Hydroxyzine pamoate 25mg,Q0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.5,,,,,,,fee schedule,0.5,0.89,
Hydroxyzine pamoate 25mg,Q0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.89,,,,,,,fee schedule,0.5,0.89,
Hydroxyzine pamoate 25mg,Q0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.77,,,,,,,fee schedule,0.5,0.89,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,256.12,,,,,,,fee schedule,205.14,359.85,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,205.14,,,,,,,fee schedule,205.14,359.85,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,359.85,,,,,,,fee schedule,205.14,359.85,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,312.91,,,,,,,fee schedule,205.14,359.85,
"Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6477.18,,,,,,,fee schedule,6477.18,7448.76,
"Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6477.18,,,,,,,fee schedule,6477.18,7448.76,
"Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6477.18,,,,,,,fee schedule,6477.18,7448.76,
"Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7448.76,,,,,,,fee schedule,6477.18,7448.76,
Tocilizumab for covid-19,Q0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.77,,,,,,,fee schedule,6.77,7.79,
Tocilizumab for covid-19,Q0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.77,,,,,,,fee schedule,6.77,7.79,
Tocilizumab for covid-19,Q0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.77,,,,,,,fee schedule,6.77,7.79,
Tocilizumab for covid-19,Q0249,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,7.79,,,,,,,fee schedule,6.77,7.79,
Pwr module pt cable lvad rpl,Q0477,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1003.12,,,,,,,fee schedule,955.35,1719.63,APC
Pwr module pt cable lvad rpl,Q0477,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,955.35,,,,,,,fee schedule,955.35,1719.63,APC
Pwr module pt cable lvad rpl,Q0477,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1719.63,,,,,,,fee schedule,955.35,1719.63,APC
"Power adapter, combo vad",Q0478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,394.98,,,,,,,fee schedule,226.28,554.94,
"Power adapter, combo vad",Q0478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,316.37,,,,,,,fee schedule,226.28,554.94,
"Power adapter, combo vad",Q0478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,554.94,,,,,,,fee schedule,226.28,554.94,
"Power adapter, combo vad",Q0478,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,482.56,,,,,,,fee schedule,226.28,554.94,
"Power adapter, combo vad",Q0478,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,237.59,,,,,,,fee schedule,226.28,554.94,APC
"Power adapter, combo vad",Q0478,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,226.28,,,,,,,fee schedule,226.28,554.94,APC
"Power adapter, combo vad",Q0478,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,407.3,,,,,,,fee schedule,226.28,554.94,APC
"Power module combo vad, rep",Q0479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17046.41,,,,,,,fee schedule,13653.79,26605.6,
"Power module combo vad, rep",Q0479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13653.79,,,,,,,fee schedule,13653.79,26605.6,
"Power module combo vad, rep",Q0479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23950.36,,,,,,,fee schedule,13653.79,26605.6,
"Power module combo vad, rep",Q0479,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20826.4,,,,,,,fee schedule,13653.79,26605.6,
"Power module combo vad, rep",Q0479,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15519.93,,,,,,,fee schedule,13653.79,26605.6,APC
"Power module combo vad, rep",Q0479,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14780.89,,,,,,,fee schedule,13653.79,26605.6,APC
"Power module combo vad, rep",Q0479,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26605.6,,,,,,,fee schedule,13653.79,26605.6,APC
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,116446.85,,,,,,,fee schedule,110901.76,199623.17,APC
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,110901.76,,,,,,,fee schedule,110901.76,199623.17,APC
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,199623.17,,,,,,,fee schedule,110901.76,199623.17,APC
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14748.54,,,,,,,fee schedule,11813.24,32206.95,
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11813.24,,,,,,,fee schedule,11813.24,32206.95,
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20721.83,,,,,,,fee schedule,11813.24,32206.95,
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18018.98,,,,,,,fee schedule,11813.24,32206.95,
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18787.39,,,,,,,fee schedule,11813.24,32206.95,APC
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17892.75,,,,,,,fee schedule,11813.24,32206.95,APC
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32206.95,,,,,,,fee schedule,11813.24,32206.95,APC
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9783.17,,,,,,,fee schedule,5604.34,13745.44,
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7836.1,,,,,,,fee schedule,5604.34,13745.44,
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13745.44,,,,,,,fee schedule,5604.34,13745.44,
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11952.56,,,,,,,fee schedule,5604.34,13745.44,
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5884.56,,,,,,,fee schedule,5604.34,13745.44,APC
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5604.34,,,,,,,fee schedule,5604.34,13745.44,APC
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10087.81,,,,,,,fee schedule,5604.34,13745.44,APC
"monitor elec vad, rep",Q0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40302.34,,,,,,,fee schedule,23087.32,56625.16,
"monitor elec vad, rep",Q0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32281.27,,,,,,,fee schedule,23087.32,56625.16,
"monitor elec vad, rep",Q0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,56625.16,,,,,,,fee schedule,23087.32,56625.16,
"monitor elec vad, rep",Q0483,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,49239.27,,,,,,,fee schedule,23087.32,56625.16,
"monitor elec vad, rep",Q0483,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24241.69,,,,,,,fee schedule,23087.32,56625.16,APC
"monitor elec vad, rep",Q0483,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23087.32,,,,,,,fee schedule,23087.32,56625.16,APC
"monitor elec vad, rep",Q0483,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41557.18,,,,,,,fee schedule,23087.32,56625.16,APC
monitor elec or comb vad rep,Q0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7826.56,,,,,,,fee schedule,4483.48,10996.39,
monitor elec or comb vad rep,Q0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6268.9,,,,,,,fee schedule,4483.48,10996.39,
monitor elec or comb vad rep,Q0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10996.39,,,,,,,fee schedule,4483.48,10996.39,
monitor elec or comb vad rep,Q0484,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9562.08,,,,,,,fee schedule,4483.48,10996.39,
monitor elec or comb vad rep,Q0484,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4707.65,,,,,,,fee schedule,4483.48,10996.39,APC
monitor elec or comb vad rep,Q0484,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4483.48,,,,,,,fee schedule,4483.48,10996.39,APC
monitor elec or comb vad rep,Q0484,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8070.26,,,,,,,fee schedule,4483.48,10996.39,APC
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,755.68,,,,,,,fee schedule,432.9,1061.74,
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,605.28,,,,,,,fee schedule,432.9,1061.74,
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1061.74,,,,,,,fee schedule,432.9,1061.74,
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,923.25,,,,,,,fee schedule,432.9,1061.74,
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,454.54,,,,,,,fee schedule,432.9,1061.74,APC
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,432.9,,,,,,,fee schedule,432.9,1061.74,APC
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,779.22,,,,,,,fee schedule,432.9,1061.74,APC
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,628.91,,,,,,,fee schedule,360.28,883.63,
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,503.74,,,,,,,fee schedule,360.28,883.63,
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,883.63,,,,,,,fee schedule,360.28,883.63,
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,768.37,,,,,,,fee schedule,360.28,883.63,
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,378.29,,,,,,,fee schedule,360.28,883.63,APC
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,360.28,,,,,,,fee schedule,360.28,883.63,APC
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,648.5,,,,,,,fee schedule,360.28,883.63,APC
"leads any type vad, rep only",Q0487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,733.69,,,,,,,fee schedule,420.31,1030.84,
"leads any type vad, rep only",Q0487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,587.67,,,,,,,fee schedule,420.31,1030.84,
"leads any type vad, rep only",Q0487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1030.84,,,,,,,fee schedule,420.31,1030.84,
"leads any type vad, rep only",Q0487,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,896.38,,,,,,,fee schedule,420.31,1030.84,
"leads any type vad, rep only",Q0487,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,441.33,,,,,,,fee schedule,420.31,1030.84,APC
"leads any type vad, rep only",Q0487,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,420.31,,,,,,,fee schedule,420.31,1030.84,APC
"leads any type vad, rep only",Q0487,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,756.56,,,,,,,fee schedule,420.31,1030.84,APC
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34939.93,,,,,,,fee schedule,20015.46,49090.92,
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27986.1,,,,,,,fee schedule,20015.46,49090.92,
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49090.92,,,,,,,fee schedule,20015.46,49090.92,
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42687.76,,,,,,,fee schedule,20015.46,49090.92,
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21016.23,,,,,,,fee schedule,20015.46,49090.92,APC
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20015.46,,,,,,,fee schedule,20015.46,49090.92,APC
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36027.83,,,,,,,fee schedule,20015.46,49090.92,APC
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1511.3,,,,,,,fee schedule,865.78,2123.39,
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1210.52,,,,,,,fee schedule,865.78,2123.39,
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2123.39,,,,,,,fee schedule,865.78,2123.39,
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1846.43,,,,,,,fee schedule,865.78,2123.39,
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,909.07,,,,,,,fee schedule,865.78,2123.39,APC
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,865.78,,,,,,,fee schedule,865.78,2123.39,APC
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1558.4,,,,,,,fee schedule,865.78,2123.39,APC
emr pwr source combo vad rep,Q0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2375.97,,,,,,,fee schedule,1361.1,3338.27,
emr pwr source combo vad rep,Q0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1903.1,,,,,,,fee schedule,1361.1,3338.27,
emr pwr source combo vad rep,Q0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3338.27,,,,,,,fee schedule,1361.1,3338.27,
emr pwr source combo vad rep,Q0491,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2902.84,,,,,,,fee schedule,1361.1,3338.27,
emr pwr source combo vad rep,Q0491,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1429.16,,,,,,,fee schedule,1361.1,3338.27,APC
emr pwr source combo vad rep,Q0491,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1361.1,,,,,,,fee schedule,1361.1,3338.27,APC
emr pwr source combo vad rep,Q0491,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2449.98,,,,,,,fee schedule,1361.1,3338.27,APC
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.44,,,,,,,fee schedule,109.67,268.97,
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,153.34,,,,,,,fee schedule,109.67,268.97,
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,268.97,,,,,,,fee schedule,109.67,268.97,
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,233.89,,,,,,,fee schedule,109.67,268.97,
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,115.15,,,,,,,fee schedule,109.67,268.97,APC
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,109.67,,,,,,,fee schedule,109.67,268.97,APC
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,197.41,,,,,,,fee schedule,109.67,268.97,APC
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,545.01,,,,,,,fee schedule,312.22,765.75,
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,436.54,,,,,,,fee schedule,312.22,765.75,
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,765.75,,,,,,,fee schedule,312.22,765.75,
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,665.87,,,,,,,fee schedule,312.22,765.75,
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,327.83,,,,,,,fee schedule,312.22,765.75,APC
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,312.22,,,,,,,fee schedule,312.22,765.75,APC
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,562,,,,,,,fee schedule,312.22,765.75,APC
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,461.17,,,,,,,fee schedule,264.19,647.94,
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,369.38,,,,,,,fee schedule,264.19,647.94,
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,647.94,,,,,,,fee schedule,264.19,647.94,
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,563.43,,,,,,,fee schedule,264.19,647.94,
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,277.4,,,,,,,fee schedule,264.19,647.94,APC
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,264.19,,,,,,,fee schedule,264.19,647.94,APC
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,475.54,,,,,,,fee schedule,264.19,647.94,APC
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14101.64,,,,,,,fee schedule,5143.47,19812.94,
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11295.1,,,,,,,fee schedule,5143.47,19812.94,
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19812.94,,,,,,,fee schedule,5143.47,19812.94,
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17228.64,,,,,,,fee schedule,5143.47,19812.94,
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5400.64,,,,,,,fee schedule,5143.47,19812.94,APC
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5143.47,,,,,,,fee schedule,5143.47,19812.94,APC
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9258.25,,,,,,,fee schedule,5143.47,19812.94,APC
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3222.63,,,,,,,fee schedule,1846.09,4527.83,
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2581.25,,,,,,,fee schedule,1846.09,4527.83,
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4527.83,,,,,,,fee schedule,1846.09,4527.83,
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3937.24,,,,,,,fee schedule,1846.09,4527.83,
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1938.39,,,,,,,fee schedule,1846.09,4527.83,APC
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1846.09,,,,,,,fee schedule,1846.09,4527.83,APC
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3322.96,,,,,,,fee schedule,1846.09,4527.83,APC
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2599.7,,,,,,,fee schedule,576.44,3652.6,
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2082.3,,,,,,,fee schedule,576.44,3652.6,
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3652.6,,,,,,,fee schedule,576.44,3652.6,
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3176.17,,,,,,,fee schedule,576.44,3652.6,
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,605.26,,,,,,,fee schedule,576.44,3652.6,APC
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,576.44,,,,,,,fee schedule,576.44,3652.6,APC
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1037.59,,,,,,,fee schedule,576.44,3652.6,APC
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1154.85,,,,,,,fee schedule,632.48,1622.58,
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,925.01,,,,,,,fee schedule,632.48,1622.58,
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1622.58,,,,,,,fee schedule,632.48,1622.58,
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1410.94,,,,,,,fee schedule,632.48,1622.58,
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,664.1,,,,,,,fee schedule,632.48,1622.58,APC
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,632.48,,,,,,,fee schedule,632.48,1622.58,APC
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1138.46,,,,,,,fee schedule,632.48,1622.58,APC
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1076.32,,,,,,,fee schedule,205.51,1512.24,
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,862.11,,,,,,,fee schedule,205.51,1512.24,
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1512.24,,,,,,,fee schedule,205.51,1512.24,
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1314.99,,,,,,,fee schedule,205.51,1512.24,
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,215.79,,,,,,,fee schedule,205.51,1512.24,APC
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,205.51,,,,,,,fee schedule,205.51,1512.24,APC
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,369.92,,,,,,,fee schedule,205.51,1512.24,APC
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.6,,,,,,,fee schedule,37.58,92.17,
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52.55,,,,,,,fee schedule,37.58,92.17,
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,92.17,,,,,,,fee schedule,37.58,92.17,
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,80.15,,,,,,,fee schedule,37.58,92.17,
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.46,,,,,,,fee schedule,37.58,92.17,APC
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37.58,,,,,,,fee schedule,37.58,92.17,APC
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67.64,,,,,,,fee schedule,37.58,92.17,APC
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1059.72,,,,,,,fee schedule,628.84,1488.92,
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,848.81,,,,,,,fee schedule,628.84,1488.92,
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1488.92,,,,,,,fee schedule,628.84,1488.92,
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1294.71,,,,,,,fee schedule,628.84,1488.92,
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,660.28,,,,,,,fee schedule,628.84,1488.92,APC
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,628.84,,,,,,,fee schedule,628.84,1488.92,APC
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1131.91,,,,,,,fee schedule,628.84,1488.92,APC
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1397.62,,,,,,,fee schedule,800.65,1963.67,
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1119.46,,,,,,,fee schedule,800.65,1963.67,
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1963.67,,,,,,,fee schedule,800.65,1963.67,
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1707.54,,,,,,,fee schedule,800.65,1963.67,
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,840.68,,,,,,,fee schedule,800.65,1963.67,APC
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,800.65,,,,,,,fee schedule,800.65,1963.67,APC
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1441.17,,,,,,,fee schedule,800.65,1963.67,APC
battery pneum vad replacemnt,Q0503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2795.14,,,,,,,fee schedule,1601.2,3927.19,
battery pneum vad replacemnt,Q0503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2238.84,,,,,,,fee schedule,1601.2,3927.19,
battery pneum vad replacemnt,Q0503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3927.19,,,,,,,fee schedule,1601.2,3927.19,
battery pneum vad replacemnt,Q0503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3414.95,,,,,,,fee schedule,1601.2,3927.19,
battery pneum vad replacemnt,Q0503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1681.26,,,,,,,fee schedule,1601.2,3927.19,APC
battery pneum vad replacemnt,Q0503,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1601.2,,,,,,,fee schedule,1601.2,3927.19,APC
battery pneum vad replacemnt,Q0503,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2882.16,,,,,,,fee schedule,1601.2,3927.19,APC
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1474.97,,,,,,,fee schedule,844.96,2072.35,
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1181.42,,,,,,,fee schedule,844.96,2072.35,
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2072.35,,,,,,,fee schedule,844.96,2072.35,
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1802.04,,,,,,,fee schedule,844.96,2072.35,
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,887.21,,,,,,,fee schedule,844.96,2072.35,APC
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,844.96,,,,,,,fee schedule,844.96,2072.35,APC
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1520.93,,,,,,,fee schedule,844.96,2072.35,APC
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1720.41,,,,,,,fee schedule,1051.71,2417.19,
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1378.01,,,,,,,fee schedule,1051.71,2417.19,
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2417.19,,,,,,,fee schedule,1051.71,2417.19,
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2101.9,,,,,,,fee schedule,1051.71,2417.19,
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1104.3,,,,,,,fee schedule,1051.71,2417.19,APC
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1051.71,,,,,,,fee schedule,1051.71,2417.19,APC
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1893.08,,,,,,,fee schedule,1051.71,2417.19,APC
Sermorelin acetate injection,Q0515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.87,,,,,,,fee schedule,1.87,2.15,
Sermorelin acetate injection,Q0515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.87,,,,,,,fee schedule,1.87,2.15,
Sermorelin acetate injection,Q0515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.87,,,,,,,fee schedule,1.87,2.15,
Sermorelin acetate injection,Q0515,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.15,,,,,,,fee schedule,1.87,2.15,
Bladder calculi irrig sol,Q2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,237.43,,,,,,,fee schedule,190.18,333.59,
Bladder calculi irrig sol,Q2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,190.18,,,,,,,fee schedule,190.18,333.59,
Bladder calculi irrig sol,Q2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,333.59,,,,,,,fee schedule,190.18,333.59,
Bladder calculi irrig sol,Q2004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,290.08,,,,,,,fee schedule,190.18,333.59,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.79,,,,,,,fee schedule,0.66,3.21,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.79,,,,,,,fee schedule,0.66,3.21,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.79,,,,,,,fee schedule,0.66,3.21,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.21,,,,,,,fee schedule,0.66,3.21,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.7,,,,,,,fee schedule,0.66,3.21,APC
Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.66,,,,,,,fee schedule,0.66,3.21,APC
Fosphenytoin inj pe,Q2009,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.2,,,,,,,fee schedule,0.66,3.21,APC
"Teniposide, 50 mg",Q2017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2545.87,,,,,,,fee schedule,2545.87,2927.75,
"Teniposide, 50 mg",Q2017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2545.87,,,,,,,fee schedule,2545.87,2927.75,
"Teniposide, 50 mg",Q2017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2545.87,,,,,,,fee schedule,2545.87,2927.75,
"Teniposide, 50 mg",Q2017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2927.75,,,,,,,fee schedule,2545.87,2927.75,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.66,,,,,,,fee schedule,0.66,3.89,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.66,,,,,,,fee schedule,0.66,3.89,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.66,,,,,,,fee schedule,0.66,3.89,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.76,,,,,,,fee schedule,0.66,3.89,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.27,,,,,,,fee schedule,0.66,3.89,APC
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.16,,,,,,,fee schedule,0.66,3.89,APC
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3.89,,,,,,,fee schedule,0.66,3.89,APC
Agriflu vaccine,Q2034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.39,,,,,,,fee schedule,12.39,14.25,
Agriflu vaccine,Q2034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.39,,,,,,,fee schedule,12.39,14.25,
Agriflu vaccine,Q2034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.39,,,,,,,fee schedule,12.39,14.25,
Agriflu vaccine,Q2034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.25,,,,,,,fee schedule,12.39,14.25,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.24,,,,,,,fee schedule,18.24,20.98,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.24,,,,,,,fee schedule,18.24,20.98,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.24,,,,,,,fee schedule,18.24,20.98,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.98,,,,,,,fee schedule,18.24,20.98,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.58,,,,,,,fee schedule,8.58,9.87,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.58,,,,,,,fee schedule,8.58,9.87,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.58,,,,,,,fee schedule,8.58,9.87,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.87,,,,,,,fee schedule,8.58,9.87,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.69,,,,,,,fee schedule,17.69,20.34,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.69,,,,,,,fee schedule,17.69,20.34,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.69,,,,,,,fee schedule,17.69,20.34,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.34,,,,,,,fee schedule,17.69,20.34,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.05,,,,,,,fee schedule,12.05,13.86,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.05,,,,,,,fee schedule,12.05,13.86,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.05,,,,,,,fee schedule,12.05,13.86,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.86,,,,,,,fee schedule,12.05,13.86,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.38,,,,,,,fee schedule,12.38,14.24,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.38,,,,,,,fee schedule,12.38,14.24,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.38,,,,,,,fee schedule,12.38,14.24,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.24,,,,,,,fee schedule,12.38,14.24,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,59168.69,,,,,,,fee schedule,55932.43,100678.37,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59168.69,,,,,,,fee schedule,55932.43,100678.37,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59168.69,,,,,,,fee schedule,55932.43,100678.37,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,68043.99,,,,,,,fee schedule,55932.43,100678.37,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58729.05,,,,,,,fee schedule,55932.43,100678.37,APC
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,55932.43,,,,,,,fee schedule,55932.43,100678.37,APC
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,100678.37,,,,,,,fee schedule,55932.43,100678.37,APC
Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,489.26,,,,,,,fee schedule,298.74,562.65,
Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,489.26,,,,,,,fee schedule,298.74,562.65,
Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,489.26,,,,,,,fee schedule,298.74,562.65,
Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,562.65,,,,,,,fee schedule,298.74,562.65,
Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,313.68,,,,,,,fee schedule,298.74,562.65,APC
Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,298.74,,,,,,,fee schedule,298.74,562.65,APC
Imported Lipodox inj,Q2049,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,537.73,,,,,,,fee schedule,298.74,562.65,APC
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,113.41,,,,,,,fee schedule,113.41,209.89,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.41,,,,,,,fee schedule,113.41,209.89,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.41,,,,,,,fee schedule,113.41,209.89,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,130.42,,,,,,,fee schedule,113.41,209.89,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.44,,,,,,,fee schedule,113.41,209.89,APC
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,116.6,,,,,,,fee schedule,113.41,209.89,APC
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,209.89,,,,,,,fee schedule,113.41,209.89,APC
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.42,,,,,,,fee schedule,73.42,84.43,
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.42,,,,,,,fee schedule,73.42,84.43,
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.42,,,,,,,fee schedule,73.42,84.43,
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.43,,,,,,,fee schedule,73.42,84.43,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.46,,,,,,,fee schedule,42.46,48.83,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.46,,,,,,,fee schedule,42.46,48.83,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.46,,,,,,,fee schedule,42.46,48.83,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.83,,,,,,,fee schedule,42.46,48.83,
Cast sup body cast plaster,Q4001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108.86,,,,,,,fee schedule,87.19,152.95,
Cast sup body cast plaster,Q4001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.19,,,,,,,fee schedule,87.19,152.95,
Cast sup body cast plaster,Q4001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,152.95,,,,,,,fee schedule,87.19,152.95,
Cast sup body cast plaster,Q4001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,133,,,,,,,fee schedule,87.19,152.95,
Cast sup body cast fiberglas,Q4002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,411.36,,,,,,,fee schedule,329.49,577.97,
Cast sup body cast fiberglas,Q4002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,329.49,,,,,,,fee schedule,329.49,577.97,
Cast sup body cast fiberglas,Q4002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,577.97,,,,,,,fee schedule,329.49,577.97,
Cast sup body cast fiberglas,Q4002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,502.58,,,,,,,fee schedule,329.49,577.97,
Cast sup shoulder cast plstr,Q4003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.17,,,,,,,fee schedule,62.62,109.84,
Cast sup shoulder cast plstr,Q4003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,62.62,,,,,,,fee schedule,62.62,109.84,
Cast sup shoulder cast plstr,Q4003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,109.84,,,,,,,fee schedule,62.62,109.84,
Cast sup shoulder cast plstr,Q4003,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,95.51,,,,,,,fee schedule,62.62,109.84,
Cast sup shoulder cast fbrgl,Q4004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,270.63,,,,,,,fee schedule,216.77,380.24,
Cast sup shoulder cast fbrgl,Q4004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,216.77,,,,,,,fee schedule,216.77,380.24,
Cast sup shoulder cast fbrgl,Q4004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,380.24,,,,,,,fee schedule,216.77,380.24,
Cast sup shoulder cast fbrgl,Q4004,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330.64,,,,,,,fee schedule,216.77,380.24,
Cast sup long arm adult plst,Q4005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.83,,,,,,,fee schedule,23.09,40.5,
Cast sup long arm adult plst,Q4005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.09,,,,,,,fee schedule,23.09,40.5,
Cast sup long arm adult plst,Q4005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.5,,,,,,,fee schedule,23.09,40.5,
Cast sup long arm adult plst,Q4005,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.22,,,,,,,fee schedule,23.09,40.5,
Cast sup long arm adult fbrg,Q4006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.92,,,,,,,fee schedule,52,91.22,
Cast sup long arm adult fbrg,Q4006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,52,,,,,,,fee schedule,52,91.22,
Cast sup long arm adult fbrg,Q4006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,91.22,,,,,,,fee schedule,52,91.22,
Cast sup long arm adult fbrg,Q4006,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.32,,,,,,,fee schedule,52,91.22,
Cast sup long arm ped plster,Q4007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.41,,,,,,,fee schedule,11.55,20.25,
Cast sup long arm ped plster,Q4007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.55,,,,,,,fee schedule,11.55,20.25,
Cast sup long arm ped plster,Q4007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.25,,,,,,,fee schedule,11.55,20.25,
Cast sup long arm ped plster,Q4007,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.61,,,,,,,fee schedule,11.55,20.25,
Cast sup long arm ped fbrgls,Q4008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.44,,,,,,,fee schedule,25.98,45.57,
Cast sup long arm ped fbrgls,Q4008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.98,,,,,,,fee schedule,25.98,45.57,
Cast sup long arm ped fbrgls,Q4008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.57,,,,,,,fee schedule,25.98,45.57,
Cast sup long arm ped fbrgls,Q4008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.63,,,,,,,fee schedule,25.98,45.57,
Cast sup sht arm adult plstr,Q4009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.26,,,,,,,fee schedule,15.43,27.06,
Cast sup sht arm adult plstr,Q4009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.43,,,,,,,fee schedule,15.43,27.06,
Cast sup sht arm adult plstr,Q4009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.06,,,,,,,fee schedule,15.43,27.06,
Cast sup sht arm adult plstr,Q4009,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.53,,,,,,,fee schedule,15.43,27.06,
Cast sup sht arm adult fbrgl,Q4010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.31,,,,,,,fee schedule,34.69,60.85,
Cast sup sht arm adult fbrgl,Q4010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.69,,,,,,,fee schedule,34.69,60.85,
Cast sup sht arm adult fbrgl,Q4010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.85,,,,,,,fee schedule,34.69,60.85,
Cast sup sht arm adult fbrgl,Q4010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.91,,,,,,,fee schedule,34.69,60.85,
Cast sup sht arm ped plaster,Q4011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.58,,,,,,,fee schedule,7.68,13.47,
Cast sup sht arm ped plaster,Q4011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.68,,,,,,,fee schedule,7.68,13.47,
Cast sup sht arm ped plaster,Q4011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.47,,,,,,,fee schedule,7.68,13.47,
Cast sup sht arm ped plaster,Q4011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.71,,,,,,,fee schedule,7.68,13.47,
Cast sup sht arm ped fbrglas,Q4012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.69,,,,,,,fee schedule,17.37,30.48,
Cast sup sht arm ped fbrglas,Q4012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.37,,,,,,,fee schedule,17.37,30.48,
Cast sup sht arm ped fbrglas,Q4012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.48,,,,,,,fee schedule,17.37,30.48,
Cast sup sht arm ped fbrglas,Q4012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.5,,,,,,,fee schedule,17.37,30.48,
Cast sup gauntlet plaster,Q4013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.02,,,,,,,fee schedule,28.05,49.21,
Cast sup gauntlet plaster,Q4013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.05,,,,,,,fee schedule,28.05,49.21,
Cast sup gauntlet plaster,Q4013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.21,,,,,,,fee schedule,28.05,49.21,
Cast sup gauntlet plaster,Q4013,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.79,,,,,,,fee schedule,28.05,49.21,
Cast sup gauntlet fiberglass,Q4014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.05,,,,,,,fee schedule,47.3,82.97,
Cast sup gauntlet fiberglass,Q4014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.3,,,,,,,fee schedule,47.3,82.97,
Cast sup gauntlet fiberglass,Q4014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,82.97,,,,,,,fee schedule,47.3,82.97,
Cast sup gauntlet fiberglass,Q4014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,72.15,,,,,,,fee schedule,47.3,82.97,
Cast sup gauntlet ped plster,Q4015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.54,,,,,,,fee schedule,14.05,24.64,
Cast sup gauntlet ped plster,Q4015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.05,,,,,,,fee schedule,14.05,24.64,
Cast sup gauntlet ped plster,Q4015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.64,,,,,,,fee schedule,14.05,24.64,
Cast sup gauntlet ped plster,Q4015,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.43,,,,,,,fee schedule,14.05,24.64,
Cast sup gauntlet ped fbrgls,Q4016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.53,,,,,,,fee schedule,23.65,41.49,
Cast sup gauntlet ped fbrgls,Q4016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.65,,,,,,,fee schedule,23.65,41.49,
Cast sup gauntlet ped fbrgls,Q4016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,41.49,,,,,,,fee schedule,23.65,41.49,
Cast sup gauntlet ped fbrgls,Q4016,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.08,,,,,,,fee schedule,23.65,41.49,
Cast sup lng arm splint plst,Q4017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.23,,,,,,,fee schedule,16.21,28.43,
Cast sup lng arm splint plst,Q4017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.21,,,,,,,fee schedule,16.21,28.43,
Cast sup lng arm splint plst,Q4017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.43,,,,,,,fee schedule,16.21,28.43,
Cast sup lng arm splint plst,Q4017,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.72,,,,,,,fee schedule,16.21,28.43,
Cast sup lng arm splint fbrg,Q4018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.28,,,,,,,fee schedule,25.86,45.36,
Cast sup lng arm splint fbrg,Q4018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.86,,,,,,,fee schedule,25.86,45.36,
Cast sup lng arm splint fbrg,Q4018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.36,,,,,,,fee schedule,25.86,45.36,
Cast sup lng arm splint fbrg,Q4018,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.44,,,,,,,fee schedule,25.86,45.36,
Cast sup lng arm splnt ped p,Q4019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.13,,,,,,,fee schedule,8.12,14.24,
Cast sup lng arm splnt ped p,Q4019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.12,,,,,,,fee schedule,8.12,14.24,
Cast sup lng arm splnt ped p,Q4019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.24,,,,,,,fee schedule,8.12,14.24,
Cast sup lng arm splnt ped p,Q4019,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.38,,,,,,,fee schedule,8.12,14.24,
Cast sup lng arm splnt ped f,Q4020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16.18,,,,,,,fee schedule,12.96,22.74,
Cast sup lng arm splnt ped f,Q4020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.96,,,,,,,fee schedule,12.96,22.74,
Cast sup lng arm splnt ped f,Q4020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.74,,,,,,,fee schedule,12.96,22.74,
Cast sup lng arm splnt ped f,Q4020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.77,,,,,,,fee schedule,12.96,22.74,
Cast sup sht arm splint plst,Q4021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14.99,,,,,,,fee schedule,12,21.06,
Cast sup sht arm splint plst,Q4021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12,,,,,,,fee schedule,12,21.06,
Cast sup sht arm splint plst,Q4021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.06,,,,,,,fee schedule,12,21.06,
Cast sup sht arm splint plst,Q4021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,18.31,,,,,,,fee schedule,12,21.06,
Cast sup sht arm splint fbrg,Q4022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.04,,,,,,,fee schedule,21.66,38,
Cast sup sht arm splint fbrg,Q4022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.66,,,,,,,fee schedule,21.66,38,
Cast sup sht arm splint fbrg,Q4022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,38,,,,,,,fee schedule,21.66,38,
Cast sup sht arm splint fbrg,Q4022,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,33.04,,,,,,,fee schedule,21.66,38,
Cast sup sht arm splnt ped p,Q4023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.54,,,,,,,fee schedule,6.04,10.59,
Cast sup sht arm splnt ped p,Q4023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.04,,,,,,,fee schedule,6.04,10.59,
Cast sup sht arm splnt ped p,Q4023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,10.59,,,,,,,fee schedule,6.04,10.59,
Cast sup sht arm splnt ped p,Q4023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,9.21,,,,,,,fee schedule,6.04,10.59,
Cast sup sht arm splnt ped f,Q4024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.55,,,,,,,fee schedule,10.85,19.03,
Cast sup sht arm splnt ped f,Q4024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.85,,,,,,,fee schedule,10.85,19.03,
Cast sup sht arm splnt ped f,Q4024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,19.03,,,,,,,fee schedule,10.85,19.03,
Cast sup sht arm splnt ped f,Q4024,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,16.55,,,,,,,fee schedule,10.85,19.03,
Cast sup hip spica plaster,Q4025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.03,,,,,,,fee schedule,67.3,118.06,
Cast sup hip spica plaster,Q4025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.3,,,,,,,fee schedule,67.3,118.06,
Cast sup hip spica plaster,Q4025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.06,,,,,,,fee schedule,67.3,118.06,
Cast sup hip spica plaster,Q4025,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.66,,,,,,,fee schedule,67.3,118.06,
Cast sup hip spica fiberglas,Q4026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.39,,,,,,,fee schedule,210.17,368.66,
Cast sup hip spica fiberglas,Q4026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,210.17,,,,,,,fee schedule,210.17,368.66,
Cast sup hip spica fiberglas,Q4026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,368.66,,,,,,,fee schedule,210.17,368.66,
Cast sup hip spica fiberglas,Q4026,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,320.57,,,,,,,fee schedule,210.17,368.66,
Cast sup hip spica ped plstr,Q4027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.02,,,,,,,fee schedule,33.66,59.04,
Cast sup hip spica ped plstr,Q4027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.66,,,,,,,fee schedule,33.66,59.04,
Cast sup hip spica ped plstr,Q4027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,59.04,,,,,,,fee schedule,33.66,59.04,
Cast sup hip spica ped plstr,Q4027,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,51.34,,,,,,,fee schedule,33.66,59.04,
Cast sup hip spica ped fbrgl,Q4028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.26,,,,,,,fee schedule,105.14,184.43,
Cast sup hip spica ped fbrgl,Q4028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.14,,,,,,,fee schedule,105.14,184.43,
Cast sup hip spica ped fbrgl,Q4028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.43,,,,,,,fee schedule,105.14,184.43,
Cast sup hip spica ped fbrgl,Q4028,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.37,,,,,,,fee schedule,105.14,184.43,
Cast sup long leg plaster,Q4029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,64.25,,,,,,,fee schedule,51.46,90.28,
Cast sup long leg plaster,Q4029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,51.46,,,,,,,fee schedule,51.46,90.28,
Cast sup long leg plaster,Q4029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.28,,,,,,,fee schedule,51.46,90.28,
Cast sup long leg plaster,Q4029,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.5,,,,,,,fee schedule,51.46,90.28,
Cast sup long leg fiberglass,Q4030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,169.19,,,,,,,fee schedule,135.52,237.72,
Cast sup long leg fiberglass,Q4030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,135.52,,,,,,,fee schedule,135.52,237.72,
Cast sup long leg fiberglass,Q4030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,237.72,,,,,,,fee schedule,135.52,237.72,
Cast sup long leg fiberglass,Q4030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,206.71,,,,,,,fee schedule,135.52,237.72,
Cast sup lng leg ped plaster,Q4031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.11,,,,,,,fee schedule,25.72,45.11,
Cast sup lng leg ped plaster,Q4031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.72,,,,,,,fee schedule,25.72,45.11,
Cast sup lng leg ped plaster,Q4031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.11,,,,,,,fee schedule,25.72,45.11,
Cast sup lng leg ped plaster,Q4031,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.23,,,,,,,fee schedule,25.72,45.11,
Cast sup lng leg ped fbrgls,Q4032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.58,,,,,,,fee schedule,67.75,118.84,
Cast sup lng leg ped fbrgls,Q4032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.75,,,,,,,fee schedule,67.75,118.84,
Cast sup lng leg ped fbrgls,Q4032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.84,,,,,,,fee schedule,67.75,118.84,
Cast sup lng leg ped fbrgls,Q4032,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,103.34,,,,,,,fee schedule,67.75,118.84,
Cast sup lng leg cylinder pl,Q4033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59.96,,,,,,,fee schedule,48.03,84.25,
Cast sup lng leg cylinder pl,Q4033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.03,,,,,,,fee schedule,48.03,84.25,
Cast sup lng leg cylinder pl,Q4033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.25,,,,,,,fee schedule,48.03,84.25,
Cast sup lng leg cylinder pl,Q4033,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.26,,,,,,,fee schedule,48.03,84.25,
Cast sup lng leg cylinder fb,Q4034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.07,,,,,,,fee schedule,119.4,209.45,
Cast sup lng leg cylinder fb,Q4034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.4,,,,,,,fee schedule,119.4,209.45,
Cast sup lng leg cylinder fb,Q4034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.45,,,,,,,fee schedule,119.4,209.45,
Cast sup lng leg cylinder fb,Q4034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.13,,,,,,,fee schedule,119.4,209.45,
Cast sup lngleg cylndr ped p,Q4035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29.95,,,,,,,fee schedule,23.99,42.08,
Cast sup lngleg cylndr ped p,Q4035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.99,,,,,,,fee schedule,23.99,42.08,
Cast sup lngleg cylndr ped p,Q4035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.08,,,,,,,fee schedule,23.99,42.08,
Cast sup lngleg cylndr ped p,Q4035,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.59,,,,,,,fee schedule,23.99,42.08,
Cast sup lngleg cylndr ped f,Q4036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74.57,,,,,,,fee schedule,59.73,104.77,
Cast sup lngleg cylndr ped f,Q4036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.73,,,,,,,fee schedule,59.73,104.77,
Cast sup lngleg cylndr ped f,Q4036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,104.77,,,,,,,fee schedule,59.73,104.77,
Cast sup lngleg cylndr ped f,Q4036,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,91.1,,,,,,,fee schedule,59.73,104.77,
Cast sup shrt leg plaster,Q4037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.55,,,,,,,fee schedule,29.27,51.35,
Cast sup shrt leg plaster,Q4037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,29.27,,,,,,,fee schedule,29.27,51.35,
Cast sup shrt leg plaster,Q4037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,51.35,,,,,,,fee schedule,29.27,51.35,
Cast sup shrt leg plaster,Q4037,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,44.65,,,,,,,fee schedule,29.27,51.35,
Cast sup shrt leg fiberglass,Q4038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91.61,,,,,,,fee schedule,73.37,128.71,
Cast sup shrt leg fiberglass,Q4038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.37,,,,,,,fee schedule,73.37,128.71,
Cast sup shrt leg fiberglass,Q4038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.71,,,,,,,fee schedule,73.37,128.71,
Cast sup shrt leg fiberglass,Q4038,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.92,,,,,,,fee schedule,73.37,128.71,
Cast sup shrt leg ped plster,Q4039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18.33,,,,,,,fee schedule,14.69,25.76,
Cast sup shrt leg ped plster,Q4039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,14.69,,,,,,,fee schedule,14.69,25.76,
Cast sup shrt leg ped plster,Q4039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.76,,,,,,,fee schedule,14.69,25.76,
Cast sup shrt leg ped plster,Q4039,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.4,,,,,,,fee schedule,14.69,25.76,
Cast sup shrt leg ped fbrgls,Q4040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.79,,,,,,,fee schedule,36.67,64.33,
Cast sup shrt leg ped fbrgls,Q4040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.67,,,,,,,fee schedule,36.67,64.33,
Cast sup shrt leg ped fbrgls,Q4040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,64.33,,,,,,,fee schedule,36.67,64.33,
Cast sup shrt leg ped fbrgls,Q4040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,55.94,,,,,,,fee schedule,36.67,64.33,
Cast sup lng leg splnt plstr,Q4041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44.47,,,,,,,fee schedule,35.62,62.48,
Cast sup lng leg splnt plstr,Q4041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.62,,,,,,,fee schedule,35.62,62.48,
Cast sup lng leg splnt plstr,Q4041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,62.48,,,,,,,fee schedule,35.62,62.48,
Cast sup lng leg splnt plstr,Q4041,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,54.33,,,,,,,fee schedule,35.62,62.48,
Cast sup lng leg splnt fbrgl,Q4042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,75.91,,,,,,,fee schedule,60.8,106.65,
Cast sup lng leg splnt fbrgl,Q4042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.8,,,,,,,fee schedule,60.8,106.65,
Cast sup lng leg splnt fbrgl,Q4042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.65,,,,,,,fee schedule,60.8,106.65,
Cast sup lng leg splnt fbrgl,Q4042,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.74,,,,,,,fee schedule,60.8,106.65,
Cast sup lng leg splnt ped p,Q4043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.25,,,,,,,fee schedule,17.82,31.26,
Cast sup lng leg splnt ped p,Q4043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.82,,,,,,,fee schedule,17.82,31.26,
Cast sup lng leg splnt ped p,Q4043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.26,,,,,,,fee schedule,17.82,31.26,
Cast sup lng leg splnt ped p,Q4043,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.18,,,,,,,fee schedule,17.82,31.26,
Cast sup lng leg splnt ped f,Q4044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37.97,,,,,,,fee schedule,30.41,53.35,
Cast sup lng leg splnt ped f,Q4044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.41,,,,,,,fee schedule,30.41,53.35,
Cast sup lng leg splnt ped f,Q4044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.35,,,,,,,fee schedule,30.41,53.35,
Cast sup lng leg splnt ped f,Q4044,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.39,,,,,,,fee schedule,30.41,53.35,
Cast sup sht leg splnt plstr,Q4045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.8,,,,,,,fee schedule,20.66,36.25,
Cast sup sht leg splnt plstr,Q4045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.66,,,,,,,fee schedule,20.66,36.25,
Cast sup sht leg splnt plstr,Q4045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.25,,,,,,,fee schedule,20.66,36.25,
Cast sup sht leg splnt plstr,Q4045,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.52,,,,,,,fee schedule,20.66,36.25,
Cast sup sht leg splnt fbrgl,Q4046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.52,,,,,,,fee schedule,33.26,58.34,
Cast sup sht leg splnt fbrgl,Q4046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.26,,,,,,,fee schedule,33.26,58.34,
Cast sup sht leg splnt fbrgl,Q4046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.34,,,,,,,fee schedule,33.26,58.34,
Cast sup sht leg splnt fbrgl,Q4046,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.73,,,,,,,fee schedule,33.26,58.34,
Cast sup sht leg splnt ped p,Q4047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.87,,,,,,,fee schedule,10.31,18.08,
Cast sup sht leg splnt ped p,Q4047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.31,,,,,,,fee schedule,10.31,18.08,
Cast sup sht leg splnt ped p,Q4047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,18.08,,,,,,,fee schedule,10.31,18.08,
Cast sup sht leg splnt ped p,Q4047,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.72,,,,,,,fee schedule,10.31,18.08,
Cast sup sht leg splnt ped f,Q4048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.74,,,,,,,fee schedule,16.61,29.14,
Cast sup sht leg splnt ped f,Q4048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,16.61,,,,,,,fee schedule,16.61,29.14,
Cast sup sht leg splnt ped f,Q4048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.14,,,,,,,fee schedule,16.61,29.14,
Cast sup sht leg splnt ped f,Q4048,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.34,,,,,,,fee schedule,16.61,29.14,
"Finger splint, static",Q4049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.67,,,,,,,fee schedule,3.74,6.57,
"Finger splint, static",Q4049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.74,,,,,,,fee schedule,3.74,6.57,
"Finger splint, static",Q4049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.57,,,,,,,fee schedule,3.74,6.57,
"Finger splint, static",Q4049,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.71,,,,,,,fee schedule,3.74,6.57,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,164.91,,,,,,,fee schedule,164.91,189.65,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,164.91,,,,,,,fee schedule,164.91,189.65,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.91,,,,,,,fee schedule,164.91,189.65,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,189.65,,,,,,,fee schedule,164.91,189.65,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.8,,,,,,,fee schedule,0.8,0.92,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.8,,,,,,,fee schedule,0.8,0.92,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.8,,,,,,,fee schedule,0.8,0.92,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.92,,,,,,,fee schedule,0.8,0.92,
Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.45,,,,,,,fee schedule,31.45,223.19,
Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.45,,,,,,,fee schedule,31.45,223.19,
Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.45,,,,,,,fee schedule,31.45,223.19,
Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,36.17,,,,,,,fee schedule,31.45,223.19,
Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,31.45,223.19,APC
Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,31.45,223.19,APC
Apligraf,Q4101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,31.45,223.19,APC
Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.14,,,,,,,fee schedule,12.14,223.19,
Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.14,,,,,,,fee schedule,12.14,223.19,
Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.14,,,,,,,fee schedule,12.14,223.19,
Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.96,,,,,,,fee schedule,12.14,223.19,
Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,12.14,223.19,APC
Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,12.14,223.19,APC
Oasis wound matrix,Q4102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,12.14,223.19,APC
Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.7,,,,,,,fee schedule,71.05,223.19,
Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,71.05,,,,,,,fee schedule,71.05,223.19,
Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,124.63,,,,,,,fee schedule,71.05,223.19,
Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,108.37,,,,,,,fee schedule,71.05,223.19,
Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,71.05,223.19,APC
Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,71.05,223.19,APC
Integra bmwd,Q4104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,71.05,223.19,APC
Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.01,,,,,,,fee schedule,91.32,223.19,
Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.32,,,,,,,fee schedule,91.32,223.19,
Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.18,,,,,,,fee schedule,91.32,223.19,
Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.29,,,,,,,fee schedule,91.32,223.19,
Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,91.32,223.19,APC
Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,91.32,223.19,APC
Integra drt or omnigraft,Q4105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,91.32,223.19,APC
Dermagraft,Q4106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.64,,,,,,,fee schedule,46.64,53.64,
Dermagraft,Q4106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46.64,,,,,,,fee schedule,46.64,53.64,
Dermagraft,Q4106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,46.64,,,,,,,fee schedule,46.64,53.64,
Dermagraft,Q4106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.64,,,,,,,fee schedule,46.64,53.64,
Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,201.52,,,,,,,fee schedule,124,283.14,
Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.42,,,,,,,fee schedule,124,283.14,
Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.14,,,,,,,fee schedule,124,283.14,
Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.21,,,,,,,fee schedule,124,283.14,
Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,283.14,APC
Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,283.14,APC
Graftjacket,Q4107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,283.14,APC
Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,84.17,,,,,,,fee schedule,67.42,223.19,
Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.42,,,,,,,fee schedule,67.42,223.19,
Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.25,,,,,,,fee schedule,67.42,223.19,
Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.83,,,,,,,fee schedule,67.42,223.19,
Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,67.42,223.19,APC
Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,67.42,223.19,APC
Integra matrix,Q4108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,67.42,223.19,APC
Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.87,,,,,,,fee schedule,67.87,223.19,
Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.87,,,,,,,fee schedule,67.87,223.19,
Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.87,,,,,,,fee schedule,67.87,223.19,
Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.05,,,,,,,fee schedule,67.87,223.19,
Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,67.87,223.19,APC
Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,67.87,223.19,APC
Primatrix,Q4110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,67.87,223.19,APC
Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.38,,,,,,,fee schedule,7.38,223.19,
Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.38,,,,,,,fee schedule,7.38,223.19,
Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.38,,,,,,,fee schedule,7.38,223.19,
Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.49,,,,,,,fee schedule,7.38,223.19,
Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,7.38,223.19,APC
Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,7.38,223.19,APC
Gammagraft,Q4111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,7.38,223.19,APC
Cymetra injectable,Q4112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,904.99,,,,,,,fee schedule,904.99,1040.74,
Cymetra injectable,Q4112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,904.99,,,,,,,fee schedule,904.99,1040.74,
Cymetra injectable,Q4112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,904.99,,,,,,,fee schedule,904.99,1040.74,
Cymetra injectable,Q4112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1040.74,,,,,,,fee schedule,904.99,1040.74,
Graftjacket xpress,Q4113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,762.88,,,,,,,fee schedule,762.88,877.31,
Graftjacket xpress,Q4113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,762.88,,,,,,,fee schedule,762.88,877.31,
Graftjacket xpress,Q4113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,762.88,,,,,,,fee schedule,762.88,877.31,
Graftjacket xpress,Q4113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,877.31,,,,,,,fee schedule,762.88,877.31,
Integra flowable wound matri,Q4114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1600.44,,,,,,,fee schedule,1600.44,1840.51,
Integra flowable wound matri,Q4114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1600.44,,,,,,,fee schedule,1600.44,1840.51,
Integra flowable wound matri,Q4114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1600.44,,,,,,,fee schedule,1600.44,1840.51,
Integra flowable wound matri,Q4114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1840.51,,,,,,,fee schedule,1600.44,1840.51,
Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.63,,,,,,,fee schedule,15.72,223.19,
Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.72,,,,,,,fee schedule,15.72,223.19,
Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.58,,,,,,,fee schedule,15.72,223.19,
Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.98,,,,,,,fee schedule,15.72,223.19,
Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,15.72,223.19,APC
Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,15.72,223.19,APC
Alloskin,Q4115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,15.72,223.19,APC
Alloderm,Q4116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.29,,,,,,,fee schedule,32.29,223.19,
Alloderm,Q4116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32.29,,,,,,,fee schedule,32.29,223.19,
Alloderm,Q4116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,32.29,,,,,,,fee schedule,32.29,223.19,
Alloderm,Q4116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.13,,,,,,,fee schedule,32.29,223.19,
Alloderm,Q4116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,32.29,223.19,APC
Alloderm,Q4116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,32.29,223.19,APC
Alloderm,Q4116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,32.29,223.19,APC
Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.69,,,,,,,fee schedule,50.69,223.19,
Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50.69,,,,,,,fee schedule,50.69,223.19,
Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,50.69,,,,,,,fee schedule,50.69,223.19,
Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.29,,,,,,,fee schedule,50.69,223.19,
Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,50.69,223.19,APC
Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,50.69,223.19,APC
Theraskin,Q4121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,50.69,223.19,APC
Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56.76,,,,,,,fee schedule,45.47,223.19,
Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.47,,,,,,,fee schedule,45.47,223.19,
Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.75,,,,,,,fee schedule,45.47,223.19,
Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,69.35,,,,,,,fee schedule,45.47,223.19,
Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,45.47,223.19,APC
Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,45.47,223.19,APC
Alloskin,Q4123,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,45.47,223.19,APC
Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,92.55,,,,,,,fee schedule,92.55,223.19,
Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92.55,,,,,,,fee schedule,92.55,223.19,
Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.55,,,,,,,fee schedule,92.55,223.19,
Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,106.43,,,,,,,fee schedule,92.55,223.19,
Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,92.55,223.19,APC
Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,92.55,223.19,APC
Grafix core,Q4132,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,92.55,223.19,APC
Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.32,,,,,,,fee schedule,124,223.19,
Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.32,,,,,,,fee schedule,124,223.19,
Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.32,,,,,,,fee schedule,124,223.19,
Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.52,,,,,,,fee schedule,124,223.19,
Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
Grafix prime,Q4133,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.52,,,,,,,fee schedule,104.52,223.19,
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.52,,,,,,,fee schedule,104.52,223.19,
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.52,,,,,,,fee schedule,104.52,223.19,
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,120.2,,,,,,,fee schedule,104.52,223.19,
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,104.52,223.19,APC
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,104.52,223.19,APC
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,104.52,223.19,APC
"Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,104.19,,,,,,,fee schedule,104.19,223.19,
"Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.19,,,,,,,fee schedule,104.19,223.19,
"Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.19,,,,,,,fee schedule,104.19,223.19,
"Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,119.82,,,,,,,fee schedule,104.19,223.19,
"Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,104.19,223.19,APC
"Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,104.19,223.19,APC
"Biodfence dryflex, 1cm",Q4138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,104.19,223.19,APC
Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,171.06,,,,,,,fee schedule,124,223.19,
Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.06,,,,,,,fee schedule,124,223.19,
Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,171.06,,,,,,,fee schedule,124,223.19,
Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,196.72,,,,,,,fee schedule,124,223.19,
Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
Biodfence 1cm,Q4140,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,67.19,,,,,,,fee schedule,67.19,223.19,
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67.19,,,,,,,fee schedule,67.19,223.19,
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,67.19,,,,,,,fee schedule,67.19,223.19,
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,77.27,,,,,,,fee schedule,67.19,223.19,
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,67.19,223.19,APC
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,67.19,223.19,APC
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,67.19,223.19,APC
"Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,35.2,,,,,,,fee schedule,35.2,223.19,
"Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.2,,,,,,,fee schedule,35.2,223.19,
"Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,35.2,,,,,,,fee schedule,35.2,223.19,
"Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,40.48,,,,,,,fee schedule,35.2,223.19,
"Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,35.2,223.19,APC
"Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,35.2,223.19,APC
"Repriza, 1cm",Q4143,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,35.2,223.19,APC
"Epifix, inj, 1mg",Q4145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.21,,,,,,,fee schedule,20.21,23.24,
"Epifix, inj, 1mg",Q4145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.21,,,,,,,fee schedule,20.21,23.24,
"Epifix, inj, 1mg",Q4145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.21,,,,,,,fee schedule,20.21,23.24,
"Epifix, inj, 1mg",Q4145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.24,,,,,,,fee schedule,20.21,23.24,
Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,48.56,,,,,,,fee schedule,48.56,223.19,
Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48.56,,,,,,,fee schedule,48.56,223.19,
Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,48.56,,,,,,,fee schedule,48.56,223.19,
Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,55.84,,,,,,,fee schedule,48.56,223.19,
Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,48.56,223.19,APC
Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,48.56,223.19,APC
Architect ecm px fx 1 sq cm,Q4147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,48.56,223.19,APC
"Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.82,,,,,,,fee schedule,124,223.19,
"Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.82,,,,,,,fee schedule,124,223.19,
"Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,130.82,,,,,,,fee schedule,124,223.19,
"Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,150.44,,,,,,,fee schedule,124,223.19,
"Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
"Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
"Neox 1k, 1cm",Q4148,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,147.9,,,,,,,fee schedule,147.9,170.09,
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.9,,,,,,,fee schedule,147.9,170.09,
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,147.9,,,,,,,fee schedule,147.9,170.09,
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.09,,,,,,,fee schedule,147.9,170.09,
Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,88.06,,,,,,,fee schedule,88.06,223.19,
Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88.06,,,,,,,fee schedule,88.06,223.19,
Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,88.06,,,,,,,fee schedule,88.06,223.19,
Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,101.27,,,,,,,fee schedule,88.06,223.19,
Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,88.06,223.19,APC
Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,88.06,223.19,APC
Allowrap ds or dry 1 sq cm,Q4150,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,88.06,223.19,APC
"Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,142.37,,,,,,,fee schedule,124,223.19,
"Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,142.37,,,,,,,fee schedule,124,223.19,
"Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.37,,,,,,,fee schedule,124,223.19,
"Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,163.73,,,,,,,fee schedule,124,223.19,
"Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
"Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
"Amnioband, guardian 1 sq cm",Q4151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.12,,,,,,,fee schedule,47.12,223.19,
Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.12,,,,,,,fee schedule,47.12,223.19,
Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.12,,,,,,,fee schedule,47.12,223.19,
Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.19,,,,,,,fee schedule,47.12,223.19,
Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,47.12,223.19,APC
Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,47.12,223.19,APC
Dermapure 1 square cm,Q4152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,47.12,223.19,APC
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,112.7,,,,,,,fee schedule,112.7,223.19,
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112.7,,,,,,,fee schedule,112.7,223.19,
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,112.7,,,,,,,fee schedule,112.7,223.19,
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,129.61,,,,,,,fee schedule,112.7,223.19,
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,112.7,223.19,APC
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,112.7,223.19,APC
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,112.7,223.19,APC
Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,148.25,,,,,,,fee schedule,124,223.19,
Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.25,,,,,,,fee schedule,124,223.19,
Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.25,,,,,,,fee schedule,124,223.19,
Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,170.49,,,,,,,fee schedule,124,223.19,
Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
Biovance 1 square cm,Q4154,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
Neoxflo or clarixflo 1 mg,Q4155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.34,,,,,,,fee schedule,28.34,32.59,
Neoxflo or clarixflo 1 mg,Q4155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28.34,,,,,,,fee schedule,28.34,32.59,
Neoxflo or clarixflo 1 mg,Q4155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.34,,,,,,,fee schedule,28.34,32.59,
Neoxflo or clarixflo 1 mg,Q4155,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.59,,,,,,,fee schedule,28.34,32.59,
Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.85,,,,,,,fee schedule,68.85,223.19,
Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.85,,,,,,,fee schedule,68.85,223.19,
Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.85,,,,,,,fee schedule,68.85,223.19,
Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.18,,,,,,,fee schedule,68.85,223.19,
Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,68.85,223.19,APC
Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,68.85,223.19,APC
Neox 100 1 square cm,Q4156,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,68.85,223.19,APC
Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,178.13,,,,,,,fee schedule,124,223.19,
Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,178.13,,,,,,,fee schedule,124,223.19,
Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,178.13,,,,,,,fee schedule,124,223.19,
Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,204.85,,,,,,,fee schedule,124,223.19,
Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
Revitalon 1 square cm,Q4157,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.82,,,,,,,fee schedule,68.82,223.19,
Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68.82,,,,,,,fee schedule,68.82,223.19,
Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,68.82,,,,,,,fee schedule,68.82,223.19,
Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,79.14,,,,,,,fee schedule,68.82,223.19,
Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,68.82,223.19,APC
Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,68.82,223.19,APC
Marigen 1 square cm,Q4158,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,68.82,223.19,APC
Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,244.05,,,,,,,fee schedule,124,280.66,
Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,244.05,,,,,,,fee schedule,124,280.66,
Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,244.05,,,,,,,fee schedule,124,280.66,
Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,280.66,,,,,,,fee schedule,124,280.66,
Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,280.66,APC
Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,280.66,APC
Affinity1 square cm,Q4159,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,280.66,APC
Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,550,,,,,,,fee schedule,124,632.5,
Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,550,,,,,,,fee schedule,124,632.5,
Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,550,,,,,,,fee schedule,124,632.5,
Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,632.5,,,,,,,fee schedule,124,632.5,
Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,632.5,APC
Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,632.5,APC
Nushield 1 square cm,Q4160,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,632.5,APC
Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1716.22,,,,,,,fee schedule,124,1973.65,
Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1716.22,,,,,,,fee schedule,124,1973.65,
Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1716.22,,,,,,,fee schedule,124,1973.65,
Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1973.65,,,,,,,fee schedule,124,1973.65,
Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,1973.65,APC
Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,1973.65,APC
Bio-connekt per square cm,Q4161,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,1973.65,APC
Amnio bio and woundex flow,Q4162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1870,,,,,,,fee schedule,1870,2150.5,
Amnio bio and woundex flow,Q4162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1870,,,,,,,fee schedule,1870,2150.5,
Amnio bio and woundex flow,Q4162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1870,,,,,,,fee schedule,1870,2150.5,
Amnio bio and woundex flow,Q4162,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2150.5,,,,,,,fee schedule,1870,2150.5,
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,189.06,,,,,,,fee schedule,124,223.19,
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,189.06,,,,,,,fee schedule,124,223.19,
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,189.06,,,,,,,fee schedule,124,223.19,
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,217.42,,,,,,,fee schedule,124,223.19,
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
"Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1702.85,,,,,,,fee schedule,124,1958.28,
"Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1702.85,,,,,,,fee schedule,124,1958.28,
"Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1702.85,,,,,,,fee schedule,124,1958.28,
"Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1958.28,,,,,,,fee schedule,124,1958.28,
"Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,1958.28,APC
"Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,1958.28,APC
"Helicoll, per square cm",Q4164,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,1958.28,APC
"Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,45.25,,,,,,,fee schedule,45.25,223.19,
"Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45.25,,,,,,,fee schedule,45.25,223.19,
"Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,45.25,,,,,,,fee schedule,45.25,223.19,
"Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,52.04,,,,,,,fee schedule,45.25,223.19,
"Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,45.25,223.19,APC
"Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,45.25,223.19,APC
"Keramatrix, per square cm",Q4165,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,45.25,223.19,APC
"Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.63,,,,,,,fee schedule,21.63,223.19,
"Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.63,,,,,,,fee schedule,21.63,223.19,
"Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.63,,,,,,,fee schedule,21.63,223.19,
"Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.87,,,,,,,fee schedule,21.63,223.19,
"Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,21.63,223.19,APC
"Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,21.63,223.19,APC
"Cytal, per square centimeter",Q4166,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,21.63,223.19,APC
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.8,,,,,,,fee schedule,102.8,223.19,
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.8,,,,,,,fee schedule,102.8,223.19,
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.8,,,,,,,fee schedule,102.8,223.19,
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,118.22,,,,,,,fee schedule,102.8,223.19,
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,102.8,223.19,APC
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,102.8,223.19,APC
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,102.8,223.19,APC
"Amnioband, 1 mg",Q4168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.7,,,,,,,fee schedule,17.7,20.36,
"Amnioband, 1 mg",Q4168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.7,,,,,,,fee schedule,17.7,20.36,
"Amnioband, 1 mg",Q4168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.7,,,,,,,fee schedule,17.7,20.36,
"Amnioband, 1 mg",Q4168,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.36,,,,,,,fee schedule,17.7,20.36,
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2304.37,,,,,,,fee schedule,124,2650.03,
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2304.37,,,,,,,fee schedule,124,2650.03,
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2304.37,,,,,,,fee schedule,124,2650.03,
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2650.03,,,,,,,fee schedule,124,2650.03,
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,2650.03,APC
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,2650.03,APC
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,2650.03,APC
"Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.12,,,,,,,fee schedule,43.12,223.19,
"Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43.12,,,,,,,fee schedule,43.12,223.19,
"Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.12,,,,,,,fee schedule,43.12,223.19,
"Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.59,,,,,,,fee schedule,43.12,223.19,
"Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,43.12,223.19,APC
"Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,43.12,223.19,APC
"Cygnus, per sq cm",Q4170,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,43.12,223.19,APC
"Interfyl, 1 mg",Q4171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.01,,,,,,,fee schedule,11.01,12.66,
"Interfyl, 1 mg",Q4171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.01,,,,,,,fee schedule,11.01,12.66,
"Interfyl, 1 mg",Q4171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.01,,,,,,,fee schedule,11.01,12.66,
"Interfyl, 1 mg",Q4171,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.66,,,,,,,fee schedule,11.01,12.66,
Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,370.01,,,,,,,fee schedule,124,425.51,
Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,370.01,,,,,,,fee schedule,124,425.51,
Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,370.01,,,,,,,fee schedule,124,425.51,
Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,425.51,,,,,,,fee schedule,124,425.51,
Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,425.51,APC
Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,425.51,APC
Palingen or palingen xplus,Q4173,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,425.51,APC
Palingen or promatrx,Q4174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1269.9,,,,,,,fee schedule,1269.9,1460.39,
Palingen or promatrx,Q4174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1269.9,,,,,,,fee schedule,1269.9,1460.39,
Palingen or promatrx,Q4174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1269.9,,,,,,,fee schedule,1269.9,1460.39,
Palingen or promatrx,Q4174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1460.39,,,,,,,fee schedule,1269.9,1460.39,
Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,70.27,,,,,,,fee schedule,70.27,223.19,
Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70.27,,,,,,,fee schedule,70.27,223.19,
Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,70.27,,,,,,,fee schedule,70.27,223.19,
Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,80.81,,,,,,,fee schedule,70.27,223.19,
Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,70.27,223.19,APC
Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,70.27,223.19,APC
Miroderm,Q4175,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,70.27,223.19,APC
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.5,,,,,,,fee schedule,124,223.19,
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161.5,,,,,,,fee schedule,124,223.19,
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,161.5,,,,,,,fee schedule,124,223.19,
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.73,,,,,,,fee schedule,124,223.19,
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
"Floweramnioflo, 0.1 cc",Q4177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,153,,,,,,,fee schedule,153,175.95,
"Floweramnioflo, 0.1 cc",Q4177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,153,,,,,,,fee schedule,153,175.95,
"Floweramnioflo, 0.1 cc",Q4177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,153,,,,,,,fee schedule,153,175.95,
"Floweramnioflo, 0.1 cc",Q4177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,175.95,,,,,,,fee schedule,153,175.95,
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,96.62,,,,,,,fee schedule,96.62,223.19,
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96.62,,,,,,,fee schedule,96.62,223.19,
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.62,,,,,,,fee schedule,96.62,223.19,
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,111.11,,,,,,,fee schedule,96.62,223.19,
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,96.62,223.19,APC
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,96.62,223.19,APC
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,96.62,223.19,APC
"Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1131.2,,,,,,,fee schedule,124,1300.88,
"Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1131.2,,,,,,,fee schedule,124,1300.88,
"Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1131.2,,,,,,,fee schedule,124,1300.88,
"Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1300.88,,,,,,,fee schedule,124,1300.88,
"Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,1300.88,APC
"Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,1300.88,APC
"Revita, per sq cm",Q4180,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,1300.88,APC
"Transcyte, per sq centimeter",Q4182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.12,,,,,,,fee schedule,40.12,223.19,
"Transcyte, per sq centimeter",Q4182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.12,,,,,,,fee schedule,40.12,223.19,
"Transcyte, per sq centimeter",Q4182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.12,,,,,,,fee schedule,40.12,223.19,
"Transcyte, per sq centimeter",Q4182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.14,,,,,,,fee schedule,40.12,223.19,
"Transcyte, per sq centimeter",Q4182,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,40.12,223.19,APC
"Transcyte, per sq centimeter",Q4182,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,40.12,223.19,APC
"Transcyte, per sq centimeter",Q4182,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,40.12,223.19,APC
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85,,,,,,,fee schedule,85,223.19,
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85,,,,,,,fee schedule,85,223.19,
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85,,,,,,,fee schedule,85,223.19,
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.75,,,,,,,fee schedule,85,223.19,
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,85,223.19,APC
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,85,223.19,APC
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,85,223.19,APC
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,83.06,,,,,,,fee schedule,83.06,223.19,
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.06,,,,,,,fee schedule,83.06,223.19,
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.06,,,,,,,fee schedule,83.06,223.19,
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,95.52,,,,,,,fee schedule,83.06,223.19,
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,83.06,223.19,APC
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,83.06,223.19,APC
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,83.06,223.19,APC
Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156,,,,,,,fee schedule,124,223.19,
Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156,,,,,,,fee schedule,124,223.19,
Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,156,,,,,,,fee schedule,124,223.19,
Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,179.4,,,,,,,fee schedule,124,223.19,
Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
Epifix 1 sq cm,Q4186,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,251,,,,,,,fee schedule,124,288.65,
Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251,,,,,,,fee schedule,124,288.65,
Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251,,,,,,,fee schedule,124,288.65,
Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,288.65,,,,,,,fee schedule,124,288.65,
Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,288.65,APC
Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,288.65,APC
Epicord 1 sq cm,Q4187,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,288.65,APC
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,505.99,,,,,,,fee schedule,124,581.89,
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,505.99,,,,,,,fee schedule,124,581.89,
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,505.99,,,,,,,fee schedule,124,581.89,
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,581.89,,,,,,,fee schedule,124,581.89,
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,581.89,APC
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,581.89,APC
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,581.89,APC
"Artacent ac, 1 mg",Q4189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,21.27,,,,,,,fee schedule,21.27,24.46,
"Artacent ac, 1 mg",Q4189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.27,,,,,,,fee schedule,21.27,24.46,
"Artacent ac, 1 mg",Q4189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.27,,,,,,,fee schedule,21.27,24.46,
"Artacent ac, 1 mg",Q4189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,24.46,,,,,,,fee schedule,21.27,24.46,
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,134.3,,,,,,,fee schedule,124,223.19,
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,134.3,,,,,,,fee schedule,124,223.19,
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,134.3,,,,,,,fee schedule,124,223.19,
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,154.45,,,,,,,fee schedule,124,223.19,
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,757.99,,,,,,,fee schedule,124,871.69,
Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,757.99,,,,,,,fee schedule,124,871.69,
Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,757.99,,,,,,,fee schedule,124,871.69,
Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,871.69,,,,,,,fee schedule,124,871.69,
Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,871.69,APC
Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,871.69,APC
Restorigin 1 sq cm,Q4191,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,871.69,APC
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1777.83,,,,,,,fee schedule,124,2044.5,
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1777.83,,,,,,,fee schedule,124,2044.5,
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1777.83,,,,,,,fee schedule,124,2044.5,
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2044.5,,,,,,,fee schedule,124,2044.5,
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,2044.5,APC
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,2044.5,APC
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,2044.5,APC
Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,744.87,,,,,,,fee schedule,124,856.6,
Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,744.87,,,,,,,fee schedule,124,856.6,
Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,744.87,,,,,,,fee schedule,124,856.6,
Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,856.6,,,,,,,fee schedule,124,856.6,
Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,856.6,APC
Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,856.6,APC
Novachor 1 sq cm,Q4194,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,856.6,APC
Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,111.99,,,,,,,fee schedule,111.99,223.19,
Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,111.99,,,,,,,fee schedule,111.99,223.19,
Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,111.99,,,,,,,fee schedule,111.99,223.19,
Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,128.79,,,,,,,fee schedule,111.99,223.19,
Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,111.99,223.19,APC
Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,111.99,223.19,APC
Puraply 1 sq cm,Q4195,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,111.99,223.19,APC
Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.26,,,,,,,fee schedule,102.26,223.19,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.26,,,,,,,fee schedule,102.26,223.19,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.26,,,,,,,fee schedule,102.26,223.19,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.6,,,,,,,fee schedule,102.26,223.19,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,102.26,223.19,APC
Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,102.26,223.19,APC
Puraply am 1 sq cm,Q4196,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,102.26,223.19,APC
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,73.72,,,,,,,fee schedule,73.72,223.19,
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.72,,,,,,,fee schedule,73.72,223.19,
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,73.72,,,,,,,fee schedule,73.72,223.19,
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,84.78,,,,,,,fee schedule,73.72,223.19,
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,73.72,223.19,APC
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,73.72,223.19,APC
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,73.72,223.19,APC
Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,82.22,,,,,,,fee schedule,82.22,223.19,
Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82.22,,,,,,,fee schedule,82.22,223.19,
Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.22,,,,,,,fee schedule,82.22,223.19,
Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,94.55,,,,,,,fee schedule,82.22,223.19,
Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,82.22,223.19,APC
Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,82.22,223.19,APC
Matrion 1 sq cm,Q4201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,82.22,223.19,APC
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,904.25,,,,,,,fee schedule,124,1039.89,
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,904.25,,,,,,,fee schedule,124,1039.89,
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,904.25,,,,,,,fee schedule,124,1039.89,
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1039.89,,,,,,,fee schedule,124,1039.89,
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,1039.89,APC
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,1039.89,APC
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,1039.89,APC
Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3917.22,,,,,,,fee schedule,124,4504.8,
Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3917.22,,,,,,,fee schedule,124,4504.8,
Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3917.22,,,,,,,fee schedule,124,4504.8,
Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4504.8,,,,,,,fee schedule,124,4504.8,
Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,4504.8,APC
Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,4504.8,APC
Xwrap 1 sq cm,Q4204,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,4504.8,APC
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1235.36,,,,,,,fee schedule,124,1420.66,
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1235.36,,,,,,,fee schedule,124,1420.66,
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1235.36,,,,,,,fee schedule,124,1420.66,
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1420.66,,,,,,,fee schedule,124,1420.66,
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,1420.66,APC
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,1420.66,APC
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,1420.66,APC
Fluid flow or fluid gf 1 cc,Q4206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2448,,,,,,,fee schedule,2448,2815.2,
Fluid flow or fluid gf 1 cc,Q4206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2448,,,,,,,fee schedule,2448,2815.2,
Fluid flow or fluid gf 1 cc,Q4206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2448,,,,,,,fee schedule,2448,2815.2,
Fluid flow or fluid gf 1 cc,Q4206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2815.2,,,,,,,fee schedule,2448,2815.2,
Novafix per sq cm,Q4208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,408,,,,,,,fee schedule,124,469.2,
Novafix per sq cm,Q4208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,408,,,,,,,fee schedule,124,469.2,
Novafix per sq cm,Q4208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,408,,,,,,,fee schedule,124,469.2,
Novafix per sq cm,Q4208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,469.2,,,,,,,fee schedule,124,469.2,
Novafix per sq cm,Q4208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,469.2,APC
Novafix per sq cm,Q4208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,469.2,APC
Novafix per sq cm,Q4208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,469.2,APC
"Ascent, 0.5 mg",Q4213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,58.6,,,,,,,fee schedule,58.6,67.39,
"Ascent, 0.5 mg",Q4213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58.6,,,,,,,fee schedule,58.6,67.39,
"Ascent, 0.5 mg",Q4213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,58.6,,,,,,,fee schedule,58.6,67.39,
"Ascent, 0.5 mg",Q4213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,67.39,,,,,,,fee schedule,58.6,67.39,
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,330,,,,,,,fee schedule,124,379.5,
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,330,,,,,,,fee schedule,124,379.5,
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,330,,,,,,,fee schedule,124,379.5,
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,379.5,,,,,,,fee schedule,124,379.5,
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,379.5,APC
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,379.5,APC
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,379.5,APC
Surgicord per sq cm,Q4218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.5,,,,,,,fee schedule,124,223.19,
Surgicord per sq cm,Q4218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127.5,,,,,,,fee schedule,124,223.19,
Surgicord per sq cm,Q4218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,127.5,,,,,,,fee schedule,124,223.19,
Surgicord per sq cm,Q4218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.63,,,,,,,fee schedule,124,223.19,
Surgicord per sq cm,Q4218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
Surgicord per sq cm,Q4218,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
Surgicord per sq cm,Q4218,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1020,,,,,,,fee schedule,124,1173,
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1020,,,,,,,fee schedule,124,1173,
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1020,,,,,,,fee schedule,124,1173,
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1173,,,,,,,fee schedule,124,1173,
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,1173,APC
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,1173,APC
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,1173,APC
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2035,,,,,,,fee schedule,124,2340.25,
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2035,,,,,,,fee schedule,124,2340.25,
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2035,,,,,,,fee schedule,124,2340.25,
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2340.25,,,,,,,fee schedule,124,2340.25,
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,2340.25,APC
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,2340.25,APC
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,2340.25,APC
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,132.36,,,,,,,fee schedule,124,223.19,
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132.36,,,,,,,fee schedule,124,223.19,
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.36,,,,,,,fee schedule,124,223.19,
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,152.21,,,,,,,fee schedule,124,223.19,
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,223.19,APC
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,223.19,APC
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,223.19,APC
Myown harv prep proc sq cm,Q4226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1224,,,,,,,fee schedule,1224,1407.6,
Myown harv prep proc sq cm,Q4226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1224,,,,,,,fee schedule,1224,1407.6,
Myown harv prep proc sq cm,Q4226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1224,,,,,,,fee schedule,1224,1407.6,
Myown harv prep proc sq cm,Q4226,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1407.6,,,,,,,fee schedule,1224,1407.6,
Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1209.36,,,,,,,fee schedule,124,1390.76,
Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1209.36,,,,,,,fee schedule,124,1390.76,
Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1209.36,,,,,,,fee schedule,124,1390.76,
Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1390.76,,,,,,,fee schedule,124,1390.76,
Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,1390.76,APC
Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,1390.76,APC
Amniocore per sq cm,Q4227,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,1390.76,APC
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,342.78,,,,,,,fee schedule,124,394.2,
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,342.78,,,,,,,fee schedule,124,394.2,
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,342.78,,,,,,,fee schedule,124,394.2,
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,394.2,,,,,,,fee schedule,124,394.2,
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.2,,,,,,,fee schedule,124,394.2,APC
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,124,,,,,,,fee schedule,124,394.2,APC
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,223.19,,,,,,,fee schedule,124,394.2,APC
"Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.65,,,,,,,fee schedule,11.55,20.79,
"Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.65,,,,,,,fee schedule,11.55,20.79,
"Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.65,,,,,,,fee schedule,11.55,20.79,
"Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,13.4,,,,,,,fee schedule,11.55,20.79,
"Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.13,,,,,,,fee schedule,11.55,20.79,APC
"Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11.55,,,,,,,fee schedule,11.55,20.79,APC
"Inj ustekinumab-srlf, 1 mg",Q5098,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20.79,,,,,,,fee schedule,11.55,20.79,APC
"Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.38,,,,,,,fee schedule,2.38,5.54,
"Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.38,,,,,,,fee schedule,2.38,5.54,
"Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.38,,,,,,,fee schedule,2.38,5.54,
"Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.74,,,,,,,fee schedule,2.38,5.54,
"Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.23,,,,,,,fee schedule,2.38,5.54,APC
"Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.08,,,,,,,fee schedule,2.38,5.54,APC
"Inj ustekinumab-stba, 1 mg",Q5099,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.54,,,,,,,fee schedule,2.38,5.54,APC
"Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.14,,,,,,,fee schedule,3.14,5.92,
"Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.14,,,,,,,fee schedule,3.14,5.92,
"Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.14,,,,,,,fee schedule,3.14,5.92,
"Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.61,,,,,,,fee schedule,3.14,5.92,
"Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.45,,,,,,,fee schedule,3.14,5.92,APC
"Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,3.29,,,,,,,fee schedule,3.14,5.92,APC
"Inj ustekinumab-kfce, 1 mg",Q5100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,5.92,,,,,,,fee schedule,3.14,5.92,APC
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.32,,,,,,,fee schedule,0.32,0.64,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.32,,,,,,,fee schedule,0.32,0.64,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.32,,,,,,,fee schedule,0.32,0.64,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.37,,,,,,,fee schedule,0.32,0.64,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.37,,,,,,,fee schedule,0.32,0.64,APC
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.35,,,,,,,fee schedule,0.32,0.64,APC
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.64,,,,,,,fee schedule,0.32,0.64,APC
"Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.06,,,,,,,fee schedule,19.06,49.88,
"Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.06,,,,,,,fee schedule,19.06,49.88,
"Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.06,,,,,,,fee schedule,19.06,49.88,
"Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,21.92,,,,,,,fee schedule,19.06,49.88,
"Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.1,,,,,,,fee schedule,19.06,49.88,APC
"Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.71,,,,,,,fee schedule,19.06,49.88,APC
"Injection, inflectra",Q5103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49.88,,,,,,,fee schedule,19.06,49.88,APC
"Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,24.97,,,,,,,fee schedule,24.97,47.91,
"Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24.97,,,,,,,fee schedule,24.97,47.91,
"Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.97,,,,,,,fee schedule,24.97,47.91,
"Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.72,,,,,,,fee schedule,24.97,47.91,
"Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.95,,,,,,,fee schedule,24.97,47.91,APC
"Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26.62,,,,,,,fee schedule,24.97,47.91,APC
"Injection, renflexis",Q5104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47.91,,,,,,,fee schedule,24.97,47.91,APC
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.77,,,,,,,fee schedule,0.77,0.89,
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.77,,,,,,,fee schedule,0.77,0.89,
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.77,,,,,,,fee schedule,0.77,0.89,
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.89,,,,,,,fee schedule,0.77,0.89,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.69,,,,,,,fee schedule,7.69,14.34,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7.69,,,,,,,fee schedule,7.69,14.34,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.69,,,,,,,fee schedule,7.69,14.34,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,8.84,,,,,,,fee schedule,7.69,14.34,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.37,,,,,,,fee schedule,7.69,14.34,APC
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7.97,,,,,,,fee schedule,7.69,14.34,APC
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14.34,,,,,,,fee schedule,7.69,14.34,APC
Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.59,,,,,,,fee schedule,24.53,44.16,
Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.59,,,,,,,fee schedule,24.53,44.16,
Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.59,,,,,,,fee schedule,24.53,44.16,
Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.58,,,,,,,fee schedule,24.53,44.16,
Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.76,,,,,,,fee schedule,24.53,44.16,APC
Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.53,,,,,,,fee schedule,24.53,44.16,APC
Inj mvasi 10 mg,Q5107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.16,,,,,,,fee schedule,24.53,44.16,APC
"Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.62,,,,,,,fee schedule,67.02,123.76,
"Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.62,,,,,,,fee schedule,67.02,123.76,
"Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.62,,,,,,,fee schedule,67.02,123.76,
"Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.76,,,,,,,fee schedule,67.02,123.76,
"Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.38,,,,,,,fee schedule,67.02,123.76,APC
"Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67.02,,,,,,,fee schedule,67.02,123.76,APC
"Injection, fulphila",Q5108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120.64,,,,,,,fee schedule,67.02,123.76,APC
Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.58,
Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.23,,,,,,,fee schedule,0.23,0.58,
Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.23,,,,,,,fee schedule,0.23,0.58,
Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.26,,,,,,,fee schedule,0.23,0.58,
Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.34,,,,,,,fee schedule,0.23,0.58,APC
Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.32,,,,,,,fee schedule,0.23,0.58,APC
Nivestym,Q5110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.58,,,,,,,fee schedule,0.23,0.58,APC
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,141.18,,,,,,,fee schedule,141.18,268.44,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.18,,,,,,,fee schedule,141.18,268.44,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,141.18,,,,,,,fee schedule,141.18,268.44,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,162.36,,,,,,,fee schedule,141.18,268.44,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,156.59,,,,,,,fee schedule,141.18,268.44,APC
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,149.13,,,,,,,fee schedule,141.18,268.44,APC
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,268.44,,,,,,,fee schedule,141.18,268.44,APC
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,17.86,,,,,,,fee schedule,17.86,37.78,
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17.86,,,,,,,fee schedule,17.86,37.78,
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.86,,,,,,,fee schedule,17.86,37.78,
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,20.54,,,,,,,fee schedule,17.86,37.78,
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.04,,,,,,,fee schedule,17.86,37.78,APC
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.99,,,,,,,fee schedule,17.86,37.78,APC
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37.78,,,,,,,fee schedule,17.86,37.78,APC
Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,78.92,,,,,,,fee schedule,54.94,98.9,
Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78.92,,,,,,,fee schedule,54.94,98.9,
Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,78.92,,,,,,,fee schedule,54.94,98.9,
Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.76,,,,,,,fee schedule,54.94,98.9,
Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.69,,,,,,,fee schedule,54.94,98.9,APC
Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.94,,,,,,,fee schedule,54.94,98.9,APC
Inj herzuma 10 mg,Q5113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,98.9,,,,,,,fee schedule,54.94,98.9,APC
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.72,,,,,,,fee schedule,31.94,57.5,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.72,,,,,,,fee schedule,31.94,57.5,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.72,,,,,,,fee schedule,31.94,57.5,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.13,,,,,,,fee schedule,31.94,57.5,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.54,,,,,,,fee schedule,31.94,57.5,APC
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.94,,,,,,,fee schedule,31.94,57.5,APC
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57.5,,,,,,,fee schedule,31.94,57.5,APC
Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.99,,,,,,,fee schedule,27.99,62.21,
Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.99,,,,,,,fee schedule,27.99,62.21,
Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.99,,,,,,,fee schedule,27.99,62.21,
Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.19,,,,,,,fee schedule,27.99,62.21,
Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.29,,,,,,,fee schedule,27.99,62.21,APC
Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34.56,,,,,,,fee schedule,27.99,62.21,APC
Inj truxima 10 mg,Q5115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,62.21,,,,,,,fee schedule,27.99,62.21,APC
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.15,,,,,,,fee schedule,13.03,28.92,
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.15,,,,,,,fee schedule,13.03,28.92,
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.15,,,,,,,fee schedule,13.03,28.92,
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,28.92,,,,,,,fee schedule,13.03,28.92,
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.68,,,,,,,fee schedule,13.03,28.92,APC
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.03,,,,,,,fee schedule,13.03,28.92,APC
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.46,,,,,,,fee schedule,13.03,28.92,APC
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.28,,,,,,,fee schedule,41.28,108.94,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.28,,,,,,,fee schedule,41.28,108.94,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.28,,,,,,,fee schedule,41.28,108.94,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,47.47,,,,,,,fee schedule,41.28,108.94,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.55,,,,,,,fee schedule,41.28,108.94,APC
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60.52,,,,,,,fee schedule,41.28,108.94,APC
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,108.94,,,,,,,fee schedule,41.28,108.94,APC
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,23.59,,,,,,,fee schedule,23.59,46.6,
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.59,,,,,,,fee schedule,23.59,46.6,
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,23.59,,,,,,,fee schedule,23.59,46.6,
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,27.13,,,,,,,fee schedule,23.59,46.6,
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.18,,,,,,,fee schedule,23.59,46.6,APC
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25.89,,,,,,,fee schedule,23.59,46.6,APC
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46.6,,,,,,,fee schedule,23.59,46.6,APC
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.85,,,,,,,fee schedule,16.16,29.09,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.85,,,,,,,fee schedule,16.16,29.09,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.85,,,,,,,fee schedule,16.16,29.09,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.28,,,,,,,fee schedule,16.16,29.09,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.97,,,,,,,fee schedule,16.16,29.09,APC
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16.16,,,,,,,fee schedule,16.16,29.09,APC
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29.09,,,,,,,fee schedule,16.16,29.09,APC
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,25.94,,,,,,,fee schedule,25.94,237.77,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25.94,,,,,,,fee schedule,25.94,237.77,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,25.94,,,,,,,fee schedule,25.94,237.77,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,29.83,,,,,,,fee schedule,25.94,237.77,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.7,,,,,,,fee schedule,25.94,237.77,APC
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.1,,,,,,,fee schedule,25.94,237.77,APC
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,237.77,,,,,,,fee schedule,25.94,237.77,APC
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,20.39,,,,,,,fee schedule,20.39,55.49,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20.39,,,,,,,fee schedule,20.39,55.49,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,20.39,,,,,,,fee schedule,20.39,55.49,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,23.45,,,,,,,fee schedule,20.39,55.49,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.37,,,,,,,fee schedule,20.39,55.49,APC
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30.83,,,,,,,fee schedule,20.39,55.49,APC
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55.49,,,,,,,fee schedule,20.39,55.49,APC
"Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,137.02,,,,,,,fee schedule,136.91,246.44,
"Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137.02,,,,,,,fee schedule,136.91,246.44,
"Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.02,,,,,,,fee schedule,136.91,246.44,
"Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.57,,,,,,,fee schedule,136.91,246.44,
"Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.76,,,,,,,fee schedule,136.91,246.44,APC
"Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,136.91,,,,,,,fee schedule,136.91,246.44,APC
"Inj, nyvepria",Q5122,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,246.44,,,,,,,fee schedule,136.91,246.44,APC
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.6,,,,,,,fee schedule,18.53,33.36,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.6,,,,,,,fee schedule,18.53,33.36,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,26.6,,,,,,,fee schedule,18.53,33.36,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.59,,,,,,,fee schedule,18.53,33.36,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.46,,,,,,,fee schedule,18.53,33.36,APC
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18.53,,,,,,,fee schedule,18.53,33.36,APC
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33.36,,,,,,,fee schedule,18.53,33.36,APC
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,60.8,,,,,,,fee schedule,60.8,433.75,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60.8,,,,,,,fee schedule,60.8,433.75,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,60.8,,,,,,,fee schedule,60.8,433.75,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,69.92,,,,,,,fee schedule,60.8,433.75,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,253.02,,,,,,,fee schedule,60.8,433.75,APC
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,240.97,,,,,,,fee schedule,60.8,433.75,APC
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,433.75,,,,,,,fee schedule,60.8,433.75,APC
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.37,,,,,,,fee schedule,0.31,0.56,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.37,,,,,,,fee schedule,0.31,0.56,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.37,,,,,,,fee schedule,0.31,0.56,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.43,,,,,,,fee schedule,0.31,0.56,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.33,,,,,,,fee schedule,0.31,0.56,APC
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,0.31,,,,,,,fee schedule,0.31,0.56,APC
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,0.56,,,,,,,fee schedule,0.31,0.56,APC
Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,40.8,,,,,,,fee schedule,40.8,143.9,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40.8,,,,,,,fee schedule,40.8,143.9,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,40.8,,,,,,,fee schedule,40.8,143.9,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,46.92,,,,,,,fee schedule,40.8,143.9,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.94,,,,,,,fee schedule,40.8,143.9,APC
Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.94,,,,,,,fee schedule,40.8,143.9,APC
Inj alymsys 10 mg,Q5126,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,143.9,,,,,,,fee schedule,40.8,143.9,APC
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,237.76,,,,,,,fee schedule,143.67,273.42,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,237.76,,,,,,,fee schedule,143.67,273.42,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,237.76,,,,,,,fee schedule,143.67,273.42,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,273.42,,,,,,,fee schedule,143.67,273.42,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,150.86,,,,,,,fee schedule,143.67,273.42,APC
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,143.67,,,,,,,fee schedule,143.67,273.42,APC
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,258.61,,,,,,,fee schedule,143.67,273.42,APC
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,87.6,,,,,,,fee schedule,82.53,148.55,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87.6,,,,,,,fee schedule,82.53,148.55,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,87.6,,,,,,,fee schedule,82.53,148.55,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,100.74,,,,,,,fee schedule,82.53,148.55,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,86.65,,,,,,,fee schedule,82.53,148.55,APC
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,82.53,,,,,,,fee schedule,82.53,148.55,APC
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,148.55,,,,,,,fee schedule,82.53,148.55,APC
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,41.92,,,,,,,fee schedule,23.65,48.21,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.92,,,,,,,fee schedule,23.65,48.21,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,41.92,,,,,,,fee schedule,23.65,48.21,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,48.21,,,,,,,fee schedule,23.65,48.21,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.83,,,,,,,fee schedule,23.65,48.21,APC
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.65,,,,,,,fee schedule,23.65,48.21,APC
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42.56,,,,,,,fee schedule,23.65,48.21,APC
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,154.84,,,,,,,fee schedule,105.11,189.2,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.84,,,,,,,fee schedule,105.11,189.2,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.84,,,,,,,fee schedule,105.11,189.2,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,178.07,,,,,,,fee schedule,105.11,189.2,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.36,,,,,,,fee schedule,105.11,189.2,APC
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,105.11,,,,,,,fee schedule,105.11,189.2,APC
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,189.2,,,,,,,fee schedule,105.11,189.2,APC
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,6.01,,,,,,,fee schedule,5.01,9.02,
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.01,,,,,,,fee schedule,5.01,9.02,
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,6.01,,,,,,,fee schedule,5.01,9.02,
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.91,,,,,,,fee schedule,5.01,9.02,
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.26,,,,,,,fee schedule,5.01,9.02,APC
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5.01,,,,,,,fee schedule,5.01,9.02,APC
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9.02,,,,,,,fee schedule,5.01,9.02,APC
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,4.68,,,,,,,fee schedule,4.06,7.3,
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.68,,,,,,,fee schedule,4.06,7.3,
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,4.68,,,,,,,fee schedule,4.06,7.3,
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.38,,,,,,,fee schedule,4.06,7.3,
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.26,,,,,,,fee schedule,4.06,7.3,APC
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4.06,,,,,,,fee schedule,4.06,7.3,APC
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,7.3,,,,,,,fee schedule,4.06,7.3,APC
"Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,27.27,,,,,,,fee schedule,27.27,49.8,
"Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27.27,,,,,,,fee schedule,27.27,49.8,
"Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,27.27,,,,,,,fee schedule,27.27,49.8,
"Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,31.36,,,,,,,fee schedule,27.27,49.8,
"Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.05,,,,,,,fee schedule,27.27,49.8,APC
"Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27.66,,,,,,,fee schedule,27.27,49.8,APC
"Inj. denosumab-bbdz, 1 mg",Q5136,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49.8,,,,,,,fee schedule,27.27,49.8,APC
"Inj, wezlana, sub cu, 1 mg",Q5137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,63.11,,,,,,,fee schedule,63.11,72.58,
"Inj, wezlana, sub cu, 1 mg",Q5137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63.11,,,,,,,fee schedule,63.11,72.58,
"Inj, wezlana, sub cu, 1 mg",Q5137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,63.11,,,,,,,fee schedule,63.11,72.58,
"Inj, wezlana, sub cu, 1 mg",Q5137,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,72.58,,,,,,,fee schedule,63.11,72.58,
"Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.12,,,,,,,fee schedule,2.35,12.79,
"Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.12,,,,,,,fee schedule,2.35,12.79,
"Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.12,,,,,,,fee schedule,2.35,12.79,
"Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.79,,,,,,,fee schedule,2.35,12.79,
"Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.47,,,,,,,fee schedule,2.35,12.79,APC
"Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2.35,,,,,,,fee schedule,2.35,12.79,APC
"Inj, wezlana, iv, 1 mg",Q5138,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4.24,,,,,,,fee schedule,2.35,12.79,APC
"Inj adalimumab-ryvk, 1 mg",Q5142,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.23,,,,,,,fee schedule,13.23,15.21,
"Inj adalimumab-ryvk, 1 mg",Q5142,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.23,,,,,,,fee schedule,13.23,15.21,
"Inj adalimumab-ryvk, 1 mg",Q5142,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.23,,,,,,,fee schedule,13.23,15.21,
"Inj adalimumab-ryvk, 1 mg",Q5142,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.21,,,,,,,fee schedule,13.23,15.21,
"Inj, idacio, 1 mg",Q5144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.92,,,,,,,fee schedule,22.92,26.36,
"Inj, idacio, 1 mg",Q5144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.92,,,,,,,fee schedule,22.92,26.36,
"Inj, idacio, 1 mg",Q5144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.92,,,,,,,fee schedule,22.92,26.36,
"Inj, idacio, 1 mg",Q5144,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,26.36,,,,,,,fee schedule,22.92,26.36,
"Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,79.06,,,,,,,fee schedule,32.46,90.92,
"Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79.06,,,,,,,fee schedule,32.46,90.92,
"Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.06,,,,,,,fee schedule,32.46,90.92,
"Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,90.92,,,,,,,fee schedule,32.46,90.92,
"Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.08,,,,,,,fee schedule,32.46,90.92,APC
"Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32.46,,,,,,,fee schedule,32.46,90.92,APC
"Inj, hercessi, 10 mg",Q5146,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58.43,,,,,,,fee schedule,32.46,90.92,APC
"Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,901.88,,,,,,,fee schedule,803.26,1445.86,
"Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,901.88,,,,,,,fee schedule,803.26,1445.86,
"Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,901.88,,,,,,,fee schedule,803.26,1445.86,
"Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1037.16,,,,,,,fee schedule,803.26,1445.86,
"Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,843.42,,,,,,,fee schedule,803.26,1445.86,APC
"Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,803.26,,,,,,,fee schedule,803.26,1445.86,APC
"Inj, aflibercept-ayyh, 1 mg",Q5147,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1445.86,,,,,,,fee schedule,803.26,1445.86,APC
"Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.53,,,,,,,fee schedule,0.53,1.86,
"Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.53,,,,,,,fee schedule,0.53,1.86,
"Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.53,,,,,,,fee schedule,0.53,1.86,
"Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.61,,,,,,,fee schedule,0.53,1.86,
"Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.09,,,,,,,fee schedule,0.53,1.86,APC
"Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1.03,,,,,,,fee schedule,0.53,1.86,APC
"Inj, nyposi 1 mcg",Q5148,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1.86,,,,,,,fee schedule,0.53,1.86,APC
"Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,31.05,,,,,,,fee schedule,31.05,57.2,
"Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31.05,,,,,,,fee schedule,31.05,57.2,
"Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,31.05,,,,,,,fee schedule,31.05,57.2,
"Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,35.71,,,,,,,fee schedule,31.05,57.2,
"Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.37,,,,,,,fee schedule,31.05,57.2,APC
"Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.78,,,,,,,fee schedule,31.05,57.2,APC
"Inj, eculizumab-aagh, 2 mg",Q5151,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57.2,,,,,,,fee schedule,31.05,57.2,APC
"Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.92,,,,,,,fee schedule,39.92,74.1,
"Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.92,,,,,,,fee schedule,39.92,74.1,
"Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.92,,,,,,,fee schedule,39.92,74.1,
"Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.91,,,,,,,fee schedule,39.92,74.1,
"Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.23,,,,,,,fee schedule,39.92,74.1,APC
"Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41.17,,,,,,,fee schedule,39.92,74.1,APC
"Inj, eculizumab-aeeb, 2 mg?",Q5152,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74.1,,,,,,,fee schedule,39.92,74.1,APC
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,19.29,,,,,,,fee schedule,19.29,22.18,
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19.29,,,,,,,fee schedule,19.29,22.18,
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,19.29,,,,,,,fee schedule,19.29,22.18,
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,22.18,,,,,,,fee schedule,19.29,22.18,
"LOCM >= 400 mg/ml iodine,1ml",Q9951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
"LOCM >= 400 mg/ml iodine,1ml",Q9951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.22,,,,,,,fee schedule,0.22,0.25,
"LOCM >= 400 mg/ml iodine,1ml",Q9951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.22,,,,,,,fee schedule,0.22,0.25,
"LOCM >= 400 mg/ml iodine,1ml",Q9951,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.25,,,,,,,fee schedule,0.22,0.25,
"Inj fe-based mr contrast,1ml",Q9953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,65.56,,,,,,,fee schedule,65.56,75.39,
"Inj fe-based mr contrast,1ml",Q9953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65.56,,,,,,,fee schedule,65.56,75.39,
"Inj fe-based mr contrast,1ml",Q9953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,65.56,,,,,,,fee schedule,65.56,75.39,
"Inj fe-based mr contrast,1ml",Q9953,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,75.39,,,,,,,fee schedule,65.56,75.39,
"Inj perflexane lip micros,ml",Q9955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.77,,,,,,,fee schedule,13.77,15.84,
"Inj perflexane lip micros,ml",Q9955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.77,,,,,,,fee schedule,13.77,15.84,
"Inj perflexane lip micros,ml",Q9955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.77,,,,,,,fee schedule,13.77,15.84,
"Inj perflexane lip micros,ml",Q9955,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.84,,,,,,,fee schedule,13.77,15.84,
"Inj octafluoropropane mic,ml",Q9956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.75,,,,,,,fee schedule,42.75,49.16,
"Inj octafluoropropane mic,ml",Q9956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.75,,,,,,,fee schedule,42.75,49.16,
"Inj octafluoropropane mic,ml",Q9956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.75,,,,,,,fee schedule,42.75,49.16,
"Inj octafluoropropane mic,ml",Q9956,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.16,,,,,,,fee schedule,42.75,49.16,
"Inj perflutren lip micros,ml",Q9957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,42.75,,,,,,,fee schedule,42.75,49.16,
"Inj perflutren lip micros,ml",Q9957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.75,,,,,,,fee schedule,42.75,49.16,
"Inj perflutren lip micros,ml",Q9957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,42.75,,,,,,,fee schedule,42.75,49.16,
"Inj perflutren lip micros,ml",Q9957,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.16,,,,,,,fee schedule,42.75,49.16,
"HOCM <=149 mg/ml iodine, 1ml",Q9958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.16,,,,,,,fee schedule,0.13,0.23,
"HOCM <=149 mg/ml iodine, 1ml",Q9958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.13,,,,,,,fee schedule,0.13,0.23,
"HOCM <=149 mg/ml iodine, 1ml",Q9958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.23,,,,,,,fee schedule,0.13,0.23,
"HOCM <=149 mg/ml iodine, 1ml",Q9958,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.2,,,,,,,fee schedule,0.13,0.23,
"HOCM 200-249mg/ml iodine,1ml",Q9960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.35,,,,,,,fee schedule,0.28,0.49,
"HOCM 200-249mg/ml iodine,1ml",Q9960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.28,,,,,,,fee schedule,0.28,0.49,
"HOCM 200-249mg/ml iodine,1ml",Q9960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.49,,,,,,,fee schedule,0.28,0.49,
"HOCM 200-249mg/ml iodine,1ml",Q9960,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.43,,,,,,,fee schedule,0.28,0.49,
"HOCM 250-299mg/ml iodine,1ml",Q9961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.56,,,,,,,fee schedule,0.45,0.78,
"HOCM 250-299mg/ml iodine,1ml",Q9961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.45,,,,,,,fee schedule,0.45,0.78,
"HOCM 250-299mg/ml iodine,1ml",Q9961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.78,,,,,,,fee schedule,0.45,0.78,
"HOCM 250-299mg/ml iodine,1ml",Q9961,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.68,,,,,,,fee schedule,0.45,0.78,
"HOCM 350-399mg/ml iodine,1ml",Q9963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.46,,,,,,,fee schedule,0.37,0.64,
"HOCM 350-399mg/ml iodine,1ml",Q9963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.37,,,,,,,fee schedule,0.37,0.64,
"HOCM 350-399mg/ml iodine,1ml",Q9963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.64,,,,,,,fee schedule,0.37,0.64,
"HOCM 350-399mg/ml iodine,1ml",Q9963,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.56,,,,,,,fee schedule,0.37,0.64,
"LOCM 100-199mg/ml iodine,1ml",Q9965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.87,,,,,,,fee schedule,1.87,2.15,
"LOCM 100-199mg/ml iodine,1ml",Q9965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.87,,,,,,,fee schedule,1.87,2.15,
"LOCM 100-199mg/ml iodine,1ml",Q9965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.87,,,,,,,fee schedule,1.87,2.15,
"LOCM 100-199mg/ml iodine,1ml",Q9965,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.15,,,,,,,fee schedule,1.87,2.15,
"LOCM 200-299mg/ml iodine,1ml",Q9966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.46,,,,,,,fee schedule,0.46,0.53,
"LOCM 200-299mg/ml iodine,1ml",Q9966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.46,,,,,,,fee schedule,0.46,0.53,
"LOCM 200-299mg/ml iodine,1ml",Q9966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.46,,,,,,,fee schedule,0.46,0.53,
"LOCM 200-299mg/ml iodine,1ml",Q9966,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.53,,,,,,,fee schedule,0.46,0.53,
"LOCM 300-399mg/ml iodine,1ml",Q9967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,0.16,,,,,,,fee schedule,0.16,0.18,
"LOCM 300-399mg/ml iodine,1ml",Q9967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.16,,,,,,,fee schedule,0.16,0.18,
"LOCM 300-399mg/ml iodine,1ml",Q9967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.16,,,,,,,fee schedule,0.16,0.18,
"LOCM 300-399mg/ml iodine,1ml",Q9967,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,0.18,,,,,,,fee schedule,0.16,0.18,
Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.75,,,,,,,fee schedule,2.75,19.57,
Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.75,,,,,,,fee schedule,2.75,19.57,
Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.75,,,,,,,fee schedule,2.75,19.57,
Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3.16,,,,,,,fee schedule,2.75,19.57,
Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.42,,,,,,,fee schedule,2.75,19.57,APC
Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.87,,,,,,,fee schedule,2.75,19.57,APC
Visualization adjunct,Q9968,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19.57,,,,,,,fee schedule,2.75,19.57,APC
Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.24,,,,,,,fee schedule,9.8,17.19,
Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,9.8,,,,,,,fee schedule,9.8,17.19,
Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.19,,,,,,,fee schedule,9.8,17.19,
Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,14.95,,,,,,,fee schedule,9.8,17.19,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3264,,,,,,,fee schedule,1944.01,3753.6,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3264,,,,,,,fee schedule,1944.01,3753.6,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3264,,,,,,,fee schedule,1944.01,3753.6,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3753.6,,,,,,,fee schedule,1944.01,3753.6,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2041.21,,,,,,,fee schedule,1944.01,3753.6,APC
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1944.01,,,,,,,fee schedule,1944.01,3753.6,APC
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3499.22,,,,,,,fee schedule,1944.01,3753.6,APC
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3468,,,,,,,fee schedule,1584.67,3988.2,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3468,,,,,,,fee schedule,1584.67,3988.2,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3468,,,,,,,fee schedule,1584.67,3988.2,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3988.2,,,,,,,fee schedule,1584.67,3988.2,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1663.9,,,,,,,fee schedule,1584.67,3988.2,APC
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1584.67,,,,,,,fee schedule,1584.67,3988.2,APC
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2852.41,,,,,,,fee schedule,1584.67,3988.2,APC
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2051.14,,,,,,,fee schedule,2051.14,3722.68,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2051.14,,,,,,,fee schedule,2051.14,3722.68,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2051.14,,,,,,,fee schedule,2051.14,3722.68,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2358.81,,,,,,,fee schedule,2051.14,3722.68,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2171.56,,,,,,,fee schedule,2051.14,3722.68,APC
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2068.16,,,,,,,fee schedule,2051.14,3722.68,APC
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3722.68,,,,,,,fee schedule,2051.14,3722.68,APC
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2051.14,,,,,,,fee schedule,2051.14,3722.68,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2051.14,,,,,,,fee schedule,2051.14,3722.68,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2051.14,,,,,,,fee schedule,2051.14,3722.68,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2358.81,,,,,,,fee schedule,2051.14,3722.68,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2171.56,,,,,,,fee schedule,2051.14,3722.68,APC
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2068.16,,,,,,,fee schedule,2051.14,3722.68,APC
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3722.68,,,,,,,fee schedule,2051.14,3722.68,APC
Ustekinumab- ttwe sub cu inj,Q9996,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,47.03,,,,,,,fee schedule,47.03,54.08,
Ustekinumab- ttwe sub cu inj,Q9996,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47.03,,,,,,,fee schedule,47.03,54.08,
Ustekinumab- ttwe sub cu inj,Q9996,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,47.03,,,,,,,fee schedule,47.03,54.08,
Ustekinumab- ttwe sub cu inj,Q9996,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,54.08,,,,,,,fee schedule,47.03,54.08,
Ustekinumab-ttwe iv inj 1 mg,Q9997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.63,,,,,,,fee schedule,8.55,15.39,
Ustekinumab-ttwe iv inj 1 mg,Q9997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.63,,,,,,,fee schedule,8.55,15.39,
Ustekinumab-ttwe iv inj 1 mg,Q9997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,8.63,,,,,,,fee schedule,8.55,15.39,
Ustekinumab-ttwe iv inj 1 mg,Q9997,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.92,,,,,,,fee schedule,8.55,15.39,
Ustekinumab-ttwe iv inj 1 mg,Q9997,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.98,,,,,,,fee schedule,8.55,15.39,APC
Ustekinumab-ttwe iv inj 1 mg,Q9997,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8.55,,,,,,,fee schedule,8.55,15.39,APC
Ustekinumab-ttwe iv inj 1 mg,Q9997,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15.39,,,,,,,fee schedule,8.55,15.39,APC
Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.98,,,,,,,fee schedule,10.53,18.95,
Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10.98,,,,,,,fee schedule,10.53,18.95,
Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,10.98,,,,,,,fee schedule,10.53,18.95,
Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.63,,,,,,,fee schedule,10.53,18.95,
Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.06,,,,,,,fee schedule,10.53,18.95,APC
Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10.53,,,,,,,fee schedule,10.53,18.95,APC
Ustekinumab-aekn inj,Q9998,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18.95,,,,,,,fee schedule,10.53,18.95,APC
Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.23,,,,,,,fee schedule,13.15,23.68,
Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.23,,,,,,,fee schedule,13.15,23.68,
Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.23,,,,,,,fee schedule,13.15,23.68,
Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.21,,,,,,,fee schedule,13.15,23.68,
Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.81,,,,,,,fee schedule,13.15,23.68,APC
Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13.15,,,,,,,fee schedule,13.15,23.68,APC
Inj ustekinumab-aauz 1 mg,Q9999,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23.68,,,,,,,fee schedule,13.15,23.68,APC
Transport portable x-ray,R0070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.26,,,,,,,fee schedule,148.39,260.29,
Transport portable x-ray,R0070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.39,,,,,,,fee schedule,148.39,260.29,
Transport portable x-ray,R0070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.29,,,,,,,fee schedule,148.39,260.29,
Transport portable x-ray,R0070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.34,,,,,,,fee schedule,148.39,260.29,
Transport portable EKG,R0076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73.77,,,,,,,fee schedule,59.09,103.65,
Transport portable EKG,R0076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,59.09,,,,,,,fee schedule,59.09,103.65,
Transport portable EKG,R0076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,103.65,,,,,,,fee schedule,59.09,103.65,
Transport portable EKG,R0076,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,90.13,,,,,,,fee schedule,59.09,103.65,
"Butorphanal tartrate, nasal spray, 25 mg",S0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,215.24,,,,,,,fee schedule,172.4,302.42,
"Butorphanal tartrate, nasal spray, 25 mg",S0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,172.4,,,,,,,fee schedule,172.4,302.42,
"Butorphanal tartrate, nasal spray, 25 mg",S0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,302.42,,,,,,,fee schedule,172.4,302.42,
"Butorphanal tartrate, nasal spray, 25 mg",S0012,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,262.97,,,,,,,fee schedule,172.4,302.42,
"Tacrine HCl, 10mg",S0014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.52,,,,,,,fee schedule,5.23,9.17,
"Tacrine HCl, 10mg",S0014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.23,,,,,,,fee schedule,5.23,9.17,
"Tacrine HCl, 10mg",S0014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.17,,,,,,,fee schedule,5.23,9.17,
"Tacrine HCl, 10mg",S0014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.97,,,,,,,fee schedule,5.23,9.17,
"Injection, cefoperazone sodium, 1 g",S0021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,15.3,,,,,,,fee schedule,15.3,17.6,
"Injection, cefoperazone sodium, 1 g",S0021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15.3,,,,,,,fee schedule,15.3,17.6,
"Injection, cefoperazone sodium, 1 g",S0021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,15.3,,,,,,,fee schedule,15.3,17.6,
"Injection, cefoperazone sodium, 1 g",S0021,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,17.6,,,,,,,fee schedule,15.3,17.6,
"Injection, cimetidine HCl, 300 mg",S0023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.44,,,,,,,fee schedule,2.44,2.81,
"Injection, cimetidine HCl, 300 mg",S0023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.44,,,,,,,fee schedule,2.44,2.81,
"Injection, cimetidine HCl, 300 mg",S0023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.44,,,,,,,fee schedule,2.44,2.81,
"Injection, cimetidine HCl, 300 mg",S0023,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.81,,,,,,,fee schedule,2.44,2.81,
"Injection, ofloxacin, 400 mg",S0034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,22.44,,,,,,,fee schedule,22.44,25.81,
"Injection, ofloxacin, 400 mg",S0034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22.44,,,,,,,fee schedule,22.44,25.81,
"Injection, ofloxacin, 400 mg",S0034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,22.44,,,,,,,fee schedule,22.44,25.81,
"Injection, ofloxacin, 400 mg",S0034,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,25.81,,,,,,,fee schedule,22.44,25.81,
"Injection, ticarcillin disodium and clavulanate potassium, 3.1 g",S0040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,13.6,,,,,,,fee schedule,13.6,15.64,
"Injection, ticarcillin disodium and clavulanate potassium, 3.1 g",S0040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13.6,,,,,,,fee schedule,13.6,15.64,
"Injection, ticarcillin disodium and clavulanate potassium, 3.1 g",S0040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,13.6,,,,,,,fee schedule,13.6,15.64,
"Injection, ticarcillin disodium and clavulanate potassium, 3.1 g",S0040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,15.64,,,,,,,fee schedule,13.6,15.64,
"Injection, cefotetan disodium, 500 mg",S0074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,12.35,,,,,,,fee schedule,12.35,14.2,
"Injection, cefotetan disodium, 500 mg",S0074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12.35,,,,,,,fee schedule,12.35,14.2,
"Injection, cefotetan disodium, 500 mg",S0074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,12.35,,,,,,,fee schedule,12.35,14.2,
"Injection, cefotetan disodium, 500 mg",S0074,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,14.2,,,,,,,fee schedule,12.35,14.2,
"Injection, fosphenytoin sodium, 750 mg",S0078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,39.24,,,,,,,fee schedule,39.24,45.13,
"Injection, fosphenytoin sodium, 750 mg",S0078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39.24,,,,,,,fee schedule,39.24,45.13,
"Injection, fosphenytoin sodium, 750 mg",S0078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,39.24,,,,,,,fee schedule,39.24,45.13,
"Injection, fosphenytoin sodium, 750 mg",S0078,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,45.13,,,,,,,fee schedule,39.24,45.13,
"Injection, pentamidine isethonate, 300 mg",S0080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,99.65,,,,,,,fee schedule,99.65,114.6,
"Injection, pentamidine isethonate, 300 mg",S0080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.65,,,,,,,fee schedule,99.65,114.6,
"Injection, pentamidine isethonate, 300 mg",S0080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,99.65,,,,,,,fee schedule,99.65,114.6,
"Injection, pentamidine isethonate, 300 mg",S0080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,114.6,,,,,,,fee schedule,99.65,114.6,
"Injection, piperacillin sodium, 500 mg",S0081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.78,,,,,,,fee schedule,1.78,2.05,
"Injection, piperacillin sodium, 500 mg",S0081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.78,,,,,,,fee schedule,1.78,2.05,
"Injection, piperacillin sodium, 500 mg",S0081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.78,,,,,,,fee schedule,1.78,2.05,
"Injection, piperacillin sodium, 500 mg",S0081,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.05,,,,,,,fee schedule,1.78,2.05,
"Sildenafil citrate, 25 mg",S0090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,165.03,,,,,,,fee schedule,132.19,231.87,
"Sildenafil citrate, 25 mg",S0090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.19,,,,,,,fee schedule,132.19,231.87,
"Sildenafil citrate, 25 mg",S0090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.87,,,,,,,fee schedule,132.19,231.87,
"Sildenafil citrate, 25 mg",S0090,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.63,,,,,,,fee schedule,132.19,231.87,
"Granisetron HCl, 1mg (for circumstances falling under the Medicare Statute, use Q0166)",S0091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.86,,,,,,,fee schedule,105.62,185.27,
"Granisetron HCl, 1mg (for circumstances falling under the Medicare Statute, use Q0166)",S0091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.62,,,,,,,fee schedule,105.62,185.27,
"Granisetron HCl, 1mg (for circumstances falling under the Medicare Statute, use Q0166)",S0091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,185.27,,,,,,,fee schedule,105.62,185.27,
"Granisetron HCl, 1mg (for circumstances falling under the Medicare Statute, use Q0166)",S0091,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,161.1,,,,,,,fee schedule,105.62,185.27,
"Injection, hydromorphone HCl, 250 mg (loading dose for infusion pump)",S0092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,85.09,,,,,,,fee schedule,85.09,97.85,
"Injection, hydromorphone HCl, 250 mg (loading dose for infusion pump)",S0092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85.09,,,,,,,fee schedule,85.09,97.85,
"Injection, hydromorphone HCl, 250 mg (loading dose for infusion pump)",S0092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.09,,,,,,,fee schedule,85.09,97.85,
"Injection, hydromorphone HCl, 250 mg (loading dose for infusion pump)",S0092,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,97.85,,,,,,,fee schedule,85.09,97.85,
"Injection, morphine sulfate, 500mg (loding dose for infusion pump)",S0093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.09,,,,,,,fee schedule,11.09,12.75,
"Injection, morphine sulfate, 500mg (loding dose for infusion pump)",S0093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11.09,,,,,,,fee schedule,11.09,12.75,
"Injection, morphine sulfate, 500mg (loding dose for infusion pump)",S0093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,11.09,,,,,,,fee schedule,11.09,12.75,
"Injection, morphine sulfate, 500mg (loding dose for infusion pump)",S0093,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.75,,,,,,,fee schedule,11.09,12.75,
"Zidovudine, oral, 100 mg",S0104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.5,,,,,,,fee schedule,3.61,6.33,
"Zidovudine, oral, 100 mg",S0104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.61,,,,,,,fee schedule,3.61,6.33,
"Zidovudine, oral, 100 mg",S0104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.33,,,,,,,fee schedule,3.61,6.33,
"Zidovudine, oral, 100 mg",S0104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.5,,,,,,,fee schedule,3.61,6.33,
"Buproprion HCl sustained release tablit, 150 mg, per bottle of 60 tablets",S0106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,259.21,,,,,,,fee schedule,207.62,364.19,
"Buproprion HCl sustained release tablit, 150 mg, per bottle of 60 tablets",S0106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,207.62,,,,,,,fee schedule,207.62,364.19,
"Buproprion HCl sustained release tablit, 150 mg, per bottle of 60 tablets",S0106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,364.19,,,,,,,fee schedule,207.62,364.19,
"Buproprion HCl sustained release tablit, 150 mg, per bottle of 60 tablets",S0106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,316.69,,,,,,,fee schedule,207.62,364.19,
"Mercaptopuine, oral, 50 mg",S0108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9.14,,,,,,,fee schedule,7.32,12.85,
"Mercaptopuine, oral, 50 mg",S0108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.32,,,,,,,fee schedule,7.32,12.85,
"Mercaptopuine, oral, 50 mg",S0108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.85,,,,,,,fee schedule,7.32,12.85,
"Mercaptopuine, oral, 50 mg",S0108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,11.17,,,,,,,fee schedule,7.32,12.85,
"Methadone, oral, 5 mg",S0109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,0.87,,,,,,,fee schedule,0.69,1.22,
"Methadone, oral, 5 mg",S0109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,0.69,,,,,,,fee schedule,0.69,1.22,
"Methadone, oral, 5 mg",S0109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.22,,,,,,,fee schedule,0.69,1.22,
"Methadone, oral, 5 mg",S0109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.06,,,,,,,fee schedule,0.69,1.22,
"Injection, menotropins, 75 IU",S0122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,257.51,,,,,,,fee schedule,257.51,296.14,
"Injection, menotropins, 75 IU",S0122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,257.51,,,,,,,fee schedule,257.51,296.14,
"Injection, menotropins, 75 IU",S0122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,257.51,,,,,,,fee schedule,257.51,296.14,
"Injection, menotropins, 75 IU",S0122,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,296.14,,,,,,,fee schedule,257.51,296.14,
"Injection, follitropin alfa, 75 IU",S0126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,246.34,,,,,,,fee schedule,246.34,283.29,
"Injection, follitropin alfa, 75 IU",S0126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,246.34,,,,,,,fee schedule,246.34,283.29,
"Injection, follitropin alfa, 75 IU",S0126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,246.34,,,,,,,fee schedule,246.34,283.29,
"Injection, follitropin alfa, 75 IU",S0126,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,283.29,,,,,,,fee schedule,246.34,283.29,
"Injection, follitropin beta, 75 IU",S0128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.85,,,,,,,fee schedule,221.85,255.13,
"Injection, follitropin beta, 75 IU",S0128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,221.85,,,,,,,fee schedule,221.85,255.13,
"Injection, follitropin beta, 75 IU",S0128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,221.85,,,,,,,fee schedule,221.85,255.13,
"Injection, follitropin beta, 75 IU",S0128,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.13,,,,,,,fee schedule,221.85,255.13,
"Injection, ganirelix acetate, 250 mcg",S0132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.61,,,,,,,fee schedule,191.61,220.35,
"Injection, ganirelix acetate, 250 mcg",S0132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,191.61,,,,,,,fee schedule,191.61,220.35,
"Injection, ganirelix acetate, 250 mcg",S0132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,191.61,,,,,,,fee schedule,191.61,220.35,
"Injection, ganirelix acetate, 250 mcg",S0132,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.35,,,,,,,fee schedule,191.61,220.35,
"Clozapine, 25 mg",S0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.95,,,,,,,fee schedule,2.37,4.15,
"Clozapine, 25 mg",S0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.37,,,,,,,fee schedule,2.37,4.15,
"Clozapine, 25 mg",S0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.15,,,,,,,fee schedule,2.37,4.15,
"Clozapine, 25 mg",S0136,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.61,,,,,,,fee schedule,2.37,4.15,
"Finasteride, 5 mg",S0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7,,,,,,,fee schedule,5.61,9.83,
"Finasteride, 5 mg",S0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.61,,,,,,,fee schedule,5.61,9.83,
"Finasteride, 5 mg",S0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.83,,,,,,,fee schedule,5.61,9.83,
"Finasteride, 5 mg",S0138,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,8.55,,,,,,,fee schedule,5.61,9.83,
"Minoxidil, 10 mg",S0139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.87,,,,,,,fee schedule,2.3,4.04,
"Minoxidil, 10 mg",S0139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.3,,,,,,,fee schedule,2.3,4.04,
"Minoxidil, 10 mg",S0139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.04,,,,,,,fee schedule,2.3,4.04,
"Minoxidil, 10 mg",S0139,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.51,,,,,,,fee schedule,2.3,4.04,
"Saquinavir, 200 mg",S0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.22,,,,,,,fee schedule,2.58,4.52,
"Saquinavir, 200 mg",S0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.58,,,,,,,fee schedule,2.58,4.52,
"Saquinavir, 200 mg",S0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.52,,,,,,,fee schedule,2.58,4.52,
"Saquinavir, 200 mg",S0140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.93,,,,,,,fee schedule,2.58,4.52,
"pegylated interferon alfa-2a, 180 mcg/ ml",S0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1135.69,,,,,,,fee schedule,1135.69,1306.04,
"pegylated interferon alfa-2a, 180 mcg/ ml",S0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1135.69,,,,,,,fee schedule,1135.69,1306.04,
"pegylated interferon alfa-2a, 180 mcg/ ml",S0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1135.69,,,,,,,fee schedule,1135.69,1306.04,
"pegylated interferon alfa-2a, 180 mcg/ ml",S0145,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1306.04,,,,,,,fee schedule,1135.69,1306.04,
"Exemestane, 25 mg",S0156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23.35,,,,,,,fee schedule,18.7,32.81,
"Exemestane, 25 mg",S0156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,18.7,,,,,,,fee schedule,18.7,32.81,
"Exemestane, 25 mg",S0156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,32.81,,,,,,,fee schedule,18.7,32.81,
"Exemestane, 25 mg",S0156,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,28.53,,,,,,,fee schedule,18.7,32.81,
"Becaplermin gel 0.01%, 0.5 gm",S0157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.72,,,,,,,fee schedule,72.67,127.47,
"Becaplermin gel 0.01%, 0.5 gm",S0157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.67,,,,,,,fee schedule,72.67,127.47,
"Becaplermin gel 0.01%, 0.5 gm",S0157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.47,,,,,,,fee schedule,72.67,127.47,
"Becaplermin gel 0.01%, 0.5 gm",S0157,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.84,,,,,,,fee schedule,72.67,127.47,
"Dextoamphetamine sulfate, 5 mg",S0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,6.47,,,,,,,fee schedule,5.19,9.1,
"Dextoamphetamine sulfate, 5 mg",S0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,5.19,,,,,,,fee schedule,5.19,9.1,
"Dextoamphetamine sulfate, 5 mg",S0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,9.1,,,,,,,fee schedule,5.19,9.1,
"Dextoamphetamine sulfate, 5 mg",S0160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,7.91,,,,,,,fee schedule,5.19,9.1,
Calcitrol,S0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.05,,,,,,,fee schedule,1.65,2.89,
Calcitrol,S0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.65,,,,,,,fee schedule,1.65,2.89,
Calcitrol,S0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.89,,,,,,,fee schedule,1.65,2.89,
Calcitrol,S0169,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2.51,,,,,,,fee schedule,1.65,2.89,
"Anastrozole, oral, 1 mg",S0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.12,,,,,,,fee schedule,24.13,42.32,
"Anastrozole, oral, 1 mg",S0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.13,,,,,,,fee schedule,24.13,42.32,
"Anastrozole, oral, 1 mg",S0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.32,,,,,,,fee schedule,24.13,42.32,
"Anastrozole, oral, 1 mg",S0170,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.8,,,,,,,fee schedule,24.13,42.32,
"Chlorambucil, oral, 2 mg",S0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.36,,,,,,,fee schedule,43.54,76.38,
"Chlorambucil, oral, 2 mg",S0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.54,,,,,,,fee schedule,43.54,76.38,
"Chlorambucil, oral, 2 mg",S0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.38,,,,,,,fee schedule,43.54,76.38,
"Chlorambucil, oral, 2 mg",S0172,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.42,,,,,,,fee schedule,43.54,76.38,
"Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)",S0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,193.21,,,,,,,fee schedule,154.75,271.46,
"Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)",S0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,154.75,,,,,,,fee schedule,154.75,271.46,
"Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)",S0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,271.46,,,,,,,fee schedule,154.75,271.46,
"Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)",S0174,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,236.05,,,,,,,fee schedule,154.75,271.46,
"Flutamide, oral, 125 mg",S0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.66,,,,,,,fee schedule,3.73,6.54,
"Flutamide, oral, 125 mg",S0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.73,,,,,,,fee schedule,3.73,6.54,
"Flutamide, oral, 125 mg",S0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,6.54,,,,,,,fee schedule,3.73,6.54,
"Flutamide, oral, 125 mg",S0175,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.69,,,,,,,fee schedule,3.73,6.54,
"Hydroxyurea, oral, 500 mg",S0176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2.86,,,,,,,fee schedule,2.29,4.01,
"Hydroxyurea, oral, 500 mg",S0176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.29,,,,,,,fee schedule,2.29,4.01,
"Hydroxyurea, oral, 500 mg",S0176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.01,,,,,,,fee schedule,2.29,4.01,
"Hydroxyurea, oral, 500 mg",S0176,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.49,,,,,,,fee schedule,2.29,4.01,
"Levamisole HCl, oral, 50 mg",S0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8.84,,,,,,,fee schedule,7.08,12.42,
"Levamisole HCl, oral, 50 mg",S0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,7.08,,,,,,,fee schedule,7.08,12.42,
"Levamisole HCl, oral, 50 mg",S0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,12.42,,,,,,,fee schedule,7.08,12.42,
"Levamisole HCl, oral, 50 mg",S0177,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,10.8,,,,,,,fee schedule,7.08,12.42,
"Lomustine, oral, 10 mg",S0178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.53,,,,,,,fee schedule,133.39,233.98,
"Lomustine, oral, 10 mg",S0178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.39,,,,,,,fee schedule,133.39,233.98,
"Lomustine, oral, 10 mg",S0178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.98,,,,,,,fee schedule,133.39,233.98,
"Lomustine, oral, 10 mg",S0178,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.46,,,,,,,fee schedule,133.39,233.98,
"Megestrol acetate, oral, 20 mg",S0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.47,,,,,,,fee schedule,1.18,2.07,
"Megestrol acetate, oral, 20 mg",S0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.18,,,,,,,fee schedule,1.18,2.07,
"Megestrol acetate, oral, 20 mg",S0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2.07,,,,,,,fee schedule,1.18,2.07,
"Megestrol acetate, oral, 20 mg",S0179,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.8,,,,,,,fee schedule,1.18,2.07,
"Procarbazine HCl, oral, 50 mg",S0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,218.84,,,,,,,fee schedule,175.29,307.48,
"Procarbazine HCl, oral, 50 mg",S0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,175.29,,,,,,,fee schedule,175.29,307.48,
"Procarbazine HCl, oral, 50 mg",S0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,307.48,,,,,,,fee schedule,175.29,307.48,
"Procarbazine HCl, oral, 50 mg",S0182,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,267.37,,,,,,,fee schedule,175.29,307.48,
"Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)",S0183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1.34,,,,,,,fee schedule,1.08,1.89,
"Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)",S0183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1.08,,,,,,,fee schedule,1.08,1.89,
"Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)",S0183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1.89,,,,,,,fee schedule,1.08,1.89,
"Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)",S0183,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1.64,,,,,,,fee schedule,1.08,1.89,
"Tamoxifen citrate, oral, 10 mg",S0187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,4.23,,,,,,,fee schedule,3.39,5.95,
"Tamoxifen citrate, oral, 10 mg",S0187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,3.39,,,,,,,fee schedule,3.39,5.95,
"Tamoxifen citrate, oral, 10 mg",S0187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,5.95,,,,,,,fee schedule,3.39,5.95,
"Tamoxifen citrate, oral, 10 mg",S0187,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,5.17,,,,,,,fee schedule,3.39,5.95,
"testosterone pellet, 75 mg",S0189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,107.24,,,,,,,fee schedule,107.24,123.33,
"testosterone pellet, 75 mg",S0189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107.24,,,,,,,fee schedule,107.24,123.33,
"testosterone pellet, 75 mg",S0189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,107.24,,,,,,,fee schedule,107.24,123.33,
"testosterone pellet, 75 mg",S0189,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,123.33,,,,,,,fee schedule,107.24,123.33,
"Mitepristone, oral, 200 mg",S0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,36.55,,,,,,,fee schedule,36.55,42.03,
"Mitepristone, oral, 200 mg",S0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36.55,,,,,,,fee schedule,36.55,42.03,
"Mitepristone, oral, 200 mg",S0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,36.55,,,,,,,fee schedule,36.55,42.03,
"Mitepristone, oral, 200 mg",S0190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,42.03,,,,,,,fee schedule,36.55,42.03,
"Misoprostol, oral, 200 mcg",S0191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3.17,,,,,,,fee schedule,2.54,4.45,
"Misoprostol, oral, 200 mcg",S0191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2.54,,,,,,,fee schedule,2.54,4.45,
"Misoprostol, oral, 200 mcg",S0191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4.45,,,,,,,fee schedule,2.54,4.45,
"Misoprostol, oral, 200 mcg",S0191,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3.87,,,,,,,fee schedule,2.54,4.45,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.07,,,,,,,fee schedule,30.49,64.66,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.49,,,,,,,fee schedule,30.49,64.66,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.49,,,,,,,fee schedule,30.49,64.66,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.51,,,,,,,fee schedule,30.49,64.66,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.72,,,,,,,fee schedule,30.49,64.66,APC
2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35.92,,,,,,,fee schedule,30.49,64.66,APC
2019 nCoV diagnostic P,U0001,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,64.66,,,,,,,fee schedule,30.49,64.66,APC
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54.39,,,,,,,fee schedule,43.56,92.36,
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,43.56,,,,,,,fee schedule,43.56,92.36,
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,76.42,,,,,,,fee schedule,43.56,92.36,
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,66.45,,,,,,,fee schedule,43.56,92.36,
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,43.56,92.36,APC
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51.31,,,,,,,fee schedule,43.56,92.36,APC
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92.36,,,,,,,fee schedule,43.56,92.36,APC
Vision svcs frames purchases,V2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160.78,,,,,,,fee schedule,92.1,225.89,
Vision svcs frames purchases,V2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,128.78,,,,,,,fee schedule,92.1,225.89,
Vision svcs frames purchases,V2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,225.89,,,,,,,fee schedule,92.1,225.89,
Vision svcs frames purchases,V2020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,196.43,,,,,,,fee schedule,92.1,225.89,
Vision svcs frames purchases,V2020,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.7,,,,,,,fee schedule,92.1,225.89,APC
Vision svcs frames purchases,V2020,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,92.1,,,,,,,fee schedule,92.1,225.89,APC
Vision svcs frames purchases,V2020,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,165.78,,,,,,,fee schedule,92.1,225.89,APC
Lens spher single plano 4.00,V2100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99.37,,,,,,,fee schedule,56.92,139.61,
Lens spher single plano 4.00,V2100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,79.59,,,,,,,fee schedule,56.92,139.61,
Lens spher single plano 4.00,V2100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,139.61,,,,,,,fee schedule,56.92,139.61,
Lens spher single plano 4.00,V2100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,121.4,,,,,,,fee schedule,56.92,139.61,
Lens spher single plano 4.00,V2100,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.77,,,,,,,fee schedule,56.92,139.61,APC
Lens spher single plano 4.00,V2100,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,56.92,,,,,,,fee schedule,56.92,139.61,APC
Lens spher single plano 4.00,V2100,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,102.46,,,,,,,fee schedule,56.92,139.61,APC
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95.46,,,,,,,fee schedule,54.69,134.12,
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.46,,,,,,,fee schedule,54.69,134.12,
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,134.12,,,,,,,fee schedule,54.69,134.12,
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,116.63,,,,,,,fee schedule,54.69,134.12,
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.42,,,,,,,fee schedule,54.69,134.12,APC
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.69,,,,,,,fee schedule,54.69,134.12,APC
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,98.44,,,,,,,fee schedule,54.69,134.12,APC
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,165.07,,,,,,,fee schedule,94.55,231.92,
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.21,,,,,,,fee schedule,94.55,231.92,
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,231.92,,,,,,,fee schedule,94.55,231.92,
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.67,,,,,,,fee schedule,94.55,231.92,
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.28,,,,,,,fee schedule,94.55,231.92,APC
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.55,,,,,,,fee schedule,94.55,231.92,APC
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.19,,,,,,,fee schedule,94.55,231.92,APC
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83.61,,,,,,,fee schedule,47.91,117.47,
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,66.97,,,,,,,fee schedule,47.91,117.47,
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,117.47,,,,,,,fee schedule,47.91,117.47,
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,102.15,,,,,,,fee schedule,47.91,117.47,
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.31,,,,,,,fee schedule,47.91,117.47,APC
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47.91,,,,,,,fee schedule,47.91,117.47,APC
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86.24,,,,,,,fee schedule,47.91,117.47,APC
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86.22,,,,,,,fee schedule,49.39,121.14,
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,69.06,,,,,,,fee schedule,49.39,121.14,
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,121.14,,,,,,,fee schedule,49.39,121.14,
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,105.34,,,,,,,fee schedule,49.39,121.14,
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.86,,,,,,,fee schedule,49.39,121.14,APC
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49.39,,,,,,,fee schedule,49.39,121.14,APC
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88.9,,,,,,,fee schedule,49.39,121.14,APC
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,102.53,,,,,,,fee schedule,58.75,144.05,
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,82.12,,,,,,,fee schedule,58.75,144.05,
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,144.05,,,,,,,fee schedule,58.75,144.05,
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,125.26,,,,,,,fee schedule,58.75,144.05,
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.69,,,,,,,fee schedule,58.75,144.05,APC
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.75,,,,,,,fee schedule,58.75,144.05,APC
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105.75,,,,,,,fee schedule,58.75,144.05,APC
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113.6,,,,,,,fee schedule,65.08,159.61,
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,90.99,,,,,,,fee schedule,65.08,159.61,
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,159.61,,,,,,,fee schedule,65.08,159.61,
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,138.79,,,,,,,fee schedule,65.08,159.61,
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.33,,,,,,,fee schedule,65.08,159.61,APC
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.08,,,,,,,fee schedule,65.08,159.61,APC
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,117.14,,,,,,,fee schedule,65.08,159.61,APC
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.17,,,,,,,fee schedule,57.95,142.14,
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.03,,,,,,,fee schedule,57.95,142.14,
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.14,,,,,,,fee schedule,57.95,142.14,
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.6,,,,,,,fee schedule,57.95,142.14,
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.85,,,,,,,fee schedule,57.95,142.14,APC
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57.95,,,,,,,fee schedule,57.95,142.14,APC
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.31,,,,,,,fee schedule,57.95,142.14,APC
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.43,,,,,,,fee schedule,58.11,142.51,
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.24,,,,,,,fee schedule,58.11,142.51,
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.51,,,,,,,fee schedule,58.11,142.51,
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.92,,,,,,,fee schedule,58.11,142.51,
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.02,,,,,,,fee schedule,58.11,142.51,APC
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.11,,,,,,,fee schedule,58.11,142.51,APC
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.6,,,,,,,fee schedule,58.11,142.51,APC
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.28,,,,,,,fee schedule,80.93,198.5,
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.16,,,,,,,fee schedule,80.93,198.5,
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.5,,,,,,,fee schedule,80.93,198.5,
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.61,,,,,,,fee schedule,80.93,198.5,
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.98,,,,,,,fee schedule,80.93,198.5,APC
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,80.93,,,,,,,fee schedule,80.93,198.5,APC
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,145.67,,,,,,,fee schedule,80.93,198.5,APC
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114.07,,,,,,,fee schedule,65.36,160.26,
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,91.36,,,,,,,fee schedule,65.36,160.26,
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,160.26,,,,,,,fee schedule,65.36,160.26,
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,139.36,,,,,,,fee schedule,65.36,160.26,
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.63,,,,,,,fee schedule,65.36,160.26,APC
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,65.36,,,,,,,fee schedule,65.36,160.26,APC
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,117.65,,,,,,,fee schedule,65.36,160.26,APC
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.26,,,,,,,fee schedule,79.21,194.26,
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.74,,,,,,,fee schedule,79.21,194.26,
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.26,,,,,,,fee schedule,79.21,194.26,
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,168.92,,,,,,,fee schedule,79.21,194.26,
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.17,,,,,,,fee schedule,79.21,194.26,APC
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.21,,,,,,,fee schedule,79.21,194.26,APC
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,142.58,,,,,,,fee schedule,79.21,194.26,APC
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.19,,,,,,,fee schedule,89.48,219.45,
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.11,,,,,,,fee schedule,89.48,219.45,
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,219.45,,,,,,,fee schedule,89.48,219.45,
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.83,,,,,,,fee schedule,89.48,219.45,
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,93.95,,,,,,,fee schedule,89.48,219.45,APC
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,89.48,,,,,,,fee schedule,89.48,219.45,APC
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,161.06,,,,,,,fee schedule,89.48,219.45,APC
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.93,,,,,,,fee schedule,90.49,221.89,
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.5,,,,,,,fee schedule,90.49,221.89,
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.89,,,,,,,fee schedule,90.49,221.89,
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.95,,,,,,,fee schedule,90.49,221.89,
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.01,,,,,,,fee schedule,90.49,221.89,APC
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,90.49,,,,,,,fee schedule,90.49,221.89,APC
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,162.88,,,,,,,fee schedule,90.49,221.89,APC
Spherocylinder over 12.00d,V2114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.17,,,,,,,fee schedule,107.21,262.97,
Spherocylinder over 12.00d,V2114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.92,,,,,,,fee schedule,107.21,262.97,
Spherocylinder over 12.00d,V2114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,262.97,,,,,,,fee schedule,107.21,262.97,
Spherocylinder over 12.00d,V2114,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,228.67,,,,,,,fee schedule,107.21,262.97,
Spherocylinder over 12.00d,V2114,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.57,,,,,,,fee schedule,107.21,262.97,APC
Spherocylinder over 12.00d,V2114,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,107.21,,,,,,,fee schedule,107.21,262.97,APC
Spherocylinder over 12.00d,V2114,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,192.98,,,,,,,fee schedule,107.21,262.97,APC
Lens lenticular bifocal,V2115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,188.63,,,,,,,fee schedule,108.06,265.03,
Lens lenticular bifocal,V2115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.09,,,,,,,fee schedule,108.06,265.03,
Lens lenticular bifocal,V2115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.03,,,,,,,fee schedule,108.06,265.03,
Lens lenticular bifocal,V2115,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,230.46,,,,,,,fee schedule,108.06,265.03,
Lens lenticular bifocal,V2115,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.46,,,,,,,fee schedule,108.06,265.03,APC
Lens lenticular bifocal,V2115,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,108.06,,,,,,,fee schedule,108.06,265.03,APC
Lens lenticular bifocal,V2115,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,194.51,,,,,,,fee schedule,108.06,265.03,APC
Lens aniseikonic single,V2118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,205.26,,,,,,,fee schedule,117.59,288.4,
Lens aniseikonic single,V2118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.41,,,,,,,fee schedule,117.59,288.4,
Lens aniseikonic single,V2118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,288.4,,,,,,,fee schedule,117.59,288.4,
Lens aniseikonic single,V2118,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,250.78,,,,,,,fee schedule,117.59,288.4,
Lens aniseikonic single,V2118,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,123.47,,,,,,,fee schedule,117.59,288.4,APC
Lens aniseikonic single,V2118,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,117.59,,,,,,,fee schedule,117.59,288.4,APC
Lens aniseikonic single,V2118,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,211.66,,,,,,,fee schedule,117.59,288.4,APC
"Lenticular lens, single",V2121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.09,,,,,,,fee schedule,106.04,260.05,
"Lenticular lens, single",V2121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.25,,,,,,,fee schedule,106.04,260.05,
"Lenticular lens, single",V2121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.05,,,,,,,fee schedule,106.04,260.05,
"Lenticular lens, single",V2121,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.13,,,,,,,fee schedule,106.04,260.05,
"Lenticular lens, single",V2121,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,111.34,,,,,,,fee schedule,106.04,260.05,APC
"Lenticular lens, single",V2121,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,106.04,,,,,,,fee schedule,106.04,260.05,APC
"Lenticular lens, single",V2121,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,190.87,,,,,,,fee schedule,106.04,260.05,APC
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,111.89,,,,,,,fee schedule,64.1,157.21,
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,89.62,,,,,,,fee schedule,64.1,157.21,
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,157.21,,,,,,,fee schedule,64.1,157.21,
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,136.7,,,,,,,fee schedule,64.1,157.21,
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.3,,,,,,,fee schedule,64.1,157.21,APC
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,64.1,,,,,,,fee schedule,64.1,157.21,APC
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,115.38,,,,,,,fee schedule,64.1,157.21,APC
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,119.86,,,,,,,fee schedule,68.68,168.41,
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,96.01,,,,,,,fee schedule,68.68,168.41,
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,168.41,,,,,,,fee schedule,68.68,168.41,
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,146.44,,,,,,,fee schedule,68.68,168.41,
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72.11,,,,,,,fee schedule,68.68,168.41,APC
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,68.68,,,,,,,fee schedule,68.68,168.41,APC
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,123.62,,,,,,,fee schedule,68.68,168.41,APC
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.59,,,,,,,fee schedule,85.14,208.77,
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.02,,,,,,,fee schedule,85.14,208.77,
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,208.77,,,,,,,fee schedule,85.14,208.77,
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.54,,,,,,,fee schedule,85.14,208.77,
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,89.4,,,,,,,fee schedule,85.14,208.77,APC
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,85.14,,,,,,,fee schedule,85.14,208.77,APC
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,153.25,,,,,,,fee schedule,85.14,208.77,APC
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115.21,,,,,,,fee schedule,66.01,161.87,
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,92.28,,,,,,,fee schedule,66.01,161.87,
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,161.87,,,,,,,fee schedule,66.01,161.87,
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,140.76,,,,,,,fee schedule,66.01,161.87,
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.31,,,,,,,fee schedule,66.01,161.87,APC
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,66.01,,,,,,,fee schedule,66.01,161.87,APC
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,118.82,,,,,,,fee schedule,66.01,161.87,APC
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.59,,,,,,,fee schedule,67.92,166.62,
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,94.99,,,,,,,fee schedule,67.92,166.62,
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,166.62,,,,,,,fee schedule,67.92,166.62,
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,144.89,,,,,,,fee schedule,67.92,166.62,
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,71.32,,,,,,,fee schedule,67.92,166.62,APC
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67.92,,,,,,,fee schedule,67.92,166.62,APC
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,122.26,,,,,,,fee schedule,67.92,166.62,APC
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131.44,,,,,,,fee schedule,75.31,184.68,
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,105.28,,,,,,,fee schedule,75.31,184.68,
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,184.68,,,,,,,fee schedule,75.31,184.68,
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,160.59,,,,,,,fee schedule,75.31,184.68,
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.08,,,,,,,fee schedule,75.31,184.68,APC
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,75.31,,,,,,,fee schedule,75.31,184.68,APC
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,135.56,,,,,,,fee schedule,75.31,184.68,APC
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,154.32,,,,,,,fee schedule,88.39,216.82,
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,123.61,,,,,,,fee schedule,88.39,216.82,
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,216.82,,,,,,,fee schedule,88.39,216.82,
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,188.54,,,,,,,fee schedule,88.39,216.82,
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.81,,,,,,,fee schedule,88.39,216.82,APC
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,88.39,,,,,,,fee schedule,88.39,216.82,APC
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,159.1,,,,,,,fee schedule,88.39,216.82,APC
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.44,,,,,,,fee schedule,74.72,183.26,
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.48,,,,,,,fee schedule,74.72,183.26,
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,183.26,,,,,,,fee schedule,74.72,183.26,
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,159.36,,,,,,,fee schedule,74.72,183.26,
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.46,,,,,,,fee schedule,74.72,183.26,APC
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.72,,,,,,,fee schedule,74.72,183.26,APC
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,134.5,,,,,,,fee schedule,74.72,183.26,APC
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.16,,,,,,,fee schedule,73.42,180.07,
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.65,,,,,,,fee schedule,73.42,180.07,
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.07,,,,,,,fee schedule,73.42,180.07,
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.58,,,,,,,fee schedule,73.42,180.07,
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.09,,,,,,,fee schedule,73.42,180.07,APC
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73.42,,,,,,,fee schedule,73.42,180.07,APC
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132.16,,,,,,,fee schedule,73.42,180.07,APC
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150.46,,,,,,,fee schedule,86.19,211.39,
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,120.51,,,,,,,fee schedule,86.19,211.39,
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,211.39,,,,,,,fee schedule,86.19,211.39,
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,183.82,,,,,,,fee schedule,86.19,211.39,
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.5,,,,,,,fee schedule,86.19,211.39,APC
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86.19,,,,,,,fee schedule,86.19,211.39,APC
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,155.14,,,,,,,fee schedule,86.19,211.39,APC
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,162.1,,,,,,,fee schedule,92.87,227.75,
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,129.84,,,,,,,fee schedule,92.87,227.75,
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,227.75,,,,,,,fee schedule,92.87,227.75,
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,198.04,,,,,,,fee schedule,92.87,227.75,
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,97.51,,,,,,,fee schedule,92.87,227.75,APC
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,92.87,,,,,,,fee schedule,92.87,227.75,APC
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,167.17,,,,,,,fee schedule,92.87,227.75,APC
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.81,,,,,,,fee schedule,90.41,221.73,
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,126.41,,,,,,,fee schedule,90.41,221.73,
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,221.73,,,,,,,fee schedule,90.41,221.73,
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,192.81,,,,,,,fee schedule,90.41,221.73,
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.93,,,,,,,fee schedule,90.41,221.73,APC
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,90.41,,,,,,,fee schedule,90.41,221.73,APC
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,162.74,,,,,,,fee schedule,90.41,221.73,APC
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,165.21,,,,,,,fee schedule,94.64,232.13,
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,132.33,,,,,,,fee schedule,94.64,232.13,
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,232.13,,,,,,,fee schedule,94.64,232.13,
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,201.85,,,,,,,fee schedule,94.64,232.13,
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.37,,,,,,,fee schedule,94.64,232.13,APC
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94.64,,,,,,,fee schedule,94.64,232.13,APC
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170.35,,,,,,,fee schedule,94.64,232.13,APC
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,173.7,,,,,,,fee schedule,99.51,244.05,
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,139.13,,,,,,,fee schedule,99.51,244.05,
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,244.05,,,,,,,fee schedule,99.51,244.05,
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,212.22,,,,,,,fee schedule,99.51,244.05,
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.49,,,,,,,fee schedule,99.51,244.05,APC
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,99.51,,,,,,,fee schedule,99.51,244.05,APC
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,179.12,,,,,,,fee schedule,99.51,244.05,APC
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,181.54,,,,,,,fee schedule,104,255.07,
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,145.41,,,,,,,fee schedule,104,255.07,
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,255.07,,,,,,,fee schedule,104,255.07,
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,221.8,,,,,,,fee schedule,104,255.07,
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.2,,,,,,,fee schedule,104,255.07,APC
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104,,,,,,,fee schedule,104,255.07,APC
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,187.2,,,,,,,fee schedule,104,255.07,APC
Lens lenticular bifocal,V2215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,226.65,,,,,,,fee schedule,129.85,318.45,
Lens lenticular bifocal,V2215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,181.54,,,,,,,fee schedule,129.85,318.45,
Lens lenticular bifocal,V2215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,318.45,,,,,,,fee schedule,129.85,318.45,
Lens lenticular bifocal,V2215,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,276.91,,,,,,,fee schedule,129.85,318.45,
Lens lenticular bifocal,V2215,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,136.34,,,,,,,fee schedule,129.85,318.45,APC
Lens lenticular bifocal,V2215,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,129.85,,,,,,,fee schedule,129.85,318.45,APC
Lens lenticular bifocal,V2215,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,233.73,,,,,,,fee schedule,129.85,318.45,APC
Lens aniseikonic bifocal,V2218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,231,,,,,,,fee schedule,132.32,324.55,
Lens aniseikonic bifocal,V2218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,185.02,,,,,,,fee schedule,132.32,324.55,
Lens aniseikonic bifocal,V2218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,324.55,,,,,,,fee schedule,132.32,324.55,
Lens aniseikonic bifocal,V2218,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,282.22,,,,,,,fee schedule,132.32,324.55,
Lens aniseikonic bifocal,V2218,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.94,,,,,,,fee schedule,132.32,324.55,APC
Lens aniseikonic bifocal,V2218,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,132.32,,,,,,,fee schedule,132.32,324.55,APC
Lens aniseikonic bifocal,V2218,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,238.18,,,,,,,fee schedule,132.32,324.55,APC
Lens bifocal seg width over,V2219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106.57,,,,,,,fee schedule,61.04,149.73,
Lens bifocal seg width over,V2219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,85.36,,,,,,,fee schedule,61.04,149.73,
Lens bifocal seg width over,V2219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,149.73,,,,,,,fee schedule,61.04,149.73,
Lens bifocal seg width over,V2219,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,130.2,,,,,,,fee schedule,61.04,149.73,
Lens bifocal seg width over,V2219,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.09,,,,,,,fee schedule,61.04,149.73,APC
Lens bifocal seg width over,V2219,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,61.04,,,,,,,fee schedule,61.04,149.73,APC
Lens bifocal seg width over,V2219,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,109.87,,,,,,,fee schedule,61.04,149.73,APC
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94.63,,,,,,,fee schedule,54.22,132.96,
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,75.8,,,,,,,fee schedule,54.22,132.96,
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,132.96,,,,,,,fee schedule,54.22,132.96,
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,115.62,,,,,,,fee schedule,54.22,132.96,
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.93,,,,,,,fee schedule,54.22,132.96,APC
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.22,,,,,,,fee schedule,54.22,132.96,APC
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,97.6,,,,,,,fee schedule,54.22,132.96,APC
"Lenticular lens, bifocal",V2221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,188.77,,,,,,,fee schedule,108.14,265.22,
"Lenticular lens, bifocal",V2221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,151.2,,,,,,,fee schedule,108.14,265.22,
"Lenticular lens, bifocal",V2221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,265.22,,,,,,,fee schedule,108.14,265.22,
"Lenticular lens, bifocal",V2221,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,230.63,,,,,,,fee schedule,108.14,265.22,
"Lenticular lens, bifocal",V2221,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.55,,,,,,,fee schedule,108.14,265.22,APC
"Lenticular lens, bifocal",V2221,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,108.14,,,,,,,fee schedule,108.14,265.22,APC
"Lenticular lens, bifocal",V2221,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,194.65,,,,,,,fee schedule,108.14,265.22,APC
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,152.97,,,,,,,fee schedule,87.62,214.92,
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,122.53,,,,,,,fee schedule,87.62,214.92,
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,214.92,,,,,,,fee schedule,87.62,214.92,
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,186.89,,,,,,,fee schedule,87.62,214.92,
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92,,,,,,,fee schedule,87.62,214.92,APC
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,87.62,,,,,,,fee schedule,87.62,214.92,APC
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,157.72,,,,,,,fee schedule,87.62,214.92,APC
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,187.58,,,,,,,fee schedule,107.47,263.55,
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,150.24,,,,,,,fee schedule,107.47,263.55,
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,263.55,,,,,,,fee schedule,107.47,263.55,
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,229.17,,,,,,,fee schedule,107.47,263.55,
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.84,,,,,,,fee schedule,107.47,263.55,APC
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,107.47,,,,,,,fee schedule,107.47,263.55,APC
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,193.45,,,,,,,fee schedule,107.47,263.55,APC
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,175.24,,,,,,,fee schedule,100.39,246.22,
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,140.36,,,,,,,fee schedule,100.39,246.22,
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,246.22,,,,,,,fee schedule,100.39,246.22,
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,214.1,,,,,,,fee schedule,100.39,246.22,
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.41,,,,,,,fee schedule,100.39,246.22,APC
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,100.39,,,,,,,fee schedule,100.39,246.22,APC
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,180.7,,,,,,,fee schedule,100.39,246.22,APC
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,147.25,,,,,,,fee schedule,84.34,206.89,
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,117.94,,,,,,,fee schedule,84.34,206.89,
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,206.89,,,,,,,fee schedule,84.34,206.89,
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,179.9,,,,,,,fee schedule,84.34,206.89,
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,88.56,,,,,,,fee schedule,84.34,206.89,APC
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,84.34,,,,,,,fee schedule,84.34,206.89,APC
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,151.81,,,,,,,fee schedule,84.34,206.89,APC
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,148.96,,,,,,,fee schedule,85.32,209.29,
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.31,,,,,,,fee schedule,85.32,209.29,
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.29,,,,,,,fee schedule,85.32,209.29,
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,181.99,,,,,,,fee schedule,85.32,209.29,
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,89.59,,,,,,,fee schedule,85.32,209.29,APC
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,85.32,,,,,,,fee schedule,85.32,209.29,APC
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,153.58,,,,,,,fee schedule,85.32,209.29,APC
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,166.39,,,,,,,fee schedule,95.32,233.78,
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,133.28,,,,,,,fee schedule,95.32,233.78,
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,233.78,,,,,,,fee schedule,95.32,233.78,
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,203.29,,,,,,,fee schedule,95.32,233.78,
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.09,,,,,,,fee schedule,95.32,233.78,APC
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,95.32,,,,,,,fee schedule,95.32,233.78,APC
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,171.58,,,,,,,fee schedule,95.32,233.78,APC
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,171.32,,,,,,,fee schedule,98.15,240.71,
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,137.22,,,,,,,fee schedule,98.15,240.71,
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,240.71,,,,,,,fee schedule,98.15,240.71,
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,209.31,,,,,,,fee schedule,98.15,240.71,
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,103.06,,,,,,,fee schedule,98.15,240.71,APC
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,98.15,,,,,,,fee schedule,98.15,240.71,APC
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,176.67,,,,,,,fee schedule,98.15,240.71,APC
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,163.13,,,,,,,fee schedule,93.45,229.2,
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,130.66,,,,,,,fee schedule,93.45,229.2,
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,229.2,,,,,,,fee schedule,93.45,229.2,
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,199.3,,,,,,,fee schedule,93.45,229.2,
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.12,,,,,,,fee schedule,93.45,229.2,APC
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,93.45,,,,,,,fee schedule,93.45,229.2,APC
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,168.21,,,,,,,fee schedule,93.45,229.2,APC
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,177.92,,,,,,,fee schedule,101.93,249.98,
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,142.51,,,,,,,fee schedule,101.93,249.98,
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,249.98,,,,,,,fee schedule,101.93,249.98,
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,217.37,,,,,,,fee schedule,101.93,249.98,
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.03,,,,,,,fee schedule,101.93,249.98,APC
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,101.93,,,,,,,fee schedule,101.93,249.98,APC
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,183.47,,,,,,,fee schedule,101.93,249.98,APC
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186.18,,,,,,,fee schedule,106.67,261.59,
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,149.13,,,,,,,fee schedule,106.67,261.59,
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,261.59,,,,,,,fee schedule,106.67,261.59,
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,227.47,,,,,,,fee schedule,106.67,261.59,
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112,,,,,,,fee schedule,106.67,261.59,APC
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,106.67,,,,,,,fee schedule,106.67,261.59,APC
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,192.01,,,,,,,fee schedule,106.67,261.59,APC
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,194.5,,,,,,,fee schedule,111.41,273.27,
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,155.79,,,,,,,fee schedule,111.41,273.27,
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,273.27,,,,,,,fee schedule,111.41,273.27,
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,237.63,,,,,,,fee schedule,111.41,273.27,
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,116.98,,,,,,,fee schedule,111.41,273.27,APC
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,111.41,,,,,,,fee schedule,111.41,273.27,APC
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,200.54,,,,,,,fee schedule,111.41,273.27,APC
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.54,,,,,,,fee schedule,128.65,315.48,
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.85,,,,,,,fee schedule,128.65,315.48,
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,315.48,,,,,,,fee schedule,128.65,315.48,
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,274.33,,,,,,,fee schedule,128.65,315.48,
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.08,,,,,,,fee schedule,128.65,315.48,APC
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.65,,,,,,,fee schedule,128.65,315.48,APC
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.57,,,,,,,fee schedule,128.65,315.48,APC
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,205.85,,,,,,,fee schedule,117.92,289.23,
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,164.88,,,,,,,fee schedule,117.92,289.23,
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,289.23,,,,,,,fee schedule,117.92,289.23,
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,251.5,,,,,,,fee schedule,117.92,289.23,
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,123.82,,,,,,,fee schedule,117.92,289.23,APC
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,117.92,,,,,,,fee schedule,117.92,289.23,APC
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,212.26,,,,,,,fee schedule,117.92,289.23,APC
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,224.69,,,,,,,fee schedule,128.72,315.7,
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.98,,,,,,,fee schedule,128.72,315.7,
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,315.7,,,,,,,fee schedule,128.72,315.7,
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,274.52,,,,,,,fee schedule,128.72,315.7,
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.16,,,,,,,fee schedule,128.72,315.7,APC
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,128.72,,,,,,,fee schedule,128.72,315.7,APC
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,231.7,,,,,,,fee schedule,128.72,315.7,APC
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,229.66,,,,,,,fee schedule,131.58,322.68,
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,183.95,,,,,,,fee schedule,131.58,322.68,
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,322.68,,,,,,,fee schedule,131.58,322.68,
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,280.59,,,,,,,fee schedule,131.58,322.68,
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.16,,,,,,,fee schedule,131.58,322.68,APC
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,131.58,,,,,,,fee schedule,131.58,322.68,APC
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,236.84,,,,,,,fee schedule,131.58,322.68,APC
Lens lenticular trifocal,V2315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,255,,,,,,,fee schedule,146.08,358.28,
Lens lenticular trifocal,V2315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,204.25,,,,,,,fee schedule,146.08,358.28,
Lens lenticular trifocal,V2315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,358.28,,,,,,,fee schedule,146.08,358.28,
Lens lenticular trifocal,V2315,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,311.55,,,,,,,fee schedule,146.08,358.28,
Lens lenticular trifocal,V2315,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,153.38,,,,,,,fee schedule,146.08,358.28,APC
Lens lenticular trifocal,V2315,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,146.08,,,,,,,fee schedule,146.08,358.28,APC
Lens lenticular trifocal,V2315,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,262.94,,,,,,,fee schedule,146.08,358.28,APC
Lens aniseikonic trifocal,V2318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,313.47,,,,,,,fee schedule,179.58,440.43,
Lens aniseikonic trifocal,V2318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,251.08,,,,,,,fee schedule,179.58,440.43,
Lens aniseikonic trifocal,V2318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,440.43,,,,,,,fee schedule,179.58,440.43,
Lens aniseikonic trifocal,V2318,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,382.98,,,,,,,fee schedule,179.58,440.43,
Lens aniseikonic trifocal,V2318,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,188.56,,,,,,,fee schedule,179.58,440.43,APC
Lens aniseikonic trifocal,V2318,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,179.58,,,,,,,fee schedule,179.58,440.43,APC
Lens aniseikonic trifocal,V2318,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,323.24,,,,,,,fee schedule,179.58,440.43,APC
Lens trifocal seg width > 28,V2319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,141.49,,,,,,,fee schedule,81.07,198.79,
Lens trifocal seg width > 28,V2319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,113.33,,,,,,,fee schedule,81.07,198.79,
Lens trifocal seg width > 28,V2319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,198.79,,,,,,,fee schedule,81.07,198.79,
Lens trifocal seg width > 28,V2319,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,172.86,,,,,,,fee schedule,81.07,198.79,
Lens trifocal seg width > 28,V2319,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.12,,,,,,,fee schedule,81.07,198.79,APC
Lens trifocal seg width > 28,V2319,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,81.07,,,,,,,fee schedule,81.07,198.79,APC
Lens trifocal seg width > 28,V2319,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,145.93,,,,,,,fee schedule,81.07,198.79,APC
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,149.27,,,,,,,fee schedule,85.52,209.73,
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,119.56,,,,,,,fee schedule,85.52,209.73,
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,209.73,,,,,,,fee schedule,85.52,209.73,
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,182.37,,,,,,,fee schedule,85.52,209.73,
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,89.8,,,,,,,fee schedule,85.52,209.73,APC
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,85.52,,,,,,,fee schedule,85.52,209.73,APC
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,153.94,,,,,,,fee schedule,85.52,209.73,APC
"Lenticular lens, trifocal",V2321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,251.33,,,,,,,fee schedule,143.98,353.12,
"Lenticular lens, trifocal",V2321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,201.31,,,,,,,fee schedule,143.98,353.12,
"Lenticular lens, trifocal",V2321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,353.12,,,,,,,fee schedule,143.98,353.12,
"Lenticular lens, trifocal",V2321,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,307.06,,,,,,,fee schedule,143.98,353.12,
"Lenticular lens, trifocal",V2321,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,151.18,,,,,,,fee schedule,143.98,353.12,APC
"Lenticular lens, trifocal",V2321,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,143.98,,,,,,,fee schedule,143.98,353.12,APC
"Lenticular lens, trifocal",V2321,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,259.16,,,,,,,fee schedule,143.98,353.12,APC
Lens variab asphericity sing,V2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,219.74,,,,,,,fee schedule,125.88,308.74,
Lens variab asphericity sing,V2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,176.01,,,,,,,fee schedule,125.88,308.74,
Lens variab asphericity sing,V2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,308.74,,,,,,,fee schedule,125.88,308.74,
Lens variab asphericity sing,V2410,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,268.47,,,,,,,fee schedule,125.88,308.74,
Lens variab asphericity sing,V2410,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.17,,,,,,,fee schedule,125.88,308.74,APC
Lens variab asphericity sing,V2410,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,125.88,,,,,,,fee schedule,125.88,308.74,APC
Lens variab asphericity sing,V2410,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,226.58,,,,,,,fee schedule,125.88,308.74,APC
Lens variable asphericity bi,V2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,232.62,,,,,,,fee schedule,133.24,326.83,
Lens variable asphericity bi,V2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,186.32,,,,,,,fee schedule,133.24,326.83,
Lens variable asphericity bi,V2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,326.83,,,,,,,fee schedule,133.24,326.83,
Lens variable asphericity bi,V2430,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,284.2,,,,,,,fee schedule,133.24,326.83,
Lens variable asphericity bi,V2430,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.9,,,,,,,fee schedule,133.24,326.83,APC
Lens variable asphericity bi,V2430,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,133.24,,,,,,,fee schedule,133.24,326.83,APC
Lens variable asphericity bi,V2430,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,239.83,,,,,,,fee schedule,133.24,326.83,APC
Contact lens pmma spherical,V2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,196.64,,,,,,,fee schedule,112.64,276.28,
Contact lens pmma spherical,V2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,157.5,,,,,,,fee schedule,112.64,276.28,
Contact lens pmma spherical,V2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,276.28,,,,,,,fee schedule,112.64,276.28,
Contact lens pmma spherical,V2500,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,240.24,,,,,,,fee schedule,112.64,276.28,
Contact lens pmma spherical,V2500,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,118.27,,,,,,,fee schedule,112.64,276.28,APC
Contact lens pmma spherical,V2500,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,112.64,,,,,,,fee schedule,112.64,276.28,APC
Contact lens pmma spherical,V2500,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,202.75,,,,,,,fee schedule,112.64,276.28,APC
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,279.04,,,,,,,fee schedule,159.84,392.06,
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,223.51,,,,,,,fee schedule,159.84,392.06,
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,392.06,,,,,,,fee schedule,159.84,392.06,
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,340.92,,,,,,,fee schedule,159.84,392.06,
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,167.83,,,,,,,fee schedule,159.84,392.06,APC
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,159.84,,,,,,,fee schedule,159.84,392.06,APC
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,287.71,,,,,,,fee schedule,159.84,392.06,APC
Contact lens pmma bifocal,V2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,378.11,,,,,,,fee schedule,216.59,531.25,
Contact lens pmma bifocal,V2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,302.86,,,,,,,fee schedule,216.59,531.25,
Contact lens pmma bifocal,V2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,531.25,,,,,,,fee schedule,216.59,531.25,
Contact lens pmma bifocal,V2502,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,461.96,,,,,,,fee schedule,216.59,531.25,
Contact lens pmma bifocal,V2502,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.42,,,,,,,fee schedule,216.59,531.25,APC
Contact lens pmma bifocal,V2502,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,216.59,,,,,,,fee schedule,216.59,531.25,APC
Contact lens pmma bifocal,V2502,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,389.86,,,,,,,fee schedule,216.59,531.25,APC
Cntct lens pmma color vision,V2503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,365.17,,,,,,,fee schedule,209.19,513.06,
Cntct lens pmma color vision,V2503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,292.49,,,,,,,fee schedule,209.19,513.06,
Cntct lens pmma color vision,V2503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,513.06,,,,,,,fee schedule,209.19,513.06,
Cntct lens pmma color vision,V2503,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,446.14,,,,,,,fee schedule,209.19,513.06,
Cntct lens pmma color vision,V2503,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,219.65,,,,,,,fee schedule,209.19,513.06,APC
Cntct lens pmma color vision,V2503,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,209.19,,,,,,,fee schedule,209.19,513.06,APC
Cntct lens pmma color vision,V2503,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,376.54,,,,,,,fee schedule,209.19,513.06,APC
Cntct gas permeable sphericl,V2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,262.2,,,,,,,fee schedule,150.2,368.39,
Cntct gas permeable sphericl,V2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,210.01,,,,,,,fee schedule,150.2,368.39,
Cntct gas permeable sphericl,V2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,368.39,,,,,,,fee schedule,150.2,368.39,
Cntct gas permeable sphericl,V2510,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,320.34,,,,,,,fee schedule,150.2,368.39,
Cntct gas permeable sphericl,V2510,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.71,,,,,,,fee schedule,150.2,368.39,APC
Cntct gas permeable sphericl,V2510,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,150.2,,,,,,,fee schedule,150.2,368.39,APC
Cntct gas permeable sphericl,V2510,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,270.36,,,,,,,fee schedule,150.2,368.39,APC
Cntct toric prism ballast,V2511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,388.62,,,,,,,fee schedule,222.63,546.01,
Cntct toric prism ballast,V2511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,311.27,,,,,,,fee schedule,222.63,546.01,
Cntct toric prism ballast,V2511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,546.01,,,,,,,fee schedule,222.63,546.01,
Cntct toric prism ballast,V2511,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,474.79,,,,,,,fee schedule,222.63,546.01,
Cntct toric prism ballast,V2511,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,233.76,,,,,,,fee schedule,222.63,546.01,APC
Cntct toric prism ballast,V2511,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,222.63,,,,,,,fee schedule,222.63,546.01,APC
Cntct toric prism ballast,V2511,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,400.73,,,,,,,fee schedule,222.63,546.01,APC
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,447.35,,,,,,,fee schedule,256.25,628.53,
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,358.32,,,,,,,fee schedule,256.25,628.53,
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,628.53,,,,,,,fee schedule,256.25,628.53,
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,546.55,,,,,,,fee schedule,256.25,628.53,
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,269.06,,,,,,,fee schedule,256.25,628.53,APC
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,256.25,,,,,,,fee schedule,256.25,628.53,APC
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,461.25,,,,,,,fee schedule,256.25,628.53,APC
Contact lens extended wear,V2513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,450.64,,,,,,,fee schedule,258.16,633.16,
Contact lens extended wear,V2513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,360.95,,,,,,,fee schedule,258.16,633.16,
Contact lens extended wear,V2513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,633.16,,,,,,,fee schedule,258.16,633.16,
Contact lens extended wear,V2513,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,550.57,,,,,,,fee schedule,258.16,633.16,
Contact lens extended wear,V2513,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,271.07,,,,,,,fee schedule,258.16,633.16,APC
Contact lens extended wear,V2513,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,258.16,,,,,,,fee schedule,258.16,633.16,APC
Contact lens extended wear,V2513,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,464.69,,,,,,,fee schedule,258.16,633.16,APC
Contact lens hydrophilic,V2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,261.25,,,,,,,fee schedule,149.66,367.06,
Contact lens hydrophilic,V2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,209.25,,,,,,,fee schedule,149.66,367.06,
Contact lens hydrophilic,V2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,367.06,,,,,,,fee schedule,149.66,367.06,
Contact lens hydrophilic,V2520,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,319.18,,,,,,,fee schedule,149.66,367.06,
Contact lens hydrophilic,V2520,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.14,,,,,,,fee schedule,149.66,367.06,APC
Contact lens hydrophilic,V2520,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,149.66,,,,,,,fee schedule,149.66,367.06,APC
Contact lens hydrophilic,V2520,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,269.39,,,,,,,fee schedule,149.66,367.06,APC
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,517.37,,,,,,,fee schedule,296.38,726.92,
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,414.4,,,,,,,fee schedule,296.38,726.92,
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,726.92,,,,,,,fee schedule,296.38,726.92,
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,632.1,,,,,,,fee schedule,296.38,726.92,
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,311.2,,,,,,,fee schedule,296.38,726.92,APC
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,296.38,,,,,,,fee schedule,296.38,726.92,APC
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,533.48,,,,,,,fee schedule,296.38,726.92,APC
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,378.61,,,,,,,fee schedule,216.89,531.96,
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,303.26,,,,,,,fee schedule,216.89,531.96,
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,531.96,,,,,,,fee schedule,216.89,531.96,
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,462.57,,,,,,,fee schedule,216.89,531.96,
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.73,,,,,,,fee schedule,216.89,531.96,APC
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,216.89,,,,,,,fee schedule,216.89,531.96,APC
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,390.4,,,,,,,fee schedule,216.89,531.96,APC
Cntct lens hydrophil extend,V2523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,397.49,,,,,,,fee schedule,227.73,558.47,
Cntct lens hydrophil extend,V2523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,318.38,,,,,,,fee schedule,227.73,558.47,
Cntct lens hydrophil extend,V2523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,558.47,,,,,,,fee schedule,227.73,558.47,
Cntct lens hydrophil extend,V2523,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,485.63,,,,,,,fee schedule,227.73,558.47,
Cntct lens hydrophil extend,V2523,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,239.12,,,,,,,fee schedule,227.73,558.47,APC
Cntct lens hydrophil extend,V2523,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,227.73,,,,,,,fee schedule,227.73,558.47,APC
Cntct lens hydrophil extend,V2523,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,409.91,,,,,,,fee schedule,227.73,558.47,APC
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,180.06,,,,,,,fee schedule,171.49,308.68,APC
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,171.49,,,,,,,fee schedule,171.49,308.68,APC
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,308.68,,,,,,,fee schedule,171.49,308.68,APC
Contact lens gas impermeable,V2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,635.52,,,,,,,fee schedule,364.07,892.91,
Contact lens gas impermeable,V2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,509.03,,,,,,,fee schedule,364.07,892.91,
Contact lens gas impermeable,V2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,892.91,,,,,,,fee schedule,364.07,892.91,
Contact lens gas impermeable,V2530,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,776.44,,,,,,,fee schedule,364.07,892.91,
Contact lens gas impermeable,V2530,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,382.27,,,,,,,fee schedule,364.07,892.91,APC
Contact lens gas impermeable,V2530,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,364.07,,,,,,,fee schedule,364.07,892.91,APC
Contact lens gas impermeable,V2530,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,655.33,,,,,,,fee schedule,364.07,892.91,APC
Contact lens gas permeable,V2531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1163.83,,,,,,,fee schedule,666.71,1635.2,
Contact lens gas permeable,V2531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,932.2,,,,,,,fee schedule,666.71,1635.2,
Contact lens gas permeable,V2531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1635.2,,,,,,,fee schedule,666.71,1635.2,
Contact lens gas permeable,V2531,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1421.91,,,,,,,fee schedule,666.71,1635.2,
Contact lens gas permeable,V2531,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,700.05,,,,,,,fee schedule,666.71,1635.2,APC
Contact lens gas permeable,V2531,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,666.71,,,,,,,fee schedule,666.71,1635.2,APC
Contact lens gas permeable,V2531,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1200.08,,,,,,,fee schedule,666.71,1635.2,APC
Plastic eye prosth custom,V2623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2015.21,,,,,,,fee schedule,1154.43,2831.39,
Plastic eye prosth custom,V2623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1614.14,,,,,,,fee schedule,1154.43,2831.39,
Plastic eye prosth custom,V2623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2831.39,,,,,,,fee schedule,1154.43,2831.39,
Plastic eye prosth custom,V2623,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2462.08,,,,,,,fee schedule,1154.43,2831.39,
Plastic eye prosth custom,V2623,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1212.15,,,,,,,fee schedule,1154.43,2831.39,APC
Plastic eye prosth custom,V2623,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1154.43,,,,,,,fee schedule,1154.43,2831.39,APC
Plastic eye prosth custom,V2623,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,2077.97,,,,,,,fee schedule,1154.43,2831.39,APC
Polishing artifical eye,V2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,130.1,,,,,,,fee schedule,74.53,182.79,
Polishing artifical eye,V2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,104.21,,,,,,,fee schedule,74.53,182.79,
Polishing artifical eye,V2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,182.79,,,,,,,fee schedule,74.53,182.79,
Polishing artifical eye,V2624,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,158.95,,,,,,,fee schedule,74.53,182.79,
Polishing artifical eye,V2624,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.26,,,,,,,fee schedule,74.53,182.79,APC
Polishing artifical eye,V2624,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,74.53,,,,,,,fee schedule,74.53,182.79,APC
Polishing artifical eye,V2624,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,134.15,,,,,,,fee schedule,74.53,182.79,APC
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1030.38,,,,,,,fee schedule,590.24,1447.69,
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,825.31,,,,,,,fee schedule,590.24,1447.69,
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1447.69,,,,,,,fee schedule,590.24,1447.69,
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1258.86,,,,,,,fee schedule,590.24,1447.69,
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,619.75,,,,,,,fee schedule,590.24,1447.69,APC
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,590.24,,,,,,,fee schedule,590.24,1447.69,APC
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,1062.43,,,,,,,fee schedule,590.24,1447.69,APC
Reduction of eye prosthesis,V2626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,426.37,,,,,,,fee schedule,244.25,599.06,
Reduction of eye prosthesis,V2626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,341.52,,,,,,,fee schedule,244.25,599.06,
Reduction of eye prosthesis,V2626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,599.06,,,,,,,fee schedule,244.25,599.06,
Reduction of eye prosthesis,V2626,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,520.92,,,,,,,fee schedule,244.25,599.06,
Reduction of eye prosthesis,V2626,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.46,,,,,,,fee schedule,244.25,599.06,APC
Reduction of eye prosthesis,V2626,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,244.25,,,,,,,fee schedule,244.25,599.06,APC
Reduction of eye prosthesis,V2626,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,439.65,,,,,,,fee schedule,244.25,599.06,APC
Scleral cover shell,V2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3056.73,,,,,,,fee schedule,1751.05,4294.73,
Scleral cover shell,V2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2448.37,,,,,,,fee schedule,1751.05,4294.73,
Scleral cover shell,V2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,4294.73,,,,,,,fee schedule,1751.05,4294.73,
Scleral cover shell,V2627,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3734.55,,,,,,,fee schedule,1751.05,4294.73,
Scleral cover shell,V2627,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1838.6,,,,,,,fee schedule,1751.05,4294.73,APC
Scleral cover shell,V2627,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,1751.05,,,,,,,fee schedule,1751.05,4294.73,APC
Scleral cover shell,V2627,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,3151.89,,,,,,,fee schedule,1751.05,4294.73,APC
Fabrication & fitting,V2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,650.21,,,,,,,fee schedule,372.48,913.55,
Fabrication & fitting,V2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,520.8,,,,,,,fee schedule,372.48,913.55,
Fabrication & fitting,V2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,913.55,,,,,,,fee schedule,372.48,913.55,
Fabrication & fitting,V2628,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,794.39,,,,,,,fee schedule,372.48,913.55,
Fabrication & fitting,V2628,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.1,,,,,,,fee schedule,372.48,913.55,APC
Fabrication & fitting,V2628,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,372.48,,,,,,,fee schedule,372.48,913.55,APC
Fabrication & fitting,V2628,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,670.46,,,,,,,fee schedule,372.48,913.55,APC
Anter chamber intraocul lens,V2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.38,,,,,,,fee schedule,203.75,357.41,
Anter chamber intraocul lens,V2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.75,,,,,,,fee schedule,203.75,357.41,
Anter chamber intraocul lens,V2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.41,,,,,,,fee schedule,203.75,357.41,
Anter chamber intraocul lens,V2630,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,310.79,,,,,,,fee schedule,203.75,357.41,
Iris support intraoclr lens,V2631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.38,,,,,,,fee schedule,203.75,357.41,
Iris support intraoclr lens,V2631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.75,,,,,,,fee schedule,203.75,357.41,
Iris support intraoclr lens,V2631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.41,,,,,,,fee schedule,203.75,357.41,
Iris support intraoclr lens,V2631,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,310.79,,,,,,,fee schedule,203.75,357.41,
Post chmbr intraocular lens,V2632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,254.38,,,,,,,fee schedule,203.75,357.41,
Post chmbr intraocular lens,V2632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,203.75,,,,,,,fee schedule,203.75,357.41,
Post chmbr intraocular lens,V2632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,357.41,,,,,,,fee schedule,203.75,357.41,
Post chmbr intraocular lens,V2632,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,310.79,,,,,,,fee schedule,203.75,357.41,
Balance lens,V2700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95.82,,,,,,,fee schedule,54.9,134.63,
Balance lens,V2700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,76.75,,,,,,,fee schedule,54.9,134.63,
Balance lens,V2700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,134.63,,,,,,,fee schedule,54.9,134.63,
Balance lens,V2700,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,117.07,,,,,,,fee schedule,54.9,134.63,
Balance lens,V2700,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.64,,,,,,,fee schedule,54.9,134.63,APC
Balance lens,V2700,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,54.9,,,,,,,fee schedule,54.9,134.63,APC
Balance lens,V2700,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,98.82,,,,,,,fee schedule,54.9,134.63,APC
Glass/plastic slab off prism,V2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,157.11,,,,,,,fee schedule,89.99,220.74,
Glass/plastic slab off prism,V2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,125.84,,,,,,,fee schedule,89.99,220.74,
Glass/plastic slab off prism,V2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,220.74,,,,,,,fee schedule,89.99,220.74,
Glass/plastic slab off prism,V2710,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,191.95,,,,,,,fee schedule,89.99,220.74,
Glass/plastic slab off prism,V2710,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.49,,,,,,,fee schedule,89.99,220.74,APC
Glass/plastic slab off prism,V2710,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,89.99,,,,,,,fee schedule,89.99,220.74,APC
Glass/plastic slab off prism,V2710,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,161.98,,,,,,,fee schedule,89.99,220.74,APC
Prism lens/es,V2715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30.78,,,,,,,fee schedule,17.65,43.25,
Prism lens/es,V2715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,24.66,,,,,,,fee schedule,17.65,43.25,
Prism lens/es,V2715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,43.25,,,,,,,fee schedule,17.65,43.25,
Prism lens/es,V2715,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,37.61,,,,,,,fee schedule,17.65,43.25,
Prism lens/es,V2715,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.53,,,,,,,fee schedule,17.65,43.25,APC
Prism lens/es,V2715,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17.65,,,,,,,fee schedule,17.65,43.25,APC
Prism lens/es,V2715,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31.77,,,,,,,fee schedule,17.65,43.25,APC
Fresnell prism press-on lens,V2718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66.49,,,,,,,fee schedule,38.11,93.43,
Fresnell prism press-on lens,V2718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,53.26,,,,,,,fee schedule,38.11,93.43,
Fresnell prism press-on lens,V2718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,93.43,,,,,,,fee schedule,38.11,93.43,
Fresnell prism press-on lens,V2718,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,81.24,,,,,,,fee schedule,38.11,93.43,
Fresnell prism press-on lens,V2718,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.02,,,,,,,fee schedule,38.11,93.43,APC
Fresnell prism press-on lens,V2718,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38.11,,,,,,,fee schedule,38.11,93.43,APC
Fresnell prism press-on lens,V2718,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,68.6,,,,,,,fee schedule,38.11,93.43,APC
Special base curve,V2730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55.69,,,,,,,fee schedule,31.9,78.25,
Special base curve,V2730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,44.61,,,,,,,fee schedule,31.9,78.25,
Special base curve,V2730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,78.25,,,,,,,fee schedule,31.9,78.25,
Special base curve,V2730,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,68.04,,,,,,,fee schedule,31.9,78.25,
Special base curve,V2730,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.5,,,,,,,fee schedule,31.9,78.25,APC
Special base curve,V2730,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31.9,,,,,,,fee schedule,31.9,78.25,APC
Special base curve,V2730,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57.42,,,,,,,fee schedule,31.9,78.25,APC
Tint photochromatic lens/es,V2744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38.06,,,,,,,fee schedule,21.83,53.48,
Tint photochromatic lens/es,V2744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,30.49,,,,,,,fee schedule,21.83,53.48,
Tint photochromatic lens/es,V2744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,53.48,,,,,,,fee schedule,21.83,53.48,
Tint photochromatic lens/es,V2744,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,46.5,,,,,,,fee schedule,21.83,53.48,
Tint photochromatic lens/es,V2744,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.92,,,,,,,fee schedule,21.83,53.48,APC
Tint photochromatic lens/es,V2744,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21.83,,,,,,,fee schedule,21.83,53.48,APC
Tint photochromatic lens/es,V2744,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39.29,,,,,,,fee schedule,21.83,53.48,APC
"Tint, any color/solid/grad",V2745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21.94,,,,,,,fee schedule,12.57,30.83,
"Tint, any color/solid/grad",V2745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,17.58,,,,,,,fee schedule,12.57,30.83,
"Tint, any color/solid/grad",V2745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,30.83,,,,,,,fee schedule,12.57,30.83,
"Tint, any color/solid/grad",V2745,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,26.81,,,,,,,fee schedule,12.57,30.83,
"Tint, any color/solid/grad",V2745,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.2,,,,,,,fee schedule,12.57,30.83,APC
"Tint, any color/solid/grad",V2745,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12.57,,,,,,,fee schedule,12.57,30.83,APC
"Tint, any color/solid/grad",V2745,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22.63,,,,,,,fee schedule,12.57,30.83,APC
Anti-reflective coating,V2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42.77,,,,,,,fee schedule,24.5,60.09,
Anti-reflective coating,V2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,34.26,,,,,,,fee schedule,24.5,60.09,
Anti-reflective coating,V2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,60.09,,,,,,,fee schedule,24.5,60.09,
Anti-reflective coating,V2750,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,52.25,,,,,,,fee schedule,24.5,60.09,
Anti-reflective coating,V2750,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.72,,,,,,,fee schedule,24.5,60.09,APC
Anti-reflective coating,V2750,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24.5,,,,,,,fee schedule,24.5,60.09,APC
Anti-reflective coating,V2750,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44.1,,,,,,,fee schedule,24.5,60.09,APC
UV lens/es,V2755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.82,,,,,,,fee schedule,20.51,50.32,
UV lens/es,V2755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.69,,,,,,,fee schedule,20.51,50.32,
UV lens/es,V2755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,50.32,,,,,,,fee schedule,20.51,50.32,
UV lens/es,V2755,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.76,,,,,,,fee schedule,20.51,50.32,
UV lens/es,V2755,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.54,,,,,,,fee schedule,20.51,50.32,APC
UV lens/es,V2755,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20.51,,,,,,,fee schedule,20.51,50.32,APC
UV lens/es,V2755,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36.92,,,,,,,fee schedule,20.51,50.32,APC
Scratch resistant coating,V2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35.3,,,,,,,fee schedule,28.28,49.6,
Scratch resistant coating,V2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,28.28,,,,,,,fee schedule,28.28,49.6,
Scratch resistant coating,V2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,49.6,,,,,,,fee schedule,28.28,49.6,
Scratch resistant coating,V2760,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,43.13,,,,,,,fee schedule,28.28,49.6,
Mirror coating,V2761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.47,,,,,,,fee schedule,21.2,37.19,
Mirror coating,V2761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.2,,,,,,,fee schedule,21.2,37.19,
Mirror coating,V2761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.19,,,,,,,fee schedule,21.2,37.19,
Mirror coating,V2761,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.34,,,,,,,fee schedule,21.2,37.19,
"Polarization, any lens",V2762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128.14,,,,,,,fee schedule,102.64,180.04,
"Polarization, any lens",V2762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,102.64,,,,,,,fee schedule,102.64,180.04,
"Polarization, any lens",V2762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,180.04,,,,,,,fee schedule,102.64,180.04,
"Polarization, any lens",V2762,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,156.56,,,,,,,fee schedule,102.64,180.04,
Occluder lens/es,V2770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41.7,,,,,,,fee schedule,23.89,58.59,
Occluder lens/es,V2770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,33.4,,,,,,,fee schedule,23.89,58.59,
Occluder lens/es,V2770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,58.59,,,,,,,fee schedule,23.89,58.59,
Occluder lens/es,V2770,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,50.95,,,,,,,fee schedule,23.89,58.59,
Occluder lens/es,V2770,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.08,,,,,,,fee schedule,23.89,58.59,APC
Occluder lens/es,V2770,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23.89,,,,,,,fee schedule,23.89,58.59,APC
Occluder lens/es,V2770,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43,,,,,,,fee schedule,23.89,58.59,APC
Oversize lens/es,V2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26.79,,,,,,,fee schedule,15.34,37.64,
Oversize lens/es,V2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,21.46,,,,,,,fee schedule,15.34,37.64,
Oversize lens/es,V2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,37.64,,,,,,,fee schedule,15.34,37.64,
Oversize lens/es,V2780,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,32.73,,,,,,,fee schedule,15.34,37.64,
Oversize lens/es,V2780,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.11,,,,,,,fee schedule,15.34,37.64,APC
Oversize lens/es,V2780,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15.34,,,,,,,fee schedule,15.34,37.64,APC
Oversize lens/es,V2780,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27.61,,,,,,,fee schedule,15.34,37.64,APC
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,138.37,,,,,,,fee schedule,79.26,194.41,
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,110.83,,,,,,,fee schedule,79.26,194.41,
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,194.41,,,,,,,fee schedule,79.26,194.41,
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,169.05,,,,,,,fee schedule,79.26,194.41,
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.22,,,,,,,fee schedule,79.26,194.41,APC
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,79.26,,,,,,,fee schedule,79.26,194.41,APC
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,142.67,,,,,,,fee schedule,79.26,194.41,APC
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,156.05,,,,,,,fee schedule,89.39,219.25,
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,124.99,,,,,,,fee schedule,89.39,219.25,
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,219.25,,,,,,,fee schedule,89.39,219.25,
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,190.65,,,,,,,fee schedule,89.39,219.25,
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,93.86,,,,,,,fee schedule,89.39,219.25,APC
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,89.39,,,,,,,fee schedule,89.39,219.25,APC
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,160.9,,,,,,,fee schedule,89.39,219.25,APC
Lens polycarb or equal,V2784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101.47,,,,,,,fee schedule,58.13,142.57,
Lens polycarb or equal,V2784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,81.27,,,,,,,fee schedule,58.13,142.57,
Lens polycarb or equal,V2784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,142.57,,,,,,,fee schedule,58.13,142.57,
Lens polycarb or equal,V2784,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,123.97,,,,,,,fee schedule,58.13,142.57,
Lens polycarb or equal,V2784,HCPCS,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.04,,,,,,,fee schedule,58.13,142.57,APC
Lens polycarb or equal,V2784,HCPCS,,,,,facility,outpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58.13,,,,,,,fee schedule,58.13,142.57,APC
Lens polycarb or equal,V2784,HCPCS,,,,,facility,outpatient,,,,,,Meridian Health Plan,Ambetter Exchange,104.63,,,,,,,fee schedule,58.13,142.57,APC
Hearing screening,V5008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90.61,,,,,,,fee schedule,72.57,127.31,
Hearing screening,V5008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,72.57,,,,,,,fee schedule,72.57,127.31,
Hearing screening,V5008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,127.31,,,,,,,fee schedule,72.57,127.31,
Hearing screening,V5008,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,110.7,,,,,,,fee schedule,72.57,127.31,
Assessment for hearing aid,V5010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,118.72,,,,,,,fee schedule,95.09,166.81,
Assessment for hearing aid,V5010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,95.09,,,,,,,fee schedule,95.09,166.81,
Assessment for hearing aid,V5010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,166.81,,,,,,,fee schedule,95.09,166.81,
Assessment for hearing aid,V5010,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,145.05,,,,,,,fee schedule,95.09,166.81,
Hearing aid fitting/checking,V5011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,185.26,,,,,,,fee schedule,148.39,260.29,
Hearing aid fitting/checking,V5011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,148.39,,,,,,,fee schedule,148.39,260.29,
Hearing aid fitting/checking,V5011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,260.29,,,,,,,fee schedule,148.39,260.29,
Hearing aid fitting/checking,V5011,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,226.34,,,,,,,fee schedule,148.39,260.29,
Hearing aid repair/modifying,V5014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,223.76,,,,,,,fee schedule,179.23,314.39,
Hearing aid repair/modifying,V5014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,179.23,,,,,,,fee schedule,179.23,314.39,
Hearing aid repair/modifying,V5014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,314.39,,,,,,,fee schedule,179.23,314.39,
Hearing aid repair/modifying,V5014,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,273.38,,,,,,,fee schedule,179.23,314.39,
Conformity evaluation,V5020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104.27,,,,,,,fee schedule,83.52,146.5,
Conformity evaluation,V5020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,83.52,,,,,,,fee schedule,83.52,146.5,
Conformity evaluation,V5020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,146.5,,,,,,,fee schedule,83.52,146.5,
Conformity evaluation,V5020,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,127.39,,,,,,,fee schedule,83.52,146.5,
Body-worn hearing aid air,V5030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1644.93,,,,,,,fee schedule,1317.55,2311.14,
Body-worn hearing aid air,V5030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1317.55,,,,,,,fee schedule,1317.55,2311.14,
Body-worn hearing aid air,V5030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2311.14,,,,,,,fee schedule,1317.55,2311.14,
Body-worn hearing aid air,V5030,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2009.69,,,,,,,fee schedule,1317.55,2311.14,
Body-worn hearing aid bone,V5040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1250.32,,,,,,,fee schedule,1001.47,1756.71,
Body-worn hearing aid bone,V5040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1001.47,,,,,,,fee schedule,1001.47,1756.71,
Body-worn hearing aid bone,V5040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1756.71,,,,,,,fee schedule,1001.47,1756.71,
Body-worn hearing aid bone,V5040,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1527.57,,,,,,,fee schedule,1001.47,1756.71,
Hearing aid monaural in ear,V5050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1445.21,,,,,,,fee schedule,1157.58,2030.53,
Hearing aid monaural in ear,V5050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1157.58,,,,,,,fee schedule,1157.58,2030.53,
Hearing aid monaural in ear,V5050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2030.53,,,,,,,fee schedule,1157.58,2030.53,
Hearing aid monaural in ear,V5050,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1765.68,,,,,,,fee schedule,1157.58,2030.53,
Behind ear hearing aid,V5060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1207.82,,,,,,,fee schedule,967.44,1697,
Behind ear hearing aid,V5060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,967.44,,,,,,,fee schedule,967.44,1697,
Behind ear hearing aid,V5060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1697,,,,,,,fee schedule,967.44,1697,
Behind ear hearing aid,V5060,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,1475.65,,,,,,,fee schedule,967.44,1697,
Glasses air conduction,V5070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,671.28,,,,,,,fee schedule,537.68,943.16,
Glasses air conduction,V5070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,537.68,,,,,,,fee schedule,537.68,943.16,
Glasses air conduction,V5070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,943.16,,,,,,,fee schedule,537.68,943.16,
Glasses air conduction,V5070,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,820.14,,,,,,,fee schedule,537.68,943.16,
Glasses bone conduction,V5080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1686.62,,,,,,,fee schedule,1350.94,2369.71,
Glasses bone conduction,V5080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1350.94,,,,,,,fee schedule,1350.94,2369.71,
Glasses bone conduction,V5080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2369.71,,,,,,,fee schedule,1350.94,2369.71,
Glasses bone conduction,V5080,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2060.62,,,,,,,fee schedule,1350.94,2369.71,
Body-worn bilat hearing aid,V5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2705.96,,,,,,,fee schedule,2167.41,3801.9,
Body-worn bilat hearing aid,V5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2167.41,,,,,,,fee schedule,2167.41,3801.9,
Body-worn bilat hearing aid,V5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3801.9,,,,,,,fee schedule,2167.41,3801.9,
Body-worn bilat hearing aid,V5100,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3306,,,,,,,fee schedule,2167.41,3801.9,
Hearing aid dispensing fee,V5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,610.31,,,,,,,fee schedule,488.85,857.5,
Hearing aid dispensing fee,V5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,488.85,,,,,,,fee schedule,488.85,857.5,
Hearing aid dispensing fee,V5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,857.5,,,,,,,fee schedule,488.85,857.5,
Hearing aid dispensing fee,V5110,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,745.65,,,,,,,fee schedule,488.85,857.5,
Body-worn binaur hearing aid,V5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2365.12,,,,,,,fee schedule,1894.41,3323.02,
Body-worn binaur hearing aid,V5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1894.41,,,,,,,fee schedule,1894.41,3323.02,
Body-worn binaur hearing aid,V5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3323.02,,,,,,,fee schedule,1894.41,3323.02,
Body-worn binaur hearing aid,V5120,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2889.58,,,,,,,fee schedule,1894.41,3323.02,
In ear binaural hearing aid,V5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2516.72,,,,,,,fee schedule,2015.84,3536.02,
In ear binaural hearing aid,V5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2015.84,,,,,,,fee schedule,2015.84,3536.02,
In ear binaural hearing aid,V5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3536.02,,,,,,,fee schedule,2015.84,3536.02,
In ear binaural hearing aid,V5130,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3074.8,,,,,,,fee schedule,2015.84,3536.02,
Behind ear binaur hearing ai,V5140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2616.96,,,,,,,fee schedule,2096.12,3676.85,
Behind ear binaur hearing ai,V5140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2096.12,,,,,,,fee schedule,2096.12,3676.85,
Behind ear binaur hearing ai,V5140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3676.85,,,,,,,fee schedule,2096.12,3676.85,
Behind ear binaur hearing ai,V5140,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3197.26,,,,,,,fee schedule,2096.12,3676.85,
Glasses binaural hearing aid,V5150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2794.2,,,,,,,fee schedule,2238.09,3925.87,
Glasses binaural hearing aid,V5150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,2238.09,,,,,,,fee schedule,2238.09,3925.87,
Glasses binaural hearing aid,V5150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,3925.87,,,,,,,fee schedule,2238.09,3925.87,
Glasses binaural hearing aid,V5150,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,3413.8,,,,,,,fee schedule,2238.09,3925.87,
Dispensing fee binaural,V5160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,730.64,,,,,,,fee schedule,585.23,1026.56,
Dispensing fee binaural,V5160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,585.23,,,,,,,fee schedule,585.23,1026.56,
Dispensing fee binaural,V5160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,1026.56,,,,,,,fee schedule,585.23,1026.56,
Dispensing fee binaural,V5160,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,892.66,,,,,,,fee schedule,585.23,1026.56,
Glasses cros hearing aid,V5190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,1922.4,,,,,,,fee schedule,1539.8,2700.99,
Glasses cros hearing aid,V5190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1539.8,,,,,,,fee schedule,1539.8,2700.99,
Glasses cros hearing aid,V5190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2700.99,,,,,,,fee schedule,1539.8,2700.99,
Glasses cros hearing aid,V5190,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2348.69,,,,,,,fee schedule,1539.8,2700.99,
Cros hearing aid dispens fee,V5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,604.72,,,,,,,fee schedule,484.36,849.63,
Cros hearing aid dispens fee,V5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,484.36,,,,,,,fee schedule,484.36,849.63,
Cros hearing aid dispens fee,V5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,849.63,,,,,,,fee schedule,484.36,849.63,
Cros hearing aid dispens fee,V5200,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,738.81,,,,,,,fee schedule,484.36,849.63,
Glasses bicros hearing aid,V5230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,2097.26,,,,,,,fee schedule,1679.86,2946.67,
Glasses bicros hearing aid,V5230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,1679.86,,,,,,,fee schedule,1679.86,2946.67,
Glasses bicros hearing aid,V5230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,2946.67,,,,,,,fee schedule,1679.86,2946.67,
Glasses bicros hearing aid,V5230,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,2562.32,,,,,,,fee schedule,1679.86,2946.67,
Dispensing fee bicros,V5240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Tiered Network HMO/PPO,626.37,,,,,,,fee schedule,501.7,880.05,
Dispensing fee bicros,V5240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Narrow Network Exchange,501.7,,,,,,,fee schedule,501.7,880.05,
Dispensing fee bicros,V5240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Cigna   HMO/PPO,880.05,,,,,,,fee schedule,501.7,880.05,
Dispensing fee bicros,V5240,HCPCS,,,,,facility,outpatient,,,,,,Priority Health,Core Network HMO/PPO,765.26,,,,,,,fee schedule,501.7,880.05,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,853302.37,,,,,,,fee schedule,243215.31,853302.37,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,535257.61,,,,,,,fee schedule,243215.31,853302.37,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,853302.37,,,,,,,fee schedule,243215.31,853302.37,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,428221.45,,,,,,,fee schedule,243215.31,853302.37,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,705079.64,,,,,,,fee schedule,243215.31,853302.37,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,613112.77,,,,,,,fee schedule,243215.31,853302.37,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,255376.08,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,243215.31,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,243215.31,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,243215.31,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,243215.31,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,243215.31,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,243215.31,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,437787.56,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,437787.56,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,255376.08,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,243215.31,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,243215.31,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,255376.08,,,,,,,fee schedule,243215.31,853302.37,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,314193.68,,,,,,,fee schedule,98794.65,314193.68,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,216437.83,,,,,,,fee schedule,98794.65,314193.68,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,314193.68,,,,,,,fee schedule,98794.65,314193.68,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,173156.48,,,,,,,fee schedule,98794.65,314193.68,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,285107.41,,,,,,,fee schedule,98794.65,314193.68,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,247919.5,,,,,,,fee schedule,98794.65,314193.68,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,103734.38,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,98794.65,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,98794.65,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,98794.65,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,98794.65,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,98794.65,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,98794.65,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,177830.37,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,177830.37,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,103734.38,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,98794.65,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,98794.65,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,103734.38,,,,,,,fee schedule,98794.65,314193.68,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,654894.86,,,,,,,fee schedule,184392.71,654894.86,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,405402.17,,,,,,,fee schedule,184392.71,654894.86,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,654894.86,,,,,,,fee schedule,184392.71,654894.86,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,324333.37,,,,,,,fee schedule,184392.71,654894.86,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,534024.76,,,,,,,fee schedule,184392.71,654894.86,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,464369.38,,,,,,,fee schedule,184392.71,654894.86,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],479405.76,239887.22,655389.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],348307.16,348307.16,348307.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",314903.18,136675.75,576984.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",271352.89,271352.89,271352.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],1524509.95,1524509.95,1524509.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",449047.71,449047.71,449047.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],198062.37,198062.37,2828298.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],179974.1,179974.1,179974.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",115250.49,115250.49,115250.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,193612.35,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,184392.71,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,184392.71,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,184392.71,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,184392.71,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,184392.71,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,184392.71,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,331906.88,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,331906.88,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,193612.35,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,184392.71,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,184392.71,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,193612.35,,,,,,,fee schedule,184392.71,654894.86,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,315958.99,,,,,,,fee schedule,120594.32,348500.39,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,264562.29,,,,,,,fee schedule,120594.32,348500.39,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,315958.99,,,,,,,fee schedule,120594.32,348500.39,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,211657.43,,,,,,,fee schedule,120594.32,348500.39,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,348500.39,,,,,,,fee schedule,120594.32,348500.39,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,303043.84,,,,,,,fee schedule,120594.32,348500.39,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],36407.95,36407.95,36407.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],315135.43,306124.88,388327.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],121231.15,121231.15,121231.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",379540.29,379540.29,379540.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",65304.21,65304.21,65304.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",232358.27,211696.43,345150.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],588265.46,588265.46,588265.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],90873.08,90873.08,97784.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",65304.21,65304.21,65304.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,126624.04,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,120594.32,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,120594.32,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,120594.32,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,120594.32,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,120594.32,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,120594.32,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,217069.78,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,217069.78,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,126624.04,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,120594.32,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,120594.32,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,126624.04,,,,,,,fee schedule,120594.32,348500.39,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,322637.22,,,,,,,fee schedule,89958.33,322637.22,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,196930.96,,,,,,,fee schedule,89958.33,322637.22,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,322637.22,,,,,,,fee schedule,89958.33,322637.22,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,157550.42,,,,,,,fee schedule,89958.33,322637.22,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,259411.56,,,,,,,fee schedule,89958.33,322637.22,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,225575.28,,,,,,,fee schedule,89958.33,322637.22,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,94456.25,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,89958.33,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,89958.33,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,89958.33,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,89958.33,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,89958.33,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,89958.33,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,161924.99,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,161924.99,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,94456.25,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,89958.33,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,89958.33,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,94456.25,,,,,,,fee schedule,89958.33,322637.22,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,124118.29,,,,,,,fee schedule,40870.99,124118.29,
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88566.89,,,,,,,fee schedule,40870.99,124118.29,
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,124118.29,,,,,,,fee schedule,40870.99,124118.29,
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,70856.05,,,,,,,fee schedule,40870.99,124118.29,
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,116666.64,,,,,,,fee schedule,40870.99,124118.29,
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,101449.26,,,,,,,fee schedule,40870.99,124118.29,
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42914.54,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40870.99,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,40870.99,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,40870.99,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,40870.99,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,40870.99,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,40870.99,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,73567.78,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,73567.78,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,42914.54,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,40870.99,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,40870.99,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,42914.54,,,,,,,fee schedule,40870.99,124118.29,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,314768.19,,,,,,,fee schedule,112797.11,325826.25,
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,247349.34,,,,,,,fee schedule,112797.11,325826.25,
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,314768.19,,,,,,,fee schedule,112797.11,325826.25,
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,197886.57,,,,,,,fee schedule,112797.11,325826.25,
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,325826.25,,,,,,,fee schedule,112797.11,325826.25,
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,283327.2,,,,,,,fee schedule,112797.11,325826.25,
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,118436.97,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,112797.11,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,112797.11,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,112797.11,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,112797.11,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,112797.11,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,112797.11,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,203034.8,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,203034.8,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,118436.97,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,112797.11,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,112797.11,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,118436.97,,,,,,,fee schedule,112797.11,325826.25,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,135020.03,,,,,,,fee schedule,49242.71,141011.4,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107048.08,,,,,,,fee schedule,49242.71,141011.4,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,135020.03,,,,,,,fee schedule,49242.71,141011.4,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,85641.54,,,,,,,fee schedule,49242.71,141011.4,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,141011.4,,,,,,,fee schedule,49242.71,141011.4,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,122618.62,,,,,,,fee schedule,49242.71,141011.4,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,51704.85,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49242.71,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,49242.71,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,49242.71,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,49242.71,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,49242.71,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,49242.71,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88636.88,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,88636.88,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,51704.85,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,49242.71,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,49242.71,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,51704.85,,,,,,,fee schedule,49242.71,141011.4,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,123522.89,,,,,,,fee schedule,62835.92,180540.18,
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137056.16,,,,,,,fee schedule,62835.92,180540.18,
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,123522.89,,,,,,,fee schedule,62835.92,180540.18,
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,109648.86,,,,,,,fee schedule,62835.92,180540.18,
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,180540.18,,,,,,,fee schedule,62835.92,180540.18,
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,156991.47,,,,,,,fee schedule,62835.92,180540.18,
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,65977.72,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62835.92,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,62835.92,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,62835.92,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,62835.92,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,62835.92,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,62835.92,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,113104.66,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,113104.66,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,65977.72,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,62835.92,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,62835.92,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,65977.72,,,,,,,fee schedule,62835.92,180540.18,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,144069.42,,,,,,,fee schedule,47940.57,144069.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104173.53,,,,,,,fee schedule,47940.57,144069.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,144069.42,,,,,,,fee schedule,47940.57,144069.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,83341.81,,,,,,,fee schedule,47940.57,144069.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,137224.83,,,,,,,fee schedule,47940.57,144069.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,119325.95,,,,,,,fee schedule,47940.57,144069.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84895.08,84895.08,84895.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,50337.6,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47940.57,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,47940.57,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,47940.57,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,47940.57,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,47940.57,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,47940.57,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86293.03,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,86293.03,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,50337.6,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,47940.57,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,47940.57,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,50337.6,,,,,,,fee schedule,47940.57,144069.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,143930.14,,,,,,,fee schedule,37228.49,143930.14,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80525.77,,,,,,,fee schedule,37228.49,143930.14,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,143930.14,,,,,,,fee schedule,37228.49,143930.14,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,64422.93,,,,,,,fee schedule,37228.49,143930.14,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,106074.31,,,,,,,fee schedule,37228.49,143930.14,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,92238.53,,,,,,,fee schedule,37228.49,143930.14,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39089.91,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37228.49,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,37228.49,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,37228.49,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,37228.49,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,37228.49,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,37228.49,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67011.28,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,67011.28,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,39089.91,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,37228.49,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,37228.49,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,39089.91,,,,,,,fee schedule,37228.49,143930.14,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,100852.42,,,,,,,fee schedule,25684.94,100852.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55042.5,,,,,,,fee schedule,25684.94,100852.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,100852.42,,,,,,,fee schedule,25684.94,100852.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44035.58,,,,,,,fee schedule,25684.94,100852.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,72505.92,,,,,,,fee schedule,25684.94,100852.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,63048.63,,,,,,,fee schedule,25684.94,100852.42,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26969.19,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25684.94,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25684.94,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25684.94,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25684.94,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25684.94,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25684.94,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46232.89,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,46232.89,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,26969.19,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25684.94,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25684.94,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,26969.19,,,,,,,fee schedule,25684.94,100852.42,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,486950.24,,,,,,,fee schedule,104730.81,486950.24,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,229542.37,,,,,,,fee schedule,104730.81,486950.24,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,486950.24,,,,,,,fee schedule,104730.81,486950.24,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,183640.48,,,,,,,fee schedule,104730.81,486950.24,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,302369.64,,,,,,,fee schedule,104730.81,486950.24,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,262930.14,,,,,,,fee schedule,104730.81,486950.24,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],380690.16,268551.21,568567.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",193414.53,193414.53,193414.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],272947.08,272947.08,272947.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,109967.35,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,104730.81,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,104730.81,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,104730.81,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,104730.81,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,104730.81,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,104730.81,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,188515.46,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,188515.46,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,109967.35,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,104730.81,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,104730.81,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,109967.35,,,,,,,fee schedule,104730.81,486950.24,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,309816.97,,,,,,,fee schedule,52055.48,309816.97,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113257.51,,,,,,,fee schedule,52055.48,309816.97,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,309816.97,,,,,,,fee schedule,52055.48,309816.97,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,90609.26,,,,,,,fee schedule,52055.48,309816.97,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,149190.9,,,,,,,fee schedule,52055.48,309816.97,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,129731.22,,,,,,,fee schedule,52055.48,309816.97,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],199503.52,199503.52,199503.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84596.68,84596.68,84596.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],246385.47,246385.47,246385.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,54658.25,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52055.48,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,52055.48,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,52055.48,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,52055.48,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,52055.48,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,52055.48,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93699.86,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,93699.86,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,54658.25,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,52055.48,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,52055.48,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,54658.25,,,,,,,fee schedule,52055.48,309816.97,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,158508.74,,,,,,,fee schedule,47751.96,158508.74,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,103757.15,,,,,,,fee schedule,47751.96,158508.74,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,158508.74,,,,,,,fee schedule,47751.96,158508.74,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,83008.69,,,,,,,fee schedule,47751.96,158508.74,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,136676.34,,,,,,,fee schedule,47751.96,158508.74,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,118849,,,,,,,fee schedule,47751.96,158508.74,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,50139.56,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,47751.96,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,47751.96,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,47751.96,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,47751.96,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,47751.96,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,47751.96,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,85953.53,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,85953.53,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,50139.56,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,47751.96,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,47751.96,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,50139.56,,,,,,,fee schedule,47751.96,158508.74,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,235795.85,,,,,,,fee schedule,235795.85,1086476.66,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,824793.21,,,,,,,fee schedule,235795.85,1086476.66,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,235795.85,,,,,,,fee schedule,235795.85,1086476.66,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,659858.23,,,,,,,fee schedule,235795.85,1086476.66,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,1086476.66,,,,,,,fee schedule,235795.85,1086476.66,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,944762.37,,,,,,,fee schedule,235795.85,1086476.66,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,393089.2,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,374370.67,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,374370.67,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,374370.67,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,374370.67,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,374370.67,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,374370.67,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,673867.21,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,673867.21,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,393089.2,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,374370.67,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,374370.67,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,393089.2,,,,,,,fee schedule,235795.85,1086476.66,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136271.15,,,,,,,fee schedule,62480.32,205120.56,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,205120.56,,,,,,,fee schedule,62480.32,205120.56,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,205120.56,,,,,,,fee schedule,62480.32,205120.56,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,109020.83,,,,,,,fee schedule,62480.32,205120.56,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,179506.11,,,,,,,fee schedule,62480.32,205120.56,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,156092.28,,,,,,,fee schedule,62480.32,205120.56,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,65604.34,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62480.32,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,62480.32,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,62480.32,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,62480.32,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,62480.32,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,62480.32,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,112464.58,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,112464.58,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,65604.34,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,62480.32,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,62480.32,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,65604.34,,,,,,,fee schedule,62480.32,205120.56,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,150294.39,,,,,,,fee schedule,68832.65,255705.2,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,255705.2,,,,,,,fee schedule,68832.65,255705.2,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,255705.2,,,,,,,fee schedule,68832.65,255705.2,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,120239.83,,,,,,,fee schedule,68832.65,255705.2,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,197978.54,,,,,,,fee schedule,68832.65,255705.2,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,172155.26,,,,,,,fee schedule,68832.65,255705.2,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,72274.28,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,68832.65,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,68832.65,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,68832.65,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,68832.65,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,68832.65,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,68832.65,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,123898.77,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,123898.77,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,72274.28,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,68832.65,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,68832.65,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,72274.28,,,,,,,fee schedule,68832.65,255705.2,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101111.79,,,,,,,fee schedule,46553.65,186903.41,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,186903.41,,,,,,,fee schedule,46553.65,186903.41,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,186903.41,,,,,,,fee schedule,46553.65,186903.41,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,80892.33,,,,,,,fee schedule,46553.65,186903.41,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,133191.69,,,,,,,fee schedule,46553.65,186903.41,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,115818.87,,,,,,,fee schedule,46553.65,186903.41,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,48881.33,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46553.65,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,46553.65,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,46553.65,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,46553.65,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,46553.65,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,46553.65,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83796.57,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,83796.57,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,48881.33,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,46553.65,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,46553.65,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,48881.33,,,,,,,fee schedule,46553.65,186903.41,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60688.47,,,,,,,fee schedule,28242.48,120772.21,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,120772.21,,,,,,,fee schedule,28242.48,120772.21,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,120772.21,,,,,,,fee schedule,28242.48,120772.21,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48552.51,,,,,,,fee schedule,28242.48,120772.21,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,79943.19,,,,,,,fee schedule,28242.48,120772.21,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,69515.82,,,,,,,fee schedule,28242.48,120772.21,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29654.6,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28242.48,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28242.48,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28242.48,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28242.48,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28242.48,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28242.48,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50836.46,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,50836.46,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29654.6,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28242.48,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28242.48,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29654.6,,,,,,,fee schedule,28242.48,120772.21,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109448.96,,,,,,,fee schedule,50330.27,156861.82,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,156861.82,,,,,,,fee schedule,50330.27,156861.82,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,156861.82,,,,,,,fee schedule,50330.27,156861.82,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,87562.31,,,,,,,fee schedule,50330.27,156861.82,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,144174,,,,,,,fee schedule,50330.27,156861.82,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,125368.71,,,,,,,fee schedule,50330.27,156861.82,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",70977.83,70977.83,70977.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],172367.24,172367.24,172367.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",62211.92,62211.92,62211.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],213567.06,213567.06,213567.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],236438.49,236438.49,236438.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,52846.78,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50330.27,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,50330.27,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,50330.27,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,50330.27,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,50330.27,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,50330.27,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,90594.49,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,90594.49,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,52846.78,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,50330.27,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,50330.27,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,52846.78,,,,,,,fee schedule,50330.27,156861.82,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74717.45,,,,,,,fee schedule,34597.4,121848.11,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,121848.11,,,,,,,fee schedule,34597.4,121848.11,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,121848.11,,,,,,,fee schedule,34597.4,121848.11,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,59776.1,,,,,,,fee schedule,34597.4,121848.11,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,98423.17,,,,,,,fee schedule,34597.4,121848.11,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,85585.37,,,,,,,fee schedule,34597.4,121848.11,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17590.44,17590.44,17590.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],167798.37,167798.37,167798.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36327.27,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34597.4,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,34597.4,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,34597.4,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,34597.4,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,34597.4,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,34597.4,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,62275.32,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,62275.32,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,36327.27,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,34597.4,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,34597.4,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,36327.27,,,,,,,fee schedule,34597.4,121848.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86842.15,,,,,,,fee schedule,40089.72,134717.11,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,134717.11,,,,,,,fee schedule,40089.72,134717.11,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,134717.11,,,,,,,fee schedule,40089.72,134717.11,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,69476.21,,,,,,,fee schedule,40089.72,134717.11,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,114394.7,,,,,,,fee schedule,40089.72,134717.11,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,99473.66,,,,,,,fee schedule,40089.72,134717.11,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],130268.73,82393.3,184206.89,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",56301.18,56301.18,56301.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",61517.74,61517.74,61517.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",26153.51,26153.51,26153.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21850.12,21850.12,54604.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",30880.87,14638.14,40645.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],231015.94,231015.94,231015.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],163945.44,163945.44,163945.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24169.97,24169.97,24169.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],164692.06,154688.32,291826.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,67394.54,67394.54,67394.54,1 through 10,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42094.21,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40089.72,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,40089.72,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,40089.72,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,40089.72,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,40089.72,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,40089.72,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,72161.5,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,72161.5,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,42094.21,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,40089.72,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,40089.72,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,42094.21,,,,,,,fee schedule,40089.72,134717.11,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59385.84,,,,,,,fee schedule,27652.41,100364.96,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,100364.96,,,,,,,fee schedule,27652.41,100364.96,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,100364.96,,,,,,,fee schedule,27652.41,100364.96,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,47510.38,,,,,,,fee schedule,27652.41,100364.96,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,78227.29,,,,,,,fee schedule,27652.41,100364.96,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,68023.73,,,,,,,fee schedule,27652.41,100364.96,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",63741.12,63741.12,63741.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],97050.89,93758.79,98700.89,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31873.56,31873.56,33355.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14638.14,14638.14,26903.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18695.97,18695.97,23625.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",39737.17,14638.14,72694.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],62140.58,62140.58,62140.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21018.58,21018.58,21018.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],161675.8,161675.8,161675.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,92038.29,92038.29,92038.29,1 through 10,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29035.03,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27652.41,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,27652.41,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,27652.41,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,27652.41,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,27652.41,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,27652.41,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49774.34,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,49774.34,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29035.03,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,27652.41,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,27652.41,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29035.03,,,,,,,fee schedule,27652.41,100364.96,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48187.49,,,,,,,fee schedule,22579.72,90723.66,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,90723.66,,,,,,,fee schedule,22579.72,90723.66,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,90723.66,,,,,,,fee schedule,22579.72,90723.66,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,38551.38,,,,,,,fee schedule,22579.72,90723.66,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,63476.01,,,,,,,fee schedule,22579.72,90723.66,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,55196.54,,,,,,,fee schedule,22579.72,90723.66,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],88206.05,55012.74,91286.93,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14638.14,14638.14,14638.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22345.61,22345.61,68772.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13315.91,13315.91,13315.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14638.14,10014.97,54937.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],49529.05,49529.05,208151.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16788.2,16788.2,16788.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],65579.25,65579.25,145335.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,88809.59,88809.59,88809.59,1 through 10,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,57867.8,57867.8,57867.8,1 through 10,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23708.71,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22579.72,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22579.72,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22579.72,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22579.72,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22579.72,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22579.72,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40643.5,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,40643.5,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23708.71,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22579.72,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22579.72,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23708.71,,,,,,,fee schedule,22579.72,90723.66,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114758.77,,,,,,,fee schedule,52735.53,151168.47,
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,135399.56,,,,,,,fee schedule,52735.53,151168.47,
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,135399.56,,,,,,,fee schedule,52735.53,151168.47,
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,91810.31,,,,,,,fee schedule,52735.53,151168.47,
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,151168.47,,,,,,,fee schedule,52735.53,151168.47,
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,131450.85,,,,,,,fee schedule,52735.53,151168.47,
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],129408.16,129408.16,129408.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",62071.8,62071.8,62071.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",41439.56,41439.56,41439.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22906.05,22906.05,22906.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],122018.18,122018.18,122018.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,55372.31,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52735.53,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,52735.53,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,52735.53,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,52735.53,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,52735.53,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,52735.53,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,94923.95,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,94923.95,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,55372.31,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,52735.53,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,52735.53,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,55372.31,,,,,,,fee schedule,52735.53,151168.47,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65161.7,,,,,,,fee schedule,30268.79,89191.63,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,89191.63,,,,,,,fee schedule,30268.79,89191.63,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,89191.63,,,,,,,fee schedule,30268.79,89191.63,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,52131.23,,,,,,,fee schedule,30268.79,89191.63,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,85835.65,,,,,,,fee schedule,30268.79,89191.63,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,74639.7,,,,,,,fee schedule,30268.79,89191.63,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27902.62,27902.62,27902.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],85244.92,75620.58,91583.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24033.32,24033.32,24033.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16754.48,16754.48,16754.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",47009.39,47009.39,47009.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22906.05,22906.05,22906.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15427.23,10588.51,19989.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],67370.83,67370.83,67370.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,94718.82,94718.82,94718.82,1 through 10,percent of total billed charges,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,90861.87,90861.87,90861.87,1 through 10,percent of total billed charges,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31782.23,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30268.79,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,30268.79,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,30268.79,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,30268.79,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,30268.79,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,30268.79,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54483.82,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,54483.82,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,31782.23,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,30268.79,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,30268.79,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,31782.23,,,,,,,fee schedule,30268.79,89191.63,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41928.41,,,,,,,fee schedule,19744.45,65295.55,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,65295.55,,,,,,,fee schedule,19744.45,65295.55,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,65295.55,,,,,,,fee schedule,19744.45,65295.55,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33543.93,,,,,,,fee schedule,19744.45,65295.55,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,55231.1,,,,,,,fee schedule,19744.45,65295.55,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,48027.05,,,,,,,fee schedule,19744.45,65295.55,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24766.81,24766.81,24766.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],63139.48,63139.48,65344.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10588.51,10588.51,10588.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14290.16,10588.51,26348.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],45100.69,45100.69,45100.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19292.69,19292.69,19292.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20731.67,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19744.45,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19744.45,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19744.45,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19744.45,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19744.45,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19744.45,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35540.01,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35540.01,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20731.67,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19744.45,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19744.45,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20731.67,,,,,,,fee schedule,19744.45,65295.55,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85577.73,,,,,,,fee schedule,39516.95,137951.77,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,137951.77,,,,,,,fee schedule,39516.95,137951.77,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,137951.77,,,,,,,fee schedule,39516.95,137951.77,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,68464.64,,,,,,,fee schedule,39516.95,137951.77,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,112729.11,,,,,,,fee schedule,39516.95,137951.77,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,98025.32,,,,,,,fee schedule,39516.95,137951.77,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],113428.3,82236.68,133396.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55471.78,55471.78,55471.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9797.79,9797.79,9797.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9942.4,9942.4,9942.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,41492.8,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39516.95,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,39516.95,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,39516.95,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,39516.95,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,39516.95,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,39516.95,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,71130.51,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,71130.51,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,41492.8,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,39516.95,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,39516.95,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,41492.8,,,,,,,fee schedule,39516.95,137951.77,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40702.19,,,,,,,fee schedule,19188.99,59184.86,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,59184.86,,,,,,,fee schedule,19188.99,59184.86,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,59184.86,,,,,,,fee schedule,19188.99,59184.86,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32562.92,,,,,,,fee schedule,19188.99,59184.86,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53615.83,,,,,,,fee schedule,19188.99,59184.86,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46622.47,,,,,,,fee schedule,19188.99,59184.86,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],57230.57,55307.47,59229.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9797.79,9797.79,9942.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9797.79,9797.79,14113.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9942.4,9797.79,10250.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38903.73,38903.73,38903.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14358.75,14358.75,14358.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,65541.11,65541.11,65541.11,1 through 10,percent of total billed charges,,,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20148.44,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19188.99,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19188.99,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19188.99,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19188.99,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19188.99,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19188.99,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34540.18,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34540.18,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20148.44,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19188.99,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19188.99,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20148.44,,,,,,,fee schedule,19188.99,59184.86,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31761.46,,,,,,,fee schedule,15138.97,54115.25,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,54115.25,,,,,,,fee schedule,15138.97,54115.25,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,54115.25,,,,,,,fee schedule,15138.97,54115.25,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25410.08,,,,,,,fee schedule,15138.97,54115.25,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41838.46,,,,,,,fee schedule,15138.97,54115.25,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36381.28,,,,,,,fee schedule,15138.97,54115.25,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],54156.1,54156.1,54156.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9942.4,9942.4,10250.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9942.4,9942.4,9942.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9797.79,9797.79,9797.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29351.48,29351.48,29351.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9942.4,9942.4,9942.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15895.92,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15138.97,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15138.97,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15138.97,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15138.97,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15138.97,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15138.97,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27250.15,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27250.15,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15895.92,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15138.97,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15138.97,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15895.92,,,,,,,fee schedule,15138.97,54115.25,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73930.52,,,,,,,fee schedule,34240.94,97386.58,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,92962.5,,,,,,,fee schedule,34240.94,97386.58,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,92962.5,,,,,,,fee schedule,34240.94,97386.58,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,59146.54,,,,,,,fee schedule,34240.94,97386.58,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,97386.58,,,,,,,fee schedule,34240.94,97386.58,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,84683.99,,,,,,,fee schedule,34240.94,97386.58,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,35952.99,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34240.94,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,34240.94,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,34240.94,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,34240.94,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,34240.94,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,34240.94,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61633.69,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,61633.69,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,35952.99,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,34240.94,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,34240.94,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,35952.99,,,,,,,fee schedule,34240.94,97386.58,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45658.65,,,,,,,fee schedule,21434.19,60144.84,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,59508.67,,,,,,,fee schedule,21434.19,60144.84,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,59508.67,,,,,,,fee schedule,21434.19,60144.84,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,36528.23,,,,,,,fee schedule,21434.19,60144.84,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,60144.84,,,,,,,fee schedule,21434.19,60144.84,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,52299.86,,,,,,,fee schedule,21434.19,60144.84,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22505.9,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21434.19,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21434.19,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21434.19,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21434.19,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21434.19,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21434.19,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38581.54,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,38581.54,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22505.9,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21434.19,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21434.19,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22505.9,,,,,,,fee schedule,21434.19,60144.84,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37107.56,,,,,,,fee schedule,17560.68,48880.73,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43948.19,,,,,,,fee schedule,17560.68,48880.73,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43948.19,,,,,,,fee schedule,17560.68,48880.73,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29687.11,,,,,,,fee schedule,17560.68,48880.73,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48880.73,,,,,,,fee schedule,17560.68,48880.73,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42504.99,,,,,,,fee schedule,17560.68,48880.73,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18438.71,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17560.68,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17560.68,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17560.68,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17560.68,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17560.68,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17560.68,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31609.22,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31609.22,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18438.71,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17560.68,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17560.68,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18438.71,,,,,,,fee schedule,17560.68,48880.73,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62879.24,,,,,,,fee schedule,29234.87,82829.04,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,66082.45,,,,,,,fee schedule,29234.87,82829.04,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,66082.45,,,,,,,fee schedule,29234.87,82829.04,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,50305.2,,,,,,,fee schedule,29234.87,82829.04,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,82829.04,,,,,,,fee schedule,29234.87,82829.04,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,72025.26,,,,,,,fee schedule,29234.87,82829.04,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30696.61,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29234.87,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,29234.87,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,29234.87,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,29234.87,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,29234.87,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,29234.87,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52622.77,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,52622.77,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30696.61,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,29234.87,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,29234.87,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30696.61,,,,,,,fee schedule,29234.87,82829.04,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30991.72,,,,,,,fee schedule,14790.29,43558.22,
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43558.22,,,,,,,fee schedule,14790.29,43558.22,
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43558.22,,,,,,,fee schedule,14790.29,43558.22,
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24794.27,,,,,,,fee schedule,14790.29,43558.22,
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40824.52,,,,,,,fee schedule,14790.29,43558.22,
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35499.58,,,,,,,fee schedule,14790.29,43558.22,
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15529.8,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14790.29,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14790.29,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14790.29,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14790.29,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14790.29,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14790.29,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26622.52,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26622.52,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15529.8,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14790.29,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14790.29,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15529.8,,,,,,,fee schedule,14790.29,43558.22,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22452.1,,,,,,,fee schedule,10921.97,42078.42,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42078.42,,,,,,,fee schedule,10921.97,42078.42,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42078.42,,,,,,,fee schedule,10921.97,42078.42,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17962.32,,,,,,,fee schedule,10921.97,42078.42,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29575.51,,,,,,,fee schedule,10921.97,42078.42,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25717.84,,,,,,,fee schedule,10921.97,42078.42,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11468.07,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10921.97,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10921.97,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10921.97,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10921.97,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10921.97,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10921.97,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19659.55,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19659.55,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11468.07,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10921.97,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10921.97,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11468.07,,,,,,,fee schedule,10921.97,42078.42,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73749.07,,,,,,,fee schedule,34158.74,97147.56,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,90486.89,,,,,,,fee schedule,34158.74,97147.56,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,90486.89,,,,,,,fee schedule,34158.74,97147.56,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,59001.38,,,,,,,fee schedule,34158.74,97147.56,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,97147.56,,,,,,,fee schedule,34158.74,97147.56,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,84476.14,,,,,,,fee schedule,34158.74,97147.56,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],86482.87,86482.87,86482.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13520.55,13520.55,13520.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13520.55,13520.55,13520.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20564.6,20564.6,20564.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27143.52,27143.52,27143.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",128352.52,128352.52,128352.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,35866.68,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34158.74,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,34158.74,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,34158.74,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,34158.74,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,34158.74,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,34158.74,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61485.73,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,61485.73,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,35866.68,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,34158.74,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,34158.74,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,35866.68,,,,,,,fee schedule,34158.74,97147.56,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41995.26,,,,,,,fee schedule,19774.73,63234.28,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,63234.28,,,,,,,fee schedule,19774.73,63234.28,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,63234.28,,,,,,,fee schedule,19774.73,63234.28,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33597.41,,,,,,,fee schedule,19774.73,63234.28,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,55319.16,,,,,,,fee schedule,19774.73,63234.28,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,48103.62,,,,,,,fee schedule,19774.73,63234.28,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],60557.18,60436.18,62695.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15165.55,15165.55,15165.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14987.69,14987.69,14987.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13520.55,13520.55,13520.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],44169.56,44169.56,45144.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17755.17,17755.17,17755.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16730.06,16730.06,16730.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20763.47,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19774.73,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19774.73,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19774.73,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19774.73,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19774.73,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19774.73,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35594.51,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35594.51,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20763.47,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19774.73,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19774.73,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20763.47,,,,,,,fee schedule,19774.73,63234.28,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32999.14,,,,,,,fee schedule,15699.62,54839.48,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,54839.48,,,,,,,fee schedule,15699.62,54839.48,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,54839.48,,,,,,,fee schedule,15699.62,54839.48,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26400.26,,,,,,,fee schedule,15699.62,54839.48,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43468.83,,,,,,,fee schedule,15699.62,54839.48,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37798.98,,,,,,,fee schedule,15699.62,54839.48,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],53028.68,53028.68,53028.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13520.55,13520.55,13520.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",37673.51,37673.51,37673.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35276.1,35276.1,35276.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9387.42,9387.42,9387.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16484.6,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15699.62,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15699.62,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15699.62,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15699.62,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15699.62,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15699.62,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28259.32,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28259.32,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16484.6,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15699.62,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15699.62,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16484.6,,,,,,,fee schedule,15699.62,54839.48,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34595.9,,,,,,,fee schedule,16422.93,45572.2,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42071.46,,,,,,,fee schedule,16422.93,45572.2,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42071.46,,,,,,,fee schedule,16422.93,45572.2,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27677.71,,,,,,,fee schedule,16422.93,45572.2,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45572.2,,,,,,,fee schedule,16422.93,45572.2,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39628,,,,,,,fee schedule,16422.93,45572.2,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],93525,93525,93525,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17244.08,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16422.93,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16422.93,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16422.93,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16422.93,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16422.93,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16422.93,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29561.27,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29561.27,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17244.08,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16422.93,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16422.93,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17244.08,,,,,,,fee schedule,16422.93,45572.2,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18702.76,,,,,,,fee schedule,9223.57,30348,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30348,,,,,,,fee schedule,9223.57,30348,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30348,,,,,,,fee schedule,9223.57,30348,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14962.74,,,,,,,fee schedule,9223.57,30348,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24636.61,,,,,,,fee schedule,9223.57,30348,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21423.14,,,,,,,fee schedule,9223.57,30348,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33424.53,33424.53,33424.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9684.75,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9223.57,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9223.57,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9223.57,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9223.57,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9223.57,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9223.57,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16602.43,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16602.43,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9684.75,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9223.57,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9223.57,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9684.75,,,,,,,fee schedule,9223.57,30348,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29163.85,,,,,,,fee schedule,13962.29,38416.71,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35187.8,,,,,,,fee schedule,13962.29,38416.71,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35187.8,,,,,,,fee schedule,13962.29,38416.71,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23331.92,,,,,,,fee schedule,13962.29,38416.71,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38416.71,,,,,,,fee schedule,13962.29,38416.71,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33405.84,,,,,,,fee schedule,13962.29,38416.71,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18776.53,18776.53,18776.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",40338.24,40338.24,40338.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14660.4,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13962.29,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13962.29,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13962.29,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13962.29,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13962.29,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13962.29,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25132.12,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25132.12,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14660.4,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13962.29,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13962.29,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14660.4,,,,,,,fee schedule,13962.29,38416.71,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33147.42,,,,,,,fee schedule,9573.12,33147.42,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19474.4,,,,,,,fee schedule,9573.12,33147.42,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33147.42,,,,,,,fee schedule,9573.12,33147.42,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15580.08,,,,,,,fee schedule,9573.12,33147.42,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25653.07,,,,,,,fee schedule,9573.12,33147.42,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22307.02,,,,,,,fee schedule,9573.12,33147.42,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10051.78,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9573.12,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9573.12,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9573.12,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9573.12,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9573.12,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9573.12,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17231.62,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17231.62,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10051.78,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9573.12,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9573.12,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10051.78,,,,,,,fee schedule,9573.12,33147.42,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,63356.14,,,,,,,fee schedule,20851.05,63356.14,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44371.3,,,,,,,fee schedule,20851.05,63356.14,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,63356.14,,,,,,,fee schedule,20851.05,63356.14,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35498.32,,,,,,,fee schedule,20851.05,63356.14,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,58449.06,,,,,,,fee schedule,20851.05,63356.14,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,50825.27,,,,,,,fee schedule,20851.05,63356.14,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22568.14,22568.14,22568.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39649.64,39649.64,39649.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],54009,44037.81,89397.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21987.56,21987.56,21987.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],182153.3,182153.3,182153.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10166.68,9045,128330.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],47322.33,17371.55,50259.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21578.88,14181.83,39675.46,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21893.6,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20851.05,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20851.05,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20851.05,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20851.05,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20851.05,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20851.05,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37531.89,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37531.89,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21893.6,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20851.05,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20851.05,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21893.6,,,,,,,fee schedule,20851.05,63356.14,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46664.05,,,,,,,fee schedule,11961.08,46664.05,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24746.01,,,,,,,fee schedule,11961.08,46664.05,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46664.05,,,,,,,fee schedule,11961.08,46664.05,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19797.52,,,,,,,fee schedule,11961.08,46664.05,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32597.22,,,,,,,fee schedule,11961.08,46664.05,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28345.41,,,,,,,fee schedule,11961.08,46664.05,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22038.86,18147.58,39483.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27877.32,16160.21,39484.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18090,18090,18090,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],51037.52,25416,73071,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8040,7231.36,20100,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],24452.26,24452.26,24452.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6030,6030,6030,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],18036.11,18036.11,18036.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12060,12060,12060,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29741.86,29741.86,29741.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18323.8,18323.8,18323.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9045,6833.54,21105,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24555.24,22427.67,26789.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20037.8,11780.26,37797.96,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20180.54,20180.54,20180.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],5254.6,5254.6,5254.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,36218.41,36218.41,36218.41,1 through 10,percent of total billed charges,,,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,21634.58,21634.58,21634.58,1 through 10,percent of total billed charges,,,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12559.13,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11961.08,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11961.08,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11961.08,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11961.08,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11961.08,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11961.08,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21529.94,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21529.94,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12559.13,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11961.08,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11961.08,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12559.13,,,,,,,fee schedule,11961.08,46664.05,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42130.65,,,,,,,fee schedule,15542.16,43010.92,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32651.52,,,,,,,fee schedule,15542.16,43010.92,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42130.65,,,,,,,fee schedule,15542.16,43010.92,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26122.15,,,,,,,fee schedule,15542.16,43010.92,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43010.92,,,,,,,fee schedule,15542.16,43010.92,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37400.8,,,,,,,fee schedule,15542.16,43010.92,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13977.85,13977.85,13977.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16319.27,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15542.16,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15542.16,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15542.16,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15542.16,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15542.16,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15542.16,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27975.89,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27975.89,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16319.27,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15542.16,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15542.16,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16319.27,,,,,,,fee schedule,15542.16,43010.92,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40368.82,,,,,,,fee schedule,11487.81,40368.82,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23701.24,,,,,,,fee schedule,11487.81,40368.82,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40368.82,,,,,,,fee schedule,11487.81,40368.82,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18961.67,,,,,,,fee schedule,11487.81,40368.82,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31220.97,,,,,,,fee schedule,11487.81,40368.82,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27148.67,,,,,,,fee schedule,11487.81,40368.82,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6557.42,6557.42,6557.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],31435.98,31435.98,31435.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7707.21,7707.21,7707.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8040,8040,8040,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17152.1,17152.1,17152.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7707.21,7707.21,7707.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11243.64,11243.64,11243.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],31276.1,31276.1,31276.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12062.2,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11487.81,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11487.81,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11487.81,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11487.81,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11487.81,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11487.81,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20678.06,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20678.06,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12062.2,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11487.81,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11487.81,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12062.2,,,,,,,fee schedule,11487.81,40368.82,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26618.91,,,,,,,fee schedule,8709.64,26618.91,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17568.22,,,,,,,fee schedule,8709.64,26618.91,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26618.91,,,,,,,fee schedule,8709.64,26618.91,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14055.08,,,,,,,fee schedule,8709.64,26618.91,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23142.11,,,,,,,fee schedule,8709.64,26618.91,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20123.58,,,,,,,fee schedule,8709.64,26618.91,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25441.03,25441.03,25739.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7707.21,7707.21,7707.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7707.21,6833.54,19095,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14769.6,14769.6,14769.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,14246.99,14246.99,14246.99,1 through 10,percent of total billed charges,,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9145.12,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8709.64,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8709.64,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8709.64,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8709.64,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8709.64,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8709.64,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15677.35,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15677.35,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9145.12,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8709.64,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8709.64,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9145.12,,,,,,,fee schedule,8709.64,26618.91,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,82482.07,,,,,,,fee schedule,24606.03,82482.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52660.72,,,,,,,fee schedule,24606.03,82482.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,82482.07,,,,,,,fee schedule,24606.03,82482.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,42130.09,,,,,,,fee schedule,24606.03,82482.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,69368.47,,,,,,,fee schedule,24606.03,82482.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,60320.41,,,,,,,fee schedule,24606.03,82482.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21897.24,21897.24,21897.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25836.33,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24606.03,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24606.03,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24606.03,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24606.03,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24606.03,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24606.03,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44290.85,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,44290.85,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25836.33,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24606.03,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24606.03,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25836.33,,,,,,,fee schedule,24606.03,82482.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51695.35,,,,,,,fee schedule,15954.86,51695.35,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33562.59,,,,,,,fee schedule,15954.86,51695.35,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51695.35,,,,,,,fee schedule,15954.86,51695.35,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26851.04,,,,,,,fee schedule,15954.86,51695.35,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44211.05,,,,,,,fee schedule,15954.86,51695.35,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38444.39,,,,,,,fee schedule,15954.86,51695.35,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],50151.7,50151.7,50151.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15556.19,15522.38,15592.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16752.6,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15954.86,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15954.86,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15954.86,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15954.86,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15954.86,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15954.86,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28718.75,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28718.75,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16752.6,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15954.86,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15954.86,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16752.6,,,,,,,fee schedule,15954.86,51695.35,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51308.87,,,,,,,fee schedule,12897.23,51308.87,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26812.64,,,,,,,fee schedule,12897.23,51308.87,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51308.87,,,,,,,fee schedule,12897.23,51308.87,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21450.88,,,,,,,fee schedule,12897.23,51308.87,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35319.52,,,,,,,fee schedule,12897.23,51308.87,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30712.63,,,,,,,fee schedule,12897.23,51308.87,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12382.01,12382.01,12382.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],48759.86,48759.86,48759.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12356.83,12356.83,12356.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],43033.96,43033.96,43033.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13542.09,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12897.23,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12897.23,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12897.23,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12897.23,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12897.23,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12897.23,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23215.01,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23215.01,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13542.09,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12897.23,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12897.23,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13542.09,,,,,,,fee schedule,12897.23,51308.87,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,52022.65,,,,,,,fee schedule,18150.75,52022.65,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38410.18,,,,,,,fee schedule,18150.75,52022.65,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,52022.65,,,,,,,fee schedule,18150.75,52022.65,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30729.25,,,,,,,fee schedule,18150.75,52022.65,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50596.64,,,,,,,fee schedule,18150.75,52022.65,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43997.08,,,,,,,fee schedule,18150.75,52022.65,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17992.06,17992.06,17992.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17776.79,17776.79,23364.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17529.19,17529.19,17529.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10238.71,10238.71,10238.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16859.86,16859.86,16859.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12098.98,12098.98,12763.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29452.98,29452.98,29452.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17298.92,17298.92,17298.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15492.7,7975.63,17725.25,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],98020.36,98020.36,98020.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19058.29,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18150.75,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18150.75,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18150.75,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18150.75,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18150.75,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18150.75,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32671.35,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32671.35,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19058.29,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18150.75,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18150.75,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19058.29,,,,,,,fee schedule,18150.75,52022.65,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32471.94,,,,,,,fee schedule,9492.65,32471.94,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19296.77,,,,,,,fee schedule,9492.65,32471.94,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32471.94,,,,,,,fee schedule,9492.65,32471.94,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15437.97,,,,,,,fee schedule,9492.65,32471.94,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25419.09,,,,,,,fee schedule,9492.65,32471.94,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22103.56,,,,,,,fee schedule,9492.65,32471.94,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8935.49,8738.99,9114.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9125.09,9103.58,9275.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20660.21,18167.81,28451.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10238.71,10238.71,10238.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],10278.09,10278.09,10278.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7809.26,7809.26,7809.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20412.97,13815.39,33236.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9112.58,7040.4,9283.9,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16956.27,16956.27,16956.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],22662.74,22662.74,25448.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,13084.88,13084.88,13084.88,1 through 10,percent of total billed charges,,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9967.28,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9492.65,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9492.65,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9492.65,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9492.65,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9492.65,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9492.65,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17086.77,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17086.77,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9967.28,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9492.65,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9492.65,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9967.28,,,,,,,fee schedule,9492.65,32471.94,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24627.28,,,,,,,fee schedule,6672.95,24627.28,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13072.07,,,,,,,fee schedule,6672.95,24627.28,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24627.28,,,,,,,fee schedule,6672.95,24627.28,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10458.03,,,,,,,fee schedule,6672.95,24627.28,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17219.46,,,,,,,fee schedule,6672.95,24627.28,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14973.45,,,,,,,fee schedule,6672.95,24627.28,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6978.5,6978.5,6978.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6517.19,6517.19,6517.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23814.08,23814.08,23814.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6186.34,6186.34,6186.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10509.05,10509.05,10509.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6376.7,6365.94,6479.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],24031.98,24031.98,24031.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7006.6,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6672.95,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6672.95,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6672.95,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6672.95,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6672.95,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6672.95,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12011.31,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12011.31,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7006.6,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6672.95,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6672.95,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7006.6,,,,,,,fee schedule,6672.95,24627.28,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42639,,,,,,,fee schedule,13458.75,42639,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28052.23,,,,,,,fee schedule,13458.75,42639,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42639,,,,,,,fee schedule,13458.75,42639,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22442.59,,,,,,,fee schedule,13458.75,42639,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,36952.4,,,,,,,fee schedule,13458.75,42639,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32132.53,,,,,,,fee schedule,13458.75,42639,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12773.93,12773.93,12773.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14131.69,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13458.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13458.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13458.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13458.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13458.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13458.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24225.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24225.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14131.69,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13458.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13458.75,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14131.69,,,,,,,fee schedule,13458.75,42639,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25341.06,,,,,,,fee schedule,8230.32,25341.06,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16510.07,,,,,,,fee schedule,8230.32,25341.06,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25341.06,,,,,,,fee schedule,8230.32,25341.06,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13208.53,,,,,,,fee schedule,8230.32,25341.06,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21748.25,,,,,,,fee schedule,8230.32,25341.06,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18911.52,,,,,,,fee schedule,8230.32,25341.06,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16598.92,16598.92,16598.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],23699.05,23699.05,23699.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8641.84,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8230.32,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8230.32,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8230.32,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8230.32,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8230.32,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8230.32,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14814.58,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14814.58,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8641.84,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8230.32,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8230.32,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8641.84,,,,,,,fee schedule,8230.32,25341.06,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25386.33,,,,,,,fee schedule,7662.75,25386.33,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15257.11,,,,,,,fee schedule,7662.75,25386.33,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25386.33,,,,,,,fee schedule,7662.75,25386.33,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12206.13,,,,,,,fee schedule,7662.75,25386.33,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20097.76,,,,,,,fee schedule,7662.75,25386.33,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17476.31,,,,,,,fee schedule,7662.75,25386.33,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6815.39,6815.39,6815.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20324.34,20324.34,20324.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7325.53,7325.53,7504.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],29793.91,29793.91,29793.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8045.89,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7662.75,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7662.75,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7662.75,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7662.75,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7662.75,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7662.75,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13792.95,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13792.95,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8045.89,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7662.75,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7662.75,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8045.89,,,,,,,fee schedule,7662.75,25386.33,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,49383.39,,,,,,,fee schedule,15155.41,49383.39,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31797.75,,,,,,,fee schedule,15155.41,49383.39,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,49383.39,,,,,,,fee schedule,15155.41,49383.39,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25439.11,,,,,,,fee schedule,15155.41,49383.39,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41886.27,,,,,,,fee schedule,15155.41,49383.39,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36422.84,,,,,,,fee schedule,15155.41,49383.39,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15175.17,15175.17,15175.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8135.58,8135.58,8135.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],49006.01,49006.01,49006.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12620.69,12620.69,12620.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15151.72,13531.21,15806.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,31022.62,31022.62,31022.62,1 through 10,percent of total billed charges,,,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15913.18,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15155.41,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15155.41,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15155.41,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15155.41,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15155.41,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15155.41,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27279.74,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27279.74,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15913.18,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15155.41,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15155.41,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15913.18,,,,,,,fee schedule,15155.41,49383.39,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26754.7,,,,,,,fee schedule,9628.49,26754.7,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19596.64,,,,,,,fee schedule,9628.49,26754.7,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26754.7,,,,,,,fee schedule,9628.49,26754.7,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15677.88,,,,,,,fee schedule,9628.49,26754.7,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25814.1,,,,,,,fee schedule,9628.49,26754.7,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22447.04,,,,,,,fee schedule,9628.49,26754.7,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9553.57,9553.57,9860.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9488.07,9488.07,9488.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6067.79,6067.79,6067.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6252.37,6252.37,6252.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5025,5025,5025,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6252.37,6252.37,6252.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9460.98,9416.18,10347.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10109.91,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9628.49,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9628.49,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9628.49,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9628.49,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9628.49,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9628.49,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17331.28,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17331.28,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10109.91,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9628.49,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9628.49,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10109.91,,,,,,,fee schedule,9628.49,26754.7,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21514.49,,,,,,,fee schedule,7294.17,21514.49,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14443.45,,,,,,,fee schedule,7294.17,21514.49,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21514.49,,,,,,,fee schedule,7294.17,21514.49,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11555.17,,,,,,,fee schedule,7294.17,21514.49,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19025.95,,,,,,,fee schedule,7294.17,21514.49,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16544.3,,,,,,,fee schedule,7294.17,21514.49,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14868,14868,14868,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6900.26,6900.26,6900.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7658.88,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7294.17,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7294.17,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7294.17,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7294.17,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7294.17,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7294.17,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13129.51,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13129.51,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7658.88,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7294.17,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7294.17,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7658.88,,,,,,,fee schedule,7294.17,21514.49,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,39606.29,,,,,,,fee schedule,14631.96,40364.09,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30642.19,,,,,,,fee schedule,14631.96,40364.09,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,39606.29,,,,,,,fee schedule,14631.96,40364.09,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24514.63,,,,,,,fee schedule,14631.96,40364.09,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40364.09,,,,,,,fee schedule,14631.96,40364.09,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35099.21,,,,,,,fee schedule,14631.96,40364.09,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8040,8040,8040,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6285.11,6285.11,6285.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19859.01,19859.01,19859.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8758.23,8758.23,8758.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],235852.43,235852.43,235852.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15363.56,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14631.96,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14631.96,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14631.96,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14631.96,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14631.96,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14631.96,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26337.53,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26337.53,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15363.56,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14631.96,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14631.96,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15363.56,,,,,,,fee schedule,14631.96,40364.09,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28676.7,,,,,,,fee schedule,9670.02,28676.7,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19688.32,,,,,,,fee schedule,9670.02,28676.7,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28676.7,,,,,,,fee schedule,9670.02,28676.7,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15751.22,,,,,,,fee schedule,9670.02,28676.7,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25934.87,,,,,,,fee schedule,9670.02,28676.7,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22552.06,,,,,,,fee schedule,9670.02,28676.7,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9443.04,9443.04,9443.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5175.16,5175.16,5175.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22229.59,15518.77,23131.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5175.16,5175.16,5175.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14863.28,14613.28,20922.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6285.11,6285.11,22110,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20922.79,20922.79,20922.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9335.37,9334.1,9443.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],1485.52,1485.52,1485.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,21422.13,14701.12,24825.31,1 through 10,percent of total billed charges,,,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,11891.62,11891.62,11891.62,1 through 10,percent of total billed charges,,,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,26473.1,26473.1,26473.1,1 through 10,percent of total billed charges,,,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10153.52,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9670.02,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9670.02,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9670.02,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9670.02,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9670.02,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9670.02,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17406.04,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17406.04,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10153.52,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9670.02,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9670.02,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10153.52,,,,,,,fee schedule,9670.02,28676.7,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26709.44,,,,,,,fee schedule,17341.78,48244.18,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36624.33,,,,,,,fee schedule,17341.78,48244.18,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26709.44,,,,,,,fee schedule,17341.78,48244.18,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29300.51,,,,,,,fee schedule,17341.78,48244.18,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48244.18,,,,,,,fee schedule,17341.78,48244.18,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,41951.47,,,,,,,fee schedule,17341.78,48244.18,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15717.36,15717.36,15717.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25527.55,25527.55,25527.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5527.68,5527.68,5527.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20133.53,20133.53,20133.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15118.22,15118.22,15118.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18208.87,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17341.78,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17341.78,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17341.78,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17341.78,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17341.78,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17341.78,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31215.2,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31215.2,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18208.87,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17341.78,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17341.78,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18208.87,,,,,,,fee schedule,17341.78,48244.18,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,15452.55,,,,,,,fee schedule,7891.16,20761.98,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15761.35,,,,,,,fee schedule,7891.16,20761.98,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,15452.55,,,,,,,fee schedule,7891.16,20761.98,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12609.53,,,,,,,fee schedule,7891.16,20761.98,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20761.98,,,,,,,fee schedule,7891.16,20761.98,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18053.9,,,,,,,fee schedule,7891.16,20761.98,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14971.59,14971.59,14971.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11248.28,11248.28,11248.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18403.79,18403.79,18403.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8292.91,8292.91,8292.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8285.72,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7891.16,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7891.16,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7891.16,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7891.16,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7891.16,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7891.16,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14204.09,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14204.09,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8285.72,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7891.16,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7891.16,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8285.72,,,,,,,fee schedule,7891.16,20761.98,MSDRG Base Rate
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11431.08,11431.08,11431.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8975.32,8975.32,8975.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16774.13,,,,,,,fee schedule,14586.2,16774.13,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14586.2,,,,,,,fee schedule,14586.2,16774.13,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,37886.25,,,,,,,fee schedule,16411.69,45539.49,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34571.07,,,,,,,fee schedule,16411.69,45539.49,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,37886.25,,,,,,,fee schedule,16411.69,45539.49,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27657.85,,,,,,,fee schedule,16411.69,45539.49,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45539.49,,,,,,,fee schedule,16411.69,45539.49,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39599.56,,,,,,,fee schedule,16411.69,45539.49,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17232.27,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16411.69,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16411.69,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16411.69,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16411.69,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16411.69,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16411.69,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29541.04,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29541.04,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17232.27,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16411.69,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16411.69,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17232.27,,,,,,,fee schedule,16411.69,45539.49,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31754.67,,,,,,,fee schedule,8500.26,31754.67,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17106,,,,,,,fee schedule,8500.26,31754.67,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31754.67,,,,,,,fee schedule,8500.26,31754.67,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13685.29,,,,,,,fee schedule,8500.26,31754.67,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22533.24,,,,,,,fee schedule,8500.26,31754.67,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19594.12,,,,,,,fee schedule,8500.26,31754.67,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11179.57,11179.57,11179.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8925.27,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8500.26,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8500.26,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8500.26,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8500.26,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8500.26,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8500.26,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15300.47,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15300.47,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8925.27,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8500.26,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8500.26,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8925.27,,,,,,,fee schedule,8500.26,31754.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,70319.89,,,,,,,fee schedule,20526.6,70319.89,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43655.05,,,,,,,fee schedule,20526.6,70319.89,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,70319.89,,,,,,,fee schedule,20526.6,70319.89,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,34925.29,,,,,,,fee schedule,20526.6,70319.89,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,57505.56,,,,,,,fee schedule,20526.6,70319.89,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,50004.84,,,,,,,fee schedule,20526.6,70319.89,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7929.85,7929.85,7929.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17873.78,17873.78,17873.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21113.37,21113.37,21113.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11124.38,11124.38,11124.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19550.07,19550.07,19550.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21552.93,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20526.6,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20526.6,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20526.6,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20526.6,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20526.6,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20526.6,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36947.88,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,36947.88,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21552.93,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20526.6,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20526.6,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21552.93,,,,,,,fee schedule,20526.6,70319.89,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,37687.78,,,,,,,fee schedule,12828.01,37687.78,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26659.84,,,,,,,fee schedule,12828.01,37687.78,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,37687.78,,,,,,,fee schedule,12828.01,37687.78,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21328.63,,,,,,,fee schedule,12828.01,37687.78,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35118.24,,,,,,,fee schedule,12828.01,37687.78,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30537.61,,,,,,,fee schedule,12828.01,37687.78,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7224.81,7224.81,7224.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7224.81,7224.81,7224.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12256.38,12256.38,12256.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12489.7,12489.7,12489.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,10752.75,10752.75,10752.75,1 through 10,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13469.41,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12828.01,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12828.01,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12828.01,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12828.01,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12828.01,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12828.01,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23090.42,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23090.42,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13469.41,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12828.01,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12828.01,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13469.41,,,,,,,fee schedule,12828.01,37687.78,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24167.67,,,,,,,fee schedule,9021.12,24167.67,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18255.82,,,,,,,fee schedule,9021.12,24167.67,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24167.67,,,,,,,fee schedule,9021.12,24167.67,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14605.18,,,,,,,fee schedule,9021.12,24167.67,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24047.87,,,,,,,fee schedule,9021.12,24167.67,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20911.19,,,,,,,fee schedule,9021.12,24167.67,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],9764.08,9764.08,9764.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7224.81,7224.81,7224.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6387.71,6387.71,6387.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15369.09,15369.09,15369.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],6588.9,6588.9,6588.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,8880.05,8880.05,8880.05,1 through 10,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,3776.72,3776.72,3776.72,1 through 10,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9472.18,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9021.12,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9021.12,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9021.12,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9021.12,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9021.12,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9021.12,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16238.02,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16238.02,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9472.18,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9021.12,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9021.12,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9472.18,,,,,,,fee schedule,9021.12,24167.67,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57934.87,,,,,,,fee schedule,20408.06,57934.87,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43393.38,,,,,,,fee schedule,20408.06,57934.87,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57934.87,,,,,,,fee schedule,20408.06,57934.87,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,34715.95,,,,,,,fee schedule,20408.06,57934.87,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,57160.87,,,,,,,fee schedule,20408.06,57934.87,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,49705.11,,,,,,,fee schedule,20408.06,57934.87,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15135.28,15135.28,15135.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11673.36,11673.36,11673.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20103.49,20103.49,20103.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21428.46,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20408.06,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20408.06,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20408.06,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20408.06,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20408.06,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20408.06,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36734.51,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,36734.51,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21428.46,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20408.06,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20408.06,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21428.46,,,,,,,fee schedule,20408.06,57934.87,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30532.54,,,,,,,fee schedule,12022.51,32775.85,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24881.62,,,,,,,fee schedule,12022.51,32775.85,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30532.54,,,,,,,fee schedule,12022.51,32775.85,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19906.01,,,,,,,fee schedule,12022.51,32775.85,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32775.85,,,,,,,fee schedule,12022.51,32775.85,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28500.74,,,,,,,fee schedule,12022.51,32775.85,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14567.18,14567.18,23769.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7070.38,7070.38,7070.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6265.33,6265.33,6265.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11622.17,11622.17,11622.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12623.64,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12022.51,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12022.51,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12022.51,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12022.51,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12022.51,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12022.51,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21640.52,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21640.52,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12623.64,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12022.51,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12022.51,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12623.64,,,,,,,fee schedule,12022.51,32775.85,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21242.9,,,,,,,fee schedule,8665.52,23013.8,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17470.81,,,,,,,fee schedule,8665.52,23013.8,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21242.9,,,,,,,fee schedule,8665.52,23013.8,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13977.15,,,,,,,fee schedule,8665.52,23013.8,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23013.8,,,,,,,fee schedule,8665.52,23013.8,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20012,,,,,,,fee schedule,8665.52,23013.8,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5378.16,5378.16,5378.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],11874.93,7057.13,18162.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4309.14,4309.14,4309.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5378.16,5378.16,5378.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4309.14,4309.14,5378.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16087.54,12579.24,16523.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5378.16,5378.16,5378.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],8956.98,5606.48,21537.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,9237.98,9237.98,9237.98,1 through 10,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,7840,7840,7840,1 through 10,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,3599.78,3599.78,3599.78,1 through 10,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9098.8,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8665.52,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8665.52,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8665.52,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8665.52,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8665.52,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8665.52,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15597.94,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15597.94,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9098.8,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8665.52,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8665.52,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9098.8,,,,,,,fee schedule,8665.52,23013.8,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57969.69,,,,,,,fee schedule,12447.32,57969.69,
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25819.43,,,,,,,fee schedule,12447.32,57969.69,
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57969.69,,,,,,,fee schedule,12447.32,57969.69,
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20656.29,,,,,,,fee schedule,12447.32,57969.69,
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34011.21,,,,,,,fee schedule,12447.32,57969.69,
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29574.96,,,,,,,fee schedule,12447.32,57969.69,
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13069.69,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12447.32,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12447.32,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12447.32,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12447.32,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12447.32,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12447.32,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22405.18,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22405.18,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13069.69,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12447.32,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12447.32,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13069.69,,,,,,,fee schedule,12447.32,57969.69,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32228.21,,,,,,,fee schedule,10256.63,32228.21,
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20983.3,,,,,,,fee schedule,10256.63,32228.21,
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32228.21,,,,,,,fee schedule,10256.63,32228.21,
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16787.25,,,,,,,fee schedule,10256.63,32228.21,
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27640.71,,,,,,,fee schedule,10256.63,32228.21,
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24035.4,,,,,,,fee schedule,10256.63,32228.21,
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15336.74,15336.74,15336.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10769.46,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10256.63,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10256.63,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10256.63,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10256.63,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10256.63,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10256.63,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18461.93,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18461.93,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10769.46,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10256.63,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10256.63,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10769.46,,,,,,,fee schedule,10256.63,32228.21,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30086.86,,,,,,,fee schedule,7873.86,30086.86,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15723.15,,,,,,,fee schedule,7873.86,30086.86,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30086.86,,,,,,,fee schedule,7873.86,30086.86,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12578.97,,,,,,,fee schedule,7873.86,30086.86,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20711.66,,,,,,,fee schedule,7873.86,30086.86,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18010.14,,,,,,,fee schedule,7873.86,30086.86,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13673.67,13673.67,26529.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4309.14,4309.14,4309.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10403.93,10403.93,10403.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4309.14,4309.14,4309.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,5946.86,5946.86,5946.86,1 through 10,percent of total billed charges,,,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8267.55,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7873.86,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7873.86,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7873.86,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7873.86,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7873.86,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7873.86,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14172.95,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14172.95,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8267.55,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7873.86,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7873.86,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8267.55,,,,,,,fee schedule,7873.86,30086.86,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,53760.1,,,,,,,fee schedule,15946.21,53760.1,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33543.49,,,,,,,fee schedule,15946.21,53760.1,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,53760.1,,,,,,,fee schedule,15946.21,53760.1,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26835.75,,,,,,,fee schedule,15946.21,53760.1,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44185.89,,,,,,,fee schedule,15946.21,53760.1,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38422.51,,,,,,,fee schedule,15946.21,53760.1,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20953.85,20953.85,20953.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15869.76,15869.76,86044.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5190.99,5190.99,5190.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45150,22239,90300,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],54330.01,54330.01,54330.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17085,17085,17085,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],50114.86,50114.86,50114.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6030,6030,6030,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9293.56,9293.56,9293.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33535.09,33535.09,33535.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9045,7035,20100,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36586.79,33535.09,377478.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18644.47,13401.12,30276.7,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],29055.64,29055.64,29055.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,60338.53,60338.53,60338.53,1 through 10,percent of total billed charges,,,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16743.52,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15946.21,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15946.21,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15946.21,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15946.21,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15946.21,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15946.21,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28703.18,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28703.18,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16743.52,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15946.21,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15946.21,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16743.52,,,,,,,fee schedule,15946.21,53760.1,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27371,,,,,,,fee schedule,9602.53,27371,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19539.34,,,,,,,fee schedule,9602.53,27371,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27371,,,,,,,fee schedule,9602.53,27371,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15632.03,,,,,,,fee schedule,9602.53,27371,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25738.62,,,,,,,fee schedule,9602.53,27371,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22381.41,,,,,,,fee schedule,9602.53,27371,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16534.86,16534.86,16534.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24831.6,9428.62,51600,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7027.27,7027.27,7027.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9644.9,9644.9,9644.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9293.56,9293.56,9293.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],10599.57,10599.57,10599.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7027.27,7027.27,7027.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14070,14070,14070,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7027.27,6252.37,8040,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21251.97,7886.92,21251.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16569.87,9121.89,28410.62,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17926,17926,17926,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7027.27,7027.27,7027.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],40861.89,40861.89,41118.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10082.66,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9602.53,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9602.53,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9602.53,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9602.53,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9602.53,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9602.53,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17284.55,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17284.55,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10082.66,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9602.53,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9602.53,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10082.66,,,,,,,fee schedule,9602.53,27371,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24797.89,,,,,,,fee schedule,7641.12,24797.89,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15209.36,,,,,,,fee schedule,7641.12,24797.89,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24797.89,,,,,,,fee schedule,7641.12,24797.89,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12167.93,,,,,,,fee schedule,7641.12,24797.89,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20034.86,,,,,,,fee schedule,7641.12,24797.89,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17421.62,,,,,,,fee schedule,7641.12,24797.89,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18066.98,18066.98,18066.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17477.72,7199.28,24816.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5293.14,5293.14,5293.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7351.33,7351.33,7351.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5190.99,5190.99,5190.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5190.99,5190.99,5190.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5190.99,5190.99,5190.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14521.2,14521.2,14521.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5190.99,5190.99,6030,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14521.2,12674.1,15842.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7509.04,7205.28,34182.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5190.99,5190.99,5190.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],10017.04,10017.04,10017.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,17196.16,17196.16,17196.16,1 through 10,percent of total billed charges,,,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8023.18,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7641.12,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7641.12,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7641.12,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7641.12,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7641.12,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7641.12,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13754.02,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13754.02,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8023.18,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7641.12,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7641.12,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8023.18,,,,,,,fee schedule,7641.12,24797.89,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,101802.97,,,,,,,fee schedule,31201.48,101802.97,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67220.68,,,,,,,fee schedule,31201.48,101802.97,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,101802.97,,,,,,,fee schedule,31201.48,101802.97,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,53778.47,,,,,,,fee schedule,31201.48,101802.97,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,88547.89,,,,,,,fee schedule,31201.48,101802.97,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,76998.17,,,,,,,fee schedule,31201.48,101802.97,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],98441.42,98441.42,98441.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17457.96,17457.96,17457.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14761.47,14761.47,14761.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21968.2,21968.2,21968.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],73229.77,73229.77,73229.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34710.16,34710.16,34710.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],24339.29,24339.29,24339.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,88684.39,88684.39,88684.39,1 through 10,percent of total billed charges,,,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,86823.93,86823.93,86823.93,1 through 10,percent of total billed charges,,,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32761.55,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31201.48,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31201.48,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31201.48,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31201.48,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31201.48,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31201.48,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56162.66,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,56162.66,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,32761.55,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31201.48,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31201.48,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,32761.55,,,,,,,fee schedule,31201.48,101802.97,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,86263.38,,,,,,,fee schedule,23066.83,86263.38,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49262.82,,,,,,,fee schedule,23066.83,86263.38,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,86263.38,,,,,,,fee schedule,23066.83,86263.38,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,39411.67,,,,,,,fee schedule,23066.83,86263.38,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,64892.52,,,,,,,fee schedule,23066.83,86263.38,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,56428.28,,,,,,,fee schedule,23066.83,86263.38,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],56576.09,54852.48,83578.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24220.17,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41520.29,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,41520.29,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24220.17,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24220.17,,,,,,,fee schedule,23066.83,86263.38,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60577.61,,,,,,,fee schedule,23066.83,64892.52,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49262.82,,,,,,,fee schedule,23066.83,64892.52,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60577.61,,,,,,,fee schedule,23066.83,64892.52,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,39411.67,,,,,,,fee schedule,23066.83,64892.52,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,64892.52,,,,,,,fee schedule,23066.83,64892.52,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,56428.28,,,,,,,fee schedule,23066.83,64892.52,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],56668.72,33015.19,58577.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],51769.06,51769.06,51769.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],48111.98,48111.98,48111.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],53114.62,53114.62,53114.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24220.17,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41520.29,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,41520.29,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24220.17,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,23066.83,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24220.17,,,,,,,fee schedule,23066.83,64892.52,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60723.85,,,,,,,fee schedule,32000.93,90872.67,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68985.52,,,,,,,fee schedule,32000.93,90872.67,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60723.85,,,,,,,fee schedule,32000.93,90872.67,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,55190.4,,,,,,,fee schedule,32000.93,90872.67,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,90872.67,,,,,,,fee schedule,32000.93,90872.67,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,79019.72,,,,,,,fee schedule,32000.93,90872.67,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],31892.08,31892.08,31892.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],58036.83,58036.83,58036.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28132.31,28132.31,28132.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9790.69,9790.69,9790.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],71953.21,71953.21,71953.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],30639.65,30639.65,30639.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33600.98,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32000.93,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32000.93,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32000.93,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32000.93,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32000.93,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32000.93,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57601.67,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,57601.67,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33600.98,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32000.93,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32000.93,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33600.98,,,,,,,fee schedule,32000.93,90872.67,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43832.68,,,,,,,fee schedule,20607.06,57739.55,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46754.58,,,,,,,fee schedule,20607.06,57739.55,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46754.58,,,,,,,fee schedule,20607.06,57739.55,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35067.4,,,,,,,fee schedule,20607.06,57739.55,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,57739.55,,,,,,,fee schedule,20607.06,57739.55,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,50208.3,,,,,,,fee schedule,20607.06,57739.55,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9790.69,9790.69,9790.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45210.73,45210.73,87075,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33435.74,33435.74,33435.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9790.69,9790.69,9790.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43537.63,39906.17,43537.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21637.41,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20607.06,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20607.06,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20607.06,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20607.06,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20607.06,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20607.06,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37092.71,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37092.71,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21637.41,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20607.06,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20607.06,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21637.41,,,,,,,fee schedule,20607.06,57739.55,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26021.89,,,,,,,fee schedule,12539.03,46173.1,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46173.1,,,,,,,fee schedule,12539.03,46173.1,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46173.1,,,,,,,fee schedule,12539.03,46173.1,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20818.26,,,,,,,fee schedule,12539.03,46173.1,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34277.9,,,,,,,fee schedule,12539.03,46173.1,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29806.87,,,,,,,fee schedule,12539.03,46173.1,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],41319.93,41319.93,42481.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9790.69,9790.69,9790.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9790.69,9790.69,9790.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24413,24413,24413,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9790.69,9790.69,9790.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],36258.28,36258.28,36258.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13165.98,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12539.03,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12539.03,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12539.03,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12539.03,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12539.03,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12539.03,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22570.25,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22570.25,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13165.98,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12539.03,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12539.03,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13165.98,,,,,,,fee schedule,12539.03,46173.1,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36992.96,,,,,,,fee schedule,17508.76,48729.77,
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43443.32,,,,,,,fee schedule,17508.76,48729.77,
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43443.32,,,,,,,fee schedule,17508.76,48729.77,
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29595.43,,,,,,,fee schedule,17508.76,48729.77,
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48729.77,,,,,,,fee schedule,17508.76,48729.77,
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42373.72,,,,,,,fee schedule,17508.76,48729.77,
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16206.54,16206.54,16206.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,4688.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],42008.81,42008.81,42008.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],29115.37,14681.61,42091.16,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14090.26,5651.01,23450.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7791.25,5651.01,32587.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7791.25,7791.25,14090.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],415765.12,415765.12,415765.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],76369.3,76369.3,76369.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7791.25,5651.01,49588.97,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36522.86,9753.64,39846.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16925.02,15019.25,17285.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,1608,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],58039.11,17351.74,79526.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,108020.85,108020.85,108020.85,1 through 10,percent of total billed charges,,,
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18384.2,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17508.76,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17508.76,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17508.76,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17508.76,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17508.76,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17508.76,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31515.77,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31515.77,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18384.2,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17508.76,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17508.76,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18384.2,,,,,,,fee schedule,17508.76,48729.77,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17239.7,,,,,,,fee schedule,8560.83,22709.36,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20222.71,,,,,,,fee schedule,8560.83,22709.36,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20222.71,,,,,,,fee schedule,8560.83,22709.36,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13792.25,,,,,,,fee schedule,8560.83,22709.36,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22709.36,,,,,,,fee schedule,8560.83,22709.36,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19747.27,,,,,,,fee schedule,8560.83,22709.36,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13930.49,7672.86,19593.29,93,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4757.61,1608,5651.01,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],10561.14,10561.14,10561.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5651.01,4688.4,5651.01,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],16740.29,16740.29,16740.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,5748.45,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4688.4,1900,5651.01,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12919.8,12919.8,18498.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14675.63,14675.63,14675.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5651.01,1608,5651.01,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15129.61,10356.43,18498.12,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8335.08,7597.29,8353.32,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10454.62,10454.62,10454.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4688.4,4688.4,5651.01,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],8778.12,5523.63,22684.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,18959.77,7910.49,53442.62,14,percent of total billed charges,,,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,16616.85,6711.33,137001.89,1 through 10,percent of total billed charges,,,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,13227.48,9270.8,19700.22,1 through 10,percent of total billed charges,,,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,16623.49,16623.49,16623.49,1 through 10,percent of total billed charges,,,
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8988.87,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8560.83,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8560.83,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8560.83,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8560.83,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8560.83,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8560.83,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15409.49,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15409.49,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8988.87,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8560.83,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8560.83,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8988.87,,,,,,,fee schedule,8560.83,22709.36,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21409.23,,,,,,,fee schedule,10449.57,29348.7,
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29348.7,,,,,,,fee schedule,10449.57,29348.7,
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29348.7,,,,,,,fee schedule,10449.57,29348.7,
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17128,,,,,,,fee schedule,10449.57,29348.7,
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28201.78,,,,,,,fee schedule,10449.57,29348.7,
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24523.29,,,,,,,fee schedule,10449.57,29348.7,
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],28379.6,28379.6,28379.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6234.91,6234.91,6234.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7140.77,7140.77,7140.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9134.17,9134.17,9134.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10972.05,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10449.57,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10449.57,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10449.57,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10449.57,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10449.57,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10449.57,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18809.23,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18809.23,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10972.05,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10449.57,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10449.57,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10972.05,,,,,,,fee schedule,10449.57,29348.7,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15973.36,,,,,,,fee schedule,7987.2,26862.64,
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26862.64,,,,,,,fee schedule,7987.2,26862.64,
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26862.64,,,,,,,fee schedule,7987.2,26862.64,
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12779.15,,,,,,,fee schedule,7987.2,26862.64,
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21041.26,,,,,,,fee schedule,7987.2,26862.64,
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18296.75,,,,,,,fee schedule,7987.2,26862.64,
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5368.83,5368.83,7027.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17910.54,7946.38,23665.87,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6234.91,6234.91,7027.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6234.91,6234.91,6234.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6234.91,6234.91,6234.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11876.25,11876.25,11876.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5207.9,5207.9,6234.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13928.8,13073.49,16786,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7095.02,7095.02,7729.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14654.46,14654.46,14654.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],15817.87,15817.87,15817.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,5909.2,5909.2,5909.2,1 through 10,percent of total billed charges,,,
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8386.56,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7987.2,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7987.2,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7987.2,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7987.2,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7987.2,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7987.2,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14376.96,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14376.96,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8386.56,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7987.2,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7987.2,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8386.56,,,,,,,fee schedule,7987.2,26862.64,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44906.1,,,,,,,fee schedule,21093.3,63422.3,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,63422.3,,,,,,,fee schedule,21093.3,63422.3,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,63422.3,,,,,,,fee schedule,21093.3,63422.3,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35926.17,,,,,,,fee schedule,21093.3,63422.3,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,59153.53,,,,,,,fee schedule,21093.3,63422.3,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,51437.86,,,,,,,fee schedule,21093.3,63422.3,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],30199.26,30199.26,30199.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22147.96,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21093.3,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21093.3,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21093.3,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21093.3,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21093.3,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21093.3,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37967.94,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37967.94,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22147.96,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21093.3,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21093.3,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22147.96,,,,,,,fee schedule,21093.3,63422.3,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25842.35,,,,,,,fee schedule,12457.71,41890.4,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41890.4,,,,,,,fee schedule,12457.71,41890.4,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41890.4,,,,,,,fee schedule,12457.71,41890.4,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20674.62,,,,,,,fee schedule,12457.71,41890.4,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34041.4,,,,,,,fee schedule,12457.71,41890.4,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29601.22,,,,,,,fee schedule,12457.71,41890.4,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13080.6,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12457.71,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12457.71,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12457.71,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12457.71,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12457.71,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12457.71,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22423.88,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22423.88,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13080.6,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12457.71,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12457.71,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13080.6,,,,,,,fee schedule,12457.71,41890.4,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29316.65,,,,,,,fee schedule,14031.51,38617.99,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26354.29,,,,,,,fee schedule,14031.51,38617.99,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26354.29,,,,,,,fee schedule,14031.51,38617.99,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23454.16,,,,,,,fee schedule,14031.51,38617.99,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38617.99,,,,,,,fee schedule,14031.51,38617.99,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33580.86,,,,,,,fee schedule,14031.51,38617.99,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14018.97,14018.97,14018.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,19874.93,19874.93,19874.93,1 through 10,percent of total billed charges,,,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14733.09,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14031.51,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14031.51,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14031.51,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14031.51,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14031.51,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14031.51,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25256.72,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25256.72,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14733.09,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14031.51,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14031.51,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14733.09,,,,,,,fee schedule,14031.51,38617.99,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34534.78,,,,,,,fee schedule,16395.25,45491.69,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40104.2,,,,,,,fee schedule,16395.25,45491.69,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40104.2,,,,,,,fee schedule,16395.25,45491.69,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27628.82,,,,,,,fee schedule,16395.25,45491.69,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45491.69,,,,,,,fee schedule,16395.25,45491.69,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39557.99,,,,,,,fee schedule,16395.25,45491.69,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17215.01,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16395.25,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16395.25,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16395.25,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16395.25,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16395.25,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16395.25,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29511.45,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29511.45,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17215.01,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16395.25,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16395.25,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17215.01,,,,,,,fee schedule,16395.25,45491.69,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20721.63,,,,,,,fee schedule,10138.09,33352.85,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33352.85,,,,,,,fee schedule,10138.09,33352.85,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33352.85,,,,,,,fee schedule,10138.09,33352.85,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16577.9,,,,,,,fee schedule,10138.09,33352.85,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27296.02,,,,,,,fee schedule,10138.09,33352.85,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23735.67,,,,,,,fee schedule,10138.09,33352.85,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9853.99,9853.99,9853.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10644.99,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10138.09,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10138.09,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10138.09,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10138.09,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10138.09,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10138.09,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18248.56,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18248.56,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10644.99,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10138.09,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10138.09,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10644.99,,,,,,,fee schedule,10138.09,33352.85,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22219.08,,,,,,,fee schedule,10816.41,29268.56,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16044.47,,,,,,,fee schedule,10816.41,29268.56,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16044.47,,,,,,,fee schedule,10816.41,29268.56,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17775.9,,,,,,,fee schedule,10816.41,29268.56,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29268.56,,,,,,,fee schedule,10816.41,29268.56,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25450.92,,,,,,,fee schedule,10816.41,29268.56,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14627.39,14627.39,14627.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6648.9,6648.9,6648.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20944.19,20944.19,20944.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11357.23,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10816.41,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10816.41,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10816.41,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10816.41,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10816.41,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10816.41,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19469.54,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19469.54,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11357.23,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10816.41,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10816.41,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11357.23,,,,,,,fee schedule,10816.41,29268.56,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15008.81,,,,,,,fee schedule,7550.27,19770.68,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14233.89,,,,,,,fee schedule,7550.27,19770.68,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14233.89,,,,,,,fee schedule,7550.27,19770.68,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12007.48,,,,,,,fee schedule,7550.27,19770.68,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19770.68,,,,,,,fee schedule,7550.27,19770.68,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17191.9,,,,,,,fee schedule,7550.27,19770.68,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13604.05,13604.05,13763.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4420.46,4420.46,4420.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4450.41,4450.41,4450.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13614.67,13614.67,13614.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7927.78,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7550.27,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7550.27,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7550.27,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7550.27,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7550.27,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7550.27,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13590.49,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13590.49,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7927.78,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7550.27,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7550.27,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7927.78,,,,,,,fee schedule,7550.27,19770.68,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15253.29,,,,,,,fee schedule,7661.02,29233.8,
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29233.8,,,,,,,fee schedule,7661.02,29233.8,
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29233.8,,,,,,,fee schedule,7661.02,29233.8,
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12203.07,,,,,,,fee schedule,7661.02,29233.8,
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20092.73,,,,,,,fee schedule,7661.02,29233.8,
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17471.94,,,,,,,fee schedule,7661.02,29233.8,
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17186.01,17186.01,17186.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27940.21,27940.21,27940.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7540.41,7540.41,7540.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10803.09,10803.09,10803.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15286.43,12566.38,20171.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7357.25,7342.82,7499.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6380.61,6380.61,6380.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,17450.55,17450.55,17450.55,1 through 10,percent of total billed charges,,,
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8044.07,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7661.02,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7661.02,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7661.02,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7661.02,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7661.02,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7661.02,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13789.84,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13789.84,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8044.07,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7661.02,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7661.02,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8044.07,,,,,,,fee schedule,7661.02,29233.8,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25271.26,,,,,,,fee schedule,12199.01,33474.72,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33474.72,,,,,,,fee schedule,12199.01,33474.72,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33474.72,,,,,,,fee schedule,12199.01,33474.72,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20217.74,,,,,,,fee schedule,12199.01,33474.72,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33289.12,,,,,,,fee schedule,12199.01,33474.72,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28947.06,,,,,,,fee schedule,12199.01,33474.72,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33499.98,33499.98,33499.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10821.52,10821.52,10821.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9567.34,9567.34,9567.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12808.96,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12199.01,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12199.01,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12199.01,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12199.01,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12199.01,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12199.01,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21958.22,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21958.22,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12808.96,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12199.01,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12199.01,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12808.96,,,,,,,fee schedule,12199.01,33474.72,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14665.01,,,,,,,fee schedule,7394.53,19317.8,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18777.74,,,,,,,fee schedule,7394.53,19317.8,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18777.74,,,,,,,fee schedule,7394.53,19317.8,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11732.43,,,,,,,fee schedule,7394.53,19317.8,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19317.8,,,,,,,fee schedule,7394.53,19317.8,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16798.09,,,,,,,fee schedule,7394.53,19317.8,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],845.82,845.82,845.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6380.61,6380.61,6380.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17738.07,15585.48,18157.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4420.46,4420.46,4420.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4450.41,4420.46,6380.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15766.12,15411.09,16573.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7552.51,7552.51,7802.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7764.26,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7394.53,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7394.53,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7394.53,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7394.53,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7394.53,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7394.53,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13310.15,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13310.15,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7764.26,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7394.53,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7394.53,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7764.26,,,,,,,fee schedule,7394.53,19317.8,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41447.09,,,,,,,fee schedule,19526.42,54597.07,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48906.37,,,,,,,fee schedule,19526.42,54597.07,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48906.37,,,,,,,fee schedule,19526.42,54597.07,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33158.86,,,,,,,fee schedule,19526.42,54597.07,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,54597.07,,,,,,,fee schedule,19526.42,54597.07,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,47475.72,,,,,,,fee schedule,19526.42,54597.07,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],47291.48,47291.48,47291.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20502.74,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19526.42,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19526.42,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19526.42,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19526.42,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19526.42,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19526.42,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35147.56,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35147.56,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20502.74,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19526.42,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19526.42,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20502.74,,,,,,,fee schedule,19526.42,54597.07,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19392.27,,,,,,,fee schedule,9535.91,28997.03,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28997.03,,,,,,,fee schedule,9535.91,28997.03,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28997.03,,,,,,,fee schedule,9535.91,28997.03,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15514.37,,,,,,,fee schedule,9535.91,28997.03,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25544.89,,,,,,,fee schedule,9535.91,28997.03,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22212.95,,,,,,,fee schedule,9535.91,28997.03,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10012.71,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9535.91,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9535.91,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9535.91,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9535.91,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9535.91,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9535.91,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17164.64,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17164.64,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10012.71,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9535.91,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9535.91,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10012.71,,,,,,,fee schedule,9535.91,28997.03,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28520.18,,,,,,,fee schedule,13670.72,37568.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,34020.72,,,,,,,fee schedule,13670.72,37568.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,34020.72,,,,,,,fee schedule,13670.72,37568.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22816.96,,,,,,,fee schedule,13670.72,37568.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37568.82,,,,,,,fee schedule,13670.72,37568.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32668.54,,,,,,,fee schedule,13670.72,37568.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2055.91,2055.91,2055.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7232.45,7232.45,7232.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,17957.88,17957.88,17957.88,1 through 10,percent of total billed charges,,,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14354.26,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13670.72,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13670.72,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13670.72,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13670.72,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13670.72,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13670.72,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24607.3,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24607.3,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14354.26,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13670.72,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13670.72,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14354.26,,,,,,,fee schedule,13670.72,37568.82,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16926.46,,,,,,,fee schedule,8418.93,22296.74,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20190.98,,,,,,,fee schedule,8418.93,22296.74,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20190.98,,,,,,,fee schedule,8418.93,22296.74,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13541.65,,,,,,,fee schedule,8418.93,22296.74,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22296.74,,,,,,,fee schedule,8418.93,22296.74,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19388.47,,,,,,,fee schedule,8418.93,22296.74,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9096.56,9096.56,16192.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7422.07,7422.07,7422.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8839.88,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8418.93,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8418.93,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8418.93,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8418.93,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8418.93,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8418.93,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15154.07,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15154.07,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8839.88,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8418.93,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8418.93,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8839.88,,,,,,,fee schedule,8418.93,22296.74,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23601.92,,,,,,,fee schedule,11442.82,33896.02,
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33896.02,,,,,,,fee schedule,11442.82,33896.02,
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33896.02,,,,,,,fee schedule,11442.82,33896.02,
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18882.21,,,,,,,fee schedule,11442.82,33896.02,
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31090.14,,,,,,,fee schedule,11442.82,33896.02,
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27034.9,,,,,,,fee schedule,11442.82,33896.02,
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],26816.83,26816.83,26816.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12014.96,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11442.82,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11442.82,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11442.82,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11442.82,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11442.82,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11442.82,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20597.08,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20597.08,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12014.96,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11442.82,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11442.82,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12014.96,,,,,,,fee schedule,11442.82,33896.02,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81467.4,,,,,,,fee schedule,37655.03,116684.49,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,116684.49,,,,,,,fee schedule,37655.03,116684.49,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,116684.49,,,,,,,fee schedule,37655.03,116684.49,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,65176.26,,,,,,,fee schedule,37655.03,116684.49,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,107314.69,,,,,,,fee schedule,37655.03,116684.49,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,93317.13,,,,,,,fee schedule,37655.03,116684.49,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39537.78,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37655.03,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,37655.03,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,37655.03,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,37655.03,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,37655.03,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,37655.03,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67779.05,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,67779.05,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,39537.78,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,37655.03,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,37655.03,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,39537.78,,,,,,,fee schedule,37655.03,116684.49,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41659.1,,,,,,,fee schedule,19622.46,89059.32,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,89059.32,,,,,,,fee schedule,19622.46,89059.32,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,89059.32,,,,,,,fee schedule,19622.46,89059.32,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33328.47,,,,,,,fee schedule,19622.46,89059.32,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,54876.35,,,,,,,fee schedule,19622.46,89059.32,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,47718.56,,,,,,,fee schedule,19622.46,89059.32,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],84175.06,84175.06,84175.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5709.47,5709.47,5709.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20603.58,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19622.46,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19622.46,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19622.46,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19622.46,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19622.46,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19622.46,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35320.43,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35320.43,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20603.58,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19622.46,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19622.46,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20603.58,,,,,,,fee schedule,19622.46,89059.32,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30491.3,,,,,,,fee schedule,14563.61,65859.61,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,65859.61,,,,,,,fee schedule,14563.61,65859.61,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,65859.61,,,,,,,fee schedule,14563.61,65859.61,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24393.92,,,,,,,fee schedule,14563.61,65859.61,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40165.33,,,,,,,fee schedule,14563.61,65859.61,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34926.37,,,,,,,fee schedule,14563.61,65859.61,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],61662.35,61662.35,65909.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26532.05,26532.05,26532.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15291.79,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14563.61,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14563.61,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14563.61,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14563.61,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14563.61,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14563.61,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26214.5,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26214.5,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15291.79,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14563.61,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14563.61,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15291.79,,,,,,,fee schedule,14563.61,65859.61,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71560.21,,,,,,,fee schedule,33167.22,107972.85,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,107972.85,,,,,,,fee schedule,33167.22,107972.85,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,107972.85,,,,,,,fee schedule,33167.22,107972.85,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,57250.22,,,,,,,fee schedule,33167.22,107972.85,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,94264.23,,,,,,,fee schedule,33167.22,107972.85,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,81968.9,,,,,,,fee schedule,33167.22,107972.85,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],69291.19,52714.91,91848.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21888.38,21888.38,21888.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8285.65,8285.65,8285.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31651.98,31651.98,110070,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],66270.9,66270.9,66270.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11376.5,11376.5,11376.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34825.58,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33167.22,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,33167.22,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,33167.22,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,33167.22,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,33167.22,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,33167.22,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59701,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,59701,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,34825.58,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,33167.22,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,33167.22,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,34825.58,,,,,,,fee schedule,33167.22,107972.85,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33098.46,,,,,,,fee schedule,15744.61,46778.95,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46778.95,,,,,,,fee schedule,15744.61,46778.95,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46778.95,,,,,,,fee schedule,15744.61,46778.95,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26479.72,,,,,,,fee schedule,15744.61,46778.95,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43599.66,,,,,,,fee schedule,15744.61,46778.95,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37912.75,,,,,,,fee schedule,15744.61,46778.95,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],43864.01,23413.72,46814.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",38189.42,38189.42,38189.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6198.35,6198.35,6198.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7232.45,7232.45,7232.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8285.65,8285.65,8285.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11392.87,11392.87,16192.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24508.71,24508.71,24508.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],86794.3,86794.3,86794.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,24487.03,24487.03,24487.03,1 through 10,percent of total billed charges,,,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,27375.42,27375.42,27375.42,1 through 10,percent of total billed charges,,,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16531.84,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15744.61,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15744.61,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15744.61,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15744.61,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15744.61,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15744.61,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28340.3,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28340.3,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16531.84,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15744.61,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15744.61,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16531.84,,,,,,,fee schedule,15744.61,46778.95,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22963.98,,,,,,,fee schedule,11153.84,36573.58,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36573.58,,,,,,,fee schedule,11153.84,36573.58,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36573.58,,,,,,,fee schedule,11153.84,36573.58,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18371.84,,,,,,,fee schedule,11153.84,36573.58,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30249.8,,,,,,,fee schedule,11153.84,36573.58,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26304.17,,,,,,,fee schedule,11153.84,36573.58,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24672.3,18358.61,35365.92,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9096.56,9096.56,9096.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11824.52,11824.52,14644.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14644.15,14644.15,14644.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7232.45,7232.45,7232.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23779,23779,23779,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7232.45,7232.45,7232.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],19140.08,19140.08,19140.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,33886.12,33886.12,33886.12,1 through 10,percent of total billed charges,,,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11711.53,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11153.84,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11153.84,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11153.84,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11153.84,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11153.84,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11153.84,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20076.91,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20076.91,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11711.53,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11153.84,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11153.84,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11711.53,,,,,,,fee schedule,11153.84,36573.58,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40442.42,,,,,,,fee schedule,19071.32,53273.66,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45609.04,,,,,,,fee schedule,19071.32,53273.66,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45609.04,,,,,,,fee schedule,19071.32,53273.66,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32355.1,,,,,,,fee schedule,19071.32,53273.66,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53273.66,,,,,,,fee schedule,19071.32,53273.66,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46324.92,,,,,,,fee schedule,19071.32,53273.66,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20024.89,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19071.32,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19071.32,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19071.32,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19071.32,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19071.32,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19071.32,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34328.38,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34328.38,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20024.89,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19071.32,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19071.32,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20024.89,,,,,,,fee schedule,19071.32,53273.66,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24285.7,,,,,,,fee schedule,11752.56,34150.2,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,34150.2,,,,,,,fee schedule,11752.56,34150.2,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,34150.2,,,,,,,fee schedule,11752.56,34150.2,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19429.26,,,,,,,fee schedule,11752.56,34150.2,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31990.86,,,,,,,fee schedule,11752.56,34150.2,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27818.14,,,,,,,fee schedule,11752.56,34150.2,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12340.19,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11752.56,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11752.56,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11752.56,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11752.56,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11752.56,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11752.56,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21154.61,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21154.61,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12340.19,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11752.56,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11752.56,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12340.19,,,,,,,fee schedule,11752.56,34150.2,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28384.22,,,,,,,fee schedule,7648.04,28384.22,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15224.64,,,,,,,fee schedule,7648.04,28384.22,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28384.22,,,,,,,fee schedule,7648.04,28384.22,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12180.15,,,,,,,fee schedule,7648.04,28384.22,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20054.99,,,,,,,fee schedule,7648.04,28384.22,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17439.12,,,,,,,fee schedule,7648.04,28384.22,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8030.44,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7648.04,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7648.04,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7648.04,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7648.04,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7648.04,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7648.04,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13766.47,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13766.47,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8030.44,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7648.04,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7648.04,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8030.44,,,,,,,fee schedule,7648.04,28384.22,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14355.59,,,,,,,fee schedule,7254.37,22524.23,
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22524.23,,,,,,,fee schedule,7254.37,22524.23,
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22524.23,,,,,,,fee schedule,7254.37,22524.23,
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11484.88,,,,,,,fee schedule,7254.37,22524.23,
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18910.21,,,,,,,fee schedule,7254.37,22524.23,
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16443.66,,,,,,,fee schedule,7254.37,22524.23,
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2791.78,2791.78,2791.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6643.13,6643.13,6643.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5673.39,5673.39,5673.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5116.23,5116.23,5116.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6861.67,6565.32,15469.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,12474.84,12474.84,12474.84,1 through 10,percent of total billed charges,,,
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7617.09,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7254.37,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7254.37,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7254.37,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7254.37,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7254.37,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7254.37,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13057.87,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13057.87,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7617.09,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7254.37,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7254.37,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7617.09,,,,,,,fee schedule,7254.37,22524.23,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25431.7,,,,,,,fee schedule,12271.69,44226.74,
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44226.74,,,,,,,fee schedule,12271.69,44226.74,
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44226.74,,,,,,,fee schedule,12271.69,44226.74,
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20346.09,,,,,,,fee schedule,12271.69,44226.74,
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33500.46,,,,,,,fee schedule,12271.69,44226.74,
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29130.84,,,,,,,fee schedule,12271.69,44226.74,
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12885.27,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12271.69,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12271.69,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12271.69,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12271.69,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12271.69,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12271.69,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22089.04,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22089.04,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12885.27,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12271.69,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12271.69,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12885.27,,,,,,,fee schedule,12271.69,44226.74,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14019.43,,,,,,,fee schedule,7102.09,22158.63,
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22158.63,,,,,,,fee schedule,7102.09,22158.63,
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22158.63,,,,,,,fee schedule,7102.09,22158.63,
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11215.95,,,,,,,fee schedule,7102.09,22158.63,
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18467.4,,,,,,,fee schedule,7102.09,22158.63,
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16058.61,,,,,,,fee schedule,7102.09,22158.63,
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6951.6,6951.6,6951.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7457.19,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7102.09,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7102.09,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7102.09,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7102.09,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7102.09,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7102.09,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12783.76,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12783.76,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7457.19,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7102.09,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7102.09,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7457.19,,,,,,,fee schedule,7102.09,22158.63,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22580.07,,,,,,,fee schedule,10979.94,29744.08,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17980.39,,,,,,,fee schedule,10979.94,29744.08,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17980.39,,,,,,,fee schedule,10979.94,29744.08,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18064.7,,,,,,,fee schedule,10979.94,29744.08,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29744.08,,,,,,,fee schedule,10979.94,29744.08,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25864.42,,,,,,,fee schedule,10979.94,29744.08,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15789.67,12433.01,24302.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4285.67,4285.67,4285.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6039.37,6039.37,6039.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11392.87,10063.54,13831.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20875.72,8007.62,22775.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10744.83,10121.66,10790.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,6237.2,6237.2,6237.2,1 through 10,percent of total billed charges,,,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11528.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10979.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10979.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10979.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10979.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10979.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10979.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19763.89,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19763.89,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11528.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10979.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10979.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11528.94,,,,,,,fee schedule,10979.94,29744.08,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14099.65,,,,,,,fee schedule,7138.43,18573.07,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,12444.21,,,,,,,fee schedule,7138.43,18573.07,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,12444.21,,,,,,,fee schedule,7138.43,18573.07,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11280.12,,,,,,,fee schedule,7138.43,18573.07,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18573.07,,,,,,,fee schedule,7138.43,18573.07,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16150.49,,,,,,,fee schedule,7138.43,18573.07,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],8423.31,5317.45,12033.3,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],4846.47,4846.47,4846.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4285.35,3530.08,4285.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3529.88,3529.88,3529.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4285.67,1700,4285.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4285.67,4285.67,4285.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9145.04,9145.04,9145.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16032.72,16032.72,16032.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3529.88,3529.88,4285.67,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8526.78,6741.26,14285.06,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7020.63,7020.63,7020.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3529.88,3529.88,4285.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],9388.26,9388.26,9388.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,9249.18,9249.18,12870.77,1 through 10,percent of total billed charges,,,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,5923.32,5923.32,5923.32,1 through 10,percent of total billed charges,,,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,6724.28,6724.28,6724.28,1 through 10,percent of total billed charges,,,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,4285.67,4285.67,4285.67,1 through 10,percent of total billed charges,,,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7495.35,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7138.43,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7138.43,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7138.43,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7138.43,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7138.43,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7138.43,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12849.17,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12849.17,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7495.35,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7138.43,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7138.43,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7495.35,,,,,,,fee schedule,7138.43,18573.07,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29862.91,,,,,,,fee schedule,14278.96,39337.57,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31841.72,,,,,,,fee schedule,14278.96,39337.57,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31841.72,,,,,,,fee schedule,14278.96,39337.57,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23891.19,,,,,,,fee schedule,14278.96,39337.57,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39337.57,,,,,,,fee schedule,14278.96,39337.57,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34206.58,,,,,,,fee schedule,14278.96,39337.57,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22069.28,22069.28,22069.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12203.78,12203.78,12203.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],49705.89,49705.89,49705.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27971.87,27971.87,27971.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14262.32,14262.32,14262.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],8578.49,8578.49,8578.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14992.91,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14278.96,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14278.96,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14278.96,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14278.96,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14278.96,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14278.96,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25702.13,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25702.13,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14992.91,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14278.96,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14278.96,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14992.91,,,,,,,fee schedule,14278.96,39337.57,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17505.19,,,,,,,fee schedule,8681.09,29494.94,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29494.94,,,,,,,fee schedule,8681.09,29494.94,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29494.94,,,,,,,fee schedule,8681.09,29494.94,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14004.65,,,,,,,fee schedule,8681.09,29494.94,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23059.09,,,,,,,fee schedule,8681.09,29494.94,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20051.38,,,,,,,fee schedule,8681.09,29494.94,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14441.99,12755.35,19546,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5657.56,5657.56,5657.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18738.99,18738.99,18738.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8415.12,8415.12,8415.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8179.79,8179.79,8179.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,23374.92,23374.92,23374.92,1 through 10,percent of total billed charges,,,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9115.14,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8681.09,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8681.09,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8681.09,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8681.09,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8681.09,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8681.09,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15625.96,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15625.96,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9115.14,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8681.09,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8681.09,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9115.14,,,,,,,fee schedule,8681.09,29494.94,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13200.04,,,,,,,fee schedule,6730.92,17388.03,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14947.68,,,,,,,fee schedule,6730.92,17388.03,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14947.68,,,,,,,fee schedule,6730.92,17388.03,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10560.41,,,,,,,fee schedule,6730.92,17388.03,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17388.03,,,,,,,fee schedule,6730.92,17388.03,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15120.03,,,,,,,fee schedule,6730.92,17388.03,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14454.1,10237.2,14477.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4526.05,4526.05,4526.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4578.17,4578.17,4578.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15952.33,15952.33,15952.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],21559.86,21559.86,21559.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,5633.58,5633.58,5633.58,1 through 10,percent of total billed charges,,,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7067.47,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6730.92,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6730.92,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6730.92,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6730.92,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6730.92,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6730.92,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12115.66,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12115.66,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7067.47,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6730.92,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6730.92,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7067.47,,,,,,,fee schedule,6730.92,17388.03,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32790.95,,,,,,,fee schedule,15605.32,71608.18,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,71608.18,,,,,,,fee schedule,15605.32,71608.18,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,71608.18,,,,,,,fee schedule,15605.32,71608.18,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26233.7,,,,,,,fee schedule,15605.32,71608.18,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43194.58,,,,,,,fee schedule,15605.32,71608.18,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37560.51,,,,,,,fee schedule,15605.32,71608.18,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],63296.53,63296.53,63296.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],69870.54,45255.24,121910.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8179.79,8179.79,8179.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8654.86,8654.86,8654.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14737.19,14737.19,14737.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16385.59,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15605.32,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15605.32,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15605.32,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15605.32,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15605.32,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15605.32,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28089.58,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28089.58,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16385.59,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15605.32,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15605.32,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16385.59,,,,,,,fee schedule,15605.32,71608.18,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17377.22,,,,,,,fee schedule,8623.12,26751.22,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26751.22,,,,,,,fee schedule,8623.12,26751.22,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26751.22,,,,,,,fee schedule,8623.12,26751.22,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13902.27,,,,,,,fee schedule,8623.12,26751.22,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22890.51,,,,,,,fee schedule,8623.12,26751.22,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19904.8,,,,,,,fee schedule,8623.12,26751.22,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5657.56,5657.56,5657.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24998.43,24998.43,24998.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],21466.37,21153.07,26175.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8179.79,8179.79,8179.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5657.56,5657.56,5657.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18877.48,18877.48,18877.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8200.51,8200.51,8200.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5657.56,5657.56,5657.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,7771.35,7771.35,7771.35,1 through 10,percent of total billed charges,,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9054.28,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8623.12,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8623.12,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8623.12,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8623.12,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8623.12,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8623.12,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15521.62,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15521.62,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9054.28,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8623.12,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8623.12,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9054.28,,,,,,,fee schedule,8623.12,26751.22,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13532.38,,,,,,,fee schedule,6881.47,19136.37,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19136.37,,,,,,,fee schedule,6881.47,19136.37,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19136.37,,,,,,,fee schedule,6881.47,19136.37,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10826.29,,,,,,,fee schedule,6881.47,19136.37,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17825.82,,,,,,,fee schedule,6881.47,19136.37,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15500.71,,,,,,,fee schedule,6881.47,19136.37,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13887.1,13887.1,13887.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],10538.57,10538.57,10538.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4578.17,4578.17,4578.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6738.66,6738.66,6738.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10154.67,10154.67,10154.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,12986.24,12986.24,12986.24,1 through 10,percent of total billed charges,,,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7225.54,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6881.47,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6881.47,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6881.47,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6881.47,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6881.47,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6881.47,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12386.65,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12386.65,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7225.54,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6881.47,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6881.47,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7225.54,,,,,,,fee schedule,6881.47,19136.37,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85602.56,,,,,,,fee schedule,39528.2,112761.82,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,100995.18,,,,,,,fee schedule,39528.2,112761.82,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,100995.18,,,,,,,fee schedule,39528.2,112761.82,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,68484.5,,,,,,,fee schedule,39528.2,112761.82,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,112761.82,,,,,,,fee schedule,39528.2,112761.82,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,98053.76,,,,,,,fee schedule,39528.2,112761.82,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],152574.72,152574.72,152574.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",36408.88,36408.88,36408.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24100.44,24100.44,24100.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],84792.56,84792.56,84792.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37499.11,37499.11,37499.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,41504.61,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39528.2,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,39528.2,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,39528.2,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,39528.2,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,39528.2,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,39528.2,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,71150.76,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,71150.76,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,41504.61,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,39528.2,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,39528.2,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,41504.61,,,,,,,fee schedule,39528.2,112761.82,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48208.5,,,,,,,fee schedule,22589.24,70647.18,
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,70647.18,,,,,,,fee schedule,22589.24,70647.18,
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,70647.18,,,,,,,fee schedule,22589.24,70647.18,
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,38568.18,,,,,,,fee schedule,22589.24,70647.18,
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,63503.69,,,,,,,fee schedule,22589.24,70647.18,
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,55220.6,,,,,,,fee schedule,22589.24,70647.18,
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45214.89,45214.89,45214.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13379.21,13379.21,13379.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5267.93,5267.93,5267.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5467.11,5467.11,5467.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],50661.1,50661.1,50661.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23718.7,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22589.24,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22589.24,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22589.24,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22589.24,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22589.24,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22589.24,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40660.63,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,40660.63,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23718.7,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22589.24,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22589.24,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23718.7,,,,,,,fee schedule,22589.24,70647.18,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36561.3,,,,,,,fee schedule,17313.23,56496.86,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,56496.86,,,,,,,fee schedule,17313.23,56496.86,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,56496.86,,,,,,,fee schedule,17313.23,56496.86,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29250.09,,,,,,,fee schedule,17313.23,56496.86,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48161.16,,,,,,,fee schedule,17313.23,56496.86,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,41879.27,,,,,,,fee schedule,17313.23,56496.86,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],54631.32,53837.63,55300.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10349.49,10349.49,10349.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",33334.22,33334.22,33334.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11947.3,11947.3,11947.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15985.06,15985.06,15985.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32106.42,32106.42,32106.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10349.49,10349.49,10349.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],31580.12,31580.12,31580.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18178.89,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17313.23,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17313.23,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17313.23,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17313.23,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17313.23,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17313.23,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31163.81,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31163.81,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18178.89,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17313.23,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17313.23,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18178.89,,,,,,,fee schedule,17313.23,56496.86,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71390.22,,,,,,,fee schedule,33090.22,94692.99,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,94692.99,,,,,,,fee schedule,33090.22,94692.99,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,94692.99,,,,,,,fee schedule,33090.22,94692.99,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,57114.22,,,,,,,fee schedule,33090.22,94692.99,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,94040.31,,,,,,,fee schedule,33090.22,94692.99,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,81774.19,,,,,,,fee schedule,33090.22,94692.99,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],90502.85,90502.85,90502.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22522.8,22522.8,22522.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],51299.44,51299.44,51299.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6324.95,6324.95,6324.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29182.76,20072.24,31047.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34744.73,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33090.22,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,33090.22,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,33090.22,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,33090.22,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,33090.22,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,33090.22,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59562.4,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,59562.4,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,34744.73,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,33090.22,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,33090.22,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,34744.73,,,,,,,fee schedule,33090.22,94692.99,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34445.01,,,,,,,fee schedule,16354.58,50438.4,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,50438.4,,,,,,,fee schedule,16354.58,50438.4,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,50438.4,,,,,,,fee schedule,16354.58,50438.4,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27557,,,,,,,fee schedule,16354.58,50438.4,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45373.44,,,,,,,fee schedule,16354.58,50438.4,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39455.16,,,,,,,fee schedule,16354.58,50438.4,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],21667.05,21667.05,21667.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15915.56,15915.56,15915.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12705.39,12705.39,12705.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17172.31,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16354.58,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16354.58,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16354.58,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16354.58,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16354.58,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16354.58,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29438.24,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29438.24,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17172.31,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16354.58,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16354.58,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17172.31,,,,,,,fee schedule,16354.58,50438.4,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26098.29,,,,,,,fee schedule,12573.64,41810.32,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41810.32,,,,,,,fee schedule,12573.64,41810.32,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41810.32,,,,,,,fee schedule,12573.64,41810.32,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20879.38,,,,,,,fee schedule,12573.64,41810.32,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34378.54,,,,,,,fee schedule,12573.64,41810.32,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29894.39,,,,,,,fee schedule,12573.64,41810.32,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],40508.99,40508.99,40508.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13202.32,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12573.64,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12573.64,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12573.64,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12573.64,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12573.64,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12573.64,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22632.55,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22632.55,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13202.32,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12573.64,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12573.64,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13202.32,,,,,,,fee schedule,12573.64,41810.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56849.36,,,,,,,fee schedule,26503.42,75135.32,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,75135.32,,,,,,,fee schedule,26503.42,75135.32,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,75135.32,,,,,,,fee schedule,26503.42,75135.32,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,45481.12,,,,,,,fee schedule,26503.42,75135.32,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,74886.05,,,,,,,fee schedule,26503.42,75135.32,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,65118.3,,,,,,,fee schedule,26503.42,75135.32,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27828.59,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26503.42,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26503.42,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26503.42,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26503.42,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26503.42,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26503.42,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47706.16,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,47706.16,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27828.59,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26503.42,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26503.42,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27828.59,,,,,,,fee schedule,26503.42,75135.32,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26235.81,,,,,,,fee schedule,12635.94,36399.49,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36399.49,,,,,,,fee schedule,12635.94,36399.49,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36399.49,,,,,,,fee schedule,12635.94,36399.49,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20989.4,,,,,,,fee schedule,12635.94,36399.49,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34559.69,,,,,,,fee schedule,12635.94,36399.49,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30051.91,,,,,,,fee schedule,12635.94,36399.49,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9933.21,9933.21,9933.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13594.34,13594.34,35197.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12390.85,12390.85,12390.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5467.11,5467.11,5467.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5467.11,5467.11,5467.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11733.85,10749.55,12428.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,36205.35,36205.35,36205.35,1 through 10,percent of total billed charges,,,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,20947.99,20947.99,20947.99,1 through 10,percent of total billed charges,,,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13267.74,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12635.94,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12635.94,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12635.94,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12635.94,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12635.94,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12635.94,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22744.69,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22744.69,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13267.74,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12635.94,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12635.94,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13267.74,,,,,,,fee schedule,12635.94,36399.49,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15375.53,,,,,,,fee schedule,7716.39,20856.41,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20856.41,,,,,,,fee schedule,7716.39,20856.41,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20856.41,,,,,,,fee schedule,7716.39,20856.41,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12300.87,,,,,,,fee schedule,7716.39,20856.41,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20253.75,,,,,,,fee schedule,7716.39,20856.41,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17611.96,,,,,,,fee schedule,7716.39,20856.41,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15164.78,11242.02,20167.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5467.11,5467.11,5467.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7968.05,7968.05,7968.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9272.25,9272.25,9272.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5467.11,5467.11,5467.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14713.6,14713.6,14713.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7437.31,6767.21,7548.83,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8102.21,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7716.39,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7716.39,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7716.39,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7716.39,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7716.39,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7716.39,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13889.5,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13889.5,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8102.21,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7716.39,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7716.39,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8102.21,,,,,,,fee schedule,7716.39,20856.41,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29847.63,,,,,,,fee schedule,14272.04,39317.44,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,34662.04,,,,,,,fee schedule,14272.04,39317.44,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,34662.04,,,,,,,fee schedule,14272.04,39317.44,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23878.96,,,,,,,fee schedule,14272.04,39317.44,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39317.44,,,,,,,fee schedule,14272.04,39317.44,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34189.08,,,,,,,fee schedule,14272.04,39317.44,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9957.32,9957.32,9957.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12323.38,12143.58,13475.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],28121.47,15058.68,33517.49,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7251.55,7251.55,7310.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33517.49,33517.49,33517.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14415.52,14415.52,14415.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16991.75,16991.75,16991.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7310.39,7310.39,7310.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],13373.96,13373.96,13373.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7251.55,7251.55,22640.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8395.99,8395.99,8395.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7251.55,7251.55,9276.1,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37312.88,37312.88,37312.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28588.64,10326.13,32445.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13715.18,9424.88,14188.9,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],35019.77,35019.77,35019.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,27425.77,27425.77,27425.77,1 through 10,percent of total billed charges,,,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,3859.61,3859.61,3859.61,1 through 10,percent of total billed charges,,,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,11543.11,11543.11,11543.11,1 through 10,percent of total billed charges,,,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14985.64,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14272.04,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14272.04,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14272.04,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14272.04,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14272.04,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14272.04,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25689.67,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25689.67,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14985.64,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14272.04,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14272.04,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14985.64,,,,,,,fee schedule,14272.04,39317.44,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18641.64,,,,,,,fee schedule,9195.89,26413.48,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26413.48,,,,,,,fee schedule,9195.89,26413.48,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26413.48,,,,,,,fee schedule,9195.89,26413.48,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14913.85,,,,,,,fee schedule,9195.89,26413.48,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24556.1,,,,,,,fee schedule,9195.89,26413.48,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21353.13,,,,,,,fee schedule,9195.89,26413.48,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8924.74,8924.74,8924.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8909.95,8909.95,8909.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],11772.93,9263.91,21883.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11549.86,11549.86,11549.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13384.13,13384.13,13384.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13061.01,9641.78,19913.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8210.43,6855.97,8929.45,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5411.45,5411.45,5411.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9655.68,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9195.89,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9195.89,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9195.89,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9195.89,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9195.89,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9195.89,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16552.6,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16552.6,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9655.68,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9195.89,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9195.89,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9655.68,,,,,,,fee schedule,9195.89,26413.48,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14420.53,,,,,,,fee schedule,7283.79,20591.79,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20591.79,,,,,,,fee schedule,7283.79,20591.79,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20591.79,,,,,,,fee schedule,7283.79,20591.79,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11536.84,,,,,,,fee schedule,7283.79,20591.79,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18995.75,,,,,,,fee schedule,7283.79,20591.79,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16518.05,,,,,,,fee schedule,7283.79,20591.79,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17890.99,11069.56,19911.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12354.58,12354.58,12354.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16991.75,16991.75,16991.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5274.49,5274.49,5274.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5411.45,5411.45,13384.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12146.86,12146.86,12146.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7122.51,7122.51,7122.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7251.55,7251.55,7251.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,4138.23,4138.23,4138.23,1 through 10,percent of total billed charges,,,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7647.98,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7283.79,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7283.79,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7283.79,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7283.79,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7283.79,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7283.79,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13110.82,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13110.82,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7647.98,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7283.79,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7283.79,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7647.98,,,,,,,fee schedule,7283.79,20591.79,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33730.67,,,,,,,fee schedule,16031,45584.67,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45584.67,,,,,,,fee schedule,16031,45584.67,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45584.67,,,,,,,fee schedule,16031,45584.67,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26985.5,,,,,,,fee schedule,16031,45584.67,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44432.45,,,,,,,fee schedule,16031,45584.67,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38636.92,,,,,,,fee schedule,16031,45584.67,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16121.53,16121.53,16121.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15249.9,15249.9,15249.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],9435.04,9435.04,9435.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16832.55,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16031,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16031,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16031,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16031,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16031,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16031,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28855.8,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28855.8,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16832.55,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16031,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16031,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16832.55,,,,,,,fee schedule,16031,45584.67,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20456.14,,,,,,,fee schedule,10017.83,28363.33,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28363.33,,,,,,,fee schedule,10017.83,28363.33,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28363.33,,,,,,,fee schedule,10017.83,28363.33,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16365.5,,,,,,,fee schedule,10017.83,28363.33,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26946.3,,,,,,,fee schedule,10017.83,28363.33,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23431.56,,,,,,,fee schedule,10017.83,28363.33,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9935.41,9935.41,10523.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10518.72,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10017.83,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10017.83,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10017.83,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10017.83,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10017.83,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10017.83,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18032.09,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18032.09,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10518.72,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10017.83,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10017.83,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10518.72,,,,,,,fee schedule,10017.83,28363.33,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14397.61,,,,,,,fee schedule,7273.41,18965.56,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,13958.82,,,,,,,fee schedule,7273.41,18965.56,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,13958.82,,,,,,,fee schedule,7273.41,18965.56,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11518.5,,,,,,,fee schedule,7273.41,18965.56,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18965.56,,,,,,,fee schedule,7273.41,18965.56,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16491.79,,,,,,,fee schedule,7273.41,18965.56,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9911.91,9911.91,9911.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7637.08,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7273.41,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7273.41,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7273.41,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7273.41,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7273.41,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7273.41,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13092.14,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13092.14,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7637.08,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7273.41,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7273.41,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7637.08,,,,,,,fee schedule,7273.41,18965.56,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29221.15,,,,,,,fee schedule,13988.25,38492.19,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30925.99,,,,,,,fee schedule,13988.25,38492.19,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30925.99,,,,,,,fee schedule,13988.25,38492.19,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23377.76,,,,,,,fee schedule,13988.25,38492.19,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38492.19,,,,,,,fee schedule,13988.25,38492.19,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33471.47,,,,,,,fee schedule,13988.25,38492.19,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13893.11,11996.74,13962.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14687.66,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13988.25,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13988.25,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13988.25,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13988.25,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13988.25,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13988.25,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25178.85,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25178.85,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14687.66,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13988.25,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13988.25,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14687.66,,,,,,,fee schedule,13988.25,38492.19,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20324.35,,,,,,,fee schedule,9958.13,26914.87,
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26914.87,,,,,,,fee schedule,9958.13,26914.87,
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26914.87,,,,,,,fee schedule,9958.13,26914.87,
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16260.07,,,,,,,fee schedule,9958.13,26914.87,
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26772.69,,,,,,,fee schedule,9958.13,26914.87,
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23280.6,,,,,,,fee schedule,9958.13,26914.87,
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],26257.62,26257.62,26257.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9544.13,9136.53,9758.52,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12206.31,12206.31,12206.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10456.04,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9958.13,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9958.13,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9958.13,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9958.13,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9958.13,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9958.13,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17924.63,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17924.63,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10456.04,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9958.13,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9958.13,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10456.04,,,,,,,fee schedule,9958.13,26914.87,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15022.18,,,,,,,fee schedule,7556.33,21368.25,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21368.25,,,,,,,fee schedule,7556.33,21368.25,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21368.25,,,,,,,fee schedule,7556.33,21368.25,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12018.18,,,,,,,fee schedule,7556.33,21368.25,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19788.29,,,,,,,fee schedule,7556.33,21368.25,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17207.21,,,,,,,fee schedule,7556.33,21368.25,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1372.83,1372.83,1372.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18912,18912,18912,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15607.79,15607.79,15607.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7139.14,6419.38,7384.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7934.15,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7556.33,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7556.33,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7556.33,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7556.33,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7556.33,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7556.33,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13601.39,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13601.39,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7934.15,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7556.33,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7556.33,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7934.15,,,,,,,fee schedule,7556.33,21368.25,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29767.41,,,,,,,fee schedule,14235.7,39211.77,
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36967.04,,,,,,,fee schedule,14235.7,39211.77,
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36967.04,,,,,,,fee schedule,14235.7,39211.77,
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23814.78,,,,,,,fee schedule,14235.7,39211.77,
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39211.77,,,,,,,fee schedule,14235.7,39211.77,
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34097.19,,,,,,,fee schedule,14235.7,39211.77,
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13837.72,13837.72,13837.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11455.62,11455.62,11455.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12612.91,12246.08,13949.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1099.99,1099.99,1099.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14947.48,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14235.7,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14235.7,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14235.7,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14235.7,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14235.7,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14235.7,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25624.26,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25624.26,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14947.48,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14235.7,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14235.7,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14947.48,,,,,,,fee schedule,14235.7,39211.77,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18891.85,,,,,,,fee schedule,9309.23,24885.7,
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24717.81,,,,,,,fee schedule,9309.23,24885.7,
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24717.81,,,,,,,fee schedule,9309.23,24885.7,
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15114.02,,,,,,,fee schedule,9309.23,24885.7,
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24885.7,,,,,,,fee schedule,9309.23,24885.7,
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21639.74,,,,,,,fee schedule,9309.23,24885.7,
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8999.33,8999.33,8999.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6347.32,6347.32,6347.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9098.81,9098.81,9098.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9774.69,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9309.23,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9309.23,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9309.23,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9309.23,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9309.23,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9309.23,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16756.61,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16756.61,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9774.69,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9309.23,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9309.23,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9774.69,,,,,,,fee schedule,9309.23,24885.7,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13698.55,,,,,,,fee schedule,6956.74,18520.08,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18520.08,,,,,,,fee schedule,6956.74,18520.08,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18520.08,,,,,,,fee schedule,6956.74,18520.08,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10959.23,,,,,,,fee schedule,6956.74,18520.08,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18044.71,,,,,,,fee schedule,6956.74,18520.08,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15691.05,,,,,,,fee schedule,6956.74,18520.08,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7304.58,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6956.74,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6956.74,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6956.74,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6956.74,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6956.74,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6956.74,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12522.13,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12522.13,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7304.58,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6956.74,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6956.74,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7304.58,,,,,,,fee schedule,6956.74,18520.08,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23596.19,,,,,,,fee schedule,11440.23,31082.59,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28916.95,,,,,,,fee schedule,11440.23,31082.59,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28916.95,,,,,,,fee schedule,11440.23,31082.59,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18877.63,,,,,,,fee schedule,11440.23,31082.59,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31082.59,,,,,,,fee schedule,11440.23,31082.59,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27028.34,,,,,,,fee schedule,11440.23,31082.59,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10393.17,10393.17,11573.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10984.41,10067.11,11210.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],28938.77,28938.77,28938.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6131.23,4828.1,8847.49,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20347.5,8778.93,27962.1,144,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11136.2,11136.2,11136.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8363.14,8363.14,8363.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6131.23,4828.1,8659.81,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6131.23,1700,9276.1,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],16706.48,13716.21,16757.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6131.23,1900,8363.14,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11664.17,11664.17,11664.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12116.98,8507.47,17348.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6131.23,4828.1,9276.1,149,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20426.99,9631.53,27810.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19875.97,7533.96,24328.59,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10968.61,9050.08,11270.08,69,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6131.23,6131.23,6131.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],19087.66,8147.29,47942.77,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,23525.27,13638.29,61043.5,14,percent of total billed charges,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,12837.01,5663.69,38957.99,1 through 10,percent of total billed charges,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,24356.71,7901.03,43445.07,1 through 10,percent of total billed charges,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,6344.37,3080.58,26304.47,1 through 10,percent of total billed charges,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12012.24,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11440.23,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11440.23,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11440.23,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11440.23,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11440.23,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11440.23,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20592.41,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20592.41,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12012.24,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11440.23,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11440.23,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12012.24,,,,,,,fee schedule,11440.23,31082.59,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21157.11,,,,,,,fee schedule,10335.36,27869.67,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25922.54,,,,,,,fee schedule,10335.36,27869.67,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25922.54,,,,,,,fee schedule,10335.36,27869.67,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16926.3,,,,,,,fee schedule,10335.36,27869.67,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27869.67,,,,,,,fee schedule,10335.36,27869.67,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24234.49,,,,,,,fee schedule,10335.36,27869.67,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6598.02,1168.07,10538.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10003.99,8908.17,10092.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16079.34,16079.34,16079.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10163.42,10163.42,10163.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10023.26,10023.26,10023.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8936.9,8936.9,8936.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],11287.1,11287.1,11287.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6545.96,6545.96,6545.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],11268.96,11268.96,11268.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8786.33,8786.33,8786.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9684.83,6545.96,10287.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9688.3,8059.8,10092.58,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11326.47,11326.47,11326.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],5493.48,5493.48,5493.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,35132.15,35132.15,35132.15,1 through 10,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10767.4,10767.4,10767.4,1 through 10,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10852.13,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10335.36,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10335.36,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10335.36,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10335.36,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10335.36,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10335.36,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18603.65,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18603.65,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10852.13,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10335.36,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10335.36,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10852.13,,,,,,,fee schedule,10335.36,27869.67,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16101.33,,,,,,,fee schedule,8045.17,23067.4,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23067.4,,,,,,,fee schedule,8045.17,23067.4,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23067.4,,,,,,,fee schedule,8045.17,23067.4,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12881.53,,,,,,,fee schedule,8045.17,23067.4,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21209.83,,,,,,,fee schedule,8045.17,23067.4,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18443.33,,,,,,,fee schedule,8045.17,23067.4,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7802.39,7802.39,7802.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5442.55,5442.55,5442.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8153.12,8153.12,8153.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5442.55,5442.55,5442.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17034.33,17034.33,17034.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7697.63,7257.95,7832.42,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,1477.44,1477.44,1477.44,1 through 10,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8447.43,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8045.17,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8045.17,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8045.17,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8045.17,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8045.17,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8045.17,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14481.31,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14481.31,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8447.43,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8045.17,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8045.17,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8447.43,,,,,,,fee schedule,8045.17,23067.4,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12262.23,,,,,,,fee schedule,6306.11,16925.38,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16925.38,,,,,,,fee schedule,6306.11,16925.38,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16925.38,,,,,,,fee schedule,6306.11,16925.38,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9810.13,,,,,,,fee schedule,6306.11,16925.38,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16152.68,,,,,,,fee schedule,6306.11,16925.38,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14045.81,,,,,,,fee schedule,6306.11,16925.38,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6290.86,6290.86,6290.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10871.01,10871.01,10871.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6621.42,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6306.11,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6306.11,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6306.11,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6306.11,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6306.11,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6306.11,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11351,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11351,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6621.42,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6306.11,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6306.11,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6621.42,,,,,,,fee schedule,6306.11,16925.38,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25105.09,,,,,,,fee schedule,12123.74,33070.23,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26744.26,,,,,,,fee schedule,12123.74,33070.23,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26744.26,,,,,,,fee schedule,12123.74,33070.23,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20084.79,,,,,,,fee schedule,12123.74,33070.23,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33070.23,,,,,,,fee schedule,12123.74,33070.23,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28756.72,,,,,,,fee schedule,12123.74,33070.23,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10711.84,10270.84,12297.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11663.78,8864.46,11963.44,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18687.25,7991.51,25861.16,74,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16696.46,16696.46,16696.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5411.45,5115.13,17299.8,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11860.54,11819.05,11867.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11749.59,11749.59,11749.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11760.2,11760.2,11760.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5115.13,4285.67,9649.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6013.9,5115.13,10294.92,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5355.79,5115.13,10219.63,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],14828.5,14828.5,15911.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22075.03,22075.03,22075.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17678.93,17678.93,26450.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5115.13,4285.67,7233,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14537.13,7060.06,23944.04,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11619.27,8016.66,11709.21,83,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13729.73,13729.73,13729.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4186.35,4186.35,7233,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],7821.94,7821.94,7821.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,8312.88,7160.2,44628.77,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,13216.51,13216.51,13216.51,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,20132.58,13788.33,26036.57,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,8527.75,8527.75,8527.75,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,14698.23,14698.23,14698.23,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12729.93,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21822.73,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21822.73,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12729.93,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12123.74,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12729.93,,,,,,,fee schedule,12123.74,33070.23,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15392.72,,,,,,,fee schedule,7724.18,20276.4,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17043.76,,,,,,,fee schedule,7724.18,20276.4,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17043.76,,,,,,,fee schedule,7724.18,20276.4,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12314.62,,,,,,,fee schedule,7724.18,20276.4,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20276.4,,,,,,,fee schedule,7724.18,20276.4,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17631.65,,,,,,,fee schedule,7724.18,20276.4,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7801.81,7801.81,7801.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7489.75,7489.75,7489.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],12867.23,7150.83,16480.98,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5115.13,4285.35,7361.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7504.26,7504.26,7504.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4186.35,4186.35,4186.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5115.13,4285.67,7233,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5115.13,4186.35,7233,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],3936.13,3936.13,3936.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4285.67,1608,6156.88,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16458.84,16458.84,16458.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9926.97,6160.8,16458.84,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7457.23,5726.53,7562.48,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14368.84,14368.84,14368.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6051.1,6051.1,6051.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7233,7233,7233,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],6750.82,6498.06,40844.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,11277.32,10977.74,16082.38,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,7846.77,7846.77,7846.77,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,3088.51,3088.51,3088.51,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8110.39,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7724.18,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7724.18,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7724.18,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7724.18,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7724.18,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7724.18,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13903.52,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13903.52,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8110.39,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7724.18,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7724.18,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8110.39,,,,,,,fee schedule,7724.18,20276.4,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12004.38,,,,,,,fee schedule,6189.31,15813.02,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,11563.3,,,,,,,fee schedule,6189.31,15813.02,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,11563.3,,,,,,,fee schedule,6189.31,15813.02,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9603.84,,,,,,,fee schedule,6189.31,15813.02,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15813.02,,,,,,,fee schedule,6189.31,15813.02,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13750.45,,,,,,,fee schedule,6189.31,15813.02,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],8545.11,5566.19,11181.47,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5355.79,5355.79,5355.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4186.35,4186.35,4186.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5115.13,5115.13,5115.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],8159.89,8159.89,8159.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4186.35,4186.35,4186.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8191.55,8191.55,8191.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4186.35,1608,5115.13,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8494.14,5070.72,10287.09,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5835.95,5835.95,5835.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4285.67,4285.67,4285.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],10323.43,7230.86,19865.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,8426.51,8426.51,8426.51,1 through 10,percent of total billed charges,,,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6498.78,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6189.31,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6189.31,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6189.31,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6189.31,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6189.31,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6189.31,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11140.76,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11140.76,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6498.78,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6189.31,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6189.31,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6498.78,,,,,,,fee schedule,6189.31,15813.02,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36045.6,,,,,,,fee schedule,17079.62,47481.84,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35448.94,,,,,,,fee schedule,17079.62,47481.84,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35448.94,,,,,,,fee schedule,17079.62,47481.84,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28837.51,,,,,,,fee schedule,17079.62,47481.84,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,47481.84,,,,,,,fee schedule,17079.62,47481.84,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,41288.56,,,,,,,fee schedule,17079.62,47481.84,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],35475.69,35475.69,35475.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6013.9,6013.9,6013.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16445.29,16445.29,16707.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17933.6,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17079.62,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17079.62,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17079.62,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17079.62,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17079.62,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17079.62,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30743.32,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30743.32,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17933.6,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17079.62,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17079.62,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17933.6,,,,,,,fee schedule,17079.62,47481.84,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18127.85,,,,,,,fee schedule,8963.15,29063.19,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29063.19,,,,,,,fee schedule,8963.15,29063.19,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29063.19,,,,,,,fee schedule,8963.15,29063.19,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14502.8,,,,,,,fee schedule,8963.15,29063.19,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23879.3,,,,,,,fee schedule,8963.15,29063.19,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20764.61,,,,,,,fee schedule,8963.15,29063.19,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6324.95,6324.95,6324.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8899.18,8899.18,8899.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6324.95,6324.95,6324.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],17503.03,17503.03,17503.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9411.31,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8963.15,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8963.15,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8963.15,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8963.15,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8963.15,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8963.15,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16133.67,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16133.67,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9411.31,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8963.15,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8963.15,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9411.31,,,,,,,fee schedule,8963.15,29063.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13679.45,,,,,,,fee schedule,6948.09,19171.19,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19171.19,,,,,,,fee schedule,6948.09,19171.19,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19171.19,,,,,,,fee schedule,6948.09,19171.19,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10943.95,,,,,,,fee schedule,6948.09,19171.19,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18019.55,,,,,,,fee schedule,6948.09,19171.19,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15669.17,,,,,,,fee schedule,6948.09,19171.19,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16856.11,16856.11,16856.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6013.9,6013.9,6013.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7295.49,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6948.09,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6948.09,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6948.09,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6948.09,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6948.09,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6948.09,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12506.56,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12506.56,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7295.49,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6948.09,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6948.09,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7295.49,,,,,,,fee schedule,6948.09,19171.19,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33694.38,,,,,,,fee schedule,16014.56,44384.65,
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33620.96,,,,,,,fee schedule,16014.56,44384.65,
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33620.96,,,,,,,fee schedule,16014.56,44384.65,
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26956.47,,,,,,,fee schedule,16014.56,44384.65,
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44384.65,,,,,,,fee schedule,16014.56,44384.65,
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38595.35,,,,,,,fee schedule,16014.56,44384.65,
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33646.33,33646.33,33646.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6319.49,6319.49,6319.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31008.75,31008.75,31008.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15333.46,15333.46,15333.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16815.29,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16014.56,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16014.56,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16014.56,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16014.56,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16014.56,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16014.56,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28826.21,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28826.21,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16815.29,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16014.56,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16014.56,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16815.29,,,,,,,fee schedule,16014.56,44384.65,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20996.67,,,,,,,fee schedule,10262.68,27658.32,
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24296.5,,,,,,,fee schedule,10262.68,27658.32,
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24296.5,,,,,,,fee schedule,10262.68,27658.32,
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16797.94,,,,,,,fee schedule,10262.68,27658.32,
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27658.32,,,,,,,fee schedule,10262.68,27658.32,
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24050.72,,,,,,,fee schedule,10262.68,27658.32,
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10039.62,10039.62,10039.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],8770.66,8770.66,8770.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4716.77,4716.77,4716.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8449.91,8449.91,8449.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13847.38,13847.38,13847.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9884.95,9402.85,9911.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10775.81,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10262.68,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10262.68,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10262.68,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10262.68,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10262.68,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10262.68,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18472.82,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18472.82,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10775.81,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10262.68,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10262.68,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10775.81,,,,,,,fee schedule,10262.68,27658.32,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13658.44,,,,,,,fee schedule,6938.57,17991.87,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16528.45,,,,,,,fee schedule,6938.57,17991.87,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16528.45,,,,,,,fee schedule,6938.57,17991.87,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10927.14,,,,,,,fee schedule,6938.57,17991.87,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17991.87,,,,,,,fee schedule,6938.57,17991.87,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15645.11,,,,,,,fee schedule,6938.57,17991.87,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],12666.18,12666.18,12666.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6347.32,6347.32,6347.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9280.96,9280.96,9280.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4716.77,4716.77,4716.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],6237.86,6237.86,6237.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7285.5,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6938.57,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6938.57,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6938.57,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6938.57,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6938.57,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6938.57,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12489.43,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12489.43,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7285.5,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6938.57,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6938.57,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7285.5,,,,,,,fee schedule,6938.57,17991.87,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18549.96,,,,,,,fee schedule,9154.36,24435.33,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17266.6,,,,,,,fee schedule,9154.36,24435.33,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17266.6,,,,,,,fee schedule,9154.36,24435.33,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14840.5,,,,,,,fee schedule,9154.36,24435.33,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24435.33,,,,,,,fee schedule,9154.36,24435.33,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21248.12,,,,,,,fee schedule,9154.36,24435.33,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8323.16,7057.11,9335.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8351.62,8351.62,8351.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5355.79,1608,7442,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],12532.23,6603.36,16729.19,101,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5267.93,4272.03,5355.79,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5267.93,1700,7442,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5267.93,1900,6358.24,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8140.12,8140.12,8140.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12421.68,12345.75,17784.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8908.25,7886.2,8943.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5355.79,1608,7442,94,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14077.79,6831.89,19403.36,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8717,8687.15,8755.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16782.95,16782.95,16782.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5267.93,5267.93,5355.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],27483.43,10789.18,58388.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,12384.54,7540.22,54334.17,1 through 10,percent of total billed charges,,,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,10177.39,5508.69,100386.09,1 through 10,percent of total billed charges,,,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,13732.31,5425.31,19104.94,1 through 10,percent of total billed charges,,,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,9300,9300,9300,1 through 10,percent of total billed charges,,,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,8811.43,5031.19,19480.09,1 through 10,percent of total billed charges,,,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9612.08,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9154.36,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9154.36,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9154.36,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9154.36,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9154.36,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9154.36,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16477.85,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16477.85,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9612.08,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9154.36,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9154.36,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9612.08,,,,,,,fee schedule,9154.36,24435.33,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12797.03,,,,,,,fee schedule,6548.36,16857.16,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,9470.69,,,,,,,fee schedule,6548.36,16857.16,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,9470.69,,,,,,,fee schedule,6548.36,16857.16,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10237.99,,,,,,,fee schedule,6548.36,16857.16,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16857.16,,,,,,,fee schedule,6548.36,16857.16,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14658.4,,,,,,,fee schedule,6548.36,16857.16,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4393.17,1608,4790.94,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],7689.31,5236.07,9477.84,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4282.53,1608,5267.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,4393.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,4393.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4299.57,4299.57,4299.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4118.14,1608,4393.17,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6744.51,6744.51,6744.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8876.47,6127.86,13975.96,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6440.89,6440.89,6440.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9506.41,9506.41,9506.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4393.17,4393.17,5355.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],8855,6806.55,12194,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,6223.65,5838.51,8227.64,1 through 10,percent of total billed charges,,,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,11963.09,11963.09,11963.09,1 through 10,percent of total billed charges,,,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2278.94,2278.94,2278.94,1 through 10,percent of total billed charges,,,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6875.78,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6548.36,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6548.36,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6548.36,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6548.36,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6548.36,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6548.36,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11787.05,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11787.05,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6875.78,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6548.36,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6548.36,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6875.78,,,,,,,fee schedule,6548.36,16857.16,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15421.37,,,,,,,fee schedule,7737.15,21852.23,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21852.23,,,,,,,fee schedule,7737.15,21852.23,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21852.23,,,,,,,fee schedule,7737.15,21852.23,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12337.54,,,,,,,fee schedule,7737.15,21852.23,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20314.14,,,,,,,fee schedule,7737.15,21852.23,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17664.47,,,,,,,fee schedule,7737.15,21852.23,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7921.06,7921.06,7921.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],7092.63,3510.14,21130.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4790.94,4790.94,4790.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8300.98,8300.98,8300.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4298.77,4298.77,4298.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7400.56,7013.02,7419.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4298.77,4298.77,4298.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],17764.5,17764.5,17764.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8124.01,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7737.15,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7737.15,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7737.15,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7737.15,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7737.15,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7737.15,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13926.87,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13926.87,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8124.01,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7737.15,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7737.15,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8124.01,,,,,,,fee schedule,7737.15,21852.23,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34972.17,,,,,,,fee schedule,16593.38,46455.14,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46455.14,,,,,,,fee schedule,16593.38,46455.14,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46455.14,,,,,,,fee schedule,16593.38,46455.14,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27978.74,,,,,,,fee schedule,16593.38,46455.14,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46067.85,,,,,,,fee schedule,16593.38,46455.14,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40059,,,,,,,fee schedule,16593.38,46455.14,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16382.41,16382.41,16382.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],44921.18,37635.21,46490.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10344.58,10344.58,10344.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8702.87,8702.87,8702.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7251.55,7251.55,7251.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9501.63,9501.63,9501.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33650.8,33650.8,33650.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15251.72,12886.51,15650.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17423.05,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16593.38,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16593.38,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16593.38,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16593.38,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16593.38,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16593.38,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29868.08,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29868.08,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17423.05,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16593.38,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16593.38,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17423.05,,,,,,,fee schedule,16593.38,46455.14,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17975.05,,,,,,,fee schedule,8893.93,23678.02,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22280.5,,,,,,,fee schedule,8893.93,23678.02,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22280.5,,,,,,,fee schedule,8893.93,23678.02,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14380.55,,,,,,,fee schedule,8893.93,23678.02,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23678.02,,,,,,,fee schedule,8893.93,23678.02,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20589.58,,,,,,,fee schedule,8893.93,23678.02,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],21544.79,21544.79,21544.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7032.43,7032.43,7032.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8449.91,8449.91,8449.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4298.77,4298.77,6319.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7634.28,7634.28,7634.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9338.63,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8893.93,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8893.93,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8893.93,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8893.93,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8893.93,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8893.93,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16009.07,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16009.07,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9338.63,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8893.93,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8893.93,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9338.63,,,,,,,fee schedule,8893.93,23678.02,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,122903.03,,,,,,,fee schedule,56424.76,192073.99,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,192073.99,,,,,,,fee schedule,56424.76,192073.99,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,192073.99,,,,,,,fee schedule,56424.76,192073.99,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,98325.95,,,,,,,fee schedule,56424.76,192073.99,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,161896.67,,,,,,,fee schedule,56424.76,192073.99,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,140779.72,,,,,,,fee schedule,56424.76,192073.99,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],54838.85,54838.85,54838.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",85813.28,85813.28,85813.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],183574.76,148879.42,188803.42,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",36637.5,36637.5,36637.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",44038.91,39260.82,199103.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",37689.83,27887.74,49759.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],112631.81,112631.81,112631.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",27244.74,25006.99,47555.24,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],339857.23,339857.23,339857.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],117627.78,69155.71,244912.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],53385.54,53385.54,54683.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55850.02,55850.02,55850.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],131104.15,131104.15,131104.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,180005.57,180005.57,180005.57,1 through 10,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,288916.35,288916.35,288916.35,1 through 10,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,284477.43,284477.43,284477.43,1 through 10,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,59246,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,56424.76,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,56424.76,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,56424.76,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,56424.76,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,56424.76,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,56424.76,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,101564.57,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,101564.57,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,59246,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,56424.76,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,56424.76,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,59246,,,,,,,fee schedule,56424.76,192073.99,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52500.28,,,,,,,fee schedule,24533.35,69157.13,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,61712.7,,,,,,,fee schedule,24533.35,69157.13,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,61712.7,,,,,,,fee schedule,24533.35,69157.13,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,42001.73,,,,,,,fee schedule,24533.35,69157.13,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,69157.13,,,,,,,fee schedule,24533.35,69157.13,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,60136.64,,,,,,,fee schedule,24533.35,69157.13,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24137.54,24137.54,24137.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23032.01,23032.01,23032.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],44615.16,29272.4,61759.28,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12145.39,12145.39,12145.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],61759.28,61759.28,61759.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9616.07,8363.14,12145.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8363.14,6131.23,17493.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12145.39,10685.51,13617.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32664.86,32664.86,32664.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11505.44,8363.14,14799.07,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31110.57,19840.22,53729.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22711.39,21320.51,23111.18,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10294.92,10294.92,10294.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,22411.54,22411.54,22411.54,1 through 10,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,15740.26,15740.26,15740.26,1 through 10,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,23158.41,23158.41,65137.6,1 through 10,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,62652.22,62652.22,62652.22,1 through 10,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25760.02,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24533.35,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24533.35,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24533.35,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24533.35,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24533.35,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24533.35,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44160.03,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,44160.03,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25760.02,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24533.35,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24533.35,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25760.02,,,,,,,fee schedule,24533.35,69157.13,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,334687.98,,,,,,,fee schedule,98682.17,334687.98,
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,216189.53,,,,,,,fee schedule,98682.17,334687.98,
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,334687.98,,,,,,,fee schedule,98682.17,334687.98,
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,172957.83,,,,,,,fee schedule,98682.17,334687.98,
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,284780.33,,,,,,,fee schedule,98682.17,334687.98,
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,247635.08,,,,,,,fee schedule,98682.17,334687.98,
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,103616.28,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,98682.17,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,98682.17,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,98682.17,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,98682.17,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,98682.17,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,98682.17,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,177627.91,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,177627.91,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,103616.28,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,98682.17,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,98682.17,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,103616.28,,,,,,,fee schedule,98682.17,334687.98,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,330795.25,,,,,,,fee schedule,94834.61,330795.25,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,207695.74,,,,,,,fee schedule,94834.61,330795.25,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,330795.25,,,,,,,fee schedule,94834.61,330795.25,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,166162.55,,,,,,,fee schedule,94834.61,330795.25,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,273591.7,,,,,,,fee schedule,94834.61,330795.25,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,237905.84,,,,,,,fee schedule,94834.61,330795.25,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],215243.34,215243.34,215243.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,99576.34,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,94834.61,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,94834.61,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,94834.61,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,94834.61,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,94834.61,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,94834.61,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,170702.3,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,170702.3,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,99576.34,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,94834.61,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,94834.61,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,99576.34,,,,,,,fee schedule,94834.61,330795.25,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,135852.2,,,,,,,fee schedule,50127.81,143585.26,
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,109002.02,,,,,,,fee schedule,50127.81,143585.26,
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,135852.2,,,,,,,fee schedule,50127.81,143585.26,
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,87204.74,,,,,,,fee schedule,50127.81,143585.26,
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,143585.26,,,,,,,fee schedule,50127.81,143585.26,
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,124856.76,,,,,,,fee schedule,50127.81,143585.26,
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,52634.2,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50127.81,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,50127.81,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,50127.81,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,50127.81,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,50127.81,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,50127.81,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,90230.06,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,90230.06,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,52634.2,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,50127.81,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,50127.81,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,52634.2,,,,,,,fee schedule,50127.81,143585.26,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,261276.19,,,,,,,fee schedule,86899.83,261276.19,
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,190179.1,,,,,,,fee schedule,86899.83,261276.19,
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,261276.19,,,,,,,fee schedule,86899.83,261276.19,
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,152148.74,,,,,,,fee schedule,86899.83,261276.19,
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,250517.52,,,,,,,fee schedule,86899.83,261276.19,
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,217841.34,,,,,,,fee schedule,86899.83,261276.19,
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,91244.82,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,86899.83,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,86899.83,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,86899.83,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,86899.83,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,86899.83,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,86899.83,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,156419.69,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,156419.69,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,91244.82,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,86899.83,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,86899.83,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,91244.82,,,,,,,fee schedule,86899.83,261276.19,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,285725.9,,,,,,,fee schedule,85392.65,285725.9,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,186851.87,,,,,,,fee schedule,85392.65,285725.9,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,285725.9,,,,,,,fee schedule,85392.65,285725.9,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,149486.86,,,,,,,fee schedule,85392.65,285725.9,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,246134.66,,,,,,,fee schedule,85392.65,285725.9,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,214030.15,,,,,,,fee schedule,85392.65,285725.9,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,89662.28,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,85392.65,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,85392.65,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,85392.65,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,85392.65,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,85392.65,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,85392.65,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,153706.77,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,153706.77,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,89662.28,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,85392.65,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,85392.65,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,89662.28,,,,,,,fee schedule,85392.65,285725.9,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,191450.73,,,,,,,fee schedule,57641.24,191450.73,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125588.49,,,,,,,fee schedule,57641.24,191450.73,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,191450.73,,,,,,,fee schedule,57641.24,191450.73,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,100474.4,,,,,,,fee schedule,57641.24,191450.73,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,165434.15,,,,,,,fee schedule,57641.24,191450.73,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,143855.79,,,,,,,fee schedule,57641.24,191450.73,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,60523.3,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,103754.23,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,103754.23,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,60523.3,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,60523.3,,,,,,,fee schedule,57641.24,191450.73,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,153978.83,,,,,,,fee schedule,57641.24,165434.15,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125588.49,,,,,,,fee schedule,57641.24,165434.15,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,153978.83,,,,,,,fee schedule,57641.24,165434.15,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,100474.4,,,,,,,fee schedule,57641.24,165434.15,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,165434.15,,,,,,,fee schedule,57641.24,165434.15,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,143855.79,,,,,,,fee schedule,57641.24,165434.15,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,60523.3,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,103754.23,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,103754.23,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,60523.3,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,57641.24,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,60523.3,,,,,,,fee schedule,57641.24,165434.15,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146655.84,,,,,,,fee schedule,67184.43,207505.64,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,207505.64,,,,,,,fee schedule,67184.43,207505.64,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,207505.64,,,,,,,fee schedule,67184.43,207505.64,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,117328.88,,,,,,,fee schedule,67184.43,207505.64,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,193185.57,,,,,,,fee schedule,67184.43,207505.64,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,167987.46,,,,,,,fee schedule,67184.43,207505.64,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],200589.8,198260.34,207662.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",50806.6,50806.6,50806.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],250595.01,250595.01,250595.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",84500.3,84500.3,84500.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],159262.42,159262.42,159262.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,141710.85,141710.85,141710.85,1 through 10,percent of total billed charges,,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,70543.65,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,67184.43,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,67184.43,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,67184.43,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,67184.43,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,67184.43,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,67184.43,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120931.97,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,120931.97,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,70543.65,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,67184.43,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,67184.43,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,70543.65,,,,,,,fee schedule,67184.43,207505.64,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101856.69,,,,,,,fee schedule,46891.08,154170.33,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,154170.33,,,,,,,fee schedule,46891.08,154170.33,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,154170.33,,,,,,,fee schedule,46891.08,154170.33,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,81488.28,,,,,,,fee schedule,46891.08,154170.33,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,134172.93,,,,,,,fee schedule,46891.08,154170.33,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,116672.12,,,,,,,fee schedule,46891.08,154170.33,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],154286.69,154286.69,154286.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",74441.25,74441.25,74441.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],140142.44,140142.44,140142.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",39508.56,39508.56,39508.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],201501.19,201501.19,201501.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],109346.5,109346.5,195415.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],117623.17,117623.17,117623.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,49235.63,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46891.08,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,46891.08,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,46891.08,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,46891.08,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,46891.08,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,46891.08,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84403.94,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,84403.94,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,49235.63,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,46891.08,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,46891.08,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,49235.63,,,,,,,fee schedule,46891.08,154170.33,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,96268.02,,,,,,,fee schedule,44359.5,131841.08,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,131841.08,,,,,,,fee schedule,44359.5,131841.08,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,131841.08,,,,,,,fee schedule,44359.5,131841.08,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,77017.18,,,,,,,fee schedule,44359.5,131841.08,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,126811.13,,,,,,,fee schedule,44359.5,131841.08,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,110270.55,,,,,,,fee schedule,44359.5,131841.08,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],131183.86,131183.86,131183.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,46577.48,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,44359.5,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,44359.5,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,44359.5,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,44359.5,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,44359.5,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,44359.5,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,79847.1,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,79847.1,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,46577.48,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,44359.5,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,44359.5,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,46577.48,,,,,,,fee schedule,44359.5,131841.08,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94495.54,,,,,,,fee schedule,43556.59,172363.11,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,172363.11,,,,,,,fee schedule,43556.59,172363.11,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,172363.11,,,,,,,fee schedule,43556.59,172363.11,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,75599.14,,,,,,,fee schedule,43556.59,172363.11,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,124476.29,,,,,,,fee schedule,43556.59,172363.11,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,108240.26,,,,,,,fee schedule,43556.59,172363.11,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],171718.63,145089.04,176358.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",67811.73,67811.73,84500.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",50806.6,50806.6,50806.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",42976.35,42976.35,42976.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",49802.74,34443.91,175224.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],100000.34,99004.44,230917.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,45734.42,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43556.59,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,43556.59,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,43556.59,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,43556.59,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,43556.59,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,43556.59,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78401.86,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,78401.86,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,45734.42,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,43556.59,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,43556.59,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,45734.42,,,,,,,fee schedule,43556.59,172363.11,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60155.58,,,,,,,fee schedule,28001.09,101921.36,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,101921.36,,,,,,,fee schedule,28001.09,101921.36,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,101921.36,,,,,,,fee schedule,28001.09,101921.36,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48126.19,,,,,,,fee schedule,28001.09,101921.36,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,79241.23,,,,,,,fee schedule,28001.09,101921.36,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,68905.42,,,,,,,fee schedule,28001.09,101921.36,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],105330.1,105330.1,109009.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",29697.02,29697.02,29697.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20624.22,20624.22,20624.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21953.81,21953.81,21953.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],57144.69,57144.69,62344.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,102001.84,102001.84,102001.84,1 through 10,percent of total billed charges,,,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29401.14,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28001.09,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28001.09,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28001.09,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28001.09,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28001.09,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28001.09,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50401.96,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,50401.96,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29401.14,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28001.09,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28001.09,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29401.14,,,,,,,fee schedule,28001.09,101921.36,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,161011.43,,,,,,,fee schedule,73687.3,213090.57,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,213090.57,,,,,,,fee schedule,73687.3,213090.57,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,213090.57,,,,,,,fee schedule,73687.3,213090.57,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,128813.76,,,,,,,fee schedule,73687.3,213090.57,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,212095.78,,,,,,,fee schedule,73687.3,213090.57,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,184431.12,,,,,,,fee schedule,73687.3,213090.57,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,77371.66,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73687.3,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,73687.3,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,73687.3,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,73687.3,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,73687.3,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,73687.3,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132637.14,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,132637.14,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,77371.66,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,73687.3,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,73687.3,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,77371.66,,,,,,,fee schedule,73687.3,213090.57,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,115795.9,,,,,,,fee schedule,53205.34,190907.56,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,190907.56,,,,,,,fee schedule,53205.34,190907.56,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,190907.56,,,,,,,fee schedule,53205.34,190907.56,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,92640.04,,,,,,,fee schedule,53205.34,190907.56,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,152534.65,,,,,,,fee schedule,53205.34,190907.56,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,132638.84,,,,,,,fee schedule,53205.34,190907.56,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,55865.61,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53205.34,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,53205.34,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,53205.34,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,53205.34,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,53205.34,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,53205.34,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,95769.61,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,95769.61,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,55865.61,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,53205.34,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,53205.34,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,55865.61,,,,,,,fee schedule,53205.34,190907.56,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,146023.63,,,,,,,fee schedule,66898.05,192352.77,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,168856.86,,,,,,,fee schedule,66898.05,192352.77,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,168856.86,,,,,,,fee schedule,66898.05,192352.77,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,116823.09,,,,,,,fee schedule,66898.05,192352.77,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,192352.77,,,,,,,fee schedule,66898.05,192352.77,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,167263.29,,,,,,,fee schedule,66898.05,192352.77,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,70242.95,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,66898.05,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,66898.05,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,66898.05,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,66898.05,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,66898.05,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,66898.05,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120416.49,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,120416.49,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,70242.95,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,66898.05,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,66898.05,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,70242.95,,,,,,,fee schedule,66898.05,192352.77,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104337.79,,,,,,,fee schedule,48014.98,139403.71,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,139403.71,,,,,,,fee schedule,48014.98,139403.71,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,139403.71,,,,,,,fee schedule,48014.98,139403.71,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,83473.22,,,,,,,fee schedule,48014.98,139403.71,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,137441.2,,,,,,,fee schedule,48014.98,139403.71,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,119514.1,,,,,,,fee schedule,48014.98,139403.71,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,50415.73,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48014.98,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,48014.98,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,48014.98,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,48014.98,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,48014.98,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,48014.98,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86426.96,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,86426.96,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,50415.73,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,48014.98,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,48014.98,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,50415.73,,,,,,,fee schedule,48014.98,139403.71,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112090.49,,,,,,,fee schedule,51526.84,147653.62,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,143686.41,,,,,,,fee schedule,51526.84,147653.62,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,143686.41,,,,,,,fee schedule,51526.84,147653.62,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,89675.61,,,,,,,fee schedule,51526.84,147653.62,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,147653.62,,,,,,,fee schedule,51526.84,147653.62,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,128394.46,,,,,,,fee schedule,51526.84,147653.62,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,54103.18,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51526.84,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,51526.84,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,51526.84,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,51526.84,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,51526.84,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,51526.84,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92748.31,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,92748.31,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,54103.18,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,51526.84,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,51526.84,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,54103.18,,,,,,,fee schedule,51526.84,147653.62,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80006.25,,,,,,,fee schedule,36993.15,114302.89,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,114302.89,,,,,,,fee schedule,36993.15,114302.89,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,114302.89,,,,,,,fee schedule,36993.15,114302.89,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,64007.29,,,,,,,fee schedule,36993.15,114302.89,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,105389.96,,,,,,,fee schedule,36993.15,114302.89,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,91643.45,,,,,,,fee schedule,36993.15,114302.89,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38842.81,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36993.15,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,36993.15,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,36993.15,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,36993.15,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,36993.15,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,36993.15,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66587.67,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,66587.67,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,38842.81,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,36993.15,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,36993.15,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,38842.81,,,,,,,fee schedule,36993.15,114302.89,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94004.67,,,,,,,fee schedule,43334.23,123829.68,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,89310.02,,,,,,,fee schedule,43334.23,123829.68,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,89310.02,,,,,,,fee schedule,43334.23,123829.68,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,75206.43,,,,,,,fee schedule,43334.23,123829.68,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,123829.68,,,,,,,fee schedule,43334.23,123829.68,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,107677.99,,,,,,,fee schedule,43334.23,123829.68,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,45500.94,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43334.23,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,43334.23,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,43334.23,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,43334.23,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,43334.23,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,43334.23,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78001.61,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,78001.61,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,45500.94,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,43334.23,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,43334.23,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,45500.94,,,,,,,fee schedule,43334.23,123829.68,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54444.66,,,,,,,fee schedule,25414.13,71718.41,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,66166.01,,,,,,,fee schedule,25414.13,71718.41,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,66166.01,,,,,,,fee schedule,25414.13,71718.41,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,43557.29,,,,,,,fee schedule,25414.13,71718.41,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,71718.41,,,,,,,fee schedule,25414.13,71718.41,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,62363.84,,,,,,,fee schedule,25414.13,71718.41,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26684.84,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25414.13,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25414.13,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25414.13,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25414.13,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25414.13,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25414.13,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45745.43,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,45745.43,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,26684.84,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25414.13,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25414.13,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,26684.84,,,,,,,fee schedule,25414.13,71718.41,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26442.1,,,,,,,fee schedule,12729.38,34831.42,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30588.25,,,,,,,fee schedule,12729.38,34831.42,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30588.25,,,,,,,fee schedule,12729.38,34831.42,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21154.43,,,,,,,fee schedule,12729.38,34831.42,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34831.42,,,,,,,fee schedule,12729.38,34831.42,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30288.19,,,,,,,fee schedule,12729.38,34831.42,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13365.85,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12729.38,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12729.38,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12729.38,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12729.38,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12729.38,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12729.38,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22912.88,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22912.88,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13365.85,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12729.38,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12729.38,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13365.85,,,,,,,fee schedule,12729.38,34831.42,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60982.61,,,,,,,fee schedule,28375.72,92969.46,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,92969.46,,,,,,,fee schedule,28375.72,92969.46,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,92969.46,,,,,,,fee schedule,28375.72,92969.46,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48787.84,,,,,,,fee schedule,28375.72,92969.46,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,80330.66,,,,,,,fee schedule,28375.72,92969.46,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,69852.75,,,,,,,fee schedule,28375.72,92969.46,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20721.09,20721.09,20721.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],62260.52,62260.52,62260.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29794.51,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28375.72,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28375.72,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28375.72,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28375.72,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28375.72,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28375.72,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51076.3,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,51076.3,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29794.51,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28375.72,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28375.72,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29794.51,,,,,,,fee schedule,28375.72,92969.46,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40700.28,,,,,,,fee schedule,19188.13,61778.85,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,61778.85,,,,,,,fee schedule,19188.13,61778.85,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,61778.85,,,,,,,fee schedule,19188.13,61778.85,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32561.39,,,,,,,fee schedule,19188.13,61778.85,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53613.32,,,,,,,fee schedule,19188.13,61778.85,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46620.28,,,,,,,fee schedule,19188.13,61778.85,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20147.54,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19188.13,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19188.13,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19188.13,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19188.13,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19188.13,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19188.13,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34538.63,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34538.63,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20147.54,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19188.13,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19188.13,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20147.54,,,,,,,fee schedule,19188.13,61778.85,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34523.32,,,,,,,fee schedule,16390.06,57663.28,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57663.28,,,,,,,fee schedule,16390.06,57663.28,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57663.28,,,,,,,fee schedule,16390.06,57663.28,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27619.65,,,,,,,fee schedule,16390.06,57663.28,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45476.59,,,,,,,fee schedule,16390.06,57663.28,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39544.86,,,,,,,fee schedule,16390.06,57663.28,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17209.56,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16390.06,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16390.06,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16390.06,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16390.06,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16390.06,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16390.06,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29502.11,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29502.11,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17209.56,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16390.06,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16390.06,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17209.56,,,,,,,fee schedule,16390.06,57663.28,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87142.02,,,,,,,fee schedule,40225.55,127481.78,
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,127481.78,,,,,,,fee schedule,40225.55,127481.78,
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,127481.78,,,,,,,fee schedule,40225.55,127481.78,
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,69716.12,,,,,,,fee schedule,40225.55,127481.78,
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,114789.71,,,,,,,fee schedule,40225.55,127481.78,
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,99817.15,,,,,,,fee schedule,40225.55,127481.78,
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42236.83,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40225.55,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,40225.55,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,40225.55,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,40225.55,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,40225.55,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,40225.55,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,72405.99,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,72405.99,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,42236.83,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,40225.55,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,40225.55,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,42236.83,,,,,,,fee schedule,40225.55,127481.78,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41685.84,,,,,,,fee schedule,19634.57,71253.03,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,71253.03,,,,,,,fee schedule,19634.57,71253.03,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,71253.03,,,,,,,fee schedule,19634.57,71253.03,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33349.87,,,,,,,fee schedule,19634.57,71253.03,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,54911.57,,,,,,,fee schedule,19634.57,71253.03,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,47749.19,,,,,,,fee schedule,19634.57,71253.03,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20616.3,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19634.57,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19634.57,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19634.57,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19634.57,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19634.57,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19634.57,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35342.23,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35342.23,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20616.3,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19634.57,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19634.57,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20616.3,,,,,,,fee schedule,19634.57,71253.03,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28545.01,,,,,,,fee schedule,13681.97,44693.31,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44693.31,,,,,,,fee schedule,13681.97,44693.31,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44693.31,,,,,,,fee schedule,13681.97,44693.31,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22836.83,,,,,,,fee schedule,13681.97,44693.31,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37601.53,,,,,,,fee schedule,13681.97,44693.31,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32696.98,,,,,,,fee schedule,13681.97,44693.31,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14366.07,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13681.97,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13681.97,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13681.97,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13681.97,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13681.97,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13681.97,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24627.55,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24627.55,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14366.07,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13681.97,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13681.97,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14366.07,,,,,,,fee schedule,13681.97,44693.31,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66626.67,,,,,,,fee schedule,30932.4,131311.84,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,131311.84,,,,,,,fee schedule,30932.4,131311.84,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,131311.84,,,,,,,fee schedule,30932.4,131311.84,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,53303.25,,,,,,,fee schedule,30932.4,131311.84,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,87765.42,,,,,,,fee schedule,30932.4,131311.84,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,76317.76,,,,,,,fee schedule,30932.4,131311.84,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],205772.87,205772.87,205772.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16541.55,16541.55,16541.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",25323.01,25323.01,25323.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",25157.6,25157.6,93896.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],169957.66,169957.66,169957.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32479.02,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30932.4,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,30932.4,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,30932.4,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,30932.4,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,30932.4,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,30932.4,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55678.32,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,55678.32,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,32479.02,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,30932.4,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,30932.4,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,32479.02,,,,,,,fee schedule,30932.4,131311.84,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49576.06,,,,,,,fee schedule,23208.73,71844.95,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,71844.95,,,,,,,fee schedule,23208.73,71844.95,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,71844.95,,,,,,,fee schedule,23208.73,71844.95,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,39662.27,,,,,,,fee schedule,23208.73,71844.95,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,65305.14,,,,,,,fee schedule,23208.73,71844.95,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,56787.08,,,,,,,fee schedule,23208.73,71844.95,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21719.76,21719.76,21719.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],71785.67,71785.67,71785.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16541.55,16541.55,16541.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],48119.49,48119.49,48119.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24369.17,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23208.73,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,23208.73,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,23208.73,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,23208.73,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,23208.73,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,23208.73,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41775.71,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,41775.71,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24369.17,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,23208.73,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,23208.73,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24369.17,,,,,,,fee schedule,23208.73,71844.95,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34030.54,,,,,,,fee schedule,16166.83,51879.89,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51879.89,,,,,,,fee schedule,16166.83,51879.89,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51879.89,,,,,,,fee schedule,16166.83,51879.89,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27225.41,,,,,,,fee schedule,16166.83,51879.89,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44827.47,,,,,,,fee schedule,16166.83,51879.89,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38980.41,,,,,,,fee schedule,16166.83,51879.89,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16975.17,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16166.83,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16166.83,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16166.83,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16166.83,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16166.83,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16166.83,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29100.29,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29100.29,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16975.17,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16166.83,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16166.83,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16975.17,,,,,,,fee schedule,16166.83,51879.89,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51520.45,,,,,,,fee schedule,24089.5,67866.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,59550.46,,,,,,,fee schedule,24089.5,67866.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,59550.46,,,,,,,fee schedule,24089.5,67866.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,41217.84,,,,,,,fee schedule,24089.5,67866.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,67866.42,,,,,,,fee schedule,24089.5,67866.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,59014.28,,,,,,,fee schedule,24089.5,67866.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22459.59,22459.59,22459.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25293.98,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24089.5,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24089.5,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24089.5,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24089.5,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24089.5,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24089.5,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43361.1,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,43361.1,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25293.98,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24089.5,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24089.5,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25293.98,,,,,,,fee schedule,24089.5,67866.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,53819.3,,,,,,,fee schedule,15441.79,53819.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32429.96,,,,,,,fee schedule,15441.79,53819.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,53819.3,,,,,,,fee schedule,15441.79,53819.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25944.9,,,,,,,fee schedule,15441.79,53819.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42719.06,,,,,,,fee schedule,15441.79,53819.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37147.01,,,,,,,fee schedule,15441.79,53819.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9675,9675,9675,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16213.88,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15441.79,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15441.79,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15441.79,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15441.79,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15441.79,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15441.79,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27795.22,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27795.22,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16213.88,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15441.79,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15441.79,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16213.88,,,,,,,fee schedule,15441.79,53819.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27673.92,,,,,,,fee schedule,10201.25,27673.92,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20861.06,,,,,,,fee schedule,10201.25,27673.92,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27673.92,,,,,,,fee schedule,10201.25,27673.92,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16689.45,,,,,,,fee schedule,10201.25,27673.92,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27479.69,,,,,,,fee schedule,10201.25,27673.92,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23895.38,,,,,,,fee schedule,10201.25,27673.92,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10711.31,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10201.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10201.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10201.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10201.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10201.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10201.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18362.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18362.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10711.31,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10201.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10201.25,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10711.31,,,,,,,fee schedule,10201.25,27673.92,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,71409.71,,,,,,,fee schedule,27937.06,79055.05,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60014.24,,,,,,,fee schedule,27937.06,79055.05,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,71409.71,,,,,,,fee schedule,27937.06,79055.05,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48013.11,,,,,,,fee schedule,27937.06,79055.05,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,79055.05,,,,,,,fee schedule,27937.06,79055.05,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,68743.52,,,,,,,fee schedule,27937.06,79055.05,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29333.91,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27937.06,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,27937.06,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,27937.06,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,27937.06,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,27937.06,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,27937.06,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50286.71,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,50286.71,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29333.91,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,27937.06,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,27937.06,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29333.91,,,,,,,fee schedule,27937.06,79055.05,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45957.23,,,,,,,fee schedule,18246.78,50875.91,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38622.19,,,,,,,fee schedule,18246.78,50875.91,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45957.23,,,,,,,fee schedule,18246.78,50875.91,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30898.86,,,,,,,fee schedule,18246.78,50875.91,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50875.91,,,,,,,fee schedule,18246.78,50875.91,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,44239.93,,,,,,,fee schedule,18246.78,50875.91,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19159.12,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18246.78,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18246.78,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18246.78,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18246.78,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18246.78,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18246.78,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32844.2,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32844.2,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19159.12,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18246.78,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18246.78,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19159.12,,,,,,,fee schedule,18246.78,50875.91,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,116444.25,,,,,,,fee schedule,28894.85,116444.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62128.61,,,,,,,fee schedule,28894.85,116444.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,116444.25,,,,,,,fee schedule,28894.85,116444.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,49704.67,,,,,,,fee schedule,28894.85,116444.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,81840.25,,,,,,,fee schedule,28894.85,116444.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,71165.44,,,,,,,fee schedule,28894.85,116444.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],110786.99,110786.99,110786.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30339.59,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28894.85,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28894.85,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28894.85,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28894.85,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28894.85,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28894.85,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52010.73,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,52010.73,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30339.59,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28894.85,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28894.85,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30339.59,,,,,,,fee schedule,28894.85,116444.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,63746.11,,,,,,,fee schedule,17108.18,63746.11,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36108.63,,,,,,,fee schedule,17108.18,63746.11,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,63746.11,,,,,,,fee schedule,17108.18,63746.11,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28887.94,,,,,,,fee schedule,17108.18,63746.11,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,47564.87,,,,,,,fee schedule,17108.18,63746.11,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,41360.76,,,,,,,fee schedule,17108.18,63746.11,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],36906.87,36906.87,36906.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17963.59,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30794.72,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30794.72,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17963.59,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17963.59,,,,,,,fee schedule,17108.18,63746.11,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57739.88,,,,,,,fee schedule,14853.45,57739.88,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31131.16,,,,,,,fee schedule,14853.45,57739.88,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57739.88,,,,,,,fee schedule,14853.45,57739.88,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24905.82,,,,,,,fee schedule,14853.45,57739.88,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41008.19,,,,,,,fee schedule,14853.45,57739.88,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35659.29,,,,,,,fee schedule,14853.45,57739.88,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15596.12,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14853.45,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14853.45,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14853.45,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14853.45,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14853.45,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14853.45,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26736.21,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26736.21,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15596.12,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14853.45,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14853.45,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15596.12,,,,,,,fee schedule,14853.45,57739.88,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,79717.46,,,,,,,fee schedule,27204.24,79717.46,
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58396.46,,,,,,,fee schedule,27204.24,79717.46,
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,79717.46,,,,,,,fee schedule,27204.24,79717.46,
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,46718.85,,,,,,,fee schedule,27204.24,79717.46,
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,76924,,,,,,,fee schedule,27204.24,79717.46,
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,66890.44,,,,,,,fee schedule,27204.24,79717.46,
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28564.45,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27204.24,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,27204.24,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,27204.24,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,27204.24,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,27204.24,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,27204.24,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48967.63,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,48967.63,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,28564.45,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,27204.24,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,27204.24,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,28564.45,,,,,,,fee schedule,27204.24,79717.46,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,73659,,,,,,,fee schedule,29654.49,84049.3,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63805.59,,,,,,,fee schedule,29654.49,84049.3,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,73659,,,,,,,fee schedule,29654.49,84049.3,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,51046.31,,,,,,,fee schedule,29654.49,84049.3,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,84049.3,,,,,,,fee schedule,29654.49,84049.3,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,73086.35,,,,,,,fee schedule,29654.49,84049.3,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22149.59,22149.59,22149.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22530.06,22530.06,22530.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13562.02,13562.02,13562.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28998.07,28224.01,29881,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31137.21,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29654.49,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,29654.49,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,29654.49,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,29654.49,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,29654.49,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,29654.49,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,53378.08,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,53378.08,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,31137.21,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,29654.49,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,29654.49,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,31137.21,,,,,,,fee schedule,29654.49,84049.3,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,105486.79,,,,,,,fee schedule,32056.3,105486.79,
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69107.76,,,,,,,fee schedule,32056.3,105486.79,
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,105486.79,,,,,,,fee schedule,32056.3,105486.79,
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,55288.19,,,,,,,fee schedule,32056.3,105486.79,
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,91033.69,,,,,,,fee schedule,32056.3,105486.79,
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,79159.74,,,,,,,fee schedule,32056.3,105486.79,
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33659.12,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32056.3,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32056.3,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32056.3,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32056.3,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32056.3,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32056.3,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57701.34,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,57701.34,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33659.12,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32056.3,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32056.3,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33659.12,,,,,,,fee schedule,32056.3,105486.79,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,171781.64,,,,,,,fee schedule,53774.64,171781.64,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,117052.69,,,,,,,fee schedule,53774.64,171781.64,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,171781.64,,,,,,,fee schedule,53774.64,171781.64,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,93645.51,,,,,,,fee schedule,53774.64,171781.64,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,154190.18,,,,,,,fee schedule,53774.64,171781.64,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,134078.42,,,,,,,fee schedule,53774.64,171781.64,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],139403.13,139403.13,139403.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,56463.37,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53774.64,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,53774.64,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,53774.64,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,53774.64,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,53774.64,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,53774.64,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,96794.35,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,96794.35,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,56463.37,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,53774.64,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,53774.64,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,56463.37,,,,,,,fee schedule,53774.64,171781.64,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,144163.43,,,,,,,fee schedule,41942.12,144163.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,90931.47,,,,,,,fee schedule,41942.12,144163.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,144163.43,,,,,,,fee schedule,41942.12,144163.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,72747.79,,,,,,,fee schedule,41942.12,144163.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,119781.44,,,,,,,fee schedule,41942.12,144163.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,104157.78,,,,,,,fee schedule,41942.12,144163.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],141458.42,141458.42,141458.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",42980.58,42980.58,42980.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],95557.59,95557.59,95557.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,44039.23,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41942.12,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,41942.12,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,41942.12,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,41942.12,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,41942.12,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,41942.12,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,75495.82,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,75495.82,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,44039.23,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,41942.12,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,41942.12,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,44039.23,,,,,,,fee schedule,41942.12,144163.43,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,159929.34,,,,,,,fee schedule,60259.34,173047.55,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,131368.17,,,,,,,fee schedule,60259.34,173047.55,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,159929.34,,,,,,,fee schedule,60259.34,173047.55,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,105098.3,,,,,,,fee schedule,60259.34,173047.55,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,173047.55,,,,,,,fee schedule,60259.34,173047.55,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,150476.14,,,,,,,fee schedule,60259.34,173047.55,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],153201.6,153201.6,153201.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24115.32,24115.32,24115.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,63272.31,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60259.34,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,60259.34,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,60259.34,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,60259.34,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,60259.34,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,60259.34,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,108466.81,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,108466.81,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,63272.31,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,60259.34,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,60259.34,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,63272.31,,,,,,,fee schedule,60259.34,173047.55,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,100326.66,,,,,,,fee schedule,37290.78,106255.46,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80663.29,,,,,,,fee schedule,37290.78,106255.46,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,100326.66,,,,,,,fee schedule,37290.78,106255.46,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,64532.95,,,,,,,fee schedule,37290.78,106255.46,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,106255.46,,,,,,,fee schedule,37290.78,106255.46,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,92396.06,,,,,,,fee schedule,37290.78,106255.46,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],100003.66,100003.66,100003.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24115.32,24115.32,24115.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12101.73,12101.73,12101.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],94090.34,94090.34,94090.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],75507.31,75507.31,75507.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39155.32,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37290.78,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,37290.78,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,37290.78,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,37290.78,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,37290.78,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,37290.78,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67123.4,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,67123.4,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,39155.32,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,37290.78,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,37290.78,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,39155.32,,,,,,,fee schedule,37290.78,106255.46,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,149908.52,,,,,,,fee schedule,46402.24,149908.52,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,100777.54,,,,,,,fee schedule,46402.24,149908.52,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,149908.52,,,,,,,fee schedule,46402.24,149908.52,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,80624.92,,,,,,,fee schedule,46402.24,149908.52,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,132751.39,,,,,,,fee schedule,46402.24,149908.52,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,115436,,,,,,,fee schedule,46402.24,149908.52,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],140537.77,140537.77,140537.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],69871.62,69871.62,140537.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",132127.43,84500.3,184447.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],117477.92,117477.92,118740.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],103024.28,72808.97,103024.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],43623.1,43623.1,43623.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,569715.87,569715.87,569715.87,1 through 10,percent of total billed charges,,,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,48722.35,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46402.24,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,46402.24,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,46402.24,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,46402.24,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,46402.24,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,46402.24,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,83524.03,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,83524.03,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,48722.35,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,46402.24,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,46402.24,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,48722.35,,,,,,,fee schedule,46402.24,149908.52,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,94912.35,,,,,,,fee schedule,31520.74,94912.35,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67925.47,,,,,,,fee schedule,31520.74,94912.35,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,94912.35,,,,,,,fee schedule,31520.74,94912.35,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,54342.33,,,,,,,fee schedule,31520.74,94912.35,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,89476.29,,,,,,,fee schedule,31520.74,94912.35,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,77805.48,,,,,,,fee schedule,31520.74,94912.35,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],88360.46,88360.46,88360.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29903.55,29903.55,29903.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",49802.74,49802.74,49802.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",26323.46,26323.46,26323.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",116202.94,116202.94,116202.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],70060.48,70060.48,70060.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],50728.58,50728.58,50728.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29359.43,29359.43,29359.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33096.78,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31520.74,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31520.74,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31520.74,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31520.74,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31520.74,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31520.74,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56737.33,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,56737.33,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33096.78,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31520.74,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31520.74,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33096.78,,,,,,,fee schedule,31520.74,94912.35,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,69317.11,,,,,,,fee schedule,22840.15,69317.11,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48762.4,,,,,,,fee schedule,22840.15,69317.11,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,69317.11,,,,,,,fee schedule,22840.15,69317.11,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,39011.32,,,,,,,fee schedule,22840.15,69317.11,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,64233.33,,,,,,,fee schedule,22840.15,69317.11,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,55855.07,,,,,,,fee schedule,22840.15,69317.11,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22472.1,22472.1,22472.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],51243.18,51243.18,51243.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20582.48,20582.48,20582.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23982.16,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22840.15,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22840.15,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22840.15,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22840.15,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22840.15,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22840.15,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41112.27,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,41112.27,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23982.16,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22840.15,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22840.15,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23982.16,,,,,,,fee schedule,22840.15,69317.11,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,102582.91,,,,,,,fee schedule,36445.48,103797.33,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,78797.22,,,,,,,fee schedule,36445.48,103797.33,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,102582.91,,,,,,,fee schedule,36445.48,103797.33,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,63040.03,,,,,,,fee schedule,36445.48,103797.33,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,103797.33,,,,,,,fee schedule,36445.48,103797.33,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,90258.56,,,,,,,fee schedule,36445.48,103797.33,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38267.75,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36445.48,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,36445.48,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,36445.48,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,36445.48,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,36445.48,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,36445.48,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,65601.86,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,65601.86,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,38267.75,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,36445.48,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,36445.48,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,38267.75,,,,,,,fee schedule,36445.48,103797.33,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,86124.1,,,,,,,fee schedule,29231.41,86124.1,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,62871.6,,,,,,,fee schedule,29231.41,86124.1,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,86124.1,,,,,,,fee schedule,29231.41,86124.1,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,50299.09,,,,,,,fee schedule,29231.41,86124.1,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,82818.97,,,,,,,fee schedule,29231.41,86124.1,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,72016.5,,,,,,,fee schedule,29231.41,86124.1,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30692.98,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29231.41,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,29231.41,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,29231.41,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,29231.41,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,29231.41,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,29231.41,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52616.54,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,52616.54,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30692.98,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,29231.41,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,29231.41,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30692.98,,,,,,,fee schedule,29231.41,86124.1,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,209587.8,,,,,,,fee schedule,62443.98,209587.8,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136190.93,,,,,,,fee schedule,62443.98,209587.8,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,209587.8,,,,,,,fee schedule,62443.98,209587.8,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,108956.65,,,,,,,fee schedule,62443.98,209587.8,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,179400.44,,,,,,,fee schedule,62443.98,209587.8,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,156000.39,,,,,,,fee schedule,62443.98,209587.8,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,65566.18,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62443.98,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,62443.98,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,62443.98,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,62443.98,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,62443.98,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,62443.98,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,112399.16,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,112399.16,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,65566.18,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,62443.98,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,62443.98,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,65566.18,,,,,,,fee schedule,62443.98,209587.8,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,202752.89,,,,,,,fee schedule,52720.82,202752.89,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,114726.3,,,,,,,fee schedule,52720.82,202752.89,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,202752.89,,,,,,,fee schedule,52720.82,202752.89,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,91784.33,,,,,,,fee schedule,52720.82,202752.89,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,151125.7,,,,,,,fee schedule,52720.82,202752.89,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,131413.66,,,,,,,fee schedule,52720.82,202752.89,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,115938.26,115938.26,115938.26,1 through 10,percent of total billed charges,,,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,55356.86,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52720.82,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,52720.82,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,52720.82,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,52720.82,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,52720.82,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,52720.82,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,94897.48,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,94897.48,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,55356.86,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,52720.82,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,52720.82,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,55356.86,,,,,,,fee schedule,52720.82,202752.89,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,157537.3,,,,,,,fee schedule,40710.93,157537.3,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,88213.53,,,,,,,fee schedule,40710.93,157537.3,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,157537.3,,,,,,,fee schedule,40710.93,157537.3,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,70573.36,,,,,,,fee schedule,40710.93,157537.3,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,116201.18,,,,,,,fee schedule,40710.93,157537.3,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,101044.51,,,,,,,fee schedule,40710.93,157537.3,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",45863.08,45863.08,45863.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42746.48,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40710.93,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,40710.93,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,40710.93,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,40710.93,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,40710.93,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,40710.93,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,73279.67,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,73279.67,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,42746.48,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,40710.93,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,40710.93,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,42746.48,,,,,,,fee schedule,40710.93,157537.3,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,154149.44,,,,,,,fee schedule,48910.47,154149.44,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,106314.64,,,,,,,fee schedule,48910.47,154149.44,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,154149.44,,,,,,,fee schedule,48910.47,154149.44,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,85054.76,,,,,,,fee schedule,48910.47,154149.44,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,140045.26,,,,,,,fee schedule,48910.47,154149.44,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,121778.49,,,,,,,fee schedule,48910.47,154149.44,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,51355.99,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48910.47,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,48910.47,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,48910.47,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,48910.47,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,48910.47,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,48910.47,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88038.85,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,88038.85,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,51355.99,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,48910.47,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,48910.47,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,51355.99,,,,,,,fee schedule,48910.47,154149.44,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,77624.85,,,,,,,fee schedule,31954.21,90736.81,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68882.38,,,,,,,fee schedule,31954.21,90736.81,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,77624.85,,,,,,,fee schedule,31954.21,90736.81,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,55107.88,,,,,,,fee schedule,31954.21,90736.81,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,90736.81,,,,,,,fee schedule,31954.21,90736.81,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,78901.58,,,,,,,fee schedule,31954.21,90736.81,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33551.92,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31954.21,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31954.21,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31954.21,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31954.21,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31954.21,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31954.21,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57517.58,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,57517.58,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33551.92,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31954.21,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31954.21,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33551.92,,,,,,,fee schedule,31954.21,90736.81,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,39425.24,,,,,,,fee schedule,14630.23,40359.06,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30638.37,,,,,,,fee schedule,14630.23,40359.06,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,39425.24,,,,,,,fee schedule,14630.23,40359.06,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24511.58,,,,,,,fee schedule,14630.23,40359.06,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40359.06,,,,,,,fee schedule,14630.23,40359.06,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35094.84,,,,,,,fee schedule,14630.23,40359.06,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14371.57,14371.57,14371.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15361.74,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14630.23,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14630.23,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14630.23,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14630.23,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14630.23,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14630.23,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26334.41,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26334.41,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15361.74,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14630.23,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14630.23,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15361.74,,,,,,,fee schedule,14630.23,40359.06,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27419.74,,,,,,,fee schedule,8703.59,27419.74,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17554.85,,,,,,,fee schedule,8703.59,27419.74,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27419.74,,,,,,,fee schedule,8703.59,27419.74,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14044.38,,,,,,,fee schedule,8703.59,27419.74,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23124.5,,,,,,,fee schedule,8703.59,27419.74,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20108.26,,,,,,,fee schedule,8703.59,27419.74,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12884.75,12884.75,12884.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8301.14,8301.14,8301.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9138.77,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8703.59,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8703.59,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8703.59,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8703.59,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8703.59,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8703.59,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15666.46,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15666.46,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9138.77,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8703.59,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8703.59,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9138.77,,,,,,,fee schedule,8703.59,27419.74,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23791.63,,,,,,,fee schedule,7007.79,23791.63,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13811.24,,,,,,,fee schedule,7007.79,23791.63,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23791.63,,,,,,,fee schedule,7007.79,23791.63,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11049.39,,,,,,,fee schedule,7007.79,23791.63,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18193.15,,,,,,,fee schedule,7007.79,23791.63,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15820.13,,,,,,,fee schedule,7007.79,23791.63,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7358.18,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7007.79,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7007.79,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7007.79,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7007.79,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7007.79,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7007.79,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12614.02,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12614.02,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7358.18,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7007.79,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7007.79,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7358.18,,,,,,,fee schedule,7007.79,23791.63,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60361.73,,,,,,,fee schedule,17889.45,60361.73,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37833.36,,,,,,,fee schedule,17889.45,60361.73,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60361.73,,,,,,,fee schedule,17889.45,60361.73,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30267.77,,,,,,,fee schedule,17889.45,60361.73,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,49836.81,,,,,,,fee schedule,17889.45,60361.73,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43336.36,,,,,,,fee schedule,17889.45,60361.73,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18783.92,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17889.45,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17889.45,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17889.45,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17889.45,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17889.45,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17889.45,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32201.01,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32201.01,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18783.92,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17889.45,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17889.45,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18783.92,,,,,,,fee schedule,17889.45,60361.73,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22813.23,,,,,,,fee schedule,6740.44,22813.23,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13221.05,,,,,,,fee schedule,6740.44,22813.23,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22813.23,,,,,,,fee schedule,6740.44,22813.23,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10577.22,,,,,,,fee schedule,6740.44,22813.23,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17415.71,,,,,,,fee schedule,6740.44,22813.23,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15144.1,,,,,,,fee schedule,6740.44,22813.23,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7077.46,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6740.44,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6740.44,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6740.44,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6740.44,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6740.44,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6740.44,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12132.79,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12132.79,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7077.46,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6740.44,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6740.44,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7077.46,,,,,,,fee schedule,6740.44,22813.23,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,15069.54,,,,,,,fee schedule,5933.2,15069.54,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11439.01,,,,,,,fee schedule,5933.2,15069.54,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,15069.54,,,,,,,fee schedule,5933.2,15069.54,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9151.54,,,,,,,fee schedule,5933.2,15069.54,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15068.29,,,,,,,fee schedule,5933.2,15069.54,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13102.86,,,,,,,fee schedule,5933.2,15069.54,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6229.86,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5933.2,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5933.2,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5933.2,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5933.2,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5933.2,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5933.2,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10679.76,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,10679.76,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6229.86,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5933.2,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5933.2,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6229.86,,,,,,,fee schedule,5933.2,15069.54,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51796.33,,,,,,,fee schedule,19896.73,55673.92,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42264.57,,,,,,,fee schedule,19896.73,55673.92,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51796.33,,,,,,,fee schedule,19896.73,55673.92,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33812.87,,,,,,,fee schedule,19896.73,55673.92,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,55673.92,,,,,,,fee schedule,19896.73,55673.92,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,48412.1,,,,,,,fee schedule,19896.73,55673.92,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],49558.57,49558.57,49558.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9288.1,9288.1,9288.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19168.64,19168.64,19168.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20891.57,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19896.73,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19896.73,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19896.73,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19896.73,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19896.73,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19896.73,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35814.11,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35814.11,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20891.57,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19896.73,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19896.73,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20891.57,,,,,,,fee schedule,19896.73,55673.92,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31998.4,,,,,,,fee schedule,10010.04,31998.4,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20438.95,,,,,,,fee schedule,10010.04,31998.4,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31998.4,,,,,,,fee schedule,10010.04,31998.4,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16351.75,,,,,,,fee schedule,10010.04,31998.4,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26923.65,,,,,,,fee schedule,10010.04,31998.4,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23411.87,,,,,,,fee schedule,10010.04,31998.4,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10510.54,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10010.04,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10010.04,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10010.04,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10010.04,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10010.04,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10010.04,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18018.07,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18018.07,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10510.54,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10010.04,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10010.04,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10510.54,,,,,,,fee schedule,10010.04,31998.4,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,94142.86,,,,,,,fee schedule,24165.64,94142.86,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51688.53,,,,,,,fee schedule,24165.64,94142.86,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,94142.86,,,,,,,fee schedule,24165.64,94142.86,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,41352.31,,,,,,,fee schedule,24165.64,94142.86,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,68087.83,,,,,,,fee schedule,24165.64,94142.86,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,59206.81,,,,,,,fee schedule,24165.64,94142.86,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],73069.16,73069.16,73069.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25373.92,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24165.64,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24165.64,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24165.64,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24165.64,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24165.64,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24165.64,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43498.15,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,43498.15,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25373.92,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24165.64,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24165.64,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25373.92,,,,,,,fee schedule,24165.64,94142.86,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33398.12,,,,,,,fee schedule,15519.66,42945.5,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32601.86,,,,,,,fee schedule,15519.66,42945.5,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33398.12,,,,,,,fee schedule,15519.66,42945.5,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26082.42,,,,,,,fee schedule,15519.66,42945.5,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42945.5,,,,,,,fee schedule,15519.66,42945.5,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37343.92,,,,,,,fee schedule,15519.66,42945.5,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16295.64,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15519.66,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15519.66,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15519.66,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15519.66,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15519.66,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15519.66,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27935.39,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27935.39,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16295.64,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15519.66,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15519.66,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16295.64,,,,,,,fee schedule,15519.66,42945.5,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28627.95,,,,,,,fee schedule,8795.3,28627.95,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17757.31,,,,,,,fee schedule,8795.3,28627.95,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28627.95,,,,,,,fee schedule,8795.3,28627.95,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14206.36,,,,,,,fee schedule,8795.3,28627.95,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23391.2,,,,,,,fee schedule,8795.3,28627.95,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20340.17,,,,,,,fee schedule,8795.3,28627.95,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9235.06,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8795.3,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8795.3,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8795.3,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8795.3,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8795.3,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8795.3,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15831.54,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15831.54,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9235.06,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8795.3,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8795.3,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9235.06,,,,,,,fee schedule,8795.3,28627.95,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31315.96,,,,,,,fee schedule,11858.98,32300.33,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24520.63,,,,,,,fee schedule,11858.98,32300.33,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31315.96,,,,,,,fee schedule,11858.98,32300.33,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19617.21,,,,,,,fee schedule,11858.98,32300.33,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32300.33,,,,,,,fee schedule,11858.98,32300.33,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28087.25,,,,,,,fee schedule,11858.98,32300.33,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12012.95,6729.71,12057.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11550.29,11532.29,11602.65,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],30281.9,21876.56,36293.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11824.11,11824.11,11824.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7056.73,7056.73,7056.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8823.71,8823.71,8823.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11857.23,11857.23,11857.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5492.76,5492.76,7062.4,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21079.37,21079.37,21079.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11528.14,9012.03,11596.85,115,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9025.31,9025.31,9025.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7056.73,7056.73,7056.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],32866.59,32866.59,32866.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12451.93,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11858.98,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11858.98,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11858.98,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11858.98,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11858.98,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11858.98,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21346.16,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21346.16,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12451.93,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11858.98,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11858.98,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12451.93,,,,,,,fee schedule,11858.98,32300.33,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21061.84,,,,,,,fee schedule,8097.08,21360.79,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16215.93,,,,,,,fee schedule,8097.08,21360.79,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21061.84,,,,,,,fee schedule,8097.08,21360.79,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12973.21,,,,,,,fee schedule,8097.08,21360.79,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21360.79,,,,,,,fee schedule,8097.08,21360.79,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18574.6,,,,,,,fee schedule,8097.08,21360.79,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7056.73,7056.73,7056.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20540.78,20540.78,20540.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7906.98,7906.98,7906.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8501.93,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8097.08,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8097.08,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8097.08,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8097.08,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8097.08,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8097.08,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14574.74,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14574.74,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8501.93,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8097.08,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8097.08,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8501.93,,,,,,,fee schedule,8097.08,21360.79,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,13809.1,,,,,,,fee schedule,5648.55,14240.53,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10810.62,,,,,,,fee schedule,5648.55,14240.53,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,13809.1,,,,,,,fee schedule,5648.55,14240.53,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,8648.81,,,,,,,fee schedule,5648.55,14240.53,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,14240.53,,,,,,,fee schedule,5648.55,14240.53,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,12383.07,,,,,,,fee schedule,5648.55,14240.53,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13819.53,13819.53,13819.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5930.98,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5648.55,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5648.55,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5648.55,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5648.55,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5648.55,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5648.55,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10167.39,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,10167.39,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,5930.98,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5648.55,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5648.55,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,5930.98,,,,,,,fee schedule,5648.55,14240.53,MSDRG Base Rate
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48875.04,,,,,,,fee schedule,14265.12,48875.04,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29832.35,,,,,,,fee schedule,14265.12,48875.04,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48875.04,,,,,,,fee schedule,14265.12,48875.04,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23866.74,,,,,,,fee schedule,14265.12,48875.04,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39297.31,,,,,,,fee schedule,14265.12,48875.04,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34171.58,,,,,,,fee schedule,14265.12,48875.04,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25754.76,25754.76,47261.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",29640.65,29640.65,29640.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30271.91,30271.91,30271.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],80421.05,80421.05,80421.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14978.38,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14265.12,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14265.12,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14265.12,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14265.12,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14265.12,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14265.12,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25677.22,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25677.22,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14978.38,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14265.12,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14265.12,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14978.38,,,,,,,fee schedule,14265.12,48875.04,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16497.11,,,,,,,fee schedule,6236.89,16497.11,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12109.43,,,,,,,fee schedule,6236.89,16497.11,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16497.11,,,,,,,fee schedule,6236.89,16497.11,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9687.89,,,,,,,fee schedule,6236.89,16497.11,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15951.4,,,,,,,fee schedule,6236.89,16497.11,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13870.79,,,,,,,fee schedule,6236.89,16497.11,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6548.73,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6236.89,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6236.89,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6236.89,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6236.89,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6236.89,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6236.89,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11226.4,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11226.4,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6548.73,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6236.89,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6236.89,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6548.73,,,,,,,fee schedule,6236.89,16497.11,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,15149.63,,,,,,,fee schedule,4689.04,15149.63,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,8692.43,,,,,,,fee schedule,4689.04,15149.63,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,15149.63,,,,,,,fee schedule,4689.04,15149.63,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,6954.19,,,,,,,fee schedule,4689.04,15149.63,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,11450.29,,,,,,,fee schedule,4689.04,15149.63,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,9956.77,,,,,,,fee schedule,4689.04,15149.63,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,4923.49,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,4689.04,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,4689.04,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,4689.04,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,4689.04,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,4689.04,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,4689.04,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,8440.27,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,8440.27,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,4923.49,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,4689.04,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,4689.04,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,4923.49,,,,,,,fee schedule,4689.04,15149.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38269.26,,,,,,,fee schedule,14877.68,41078.63,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31184.64,,,,,,,fee schedule,14877.68,41078.63,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38269.26,,,,,,,fee schedule,14877.68,41078.63,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24948.6,,,,,,,fee schedule,14877.68,41078.63,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41078.63,,,,,,,fee schedule,14877.68,41078.63,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35720.55,,,,,,,fee schedule,14877.68,41078.63,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12046.97,12046.97,12046.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33055.28,33055.28,48106.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",874.28,874.28,874.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8490.29,8490.29,8490.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21172.45,21172.45,21172.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5981.71,5981.71,5981.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12632.12,12632.12,21836.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14565.7,14565.7,14565.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15621.56,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14877.68,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14877.68,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14877.68,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14877.68,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14877.68,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14877.68,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26779.82,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26779.82,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15621.56,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14877.68,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14877.68,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15621.56,,,,,,,fee schedule,14877.68,41078.63,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26751.22,,,,,,,fee schedule,9987.55,26858.24,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20389.29,,,,,,,fee schedule,9987.55,26858.24,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26751.22,,,,,,,fee schedule,9987.55,26858.24,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16312.02,,,,,,,fee schedule,9987.55,26858.24,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26858.24,,,,,,,fee schedule,9987.55,26858.24,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23354.99,,,,,,,fee schedule,9987.55,26858.24,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25567.49,15885,25746.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25867.89,25867.89,25867.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4772.98,4772.98,4772.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5981.71,5981.71,8490.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13621.73,13621.73,13621.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5981.71,5981.71,5981.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12977.52,12198.51,21426.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9570.34,7806.34,9773.82,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10486.93,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9987.55,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9987.55,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9987.55,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9987.55,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9987.55,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9987.55,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17977.59,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17977.59,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10486.93,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9987.55,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9987.55,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10486.93,,,,,,,fee schedule,9987.55,26858.24,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22252.64,,,,,,,fee schedule,6978.37,22252.64,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13746.3,,,,,,,fee schedule,6978.37,22252.64,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22252.64,,,,,,,fee schedule,6978.37,22252.64,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10997.43,,,,,,,fee schedule,6978.37,22252.64,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18107.61,,,,,,,fee schedule,6978.37,22252.64,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15745.75,,,,,,,fee schedule,6978.37,22252.64,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6518.13,6518.13,6518.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22269.44,22269.44,22269.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4772.98,4772.98,4772.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],4976.1,4976.1,4976.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7327.29,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6978.37,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6978.37,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6978.37,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6978.37,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6978.37,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6978.37,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12561.07,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12561.07,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7327.29,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6978.37,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6978.37,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7327.29,,,,,,,fee schedule,6978.37,22252.64,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41852.1,,,,,,,fee schedule,11104.53,41852.1,
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22855.11,,,,,,,fee schedule,11104.53,41852.1,
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41852.1,,,,,,,fee schedule,11104.53,41852.1,
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18284.74,,,,,,,fee schedule,11104.53,41852.1,
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30106.38,,,,,,,fee schedule,11104.53,41852.1,
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26179.47,,,,,,,fee schedule,11104.53,41852.1,
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],8178,8178,8178,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5607.3,5607.3,5607.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11659.76,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11104.53,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11104.53,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11104.53,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11104.53,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11104.53,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11104.53,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19988.15,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19988.15,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11659.76,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11104.53,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11104.53,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11659.76,,,,,,,fee schedule,11104.53,41852.1,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19233.86,,,,,,,fee schedule,6576.05,19233.86,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12858.15,,,,,,,fee schedule,6576.05,19233.86,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19233.86,,,,,,,fee schedule,6576.05,19233.86,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10286.89,,,,,,,fee schedule,6576.05,19233.86,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16937.67,,,,,,,fee schedule,6576.05,19233.86,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14728.41,,,,,,,fee schedule,6576.05,19233.86,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10628.35,10628.35,10628.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6904.85,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6576.05,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6576.05,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6576.05,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6576.05,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6576.05,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6576.05,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11836.89,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11836.89,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6904.85,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6576.05,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6576.05,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6904.85,,,,,,,fee schedule,6576.05,19233.86,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38763.68,,,,,,,fee schedule,11047.42,38763.68,
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22729.05,,,,,,,fee schedule,11047.42,38763.68,
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38763.68,,,,,,,fee schedule,11047.42,38763.68,
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18183.89,,,,,,,fee schedule,11047.42,38763.68,
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29940.33,,,,,,,fee schedule,11047.42,38763.68,
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26035.07,,,,,,,fee schedule,11047.42,38763.68,
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],37557.18,37557.18,37557.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10603.89,10603.89,10603.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],6934.5,6934.5,6934.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6934.5,6934.5,6934.5,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21613.47,21613.47,21613.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8679.27,8555.11,10469.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6934.5,6934.5,6934.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,79651.57,79651.57,79651.57,1 through 10,percent of total billed charges,,,
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11599.79,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11047.42,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11047.42,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11047.42,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11047.42,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11047.42,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11047.42,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19885.36,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19885.36,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11599.79,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11047.42,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11047.42,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11599.79,,,,,,,fee schedule,11047.42,38763.68,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20167,,,,,,,fee schedule,7284.65,20167,
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14422.44,,,,,,,fee schedule,7284.65,20167,
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20167,,,,,,,fee schedule,7284.65,20167,
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11538.37,,,,,,,fee schedule,7284.65,20167,
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18998.27,,,,,,,fee schedule,7284.65,20167,
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16520.24,,,,,,,fee schedule,7284.65,20167,
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],981.3,981.3,981.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15291.35,14816.66,19274.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5215.54,5215.54,5215.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5575.7,5575.7,6934.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5575.7,5575.7,5575.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5575.7,5575.7,6934.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12083.23,11383.89,15067.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6909.29,6899.35,7177.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7503.83,7503.83,7503.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],7774.17,7774.17,29712.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7648.88,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7284.65,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7284.65,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7284.65,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7284.65,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7284.65,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7284.65,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13112.37,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13112.37,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7648.88,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7284.65,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7284.65,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7648.88,,,,,,,fee schedule,7284.65,20167,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,53937.68,,,,,,,fee schedule,14385.38,53937.68,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30097.84,,,,,,,fee schedule,14385.38,53937.68,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,53937.68,,,,,,,fee schedule,14385.38,53937.68,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24079.14,,,,,,,fee schedule,14385.38,53937.68,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39647.03,,,,,,,fee schedule,14385.38,53937.68,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34475.68,,,,,,,fee schedule,14385.38,53937.68,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",234506.9,234506.9,234506.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12433.52,12433.52,12433.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17663.48,17663.48,17663.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13084.76,13084.76,13084.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14754,14754,14754,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15104.65,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14385.38,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14385.38,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14385.38,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14385.38,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14385.38,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14385.38,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25893.68,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25893.68,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15104.65,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14385.38,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14385.38,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15104.65,,,,,,,fee schedule,14385.38,53937.68,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29334.77,,,,,,,fee schedule,8652.54,29334.77,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17442.16,,,,,,,fee schedule,8652.54,29334.77,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29334.77,,,,,,,fee schedule,8652.54,29334.77,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13954.23,,,,,,,fee schedule,8652.54,29334.77,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22976.06,,,,,,,fee schedule,8652.54,29334.77,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19979.18,,,,,,,fee schedule,8652.54,29334.77,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],28366.13,28366.13,28366.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18592.46,18592.46,18592.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21381.33,21381.33,21381.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5091.12,5091.12,5091.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9085.17,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8652.54,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8652.54,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8652.54,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8652.54,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8652.54,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8652.54,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15574.57,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15574.57,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9085.17,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8652.54,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8652.54,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9085.17,,,,,,,fee schedule,8652.54,29334.77,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29481.01,,,,,,,fee schedule,11168.55,30292.57,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22996.45,,,,,,,fee schedule,11168.55,30292.57,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29481.01,,,,,,,fee schedule,11168.55,30292.57,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18397.82,,,,,,,fee schedule,11168.55,30292.57,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30292.57,,,,,,,fee schedule,11168.55,30292.57,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26341.36,,,,,,,fee schedule,11168.55,30292.57,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10956.31,10956.31,37769.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6861.37,6861.37,6861.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24206.53,24206.53,24206.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10731.59,10689.49,10925.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11726.98,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20103.39,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20103.39,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11726.98,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11726.98,,,,,,,fee schedule,11168.55,30292.57,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19355.73,,,,,,,fee schedule,7116.8,19355.73,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14051.9,,,,,,,fee schedule,7116.8,19355.73,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19355.73,,,,,,,fee schedule,7116.8,19355.73,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11241.92,,,,,,,fee schedule,7116.8,19355.73,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18510.17,,,,,,,fee schedule,7116.8,19355.73,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16095.8,,,,,,,fee schedule,7116.8,19355.73,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6196.59,6196.59,6196.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18716.6,10352.27,18716.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5215.54,5215.54,5215.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13601.32,13601.32,13601.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6788.09,6782.9,6801.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7472.64,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7116.8,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7116.8,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7116.8,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7116.8,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7116.8,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7116.8,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12810.24,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12810.24,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7472.64,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7116.8,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7116.8,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7472.64,,,,,,,fee schedule,7116.8,19355.73,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14881.52,,,,,,,fee schedule,5649.42,14881.52,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10812.53,,,,,,,fee schedule,5649.42,14881.52,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14881.52,,,,,,,fee schedule,5649.42,14881.52,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,8650.34,,,,,,,fee schedule,5649.42,14881.52,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,14243.04,,,,,,,fee schedule,5649.42,14881.52,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,12385.25,,,,,,,fee schedule,5649.42,14881.52,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4259.37,4259.37,4259.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13349.62,13349.62,13349.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4195.08,4195.08,4195.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7843.56,7843.56,7843.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5215.54,5215.54,5215.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11230.14,11230.14,11230.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],3906.52,3906.52,3906.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,4061.13,4061.13,4061.13,1 through 10,percent of total billed charges,,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5931.89,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5649.42,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5649.42,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5649.42,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5649.42,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5649.42,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5649.42,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10168.96,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,10168.96,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,5931.89,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5649.42,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5649.42,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,5931.89,,,,,,,fee schedule,5649.42,14881.52,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20664.91,,,,,,,fee schedule,6824.36,20664.91,
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13406.32,,,,,,,fee schedule,6824.36,20664.91,
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20664.91,,,,,,,fee schedule,6824.36,20664.91,
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10725.44,,,,,,,fee schedule,6824.36,20664.91,
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17659.76,,,,,,,fee schedule,6824.36,20664.91,
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15356.32,,,,,,,fee schedule,6824.36,20664.91,
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7165.58,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6824.36,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6824.36,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6824.36,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6824.36,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6824.36,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6824.36,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12283.85,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12283.85,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7165.58,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6824.36,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6824.36,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7165.58,,,,,,,fee schedule,6824.36,20664.91,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24286.06,,,,,,,fee schedule,8292.62,24286.06,
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16647.59,,,,,,,fee schedule,8292.62,24286.06,
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24286.06,,,,,,,fee schedule,8292.62,24286.06,
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13318.55,,,,,,,fee schedule,8292.62,24286.06,
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21929.4,,,,,,,fee schedule,8292.62,24286.06,
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19069.05,,,,,,,fee schedule,8292.62,24286.06,
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1938.39,1938.39,1938.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7889.79,7889.79,7889.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],12983.81,12983.81,14905.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8023.06,8023.06,8023.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5093.85,5093.85,5093.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],17839.39,17839.39,17839.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6819.36,6819.36,6819.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17488.52,17488.52,17488.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7885.66,6963.53,7946.24,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,6917.6,6917.6,6917.6,1 through 10,percent of total billed charges,,,
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8707.25,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8292.62,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8292.62,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8292.62,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8292.62,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8292.62,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8292.62,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14926.72,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14926.72,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8707.25,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8292.62,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8292.62,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8707.25,,,,,,,fee schedule,8292.62,24286.06,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20501.26,,,,,,,fee schedule,6980.97,20501.26,
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13752.03,,,,,,,fee schedule,6980.97,20501.26,
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20501.26,,,,,,,fee schedule,6980.97,20501.26,
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11002.02,,,,,,,fee schedule,6980.97,20501.26,
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18115.16,,,,,,,fee schedule,6980.97,20501.26,
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15752.31,,,,,,,fee schedule,6980.97,20501.26,
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7330.02,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6980.97,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6980.97,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6980.97,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6980.97,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6980.97,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6980.97,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12565.75,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12565.75,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7330.02,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6980.97,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6980.97,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7330.02,,,,,,,fee schedule,6980.97,20501.26,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,49505.26,,,,,,,fee schedule,18792.73,52463.51,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39827.4,,,,,,,fee schedule,18792.73,52463.51,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,49505.26,,,,,,,fee schedule,18792.73,52463.51,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31863.07,,,,,,,fee schedule,18792.73,52463.51,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52463.51,,,,,,,fee schedule,18792.73,52463.51,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45620.44,,,,,,,fee schedule,18792.73,52463.51,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16331.53,16331.53,16331.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14359.29,14359.29,14359.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],49542.62,49542.62,150385.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",39249.44,39249.44,39249.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],34888.1,34888.1,34888.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28625.32,28625.32,28625.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",101515.86,101515.86,101515.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",67402.71,14031.87,73753.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],40469.63,40469.63,40469.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18348.95,15349.05,18644.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10233.8,10233.8,10233.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,423016.12,423016.12,423016.12,1 through 10,percent of total billed charges,,,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,47242.47,47242.47,47242.47,1 through 10,percent of total billed charges,,,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19732.37,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18792.73,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18792.73,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18792.73,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18792.73,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18792.73,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18792.73,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33826.91,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33826.91,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19732.37,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18792.73,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18792.73,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19732.37,,,,,,,fee schedule,18792.73,52463.51,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27054.15,,,,,,,fee schedule,9086.01,27054.15,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18399.07,,,,,,,fee schedule,9086.01,27054.15,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27054.15,,,,,,,fee schedule,9086.01,27054.15,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14719.78,,,,,,,fee schedule,9086.01,27054.15,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24236.57,,,,,,,fee schedule,9086.01,27054.15,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21075.28,,,,,,,fee schedule,9086.01,27054.15,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9029.09,9029.09,9029.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],26160.81,10312.64,27074.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5414.72,5414.72,5414.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5985.53,5414.72,10233.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17997.51,17997.51,19315.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8663.08,8625.77,8675.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5414.72,5414.72,5414.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,31849.9,31849.9,31849.9,1 through 10,percent of total billed charges,,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9540.31,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9086.01,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9086.01,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9086.01,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9086.01,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9086.01,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9086.01,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16354.82,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16354.82,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9540.31,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9086.01,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9086.01,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9540.31,,,,,,,fee schedule,9086.01,27054.15,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16420.51,,,,,,,fee schedule,6653.05,17161.6,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13028.14,,,,,,,fee schedule,6653.05,17161.6,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16420.51,,,,,,,fee schedule,6653.05,17161.6,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10422.88,,,,,,,fee schedule,6653.05,17161.6,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17161.6,,,,,,,fee schedule,6653.05,17161.6,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14923.13,,,,,,,fee schedule,6653.05,17161.6,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15878.3,15878.3,16432.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4331.51,4331.51,4331.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5414.72,5414.72,5414.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13700.98,13700.98,13700.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13700.98,13700.98,13700.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,6542.47,6542.47,6542.47,1 through 10,percent of total billed charges,,,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,30484.1,30484.1,30484.1,1 through 10,percent of total billed charges,,,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6985.7,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6653.05,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6653.05,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6653.05,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6653.05,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6653.05,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6653.05,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11975.49,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11975.49,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6985.7,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6653.05,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6653.05,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6985.7,,,,,,,fee schedule,6653.05,17161.6,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,161200.23,,,,,,,fee schedule,58603.34,168231.94,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127712.42,,,,,,,fee schedule,58603.34,168231.94,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,161200.23,,,,,,,fee schedule,58603.34,168231.94,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,102173.6,,,,,,,fee schedule,58603.34,168231.94,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,168231.94,,,,,,,fee schedule,58603.34,168231.94,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,146288.65,,,,,,,fee schedule,58603.34,168231.94,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,61533.51,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58603.34,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,58603.34,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,58603.34,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,58603.34,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,58603.34,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,58603.34,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105486.01,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,105486.01,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,61533.51,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,58603.34,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,58603.34,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,61533.51,,,,,,,fee schedule,58603.34,168231.94,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,59543.49,,,,,,,fee schedule,21708.46,60942.41,
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46264.12,,,,,,,fee schedule,21708.46,60942.41,
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,59543.49,,,,,,,fee schedule,21708.46,60942.41,
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,37012.62,,,,,,,fee schedule,21708.46,60942.41,
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,60942.41,,,,,,,fee schedule,21708.46,60942.41,
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,52993.4,,,,,,,fee schedule,21708.46,60942.41,
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22793.88,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21708.46,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21708.46,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21708.46,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21708.46,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21708.46,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21708.46,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39075.23,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,39075.23,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22793.88,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21708.46,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21708.46,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22793.88,,,,,,,fee schedule,21708.46,60942.41,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,104856.58,,,,,,,fee schedule,39364.67,112286.3,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,85241.57,,,,,,,fee schedule,39364.67,112286.3,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,104856.58,,,,,,,fee schedule,39364.67,112286.3,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,68195.7,,,,,,,fee schedule,39364.67,112286.3,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,112286.3,,,,,,,fee schedule,39364.67,112286.3,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,97640.26,,,,,,,fee schedule,39364.67,112286.3,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,41332.9,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39364.67,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,39364.67,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,39364.67,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,39364.67,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,39364.67,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,39364.67,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,70856.41,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,70856.41,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,41332.9,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,39364.67,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,39364.67,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,41332.9,,,,,,,fee schedule,39364.67,112286.3,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,82555.19,,,,,,,fee schedule,21562.24,82555.19,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45941.33,,,,,,,fee schedule,21562.24,82555.19,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,82555.19,,,,,,,fee schedule,21562.24,82555.19,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,36754.38,,,,,,,fee schedule,21562.24,82555.19,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,60517.2,,,,,,,fee schedule,21562.24,82555.19,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,52623.66,,,,,,,fee schedule,21562.24,82555.19,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",45470.74,45470.74,45470.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22640.35,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21562.24,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21562.24,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21562.24,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21562.24,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21562.24,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21562.24,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38812.03,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,38812.03,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22640.35,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21562.24,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21562.24,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22640.35,,,,,,,fee schedule,21562.24,82555.19,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,84651.27,,,,,,,fee schedule,24291.96,84651.27,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51967.39,,,,,,,fee schedule,24291.96,84651.27,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,84651.27,,,,,,,fee schedule,24291.96,84651.27,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,41575.4,,,,,,,fee schedule,24291.96,84651.27,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,68455.16,,,,,,,fee schedule,24291.96,84651.27,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,59526.23,,,,,,,fee schedule,24291.96,84651.27,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25506.56,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24291.96,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24291.96,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24291.96,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24291.96,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24291.96,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24291.96,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43725.53,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,43725.53,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25506.56,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24291.96,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24291.96,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25506.56,,,,,,,fee schedule,24291.96,84651.27,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,58934.17,,,,,,,fee schedule,16005.04,58934.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33673.37,,,,,,,fee schedule,16005.04,58934.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,58934.17,,,,,,,fee schedule,16005.04,58934.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26939.66,,,,,,,fee schedule,16005.04,58934.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44356.97,,,,,,,fee schedule,16005.04,58934.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38571.28,,,,,,,fee schedule,16005.04,58934.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16805.29,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16005.04,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16005.04,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16005.04,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16005.04,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16005.04,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16005.04,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28809.07,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28809.07,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16805.29,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16005.04,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16005.04,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16805.29,,,,,,,fee schedule,16005.04,58934.17,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,145040.86,,,,,,,fee schedule,38192.32,145040.86,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,82653.51,,,,,,,fee schedule,38192.32,145040.86,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,145040.86,,,,,,,fee schedule,38192.32,145040.86,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,66125.18,,,,,,,fee schedule,38192.32,145040.86,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,108877.12,,,,,,,fee schedule,38192.32,145040.86,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,94675.77,,,,,,,fee schedule,38192.32,145040.86,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,40101.94,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38192.32,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,38192.32,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,38192.32,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,38192.32,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,38192.32,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,38192.32,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,68746.18,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,68746.18,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,40101.94,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,38192.32,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,38192.32,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,40101.94,,,,,,,fee schedule,38192.32,145040.86,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,95633.1,,,,,,,fee schedule,28014.07,95633.1,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60184.23,,,,,,,fee schedule,28014.07,95633.1,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,95633.1,,,,,,,fee schedule,28014.07,95633.1,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48149.11,,,,,,,fee schedule,28014.07,95633.1,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,79278.97,,,,,,,fee schedule,28014.07,95633.1,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,68938.24,,,,,,,fee schedule,28014.07,95633.1,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29414.77,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28014.07,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28014.07,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28014.07,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28014.07,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28014.07,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28014.07,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50425.33,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,50425.33,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29414.77,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28014.07,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28014.07,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29414.77,,,,,,,fee schedule,28014.07,95633.1,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,56660.5,,,,,,,fee schedule,28528,80773.47,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61318.77,,,,,,,fee schedule,28528,80773.47,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,56660.5,,,,,,,fee schedule,28528,80773.47,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,49056.77,,,,,,,fee schedule,28528,80773.47,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,80773.47,,,,,,,fee schedule,28528,80773.47,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,70237.81,,,,,,,fee schedule,28528,80773.47,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29954.4,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28528,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28528,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28528,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28528,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28528,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28528,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51350.4,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,51350.4,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29954.4,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28528,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28528,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29954.4,,,,,,,fee schedule,28528,80773.47,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,126029.84,,,,,,,fee schedule,43902.67,126029.84,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,95259.54,,,,,,,fee schedule,43902.67,126029.84,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,126029.84,,,,,,,fee schedule,43902.67,126029.84,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,76210.36,,,,,,,fee schedule,43902.67,126029.84,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,125482.68,,,,,,,fee schedule,43902.67,126029.84,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,109115.38,,,,,,,fee schedule,43902.67,126029.84,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1755.89,1755.89,1755.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],40996.97,40996.97,40996.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],75186.02,61774.76,121868.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1255.11,1255.11,1255.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",46149.01,46149.01,46149.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15491.07,15491.07,15491.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],42117.69,28335.47,71059.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,46097.8,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43902.67,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,43902.67,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,43902.67,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,43902.67,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,43902.67,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,43902.67,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,79024.81,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,79024.81,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,46097.8,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,43902.67,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,43902.67,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,46097.8,,,,,,,fee schedule,43902.67,126029.84,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,67241.91,,,,,,,fee schedule,21898.81,67241.91,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46684.32,,,,,,,fee schedule,21898.81,67241.91,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,67241.91,,,,,,,fee schedule,21898.81,67241.91,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,37348.79,,,,,,,fee schedule,21898.81,67241.91,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,61495.93,,,,,,,fee schedule,21898.81,67241.91,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,53474.72,,,,,,,fee schedule,21898.81,67241.91,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],52060.52,34083.13,65021.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12705.28,12705.28,12705.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12705.28,12705.28,12705.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],27442.42,27442.42,27442.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27221.14,27221.14,27221.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10824.79,10824.79,12705.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],48700.18,44671.14,48736.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21020.58,20836.46,21547.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20304.43,20304.43,20304.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],61809,61809,61809,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22993.75,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21898.81,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21898.81,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21898.81,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21898.81,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21898.81,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21898.81,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39417.86,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,39417.86,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22993.75,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21898.81,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21898.81,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22993.75,,,,,,,fee schedule,21898.81,67241.91,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44362.53,,,,,,,fee schedule,14614.66,44362.53,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30603.99,,,,,,,fee schedule,14614.66,44362.53,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44362.53,,,,,,,fee schedule,14614.66,44362.53,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24484.07,,,,,,,fee schedule,14614.66,44362.53,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40313.77,,,,,,,fee schedule,14614.66,44362.53,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35055.46,,,,,,,fee schedule,14614.66,44362.53,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10379.39,10379.39,10379.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],42897.67,23476.19,44396.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9971.86,9971.86,9971.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10824.79,10824.79,10824.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6239.82,6239.82,6239.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6570.37,6570.37,6570.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10824.79,6239.82,12705.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31982.33,31685.73,32160.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13887.29,1660.54,13958.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],28777.47,20564.06,37531.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15345.39,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14614.66,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14614.66,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14614.66,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14614.66,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14614.66,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14614.66,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26306.39,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26306.39,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15345.39,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14614.66,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14614.66,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15345.39,,,,,,,fee schedule,14614.66,44362.53,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,99755.63,,,,,,,fee schedule,40520.59,115647.66,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87793.33,,,,,,,fee schedule,40520.59,115647.66,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,99755.63,,,,,,,fee schedule,40520.59,115647.66,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,70237.19,,,,,,,fee schedule,40520.59,115647.66,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,115647.66,,,,,,,fee schedule,40520.59,115647.66,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,100563.19,,,,,,,fee schedule,40520.59,115647.66,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],41332.33,39970.88,43702.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39069.17,39069.17,39112.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",25288.03,25288.03,25288.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],93893.47,48316.24,99830.93,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39072.68,39072.68,39072.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34416.45,34416.45,34416.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18387.1,12470.62,57350.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18387.1,12883.17,44528.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28491.29,18891.88,71280.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],61534.55,61534.55,61534.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39652.04,39652.04,39652.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],88339.61,88339.61,88339.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20879.64,12883.17,62046.34,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],92163.45,92163.45,92163.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],71329.68,46816.63,92163.45,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37071.03,22648.23,39141.34,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],80544.33,80460.22,80544.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],38912.64,38912.64,38912.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28491.29,28491.29,34208.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],61594.64,37525.1,92163.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,59808.29,59808.29,59808.29,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,71238,71238,71238,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,149891.32,149891.32,149891.32,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42546.62,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40520.59,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,40520.59,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,40520.59,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,40520.59,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,40520.59,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,40520.59,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,72937.06,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,72937.06,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,42546.62,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,40520.59,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,40520.59,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,42546.62,,,,,,,fee schedule,40520.59,115647.66,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60473.15,,,,,,,fee schedule,21492.16,60473.15,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45786.62,,,,,,,fee schedule,21492.16,60473.15,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60473.15,,,,,,,fee schedule,21492.16,60473.15,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,36630.61,,,,,,,fee schedule,21492.16,60473.15,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,60313.41,,,,,,,fee schedule,21492.16,60473.15,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,52446.45,,,,,,,fee schedule,21492.16,60473.15,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19400.3,19334.91,26638,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20365.43,18638.96,20513.78,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12470.62,8398.07,18387.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],57597.43,57597.43,58476.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],57797.23,36365.61,60518.8,94,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20378.96,20378.96,20378.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15322.58,12883.17,21007.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],39412.42,39412.42,39412.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12470.62,9983.87,12883.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],31889.52,31889.52,31941.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12883.17,12883.17,12883.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19646.64,19646.64,19646.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33606.06,27106.5,47443.6,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12470.62,8402.35,18387.1,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43486.34,40732.11,54598.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],47443.6,33138.46,47573.6,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20370.42,16800.22,20984.24,105,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27660.53,27660.53,27660.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23455.57,23455.57,23455.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12470.62,10286.59,20624.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],31017.09,21160.01,60073.54,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,58553.37,58553.37,100913.21,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,76148.76,26838.64,90946.8,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,49853.09,49853.09,53817.36,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22566.77,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21492.16,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21492.16,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21492.16,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21492.16,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21492.16,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21492.16,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38685.89,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,38685.89,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22566.77,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21492.16,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21492.16,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22566.77,,,,,,,fee schedule,21492.16,60473.15,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44320.75,,,,,,,fee schedule,15312.01,44320.75,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32143.46,,,,,,,fee schedule,15312.01,44320.75,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44320.75,,,,,,,fee schedule,15312.01,44320.75,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25715.69,,,,,,,fee schedule,15312.01,44320.75,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42341.66,,,,,,,fee schedule,15312.01,44320.75,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36818.84,,,,,,,fee schedule,15312.01,44320.75,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14320.41,13177.45,15810.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14403.21,14403.21,14403.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],42857.27,32056.6,44354.2,75,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14139.57,14139.57,14139.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12883.17,8398.07,15327.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],27332.15,27332.15,27332.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9983.87,9983.87,9983.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],22243.57,22243.57,22243.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26008.57,21214.64,33778.75,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9983.87,8398.07,12883.17,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32678.46,28742.57,33754.23,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14438.99,14271.95,14983.7,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28930.42,28930.42,29287.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9983.87,9983.87,9983.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],50601.81,30331.68,73595.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,53845.6,39937.49,57766.34,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,38781.93,26028.74,59441.09,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,25777.87,25777.87,25777.87,1 through 10,percent of total billed charges,,,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16077.61,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15312.01,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15312.01,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15312.01,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15312.01,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15312.01,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15312.01,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27561.62,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27561.62,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16077.61,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15312.01,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15312.01,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16077.61,,,,,,,fee schedule,15312.01,44320.75,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,85685.39,,,,,,,fee schedule,32077.93,91096.59,
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69155.51,,,,,,,fee schedule,32077.93,91096.59,
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,85685.39,,,,,,,fee schedule,32077.93,91096.59,
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,55326.4,,,,,,,fee schedule,32077.93,91096.59,
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,91096.59,,,,,,,fee schedule,32077.93,91096.59,
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,79214.43,,,,,,,fee schedule,32077.93,91096.59,
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],82856.04,82856.04,82856.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33681.83,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32077.93,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32077.93,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32077.93,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32077.93,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32077.93,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32077.93,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57740.27,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,57740.27,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33681.83,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32077.93,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32077.93,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33681.83,,,,,,,fee schedule,32077.93,91096.59,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,66740.52,,,,,,,fee schedule,21016.3,66740.52,
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44736.11,,,,,,,fee schedule,21016.3,66740.52,
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,66740.52,,,,,,,fee schedule,21016.3,66740.52,
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35790.17,,,,,,,fee schedule,21016.3,66740.52,
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,58929.61,,,,,,,fee schedule,21016.3,66740.52,
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,51243.14,,,,,,,fee schedule,21016.3,66740.52,
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],60468.32,60468.32,60468.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42654.48,42654.48,42654.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24845.54,24845.54,24845.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42304.48,42304.48,42304.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20528.85,20528.85,20528.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,60742.12,60742.12,60742.12,1 through 10,percent of total billed charges,,,
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22067.12,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21016.3,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21016.3,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21016.3,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21016.3,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21016.3,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21016.3,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37829.34,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37829.34,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22067.12,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21016.3,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21016.3,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22067.12,,,,,,,fee schedule,21016.3,66740.52,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,52325.57,,,,,,,fee schedule,14922.67,52325.57,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31283.96,,,,,,,fee schedule,14922.67,52325.57,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,52325.57,,,,,,,fee schedule,14922.67,52325.57,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25028.06,,,,,,,fee schedule,14922.67,52325.57,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41209.47,,,,,,,fee schedule,14922.67,52325.57,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35834.32,,,,,,,fee schedule,14922.67,52325.57,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14706.78,14706.78,14706.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14506.67,14506.67,14506.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],52365.07,52365.07,52365.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22961.52,22961.52,22961.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33808,33808,33808,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14630.83,14630.83,14640.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28700.87,28700.87,28700.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15668.8,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14922.67,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14922.67,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14922.67,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14922.67,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14922.67,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14922.67,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26860.81,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26860.81,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15668.8,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14922.67,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14922.67,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15668.8,,,,,,,fee schedule,14922.67,52325.57,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,81817.03,,,,,,,fee schedule,31647.06,89843.63,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68204.33,,,,,,,fee schedule,31647.06,89843.63,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,81817.03,,,,,,,fee schedule,31647.06,89843.63,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,54565.42,,,,,,,fee schedule,31647.06,89843.63,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,89843.63,,,,,,,fee schedule,31647.06,89843.63,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,78124.9,,,,,,,fee schedule,31647.06,89843.63,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",143262.39,143262.39,143262.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],80921.31,80921.31,80921.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28620.26,28620.26,28620.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],72738.01,72738.01,72738.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29866.99,25287.77,30962.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,85407.18,85407.18,85407.18,1 through 10,percent of total billed charges,,,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33229.41,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31647.06,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31647.06,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31647.06,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31647.06,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31647.06,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31647.06,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56964.71,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,56964.71,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33229.41,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31647.06,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31647.06,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33229.41,,,,,,,fee schedule,31647.06,89843.63,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,53035.87,,,,,,,fee schedule,18996.05,53054.77,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40276.25,,,,,,,fee schedule,18996.05,53054.77,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,53035.87,,,,,,,fee schedule,18996.05,53054.77,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32222.16,,,,,,,fee schedule,18996.05,53054.77,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53054.77,,,,,,,fee schedule,18996.05,53054.77,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46134.58,,,,,,,fee schedule,18996.05,53054.77,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18296.94,18296.94,18296.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],54476.12,54476.12,54476.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42325.3,38863.03,42399.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16136.48,10849.86,18592.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],56025.36,56025.36,56025.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,21988.35,21988.35,21988.35,1 through 10,percent of total billed charges,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,25843.42,25843.42,25843.42,1 through 10,percent of total billed charges,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19945.85,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18996.05,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18996.05,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18996.05,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18996.05,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18996.05,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18996.05,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34192.89,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34192.89,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19945.85,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18996.05,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18996.05,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19945.85,,,,,,,fee schedule,18996.05,53054.77,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29318.56,,,,,,,fee schedule,14032.38,45271.3,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45271.3,,,,,,,fee schedule,14032.38,45271.3,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45271.3,,,,,,,fee schedule,14032.38,45271.3,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23455.69,,,,,,,fee schedule,14032.38,45271.3,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38620.51,,,,,,,fee schedule,14032.38,45271.3,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33583.05,,,,,,,fee schedule,14032.38,45271.3,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14018.93,14018.93,14018.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],25123.41,25123.41,25123.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12262.71,12262.71,12262.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35431.66,35431.66,35431.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28083.42,28083.42,28083.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13480.77,13480.77,13480.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14734,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14032.38,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14032.38,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14032.38,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14032.38,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14032.38,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14032.38,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25258.28,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25258.28,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14734,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14032.38,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14032.38,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14734,,,,,,,fee schedule,14032.38,45271.3,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49331.58,,,,,,,fee schedule,23097.98,74867.21,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,74867.21,,,,,,,fee schedule,23097.98,74867.21,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,74867.21,,,,,,,fee schedule,23097.98,74867.21,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,39466.68,,,,,,,fee schedule,23097.98,74867.21,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,64983.09,,,,,,,fee schedule,23097.98,74867.21,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,56507.04,,,,,,,fee schedule,23097.98,74867.21,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12423.15,12423.15,12423.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23174.16,23174.16,23174.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26732.19,26732.19,26732.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24252.88,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23097.98,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,23097.98,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,23097.98,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,23097.98,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,23097.98,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,23097.98,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41576.36,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,41576.36,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24252.88,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,23097.98,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,23097.98,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24252.88,,,,,,,fee schedule,23097.98,74867.21,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28739.83,,,,,,,fee schedule,13770.22,43081.2,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43081.2,,,,,,,fee schedule,13770.22,43081.2,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43081.2,,,,,,,fee schedule,13770.22,43081.2,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22992.69,,,,,,,fee schedule,13770.22,43081.2,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37858.16,,,,,,,fee schedule,13770.22,43081.2,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32920.14,,,,,,,fee schedule,13770.22,43081.2,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12158.95,12158.95,12158.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12106.1,12106.1,12106.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],40964.19,29798.57,41658.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12394.53,12394.53,12394.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12106.1,12106.1,12106.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12106.1,12106.1,12106.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29336.78,29336.78,29336.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11293.87,11293.87,11293.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14458.73,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13770.22,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13770.22,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13770.22,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13770.22,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13770.22,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13770.22,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24786.4,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24786.4,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14458.73,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13770.22,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13770.22,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14458.73,,,,,,,fee schedule,13770.22,43081.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22656.47,,,,,,,fee schedule,11014.55,40104.2,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40104.2,,,,,,,fee schedule,11014.55,40104.2,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40104.2,,,,,,,fee schedule,11014.55,40104.2,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18125.82,,,,,,,fee schedule,11014.55,40104.2,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29844.72,,,,,,,fee schedule,11014.55,40104.2,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25951.93,,,,,,,fee schedule,11014.55,40104.2,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9581.66,9581.66,9581.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],38329.6,38329.6,38329.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24993.34,24993.34,24993.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4139.42,4139.42,4139.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],33935.54,33935.54,33935.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11565.28,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11014.55,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11014.55,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11014.55,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11014.55,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11014.55,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11014.55,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19826.19,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19826.19,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11565.28,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11014.55,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11014.55,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11565.28,,,,,,,fee schedule,11014.55,40104.2,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43846.05,,,,,,,fee schedule,20613.12,94679.06,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,94679.06,,,,,,,fee schedule,20613.12,94679.06,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,94679.06,,,,,,,fee schedule,20613.12,94679.06,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35078.1,,,,,,,fee schedule,20613.12,94679.06,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,57757.16,,,,,,,fee schedule,20613.12,94679.06,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,50223.62,,,,,,,fee schedule,20613.12,94679.06,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],53060.17,53060.17,53060.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29153.79,29153.79,29153.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20428.96,20428.96,20430.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21643.78,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20613.12,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20613.12,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20613.12,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20613.12,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20613.12,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20613.12,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37103.62,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37103.62,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21643.78,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20613.12,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20613.12,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21643.78,,,,,,,fee schedule,20613.12,94679.06,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24998.13,,,,,,,fee schedule,12075.29,32976.81,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32976.81,,,,,,,fee schedule,12075.29,32976.81,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32976.81,,,,,,,fee schedule,12075.29,32976.81,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19999.22,,,,,,,fee schedule,12075.29,32976.81,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32929.33,,,,,,,fee schedule,12075.29,32976.81,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28634.2,,,,,,,fee schedule,12075.29,32976.81,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],31887.91,31887.91,31887.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7516.21,7516.21,7516.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11144.73,9361.23,11168.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20300.08,20300.08,20300.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12679.05,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12075.29,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12075.29,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12075.29,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12075.29,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12075.29,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12075.29,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21735.52,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21735.52,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12679.05,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12075.29,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12075.29,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12679.05,,,,,,,fee schedule,12075.29,32976.81,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16628.49,,,,,,,fee schedule,8283.96,30838.94,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30838.94,,,,,,,fee schedule,8283.96,30838.94,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30838.94,,,,,,,fee schedule,8283.96,30838.94,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13303.27,,,,,,,fee schedule,8283.96,30838.94,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21904.24,,,,,,,fee schedule,8283.96,30838.94,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19047.17,,,,,,,fee schedule,8283.96,30838.94,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8104.55,8104.55,8104.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25326.75,16627.06,29879.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7994.16,7994.16,7994.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],13173.34,13173.34,13173.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8698.16,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8283.96,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8283.96,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8283.96,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8283.96,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8283.96,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8283.96,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14911.13,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14911.13,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8698.16,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8283.96,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8283.96,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8698.16,,,,,,,fee schedule,8283.96,30838.94,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47595.39,,,,,,,fee schedule,22311.51,62696.05,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48244.82,,,,,,,fee schedule,22311.51,62696.05,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48244.82,,,,,,,fee schedule,22311.51,62696.05,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,38077.68,,,,,,,fee schedule,22311.51,62696.05,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,62696.05,,,,,,,fee schedule,22311.51,62696.05,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,54518.31,,,,,,,fee schedule,22311.51,62696.05,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23427.09,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22311.51,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22311.51,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22311.51,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22311.51,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22311.51,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22311.51,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40160.72,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,40160.72,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23427.09,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22311.51,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22311.51,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23427.09,,,,,,,fee schedule,22311.51,62696.05,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29118.01,,,,,,,fee schedule,13941.53,41455.17,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41455.17,,,,,,,fee schedule,13941.53,41455.17,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41455.17,,,,,,,fee schedule,13941.53,41455.17,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23295.24,,,,,,,fee schedule,13941.53,41455.17,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38356.33,,,,,,,fee schedule,13941.53,41455.17,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33353.33,,,,,,,fee schedule,13941.53,41455.17,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],40086.31,40086.31,40086.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14638.61,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13941.53,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13941.53,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13941.53,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13941.53,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13941.53,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13941.53,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25094.75,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25094.75,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14638.61,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13941.53,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13941.53,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14638.61,,,,,,,fee schedule,13941.53,41455.17,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22305.03,,,,,,,fee schedule,10855.35,40964.22,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40964.22,,,,,,,fee schedule,10855.35,40964.22,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40964.22,,,,,,,fee schedule,10855.35,40964.22,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17844.66,,,,,,,fee schedule,10855.35,40964.22,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29381.78,,,,,,,fee schedule,10855.35,40964.22,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25549.37,,,,,,,fee schedule,10855.35,40964.22,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],29886.96,29886.96,39151.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7673.92,7673.92,7673.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9598.06,9598.06,9598.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9855.51,9855.51,9855.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11398.12,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10855.35,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10855.35,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10855.35,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10855.35,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10855.35,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10855.35,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19539.63,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19539.63,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11398.12,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10855.35,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10855.35,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11398.12,,,,,,,fee schedule,10855.35,40964.22,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55428.32,,,,,,,fee schedule,25859.71,87610.86,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,87610.86,,,,,,,fee schedule,25859.71,87610.86,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,87610.86,,,,,,,fee schedule,25859.71,87610.86,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44344.24,,,,,,,fee schedule,25859.71,87610.86,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,73014.15,,,,,,,fee schedule,25859.71,87610.86,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,63490.57,,,,,,,fee schedule,25859.71,87610.86,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24883.28,24883.28,25047.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27152.7,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25859.71,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25859.71,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25859.71,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25859.71,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25859.71,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25859.71,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46547.48,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,46547.48,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27152.7,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25859.71,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25859.71,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27152.7,,,,,,,fee schedule,25859.71,87610.86,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32133.91,,,,,,,fee schedule,15307.69,45525.48,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45525.48,,,,,,,fee schedule,15307.69,45525.48,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45525.48,,,,,,,fee schedule,15307.69,45525.48,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25708.05,,,,,,,fee schedule,15307.69,45525.48,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42329.08,,,,,,,fee schedule,15307.69,45525.48,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36807.9,,,,,,,fee schedule,15307.69,45525.48,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13972.15,13972.15,13972.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14815.72,14815.72,14887.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],44022.22,40515.48,54856.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4893.42,4893.42,4893.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11417.97,11417.97,11417.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7673.92,7673.92,7673.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11759.58,11759.58,11759.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34144.05,34144.05,34144.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14750.59,6584.64,14908.19,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16775.56,16775.56,16775.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],41224.59,34749.28,43247.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,25325.47,25325.47,25325.47,1 through 10,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,49828.89,49828.89,49828.89,1 through 10,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16073.07,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15307.69,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15307.69,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15307.69,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15307.69,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15307.69,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15307.69,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27553.84,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27553.84,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16073.07,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15307.69,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15307.69,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16073.07,,,,,,,fee schedule,15307.69,45525.48,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25689.55,,,,,,,fee schedule,12388.49,38436.39,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38436.39,,,,,,,fee schedule,12388.49,38436.39,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38436.39,,,,,,,fee schedule,12388.49,38436.39,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20552.38,,,,,,,fee schedule,12388.49,38436.39,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33840.12,,,,,,,fee schedule,12388.49,38436.39,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29426.19,,,,,,,fee schedule,12388.49,38436.39,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11788.21,11788.21,11788.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9933.79,9933.79,9933.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],36971.62,34889.7,38465.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11417.97,11417.97,11417.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9598.06,9598.06,9598.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9598.06,9598.06,9598.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18855.39,18855.39,18855.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9598.06,9598.06,9598.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28046.29,28046.29,28046.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24708.69,24708.69,26757.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11768.63,11435.41,12160.58,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],25969.79,25969.79,25969.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,28737.8,28737.8,28737.8,1 through 10,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13007.91,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12388.49,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12388.49,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12388.49,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12388.49,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12388.49,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12388.49,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22299.28,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22299.28,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13007.91,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12388.49,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12388.49,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13007.91,,,,,,,fee schedule,12388.49,38436.39,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,83902.66,,,,,,,fee schedule,38758.17,110522.58,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,99640.73,,,,,,,fee schedule,38758.17,110522.58,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,99640.73,,,,,,,fee schedule,38758.17,110522.58,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,67124.53,,,,,,,fee schedule,38758.17,110522.58,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,110522.58,,,,,,,fee schedule,38758.17,110522.58,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,96106.6,,,,,,,fee schedule,38758.17,110522.58,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",43701.04,43701.04,44520.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],83898.57,83898.57,83898.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11120.64,11120.64,11120.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],52315.18,52315.18,52315.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],85614.04,85614.04,85614.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11041.98,11041.98,11041.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],36262.83,33813.06,36354.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,40696.08,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,38758.17,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,38758.17,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,38758.17,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,38758.17,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,38758.17,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,38758.17,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,69764.71,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,69764.71,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,40696.08,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,38758.17,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,38758.17,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,40696.08,,,,,,,fee schedule,38758.17,110522.58,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44417.14,,,,,,,fee schedule,20871.81,58509.44,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57363.84,,,,,,,fee schedule,20871.81,58509.44,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57363.84,,,,,,,fee schedule,20871.81,58509.44,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35534.99,,,,,,,fee schedule,20871.81,58509.44,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,58509.44,,,,,,,fee schedule,20871.81,58509.44,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,50877.78,,,,,,,fee schedule,20871.81,58509.44,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],55381.36,55381.36,55381.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],24138.87,24138.87,24138.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],30370.91,30370.91,30370.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20250.58,20250.58,20250.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11041.98,11041.98,11041.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19477.39,17863.88,20405.61,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11041.98,11041.98,11041.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21915.4,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20871.81,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20871.81,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20871.81,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20871.81,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20871.81,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20871.81,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37569.26,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37569.26,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21915.4,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20871.81,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20871.81,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21915.4,,,,,,,fee schedule,20871.81,58509.44,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26699.95,,,,,,,fee schedule,12846.18,46942.6,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46942.6,,,,,,,fee schedule,12846.18,46942.6,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46942.6,,,,,,,fee schedule,12846.18,46942.6,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21360.72,,,,,,,fee schedule,12846.18,46942.6,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35171.08,,,,,,,fee schedule,12846.18,46942.6,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30583.55,,,,,,,fee schedule,12846.18,46942.6,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5566.97,5566.97,5566.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8847.72,8847.72,8847.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13488.49,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12846.18,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12846.18,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12846.18,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12846.18,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12846.18,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12846.18,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23123.12,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23123.12,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13488.49,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12846.18,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12846.18,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13488.49,,,,,,,fee schedule,12846.18,46942.6,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65677.4,,,,,,,fee schedule,30502.39,94940.2,
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,94940.2,,,,,,,fee schedule,30502.39,94940.2,
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,94940.2,,,,,,,fee schedule,30502.39,94940.2,
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,52543.8,,,,,,,fee schedule,30502.39,94940.2,
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,86514.97,,,,,,,fee schedule,30502.39,94940.2,
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,75230.41,,,,,,,fee schedule,30502.39,94940.2,
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32027.51,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30502.39,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,30502.39,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,30502.39,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,30502.39,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,30502.39,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,30502.39,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54904.3,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,54904.3,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,32027.51,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,30502.39,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,30502.39,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,32027.51,,,,,,,fee schedule,30502.39,94940.2,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46113.23,,,,,,,fee schedule,21640.11,73582.4,
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,73582.4,,,,,,,fee schedule,21640.11,73582.4,
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,73582.4,,,,,,,fee schedule,21640.11,73582.4,
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,36891.9,,,,,,,fee schedule,21640.11,73582.4,
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,60743.64,,,,,,,fee schedule,21640.11,73582.4,
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,52820.56,,,,,,,fee schedule,21640.11,73582.4,
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22722.12,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21640.11,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21640.11,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21640.11,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21640.11,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21640.11,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21640.11,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38952.2,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,38952.2,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22722.12,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21640.11,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21640.11,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22722.12,,,,,,,fee schedule,21640.11,73582.4,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30405.35,,,,,,,fee schedule,14524.68,40285.26,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40285.26,,,,,,,fee schedule,14524.68,40285.26,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40285.26,,,,,,,fee schedule,14524.68,40285.26,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24325.16,,,,,,,fee schedule,14524.68,40285.26,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40052.11,,,,,,,fee schedule,14524.68,40285.26,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34827.92,,,,,,,fee schedule,14524.68,40285.26,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],40315.67,40315.67,40315.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13292.45,13292.45,13292.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14572.25,14529.46,14576.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15250.91,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14524.68,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14524.68,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14524.68,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14524.68,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14524.68,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14524.68,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26144.42,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26144.42,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15250.91,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14524.68,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14524.68,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15250.91,,,,,,,fee schedule,14524.68,40285.26,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19103.86,,,,,,,fee schedule,9405.27,29212.91,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29212.91,,,,,,,fee schedule,9405.27,29212.91,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29212.91,,,,,,,fee schedule,9405.27,29212.91,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15283.64,,,,,,,fee schedule,9405.27,29212.91,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25164.97,,,,,,,fee schedule,9405.27,29212.91,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21882.59,,,,,,,fee schedule,9405.27,29212.91,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9119.97,9119.97,9119.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],26280.4,21845.03,27920.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],14614.74,14614.74,14614.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8772.42,8772.42,8772.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18721.37,18721.37,18721.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8772.42,8772.42,8772.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20425.01,20425.01,20425.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16390.01,16390.01,16390.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9122.45,7431.49,9227.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9875.53,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9405.27,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9405.27,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9405.27,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9405.27,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9405.27,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9405.27,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16929.49,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16929.49,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9875.53,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9405.27,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9405.27,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9875.53,,,,,,,fee schedule,9405.27,29212.91,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13385.31,,,,,,,fee schedule,6814.85,20114.77,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20114.77,,,,,,,fee schedule,6814.85,20114.77,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20114.77,,,,,,,fee schedule,6814.85,20114.77,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10708.63,,,,,,,fee schedule,6814.85,20114.77,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17632.09,,,,,,,fee schedule,6814.85,20114.77,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15332.25,,,,,,,fee schedule,6814.85,20114.77,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],9849.58,9849.58,9849.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7155.59,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6814.85,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6814.85,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6814.85,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6814.85,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6814.85,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6814.85,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12266.73,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12266.73,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7155.59,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6814.85,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6814.85,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7155.59,,,,,,,fee schedule,6814.85,20114.77,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33866.28,,,,,,,fee schedule,16092.43,45462.8,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45462.8,,,,,,,fee schedule,16092.43,45462.8,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45462.8,,,,,,,fee schedule,16092.43,45462.8,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27094,,,,,,,fee schedule,16092.43,45462.8,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44611.09,,,,,,,fee schedule,16092.43,45462.8,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38792.25,,,,,,,fee schedule,16092.43,45462.8,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],21815.79,13200.62,45497.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7351.96,7351.96,7351.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35091.44,35091.44,35091.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7351.96,7351.96,7351.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32164.47,32164.47,32164.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15245.08,13195.12,15726.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],10684.96,10684.96,10684.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,60964.21,60964.21,60964.21,1 through 10,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16897.05,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16092.43,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16092.43,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16092.43,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16092.43,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16092.43,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16092.43,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28966.37,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28966.37,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16897.05,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16092.43,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16092.43,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16897.05,,,,,,,fee schedule,16092.43,45462.8,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19501.14,,,,,,,fee schedule,9585.23,25688.3,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23603.61,,,,,,,fee schedule,9585.23,25688.3,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23603.61,,,,,,,fee schedule,9585.23,25688.3,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15601.47,,,,,,,fee schedule,9585.23,25688.3,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25688.3,,,,,,,fee schedule,9585.23,25688.3,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22337.65,,,,,,,fee schedule,9585.23,25688.3,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8191.89,8191.89,8191.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22559.16,9810.91,23621.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5972.97,5972.97,5972.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4850.03,4850.03,4850.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5972.97,5972.97,5972.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6094.73,6094.73,6094.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5972.97,5972.97,7351.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20659.85,18036.39,20659.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9229.85,7712.95,9380.12,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16531.99,16531.99,16531.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5972.97,5972.97,5972.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],7519.03,7519.03,7519.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,26305.58,26305.58,26305.58,1 through 10,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10064.49,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9585.23,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9585.23,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9585.23,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9585.23,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9585.23,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9585.23,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17253.41,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17253.41,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10064.49,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9585.23,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9585.23,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10064.49,,,,,,,fee schedule,9585.23,25688.3,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13893.37,,,,,,,fee schedule,7044.99,20334.13,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20334.13,,,,,,,fee schedule,7044.99,20334.13,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20334.13,,,,,,,fee schedule,7044.99,20334.13,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11115.09,,,,,,,fee schedule,7044.99,20334.13,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18301.34,,,,,,,fee schedule,7044.99,20334.13,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15914.21,,,,,,,fee schedule,7044.99,20334.13,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18732.7,11504.42,20071.26,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5972.97,5972.97,5972.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5972.97,5972.97,5972.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5972.97,5972.97,5972.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12709.41,10612.43,14558.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6706.5,6706.5,6706.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8320.93,8320.93,8320.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5972.97,5972.97,5972.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],19971.34,19971.34,19971.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,11267.12,11267.12,11267.12,1 through 10,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,6397.03,6397.03,6397.03,1 through 10,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7397.24,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7044.99,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7044.99,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7044.99,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7044.99,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7044.99,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7044.99,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12680.98,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12680.98,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7397.24,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7044.99,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7044.99,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7397.24,,,,,,,fee schedule,7044.99,20334.13,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40849.26,,,,,,,fee schedule,19255.61,53809.56,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48352.76,,,,,,,fee schedule,19255.61,53809.56,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48352.76,,,,,,,fee schedule,19255.61,53809.56,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32680.58,,,,,,,fee schedule,19255.61,53809.56,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53809.56,,,,,,,fee schedule,19255.61,53809.56,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46790.93,,,,,,,fee schedule,19255.61,53809.56,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],46764.69,46764.69,46764.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22321.62,22321.62,22321.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17931.13,15614.91,18803.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20218.39,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19255.61,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19255.61,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19255.61,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19255.61,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19255.61,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19255.61,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34660.1,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34660.1,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20218.39,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19255.61,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19255.61,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20218.39,,,,,,,fee schedule,19255.61,53809.56,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23103.41,,,,,,,fee schedule,11217,30433.46,
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27764.91,,,,,,,fee schedule,11217,30433.46,
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27764.91,,,,,,,fee schedule,11217,30433.46,
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18483.39,,,,,,,fee schedule,11217,30433.46,
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30433.46,,,,,,,fee schedule,11217,30433.46,
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26463.88,,,,,,,fee schedule,11217,30433.46,
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24838.85,24838.85,27221.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],11649.13,11649.13,11649.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7523.85,7523.85,7523.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11470.42,11470.42,11470.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7523.85,7523.85,7523.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11777.85,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11217,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11217,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11217,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11217,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11217,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11217,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20190.6,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20190.6,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11777.85,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11217,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11217,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11777.85,,,,,,,fee schedule,11217,30433.46,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17654.17,,,,,,,fee schedule,8748.58,23255.33,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21216.19,,,,,,,fee schedule,8748.58,23255.33,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21216.19,,,,,,,fee schedule,8748.58,23255.33,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14123.84,,,,,,,fee schedule,8748.58,23255.33,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23255.33,,,,,,,fee schedule,8748.58,23255.33,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20222.03,,,,,,,fee schedule,8748.58,23255.33,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8024.76,8024.76,8024.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9186.01,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8748.58,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8748.58,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8748.58,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8748.58,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8748.58,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8748.58,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15747.44,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15747.44,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9186.01,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8748.58,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8748.58,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9186.01,,,,,,,fee schedule,8748.58,23255.33,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34914.87,,,,,,,fee schedule,16567.42,45992.37,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42231.63,,,,,,,fee schedule,16567.42,45992.37,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42231.63,,,,,,,fee schedule,16567.42,45992.37,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27932.9,,,,,,,fee schedule,16567.42,45992.37,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45992.37,,,,,,,fee schedule,16567.42,45992.37,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39993.37,,,,,,,fee schedule,16567.42,45992.37,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16530.09,16530.09,16530.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15818.52,15818.52,15818.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23755.03,19483.03,40837.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6470.95,6470.95,8146.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15684.39,15684.39,15684.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8088.11,8088.11,10402.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8146.5,8146.5,8146.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8088.11,8088.11,8088.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21205.17,21205.17,21205.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8146.5,8146.5,8246.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36492.45,36492.45,36492.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15147.51,10761.48,15861.73,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17395.79,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16567.42,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16567.42,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16567.42,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16567.42,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16567.42,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16567.42,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29821.36,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29821.36,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17395.79,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16567.42,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16567.42,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17395.79,,,,,,,fee schedule,16567.42,45992.37,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18731.41,,,,,,,fee schedule,9236.55,27677.4,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27677.4,,,,,,,fee schedule,9236.55,27677.4,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27677.4,,,,,,,fee schedule,9236.55,27677.4,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14985.66,,,,,,,fee schedule,9236.55,27677.4,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24674.35,,,,,,,fee schedule,9236.55,27677.4,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21455.96,,,,,,,fee schedule,9236.55,27677.4,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8786.35,1237.12,9256.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8853.63,7966.14,8893.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18134.97,11767.36,26763.49,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6120.86,6120.86,6120.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6470.95,6120.86,8146.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6000.81,6000.81,6000.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17467.56,13821.21,19788.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8088.11,5333.41,8146.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16811.76,10563.72,19788.74,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8848.83,7321.96,8999.25,70,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1027.37,1027.37,1027.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9698.38,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9236.55,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9236.55,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9236.55,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9236.55,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9236.55,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9236.55,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16625.79,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16625.79,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9698.38,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9236.55,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9236.55,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9698.38,,,,,,,fee schedule,9236.55,27677.4,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12040.67,,,,,,,fee schedule,6205.74,20407.25,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20407.25,,,,,,,fee schedule,6205.74,20407.25,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20407.25,,,,,,,fee schedule,6205.74,20407.25,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9632.88,,,,,,,fee schedule,6205.74,20407.25,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15860.83,,,,,,,fee schedule,6205.74,20407.25,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13792.02,,,,,,,fee schedule,6205.74,20407.25,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],5565.88,5565.88,5565.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5224.27,5224.27,5224.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20422.65,20422.65,20422.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5638.29,5638.29,5638.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5935.44,5935.44,5935.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],3518.4,3518.4,3518.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6516.03,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6205.74,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6205.74,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6205.74,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6205.74,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6205.74,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6205.74,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11170.33,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11170.33,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6516.03,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6205.74,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6205.74,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6516.03,,,,,,,fee schedule,6205.74,20407.25,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37478.1,,,,,,,fee schedule,17728.53,55577.64,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,55577.64,,,,,,,fee schedule,17728.53,55577.64,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,55577.64,,,,,,,fee schedule,17728.53,55577.64,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29983.55,,,,,,,fee schedule,17728.53,55577.64,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,49368.83,,,,,,,fee schedule,17728.53,55577.64,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42929.42,,,,,,,fee schedule,17728.53,55577.64,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],37619.72,37619.72,48974.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8772.42,8772.42,8772.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",54287.5,54287.5,54287.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27507.85,27507.85,27507.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16720.24,16711.18,16757.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18614.96,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17728.53,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17728.53,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17728.53,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17728.53,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17728.53,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17728.53,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31911.35,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31911.35,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18614.96,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17728.53,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17728.53,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18614.96,,,,,,,fee schedule,17728.53,55577.64,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20694.89,,,,,,,fee schedule,10125.98,27260.79,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25536.05,,,,,,,fee schedule,10125.98,27260.79,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25536.05,,,,,,,fee schedule,10125.98,27260.79,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16556.51,,,,,,,fee schedule,10125.98,27260.79,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27260.79,,,,,,,fee schedule,10125.98,27260.79,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23705.04,,,,,,,fee schedule,10125.98,27260.79,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24692.84,24692.84,24692.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9725.31,9044.33,9906.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,12742.22,12742.22,12742.22,1 through 10,percent of total billed charges,,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10632.28,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10125.98,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10125.98,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10125.98,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10125.98,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10125.98,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10125.98,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18226.76,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18226.76,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10632.28,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10125.98,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10125.98,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10632.28,,,,,,,fee schedule,10125.98,27260.79,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15291.49,,,,,,,fee schedule,7678.32,20852.93,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20852.93,,,,,,,fee schedule,7678.32,20852.93,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20852.93,,,,,,,fee schedule,7678.32,20852.93,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12233.63,,,,,,,fee schedule,7678.32,20852.93,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20143.05,,,,,,,fee schedule,7678.32,20852.93,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17515.69,,,,,,,fee schedule,7678.32,20852.93,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17661.95,17661.95,17661.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15039.76,15039.76,15039.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6885.13,6885.13,6885.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8062.24,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7678.32,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7678.32,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7678.32,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7678.32,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7678.32,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7678.32,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13820.98,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13820.98,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8062.24,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7678.32,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7678.32,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8062.24,,,,,,,fee schedule,7678.32,20852.93,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26371.43,,,,,,,fee schedule,12697.37,34738.33,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30873.76,,,,,,,fee schedule,12697.37,34738.33,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30873.76,,,,,,,fee schedule,12697.37,34738.33,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21097.9,,,,,,,fee schedule,12697.37,34738.33,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34738.33,,,,,,,fee schedule,12697.37,34738.33,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30207.24,,,,,,,fee schedule,12697.37,34738.33,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],11739.44,11739.44,11739.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13332.24,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12697.37,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12697.37,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12697.37,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12697.37,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12697.37,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12697.37,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22855.27,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22855.27,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13332.24,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12697.37,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12697.37,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13332.24,,,,,,,fee schedule,12697.37,34738.33,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16326.71,,,,,,,fee schedule,8147.26,21506.72,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19334.84,,,,,,,fee schedule,8147.26,21506.72,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19334.84,,,,,,,fee schedule,8147.26,21506.72,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13061.84,,,,,,,fee schedule,8147.26,21506.72,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21506.72,,,,,,,fee schedule,8147.26,21506.72,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18701.49,,,,,,,fee schedule,8147.26,21506.72,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6120.86,6120.86,6120.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8146.5,8146.5,8146.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7911.08,7911.08,7911.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,12435.47,12435.47,12435.47,1 through 10,percent of total billed charges,,,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8554.62,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8147.26,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8147.26,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8147.26,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8147.26,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8147.26,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8147.26,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14665.07,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14665.07,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8554.62,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8147.26,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8147.26,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8554.62,,,,,,,fee schedule,8147.26,21506.72,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30221.99,,,,,,,fee schedule,14441.62,39810.57,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36399.49,,,,,,,fee schedule,14441.62,39810.57,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36399.49,,,,,,,fee schedule,14441.62,39810.57,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24178.46,,,,,,,fee schedule,14441.62,39810.57,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39810.57,,,,,,,fee schedule,14441.62,39810.57,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34617.89,,,,,,,fee schedule,14441.62,39810.57,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1693.16,1693.16,13023.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33049.1,14607,36426.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8742.98,8742.98,8742.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8742.98,8742.98,8742.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],21903.05,21903.05,21903.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21864.06,21864.06,21864.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8742.98,8742.98,9346.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32610.57,32610.57,32610.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14185.36,14185.36,14238.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],6848.13,6848.13,6848.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,19974.41,19974.41,19974.41,1 through 10,percent of total billed charges,,,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,14857.88,14857.88,14857.88,1 through 10,percent of total billed charges,,,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15163.7,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14441.62,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14441.62,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14441.62,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14441.62,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14441.62,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14441.62,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25994.92,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25994.92,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15163.7,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14441.62,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14441.62,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15163.7,,,,,,,fee schedule,14441.62,39810.57,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18647.37,,,,,,,fee schedule,9198.48,27116.82,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27116.82,,,,,,,fee schedule,9198.48,27116.82,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27116.82,,,,,,,fee schedule,9198.48,27116.82,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14918.43,,,,,,,fee schedule,9198.48,27116.82,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24563.65,,,,,,,fee schedule,9198.48,27116.82,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21359.7,,,,,,,fee schedule,9198.48,27116.82,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8943.09,8943.09,8943.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27137.29,27137.29,27137.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8742.98,8742.98,8742.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24875.39,16150.83,26221.42,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5914.04,5914.04,5914.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5914.04,5914.04,5914.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7651.94,7651.94,7651.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13912.34,13912.34,19919.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5914.04,4501.22,8264.37,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18524.11,18524.11,18524.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18257.75,16558.13,19919.2,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8934.09,8934.09,8940.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13911.84,13911.84,13911.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8264.37,8264.37,8264.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],29207.78,29207.78,39206,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,17889.33,17889.33,43948.3,1 through 10,percent of total billed charges,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,19341.77,19341.77,19341.77,1 through 10,percent of total billed charges,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,16539.41,16539.41,16539.41,1 through 10,percent of total billed charges,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9658.4,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9198.48,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9198.48,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9198.48,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9198.48,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9198.48,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9198.48,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16557.26,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16557.26,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9658.4,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9198.48,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9198.48,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9658.4,,,,,,,fee schedule,9198.48,27116.82,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13012.86,,,,,,,fee schedule,6646.13,18547.93,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18547.93,,,,,,,fee schedule,6646.13,18547.93,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18547.93,,,,,,,fee schedule,6646.13,18547.93,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10410.66,,,,,,,fee schedule,6646.13,18547.93,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17141.47,,,,,,,fee schedule,6646.13,18547.93,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14905.62,,,,,,,fee schedule,6646.13,18547.93,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16646.95,8964.39,17970.63,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4501.22,4501.22,4501.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5914.04,5914.04,5914.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12620.67,12620.67,12620.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5914.04,5914.04,8264.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13974.98,13974.98,15373.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9865.51,6579.63,13674.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6196.56,6196.56,6196.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11745.65,11745.65,11745.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],26845.62,26845.62,26845.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,18638.88,18638.88,18638.88,1 through 10,percent of total billed charges,,,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6978.44,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6646.13,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6646.13,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6646.13,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6646.13,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6646.13,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6646.13,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11963.03,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11963.03,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6978.44,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6646.13,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6646.13,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6978.44,,,,,,,fee schedule,6646.13,18547.93,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28206.94,,,,,,,fee schedule,13528.83,37156.2,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32872.35,,,,,,,fee schedule,13528.83,37156.2,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32872.35,,,,,,,fee schedule,13528.83,37156.2,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22566.36,,,,,,,fee schedule,13528.83,37156.2,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37156.2,,,,,,,fee schedule,13528.83,37156.2,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32309.74,,,,,,,fee schedule,13528.83,37156.2,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13484.55,13484.55,13484.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12937.43,12937.43,12937.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],31786.9,18841.57,31786.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5022.91,5022.91,5022.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6647.46,5022.91,6919.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6647.46,6647.46,6647.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6647.46,5022.91,11687.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27391.08,12545.87,29505.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12861.68,11331.94,12959.59,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,68409.27,68409.27,68409.27,1 through 10,percent of total billed charges,,,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14205.27,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13528.83,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13528.83,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13528.83,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13528.83,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13528.83,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13528.83,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24351.89,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24351.89,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14205.27,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13528.83,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13528.83,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14205.27,,,,,,,fee schedule,13528.83,37156.2,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15085.21,,,,,,,fee schedule,7584.88,19871.32,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18206.71,,,,,,,fee schedule,7584.88,19871.32,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18206.71,,,,,,,fee schedule,7584.88,19871.32,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12068.6,,,,,,,fee schedule,7584.88,19871.32,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19871.32,,,,,,,fee schedule,7584.88,19871.32,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17279.41,,,,,,,fee schedule,7584.88,19871.32,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7662.52,7662.52,7662.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15611.61,5863.3,19928.52,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6147.09,6147.09,6147.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5022.91,5022.91,5022.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7351.58,7351.58,7351.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5022.91,5022.91,5022.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5022.91,4139.42,5022.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5022.91,5022.91,5022.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],38129.26,38129.26,38129.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7640.92,7640.92,7640.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16091.52,16091.52,16091.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5022.91,5022.91,6647.46,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13000.67,11796.67,14749.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7322.39,6287.84,7440.14,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14048.17,14048.17,14048.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5022.91,5022.91,5022.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],52888.08,52888.08,52888.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,19797.55,19797.55,19797.55,1 through 10,percent of total billed charges,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,7818.62,7818.62,7818.62,1 through 10,percent of total billed charges,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7964.12,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7584.88,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7584.88,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7584.88,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7584.88,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7584.88,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7584.88,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13652.78,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13652.78,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7964.12,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7584.88,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7584.88,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7964.12,,,,,,,fee schedule,7584.88,19871.32,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10390.42,,,,,,,fee schedule,5458.21,14226.93,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14226.93,,,,,,,fee schedule,5458.21,14226.93,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14226.93,,,,,,,fee schedule,5458.21,14226.93,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,8312.64,,,,,,,fee schedule,5458.21,14226.93,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,13687.01,,,,,,,fee schedule,5458.21,14226.93,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,11901.75,,,,,,,fee schedule,5458.21,14226.93,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4510.63,4510.63,4510.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5445.89,5445.89,5445.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],12715.74,6062.66,14237.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],12040.93,12040.93,13757.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5022.91,5022.91,5022.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4139.42,4139.42,5566.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4139.42,4139.42,4139.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7669.73,7669.73,7669.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4139.42,4139.42,6647.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10981.25,9503.93,11201.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5193.84,4510.53,5331.33,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8717.82,8717.82,8717.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4139.42,4139.42,5022.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],10637.73,9440.21,17385.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,13579.49,13579.49,13579.49,1 through 10,percent of total billed charges,,,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,9472.62,9472.62,9472.62,1 through 10,percent of total billed charges,,,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5731.12,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5458.21,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5458.21,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5458.21,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5458.21,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5458.21,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5458.21,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9824.78,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,9824.78,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,5731.12,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5458.21,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5458.21,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,5731.12,,,,,,,fee schedule,5458.21,14226.93,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24224.58,,,,,,,fee schedule,11724.88,31910.35,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29982.4,,,,,,,fee schedule,11724.88,31910.35,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29982.4,,,,,,,fee schedule,11724.88,31910.35,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19380.36,,,,,,,fee schedule,11724.88,31910.35,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31910.35,,,,,,,fee schedule,11724.88,31910.35,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27748.13,,,,,,,fee schedule,11724.88,31910.35,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11833.51,10892.71,11833.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11449.07,11449.07,11449.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19029.29,9776.12,29717.36,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9377.51,9377.51,9377.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11334.56,11334.56,11334.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7020.17,7020.17,7020.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5888.94,5526.59,12608.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12936.8,12936.8,12936.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23639.04,23639.04,23639.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7614.99,5611.74,8246.91,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16057.4,8799.12,25790.19,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11371.22,9207.02,11522.75,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22515.26,22515.26,22515.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],9825.17,9825.17,15411.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,19413.07,19413.07,19413.07,1 through 10,percent of total billed charges,,,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,12253.72,12253.72,12253.72,1 through 10,percent of total billed charges,,,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,16804.88,16804.88,16804.88,1 through 10,percent of total billed charges,,,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12311.12,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11724.88,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11724.88,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11724.88,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11724.88,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11724.88,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11724.88,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21104.78,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21104.78,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12311.12,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11724.88,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11724.88,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12311.12,,,,,,,fee schedule,11724.88,31910.35,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14890.39,,,,,,,fee schedule,7496.63,19614.69,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18321.61,,,,,,,fee schedule,7496.63,19614.69,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18321.61,,,,,,,fee schedule,7496.63,19614.69,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11912.74,,,,,,,fee schedule,7496.63,19614.69,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19614.69,,,,,,,fee schedule,7496.63,19614.69,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17056.25,,,,,,,fee schedule,7496.63,19614.69,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7452.7,7016.36,7462.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7146.26,7127.09,7163.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5526.59,4729.93,8246.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17716.63,17716.63,17716.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15292.87,5969.93,18335.44,90,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7274.6,7274.6,7274.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6805.08,813.13,7022.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5526.59,4667.66,8557.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5081.85,1700,7020.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4667.66,4048.29,6164.21,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5812.21,5812.21,5812.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10929.12,5927.62,14061.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14705.79,14705.79,14705.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5526.59,5081.85,7020.17,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12791.76,6674.47,15647.94,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7132.17,5557.3,7321.3,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11270.91,11270.91,11270.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2031.83,2031.83,2031.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5526.59,4667.66,7020.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],14774.96,5540.02,53335.87,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,10140.88,6728.5,22965.32,1 through 10,percent of total billed charges,,,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,11449.06,5209.76,32823.82,1 through 10,percent of total billed charges,,,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,12511.46,6761.71,14887.48,1 through 10,percent of total billed charges,,,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,7713.41,7713.41,7713.41,1 through 10,percent of total billed charges,,,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7871.46,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7496.63,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7496.63,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7496.63,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7496.63,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7496.63,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7496.63,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13493.93,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13493.93,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7871.46,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7496.63,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7496.63,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7871.46,,,,,,,fee schedule,7496.63,19614.69,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30546.69,,,,,,,fee schedule,14588.7,40238.29,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38464.24,,,,,,,fee schedule,14588.7,40238.29,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38464.24,,,,,,,fee schedule,14588.7,40238.29,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24438.23,,,,,,,fee schedule,14588.7,40238.29,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40238.29,,,,,,,fee schedule,14588.7,40238.29,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34989.82,,,,,,,fee schedule,14588.7,40238.29,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1522.94,1522.94,1522.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8088.11,8088.11,8088.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],36762.21,22061.8,38493.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13453.12,13453.12,13453.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9139.67,9139.67,181036.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],35434.39,35434.39,35434.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7020.17,7020.17,7020.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13438.16,13438.16,13438.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12260.57,12260.57,12260.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8246.91,8246.91,8246.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26624.32,17172.4,33236.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14442.51,12710.38,14502.45,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],17102.29,17102.29,17102.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,36338.7,36338.7,36338.7,1 through 10,percent of total billed charges,,,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,5692.76,5692.76,5692.76,1 through 10,percent of total billed charges,,,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15318.14,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14588.7,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14588.7,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14588.7,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14588.7,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14588.7,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14588.7,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26259.66,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26259.66,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15318.14,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14588.7,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14588.7,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15318.14,,,,,,,fee schedule,14588.7,40238.29,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17871.91,,,,,,,fee schedule,8847.21,24212.94,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24212.94,,,,,,,fee schedule,8847.21,24212.94,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24212.94,,,,,,,fee schedule,8847.21,24212.94,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14298.04,,,,,,,fee schedule,8847.21,24212.94,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23542.16,,,,,,,fee schedule,8847.21,24212.94,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20471.44,,,,,,,fee schedule,8847.21,24212.94,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8379.79,8379.79,8379.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8676.66,8676.66,8676.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22481.21,12140.48,24231.21,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8246.91,8246.91,8246.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23413.42,23413.42,23413.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7020.17,7020.17,8246.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,5081.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14134.25,14134.25,16181.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6625.63,5081.85,9139.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17317.63,17317.63,17317.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12634.42,8666.52,18893.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8519.66,8491.03,8639.79,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14206.22,14206.22,14206.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],12103.24,8649.62,15535.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,26433.64,26433.64,26433.64,1 through 10,percent of total billed charges,,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9289.57,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8847.21,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8847.21,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8847.21,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8847.21,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8847.21,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8847.21,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15924.98,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15924.98,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9289.57,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8847.21,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8847.21,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9289.57,,,,,,,fee schedule,8847.21,24212.94,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12395.93,,,,,,,fee schedule,6366.67,19547.23,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19547.23,,,,,,,fee schedule,6366.67,19547.23,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19547.23,,,,,,,fee schedule,6366.67,19547.23,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9917.1,,,,,,,fee schedule,6366.67,19547.23,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16328.8,,,,,,,fee schedule,6366.67,19547.23,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14198.96,,,,,,,fee schedule,6366.67,19547.23,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1358.34,1358.34,1358.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16660.28,12773.35,18938.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5081.85,5081.85,5081.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5081.85,5081.85,5081.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5566.97,5566.97,5566.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5081.85,5081.85,5081.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13026.57,13026.57,13026.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5972.97,5933.99,6234.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],16064.39,16064.39,16064.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,12684.62,12684.62,12684.62,1 through 10,percent of total billed charges,,,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,11215.66,11215.66,11215.66,1 through 10,percent of total billed charges,,,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,13618.5,13618.5,13618.5,1 through 10,percent of total billed charges,,,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6685,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6366.67,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6366.67,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6366.67,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6366.67,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6366.67,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6366.67,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11460.01,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11460.01,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6685,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6366.67,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6366.67,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6685,,,,,,,fee schedule,6366.67,19547.23,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45742.69,,,,,,,fee schedule,21472.26,60255.54,
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45772.69,,,,,,,fee schedule,21472.26,60255.54,
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45772.69,,,,,,,fee schedule,21472.26,60255.54,
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,36595.46,,,,,,,fee schedule,21472.26,60255.54,
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,60255.54,,,,,,,fee schedule,21472.26,60255.54,
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,52396.13,,,,,,,fee schedule,21472.26,60255.54,
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],32478.29,32478.29,43996.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15935.84,15935.84,15935.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20004.28,20004.28,20004.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22545.87,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21472.26,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21472.26,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21472.26,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21472.26,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21472.26,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21472.26,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38650.07,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,38650.07,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22545.87,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21472.26,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21472.26,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22545.87,,,,,,,fee schedule,21472.26,60255.54,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28909.82,,,,,,,fee schedule,13847.22,40051.97,
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40051.97,,,,,,,fee schedule,13847.22,40051.97,
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40051.97,,,,,,,fee schedule,13847.22,40051.97,
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23128.69,,,,,,,fee schedule,13847.22,40051.97,
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38082.09,,,,,,,fee schedule,13847.22,40051.97,
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33114.86,,,,,,,fee schedule,13847.22,40051.97,
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],38279.68,26897.73,40082.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21214.77,21214.77,21214.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9319.75,7486.75,9319.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30374.58,26554.58,30380.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,52935.24,52935.24,52935.24,1 through 10,percent of total billed charges,,,
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,13088.14,13088.14,13088.14,1 through 10,percent of total billed charges,,,
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14539.58,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13847.22,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13847.22,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13847.22,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13847.22,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13847.22,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13847.22,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24925,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24925,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14539.58,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13847.22,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13847.22,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14539.58,,,,,,,fee schedule,13847.22,40051.97,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21863.82,,,,,,,fee schedule,10655.49,33708,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33708,,,,,,,fee schedule,10655.49,33708,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33708,,,,,,,fee schedule,10655.49,33708,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17491.68,,,,,,,fee schedule,10655.49,33708,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28800.58,,,,,,,fee schedule,10655.49,33708,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25043.99,,,,,,,fee schedule,10655.49,33708,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],29638.6,25381.44,32658.85,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7673.92,7673.92,7673.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7075.83,7075.83,7075.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],16704.35,16704.35,16704.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7486.75,7486.75,7486.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7486.75,7075.83,7616.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7486.75,7486.75,7486.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20554.73,20554.73,20554.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20275.88,18031.94,22044.82,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10023.01,10023.01,10023.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20058.54,20058.54,20058.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7486.75,7486.75,7486.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],23372.58,18471.07,42916.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,36954.9,29233.26,44475.37,1 through 10,percent of total billed charges,,,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,23409.41,23409.41,26866.77,1 through 10,percent of total billed charges,,,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,27958.76,27958.76,28691.34,1 through 10,percent of total billed charges,,,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11188.26,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10655.49,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10655.49,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10655.49,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10655.49,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10655.49,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10655.49,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19179.88,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19179.88,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11188.26,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10655.49,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10655.49,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11188.26,,,,,,,fee schedule,10655.49,33708,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76791.71,,,,,,,fee schedule,35537.01,101155.54,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,85956.97,,,,,,,fee schedule,35537.01,101155.54,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,85956.97,,,,,,,fee schedule,35537.01,101155.54,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,61435.57,,,,,,,fee schedule,35537.01,101155.54,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,101155.54,,,,,,,fee schedule,35537.01,101155.54,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,87961.34,,,,,,,fee schedule,35537.01,101155.54,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35334.71,35334.71,35334.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33225.31,32528.15,33399.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],83909.88,83909.88,83909.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],83909.88,82935.43,86603.72,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14450.42,14450.42,14450.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],48414.21,48414.21,48414.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16253.96,16253.96,16253.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],55082.98,55082.98,55082.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24861.74,24861.74,32023.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],78865.92,78865.92,78865.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33303.28,28619.37,33459.12,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],79533.9,79533.9,87414.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,37313.86,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35537.01,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,35537.01,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,35537.01,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,35537.01,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,35537.01,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,35537.01,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63966.62,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,63966.62,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,37313.86,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,35537.01,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,35537.01,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,37313.86,,,,,,,fee schedule,35537.01,101155.54,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104486.77,,,,,,,fee schedule,48082.47,137637.45,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,131203.9,,,,,,,fee schedule,48082.47,137637.45,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,131203.9,,,,,,,fee schedule,48082.47,137637.45,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,83592.41,,,,,,,fee schedule,48082.47,137637.45,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,137637.45,,,,,,,fee schedule,48082.47,137637.45,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,119684.75,,,,,,,fee schedule,48082.47,137637.45,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23390.08,23390.08,23390.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],96762.4,96762.4,96762.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],46114.25,46114.25,46114.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,50486.59,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48082.47,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,48082.47,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,48082.47,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,48082.47,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,48082.47,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,48082.47,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86548.45,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,86548.45,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,50486.59,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,48082.47,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,48082.47,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,50486.59,,,,,,,fee schedule,48082.47,137637.45,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55393.94,,,,,,,fee schedule,25844.14,94174.19,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,94174.19,,,,,,,fee schedule,25844.14,94174.19,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,94174.19,,,,,,,fee schedule,25844.14,94174.19,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44316.74,,,,,,,fee schedule,25844.14,94174.19,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,72968.86,,,,,,,fee schedule,25844.14,94174.19,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,63451.18,,,,,,,fee schedule,25844.14,94174.19,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10751.12,10751.12,10751.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27136.35,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25844.14,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25844.14,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25844.14,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25844.14,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25844.14,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25844.14,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46519.45,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,46519.45,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27136.35,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25844.14,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25844.14,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27136.35,,,,,,,fee schedule,25844.14,94174.19,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42394.45,,,,,,,fee schedule,19955.56,62541.38,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,62541.38,,,,,,,fee schedule,19955.56,62541.38,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,62541.38,,,,,,,fee schedule,19955.56,62541.38,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33916.78,,,,,,,fee schedule,19955.56,62541.38,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,55845,,,,,,,fee schedule,19955.56,62541.38,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,48560.87,,,,,,,fee schedule,19955.56,62541.38,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20953.34,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19955.56,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19955.56,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19955.56,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19955.56,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19955.56,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19955.56,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35920.01,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35920.01,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20953.34,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19955.56,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19955.56,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20953.34,,,,,,,fee schedule,19955.56,62541.38,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68103.1,,,,,,,fee schedule,31601.2,134135.64,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,134135.64,,,,,,,fee schedule,31601.2,134135.64,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,134135.64,,,,,,,fee schedule,31601.2,134135.64,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,54484.44,,,,,,,fee schedule,31601.2,134135.64,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,89710.28,,,,,,,fee schedule,31601.2,134135.64,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,78008.95,,,,,,,fee schedule,31601.2,134135.64,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29793.13,29793.13,29793.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],122021.77,122021.77,122021.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],79333.62,79333.62,79333.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33181.26,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31601.2,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31601.2,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31601.2,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31601.2,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31601.2,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31601.2,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56882.16,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,56882.16,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33181.26,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31601.2,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31601.2,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33181.26,,,,,,,fee schedule,31601.2,134135.64,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41586.52,,,,,,,fee schedule,19589.58,82966.05,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,82966.05,,,,,,,fee schedule,19589.58,82966.05,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,82966.05,,,,,,,fee schedule,19589.58,82966.05,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33270.41,,,,,,,fee schedule,19589.58,82966.05,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,54780.74,,,,,,,fee schedule,19589.58,82966.05,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,47635.43,,,,,,,fee schedule,19589.58,82966.05,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24489.5,24489.5,24489.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18116.03,18116.03,18116.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20569.06,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19589.58,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19589.58,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19589.58,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19589.58,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19589.58,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19589.58,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35261.24,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35261.24,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20569.06,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19589.58,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19589.58,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20569.06,,,,,,,fee schedule,19589.58,82966.05,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30325.13,,,,,,,fee schedule,14488.34,53140.33,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,53140.33,,,,,,,fee schedule,14488.34,53140.33,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,53140.33,,,,,,,fee schedule,14488.34,53140.33,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24260.98,,,,,,,fee schedule,14488.34,53140.33,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39946.44,,,,,,,fee schedule,14488.34,53140.33,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34736.03,,,,,,,fee schedule,14488.34,53140.33,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13607.32,13607.32,13607.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13607.32,13607.32,13607.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28534.63,28534.63,28534.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15212.76,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14488.34,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14488.34,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14488.34,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14488.34,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14488.34,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14488.34,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26079.01,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26079.01,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15212.76,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14488.34,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14488.34,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15212.76,,,,,,,fee schedule,14488.34,53140.33,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,63093.16,,,,,,,fee schedule,29331.77,83110.83,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,70003.04,,,,,,,fee schedule,29331.77,83110.83,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,70003.04,,,,,,,fee schedule,29331.77,83110.83,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,50476.34,,,,,,,fee schedule,29331.77,83110.83,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,83110.83,,,,,,,fee schedule,29331.77,83110.83,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,72270.29,,,,,,,fee schedule,29331.77,83110.83,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23481.89,23481.89,23481.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30798.36,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,29331.77,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,29331.77,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,29331.77,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,29331.77,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,29331.77,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,29331.77,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,52797.19,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,52797.19,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30798.36,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,29331.77,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,29331.77,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30798.36,,,,,,,fee schedule,29331.77,83110.83,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40157.83,,,,,,,fee schedule,18942.41,52898.77,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46636.19,,,,,,,fee schedule,18942.41,52898.77,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46636.19,,,,,,,fee schedule,18942.41,52898.77,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32127.42,,,,,,,fee schedule,18942.41,52898.77,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52898.77,,,,,,,fee schedule,18942.41,52898.77,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45998.94,,,,,,,fee schedule,18942.41,52898.77,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18390.13,18390.13,18390.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19889.53,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18942.41,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18942.41,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18942.41,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18942.41,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18942.41,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18942.41,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34096.34,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34096.34,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19889.53,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18942.41,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18942.41,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19889.53,,,,,,,fee schedule,18942.41,52898.77,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31715.62,,,,,,,fee schedule,15118.21,42221.18,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42221.18,,,,,,,fee schedule,15118.21,42221.18,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42221.18,,,,,,,fee schedule,15118.21,42221.18,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25373.4,,,,,,,fee schedule,15118.21,42221.18,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41778.08,,,,,,,fee schedule,15118.21,42221.18,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36328.77,,,,,,,fee schedule,15118.21,42221.18,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15874.12,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15118.21,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15118.21,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15118.21,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15118.21,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15118.21,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15118.21,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27212.78,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27212.78,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15874.12,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15118.21,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15118.21,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15874.12,,,,,,,fee schedule,15118.21,42221.18,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68045.8,,,,,,,fee schedule,31575.25,94014.03,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,94014.03,,,,,,,fee schedule,31575.25,94014.03,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,94014.03,,,,,,,fee schedule,31575.25,94014.03,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,54438.59,,,,,,,fee schedule,31575.25,94014.03,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,89634.8,,,,,,,fee schedule,31575.25,94014.03,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,77943.31,,,,,,,fee schedule,31575.25,94014.03,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33154.01,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31575.25,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31575.25,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31575.25,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31575.25,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31575.25,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31575.25,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56835.45,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,56835.45,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33154.01,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31575.25,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31575.25,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33154.01,,,,,,,fee schedule,31575.25,94014.03,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39474.05,,,,,,,fee schedule,18632.66,54160.52,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,54160.52,,,,,,,fee schedule,18632.66,54160.52,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,54160.52,,,,,,,fee schedule,18632.66,54160.52,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31580.37,,,,,,,fee schedule,18632.66,54160.52,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,51998.05,,,,,,,fee schedule,18632.66,54160.52,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45215.7,,,,,,,fee schedule,18632.66,54160.52,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19564.29,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18632.66,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18632.66,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18632.66,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18632.66,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18632.66,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18632.66,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33538.79,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33538.79,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19564.29,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18632.66,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18632.66,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19564.29,,,,,,,fee schedule,18632.66,54160.52,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26039.08,,,,,,,fee schedule,12546.82,41973.97,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41973.97,,,,,,,fee schedule,12546.82,41973.97,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41973.97,,,,,,,fee schedule,12546.82,41973.97,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20832.01,,,,,,,fee schedule,12546.82,41973.97,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34300.55,,,,,,,fee schedule,12546.82,41973.97,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29826.56,,,,,,,fee schedule,12546.82,41973.97,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13174.16,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12546.82,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12546.82,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12546.82,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12546.82,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12546.82,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12546.82,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22584.28,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22584.28,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13174.16,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12546.82,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12546.82,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13174.16,,,,,,,fee schedule,12546.82,41973.97,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,45580.34,,,,,,,fee schedule,21398.72,60041.68,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51782.4,,,,,,,fee schedule,21398.72,60041.68,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51782.4,,,,,,,fee schedule,21398.72,60041.68,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,36465.58,,,,,,,fee schedule,21398.72,60041.68,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,60041.68,,,,,,,fee schedule,21398.72,60041.68,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,52210.16,,,,,,,fee schedule,21398.72,60041.68,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21367.34,21367.34,21367.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19366.57,19366.57,19366.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],50072.54,44581.47,86537.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10012.25,10012.25,10012.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10012.25,10012.25,10012.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33315.87,33315.87,33315.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13336.1,13336.1,13336.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19417.45,18109.19,21644.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10012.25,10012.25,10012.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,40356.9,40356.9,40356.9,1 through 10,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,26564.34,26564.34,26564.34,1 through 10,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22468.66,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21398.72,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21398.72,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21398.72,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21398.72,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21398.72,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21398.72,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,38517.7,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,38517.7,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22468.66,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21398.72,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21398.72,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22468.66,,,,,,,fee schedule,21398.72,60041.68,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32309.63,,,,,,,fee schedule,15387.29,46973.94,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46973.94,,,,,,,fee schedule,15387.29,46973.94,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46973.94,,,,,,,fee schedule,15387.29,46973.94,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25848.63,,,,,,,fee schedule,15387.29,46973.94,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42560.55,,,,,,,fee schedule,15387.29,46973.94,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37009.18,,,,,,,fee schedule,15387.29,46973.94,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15143.62,15143.62,15143.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15057.35,15057.35,15057.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45422.85,28575.89,45511.89,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],41494.19,41494.19,41494.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14501,14501,14501,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11957.83,11957.83,11957.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13336.1,13336.1,13336.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10012.25,10012.25,10012.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29241.63,29241.63,33953.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,10012.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31037.97,22369.84,33289,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14492.56,13941.91,15057.91,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,49554.23,49554.23,49554.23,1 through 10,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,42143.4,42143.4,42143.4,1 through 10,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,38605.32,36091.79,46438,1 through 10,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16156.65,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15387.29,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15387.29,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15387.29,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15387.29,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15387.29,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15387.29,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27697.12,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27697.12,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16156.65,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15387.29,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15387.29,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16156.65,,,,,,,fee schedule,15387.29,46973.94,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26086.83,,,,,,,fee schedule,12568.45,41886.92,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41886.92,,,,,,,fee schedule,12568.45,41886.92,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41886.92,,,,,,,fee schedule,12568.45,41886.92,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20870.22,,,,,,,fee schedule,12568.45,41886.92,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34363.45,,,,,,,fee schedule,12568.45,41886.92,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29881.26,,,,,,,fee schedule,12568.45,41886.92,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5882.17,5882.17,5882.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11624.58,11624.58,11624.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8394.44,8394.44,8394.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],37860.37,20842.19,40783.21,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8394.44,8394.44,8394.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19146.99,19146.99,19146.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,10012.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26446.54,26446.54,32543.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11626.58,11598.62,12304.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],22889.62,22889.62,22889.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,29941.89,16437.71,33345.48,1 through 10,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,17521.7,17521.7,17521.7,1 through 10,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13196.87,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12568.45,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12568.45,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12568.45,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12568.45,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12568.45,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12568.45,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22623.21,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22623.21,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13196.87,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12568.45,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12568.45,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13196.87,,,,,,,fee schedule,12568.45,41886.92,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65075.75,,,,,,,fee schedule,30229.85,116538.26,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,116538.26,,,,,,,fee schedule,30229.85,116538.26,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,116538.26,,,,,,,fee schedule,30229.85,116538.26,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,52062.46,,,,,,,fee schedule,30229.85,116538.26,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,85722.43,,,,,,,fee schedule,30229.85,116538.26,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,74541.25,,,,,,,fee schedule,30229.85,116538.26,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],3802.99,3802.99,3802.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],38566.57,38566.57,38566.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31741.34,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30229.85,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,30229.85,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,30229.85,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,30229.85,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,30229.85,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,30229.85,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54413.73,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,54413.73,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,31741.34,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,30229.85,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,30229.85,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,31741.34,,,,,,,fee schedule,30229.85,116538.26,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33186.32,,,,,,,fee schedule,15784.41,55918.86,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,55918.86,,,,,,,fee schedule,15784.41,55918.86,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,55918.86,,,,,,,fee schedule,15784.41,55918.86,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26550.01,,,,,,,fee schedule,15784.41,55918.86,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43715.4,,,,,,,fee schedule,15784.41,55918.86,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38013.39,,,,,,,fee schedule,15784.41,55918.86,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14337.74,14337.74,14337.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],89653.7,89653.7,89653.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16573.63,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15784.41,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15784.41,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15784.41,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15784.41,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15784.41,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15784.41,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28411.94,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28411.94,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16573.63,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15784.41,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15784.41,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16573.63,,,,,,,fee schedule,15784.41,55918.86,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26730.51,,,,,,,fee schedule,12860.03,46152.21,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46152.21,,,,,,,fee schedule,12860.03,46152.21,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46152.21,,,,,,,fee schedule,12860.03,46152.21,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21385.17,,,,,,,fee schedule,12860.03,46152.21,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35211.34,,,,,,,fee schedule,12860.03,46152.21,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30618.55,,,,,,,fee schedule,12860.03,46152.21,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],38581.5,38581.5,38581.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13503.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12860.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12860.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12860.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12860.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12860.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12860.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23148.05,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23148.05,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13503.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12860.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12860.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13503.03,,,,,,,fee schedule,12860.03,46152.21,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79322.47,,,,,,,fee schedule,36683.41,113533.4,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,113533.4,,,,,,,fee schedule,36683.41,113533.4,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,113533.4,,,,,,,fee schedule,36683.41,113533.4,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,63460.25,,,,,,,fee schedule,36683.41,113533.4,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,104489.23,,,,,,,fee schedule,36683.41,113533.4,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,90860.21,,,,,,,fee schedule,36683.41,113533.4,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38517.58,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36683.41,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,36683.41,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,36683.41,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,36683.41,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,36683.41,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,36683.41,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66030.14,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,66030.14,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,38517.58,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,36683.41,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,36683.41,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,38517.58,,,,,,,fee schedule,36683.41,113533.4,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41788.98,,,,,,,fee schedule,19681.29,60128.45,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60128.45,,,,,,,fee schedule,19681.29,60128.45,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60128.45,,,,,,,fee schedule,19681.29,60128.45,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33432.38,,,,,,,fee schedule,19681.29,60128.45,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,55047.43,,,,,,,fee schedule,19681.29,60128.45,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,47867.34,,,,,,,fee schedule,19681.29,60128.45,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",30250.5,30250.5,30250.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19307.99,19307.99,19307.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20665.35,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19681.29,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19681.29,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19681.29,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19681.29,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19681.29,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19681.29,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35426.32,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35426.32,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20665.35,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19681.29,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19681.29,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20665.35,,,,,,,fee schedule,19681.29,60128.45,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28655.79,,,,,,,fee schedule,13732.15,46145.25,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46145.25,,,,,,,fee schedule,13732.15,46145.25,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46145.25,,,,,,,fee schedule,13732.15,46145.25,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22925.45,,,,,,,fee schedule,13732.15,46145.25,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37747.46,,,,,,,fee schedule,13732.15,46145.25,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32823.88,,,,,,,fee schedule,13732.15,46145.25,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14418.76,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13732.15,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13732.15,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13732.15,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13732.15,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13732.15,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13732.15,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24717.87,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24717.87,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14418.76,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13732.15,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13732.15,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14418.76,,,,,,,fee schedule,13732.15,46145.25,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,210505.36,,,,,,,fee schedule,96107.33,277292.73,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,201502.9,,,,,,,fee schedule,96107.33,277292.73,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,201502.9,,,,,,,fee schedule,96107.33,277292.73,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,168410.33,,,,,,,fee schedule,96107.33,277292.73,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,277292.73,,,,,,,fee schedule,96107.33,277292.73,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,241124.13,,,,,,,fee schedule,96107.33,277292.73,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],91984.94,91984.94,91984.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],181414.51,181414.51,194849.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],129991.36,129991.36,350013.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],88133.89,88133.89,88530.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,100912.7,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,96107.33,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,96107.33,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,96107.33,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,96107.33,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,96107.33,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,96107.33,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,172993.19,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,172993.19,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,100912.7,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,96107.33,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,96107.33,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,100912.7,,,,,,,fee schedule,96107.33,277292.73,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,137875.55,,,,,,,fee schedule,63207.09,181619.54,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,134713.63,,,,,,,fee schedule,63207.09,181619.54,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,134713.63,,,,,,,fee schedule,63207.09,181619.54,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,110304.39,,,,,,,fee schedule,63207.09,181619.54,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,181619.54,,,,,,,fee schedule,63207.09,181619.54,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,157930.05,,,,,,,fee schedule,63207.09,181619.54,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],64565.59,64565.59,64565.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],61731.79,59986,64897,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",30134.71,30134.71,30134.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],130265.36,122327.31,134815.31,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],57805.18,57805.18,57805.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",39895.48,39895.48,39895.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],112032.03,112032.03,112032.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",30014.33,30014.33,30014.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",30014.33,30014.33,30014.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],171977.36,171977.36,171977.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],163855.83,163855.83,163855.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",33029.37,33029.37,33029.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],142483.33,129388.61,230628.1,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],59986,57608.42,61742.79,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],89732.22,84598.98,150598.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,115761.25,115761.25,115761.25,1 through 10,percent of total billed charges,,,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,66367.44,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,63207.09,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,63207.09,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,63207.09,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,63207.09,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,63207.09,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,63207.09,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,113772.76,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,113772.76,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,66367.44,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,63207.09,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,63207.09,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,66367.44,,,,,,,fee schedule,63207.09,181619.54,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,107380.42,,,,,,,fee schedule,49393.25,141449.18,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,113345.38,,,,,,,fee schedule,49393.25,141449.18,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,113345.38,,,,,,,fee schedule,49393.25,141449.18,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,85907.42,,,,,,,fee schedule,49393.25,141449.18,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,141449.18,,,,,,,fee schedule,49393.25,141449.18,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,122999.3,,,,,,,fee schedule,49393.25,141449.18,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],46610.15,46610.15,46613.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],111136.09,108769.48,113430.93,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],109817.55,109817.55,109817.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],78814.14,78814.14,94137.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",32698.34,32698.34,48235.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],110499,110499,111719.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],46623.65,45285.37,48383.31,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,120943.84,120943.84,125015.89,1 through 10,percent of total billed charges,,,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,123622.93,123622.93,123622.93,1 through 10,percent of total billed charges,,,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,105600.91,105600.91,105600.91,1 through 10,percent of total billed charges,,,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,51862.91,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,49393.25,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,49393.25,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,49393.25,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,49393.25,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,49393.25,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,49393.25,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,88907.85,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,88907.85,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,51862.91,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,49393.25,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,49393.25,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,51862.91,,,,,,,fee schedule,49393.25,141449.18,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,172083.72,,,,,,,fee schedule,78702.89,226681,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,198097.63,,,,,,,fee schedule,78702.89,226681,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,198097.63,,,,,,,fee schedule,78702.89,226681,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,137671.91,,,,,,,fee schedule,78702.89,226681,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,226681,,,,,,,fee schedule,78702.89,226681,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,197113.92,,,,,,,fee schedule,78702.89,226681,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],68758.01,68758.01,68758.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,82638.03,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,78702.89,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,78702.89,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,78702.89,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,78702.89,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,78702.89,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,78702.89,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,141665.2,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,141665.2,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,82638.03,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,78702.89,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,78702.89,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,82638.03,,,,,,,fee schedule,78702.89,226681,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,110151.84,,,,,,,fee schedule,50648.66,145099.89,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,139243.54,,,,,,,fee schedule,50648.66,145099.89,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,139243.54,,,,,,,fee schedule,50648.66,145099.89,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,88124.63,,,,,,,fee schedule,50648.66,145099.89,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,145099.89,,,,,,,fee schedule,50648.66,145099.89,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,126173.82,,,,,,,fee schedule,50648.66,145099.89,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],133082.05,133082.05,133082.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],134645.7,134645.7,134645.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",25968.76,25968.76,25968.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",43792.43,43792.43,43792.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],109794.48,109794.48,109794.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],46342.96,45944.65,61251.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,53181.09,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50648.66,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,50648.66,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,50648.66,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,50648.66,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,50648.66,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,50648.66,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,91167.59,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,91167.59,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,53181.09,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,50648.66,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,50648.66,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,53181.09,,,,,,,fee schedule,50648.66,145099.89,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37592.7,,,,,,,fee schedule,17780.44,51305.38,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51305.38,,,,,,,fee schedule,17780.44,51305.38,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51305.38,,,,,,,fee schedule,17780.44,51305.38,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30075.24,,,,,,,fee schedule,17780.44,51305.38,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,49519.79,,,,,,,fee schedule,17780.44,51305.38,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43060.69,,,,,,,fee schedule,17780.44,51305.38,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16430.33,16430.33,16430.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],32216.03,16959.5,49611.27,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,7137.5,7137.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,7137.5,21973.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],33089.74,33089.74,33089.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,5879.5,7405.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],25592.44,25592.44,25592.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27591.96,27464.39,29118.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,7137.5,38372.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28007.36,18916.36,39322.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16962.32,15214.04,17360.71,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,7137.5,7137.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18669.46,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17780.44,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17780.44,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17780.44,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17780.44,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17780.44,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17780.44,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32004.79,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32004.79,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18669.46,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17780.44,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17780.44,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18669.46,,,,,,,fee schedule,17780.44,51305.38,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20173.46,,,,,,,fee schedule,9889.78,26573.93,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22433.7,,,,,,,fee schedule,9889.78,26573.93,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22433.7,,,,,,,fee schedule,9889.78,26573.93,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16139.35,,,,,,,fee schedule,9889.78,26573.93,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26573.93,,,,,,,fee schedule,9889.78,26573.93,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23107.77,,,,,,,fee schedule,9889.78,26573.93,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],12699.48,8748.99,21553.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,7137.5,7137.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5506.4,5506.4,7137.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],23294.47,23294.47,23294.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,7137.5,7137.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],14447.18,14447.18,14447.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14996,14996,21199.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5506.4,5506.4,7137.5,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19679.88,19679.88,19679.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16055.96,13667.38,21470.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9563.64,8884.35,9717.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,48506.03,48506.03,48506.03,1 through 10,percent of total billed charges,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,53710.63,53710.63,53710.63,1 through 10,percent of total billed charges,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10384.27,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9889.78,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9889.78,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9889.78,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9889.78,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9889.78,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9889.78,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17801.6,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17801.6,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10384.27,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9889.78,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9889.78,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10384.27,,,,,,,fee schedule,9889.78,26573.93,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13608.78,,,,,,,fee schedule,6916.08,17926.46,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,15055.61,,,,,,,fee schedule,6916.08,17926.46,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,15055.61,,,,,,,fee schedule,6916.08,17926.46,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10887.41,,,,,,,fee schedule,6916.08,17926.46,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17926.46,,,,,,,fee schedule,6916.08,17926.46,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15588.22,,,,,,,fee schedule,6916.08,17926.46,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7261.88,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6916.08,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6916.08,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6916.08,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6916.08,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6916.08,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6916.08,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12448.94,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12448.94,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7261.88,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6916.08,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6916.08,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7261.88,,,,,,,fee schedule,6916.08,17926.46,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35081.04,,,,,,,fee schedule,16642.7,48878.52,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48878.52,,,,,,,fee schedule,16642.7,48878.52,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48878.52,,,,,,,fee schedule,16642.7,48878.52,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28065.84,,,,,,,fee schedule,16642.7,48878.52,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46211.26,,,,,,,fee schedule,16642.7,48878.52,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40183.71,,,,,,,fee schedule,16642.7,48878.52,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16612.05,16612.05,16612.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],42839.82,42839.82,42839.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45479.59,45479.59,45479.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36620.91,36620.91,36620.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15921.78,14872.45,16299.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17474.84,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16642.7,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16642.7,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16642.7,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16642.7,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16642.7,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16642.7,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29956.86,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29956.86,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17474.84,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16642.7,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16642.7,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17474.84,,,,,,,fee schedule,16642.7,48878.52,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21604.06,,,,,,,fee schedule,10537.82,31409.97,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31409.97,,,,,,,fee schedule,10537.82,31409.97,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31409.97,,,,,,,fee schedule,10537.82,31409.97,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17283.86,,,,,,,fee schedule,10537.82,31409.97,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28458.41,,,,,,,fee schedule,10537.82,31409.97,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24746.44,,,,,,,fee schedule,10537.82,31409.97,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23663.65,23663.65,23663.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7720.14,7720.14,10097.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11064.71,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10537.82,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10537.82,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10537.82,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10537.82,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10537.82,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10537.82,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18968.08,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18968.08,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11064.71,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10537.82,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10537.82,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11064.71,,,,,,,fee schedule,10537.82,31409.97,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16298.06,,,,,,,fee schedule,8134.28,26416.96,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26416.96,,,,,,,fee schedule,8134.28,26416.96,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26416.96,,,,,,,fee schedule,8134.28,26416.96,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13038.92,,,,,,,fee schedule,8134.28,26416.96,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21468.98,,,,,,,fee schedule,8134.28,26416.96,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18668.68,,,,,,,fee schedule,8134.28,26416.96,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7224.96,7224.96,7224.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8540.99,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8134.28,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8134.28,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8134.28,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8134.28,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8134.28,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8134.28,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14641.7,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14641.7,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8540.99,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8134.28,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8134.28,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8540.99,,,,,,,fee schedule,8134.28,26416.96,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31136.89,,,,,,,fee schedule,14856.05,45180.77,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45180.77,,,,,,,fee schedule,14856.05,45180.77,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45180.77,,,,,,,fee schedule,14856.05,45180.77,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24910.4,,,,,,,fee schedule,14856.05,45180.77,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41015.73,,,,,,,fee schedule,14856.05,45180.77,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35665.86,,,,,,,fee schedule,14856.05,45180.77,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14588.94,14529.31,83023.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14208.13,14208.13,34747.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45214.87,21746.53,71985.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],29038.46,29038.46,29038.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7497.66,7497.66,7497.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,5563.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33395.38,33395.38,33395.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,7497.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30609.88,30283.09,33395.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13869.83,12343.21,14562.87,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7497.66,7497.66,7497.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],40318.8,40318.8,40318.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,22147.91,22147.91,22147.91,1 through 10,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15598.85,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14856.05,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14856.05,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14856.05,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14856.05,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14856.05,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14856.05,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26740.89,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26740.89,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15598.85,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14856.05,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14856.05,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15598.85,,,,,,,fee schedule,14856.05,45180.77,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16066.95,,,,,,,fee schedule,8029.59,23255.42,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23255.42,,,,,,,fee schedule,8029.59,23255.42,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23255.42,,,,,,,fee schedule,8029.59,23255.42,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12854.02,,,,,,,fee schedule,8029.59,23255.42,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21164.54,,,,,,,fee schedule,8029.59,23255.42,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18403.95,,,,,,,fee schedule,8029.59,23255.42,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8138.67,8138.67,8138.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5581.8,5563.7,7497.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17518.03,10277.31,22487.53,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7497.66,7497.66,7497.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6938.36,6938.36,6938.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,7497.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,5563.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],11170.02,11170.02,11170.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12059.04,11291.7,15825.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,4365.34,7497.66,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11039.56,11039.56,18856.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16884.36,10642.81,17265.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7191.25,6199.24,7841.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,7497.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],10777.21,10777.21,25857.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,22634.42,22634.42,22634.42,1 through 10,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,12148.35,12148.35,12148.35,1 through 10,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8431.07,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8029.59,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8029.59,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8029.59,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8029.59,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8029.59,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8029.59,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14453.26,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14453.26,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8431.07,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8029.59,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8029.59,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8431.07,,,,,,,fee schedule,8029.59,23255.42,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11868.76,,,,,,,fee schedule,6127.88,17040.28,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17040.28,,,,,,,fee schedule,6127.88,17040.28,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17040.28,,,,,,,fee schedule,6127.88,17040.28,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9495.35,,,,,,,fee schedule,6127.88,17040.28,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15634.39,,,,,,,fee schedule,6127.88,17040.28,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13595.12,,,,,,,fee schedule,6127.88,17040.28,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5472.17,5472.17,5472.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,1608,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15950.13,10809.24,17053.14,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,5563.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,4365.34,5563.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,5563.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8711.33,8711.33,8711.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,5563.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9735.6,9735.6,9735.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12346.13,11395.05,12472.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5396.11,5396.11,5744.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,1608,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5563.7,5563.7,5563.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],15006.94,15006.94,15006.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,6167.78,6167.78,6167.78,1 through 10,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,11079.63,11079.63,11079.63,1 through 10,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,5578.04,5578.04,5578.04,1 through 10,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6434.27,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6127.88,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6127.88,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6127.88,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6127.88,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6127.88,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6127.88,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11030.18,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11030.18,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6434.27,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6127.88,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6127.88,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6434.27,,,,,,,fee schedule,6127.88,17040.28,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34278.84,,,,,,,fee schedule,16279.31,69849.83,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,69849.83,,,,,,,fee schedule,16279.31,69849.83,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,69849.83,,,,,,,fee schedule,16279.31,69849.83,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27424.06,,,,,,,fee schedule,16279.31,69849.83,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45154.54,,,,,,,fee schedule,16279.31,69849.83,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39264.82,,,,,,,fee schedule,16279.31,69849.83,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16453.24,16453.24,16453.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15279.52,10534.92,53643.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5730.68,5730.68,5730.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,7137.5,7137.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],26394.55,26394.55,26394.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37941.63,37941.63,37941.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7957.69,7957.69,7957.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27170.97,27170.97,27170.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34776.93,34776.93,34776.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14674.01,13797.61,22084.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22196.4,22196.4,22196.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17978.56,17978.56,17978.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,9730.33,9730.33,9730.33,1 through 10,percent of total billed charges,,,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17093.28,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16279.31,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16279.31,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16279.31,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16279.31,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16279.31,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16279.31,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29302.76,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29302.76,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17093.28,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16279.31,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16279.31,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17093.28,,,,,,,fee schedule,16279.31,69849.83,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18437.27,,,,,,,fee schedule,9103.31,26145.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26145.38,,,,,,,fee schedule,9103.31,26145.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26145.38,,,,,,,fee schedule,9103.31,26145.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14750.34,,,,,,,fee schedule,9103.31,26145.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24286.89,,,,,,,fee schedule,9103.31,26145.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21119.04,,,,,,,fee schedule,9103.31,26145.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17475.55,17089.47,24988.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5688.57,5688.57,5688.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18349.16,18349.16,18349.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7137.5,5730.68,7957.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19393.32,19393.32,19393.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8695.73,7938.63,8722.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7853.46,7853.46,7853.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],35357.99,35357.99,35357.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,16660.28,16660.28,16660.28,1 through 10,percent of total billed charges,,,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,6939.43,6939.43,6939.43,1 through 10,percent of total billed charges,,,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9558.48,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9103.31,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9103.31,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9103.31,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9103.31,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9103.31,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9103.31,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16385.96,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16385.96,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9558.48,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9103.31,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9103.31,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9558.48,,,,,,,fee schedule,9103.31,26145.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13364.3,,,,,,,fee schedule,6805.33,20776.33,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20776.33,,,,,,,fee schedule,6805.33,20776.33,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20776.33,,,,,,,fee schedule,6805.33,20776.33,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10691.82,,,,,,,fee schedule,6805.33,20776.33,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17604.41,,,,,,,fee schedule,6805.33,20776.33,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15308.18,,,,,,,fee schedule,6805.33,20776.33,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16382.22,10563.03,17882.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14044.2,14044.2,14044.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7145.6,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6805.33,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6805.33,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6805.33,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6805.33,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6805.33,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6805.33,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12249.59,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12249.59,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7145.6,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6805.33,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6805.33,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7145.6,,,,,,,fee schedule,6805.33,20776.33,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31914.26,,,,,,,fee schedule,15208.19,46643.16,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46643.16,,,,,,,fee schedule,15208.19,46643.16,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46643.16,,,,,,,fee schedule,15208.19,46643.16,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25532.32,,,,,,,fee schedule,15208.19,46643.16,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42039.74,,,,,,,fee schedule,15208.19,46643.16,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36556.3,,,,,,,fee schedule,15208.19,46643.16,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19410.21,14108.77,45102.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15112.99,15112.99,15112.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23976.39,23976.39,23976.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8020.44,8020.44,8020.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6584.7,6584.7,6584.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30990.71,30990.71,33810.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14730.3,13925.12,14876.27,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6584.7,6584.7,6584.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15968.6,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15208.19,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15208.19,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15208.19,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15208.19,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15208.19,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15208.19,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27374.74,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27374.74,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15968.6,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15208.19,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15208.19,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15968.6,,,,,,,fee schedule,15208.19,46643.16,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20903.08,,,,,,,fee schedule,10220.29,27535.04,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27444.12,,,,,,,fee schedule,10220.29,27535.04,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27444.12,,,,,,,fee schedule,10220.29,27535.04,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16723.07,,,,,,,fee schedule,10220.29,27535.04,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27535.04,,,,,,,fee schedule,10220.29,27535.04,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23943.51,,,,,,,fee schedule,10220.29,27535.04,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10135.98,10135.98,10135.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9701.36,9677.34,9716.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25875.98,22665.04,26229.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8020.44,8020.44,8020.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6584.7,6584.7,6584.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6584.7,6584.7,6584.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21765.81,21765.81,21765.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5393.99,5393.99,6584.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20016.45,10437.88,21765.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9691.24,8673.99,9744.36,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],38989.37,38989.37,38989.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10731.3,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10220.29,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10220.29,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10220.29,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10220.29,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10220.29,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10220.29,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18396.52,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18396.52,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10731.3,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10220.29,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10220.29,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10731.3,,,,,,,fee schedule,10220.29,27535.04,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15801.46,,,,,,,fee schedule,7909.33,23203.2,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23203.2,,,,,,,fee schedule,7909.33,23203.2,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23203.2,,,,,,,fee schedule,7909.33,23203.2,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12641.62,,,,,,,fee schedule,7909.33,23203.2,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20814.82,,,,,,,fee schedule,7909.33,23203.2,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18099.84,,,,,,,fee schedule,7909.33,23203.2,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22176.46,16961.09,23220.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5393.99,5393.99,5393.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11175.85,11175.85,11175.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5393.99,5393.99,6584.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16001.2,16001.2,16001.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7301.83,7288.61,7396.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,17952.24,17952.24,17952.24,1 through 10,percent of total billed charges,,,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,15798.48,15798.48,15798.48,1 through 10,percent of total billed charges,,,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8304.8,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7909.33,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7909.33,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7909.33,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7909.33,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7909.33,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7909.33,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14236.79,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14236.79,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8304.8,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7909.33,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7909.33,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8304.8,,,,,,,fee schedule,7909.33,23203.2,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,127618.83,,,,,,,fee schedule,58560.95,168108.66,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,144581.25,,,,,,,fee schedule,58560.95,168108.66,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,144581.25,,,,,,,fee schedule,58560.95,168108.66,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,102098.72,,,,,,,fee schedule,58560.95,168108.66,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,168108.66,,,,,,,fee schedule,58560.95,168108.66,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,146181.45,,,,,,,fee schedule,58560.95,168108.66,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],46123.39,46123.39,46123.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],56796.2,56796.2,56796.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,61489,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58560.95,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,58560.95,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,58560.95,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,58560.95,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,58560.95,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,58560.95,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,105409.71,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,105409.71,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,61489,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,58560.95,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,58560.95,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,61489,,,,,,,fee schedule,58560.95,168108.66,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,91775.18,,,,,,,fee schedule,37443.06,106698.27,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80999.45,,,,,,,fee schedule,37443.06,106698.27,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,91775.18,,,,,,,fee schedule,37443.06,106698.27,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,64801.88,,,,,,,fee schedule,37443.06,106698.27,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,106698.27,,,,,,,fee schedule,37443.06,106698.27,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,92781.11,,,,,,,fee schedule,37443.06,106698.27,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19073.25,19073.25,38158.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34834.18,33552.29,36556.06,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],88266.65,86911.21,91349.65,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],91844.45,91844.45,91844.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14141.01,14141.01,14141.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14141.01,14141.01,14141.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21632.74,21632.74,21632.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34643.49,34643.49,34643.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],81956.97,81956.97,81956.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21528.19,16165.22,25975.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],81856.99,72844.32,84139.33,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34759.29,32953.76,36556.06,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],41006.3,41006.3,41006.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],100450.21,100450.21,100450.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,79970.26,79970.26,79970.26,1 through 10,percent of total billed charges,,,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39315.21,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37443.06,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,37443.06,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,37443.06,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,37443.06,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,37443.06,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,37443.06,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,67397.51,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,67397.51,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,39315.21,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,37443.06,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,37443.06,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,39315.21,,,,,,,fee schedule,37443.06,106698.27,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,119034.76,,,,,,,fee schedule,46863.4,134092.42,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,101795.57,,,,,,,fee schedule,46863.4,134092.42,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,119034.76,,,,,,,fee schedule,46863.4,134092.42,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,81439.38,,,,,,,fee schedule,46863.4,134092.42,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,134092.42,,,,,,,fee schedule,46863.4,134092.42,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,116602.11,,,,,,,fee schedule,46863.4,134092.42,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],99694.67,99694.67,99694.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],43679.64,43679.64,43702.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,49206.57,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,46863.4,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,46863.4,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,46863.4,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,46863.4,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,46863.4,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,46863.4,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,84354.12,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,84354.12,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,49206.57,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,46863.4,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,46863.4,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,49206.57,,,,,,,fee schedule,46863.4,134092.42,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,78432.65,,,,,,,fee schedule,28701.04,81276.67,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61700.77,,,,,,,fee schedule,28701.04,81276.67,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,78432.65,,,,,,,fee schedule,28701.04,81276.67,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,49362.39,,,,,,,fee schedule,28701.04,81276.67,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,81276.67,,,,,,,fee schedule,28701.04,81276.67,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,70675.37,,,,,,,fee schedule,28701.04,81276.67,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],73482.36,65894.26,75418.56,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26050.39,26050.39,26428.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16255.76,16255.76,16255.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17820.12,17820.12,17820.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16258.33,16258.33,17820.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],57415.28,57415.28,57415.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16036.49,14654.66,25407.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],58594.83,56771.22,61937.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26411.38,25486.38,26480.85,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],72826.79,72826.79,72826.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,72484.57,72484.57,72484.57,1 through 10,percent of total billed charges,,,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,45178.94,45178.94,45178.94,1 through 10,percent of total billed charges,,,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30136.09,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28701.04,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28701.04,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28701.04,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28701.04,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28701.04,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28701.04,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51661.87,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,51661.87,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30136.09,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28701.04,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28701.04,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30136.09,,,,,,,fee schedule,28701.04,81276.67,MSDRG Base Rate
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,175164,,,,,,,fee schedule,175164,175164,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,119798,,,,,,,fee schedule,119798,153885.74,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,153885.74,,,,,,,fee schedule,119798,153885.74,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,133813.7,,,,,,,fee schedule,119798,153885.74,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,98566,,,,,,,fee schedule,98566,115876.62,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,115876.62,,,,,,,fee schedule,98566,115876.62,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,100762.28,,,,,,,fee schedule,98566,115876.62,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,186356.75,,,,,,,fee schedule,73458.03,211429.04,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,160505.28,,,,,,,fee schedule,73458.03,211429.04,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,186356.75,,,,,,,fee schedule,73458.03,211429.04,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,128408.83,,,,,,,fee schedule,73458.03,211429.04,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,211429.04,,,,,,,fee schedule,73458.03,211429.04,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,183851.35,,,,,,,fee schedule,73458.03,211429.04,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],71757.12,71757.12,71757.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],186497.41,186497.41,186497.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",38778.82,38778.82,38778.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",38778.82,38778.82,38778.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],159289.23,159289.23,165765.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1455.54,1455.54,1455.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,77130.93,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,73458.03,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,73458.03,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,73458.03,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,73458.03,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,73458.03,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,73458.03,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,132224.45,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,132224.45,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,77130.93,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,73458.03,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,73458.03,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,77130.93,,,,,,,fee schedule,73458.03,211429.04,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,150472.58,,,,,,,fee schedule,52344.46,150472.58,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113895.45,,,,,,,fee schedule,52344.46,150472.58,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,150472.58,,,,,,,fee schedule,52344.46,150472.58,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,91119.63,,,,,,,fee schedule,52344.46,150472.58,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,150031.24,,,,,,,fee schedule,52344.46,150472.58,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,130461.95,,,,,,,fee schedule,52344.46,150472.58,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],48561.28,48561.28,48561.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],148109.93,138016.9,150586.15,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22035.65,22035.65,22035.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",34650.17,30658.57,99080.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",38778.82,38778.82,38778.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",29074.18,29074.18,105434.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],85297.01,80454.35,130525.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",35994.73,34269.35,41715.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],115191.77,105583.65,115549.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],48714.08,48701.56,48730.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],108848.68,108848.68,108848.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",36111.97,36111.97,36111.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],118505.98,118505.98,118505.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,130008.74,130008.74,130008.74,1 through 10,percent of total billed charges,,,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,54961.68,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52344.46,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,52344.46,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,52344.46,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,52344.46,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,52344.46,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,52344.46,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,94220.03,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,94220.03,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,54961.68,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,52344.46,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,52344.46,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,54961.68,,,,,,,fee schedule,52344.46,150472.58,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,143167.61,,,,,,,fee schedule,36852.99,143167.61,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79696.83,,,,,,,fee schedule,36852.99,143167.61,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,143167.61,,,,,,,fee schedule,36852.99,143167.61,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,63759.75,,,,,,,fee schedule,36852.99,143167.61,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,104982.37,,,,,,,fee schedule,36852.99,143167.61,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,91289.02,,,,,,,fee schedule,36852.99,143167.61,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],130548.13,63753.5,143275.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],144962.17,144962.17,144962.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16253.96,16253.96,16253.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",34664.17,34664.17,35360.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],98125.2,98125.2,98125.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39437.06,39437.06,39437.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38695.64,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36852.99,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,36852.99,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,36852.99,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,36852.99,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,36852.99,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,36852.99,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66335.38,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,66335.38,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,38695.64,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,36852.99,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,36852.99,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,38695.64,,,,,,,fee schedule,36852.99,143167.61,MSDRG Base Rate
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,132417,,,,,,,fee schedule,132417,132417,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,85038,,,,,,,fee schedule,55894.83,92032.54,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,55894.83,,,,,,,fee schedule,55894.83,92032.54,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,92032.54,,,,,,,fee schedule,55894.83,92032.54,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,80028.3,,,,,,,fee schedule,55894.83,92032.54,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,154410.58,,,,,,,fee schedule,48536.7,154410.58,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,105489.52,,,,,,,fee schedule,48536.7,154410.58,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,154410.58,,,,,,,fee schedule,48536.7,154410.58,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,84394.64,,,,,,,fee schedule,48536.7,154410.58,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,138958.35,,,,,,,fee schedule,48536.7,154410.58,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,120833.35,,,,,,,fee schedule,48536.7,154410.58,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,50963.54,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48536.7,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,48536.7,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,48536.7,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,48536.7,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,48536.7,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,48536.7,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,87366.06,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,87366.06,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,50963.54,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,48536.7,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,48536.7,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,50963.54,,,,,,,fee schedule,48536.7,154410.58,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50806.11,,,,,,,fee schedule,23765.92,83178.44,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,83178.44,,,,,,,fee schedule,23765.92,83178.44,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,83178.44,,,,,,,fee schedule,23765.92,83178.44,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,40646.34,,,,,,,fee schedule,23765.92,83178.44,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,66925.44,,,,,,,fee schedule,23765.92,83178.44,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,58196.04,,,,,,,fee schedule,23765.92,83178.44,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24954.22,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23765.92,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,23765.92,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,23765.92,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,23765.92,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,23765.92,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,23765.92,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42778.66,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,42778.66,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24954.22,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,23765.92,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,23765.92,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24954.22,,,,,,,fee schedule,23765.92,83178.44,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,108860.68,,,,,,,fee schedule,50063.78,151398.76,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,151398.76,,,,,,,fee schedule,50063.78,151398.76,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,151398.76,,,,,,,fee schedule,50063.78,151398.76,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,87091.67,,,,,,,fee schedule,50063.78,151398.76,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,143399.08,,,,,,,fee schedule,50063.78,151398.76,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,124694.86,,,,,,,fee schedule,50063.78,151398.76,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],275663.14,275663.14,275663.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8544.31,8544.31,8544.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],30740.83,30740.83,30740.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,52566.97,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,50063.78,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,50063.78,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,50063.78,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,50063.78,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,50063.78,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,50063.78,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,90114.8,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,90114.8,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,52566.97,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,50063.78,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,50063.78,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,52566.97,,,,,,,fee schedule,50063.78,151398.76,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59490.89,,,,,,,fee schedule,27700,82677.05,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,82677.05,,,,,,,fee schedule,27700,82677.05,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,82677.05,,,,,,,fee schedule,27700,82677.05,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,47594.42,,,,,,,fee schedule,27700,82677.05,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,78365.67,,,,,,,fee schedule,27700,82677.05,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,68144.06,,,,,,,fee schedule,27700,82677.05,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],3072.64,3072.64,3072.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18276.71,18276.71,18276.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10922.47,10922.47,10922.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21783.49,21783.49,21783.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20861.31,20861.31,20861.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25313.76,23538.84,25384.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29085,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27700,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,27700,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,27700,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,27700,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,27700,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,27700,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49860,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,49860,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29085,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,27700,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,27700,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29085,,,,,,,fee schedule,27700,82677.05,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34832.74,,,,,,,fee schedule,16530.22,47189.81,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,47189.81,,,,,,,fee schedule,16530.22,47189.81,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,47189.81,,,,,,,fee schedule,16530.22,47189.81,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27867.19,,,,,,,fee schedule,16530.22,47189.81,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45884.18,,,,,,,fee schedule,16530.22,47189.81,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39899.29,,,,,,,fee schedule,16530.22,47189.81,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],41752.53,41752.53,41752.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34842.55,34842.55,34842.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15150.42,15150.42,15470.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],24235.76,24235.76,24235.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17356.73,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29754.4,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29754.4,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17356.73,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17356.73,,,,,,,fee schedule,16530.22,47189.81,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99423.35,,,,,,,fee schedule,45788.81,130967.55,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,108895.55,,,,,,,fee schedule,45788.81,130967.55,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,108895.55,,,,,,,fee schedule,45788.81,130967.55,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,79541.53,,,,,,,fee schedule,45788.81,130967.55,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,130967.55,,,,,,,fee schedule,45788.81,130967.55,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,113884.83,,,,,,,fee schedule,45788.81,130967.55,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],43313.18,43313.18,43313.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],106486.16,106486.16,106486.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24179.16,24179.16,24179.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],41491.04,30611.39,43356.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,48078.25,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,45788.81,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,45788.81,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,45788.81,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,45788.81,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,45788.81,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,45788.81,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,82419.86,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,82419.86,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,48078.25,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,45788.81,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,45788.81,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,48078.25,,,,,,,fee schedule,45788.81,130967.55,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67358.2,,,,,,,fee schedule,31263.77,88729.04,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,75786.43,,,,,,,fee schedule,31263.77,88729.04,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,75786.43,,,,,,,fee schedule,31263.77,88729.04,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,53888.49,,,,,,,fee schedule,31263.77,88729.04,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,88729.04,,,,,,,fee schedule,31263.77,88729.04,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,77155.7,,,,,,,fee schedule,31263.77,88729.04,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29902.66,29902.66,29902.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29176.2,19635.14,29243.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],66603.87,37338.64,74759.41,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14182.8,14182.8,14182.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],68743.74,68743.74,68743.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",27081.08,27081.08,27081.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],63009.84,63009.84,63009.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28984.93,19634.07,30540.13,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32826.96,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31263.77,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31263.77,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31263.77,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31263.77,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31263.77,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31263.77,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56274.79,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,56274.79,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,32826.96,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31263.77,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31263.77,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,32826.96,,,,,,,fee schedule,31263.77,88729.04,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52486.91,,,,,,,fee schedule,24527.3,69139.52,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,66437.6,,,,,,,fee schedule,24527.3,69139.52,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,66437.6,,,,,,,fee schedule,24527.3,69139.52,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,41991.03,,,,,,,fee schedule,24527.3,69139.52,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,69139.52,,,,,,,fee schedule,24527.3,69139.52,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,60121.32,,,,,,,fee schedule,24527.3,69139.52,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23334.69,23334.69,24735.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24226.73,24226.73,24226.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],57259.65,34818.52,64369.75,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24586.21,24586.21,24586.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22466.84,22466.84,22466.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],41837.29,41837.29,41837.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],34468.89,34468.89,34468.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10464.09,10464.09,10464.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37023.66,37023.66,52652.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25766.43,25766.43,25766.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12392.04,12392.04,12392.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],52652.21,52652.21,52652.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22552.11,22496.47,23953.73,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10464.09,10464.09,10464.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],101061.99,101061.99,101061.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,41774.53,41774.53,41774.53,1 through 10,percent of total billed charges,,,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25753.66,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24527.3,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24527.3,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24527.3,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24527.3,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24527.3,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24527.3,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44149.14,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,44149.14,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25753.66,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24527.3,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24527.3,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25753.66,,,,,,,fee schedule,24527.3,69139.52,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57934.24,,,,,,,fee schedule,26994.86,98039.07,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,98039.07,,,,,,,fee schedule,26994.86,98039.07,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,98039.07,,,,,,,fee schedule,26994.86,98039.07,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,46349.06,,,,,,,fee schedule,26994.86,98039.07,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,76315.13,,,,,,,fee schedule,26994.86,98039.07,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,66360.99,,,,,,,fee schedule,26994.86,98039.07,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25091.95,25091.95,25091.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],44082.9,44082.9,44082.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27843.69,24027.32,27932.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28344.6,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26994.86,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26994.86,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26994.86,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26994.86,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26994.86,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26994.86,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48590.75,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,48590.75,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,28344.6,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26994.86,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26994.86,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,28344.6,,,,,,,fee schedule,26994.86,98039.07,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21427.3,,,,,,,fee schedule,17143.97,52015.69,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,52015.69,,,,,,,fee schedule,17143.97,52015.69,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,52015.69,,,,,,,fee schedule,17143.97,52015.69,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17143.97,,,,,,,fee schedule,17143.97,52015.69,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28227.43,,,,,,,fee schedule,17143.97,52015.69,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24545.58,,,,,,,fee schedule,17143.97,52015.69,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12116.88,12116.88,12123.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16326.12,16326.12,16326.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9129.85,9129.85,9129.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],51648.25,49024.3,52785.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16362.69,16362.69,16362.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9129.85,9129.85,9129.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10866.27,10866.27,10866.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22012.21,22012.21,22012.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16403.47,16042.59,17608.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17323.93,17323.93,17323.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],44235.91,44235.91,44235.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,74687.4,74687.4,74687.4,1 through 10,percent of total billed charges,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18312.43,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17440.41,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17440.41,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17440.41,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17440.41,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17440.41,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17440.41,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31392.74,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31392.74,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18312.43,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17440.41,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17440.41,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18312.43,,,,,,,fee schedule,17143.97,52015.69,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,92228.36,,,,,,,fee schedule,42529.59,121489.8,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,89988.98,,,,,,,fee schedule,42529.59,121489.8,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,89988.98,,,,,,,fee schedule,42529.59,121489.8,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,73785.34,,,,,,,fee schedule,42529.59,121489.8,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,121489.8,,,,,,,fee schedule,42529.59,121489.8,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,105643.31,,,,,,,fee schedule,42529.59,121489.8,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],55246.71,55246.71,55246.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],41319.49,41319.49,41319.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,44656.07,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42529.59,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,42529.59,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,42529.59,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,42529.59,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,42529.59,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,42529.59,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,76553.26,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,76553.26,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,44656.07,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,42529.59,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,42529.59,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,44656.07,,,,,,,fee schedule,42529.59,121489.8,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56270.63,,,,,,,fee schedule,26241.27,74123.7,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,67945.25,,,,,,,fee schedule,26241.27,74123.7,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,67945.25,,,,,,,fee schedule,26241.27,74123.7,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,45018.12,,,,,,,fee schedule,26241.27,74123.7,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,74123.7,,,,,,,fee schedule,26241.27,74123.7,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,64455.39,,,,,,,fee schedule,26241.27,74123.7,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24515.65,24515.65,24515.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23918.92,22505.58,25638.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],65045.75,56731.3,67786.79,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14308.94,14308.94,14308.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24886.95,24886.95,24886.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13898.72,13898.72,13898.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13898.72,13898.72,13898.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13898.72,13898.72,13898.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25102.66,25102.66,25102.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16571.02,16571.02,16571.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],58147.86,58147.86,59135.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24811.19,3582.36,25097.24,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,36205.79,36205.79,36205.79,1 through 10,percent of total billed charges,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,51620.5,51620.5,51620.5,1 through 10,percent of total billed charges,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27553.33,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26241.27,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26241.27,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26241.27,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26241.27,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26241.27,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26241.27,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47234.29,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,47234.29,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27553.33,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26241.27,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26241.27,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27553.33,,,,,,,fee schedule,26241.27,74123.7,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46628.93,,,,,,,fee schedule,21873.72,61422.96,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,55556.75,,,,,,,fee schedule,21873.72,61422.96,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,55556.75,,,,,,,fee schedule,21873.72,61422.96,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,37304.48,,,,,,,fee schedule,21873.72,61422.96,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,61422.96,,,,,,,fee schedule,21873.72,61422.96,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,53411.27,,,,,,,fee schedule,21873.72,61422.96,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20517.93,20517.93,20517.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1294.04,1294.04,1294.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],53236.75,47622.04,53902.26,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13898.72,13898.72,13898.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13898.72,10795.87,13898.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],47513.85,47513.85,47513.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20447.96,12947.6,20963.32,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],51971.1,51971.1,51971.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22967.41,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21873.72,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21873.72,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21873.72,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21873.72,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21873.72,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21873.72,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39372.7,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,39372.7,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22967.41,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21873.72,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21873.72,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22967.41,,,,,,,fee schedule,21873.72,61422.96,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,81994.56,,,,,,,fee schedule,37893.83,111513.91,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,111513.91,,,,,,,fee schedule,37893.83,111513.91,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,111513.91,,,,,,,fee schedule,37893.83,111513.91,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,65598,,,,,,,fee schedule,37893.83,111513.91,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,108009.11,,,,,,,fee schedule,37893.83,111513.91,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,93920.97,,,,,,,fee schedule,37893.83,111513.91,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],36080.37,36080.37,36080.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15363.3,15363.3,15363.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39788.52,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37893.83,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,37893.83,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,37893.83,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,37893.83,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,37893.83,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,37893.83,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,68208.89,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,68208.89,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,39788.52,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,37893.83,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,37893.83,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,39788.52,,,,,,,fee schedule,37893.83,111513.91,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43465.96,,,,,,,fee schedule,20440.94,57256.48,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,53474.59,,,,,,,fee schedule,20440.94,57256.48,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,53474.59,,,,,,,fee schedule,20440.94,57256.48,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,34774.02,,,,,,,fee schedule,20440.94,57256.48,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,57256.48,,,,,,,fee schedule,20440.94,57256.48,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,49788.24,,,,,,,fee schedule,20440.94,57256.48,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14487.44,14487.44,14487.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],28201.05,28201.05,51708.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12626.03,12626.03,12626.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15562.01,15562.01,15562.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12230.73,12230.73,17161.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21462.99,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20440.94,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20440.94,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20440.94,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20440.94,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20440.94,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20440.94,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36793.69,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,36793.69,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21462.99,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20440.94,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20440.94,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21462.99,,,,,,,fee schedule,20440.94,57256.48,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22541.87,,,,,,,fee schedule,10962.63,29696.89,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29696.89,,,,,,,fee schedule,10962.63,29696.89,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29696.89,,,,,,,fee schedule,10962.63,29696.89,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18034.14,,,,,,,fee schedule,10962.63,29696.89,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29693.76,,,,,,,fee schedule,10962.63,29696.89,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25820.66,,,,,,,fee schedule,10962.63,29696.89,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20491.36,20491.36,20491.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11510.76,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10962.63,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10962.63,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10962.63,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10962.63,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10962.63,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10962.63,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19732.73,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19732.73,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11510.76,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10962.63,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10962.63,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11510.76,,,,,,,fee schedule,10962.63,29696.89,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65983,,,,,,,fee schedule,30640.83,86917.53,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,80229.29,,,,,,,fee schedule,30640.83,86917.53,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,80229.29,,,,,,,fee schedule,30640.83,86917.53,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,52788.29,,,,,,,fee schedule,30640.83,86917.53,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,86917.53,,,,,,,fee schedule,30640.83,86917.53,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,75580.46,,,,,,,fee schedule,30640.83,86917.53,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],45011.81,45011.81,45011.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27657.36,27657.36,27657.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],107109.06,107109.06,107109.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32172.87,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30640.83,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,30640.83,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,30640.83,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,30640.83,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,30640.83,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,30640.83,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55153.49,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,55153.49,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,32172.87,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,30640.83,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,30640.83,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,32172.87,,,,,,,fee schedule,30640.83,86917.53,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46970.82,,,,,,,fee schedule,22028.59,61873.32,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60873.57,,,,,,,fee schedule,22028.59,61873.32,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60873.57,,,,,,,fee schedule,22028.59,61873.32,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,37578,,,,,,,fee schedule,22028.59,61873.32,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,61873.32,,,,,,,fee schedule,22028.59,61873.32,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,53802.89,,,,,,,fee schedule,22028.59,61873.32,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20155.31,20155.31,20155.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6648.55,6648.55,6648.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],32337.71,32337.71,51662.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43020.88,43020.88,43020.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20277.54,20277.54,20277.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23130.02,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22028.59,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22028.59,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22028.59,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22028.59,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22028.59,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22028.59,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39651.46,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,39651.46,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23130.02,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22028.59,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22028.59,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23130.02,,,,,,,fee schedule,22028.59,61873.32,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35505.06,,,,,,,fee schedule,16834.77,46769.81,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,39320.78,,,,,,,fee schedule,16834.77,46769.81,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,39320.78,,,,,,,fee schedule,16834.77,46769.81,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28405.07,,,,,,,fee schedule,16834.77,46769.81,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46769.81,,,,,,,fee schedule,16834.77,46769.81,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40669.4,,,,,,,fee schedule,16834.77,46769.81,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],37857.05,37857.05,37857.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35641.41,35641.41,35641.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17934.65,17934.65,17934.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17676.51,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30302.59,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30302.59,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17676.51,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17676.51,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55625.05,,,,,,,fee schedule,25948.83,88749.44,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,88749.44,,,,,,,fee schedule,25948.83,88749.44,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,88749.44,,,,,,,fee schedule,25948.83,88749.44,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44501.63,,,,,,,fee schedule,25948.83,88749.44,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,73273.29,,,,,,,fee schedule,25948.83,88749.44,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,63715.91,,,,,,,fee schedule,25948.83,88749.44,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],73747.89,54547.12,95966.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],50793.07,50793.07,50793.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13325.19,13325.19,13325.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13325.19,13325.19,13325.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22443.65,19683.41,45247.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",33154.32,33154.32,33154.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13325.19,13325.19,15608.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],65553.42,65553.42,65553.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],58073.25,58073.25,59031.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23634.25,18756.62,25266.19,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27246.27,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25948.83,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25948.83,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25948.83,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25948.83,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25948.83,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25948.83,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46707.89,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,46707.89,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27246.27,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25948.83,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25948.83,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27246.27,,,,,,,fee schedule,25948.83,88749.44,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40005.03,,,,,,,fee schedule,18873.19,56636.13,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,56636.13,,,,,,,fee schedule,18873.19,56636.13,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,56636.13,,,,,,,fee schedule,18873.19,56636.13,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32005.17,,,,,,,fee schedule,18873.19,56636.13,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52697.49,,,,,,,fee schedule,18873.19,56636.13,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45823.91,,,,,,,fee schedule,18873.19,56636.13,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17823.59,17823.59,18383.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3952.25,3952.25,3952.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],56678.88,56678.88,61324.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15608.4,15608.4,15608.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11438.71,11438.71,11438.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10216.88,10216.88,10216.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13325.19,13325.19,15608.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38173.12,34596.99,41646.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17974.91,15241.46,18036.27,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],54694.59,54694.59,54694.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,43173.06,43173.06,43173.06,1 through 10,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19816.85,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18873.19,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18873.19,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18873.19,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18873.19,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18873.19,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18873.19,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33971.74,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33971.74,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19816.85,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18873.19,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18873.19,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19816.85,,,,,,,fee schedule,18873.19,56636.13,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31152.17,,,,,,,fee schedule,14862.97,43411.98,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43411.98,,,,,,,fee schedule,14862.97,43411.98,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43411.98,,,,,,,fee schedule,14862.97,43411.98,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24922.63,,,,,,,fee schedule,14862.97,43411.98,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41035.86,,,,,,,fee schedule,14862.97,43411.98,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35683.36,,,,,,,fee schedule,14862.97,43411.98,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14302.52,14302.52,14302.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13904.83,13904.83,13904.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10216.88,10216.88,10216.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],36850.79,36850.79,36850.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],42449.42,32035.41,43444.75,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10216.88,10216.88,10216.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10216.88,10216.88,13325.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3952.25,3952.25,3952.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9140.22,9140.22,10216.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29185.91,29185.91,29185.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31841.82,31841.82,32634.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13891.1,12613.71,13921.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10216.88,10216.88,10216.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],50374.51,50374.51,50374.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,31032.59,31032.59,31032.59,1 through 10,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,53658.32,53658.32,59270.77,1 through 10,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,27817.59,27817.59,27817.59,1 through 10,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15606.12,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14862.97,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14862.97,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14862.97,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14862.97,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14862.97,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14862.97,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26753.35,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26753.35,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15606.12,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14862.97,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14862.97,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15606.12,,,,,,,fee schedule,14862.97,43411.98,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52943.4,,,,,,,fee schedule,24734.08,69740.84,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,55657.72,,,,,,,fee schedule,24734.08,69740.84,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,55657.72,,,,,,,fee schedule,24734.08,69740.84,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,42356.24,,,,,,,fee schedule,24734.08,69740.84,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,69740.84,,,,,,,fee schedule,24734.08,69740.84,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,60644.21,,,,,,,fee schedule,24734.08,69740.84,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22913.22,22913.22,22913.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],53133.72,53133.72,53133.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11204.25,11204.25,11204.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10609.24,10609.24,10609.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21883.93,20184.56,22141.57,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25970.78,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24734.08,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24734.08,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24734.08,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24734.08,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24734.08,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24734.08,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44521.34,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,44521.34,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25970.78,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24734.08,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24734.08,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25970.78,,,,,,,fee schedule,24734.08,69740.84,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61637.74,,,,,,,fee schedule,28672.49,81193.64,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,70598.44,,,,,,,fee schedule,28672.49,81193.64,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,70598.44,,,,,,,fee schedule,28672.49,81193.64,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,49311.96,,,,,,,fee schedule,28672.49,81193.64,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,81193.64,,,,,,,fee schedule,28672.49,81193.64,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,70603.17,,,,,,,fee schedule,28672.49,81193.64,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],36795.8,36795.8,36795.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27989.39,27989.39,27989.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42212.78,42212.78,42212.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27606.21,27606.21,27606.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30106.11,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28672.49,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28672.49,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28672.49,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28672.49,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28672.49,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28672.49,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51610.48,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,51610.48,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30106.11,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28672.49,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28672.49,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30106.11,,,,,,,fee schedule,28672.49,81193.64,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39940.09,,,,,,,fee schedule,18843.77,52611.95,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46886.89,,,,,,,fee schedule,18843.77,52611.95,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46886.89,,,,,,,fee schedule,18843.77,52611.95,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31953.22,,,,,,,fee schedule,18843.77,52611.95,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52611.95,,,,,,,fee schedule,18843.77,52611.95,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45749.52,,,,,,,fee schedule,18843.77,52611.95,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18425.05,18425.05,18425.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42566.16,40946.2,42566.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18364.5,18351.18,18389.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19785.96,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18843.77,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18843.77,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18843.77,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18843.77,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18843.77,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18843.77,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33918.79,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33918.79,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19785.96,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18843.77,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18843.77,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19785.96,,,,,,,fee schedule,18843.77,52611.95,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29914.48,,,,,,,fee schedule,14302.32,39405.5,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36580.55,,,,,,,fee schedule,14302.32,39405.5,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36580.55,,,,,,,fee schedule,14302.32,39405.5,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23932.44,,,,,,,fee schedule,14302.32,39405.5,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39405.5,,,,,,,fee schedule,14302.32,39405.5,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34265.65,,,,,,,fee schedule,14302.32,39405.5,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13842.32,13842.32,13842.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],34757.63,30295.33,36608.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10396.96,10396.96,10396.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10396.96,10396.96,10396.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31715.37,31715.37,31715.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13896.54,13896.54,13896.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,25163.03,25163.03,25163.03,1 through 10,percent of total billed charges,,,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15017.44,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14302.32,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14302.32,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14302.32,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14302.32,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14302.32,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14302.32,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25744.18,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25744.18,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15017.44,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14302.32,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14302.32,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15017.44,,,,,,,fee schedule,14302.32,39405.5,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33786.06,,,,,,,fee schedule,16056.09,44675.9,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44675.9,,,,,,,fee schedule,16056.09,44675.9,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44675.9,,,,,,,fee schedule,16056.09,44675.9,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27029.82,,,,,,,fee schedule,16056.09,44675.9,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44505.42,,,,,,,fee schedule,16056.09,44675.9,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38700.37,,,,,,,fee schedule,16056.09,44675.9,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14056.51,14056.51,14056.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],34221.77,34221.77,34221.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14086.21,14086.21,17623.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16858.89,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16056.09,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16056.09,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16056.09,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16056.09,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16056.09,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16056.09,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28900.96,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28900.96,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16858.89,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16056.09,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16056.09,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16858.89,,,,,,,fee schedule,16056.09,44675.9,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21330.92,,,,,,,fee schedule,10414.09,28603.58,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28603.58,,,,,,,fee schedule,10414.09,28603.58,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28603.58,,,,,,,fee schedule,10414.09,28603.58,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17065.35,,,,,,,fee schedule,10414.09,28603.58,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28098.62,,,,,,,fee schedule,10414.09,28603.58,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24433.58,,,,,,,fee schedule,10414.09,28603.58,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10216.88,10216.88,10216.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10396.96,10396.96,10396.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10928.89,10928.89,10928.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10934.79,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.36,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18745.36,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10934.79,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10934.79,,,,,,,fee schedule,10414.09,28603.58,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70127.71,,,,,,,fee schedule,32518.32,92377.24,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,91719.47,,,,,,,fee schedule,32518.32,92377.24,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,91719.47,,,,,,,fee schedule,32518.32,92377.24,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,56104.18,,,,,,,fee schedule,32518.32,92377.24,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,92377.24,,,,,,,fee schedule,32518.32,92377.24,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,80328.04,,,,,,,fee schedule,32518.32,92377.24,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],70137.57,70137.57,91560.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",27530.96,27530.96,27530.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],49781.04,49781.04,49781.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34144.24,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32518.32,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32518.32,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32518.32,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32518.32,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32518.32,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32518.32,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58532.98,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,58532.98,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,34144.24,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32518.32,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32518.32,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,34144.24,,,,,,,fee schedule,32518.32,92377.24,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48439.61,,,,,,,fee schedule,22693.93,72955.66,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,72955.66,,,,,,,fee schedule,22693.93,72955.66,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,72955.66,,,,,,,fee schedule,22693.93,72955.66,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,38753.08,,,,,,,fee schedule,22693.93,72955.66,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,63808.12,,,,,,,fee schedule,22693.93,72955.66,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,55485.33,,,,,,,fee schedule,22693.93,72955.66,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17808.85,17808.85,17808.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],53873.37,53873.37,53873.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],65927.27,50863.55,68229.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",27359.78,27359.78,27359.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10396.96,10396.96,12700.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20728.38,20728.38,20728.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,29056.07,29056.07,29056.07,1 through 10,percent of total billed charges,,,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,18261.48,18261.48,18261.48,1 through 10,percent of total billed charges,,,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,67767.27,67767.27,67767.27,1 through 10,percent of total billed charges,,,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23828.63,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22693.93,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22693.93,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22693.93,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22693.93,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22693.93,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22693.93,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40849.07,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,40849.07,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23828.63,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22693.93,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22693.93,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23828.63,,,,,,,fee schedule,22693.93,72955.66,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38324.23,,,,,,,fee schedule,18111.81,50483.42,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,49613.19,,,,,,,fee schedule,18111.81,50483.42,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,49613.19,,,,,,,fee schedule,18111.81,50483.42,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30660.48,,,,,,,fee schedule,18111.81,50483.42,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50483.42,,,,,,,fee schedule,18111.81,50483.42,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43898.63,,,,,,,fee schedule,18111.81,50483.42,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],44226.43,26212.44,49650.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10396.96,10396.96,10396.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13771.72,13771.72,13771.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10396.96,10396.96,10396.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37845.28,37845.28,37845.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10396.96,10396.96,10396.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],22835.29,22835.29,22835.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,24641.07,24641.07,24641.07,1 through 10,percent of total billed charges,,,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,26957.43,26957.43,26957.43,1 through 10,percent of total billed charges,,,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,8180.21,8180.21,8180.21,1 through 10,percent of total billed charges,,,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19017.4,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18111.81,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18111.81,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18111.81,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18111.81,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18111.81,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18111.81,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32601.26,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32601.26,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19017.4,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18111.81,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18111.81,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19017.4,,,,,,,fee schedule,18111.81,50483.42,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69251.02,,,,,,,fee schedule,32121.19,97286.99,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,97286.99,,,,,,,fee schedule,32121.19,97286.99,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,97286.99,,,,,,,fee schedule,32121.19,97286.99,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,55402.8,,,,,,,fee schedule,32121.19,97286.99,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,91222.39,,,,,,,fee schedule,32121.19,97286.99,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,79323.83,,,,,,,fee schedule,32121.19,97286.99,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33007.12,33007.12,33007.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33727.25,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32121.19,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32121.19,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32121.19,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32121.19,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32121.19,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32121.19,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57818.14,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,57818.14,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33727.25,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32121.19,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32121.19,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33727.25,,,,,,,fee schedule,32121.19,97286.99,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34454.56,,,,,,,fee schedule,16358.91,58774,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,58774,,,,,,,fee schedule,16358.91,58774,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,58774,,,,,,,fee schedule,16358.91,58774,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27564.64,,,,,,,fee schedule,16358.91,58774,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45386.02,,,,,,,fee schedule,16358.91,58774,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39466.1,,,,,,,fee schedule,16358.91,58774,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36296.57,36296.57,36296.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15979.96,15979.96,15979.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],89008.65,89008.65,89008.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17176.86,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16358.91,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16358.91,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16358.91,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16358.91,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16358.91,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16358.91,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29446.04,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29446.04,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17176.86,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16358.91,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16358.91,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17176.86,,,,,,,fee schedule,16358.91,58774,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23078.58,,,,,,,fee schedule,11205.76,38568.7,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38568.7,,,,,,,fee schedule,11205.76,38568.7,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38568.7,,,,,,,fee schedule,11205.76,38568.7,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18463.52,,,,,,,fee schedule,11205.76,38568.7,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30400.76,,,,,,,fee schedule,11205.76,38568.7,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26435.44,,,,,,,fee schedule,11205.76,38568.7,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24010.89,24010.89,24010.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8856.45,8856.45,8856.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",35611.78,35611.78,35611.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8856.45,8856.45,8856.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10942.29,10942.29,10942.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11766.05,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11205.76,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11205.76,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11205.76,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11205.76,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11205.76,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11205.76,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20170.37,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20170.37,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11766.05,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11205.76,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11205.76,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11766.05,,,,,,,fee schedule,11205.76,38568.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57621,,,,,,,fee schedule,26852.96,76792.69,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,76792.69,,,,,,,fee schedule,26852.96,76792.69,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,76792.69,,,,,,,fee schedule,26852.96,76792.69,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,46098.45,,,,,,,fee schedule,26852.96,76792.69,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,75902.51,,,,,,,fee schedule,26852.96,76792.69,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,66002.18,,,,,,,fee schedule,26852.96,76792.69,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16447.09,16447.09,16447.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28195.61,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26852.96,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26852.96,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26852.96,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26852.96,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26852.96,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26852.96,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48335.33,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,48335.33,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,28195.61,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26852.96,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26852.96,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,28195.61,,,,,,,fee schedule,26852.96,76792.69,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38482.76,,,,,,,fee schedule,18183.62,57102.7,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57102.7,,,,,,,fee schedule,18183.62,57102.7,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57102.7,,,,,,,fee schedule,18183.62,57102.7,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30787.31,,,,,,,fee schedule,18183.62,57102.7,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50692.25,,,,,,,fee schedule,18183.62,57102.7,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,44080.22,,,,,,,fee schedule,18183.62,57102.7,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],30413.21,30413.21,30413.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19092.8,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18183.62,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18183.62,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18183.62,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18183.62,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18183.62,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18183.62,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32730.52,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32730.52,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19092.8,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18183.62,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18183.62,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19092.8,,,,,,,fee schedule,18183.62,57102.7,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60447.81,,,,,,,fee schedule,28133.47,115424.06,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,115424.06,,,,,,,fee schedule,28133.47,115424.06,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,115424.06,,,,,,,fee schedule,28133.47,115424.06,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48359.98,,,,,,,fee schedule,28133.47,115424.06,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,79626.18,,,,,,,fee schedule,28133.47,115424.06,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,69240.16,,,,,,,fee schedule,28133.47,115424.06,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26110.65,26110.65,26110.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],48477.41,48477.41,48477.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",139574,139574,139574,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],63597.34,63597.34,63597.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27467.72,27146.66,27482.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29540.14,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28133.47,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28133.47,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28133.47,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28133.47,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28133.47,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28133.47,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50640.25,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,50640.25,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29540.14,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28133.47,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28133.47,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29540.14,,,,,,,fee schedule,28133.47,115424.06,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33388.78,,,,,,,fee schedule,15876.13,47628.53,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,47628.53,,,,,,,fee schedule,15876.13,47628.53,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,47628.53,,,,,,,fee schedule,15876.13,47628.53,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26711.98,,,,,,,fee schedule,15876.13,47628.53,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43982.09,,,,,,,fee schedule,15876.13,47628.53,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38245.3,,,,,,,fee schedule,15876.13,47628.53,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16255.61,16255.61,16255.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],39720.18,37013.65,60153.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],15746.03,15746.03,15746.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11174.87,11174.87,11174.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35826.07,35826.07,35826.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15584.02,15584.02,15584.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16669.94,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15876.13,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15876.13,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15876.13,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15876.13,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15876.13,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15876.13,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28577.03,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28577.03,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16669.94,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15876.13,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15876.13,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16669.94,,,,,,,fee schedule,15876.13,47628.53,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25706.74,,,,,,,fee schedule,12396.28,40180.8,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40180.8,,,,,,,fee schedule,12396.28,40180.8,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40180.8,,,,,,,fee schedule,12396.28,40180.8,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20566.13,,,,,,,fee schedule,12396.28,40180.8,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33862.76,,,,,,,fee schedule,12396.28,40180.8,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29445.88,,,,,,,fee schedule,12396.28,40180.8,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],40228.34,28983.36,41281.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8927.14,8927.14,8927.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28042.24,28042.24,28042.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12328.13,12328.13,12328.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,62867.86,62867.86,62867.86,1 through 10,percent of total billed charges,,,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13016.09,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12396.28,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12396.28,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12396.28,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12396.28,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12396.28,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12396.28,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22313.3,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22313.3,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13016.09,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12396.28,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12396.28,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13016.09,,,,,,,fee schedule,12396.28,40180.8,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53310.12,,,,,,,fee schedule,24900.2,70223.91,
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,69188.28,,,,,,,fee schedule,24900.2,70223.91,
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,69188.28,,,,,,,fee schedule,24900.2,70223.91,
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,42649.63,,,,,,,fee schedule,24900.2,70223.91,
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,70223.91,,,,,,,fee schedule,24900.2,70223.91,
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,61064.27,,,,,,,fee schedule,24900.2,70223.91,
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23767.35,23767.35,23767.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26145.21,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24900.2,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24900.2,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24900.2,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24900.2,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24900.2,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24900.2,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44820.36,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,44820.36,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,26145.21,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24900.2,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24900.2,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,26145.21,,,,,,,fee schedule,24900.2,70223.91,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35701.79,,,,,,,fee schedule,16923.89,48509.44,
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48509.44,,,,,,,fee schedule,16923.89,48509.44,
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48509.44,,,,,,,fee schedule,16923.89,48509.44,
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28562.46,,,,,,,fee schedule,16923.89,48509.44,
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,47028.96,,,,,,,fee schedule,16923.89,48509.44,
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40894.75,,,,,,,fee schedule,16923.89,48509.44,
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15315.92,15315.92,15315.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],31909.67,31909.67,39650.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15324.93,15324.93,15324.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9675,9675,9675,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9675,9675,9675,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28325.69,28325.69,35237.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16544.01,16544.01,16544.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,29329.95,29329.95,29329.95,1 through 10,percent of total billed charges,,,
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17770.08,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16923.89,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16923.89,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16923.89,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16923.89,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16923.89,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16923.89,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30463,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30463,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17770.08,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16923.89,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16923.89,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17770.08,,,,,,,fee schedule,16923.89,48509.44,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34242.55,,,,,,,fee schedule,16262.87,45106.74,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38760.2,,,,,,,fee schedule,16262.87,45106.74,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38760.2,,,,,,,fee schedule,16262.87,45106.74,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27395.02,,,,,,,fee schedule,16262.87,45106.74,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45106.74,,,,,,,fee schedule,16262.87,45106.74,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39223.25,,,,,,,fee schedule,16262.87,45106.74,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],34108.37,34108.37,34108.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],22798.39,22798.39,22798.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35237.96,35237.96,35237.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17076.01,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16262.87,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16262.87,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16262.87,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16262.87,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16262.87,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16262.87,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29273.17,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29273.17,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17076.01,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16262.87,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16262.87,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17076.01,,,,,,,fee schedule,16262.87,45106.74,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25769.77,,,,,,,fee schedule,12424.83,33945.79,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29185.05,,,,,,,fee schedule,12424.83,33945.79,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29185.05,,,,,,,fee schedule,12424.83,33945.79,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20616.56,,,,,,,fee schedule,12424.83,33945.79,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33945.79,,,,,,,fee schedule,12424.83,33945.79,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29518.08,,,,,,,fee schedule,12424.83,33945.79,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20502.44,20502.44,20502.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7894.38,7894.38,7894.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27445.68,27445.68,27445.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10368.37,10368.37,10368.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13046.07,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12424.83,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12424.83,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12424.83,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12424.83,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12424.83,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12424.83,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22364.69,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22364.69,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13046.07,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12424.83,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12424.83,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13046.07,,,,,,,fee schedule,12424.83,33945.79,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34502.31,,,,,,,fee schedule,16380.54,45448.92,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32304.81,,,,,,,fee schedule,16380.54,45448.92,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32304.81,,,,,,,fee schedule,16380.54,45448.92,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27602.84,,,,,,,fee schedule,16380.54,45448.92,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45448.92,,,,,,,fee schedule,16380.54,45448.92,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39520.8,,,,,,,fee schedule,16380.54,45448.92,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17199.57,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16380.54,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16380.54,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16380.54,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16380.54,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16380.54,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16380.54,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29484.97,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29484.97,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17199.57,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16380.54,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16380.54,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17199.57,,,,,,,fee schedule,16380.54,45448.92,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28925.1,,,,,,,fee schedule,13854.14,38102.21,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21730.36,,,,,,,fee schedule,13854.14,38102.21,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21730.36,,,,,,,fee schedule,13854.14,38102.21,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23140.91,,,,,,,fee schedule,13854.14,38102.21,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38102.21,,,,,,,fee schedule,13854.14,38102.21,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33132.36,,,,,,,fee schedule,13854.14,38102.21,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14546.85,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13854.14,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13854.14,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13854.14,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13854.14,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13854.14,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13854.14,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24937.45,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24937.45,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14546.85,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13854.14,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13854.14,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14546.85,,,,,,,fee schedule,13854.14,38102.21,MSDRG Base Rate
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57691.67,,,,,,,fee schedule,26884.98,75995.6,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,61434.15,,,,,,,fee schedule,26884.98,75995.6,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,61434.15,,,,,,,fee schedule,26884.98,75995.6,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,46154.99,,,,,,,fee schedule,26884.98,75995.6,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,75995.6,,,,,,,fee schedule,26884.98,75995.6,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,66083.13,,,,,,,fee schedule,26884.98,75995.6,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19351.54,19351.54,19351.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],44775.86,44775.86,44775.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],52177.22,52177.22,52177.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28229.23,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26884.98,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26884.98,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26884.98,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26884.98,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26884.98,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26884.98,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48392.96,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,48392.96,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,28229.23,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26884.98,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26884.98,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,28229.23,,,,,,,fee schedule,26884.98,75995.6,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39716.62,,,,,,,fee schedule,18742.55,59620.09,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,59620.09,,,,,,,fee schedule,18742.55,59620.09,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,59620.09,,,,,,,fee schedule,18742.55,59620.09,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31774.44,,,,,,,fee schedule,18742.55,59620.09,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52317.58,,,,,,,fee schedule,18742.55,59620.09,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45493.55,,,,,,,fee schedule,18742.55,59620.09,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12058.62,12058.62,12058.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19679.68,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18742.55,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18742.55,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18742.55,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18742.55,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18742.55,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18742.55,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33736.59,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33736.59,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19679.68,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18742.55,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18742.55,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19679.68,,,,,,,fee schedule,18742.55,59620.09,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31618.21,,,,,,,fee schedule,15074.08,50755.25,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,50755.25,,,,,,,fee schedule,15074.08,50755.25,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,50755.25,,,,,,,fee schedule,15074.08,50755.25,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25295.47,,,,,,,fee schedule,15074.08,50755.25,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41649.76,,,,,,,fee schedule,15074.08,50755.25,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36217.19,,,,,,,fee schedule,15074.08,50755.25,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],40134.91,40134.91,42839.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13346.66,13346.66,13346.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15827.78,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15074.08,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15074.08,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15074.08,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15074.08,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15074.08,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15074.08,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27133.34,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27133.34,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15827.78,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15074.08,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15074.08,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15827.78,,,,,,,fee schedule,15074.08,50755.25,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30069.19,,,,,,,fee schedule,14372.4,39609.29,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36402.97,,,,,,,fee schedule,14372.4,39609.29,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36402.97,,,,,,,fee schedule,14372.4,39609.29,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24056.22,,,,,,,fee schedule,14372.4,39609.29,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39609.29,,,,,,,fee schedule,14372.4,39609.29,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34442.87,,,,,,,fee schedule,14372.4,39609.29,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11812.58,11812.58,11812.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],32457.91,32457.91,32457.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12443.34,12443.34,12443.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6912.57,6912.57,6912.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20156.9,20156.9,20156.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15091.02,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14372.4,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14372.4,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14372.4,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14372.4,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14372.4,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14372.4,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25870.32,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25870.32,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15091.02,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14372.4,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14372.4,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15091.02,,,,,,,fee schedule,14372.4,39609.29,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19525.97,,,,,,,fee schedule,9596.48,25721.01,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25616.13,,,,,,,fee schedule,9596.48,25721.01,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25616.13,,,,,,,fee schedule,9596.48,25721.01,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15621.34,,,,,,,fee schedule,9596.48,25721.01,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25721.01,,,,,,,fee schedule,9596.48,25721.01,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22366.09,,,,,,,fee schedule,9596.48,25721.01,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16857.39,16857.39,16857.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10076.3,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9596.48,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9596.48,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9596.48,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9596.48,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9596.48,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9596.48,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17273.66,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17273.66,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10076.3,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9596.48,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9596.48,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10076.3,,,,,,,fee schedule,9596.48,25721.01,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60869.92,,,,,,,fee schedule,28324.68,130643.32,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,130643.32,,,,,,,fee schedule,28324.68,130643.32,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,130643.32,,,,,,,fee schedule,28324.68,130643.32,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48697.68,,,,,,,fee schedule,28324.68,130643.32,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,80182.21,,,,,,,fee schedule,28324.68,130643.32,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,69723.67,,,,,,,fee schedule,28324.68,130643.32,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26772.36,26772.36,26772.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],95465.82,95465.82,95465.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],62065.87,62065.87,62065.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26393.06,26393.06,26393.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,34742.84,34742.84,34742.84,1 through 10,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29740.91,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28324.68,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28324.68,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28324.68,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28324.68,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28324.68,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28324.68,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50984.42,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,50984.42,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29740.91,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28324.68,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28324.68,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29740.91,,,,,,,fee schedule,28324.68,130643.32,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39691.79,,,,,,,fee schedule,18731.3,62207.13,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,62207.13,,,,,,,fee schedule,18731.3,62207.13,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,62207.13,,,,,,,fee schedule,18731.3,62207.13,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31754.57,,,,,,,fee schedule,18731.3,62207.13,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52284.87,,,,,,,fee schedule,18731.3,62207.13,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45465.11,,,,,,,fee schedule,18731.3,62207.13,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18268.12,18268.12,18268.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16899.34,16899.34,16899.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],59454.47,43792.41,62254.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23949.42,23949.42,23949.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17436.94,17436.94,17436.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],32453.12,32453.12,32453.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43850.78,43850.78,46432.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17755.18,13223.69,74068.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38472.98,26675.93,41617.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17484.92,17466.36,17556.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",27266.55,27266.55,27266.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,15044.5,15044.5,15044.5,1 through 10,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19667.86,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18731.3,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18731.3,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18731.3,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18731.3,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18731.3,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18731.3,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33716.34,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33716.34,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19667.86,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18731.3,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18731.3,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19667.86,,,,,,,fee schedule,18731.3,62207.13,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29351.03,,,,,,,fee schedule,14047.08,42308.23,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42308.23,,,,,,,fee schedule,14047.08,42308.23,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42308.23,,,,,,,fee schedule,14047.08,42308.23,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23481.67,,,,,,,fee schedule,14047.08,42308.23,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38663.28,,,,,,,fee schedule,14047.08,42308.23,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33620.25,,,,,,,fee schedule,14047.08,42308.23,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12949.2,12949.2,13302.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],40911.2,37243.84,41601.04,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12949.2,12949.2,12949.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10349.49,10349.49,16933.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10349.49,10349.49,10349.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27460.21,27460.21,27460.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12949.2,10349.49,17755.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34245.78,34245.78,34245.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29236.77,26783.05,30383.22,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13048.13,13048.13,13120.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10349.49,10349.49,10349.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],45708.45,45708.45,45708.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,45993.46,45993.46,45993.46,1 through 10,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,82422.68,82422.68,82422.68,1 through 10,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,33170.26,33170.26,33170.26,1 through 10,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14749.43,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14047.08,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14047.08,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14047.08,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14047.08,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14047.08,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14047.08,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25284.74,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25284.74,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14749.43,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14047.08,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14047.08,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14749.43,,,,,,,fee schedule,14047.08,42308.23,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71382.58,,,,,,,fee schedule,33086.76,94030.24,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,82701.42,,,,,,,fee schedule,33086.76,94030.24,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,82701.42,,,,,,,fee schedule,33086.76,94030.24,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,57108.11,,,,,,,fee schedule,33086.76,94030.24,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,94030.24,,,,,,,fee schedule,33086.76,94030.24,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,81765.43,,,,,,,fee schedule,33086.76,94030.24,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45596.84,45596.84,45596.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],71933.14,71933.14,71933.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],30485.15,30485.15,30485.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],41712.09,41712.09,41712.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],80127.52,80127.52,80127.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34741.1,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33086.76,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,33086.76,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,33086.76,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,33086.76,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,33086.76,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,33086.76,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59556.17,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,59556.17,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,34741.1,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,33086.76,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,33086.76,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,34741.1,,,,,,,fee schedule,33086.76,94030.24,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38203.9,,,,,,,fee schedule,18057.3,57228.05,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57228.05,,,,,,,fee schedule,18057.3,57228.05,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57228.05,,,,,,,fee schedule,18057.3,57228.05,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30564.22,,,,,,,fee schedule,18057.3,57228.05,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50324.91,,,,,,,fee schedule,18057.3,57228.05,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43760.8,,,,,,,fee schedule,18057.3,57228.05,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17828.14,17828.14,17828.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],57271.24,57271.24,57271.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13223.69,13223.69,13223.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20493.51,20493.51,20493.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13223.69,13223.69,13223.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13223.69,13223.69,13223.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37080.92,36274.49,40147.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17131.74,17095.45,17148.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18960.16,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18057.3,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18057.3,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18057.3,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18057.3,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18057.3,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18057.3,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32503.14,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32503.14,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18960.16,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18057.3,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18057.3,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18960.16,,,,,,,fee schedule,18057.3,57228.05,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28533.55,,,,,,,fee schedule,13676.78,45375.76,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45375.76,,,,,,,fee schedule,13676.78,45375.76,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45375.76,,,,,,,fee schedule,13676.78,45375.76,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22827.66,,,,,,,fee schedule,13676.78,45375.76,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37586.43,,,,,,,fee schedule,13676.78,45375.76,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32683.86,,,,,,,fee schedule,13676.78,45375.76,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13223.69,13223.69,13223.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],43877.44,43877.44,43877.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25888.34,25888.34,25888.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12610.57,12424.26,13354.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],17456.1,17456.1,17456.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,1110.3,1110.3,1110.3,1 through 10,percent of total billed charges,,,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14360.62,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13676.78,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13676.78,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13676.78,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13676.78,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13676.78,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13676.78,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24618.2,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24618.2,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14360.62,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13676.78,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13676.78,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14360.62,,,,,,,fee schedule,13676.78,45375.76,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,54820.93,,,,,,,fee schedule,25584.58,105006.3,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,105006.3,,,,,,,fee schedule,25584.58,105006.3,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,105006.3,,,,,,,fee schedule,25584.58,105006.3,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,43858.32,,,,,,,fee schedule,25584.58,105006.3,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,72214.06,,,,,,,fee schedule,25584.58,105006.3,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,62794.84,,,,,,,fee schedule,25584.58,105006.3,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12392.04,12392.04,12392.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22667.16,22667.16,24672.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26863.81,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25584.58,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25584.58,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25584.58,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25584.58,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25584.58,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25584.58,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46052.24,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,46052.24,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,26863.81,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25584.58,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25584.58,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,26863.81,,,,,,,fee schedule,25584.58,105006.3,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40448.15,,,,,,,fee schedule,19073.92,59898.64,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,59898.64,,,,,,,fee schedule,19073.92,59898.64,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,59898.64,,,,,,,fee schedule,19073.92,59898.64,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32359.68,,,,,,,fee schedule,19073.92,59898.64,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53281.2,,,,,,,fee schedule,19073.92,59898.64,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46331.49,,,,,,,fee schedule,19073.92,59898.64,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18035.44,16071.57,18260.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],54916.71,47176.98,62807.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18275.21,18275.21,18275.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29554.6,29554.6,29554.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12392.04,12392.04,12392.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42315.26,40439.49,42315.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18261.75,16068.23,18644.44,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35679.41,35679.41,35679.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,31951.31,31951.31,31951.31,1 through 10,percent of total billed charges,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20027.62,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19073.92,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19073.92,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19073.92,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19073.92,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19073.92,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19073.92,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34333.06,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34333.06,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20027.62,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19073.92,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19073.92,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20027.62,,,,,,,fee schedule,19073.92,59898.64,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29943.13,,,,,,,fee schedule,14315.3,39443.24,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,37068.01,,,,,,,fee schedule,14315.3,39443.24,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,37068.01,,,,,,,fee schedule,14315.3,39443.24,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23955.37,,,,,,,fee schedule,14315.3,39443.24,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39443.24,,,,,,,fee schedule,14315.3,39443.24,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34298.47,,,,,,,fee schedule,14315.3,39443.24,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15031.06,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14315.3,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14315.3,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14315.3,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14315.3,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14315.3,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14315.3,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25767.54,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25767.54,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15031.06,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14315.3,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14315.3,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15031.06,,,,,,,fee schedule,14315.3,39443.24,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15396.54,,,,,,,fee schedule,7725.91,20717.14,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20717.14,,,,,,,fee schedule,7725.91,20717.14,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20717.14,,,,,,,fee schedule,7725.91,20717.14,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12317.68,,,,,,,fee schedule,7725.91,20717.14,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20281.43,,,,,,,fee schedule,7725.91,20717.14,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17636.03,,,,,,,fee schedule,7725.91,20717.14,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19252.83,17942.41,20732.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9140.22,9140.22,9140.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16336.4,16336.4,16336.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7681.4,7681.4,7681.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],14513.56,14513.56,14513.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,16657.4,16657.4,16657.4,1 through 10,percent of total billed charges,,,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8112.21,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7725.91,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7725.91,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7725.91,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7725.91,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7725.91,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7725.91,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13906.64,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13906.64,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8112.21,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7725.91,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7725.91,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8112.21,,,,,,,fee schedule,7725.91,20717.14,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24486.25,,,,,,,fee schedule,11843.41,32255.04,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28822.94,,,,,,,fee schedule,11843.41,32255.04,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28822.94,,,,,,,fee schedule,11843.41,32255.04,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19589.7,,,,,,,fee schedule,11843.41,32255.04,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32255.04,,,,,,,fee schedule,11843.41,32255.04,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28047.87,,,,,,,fee schedule,11843.41,32255.04,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12243.91,12243.91,12243.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12435.58,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11843.41,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11843.41,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11843.41,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11843.41,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11843.41,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11843.41,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21318.14,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21318.14,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12435.58,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11843.41,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11843.41,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12435.58,,,,,,,fee schedule,11843.41,32255.04,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15425.19,,,,,,,fee schedule,7738.88,20319.17,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17496.41,,,,,,,fee schedule,7738.88,20319.17,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17496.41,,,,,,,fee schedule,7738.88,20319.17,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12340.6,,,,,,,fee schedule,7738.88,20319.17,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20319.17,,,,,,,fee schedule,7738.88,20319.17,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17668.84,,,,,,,fee schedule,7738.88,20319.17,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7394.75,7394.75,7394.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15524.15,15524.15,15524.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4201.09,4201.09,4201.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7414.51,7414.51,7621.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],8215.33,8215.33,8215.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8125.82,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7738.88,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7738.88,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7738.88,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7738.88,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7738.88,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7738.88,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13929.98,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13929.98,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8125.82,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7738.88,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7738.88,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8125.82,,,,,,,fee schedule,7738.88,20319.17,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18227.17,,,,,,,fee schedule,9008.14,42343.05,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42343.05,,,,,,,fee schedule,9008.14,42343.05,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42343.05,,,,,,,fee schedule,9008.14,42343.05,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14582.26,,,,,,,fee schedule,9008.14,42343.05,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24010.13,,,,,,,fee schedule,9008.14,42343.05,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20878.38,,,,,,,fee schedule,9008.14,42343.05,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9458.55,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9008.14,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9008.14,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9008.14,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9008.14,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9008.14,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9008.14,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16214.65,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16214.65,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9458.55,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9008.14,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9008.14,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9458.55,,,,,,,fee schedule,9008.14,42343.05,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13757.76,,,,,,,fee schedule,6983.56,21354.32,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21354.32,,,,,,,fee schedule,6983.56,21354.32,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21354.32,,,,,,,fee schedule,6983.56,21354.32,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11006.6,,,,,,,fee schedule,6983.56,21354.32,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18122.7,,,,,,,fee schedule,6983.56,21354.32,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15758.87,,,,,,,fee schedule,6983.56,21354.32,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7332.74,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6983.56,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6983.56,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6983.56,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6983.56,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6983.56,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6983.56,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12570.41,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12570.41,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7332.74,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6983.56,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6983.56,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7332.74,,,,,,,fee schedule,6983.56,21354.32,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37621.35,,,,,,,fee schedule,17793.42,49557.53,
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,37618.15,,,,,,,fee schedule,17793.42,49557.53,
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,37618.15,,,,,,,fee schedule,17793.42,49557.53,
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30098.16,,,,,,,fee schedule,17793.42,49557.53,
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,49557.53,,,,,,,fee schedule,17793.42,49557.53,
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43093.51,,,,,,,fee schedule,17793.42,49557.53,
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],37646.54,37646.54,37646.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8544.31,8544.31,8544.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14945.67,14945.67,16658.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8544.31,8544.31,8544.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18683.09,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17793.42,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17793.42,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17793.42,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17793.42,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17793.42,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17793.42,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32028.16,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32028.16,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18683.09,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17793.42,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17793.42,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18683.09,,,,,,,fee schedule,17793.42,49557.53,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24759.38,,,,,,,fee schedule,11967.14,32614.83,
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27263.06,,,,,,,fee schedule,11967.14,32614.83,
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27263.06,,,,,,,fee schedule,11967.14,32614.83,
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19808.22,,,,,,,fee schedule,11967.14,32614.83,
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32614.83,,,,,,,fee schedule,11967.14,32614.83,
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28360.72,,,,,,,fee schedule,11967.14,32614.83,
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21223.78,21223.78,21223.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23118.94,23118.94,23118.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6648.55,6648.55,6648.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8524.12,8524.12,8524.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23813.81,23813.81,26019.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12565.5,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21540.85,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21540.85,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12565.5,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12565.5,,,,,,,fee schedule,11967.14,32614.83,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15039.37,,,,,,,fee schedule,7564.11,19810.94,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14383.61,,,,,,,fee schedule,7564.11,19810.94,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14383.61,,,,,,,fee schedule,7564.11,19810.94,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12031.93,,,,,,,fee schedule,7564.11,19810.94,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19810.94,,,,,,,fee schedule,7564.11,19810.94,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17226.9,,,,,,,fee schedule,7564.11,19810.94,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14394.47,14394.47,14394.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4729.32,4729.32,4729.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4729.32,4729.32,4729.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17558.77,17558.77,17558.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7942.32,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7564.11,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7564.11,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7564.11,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7564.11,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7564.11,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7564.11,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13615.4,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13615.4,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7942.32,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7564.11,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7564.11,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7942.32,,,,,,,fee schedule,7564.11,19810.94,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33740.22,,,,,,,fee schedule,16035.32,66667.4,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,66667.4,,,,,,,fee schedule,16035.32,66667.4,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,66667.4,,,,,,,fee schedule,16035.32,66667.4,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26993.14,,,,,,,fee schedule,16035.32,66667.4,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44445.03,,,,,,,fee schedule,16035.32,66667.4,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38647.86,,,,,,,fee schedule,16035.32,66667.4,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24678.5,24678.5,24678.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8744.04,8744.04,8744.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16276.79,16276.79,16276.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16837.09,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16035.32,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16035.32,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16035.32,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16035.32,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16035.32,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16035.32,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28863.58,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28863.58,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16837.09,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16035.32,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16035.32,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16837.09,,,,,,,fee schedule,16035.32,66667.4,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19634.84,,,,,,,fee schedule,9645.79,34916.21,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,34916.21,,,,,,,fee schedule,9645.79,34916.21,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,34916.21,,,,,,,fee schedule,9645.79,34916.21,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15708.44,,,,,,,fee schedule,9645.79,34916.21,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25864.42,,,,,,,fee schedule,9645.79,34916.21,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22490.8,,,,,,,fee schedule,9645.79,34916.21,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20633.76,20633.76,20633.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9437.38,9437.38,9437.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14091.22,14091.22,14091.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10128.08,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9645.79,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9645.79,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9645.79,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9645.79,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9645.79,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9645.79,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17362.42,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17362.42,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10128.08,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9645.79,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9645.79,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10128.08,,,,,,,fee schedule,9645.79,34916.21,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14412.89,,,,,,,fee schedule,7280.33,25939.95,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25939.95,,,,,,,fee schedule,7280.33,25939.95,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25939.95,,,,,,,fee schedule,7280.33,25939.95,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11530.73,,,,,,,fee schedule,7280.33,25939.95,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18985.69,,,,,,,fee schedule,7280.33,25939.95,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16509.3,,,,,,,fee schedule,7280.33,25939.95,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6217.99,6217.99,6217.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],9917.92,9917.92,9917.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7644.35,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7280.33,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7280.33,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7280.33,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7280.33,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7280.33,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7280.33,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13104.59,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13104.59,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7644.35,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7280.33,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7280.33,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7644.35,,,,,,,fee schedule,7280.33,25939.95,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,47400.57,,,,,,,fee schedule,22223.26,73115.83,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,73115.83,,,,,,,fee schedule,22223.26,73115.83,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,73115.83,,,,,,,fee schedule,22223.26,73115.83,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,37921.82,,,,,,,fee schedule,22223.26,73115.83,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,62439.42,,,,,,,fee schedule,22223.26,73115.83,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,54295.15,,,,,,,fee schedule,22223.26,73115.83,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],70701.53,48375,90369.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7374.23,7374.23,7374.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",354818.8,354818.8,354818.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],49627.11,49627.11,49627.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],24492.47,24492.47,24492.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23334.42,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22223.26,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22223.26,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22223.26,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22223.26,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22223.26,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22223.26,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40001.87,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,40001.87,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23334.42,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22223.26,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22223.26,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23334.42,,,,,,,fee schedule,22223.26,73115.83,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22029.99,,,,,,,fee schedule,10730.76,35769.27,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35769.27,,,,,,,fee schedule,10730.76,35769.27,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35769.27,,,,,,,fee schedule,10730.76,35769.27,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17624.62,,,,,,,fee schedule,10730.76,35769.27,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29019.47,,,,,,,fee schedule,10730.76,35769.27,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25234.33,,,,,,,fee schedule,10730.76,35769.27,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33116.11,29676.96,41925,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7604.62,7604.62,7604.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],15645.17,15645.17,15645.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7604.62,7604.62,7604.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23135.3,21298.87,23150.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9644.47,9644.47,10478.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],54746.3,54746.3,54746.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,7968.69,7968.69,7968.69,1 through 10,percent of total billed charges,,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11267.3,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10730.76,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10730.76,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10730.76,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10730.76,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10730.76,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10730.76,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19315.37,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19315.37,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11267.3,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10730.76,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10730.76,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11267.3,,,,,,,fee schedule,10730.76,35769.27,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15971.45,,,,,,,fee schedule,7986.33,29073.63,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29073.63,,,,,,,fee schedule,7986.33,29073.63,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29073.63,,,,,,,fee schedule,7986.33,29073.63,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12777.62,,,,,,,fee schedule,7986.33,29073.63,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21038.74,,,,,,,fee schedule,7986.33,29073.63,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18294.56,,,,,,,fee schedule,7986.33,29073.63,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],21507.07,9282.98,27787.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6423.18,6423.18,6423.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7604.62,7604.62,7604.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6423.18,6423.18,6423.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12885.33,12885.33,12885.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6423.18,6423.18,6423.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,42111.14,42111.14,42111.14,1 through 10,percent of total billed charges,,,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8385.65,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7986.33,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7986.33,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7986.33,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7986.33,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7986.33,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7986.33,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14375.39,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14375.39,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8385.65,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7986.33,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7986.33,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8385.65,,,,,,,fee schedule,7986.33,29073.63,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36880.27,,,,,,,fee schedule,17457.72,48581.33,
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43380.64,,,,,,,fee schedule,17457.72,48581.33,
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43380.64,,,,,,,fee schedule,17457.72,48581.33,
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29505.27,,,,,,,fee schedule,17457.72,48581.33,
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48581.33,,,,,,,fee schedule,17457.72,48581.33,
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42244.64,,,,,,,fee schedule,17457.72,48581.33,
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18330.61,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17457.72,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17457.72,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17457.72,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17457.72,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17457.72,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17457.72,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31423.9,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31423.9,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18330.61,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17457.72,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17457.72,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18330.61,,,,,,,fee schedule,17457.72,48581.33,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23057.57,,,,,,,fee schedule,11196.24,30373.08,
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24871.01,,,,,,,fee schedule,11196.24,30373.08,
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24871.01,,,,,,,fee schedule,11196.24,30373.08,
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18446.72,,,,,,,fee schedule,11196.24,30373.08,
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30373.08,,,,,,,fee schedule,11196.24,30373.08,
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26411.38,,,,,,,fee schedule,11196.24,30373.08,
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6648.55,6648.55,6648.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5785.6,5785.6,5785.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6648.55,6648.55,6648.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,52133.42,52133.42,52133.42,1 through 10,percent of total billed charges,,,
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11756.05,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11196.24,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11196.24,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11196.24,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11196.24,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11196.24,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11196.24,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20153.23,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20153.23,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11756.05,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11196.24,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11196.24,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11756.05,,,,,,,fee schedule,11196.24,30373.08,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16695.34,,,,,,,fee schedule,8314.25,21992.3,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21921.87,,,,,,,fee schedule,8314.25,21992.3,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21921.87,,,,,,,fee schedule,8314.25,21992.3,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13356.75,,,,,,,fee schedule,8314.25,21992.3,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21992.3,,,,,,,fee schedule,8314.25,21992.3,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19123.74,,,,,,,fee schedule,8314.25,21992.3,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4729.32,4729.32,4729.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7828.11,7828.11,7828.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8729.96,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8314.25,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8314.25,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8314.25,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8314.25,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8314.25,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8314.25,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14965.65,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14965.65,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8729.96,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8314.25,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8314.25,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8729.96,,,,,,,fee schedule,8314.25,21992.3,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32013.58,,,,,,,fee schedule,15253.18,42496.25,
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42496.25,,,,,,,fee schedule,15253.18,42496.25,
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42496.25,,,,,,,fee schedule,15253.18,42496.25,
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25611.78,,,,,,,fee schedule,15253.18,42496.25,
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42170.58,,,,,,,fee schedule,15253.18,42496.25,
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36670.07,,,,,,,fee schedule,15253.18,42496.25,
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8744.04,8744.04,8744.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34248.43,34248.43,34248.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13938.01,13938.01,13938.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16015.84,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15253.18,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15253.18,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15253.18,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15253.18,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15253.18,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15253.18,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27455.72,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27455.72,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16015.84,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15253.18,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15253.18,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16015.84,,,,,,,fee schedule,15253.18,42496.25,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18360.87,,,,,,,fee schedule,9068.7,24432.3,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24432.3,,,,,,,fee schedule,9068.7,24432.3,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24432.3,,,,,,,fee schedule,9068.7,24432.3,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14689.22,,,,,,,fee schedule,9068.7,24432.3,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24186.25,,,,,,,fee schedule,9068.7,24432.3,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21031.52,,,,,,,fee schedule,9068.7,24432.3,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9662.5,9662.5,9662.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20155.32,20155.32,20155.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6217.99,6217.99,6217.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22264.91,13123.87,23671.85,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6987.43,6987.43,6987.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6987.43,6987.43,8744.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16091.01,15934.3,19345.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8032.59,6615.93,8872.85,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],9788.8,9788.8,9788.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,12089.92,12089.92,12089.92,1 through 10,percent of total billed charges,,,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,7561.91,7561.91,7561.91,1 through 10,percent of total billed charges,,,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9522.14,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9068.7,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9068.7,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9068.7,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9068.7,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9068.7,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9068.7,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16323.66,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16323.66,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9522.14,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9068.7,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9068.7,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9522.14,,,,,,,fee schedule,9068.7,24432.3,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24759.38,,,,,,,fee schedule,11967.14,32868.87,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32868.87,,,,,,,fee schedule,11967.14,32868.87,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32868.87,,,,,,,fee schedule,11967.14,32868.87,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19808.22,,,,,,,fee schedule,11967.14,32868.87,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32614.83,,,,,,,fee schedule,11967.14,32868.87,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28360.72,,,,,,,fee schedule,11967.14,32868.87,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],29785.43,29785.43,29785.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11541.39,11541.39,18936.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12565.5,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21540.85,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21540.85,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12565.5,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11967.14,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12565.5,,,,,,,fee schedule,11967.14,32868.87,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15854.94,,,,,,,fee schedule,7933.56,20885.27,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20859.9,,,,,,,fee schedule,7933.56,20885.27,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20859.9,,,,,,,fee schedule,7933.56,20885.27,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12684.41,,,,,,,fee schedule,7933.56,20885.27,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20885.27,,,,,,,fee schedule,7933.56,20885.27,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18161.1,,,,,,,fee schedule,7933.56,20885.27,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],10575.77,10575.77,10575.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6768.61,6768.61,6768.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],14626.54,14626.54,14626.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6768.61,6768.61,6768.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7613.74,6751.57,28410.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,6786.94,6786.94,6786.94,1 through 10,percent of total billed charges,,,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8330.24,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7933.56,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7933.56,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7933.56,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7933.56,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7933.56,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7933.56,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14280.41,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14280.41,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8330.24,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7933.56,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7933.56,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8330.24,,,,,,,fee schedule,7933.56,20885.27,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25246.43,,,,,,,fee schedule,12187.76,43819.36,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43819.36,,,,,,,fee schedule,12187.76,43819.36,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43819.36,,,,,,,fee schedule,12187.76,43819.36,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20197.87,,,,,,,fee schedule,12187.76,43819.36,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33256.41,,,,,,,fee schedule,12187.76,43819.36,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28918.62,,,,,,,fee schedule,12187.76,43819.36,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13656.66,13656.66,13656.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26983.58,26983.58,30472.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12797.15,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12187.76,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12187.76,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12187.76,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12187.76,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12187.76,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12187.76,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21937.97,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21937.97,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12797.15,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12187.76,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12187.76,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12797.15,,,,,,,fee schedule,12187.76,43819.36,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15864.49,,,,,,,fee schedule,7937.88,24700.4,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24700.4,,,,,,,fee schedule,7937.88,24700.4,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24700.4,,,,,,,fee schedule,7937.88,24700.4,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12692.05,,,,,,,fee schedule,7937.88,24700.4,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20897.85,,,,,,,fee schedule,7937.88,24700.4,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18172.04,,,,,,,fee schedule,7937.88,24700.4,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13006.7,13006.7,13006.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4776.25,4776.25,4776.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17881.27,17881.27,17881.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8334.77,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7937.88,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7937.88,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7937.88,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7937.88,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7937.88,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7937.88,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14288.18,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14288.18,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8334.77,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7937.88,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7937.88,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8334.77,,,,,,,fee schedule,7937.88,24700.4,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28399.85,,,,,,,fee schedule,13616.21,45191.22,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45191.22,,,,,,,fee schedule,13616.21,45191.22,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45191.22,,,,,,,fee schedule,13616.21,45191.22,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22720.69,,,,,,,fee schedule,13616.21,45191.22,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37410.31,,,,,,,fee schedule,13616.21,45191.22,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32530.71,,,,,,,fee schedule,13616.21,45191.22,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13342.38,13342.38,13342.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],51029.93,51029.93,51029.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7115.5,7115.5,7115.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13600.02,13600.02,13600.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14297.02,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13616.21,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13616.21,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13616.21,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13616.21,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13616.21,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13616.21,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24509.18,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24509.18,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14297.02,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13616.21,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13616.21,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14297.02,,,,,,,fee schedule,13616.21,45191.22,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17060.16,,,,,,,fee schedule,8479.5,22472.86,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14777.06,,,,,,,fee schedule,8479.5,22472.86,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14777.06,,,,,,,fee schedule,8479.5,22472.86,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13648.61,,,,,,,fee schedule,8479.5,22472.86,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22472.86,,,,,,,fee schedule,8479.5,22472.86,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19541.62,,,,,,,fee schedule,8479.5,22472.86,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5240.37,5240.37,5240.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7837.9,7837.9,7837.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13050.01,6556.29,14317.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3952.25,3952.25,3952.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],10505.72,10505.72,10505.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4776.25,4776.25,4776.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6648.55,6648.55,6648.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],10491.56,10491.56,10491.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4729.32,3952.25,8816.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17256.88,7765.15,17928.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9262.12,9262.12,9262.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],11100.24,11100.24,11100.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,18176.74,18176.74,18176.74,1 through 10,percent of total billed charges,,,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,12508.04,12508.04,12508.04,1 through 10,percent of total billed charges,,,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8903.48,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8479.5,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8479.5,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8479.5,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8479.5,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8479.5,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8479.5,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15263.1,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15263.1,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8903.48,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8479.5,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8479.5,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8903.48,,,,,,,fee schedule,8479.5,22472.86,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35619.66,,,,,,,fee schedule,16886.68,66232.17,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,66232.17,,,,,,,fee schedule,16886.68,66232.17,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,66232.17,,,,,,,fee schedule,16886.68,66232.17,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28496.75,,,,,,,fee schedule,16886.68,66232.17,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46920.77,,,,,,,fee schedule,16886.68,66232.17,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40800.67,,,,,,,fee schedule,16886.68,66232.17,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],38166.67,38166.67,38166.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45150,45150,45150,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8040,8040,8040,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21757.25,12798.06,38987.05,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20238.94,20238.94,20238.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17731.01,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16886.68,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16886.68,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16886.68,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16886.68,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16886.68,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16886.68,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30396.02,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30396.02,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17731.01,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16886.68,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16886.68,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17731.01,,,,,,,fee schedule,16886.68,66232.17,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21508.56,,,,,,,fee schedule,10494.56,28332.61,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26622.39,,,,,,,fee schedule,10494.56,28332.61,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26622.39,,,,,,,fee schedule,10494.56,28332.61,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17207.46,,,,,,,fee schedule,10494.56,28332.61,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28332.61,,,,,,,fee schedule,10494.56,28332.61,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24637.05,,,,,,,fee schedule,10494.56,28332.61,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24440.52,24440.52,33068.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21200.83,15889.55,35165.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12060,8040,14070,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22575,19978.64,51600,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30860.17,30860.17,30860.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9045,9045,9045,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15964.7,15964.7,15964.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8040,4020,24120,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22857.71,22857.71,22857.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22857.71,22810.39,22857.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20481.36,15919.45,29404.96,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16435.62,16435.62,16435.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],26106.99,26106.99,26106.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11019.29,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10494.56,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10494.56,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10494.56,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10494.56,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10494.56,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10494.56,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18890.21,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18890.21,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11019.29,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10494.56,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10494.56,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11019.29,,,,,,,fee schedule,10494.56,28332.61,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15354.52,,,,,,,fee schedule,7706.87,20285.39,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20285.39,,,,,,,fee schedule,7706.87,20285.39,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20285.39,,,,,,,fee schedule,7706.87,20285.39,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12284.06,,,,,,,fee schedule,7706.87,20285.39,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20226.08,,,,,,,fee schedule,7706.87,20285.39,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17587.89,,,,,,,fee schedule,7706.87,20285.39,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2110.66,2110.66,2110.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],53568,53568,53568,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8040,8040,8040,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15190.48,15190.48,16135.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20186.3,14834.76,24158.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],32256.66,32256.66,32256.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8092.21,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7706.87,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7706.87,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7706.87,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7706.87,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7706.87,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7706.87,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13872.37,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13872.37,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8092.21,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7706.87,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7706.87,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8092.21,,,,,,,fee schedule,7706.87,20285.39,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27213.74,,,,,,,fee schedule,13078.92,35847.88,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31897.43,,,,,,,fee schedule,13078.92,35847.88,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31897.43,,,,,,,fee schedule,13078.92,35847.88,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21771.77,,,,,,,fee schedule,13078.92,35847.88,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35847.88,,,,,,,fee schedule,13078.92,35847.88,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31172.07,,,,,,,fee schedule,13078.92,35847.88,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6328.77,6328.77,6328.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7035,7035,7035,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12875.27,12875.27,12875.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13732.87,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13078.92,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13078.92,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13078.92,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13078.92,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13078.92,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13078.92,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23542.06,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23542.06,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13732.87,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13078.92,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13078.92,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13732.87,,,,,,,fee schedule,13078.92,35847.88,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17104.09,,,,,,,fee schedule,8499.4,24251.24,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24251.24,,,,,,,fee schedule,8499.4,24251.24,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24251.24,,,,,,,fee schedule,8499.4,24251.24,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13683.76,,,,,,,fee schedule,8499.4,24251.24,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22530.73,,,,,,,fee schedule,8499.4,24251.24,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19591.94,,,,,,,fee schedule,8499.4,24251.24,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20373.94,20373.94,20373.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8127.62,8127.62,8127.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8924.37,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8499.4,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8499.4,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8499.4,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8499.4,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8499.4,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8499.4,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15298.92,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15298.92,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8924.37,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8499.4,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8499.4,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8924.37,,,,,,,fee schedule,8499.4,24251.24,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29482.82,,,,,,,fee schedule,14106.78,51047.73,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51047.73,,,,,,,fee schedule,14106.78,51047.73,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51047.73,,,,,,,fee schedule,14106.78,51047.73,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23587.1,,,,,,,fee schedule,14106.78,51047.73,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38836.88,,,,,,,fee schedule,14106.78,51047.73,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33771.2,,,,,,,fee schedule,14106.78,51047.73,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],54825,54825,54825,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6768.61,6768.61,6768.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13747.24,13747.24,13747.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14812.12,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14106.78,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14106.78,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14106.78,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14106.78,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14106.78,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14106.78,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25392.2,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25392.2,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14812.12,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14106.78,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14106.78,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14812.12,,,,,,,fee schedule,14106.78,51047.73,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18611.08,,,,,,,fee schedule,9182.04,24515.85,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22886.34,,,,,,,fee schedule,9182.04,24515.85,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22886.34,,,,,,,fee schedule,9182.04,24515.85,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14889.4,,,,,,,fee schedule,9182.04,24515.85,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24515.85,,,,,,,fee schedule,9182.04,24515.85,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21318.13,,,,,,,fee schedule,9182.04,24515.85,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4981.31,4981.31,4981.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9128.98,8143.78,9156.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4776.25,4776.25,4776.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,6131.34,6131.34,6131.34,1 through 10,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9641.14,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9182.04,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9182.04,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9182.04,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9182.04,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9182.04,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9182.04,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16527.67,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16527.67,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9641.14,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9182.04,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9182.04,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9641.14,,,,,,,fee schedule,9182.04,24515.85,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14311.66,,,,,,,fee schedule,7234.47,18852.34,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,15950.46,,,,,,,fee schedule,7234.47,18852.34,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,15950.46,,,,,,,fee schedule,7234.47,18852.34,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11449.74,,,,,,,fee schedule,7234.47,18852.34,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18852.34,,,,,,,fee schedule,7234.47,18852.34,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16393.34,,,,,,,fee schedule,7234.47,18852.34,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7065.36,7065.36,7065.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15541.97,15541.97,15541.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3952.25,3952.25,5657.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9357.2,9357.2,9357.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7596.19,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7234.47,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7234.47,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7234.47,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7234.47,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7234.47,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7234.47,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13022.05,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13022.05,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7596.19,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7234.47,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7234.47,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7596.19,,,,,,,fee schedule,7234.47,18852.34,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56175.13,,,,,,,fee schedule,26198.01,73997.9,
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,53690.47,,,,,,,fee schedule,26198.01,73997.9,
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,53690.47,,,,,,,fee schedule,26198.01,73997.9,
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44941.71,,,,,,,fee schedule,26198.01,73997.9,
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,73997.9,,,,,,,fee schedule,26198.01,73997.9,
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,64346,,,,,,,fee schedule,26198.01,73997.9,
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5162.61,5162.61,5162.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27507.91,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26198.01,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26198.01,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26198.01,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26198.01,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26198.01,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26198.01,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47156.42,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,47156.42,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27507.91,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26198.01,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26198.01,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27507.91,,,,,,,fee schedule,26198.01,73997.9,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32269.52,,,,,,,fee schedule,15369.12,42507.72,
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41890.4,,,,,,,fee schedule,15369.12,42507.72,
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41890.4,,,,,,,fee schedule,15369.12,42507.72,
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25816.54,,,,,,,fee schedule,15369.12,42507.72,
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42507.72,,,,,,,fee schedule,15369.12,42507.72,
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36963.24,,,,,,,fee schedule,15369.12,42507.72,
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15271.83,15271.83,15271.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17474.84,17474.84,17474.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12912.68,12912.68,12912.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16137.58,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15369.12,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15369.12,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15369.12,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15369.12,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15369.12,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15369.12,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27664.42,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27664.42,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16137.58,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15369.12,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15369.12,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16137.58,,,,,,,fee schedule,15369.12,42507.72,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21894.38,,,,,,,fee schedule,10669.33,28840.84,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28213.61,,,,,,,fee schedule,10669.33,28840.84,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28213.61,,,,,,,fee schedule,10669.33,28840.84,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17516.13,,,,,,,fee schedule,10669.33,28840.84,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28840.84,,,,,,,fee schedule,10669.33,28840.84,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25078.99,,,,,,,fee schedule,10669.33,28840.84,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7158.17,7158.17,7158.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22929.97,22929.97,22929.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11202.8,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10669.33,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10669.33,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10669.33,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10669.33,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10669.33,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10669.33,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19204.79,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19204.79,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11202.8,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10669.33,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10669.33,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11202.8,,,,,,,fee schedule,10669.33,28840.84,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,125132,,,,,,,fee schedule,57434.45,180058.05,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,180058.05,,,,,,,fee schedule,57434.45,180058.05,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,180058.05,,,,,,,fee schedule,57434.45,180058.05,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,100109.19,,,,,,,fee schedule,57434.45,180058.05,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,164832.83,,,,,,,fee schedule,57434.45,180058.05,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,143332.9,,,,,,,fee schedule,57434.45,180058.05,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,60306.17,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,57434.45,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,57434.45,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,57434.45,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,57434.45,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,57434.45,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,57434.45,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,103382.01,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,103382.01,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,60306.17,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,57434.45,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,57434.45,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,60306.17,,,,,,,fee schedule,57434.45,180058.05,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66303.88,,,,,,,fee schedule,30786.18,87340.22,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,61705.74,,,,,,,fee schedule,30786.18,87340.22,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,61705.74,,,,,,,fee schedule,30786.18,87340.22,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,53045.01,,,,,,,fee schedule,30786.18,87340.22,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,87340.22,,,,,,,fee schedule,30786.18,87340.22,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,75948.02,,,,,,,fee schedule,30786.18,87340.22,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32325.49,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30786.18,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,30786.18,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,30786.18,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,30786.18,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,30786.18,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,30786.18,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55415.12,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,55415.12,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,32325.49,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,30786.18,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,30786.18,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,32325.49,,,,,,,fee schedule,30786.18,87340.22,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34322.77,,,,,,,fee schedule,16299.21,45212.41,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,37068.01,,,,,,,fee schedule,16299.21,45212.41,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,37068.01,,,,,,,fee schedule,16299.21,45212.41,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27459.2,,,,,,,fee schedule,16299.21,45212.41,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45212.41,,,,,,,fee schedule,16299.21,45212.41,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39315.14,,,,,,,fee schedule,16299.21,45212.41,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17114.17,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16299.21,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16299.21,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16299.21,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16299.21,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16299.21,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16299.21,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29338.58,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29338.58,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17114.17,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16299.21,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16299.21,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17114.17,,,,,,,fee schedule,16299.21,45212.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,93613.12,,,,,,,fee schedule,43156.86,158630.61,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,158630.61,,,,,,,fee schedule,43156.86,158630.61,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,158630.61,,,,,,,fee schedule,43156.86,158630.61,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,74893.18,,,,,,,fee schedule,43156.86,158630.61,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,123313.9,,,,,,,fee schedule,43156.86,158630.61,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,107229.48,,,,,,,fee schedule,43156.86,158630.61,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,45314.7,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43156.86,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,43156.86,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,43156.86,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,43156.86,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,43156.86,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,43156.86,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,77682.35,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,77682.35,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,45314.7,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,43156.86,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,43156.86,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,45314.7,,,,,,,fee schedule,43156.86,158630.61,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50628.48,,,,,,,fee schedule,23685.45,101733.34,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,101733.34,,,,,,,fee schedule,23685.45,101733.34,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,101733.34,,,,,,,fee schedule,23685.45,101733.34,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,40504.23,,,,,,,fee schedule,23685.45,101733.34,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,66691.45,,,,,,,fee schedule,23685.45,101733.34,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,57992.57,,,,,,,fee schedule,23685.45,101733.34,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24869.72,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23685.45,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,23685.45,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,23685.45,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,23685.45,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,23685.45,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,23685.45,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42633.81,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,42633.81,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24869.72,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,23685.45,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,23685.45,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24869.72,,,,,,,fee schedule,23685.45,101733.34,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30682.3,,,,,,,fee schedule,14650.13,50532.41,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,50532.41,,,,,,,fee schedule,14650.13,50532.41,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,50532.41,,,,,,,fee schedule,14650.13,50532.41,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24546.72,,,,,,,fee schedule,14650.13,50532.41,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40416.93,,,,,,,fee schedule,14650.13,50532.41,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35145.16,,,,,,,fee schedule,14650.13,50532.41,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],48959.61,48959.61,48959.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15382.64,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14650.13,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14650.13,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14650.13,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14650.13,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14650.13,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14650.13,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26370.23,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26370.23,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15382.64,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14650.13,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14650.13,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15382.64,,,,,,,fee schedule,14650.13,50532.41,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61855.48,,,,,,,fee schedule,28771.12,81480.47,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,64564.35,,,,,,,fee schedule,28771.12,81480.47,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,64564.35,,,,,,,fee schedule,28771.12,81480.47,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,49486.16,,,,,,,fee schedule,28771.12,81480.47,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,81480.47,,,,,,,fee schedule,28771.12,81480.47,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,70852.58,,,,,,,fee schedule,28771.12,81480.47,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],64613.08,64613.08,64613.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7414.17,7414.17,7414.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],48191.15,48191.15,48191.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25773.66,25773.66,27931.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30209.68,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28771.12,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28771.12,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28771.12,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28771.12,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28771.12,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28771.12,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51788.02,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,51788.02,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30209.68,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28771.12,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28771.12,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30209.68,,,,,,,fee schedule,28771.12,81480.47,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33004.87,,,,,,,fee schedule,15702.22,59076.92,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,59076.92,,,,,,,fee schedule,15702.22,59076.92,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,59076.92,,,,,,,fee schedule,15702.22,59076.92,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26404.84,,,,,,,fee schedule,15702.22,59076.92,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43476.38,,,,,,,fee schedule,15702.22,59076.92,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37805.55,,,,,,,fee schedule,15702.22,59076.92,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],59121.51,59121.51,59121.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35585.21,35585.21,35585.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7414.17,7414.17,7414.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16683.89,16683.89,16683.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13411.93,13411.93,13411.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16010.54,16010.54,16010.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16487.33,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15702.22,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15702.22,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15702.22,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15702.22,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15702.22,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15702.22,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28264,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28264,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16487.33,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15702.22,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15702.22,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16487.33,,,,,,,fee schedule,15702.22,59076.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27563.27,,,,,,,fee schedule,13237.25,57064.4,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57064.4,,,,,,,fee schedule,13237.25,57064.4,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57064.4,,,,,,,fee schedule,13237.25,57064.4,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22051.4,,,,,,,fee schedule,13237.25,57064.4,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,36308.31,,,,,,,fee schedule,13237.25,57064.4,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31572.44,,,,,,,fee schedule,13237.25,57064.4,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25755.01,25755.01,26993.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12629.53,12629.53,12629.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],18871.41,18871.41,18871.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25707.62,25707.62,25707.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26230.13,26230.13,26230.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12665.18,12665.18,12665.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6428.09,6428.09,6428.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13899.11,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13237.25,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13237.25,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13237.25,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13237.25,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13237.25,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13237.25,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23827.05,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23827.05,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13899.11,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13237.25,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13237.25,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13899.11,,,,,,,fee schedule,13237.25,57064.4,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36798.14,,,,,,,fee schedule,17420.51,110305.7,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,110305.7,,,,,,,fee schedule,17420.51,110305.7,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,110305.7,,,,,,,fee schedule,17420.51,110305.7,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29439.57,,,,,,,fee schedule,17420.51,110305.7,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48473.14,,,,,,,fee schedule,17420.51,110305.7,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42150.56,,,,,,,fee schedule,17420.51,110305.7,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18291.54,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17420.51,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17420.51,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17420.51,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17420.51,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17420.51,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17420.51,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31356.92,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31356.92,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18291.54,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17420.51,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17420.51,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18291.54,,,,,,,fee schedule,17420.51,110305.7,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32936.11,,,,,,,fee schedule,15671.07,99741.71,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,99741.71,,,,,,,fee schedule,15671.07,99741.71,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,99741.71,,,,,,,fee schedule,15671.07,99741.71,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26349.83,,,,,,,fee schedule,15671.07,99741.71,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43385.8,,,,,,,fee schedule,15671.07,99741.71,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37726.79,,,,,,,fee schedule,15671.07,99741.71,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],95234.58,95234.58,95234.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16454.62,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15671.07,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15671.07,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15671.07,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15671.07,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15671.07,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15671.07,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28207.93,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28207.93,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16454.62,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15671.07,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15671.07,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16454.62,,,,,,,fee schedule,15671.07,99741.71,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40887.46,,,,,,,fee schedule,19272.92,88982.72,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,88982.72,,,,,,,fee schedule,19272.92,88982.72,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,88982.72,,,,,,,fee schedule,19272.92,88982.72,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32711.14,,,,,,,fee schedule,19272.92,88982.72,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53859.88,,,,,,,fee schedule,19272.92,88982.72,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46834.68,,,,,,,fee schedule,19272.92,88982.72,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16148.61,16148.61,16148.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9117.84,9117.84,9117.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20236.57,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19272.92,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19272.92,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19272.92,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19272.92,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19272.92,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19272.92,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34691.26,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34691.26,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20236.57,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19272.92,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19272.92,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20236.57,,,,,,,fee schedule,19272.92,88982.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36845.89,,,,,,,fee schedule,17442.14,77638.78,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,77638.78,,,,,,,fee schedule,17442.14,77638.78,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,77638.78,,,,,,,fee schedule,17442.14,77638.78,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29477.77,,,,,,,fee schedule,17442.14,77638.78,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48536.04,,,,,,,fee schedule,17442.14,77638.78,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42205.25,,,,,,,fee schedule,17442.14,77638.78,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],75075.14,75075.14,75075.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],39994.81,39994.81,39994.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17754.9,17754.9,17754.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18314.25,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17442.14,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17442.14,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17442.14,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17442.14,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17442.14,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17442.14,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31395.85,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31395.85,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18314.25,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17442.14,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17442.14,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18314.25,,,,,,,fee schedule,17442.14,77638.78,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36964.31,,,,,,,fee schedule,17495.79,48692.03,
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36953.11,,,,,,,fee schedule,17495.79,48692.03,
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36953.11,,,,,,,fee schedule,17495.79,48692.03,
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29572.51,,,,,,,fee schedule,17495.79,48692.03,
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48692.03,,,,,,,fee schedule,17495.79,48692.03,
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42340.9,,,,,,,fee schedule,17495.79,48692.03,
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17834.26,17834.26,17834.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18370.58,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17495.79,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17495.79,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17495.79,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17495.79,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17495.79,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17495.79,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31492.42,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31492.42,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18370.58,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17495.79,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17495.79,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18370.58,,,,,,,fee schedule,17495.79,48692.03,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22658.38,,,,,,,fee schedule,11015.41,29847.24,
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22036.77,,,,,,,fee schedule,11015.41,29847.24,
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22036.77,,,,,,,fee schedule,11015.41,29847.24,
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18127.35,,,,,,,fee schedule,11015.41,29847.24,
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29847.24,,,,,,,fee schedule,11015.41,29847.24,
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25954.12,,,,,,,fee schedule,11015.41,29847.24,
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6760.97,6760.97,6760.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],11905.12,11905.12,11905.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11566.18,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11015.41,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11015.41,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11015.41,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11015.41,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11015.41,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11015.41,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19827.74,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19827.74,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11566.18,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11015.41,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11015.41,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11566.18,,,,,,,fee schedule,11015.41,29847.24,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16555.91,,,,,,,fee schedule,8251.09,21808.64,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14341.83,,,,,,,fee schedule,8251.09,21808.64,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14341.83,,,,,,,fee schedule,8251.09,21808.64,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13245.21,,,,,,,fee schedule,8251.09,21808.64,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21808.64,,,,,,,fee schedule,8251.09,21808.64,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18964.03,,,,,,,fee schedule,8251.09,21808.64,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8663.64,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8251.09,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8251.09,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8251.09,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8251.09,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8251.09,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8251.09,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14851.96,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14851.96,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8663.64,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8251.09,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8251.09,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8663.64,,,,,,,fee schedule,8251.09,21808.64,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40505.45,,,,,,,fee schedule,19099.87,72492.58,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,72492.58,,,,,,,fee schedule,19099.87,72492.58,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,72492.58,,,,,,,fee schedule,19099.87,72492.58,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32405.53,,,,,,,fee schedule,19099.87,72492.58,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53356.68,,,,,,,fee schedule,19099.87,72492.58,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46397.12,,,,,,,fee schedule,19099.87,72492.58,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19468.69,19468.69,19468.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20054.86,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19099.87,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19099.87,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19099.87,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19099.87,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19099.87,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19099.87,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34379.77,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34379.77,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20054.86,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19099.87,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19099.87,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20054.86,,,,,,,fee schedule,19099.87,72492.58,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20675.79,,,,,,,fee schedule,10117.33,27235.64,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19254.75,,,,,,,fee schedule,10117.33,27235.64,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19254.75,,,,,,,fee schedule,10117.33,27235.64,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16541.23,,,,,,,fee schedule,10117.33,27235.64,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27235.64,,,,,,,fee schedule,10117.33,27235.64,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23683.16,,,,,,,fee schedule,10117.33,27235.64,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],247.31,247.31,247.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15682.51,14646.87,19269.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3675.03,3675.03,3675.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3675.03,3675.03,3675.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3675.03,3675.03,3675.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14133.06,9726.34,21697.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9387.54,9387.54,9659.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,16195.18,16195.18,16195.18,1 through 10,percent of total billed charges,,,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,5968.65,5968.65,5968.65,1 through 10,percent of total billed charges,,,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10623.2,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10117.33,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10117.33,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10117.33,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10117.33,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10117.33,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10117.33,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18211.19,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18211.19,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10623.2,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10117.33,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10117.33,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10623.2,,,,,,,fee schedule,10117.33,27235.64,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31841.68,,,,,,,fee schedule,15175.31,47391.76,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,47391.76,,,,,,,fee schedule,15175.31,47391.76,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,47391.76,,,,,,,fee schedule,15175.31,47391.76,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25474.25,,,,,,,fee schedule,15175.31,47391.76,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41944.14,,,,,,,fee schedule,15175.31,47391.76,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36473.16,,,,,,,fee schedule,15175.31,47391.76,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15934.08,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15175.31,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15175.31,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15175.31,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15175.31,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15175.31,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15175.31,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27315.56,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27315.56,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15934.08,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15175.31,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15175.31,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15934.08,,,,,,,fee schedule,15175.31,47391.76,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21607.88,,,,,,,fee schedule,10539.55,28463.44,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25045.11,,,,,,,fee schedule,10539.55,28463.44,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25045.11,,,,,,,fee schedule,10539.55,28463.44,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17286.92,,,,,,,fee schedule,10539.55,28463.44,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28463.44,,,,,,,fee schedule,10539.55,28463.44,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24750.82,,,,,,,fee schedule,10539.55,28463.44,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11066.53,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10539.55,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10539.55,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10539.55,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10539.55,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10539.55,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10539.55,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18971.19,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18971.19,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11066.53,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10539.55,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10539.55,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11066.53,,,,,,,fee schedule,10539.55,28463.44,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14695.57,,,,,,,fee schedule,7408.38,19358.06,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17343.2,,,,,,,fee schedule,7408.38,19358.06,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17343.2,,,,,,,fee schedule,7408.38,19358.06,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11756.88,,,,,,,fee schedule,7408.38,19358.06,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19358.06,,,,,,,fee schedule,7408.38,19358.06,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16833.09,,,,,,,fee schedule,7408.38,19358.06,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7778.8,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7408.38,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7408.38,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7408.38,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7408.38,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7408.38,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7408.38,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13335.08,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13335.08,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7778.8,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7408.38,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7408.38,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7778.8,,,,,,,fee schedule,7408.38,19358.06,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19894.6,,,,,,,fee schedule,9763.46,26206.59,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20254.05,,,,,,,fee schedule,9763.46,26206.59,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20254.05,,,,,,,fee schedule,9763.46,26206.59,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15916.25,,,,,,,fee schedule,9763.46,26206.59,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26206.59,,,,,,,fee schedule,9763.46,26206.59,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22788.34,,,,,,,fee schedule,9763.46,26206.59,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10251.63,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9763.46,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9763.46,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9763.46,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9763.46,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9763.46,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9763.46,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17574.23,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17574.23,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10251.63,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9763.46,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9763.46,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10251.63,,,,,,,fee schedule,9763.46,26206.59,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11555.52,,,,,,,fee schedule,5985.98,15221.76,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,11263.86,,,,,,,fee schedule,5985.98,15221.76,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,11263.86,,,,,,,fee schedule,5985.98,15221.76,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9244.75,,,,,,,fee schedule,5985.98,15221.76,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15221.76,,,,,,,fee schedule,5985.98,15221.76,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13236.32,,,,,,,fee schedule,5985.98,15221.76,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6285.28,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5985.98,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5985.98,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5985.98,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5985.98,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5985.98,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5985.98,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10774.76,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,10774.76,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6285.28,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5985.98,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5985.98,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6285.28,,,,,,,fee schedule,5985.98,15221.76,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27146.89,,,,,,,fee schedule,13048.64,36914.81,
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36914.81,,,,,,,fee schedule,13048.64,36914.81,
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36914.81,,,,,,,fee schedule,13048.64,36914.81,
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21718.29,,,,,,,fee schedule,13048.64,36914.81,
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35759.82,,,,,,,fee schedule,13048.64,36914.81,
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31095.5,,,,,,,fee schedule,13048.64,36914.81,
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],11409.78,11409.78,11409.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7038.73,7038.73,7038.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7038.73,7038.73,7038.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12879.72,11687.95,12951.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13701.07,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13048.64,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13048.64,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13048.64,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13048.64,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13048.64,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13048.64,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23487.55,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23487.55,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13701.07,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13048.64,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13048.64,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13701.07,,,,,,,fee schedule,13048.64,36914.81,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16634.22,,,,,,,fee schedule,8286.56,21911.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17604.34,,,,,,,fee schedule,8286.56,21911.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17604.34,,,,,,,fee schedule,8286.56,21911.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13307.86,,,,,,,fee schedule,8286.56,21911.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21911.79,,,,,,,fee schedule,8286.56,21911.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19053.73,,,,,,,fee schedule,8286.56,21911.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8456.86,8456.86,8456.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6328.45,6328.45,6328.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5162.61,5162.61,5162.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15278.45,8955.41,17023.05,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4336.97,4336.97,4336.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],11192.31,11192.31,11192.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5162.61,4336.97,7038.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5162.61,4336.97,7397.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5162.61,4336.97,7038.73,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17681.2,17681.2,17681.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15007.21,7459.4,17490.93,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7824.01,6206.17,8019.26,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15435.98,15435.98,15435.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23.11,23.11,23.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7414.17,7414.17,7414.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],12313.17,9752,50380.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,9594,9594,9594,1 through 10,percent of total billed charges,,,
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,13208.22,13208.22,13208.22,1 through 10,percent of total billed charges,,,
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8700.89,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8286.56,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8286.56,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8286.56,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8286.56,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8286.56,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8286.56,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14915.81,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14915.81,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8700.89,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8286.56,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8286.56,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8700.89,,,,,,,fee schedule,8286.56,21911.79,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28117.17,,,,,,,fee schedule,13488.16,37037.95,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22917.68,,,,,,,fee schedule,13488.16,37037.95,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22917.68,,,,,,,fee schedule,13488.16,37037.95,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22494.54,,,,,,,fee schedule,13488.16,37037.95,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37037.95,,,,,,,fee schedule,13488.16,37037.95,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32206.91,,,,,,,fee schedule,13488.16,37037.95,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],18434.31,18434.31,18434.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18540.28,18540.28,18540.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13181.48,13181.48,13181.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14162.57,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13488.16,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13488.16,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13488.16,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13488.16,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13488.16,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13488.16,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24278.69,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24278.69,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14162.57,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13488.16,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13488.16,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14162.57,,,,,,,fee schedule,13488.16,37037.95,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17495.64,,,,,,,fee schedule,8676.77,23046.51,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19738.73,,,,,,,fee schedule,8676.77,23046.51,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19738.73,,,,,,,fee schedule,8676.77,23046.51,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13997.01,,,,,,,fee schedule,8676.77,23046.51,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23046.51,,,,,,,fee schedule,8676.77,23046.51,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20040.44,,,,,,,fee schedule,8676.77,23046.51,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],5561,5561,5561,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6023.18,6023.18,6023.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20003.63,20003.63,20003.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9042.54,6023.18,9042.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18540.28,18540.28,18540.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8361.73,8354.05,8413.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,13347.89,13347.89,13347.89,1 through 10,percent of total billed charges,,,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,1500,1500,1500,1 through 10,percent of total billed charges,,,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9110.61,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8676.77,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8676.77,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8676.77,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8676.77,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8676.77,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8676.77,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15618.19,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15618.19,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9110.61,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8676.77,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8676.77,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9110.61,,,,,,,fee schedule,8676.77,23046.51,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28902.18,,,,,,,fee schedule,13843.76,38808.95,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38808.95,,,,,,,fee schedule,13843.76,38808.95,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38808.95,,,,,,,fee schedule,13843.76,38808.95,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23122.57,,,,,,,fee schedule,13843.76,38808.95,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38072.02,,,,,,,fee schedule,13843.76,38808.95,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33106.11,,,,,,,fee schedule,13843.76,38808.95,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7623.72,5457.29,7863.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14535.95,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13843.76,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13843.76,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13843.76,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13843.76,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13843.76,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13843.76,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24918.77,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24918.77,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14535.95,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13843.76,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13843.76,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14535.95,,,,,,,fee schedule,13843.76,38808.95,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17312.28,,,,,,,fee schedule,8593.71,22804.97,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18746.4,,,,,,,fee schedule,8593.71,22804.97,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18746.4,,,,,,,fee schedule,8593.71,22804.97,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13850.32,,,,,,,fee schedule,8593.71,22804.97,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22804.97,,,,,,,fee schedule,8593.71,22804.97,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19830.41,,,,,,,fee schedule,8593.71,22804.97,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4725.98,4725.98,4725.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18127.39,18127.39,18127.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5457.29,5457.29,5457.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6685.66,6685.66,6685.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5457.29,5457.29,32918.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12461.93,7563.59,16896.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7321.37,7321.37,7831.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15882.82,15882.82,15882.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4772.43,4772.43,4772.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],15114.51,15114.51,15114.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,10965.01,10965.01,10965.01,1 through 10,percent of total billed charges,,,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,8172.9,8172.9,8172.9,1 through 10,percent of total billed charges,,,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9023.4,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8593.71,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8593.71,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8593.71,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8593.71,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8593.71,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8593.71,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15468.68,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15468.68,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9023.4,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8593.71,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8593.71,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9023.4,,,,,,,fee schedule,8593.71,22804.97,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41863.47,,,,,,,fee schedule,19715.03,84463.25,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,84463.25,,,,,,,fee schedule,19715.03,84463.25,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,84463.25,,,,,,,fee schedule,19715.03,84463.25,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33491.98,,,,,,,fee schedule,19715.03,84463.25,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,55145.56,,,,,,,fee schedule,19715.03,84463.25,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,47952.66,,,,,,,fee schedule,19715.03,84463.25,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],79811.78,79811.78,79811.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20700.78,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19715.03,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19715.03,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19715.03,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19715.03,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19715.03,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19715.03,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35487.05,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35487.05,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20700.78,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19715.03,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19715.03,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20700.78,,,,,,,fee schedule,19715.03,84463.25,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26726.69,,,,,,,fee schedule,12858.3,51538.67,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51538.67,,,,,,,fee schedule,12858.3,51538.67,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51538.67,,,,,,,fee schedule,12858.3,51538.67,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21382.12,,,,,,,fee schedule,12858.3,51538.67,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35206.3,,,,,,,fee schedule,12858.3,51538.67,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30614.18,,,,,,,fee schedule,12858.3,51538.67,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14638.14,14638.14,14638.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13501.22,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12858.3,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12858.3,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12858.3,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12858.3,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12858.3,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12858.3,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23144.94,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23144.94,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13501.22,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12858.3,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12858.3,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13501.22,,,,,,,fee schedule,12858.3,51538.67,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,66609.48,,,,,,,fee schedule,30924.61,87742.77,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60420.92,,,,,,,fee schedule,30924.61,87742.77,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60420.92,,,,,,,fee schedule,30924.61,87742.77,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,53289.49,,,,,,,fee schedule,30924.61,87742.77,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,87742.77,,,,,,,fee schedule,30924.61,87742.77,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,76298.07,,,,,,,fee schedule,30924.61,87742.77,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25067.04,25067.04,25067.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16798.57,16798.57,16798.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9053.04,9053.04,9053.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],77575.31,77575.31,77575.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32470.84,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30924.61,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,30924.61,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,30924.61,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,30924.61,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,30924.61,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,30924.61,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,55664.3,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,55664.3,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,32470.84,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,30924.61,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,30924.61,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,32470.84,,,,,,,fee schedule,30924.61,87742.77,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35722.8,,,,,,,fee schedule,16933.4,47056.64,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,39613.26,,,,,,,fee schedule,16933.4,47056.64,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,39613.26,,,,,,,fee schedule,16933.4,47056.64,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28579.27,,,,,,,fee schedule,16933.4,47056.64,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,47056.64,,,,,,,fee schedule,16933.4,47056.64,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40918.82,,,,,,,fee schedule,16933.4,47056.64,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9531.69,9531.69,9531.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9106.07,9106.07,9106.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9675,9675,9675,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],36780.12,21306.95,38490.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9675,9675,9675,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],21048.43,21048.43,21048.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10922.47,10922.47,10922.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10922.47,10054.11,10922.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29352.42,28680.78,36489.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15019.16,14553.66,16800.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9675,9675,9675,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],44491.7,44491.7,44491.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,20858.61,20858.61,20858.61,1 through 10,percent of total billed charges,,,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17780.07,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16933.4,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16933.4,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16933.4,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16933.4,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16933.4,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16933.4,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30480.12,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30480.12,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17780.07,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16933.4,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16933.4,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17780.07,,,,,,,fee schedule,16933.4,47056.64,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27089.59,,,,,,,fee schedule,13022.68,35684.34,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30744.93,,,,,,,fee schedule,13022.68,35684.34,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30744.93,,,,,,,fee schedule,13022.68,35684.34,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21672.45,,,,,,,fee schedule,13022.68,35684.34,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35684.34,,,,,,,fee schedule,13022.68,35684.34,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31029.87,,,,,,,fee schedule,13022.68,35684.34,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13673.81,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13022.68,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13022.68,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13022.68,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13022.68,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13022.68,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13022.68,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23440.82,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23440.82,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13673.81,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13022.68,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13022.68,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13673.81,,,,,,,fee schedule,13022.68,35684.34,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55149.46,,,,,,,fee schedule,25733.39,72646.81,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60626.36,,,,,,,fee schedule,25733.39,72646.81,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60626.36,,,,,,,fee schedule,25733.39,72646.81,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44121.15,,,,,,,fee schedule,25733.39,72646.81,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,72646.81,,,,,,,fee schedule,25733.39,72646.81,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,63171.14,,,,,,,fee schedule,25733.39,72646.81,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],58624.46,58624.46,58624.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],46740.33,46740.33,46740.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8787.7,8787.7,8787.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13479.42,13479.42,13479.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],41841.12,41841.12,41841.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27020.06,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25733.39,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25733.39,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25733.39,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25733.39,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25733.39,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25733.39,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46320.1,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,46320.1,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27020.06,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25733.39,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25733.39,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27020.06,,,,,,,fee schedule,25733.39,72646.81,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30565.79,,,,,,,fee schedule,14597.35,43749.72,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43749.72,,,,,,,fee schedule,14597.35,43749.72,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43749.72,,,,,,,fee schedule,14597.35,43749.72,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24453.51,,,,,,,fee schedule,14597.35,43749.72,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40263.45,,,,,,,fee schedule,14597.35,43749.72,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35011.7,,,,,,,fee schedule,14597.35,43749.72,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12852.53,12852.53,12852.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14367.84,14367.84,14367.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],39655.77,34006.88,42306.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6877.2,6877.2,6877.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],26772.46,26772.46,26772.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6877.2,6877.2,8787.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14645.62,14645.62,14645.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29379.08,29379.08,32120.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8787.7,6877.2,8900.59,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29812.43,29379.08,32052.58,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14253.28,12982.63,25908.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8787.7,8787.7,8787.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,28964.57,28964.57,28964.57,1 through 10,percent of total billed charges,,,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15327.22,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14597.35,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14597.35,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14597.35,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14597.35,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14597.35,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14597.35,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26275.23,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26275.23,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15327.22,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14597.35,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14597.35,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15327.22,,,,,,,fee schedule,14597.35,43749.72,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28810.5,,,,,,,fee schedule,13802.23,39804.76,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,39804.76,,,,,,,fee schedule,13802.23,39804.76,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,39804.76,,,,,,,fee schedule,13802.23,39804.76,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23049.23,,,,,,,fee schedule,13802.23,39804.76,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37951.25,,,,,,,fee schedule,13802.23,39804.76,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33001.09,,,,,,,fee schedule,13802.23,39804.76,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],38043.41,35353.37,38289.17,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12822.69,12822.69,12822.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6877.2,6877.2,8787.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6877.2,6877.2,8787.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6877.2,6877.2,8787.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],18956.38,18956.38,18956.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6877.2,6877.2,8787.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21146.08,18782.22,27487.31,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6877.2,6877.2,8787.7,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28405.08,26193.52,29364.77,74,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12827.59,12165.86,13100.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26431.65,25613.33,27136.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],24335.93,21048,55695.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,18899.47,18899.47,18899.47,1 through 10,percent of total billed charges,,,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,27823.75,27823.75,28206.11,1 through 10,percent of total billed charges,,,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,42685.9,42685.9,42685.9,1 through 10,percent of total billed charges,,,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14492.34,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13802.23,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13802.23,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13802.23,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13802.23,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13802.23,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13802.23,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24844.01,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24844.01,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14492.34,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13802.23,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13802.23,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14492.34,,,,,,,fee schedule,13802.23,39804.76,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,67980.86,,,,,,,fee schedule,31545.83,89549.26,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60278.17,,,,,,,fee schedule,31545.83,89549.26,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60278.17,,,,,,,fee schedule,31545.83,89549.26,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,54386.64,,,,,,,fee schedule,31545.83,89549.26,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,89549.26,,,,,,,fee schedule,31545.83,89549.26,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,77868.93,,,,,,,fee schedule,31545.83,89549.26,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21711.07,21711.07,21711.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33123.12,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31545.83,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31545.83,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31545.83,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31545.83,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31545.83,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31545.83,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,56782.49,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,56782.49,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33123.12,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31545.83,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31545.83,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33123.12,,,,,,,fee schedule,31545.83,89549.26,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34263.56,,,,,,,fee schedule,16272.39,45134.42,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40636.93,,,,,,,fee schedule,16272.39,45134.42,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40636.93,,,,,,,fee schedule,16272.39,45134.42,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27411.83,,,,,,,fee schedule,16272.39,45134.42,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45134.42,,,,,,,fee schedule,16272.39,45134.42,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39247.32,,,,,,,fee schedule,16272.39,45134.42,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],39592.54,39592.54,39592.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13317.54,13317.54,13317.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6648.55,6648.55,6648.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5719.22,5719.22,6760.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15438.28,15438.28,15684.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33538.96,33538.96,33538.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17086.01,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16272.39,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16272.39,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16272.39,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16272.39,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16272.39,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16272.39,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29290.3,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29290.3,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17086.01,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16272.39,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16272.39,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17086.01,,,,,,,fee schedule,16272.39,45134.42,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23911.34,,,,,,,fee schedule,11582.98,31497.73,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29091.04,,,,,,,fee schedule,11582.98,31497.73,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29091.04,,,,,,,fee schedule,11582.98,31497.73,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19129.76,,,,,,,fee schedule,11582.98,31497.73,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31497.73,,,,,,,fee schedule,11582.98,31497.73,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27389.33,,,,,,,fee schedule,11582.98,31497.73,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12162.13,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11582.98,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11582.98,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11582.98,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11582.98,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11582.98,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11582.98,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20849.36,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20849.36,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12162.13,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11582.98,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11582.98,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12162.13,,,,,,,fee schedule,11582.98,31497.73,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,57684.03,,,,,,,fee schedule,26881.52,75985.53,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,62645.84,,,,,,,fee schedule,26881.52,75985.53,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,62645.84,,,,,,,fee schedule,26881.52,75985.53,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,46148.88,,,,,,,fee schedule,26881.52,75985.53,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,75985.53,,,,,,,fee schedule,26881.52,75985.53,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,66074.38,,,,,,,fee schedule,26881.52,75985.53,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],51802.45,51802.45,51802.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28225.6,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26881.52,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26881.52,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26881.52,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26881.52,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26881.52,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26881.52,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,48386.74,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,48386.74,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,28225.6,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26881.52,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26881.52,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,28225.6,,,,,,,fee schedule,26881.52,75985.53,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28638.6,,,,,,,fee schedule,13724.36,46503.88,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46503.88,,,,,,,fee schedule,13724.36,46503.88,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46503.88,,,,,,,fee schedule,13724.36,46503.88,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22911.7,,,,,,,fee schedule,13724.36,46503.88,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37724.81,,,,,,,fee schedule,13724.36,46503.88,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32804.19,,,,,,,fee schedule,13724.36,46503.88,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],45056.47,45056.47,45056.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11530.93,11530.93,11530.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],30719.32,30719.32,30719.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14410.58,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13724.36,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13724.36,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13724.36,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13724.36,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13724.36,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13724.36,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24703.85,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24703.85,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14410.58,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13724.36,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13724.36,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14410.58,,,,,,,fee schedule,13724.36,46503.88,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25370.58,,,,,,,fee schedule,12244,38526.91,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38526.91,,,,,,,fee schedule,12244,38526.91,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38526.91,,,,,,,fee schedule,12244,38526.91,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20297.19,,,,,,,fee schedule,12244,38526.91,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33419.95,,,,,,,fee schedule,12244,38526.91,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29060.83,,,,,,,fee schedule,12244,38526.91,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11530.93,11530.93,11530.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8200.52,8200.52,8200.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29240.92,29240.92,29240.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26661.31,26661.31,26661.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,31516.78,31516.78,31516.78,1 through 10,percent of total billed charges,,,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12856.2,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12244,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12244,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12244,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12244,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12244,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12244,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22039.2,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22039.2,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12856.2,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12244,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12244,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12856.2,,,,,,,fee schedule,12244,38526.91,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71182.03,,,,,,,fee schedule,32995.91,93766.06,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,71343.56,,,,,,,fee schedule,32995.91,93766.06,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,71343.56,,,,,,,fee schedule,32995.91,93766.06,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,56947.67,,,,,,,fee schedule,32995.91,93766.06,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,93766.06,,,,,,,fee schedule,32995.91,93766.06,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,81535.71,,,,,,,fee schedule,32995.91,93766.06,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33152.44,33152.44,33152.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34645.71,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32995.91,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32995.91,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32995.91,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32995.91,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32995.91,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32995.91,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59392.64,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,59392.64,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,34645.71,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32995.91,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32995.91,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,34645.71,,,,,,,fee schedule,32995.91,93766.06,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,41615.17,,,,,,,fee schedule,19602.56,54818.48,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,43502.51,,,,,,,fee schedule,19602.56,54818.48,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,43502.51,,,,,,,fee schedule,19602.56,54818.48,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33293.33,,,,,,,fee schedule,19602.56,54818.48,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,54818.48,,,,,,,fee schedule,19602.56,54818.48,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,47668.24,,,,,,,fee schedule,19602.56,54818.48,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],38188.75,38188.75,38188.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],43535.34,43535.34,43535.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35040.97,35040.97,35040.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19429.6,19429.6,19429.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37986.47,37986.47,37986.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20582.69,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19602.56,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19602.56,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19602.56,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19602.56,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19602.56,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19602.56,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35284.61,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35284.61,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20582.69,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19602.56,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19602.56,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20582.69,,,,,,,fee schedule,19602.56,54818.48,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27876.51,,,,,,,fee schedule,13379.15,38366.75,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38366.75,,,,,,,fee schedule,13379.15,38366.75,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38366.75,,,,,,,fee schedule,13379.15,38366.75,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22302.01,,,,,,,fee schedule,13379.15,38366.75,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,36720.93,,,,,,,fee schedule,13379.15,38366.75,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31931.25,,,,,,,fee schedule,13379.15,38366.75,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4318.41,4318.41,4318.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14048.11,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13379.15,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13379.15,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13379.15,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13379.15,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13379.15,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13379.15,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24082.47,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24082.47,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14048.11,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13379.15,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13379.15,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14048.11,,,,,,,fee schedule,13379.15,38366.75,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27441.03,,,,,,,fee schedule,13181.88,36147.29,
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28809.01,,,,,,,fee schedule,13181.88,36147.29,
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28809.01,,,,,,,fee schedule,13181.88,36147.29,
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21953.61,,,,,,,fee schedule,13181.88,36147.29,
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,36147.29,,,,,,,fee schedule,13181.88,36147.29,
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31432.42,,,,,,,fee schedule,13181.88,36147.29,
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13331.63,13331.63,13331.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12871.44,12871.44,12871.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5389.73,5389.73,5389.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22764.09,12995.27,28047.28,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10142.67,10142.67,10142.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7219.44,6882.66,10847.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],18221.85,18221.85,18221.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6882.66,6882.66,6882.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7449.98,7449.98,7449.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5040.31,5040.31,5040.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6882.66,5186.08,21748.85,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23353.56,14280.37,26244.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11736.78,10877.28,12856.95,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15997.47,15997.47,15997.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5186.08,5186.08,6882.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],101855.88,101855.88,101855.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,71041.62,71041.62,71041.62,1 through 10,percent of total billed charges,,,
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,19279.78,19279.78,19279.78,1 through 10,percent of total billed charges,,,
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13840.97,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13181.88,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13181.88,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13181.88,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13181.88,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13181.88,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13181.88,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23727.38,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23727.38,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13840.97,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13181.88,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13181.88,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13840.97,,,,,,,fee schedule,13181.88,36147.29,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17117.46,,,,,,,fee schedule,8505.46,22548.34,
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18178.85,,,,,,,fee schedule,8505.46,22548.34,
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18178.85,,,,,,,fee schedule,8505.46,22548.34,
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13694.46,,,,,,,fee schedule,8505.46,22548.34,
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22548.34,,,,,,,fee schedule,8505.46,22548.34,
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19607.25,,,,,,,fee schedule,8505.46,22548.34,
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1255.33,1255.33,6691.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17068.77,12109.38,17598.79,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5719.22,5719.22,5719.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8413.37,8413.37,8413.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5186.08,5186.08,5186.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],14013.67,14013.67,14013.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4041.2,1700,6882.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5186.08,4041.2,5186.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12961.57,12961.57,13283.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5186.08,1608,6648.55,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],3367.68,3367.68,3367.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13274.1,10878.59,17791.66,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8246.5,6504.74,8306.16,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5186.08,5186.08,6648.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],6669.87,6555.29,12519.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,14798.02,13542.91,22221.3,1 through 10,percent of total billed charges,,,
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,10028.6,10028.6,10028.6,1 through 10,percent of total billed charges,,,
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8930.73,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8505.46,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8505.46,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8505.46,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8505.46,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8505.46,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8505.46,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15309.83,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15309.83,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8930.73,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8505.46,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8505.46,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8930.73,,,,,,,fee schedule,8505.46,22548.34,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11864.94,,,,,,,fee schedule,6126.15,15629.35,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14724.84,,,,,,,fee schedule,6126.15,15629.35,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14724.84,,,,,,,fee schedule,6126.15,15629.35,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9492.3,,,,,,,fee schedule,6126.15,15629.35,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15629.35,,,,,,,fee schedule,6126.15,15629.35,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13590.74,,,,,,,fee schedule,6126.15,15629.35,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],12335.81,9709.12,14735.95,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,1608,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,4041.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1608,4041.2,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],8466.19,8466.19,8466.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4041.2,4041.2,4041.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],2862.2,2862.2,2862.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,5186.08,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9694.23,6286.47,11915.35,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5867.69,5027.87,6032.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1608,1608,4041.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],11448.09,11448.09,15255.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,18701.01,18701.01,33995.55,1 through 10,percent of total billed charges,,,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,11702.3,11702.3,11702.3,1 through 10,percent of total billed charges,,,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6432.46,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6126.15,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6126.15,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6126.15,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6126.15,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6126.15,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6126.15,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11027.07,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11027.07,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6432.46,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6126.15,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6126.15,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6432.46,,,,,,,fee schedule,6126.15,15629.35,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25510.01,,,,,,,fee schedule,12307.16,33972.63,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33972.63,,,,,,,fee schedule,12307.16,33972.63,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33972.63,,,,,,,fee schedule,12307.16,33972.63,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20408.74,,,,,,,fee schedule,12307.16,33972.63,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33603.62,,,,,,,fee schedule,12307.16,33972.63,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29220.54,,,,,,,fee schedule,12307.16,33972.63,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12079.07,1741.67,12567.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10350.76,10176.51,12017.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20121.63,20121.63,20121.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7288.11,5163.7,11331.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25341.54,10929.21,33137.14,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11876.03,11876.03,11876.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11906.63,11906.63,11906.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11718.16,11718.16,11718.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8496.29,5163.7,11331.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],14571.35,14571.35,14571.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6728.22,4048.29,9221.53,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],10533.62,10533.62,10533.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7288.11,5401.03,9221.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18618.47,18618.47,26807.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7288.11,5163.7,14800.07,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30655.88,20052.26,30829,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19410.41,13001.75,26657.29,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11726.64,9662.01,12020.78,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17571.77,17571.77,17571.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5163.7,5163.7,5163.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9221.53,6728.22,9221.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],8533.38,8422.43,29095.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,17772.64,17772.64,17772.64,1 through 10,percent of total billed charges,,,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,25757.11,25757.11,25757.11,1 through 10,percent of total billed charges,,,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,13242.99,13242.99,13242.99,1 through 10,percent of total billed charges,,,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12922.52,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12307.16,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12307.16,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12307.16,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12307.16,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12307.16,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12307.16,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22152.89,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22152.89,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12922.52,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12307.16,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12307.16,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12922.52,,,,,,,fee schedule,12307.16,33972.63,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14863.65,,,,,,,fee schedule,7484.52,19579.47,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18990.13,,,,,,,fee schedule,7484.52,19579.47,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18990.13,,,,,,,fee schedule,7484.52,19579.47,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11891.35,,,,,,,fee schedule,7484.52,19579.47,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19579.47,,,,,,,fee schedule,7484.52,19579.47,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17025.62,,,,,,,fee schedule,7484.52,19579.47,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7446.1,7446.1,7464.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7148.28,6186.01,7330.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18363.07,18363.07,18363.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5073.12,3960.98,7288.11,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14890.46,8109.1,19004.46,82,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6412.26,1608,9221.53,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5073.12,1700,7025.68,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6412.26,4048.29,6412.26,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10909.49,10031.33,15533.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5163.7,1608,7497.66,86,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14853.13,14853.13,14853.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12712.25,7384.27,15686.07,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7131.44,5505.48,7332.26,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6412.26,6412.26,6412.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6412.26,3927.69,6412.26,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],9809.01,5113.14,33082.98,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,13189.49,13189.49,21109.1,1 through 10,percent of total billed charges,,,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,8462.01,8462.01,11403.38,1 through 10,percent of total billed charges,,,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,7674.6,5676.37,77041.95,1 through 10,percent of total billed charges,,,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,14997.29,14997.29,14997.29,1 through 10,percent of total billed charges,,,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7858.75,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7484.52,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7484.52,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7484.52,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7484.52,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7484.52,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7484.52,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13472.14,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13472.14,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7858.75,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7484.52,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7484.52,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7858.75,,,,,,,fee schedule,7484.52,19579.47,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27162.17,,,,,,,fee schedule,13055.56,60058.81,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60058.81,,,,,,,fee schedule,13055.56,60058.81,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60058.81,,,,,,,fee schedule,13055.56,60058.81,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21730.51,,,,,,,fee schedule,13055.56,60058.81,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35779.95,,,,,,,fee schedule,13055.56,60058.81,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31113,,,,,,,fee schedule,13055.56,60058.81,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],112593.78,112593.78,112593.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11942.39,11942.39,11942.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",35843.39,35843.39,35843.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4318.41,4318.41,4318.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,18161.73,18161.73,18161.73,1 through 10,percent of total billed charges,,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13708.34,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13055.56,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13055.56,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13055.56,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13055.56,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13055.56,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13055.56,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23500.01,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23500.01,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13708.34,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13055.56,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13055.56,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13708.34,,,,,,,fee schedule,13055.56,60058.81,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31440.58,,,,,,,fee schedule,14993.62,41415.78,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,37677.34,,,,,,,fee schedule,14993.62,41415.78,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,37677.34,,,,,,,fee schedule,14993.62,41415.78,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25153.36,,,,,,,fee schedule,14993.62,41415.78,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41415.78,,,,,,,fee schedule,14993.62,41415.78,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36013.72,,,,,,,fee schedule,14993.62,41415.78,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14523.58,14523.58,14523.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],35358.75,35358.75,35358.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14763.4,14763.4,14763.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8314.03,8314.03,8314.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20877.85,20877.85,63972.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5824.54,5824.54,8854.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16866.8,16866.8,19466.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13826.15,12099.51,14516.21,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],12639.73,12639.73,12639.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15743.3,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14993.62,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14993.62,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14993.62,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14993.62,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14993.62,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14993.62,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26988.52,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26988.52,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15743.3,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14993.62,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14993.62,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15743.3,,,,,,,fee schedule,14993.62,41415.78,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25522.12,,,,,,,fee schedule,9619.84,25788.94,
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19577.54,,,,,,,fee schedule,9619.84,25788.94,
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25522.12,,,,,,,fee schedule,9619.84,25788.94,
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15662.59,,,,,,,fee schedule,9619.84,25788.94,
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25788.94,,,,,,,fee schedule,9619.84,25788.94,
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22425.17,,,,,,,fee schedule,9619.84,25788.94,
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14387.12,14387.12,14387.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15696.52,8851.96,24454,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9447.08,9447.08,9447.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13180.66,13180.66,13180.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19744.15,19744.15,19744.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5163.7,5163.7,5163.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20573.54,16079.69,20744.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9307.7,8158.6,9426.55,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10100.83,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9619.84,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9619.84,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9619.84,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9619.84,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9619.84,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9619.84,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17315.71,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17315.71,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10100.83,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9619.84,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9619.84,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10100.83,,,,,,,fee schedule,9619.84,25788.94,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14696.98,,,,,,,fee schedule,7398.86,19330.38,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14674.56,,,,,,,fee schedule,7398.86,19330.38,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14696.98,,,,,,,fee schedule,7398.86,19330.38,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11740.07,,,,,,,fee schedule,7398.86,19330.38,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19330.38,,,,,,,fee schedule,7398.86,19330.38,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16809.03,,,,,,,fee schedule,7398.86,19330.38,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6799.81,6799.81,6799.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13077.39,13077.39,13077.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4417.18,4417.18,4417.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6706.05,6706.05,6706.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7136.16,6161.74,7154.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7768.8,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7398.86,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7398.86,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7398.86,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7398.86,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7398.86,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7398.86,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13317.95,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13317.95,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7768.8,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7398.86,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7398.86,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7768.8,,,,,,,fee schedule,7398.86,19330.38,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,267372.95,,,,,,,fee schedule,41428.19,267372.95,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89796.93,,,,,,,fee schedule,41428.19,267372.95,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,267372.95,,,,,,,fee schedule,41428.19,267372.95,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,71840.12,,,,,,,fee schedule,41428.19,267372.95,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,118286.94,,,,,,,fee schedule,41428.19,267372.95,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,102858.22,,,,,,,fee schedule,41428.19,267372.95,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,43499.6,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41428.19,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,41428.19,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,41428.19,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,41428.19,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,41428.19,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,41428.19,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74570.74,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,74570.74,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,43499.6,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,41428.19,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,41428.19,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,43499.6,,,,,,,fee schedule,41428.19,267372.95,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,170702.26,,,,,,,fee schedule,32814.22,170702.26,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70780.93,,,,,,,fee schedule,32814.22,170702.26,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,170702.26,,,,,,,fee schedule,32814.22,170702.26,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,56626.77,,,,,,,fee schedule,32814.22,170702.26,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,93237.71,,,,,,,fee schedule,32814.22,170702.26,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,81076.27,,,,,,,fee schedule,32814.22,170702.26,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34454.93,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32814.22,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32814.22,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32814.22,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32814.22,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32814.22,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32814.22,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59065.6,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,59065.6,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,34454.93,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32814.22,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32814.22,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,34454.93,,,,,,,fee schedule,32814.22,170702.26,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,212763.27,,,,,,,fee schedule,28693.25,212763.27,
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61683.58,,,,,,,fee schedule,28693.25,212763.27,
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,212763.27,,,,,,,fee schedule,28693.25,212763.27,
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,49348.63,,,,,,,fee schedule,28693.25,212763.27,
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,81254.03,,,,,,,fee schedule,28693.25,212763.27,
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,70655.68,,,,,,,fee schedule,28693.25,212763.27,
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",148511.43,148511.43,148511.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],165000,165000,165000,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",151274.29,151274.29,151274.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30127.91,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28693.25,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28693.25,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28693.25,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28693.25,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28693.25,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28693.25,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51647.85,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,51647.85,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30127.91,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28693.25,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28693.25,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30127.91,,,,,,,fee schedule,28693.25,212763.27,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,92105.96,,,,,,,fee schedule,45710.94,130741.11,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,99251.45,,,,,,,fee schedule,45710.94,130741.11,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,92105.96,,,,,,,fee schedule,45710.94,130741.11,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,79404.01,,,,,,,fee schedule,45710.94,130741.11,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,130741.11,,,,,,,fee schedule,45710.94,130741.11,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,113687.93,,,,,,,fee schedule,45710.94,130741.11,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",32713.95,32713.95,32713.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28579.8,28579.8,28579.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,47996.49,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,45710.94,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,45710.94,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,45710.94,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,45710.94,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,45710.94,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,45710.94,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,82279.69,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,82279.69,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,47996.49,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,45710.94,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,45710.94,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,47996.49,,,,,,,fee schedule,45710.94,130741.11,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,92022.4,,,,,,,fee schedule,24971.15,92022.4,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53466.74,,,,,,,fee schedule,24971.15,92022.4,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,92022.4,,,,,,,fee schedule,24971.15,92022.4,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,42774.93,,,,,,,fee schedule,24971.15,92022.4,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,70430.22,,,,,,,fee schedule,24971.15,92022.4,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,61243.67,,,,,,,fee schedule,24971.15,92022.4,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11683.28,11683.28,11683.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],92091.85,88983.8,92091.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],37970.8,37970.8,37970.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9404.48,9404.48,9404.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],56640.47,56640.47,56640.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24243.1,24137.64,24405.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26219.71,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24971.15,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24971.15,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24971.15,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24971.15,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24971.15,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24971.15,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,44948.07,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,44948.07,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,26219.71,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24971.15,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24971.15,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,26219.71,,,,,,,fee schedule,24971.15,92022.4,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,81883.18,,,,,,,fee schedule,19064.4,81883.18,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40427.14,,,,,,,fee schedule,19064.4,81883.18,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,81883.18,,,,,,,fee schedule,19064.4,81883.18,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32342.88,,,,,,,fee schedule,19064.4,81883.18,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53253.53,,,,,,,fee schedule,19064.4,81883.18,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46307.42,,,,,,,fee schedule,19064.4,81883.18,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18021.03,18021.03,18021.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],79179.39,79179.39,79179.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9995.33,9995.33,9995.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],41693.04,41693.04,41693.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18019.97,17968.97,18049.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20017.62,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19064.4,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19064.4,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19064.4,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19064.4,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19064.4,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19064.4,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34315.92,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34315.92,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20017.62,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19064.4,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19064.4,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20017.62,,,,,,,fee schedule,19064.4,81883.18,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,99957.58,,,,,,,fee schedule,28297.85,99957.58,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60810.71,,,,,,,fee schedule,28297.85,99957.58,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,99957.58,,,,,,,fee schedule,28297.85,99957.58,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48650.31,,,,,,,fee schedule,28297.85,99957.58,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,80104.22,,,,,,,fee schedule,28297.85,99957.58,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,69655.84,,,,,,,fee schedule,28297.85,99957.58,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],186039.34,186039.34,186039.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27908.14,27908.14,27908.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29712.74,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28297.85,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28297.85,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28297.85,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28297.85,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28297.85,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28297.85,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50936.13,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,50936.13,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29712.74,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28297.85,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28297.85,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29712.74,,,,,,,fee schedule,28297.85,99957.58,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,55776.11,,,,,,,fee schedule,16584.73,55776.11,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34953.07,,,,,,,fee schedule,16584.73,55776.11,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,55776.11,,,,,,,fee schedule,16584.73,55776.11,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27963.46,,,,,,,fee schedule,16584.73,55776.11,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46042.69,,,,,,,fee schedule,16584.73,55776.11,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40037.12,,,,,,,fee schedule,16584.73,55776.11,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14639.73,14639.73,14639.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],53934.37,53308.03,54192.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10328.21,10328.21,10328.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11833.79,11833.79,11833.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36691.16,36691.16,36691.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15851.7,15851.7,15851.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,74676.42,74676.42,74676.42,1 through 10,percent of total billed charges,,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17413.97,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16584.73,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16584.73,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16584.73,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16584.73,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16584.73,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16584.73,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29852.51,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29852.51,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17413.97,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16584.73,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16584.73,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17413.97,,,,,,,fee schedule,16584.73,55776.11,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48749.69,,,,,,,fee schedule,14177.73,48749.69,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29639.44,,,,,,,fee schedule,14177.73,48749.69,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48749.69,,,,,,,fee schedule,14177.73,48749.69,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23712.4,,,,,,,fee schedule,14177.73,48749.69,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39043.19,,,,,,,fee schedule,14177.73,48749.69,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33950.61,,,,,,,fee schedule,14177.73,48749.69,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13201.05,13201.05,13201.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],48786.48,48786.48,48786.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10328.21,10328.21,10328.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10328.21,10328.21,10328.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30185.9,30185.9,30185.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14184.37,14184.37,14184.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,116209.23,116209.23,116209.23,1 through 10,percent of total billed charges,,,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14886.62,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14177.73,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14177.73,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14177.73,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14177.73,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14177.73,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14177.73,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25519.91,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25519.91,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14886.62,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14177.73,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14177.73,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14886.62,,,,,,,fee schedule,14177.73,48749.69,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51632.68,,,,,,,fee schedule,22735.46,63928.89,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,48531.29,,,,,,,fee schedule,22735.46,63928.89,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51632.68,,,,,,,fee schedule,22735.46,63928.89,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,38826.43,,,,,,,fee schedule,22735.46,63928.89,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,63928.89,,,,,,,fee schedule,22735.46,63928.89,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,55590.34,,,,,,,fee schedule,22735.46,63928.89,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22232.38,22232.38,22232.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],48752.27,48752.27,48752.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8650.18,8650.18,8650.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12702.55,12702.55,12702.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],51869.42,51869.42,51869.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21223.97,19252.84,24201.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23872.23,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22735.46,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22735.46,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22735.46,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22735.46,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22735.46,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22735.46,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,40923.83,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,40923.83,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23872.23,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22735.46,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22735.46,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23872.23,,,,,,,fee schedule,22735.46,63928.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31127.94,,,,,,,fee schedule,12186.9,33253.89,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25244.52,,,,,,,fee schedule,12186.9,33253.89,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31127.94,,,,,,,fee schedule,12186.9,33253.89,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20196.34,,,,,,,fee schedule,12186.9,33253.89,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33253.89,,,,,,,fee schedule,12186.9,33253.89,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28916.43,,,,,,,fee schedule,12186.9,33253.89,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11834.28,11834.28,11857.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],30241.5,27378.44,31297.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12702.55,12702.55,12702.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1402.8,1402.8,1402.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11280.45,11280.45,11280.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9995.33,9995.33,9995.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12292.88,12292.88,12292.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11280.45,8650.18,11280.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30508.15,30508.15,30508.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22561.31,21595.15,26894.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11831.78,11710.92,11933.22,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],38719.12,38719.12,38719.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,18348.59,18348.59,18348.59,1 through 10,percent of total billed charges,,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12796.24,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12186.9,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12186.9,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12186.9,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12186.9,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12186.9,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12186.9,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21936.42,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21936.42,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12796.24,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12186.9,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12186.9,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12796.24,,,,,,,fee schedule,12186.9,33253.89,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28826.42,,,,,,,fee schedule,9709.82,28826.42,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19776.18,,,,,,,fee schedule,9709.82,28826.42,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28826.42,,,,,,,fee schedule,9709.82,28826.42,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15821.51,,,,,,,fee schedule,9709.82,28826.42,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26050.6,,,,,,,fee schedule,9709.82,28826.42,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22652.7,,,,,,,fee schedule,9709.82,28826.42,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9187.12,9187.12,9187.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25774.39,17372.92,28074.27,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11280.45,11280.45,11280.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9995.33,9995.33,9995.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20605.66,20605.66,20605.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9195.62,9157.94,9501.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15294.23,15294.23,15294.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],18245.78,13034.56,43826.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,37320.63,37320.63,37320.63,1 through 10,percent of total billed charges,,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10195.31,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9709.82,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9709.82,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9709.82,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9709.82,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9709.82,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9709.82,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17477.68,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17477.68,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10195.31,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9709.82,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9709.82,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10195.31,,,,,,,fee schedule,9709.82,28826.42,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,58474.77,,,,,,,fee schedule,27239.71,77027.16,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,76757.87,,,,,,,fee schedule,27239.71,77027.16,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,76757.87,,,,,,,fee schedule,27239.71,77027.16,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,46781.5,,,,,,,fee schedule,27239.71,77027.16,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,77027.16,,,,,,,fee schedule,27239.71,77027.16,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,66980.14,,,,,,,fee schedule,27239.71,77027.16,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28601.7,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27239.71,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,27239.71,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,27239.71,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,27239.71,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,27239.71,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,27239.71,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49031.48,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,49031.48,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,28601.7,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,27239.71,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,27239.71,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,28601.7,,,,,,,fee schedule,27239.71,77027.16,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29035.88,,,,,,,fee schedule,13904.33,47548.44,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,47548.44,,,,,,,fee schedule,13904.33,47548.44,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,47548.44,,,,,,,fee schedule,13904.33,47548.44,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23229.54,,,,,,,fee schedule,13904.33,47548.44,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38248.14,,,,,,,fee schedule,13904.33,47548.44,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33259.25,,,,,,,fee schedule,13904.33,47548.44,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12571.54,12571.54,12571.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20187.43,20187.43,20187.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30655.58,30655.58,30655.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11615.51,11615.51,11615.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13379.22,13379.22,13379.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14599.55,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13904.33,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13904.33,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13904.33,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13904.33,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13904.33,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13904.33,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25027.79,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25027.79,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14599.55,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13904.33,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13904.33,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14599.55,,,,,,,fee schedule,13904.33,47548.44,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19995.83,,,,,,,fee schedule,9809.32,34599.36,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,34599.36,,,,,,,fee schedule,9809.32,34599.36,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,34599.36,,,,,,,fee schedule,9809.32,34599.36,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15997.24,,,,,,,fee schedule,9809.32,34599.36,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26339.94,,,,,,,fee schedule,9809.32,34599.36,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22904.3,,,,,,,fee schedule,9809.32,34599.36,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33456.89,33456.89,33456.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10299.79,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9809.32,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9809.32,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9809.32,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9809.32,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9809.32,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9809.32,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17656.78,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17656.78,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10299.79,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9809.32,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9809.32,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10299.79,,,,,,,fee schedule,9809.32,34599.36,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,76040.6,,,,,,,fee schedule,27756.24,78529.2,
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,59615.04,,,,,,,fee schedule,27756.24,78529.2,
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,76040.6,,,,,,,fee schedule,27756.24,78529.2,
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,47693.75,,,,,,,fee schedule,27756.24,78529.2,
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,78529.2,,,,,,,fee schedule,27756.24,78529.2,
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,68286.27,,,,,,,fee schedule,27756.24,78529.2,
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],42514.25,42514.25,42514.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29387.79,29387.79,29387.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29144.05,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,27756.24,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,27756.24,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,27756.24,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,27756.24,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,27756.24,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,27756.24,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,49961.23,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,49961.23,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29144.05,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,27756.24,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,27756.24,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29144.05,,,,,,,fee schedule,27756.24,78529.2,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,39794.32,,,,,,,fee schedule,15886.51,44012.28,
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33411.7,,,,,,,fee schedule,15886.51,44012.28,
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,39794.32,,,,,,,fee schedule,15886.51,44012.28,
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26730.32,,,,,,,fee schedule,15886.51,44012.28,
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44012.28,,,,,,,fee schedule,15886.51,44012.28,
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38271.55,,,,,,,fee schedule,15886.51,44012.28,
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16680.84,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15886.51,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15886.51,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15886.51,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15886.51,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15886.51,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15886.51,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28595.72,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28595.72,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16680.84,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15886.51,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15886.51,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16680.84,,,,,,,fee schedule,15886.51,44012.28,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24320.88,,,,,,,fee schedule,10322.38,27831.93,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21128.46,,,,,,,fee schedule,10322.38,27831.93,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24320.88,,,,,,,fee schedule,10322.38,27831.93,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16903.38,,,,,,,fee schedule,10322.38,27831.93,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27831.93,,,,,,,fee schedule,10322.38,27831.93,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24201.68,,,,,,,fee schedule,10322.38,27831.93,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10838.5,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10322.38,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10322.38,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10322.38,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10322.38,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10322.38,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10322.38,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18580.28,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18580.28,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10838.5,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10322.38,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10322.38,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10838.5,,,,,,,fee schedule,10322.38,27831.93,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,65312.95,,,,,,,fee schedule,26015.45,73467.02,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55772.12,,,,,,,fee schedule,26015.45,73467.02,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,65312.95,,,,,,,fee schedule,26015.45,73467.02,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44619.29,,,,,,,fee schedule,26015.45,73467.02,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,73467.02,,,,,,,fee schedule,26015.45,73467.02,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,63884.37,,,,,,,fee schedule,26015.45,73467.02,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25059.25,25059.25,25059.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27316.22,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26015.45,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26015.45,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26015.45,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26015.45,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26015.45,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26015.45,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46827.81,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,46827.81,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27316.22,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26015.45,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26015.45,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27316.22,,,,,,,fee schedule,26015.45,73467.02,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46496.92,,,,,,,fee schedule,14179.46,46496.92,
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29643.26,,,,,,,fee schedule,14179.46,46496.92,
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46496.92,,,,,,,fee schedule,14179.46,46496.92,
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23715.46,,,,,,,fee schedule,14179.46,46496.92,
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39048.23,,,,,,,fee schedule,14179.46,46496.92,
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33954.98,,,,,,,fee schedule,14179.46,46496.92,
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29089.1,29089.1,29089.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13558.59,13558.59,13558.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14888.43,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14179.46,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14179.46,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14179.46,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14179.46,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14179.46,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14179.46,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25523.03,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25523.03,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14888.43,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14179.46,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14179.46,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14888.43,,,,,,,fee schedule,14179.46,46496.92,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27743.56,,,,,,,fee schedule,9207.14,27743.56,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18666.47,,,,,,,fee schedule,9207.14,27743.56,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27743.56,,,,,,,fee schedule,9207.14,27743.56,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14933.71,,,,,,,fee schedule,9207.14,27743.56,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24588.81,,,,,,,fee schedule,9207.14,27743.56,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21381.57,,,,,,,fee schedule,9207.14,27743.56,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9667.5,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9207.14,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9207.14,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9207.14,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9207.14,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9207.14,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9207.14,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16572.85,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16572.85,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9667.5,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9207.14,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9207.14,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9667.5,,,,,,,fee schedule,9207.14,27743.56,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,62447.37,,,,,,,fee schedule,16281.91,62447.37,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34284.57,,,,,,,fee schedule,16281.91,62447.37,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,62447.37,,,,,,,fee schedule,16281.91,62447.37,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27428.64,,,,,,,fee schedule,16281.91,62447.37,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45162.09,,,,,,,fee schedule,16281.91,62447.37,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39271.39,,,,,,,fee schedule,16281.91,62447.37,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17096.01,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16281.91,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16281.91,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16281.91,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16281.91,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16281.91,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16281.91,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29307.44,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29307.44,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17096.01,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16281.91,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16281.91,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17096.01,,,,,,,fee schedule,16281.91,62447.37,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24105,,,,,,,fee schedule,10091.37,27160.16,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20618.49,,,,,,,fee schedule,10091.37,27160.16,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24105,,,,,,,fee schedule,10091.37,27160.16,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16495.39,,,,,,,fee schedule,10091.37,27160.16,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27160.16,,,,,,,fee schedule,10091.37,27160.16,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23617.53,,,,,,,fee schedule,10091.37,27160.16,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23309.05,23309.05,23309.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10595.94,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10091.37,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10091.37,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10091.37,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10091.37,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10091.37,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10091.37,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18164.47,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18164.47,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10595.94,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10091.37,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10091.37,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10595.94,,,,,,,fee schedule,10091.37,27160.16,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,96378.22,,,,,,,fee schedule,37103.9,105712,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80250.73,,,,,,,fee schedule,37103.9,105712,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,96378.22,,,,,,,fee schedule,37103.9,105712,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,64202.88,,,,,,,fee schedule,37103.9,105712,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,105712,,,,,,,fee schedule,37103.9,105712,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,91923.49,,,,,,,fee schedule,37103.9,105712,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35649.72,35649.72,35649.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19322.24,19322.24,19322.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",46246.76,46246.76,46246.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10589.05,6934.5,46427.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35699.01,34077.23,35819.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,45785.82,45785.82,45785.82,1 through 10,percent of total billed charges,,,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38959.1,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37103.9,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,37103.9,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,37103.9,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,37103.9,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,37103.9,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,37103.9,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66787.02,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,66787.02,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,38959.1,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,37103.9,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,37103.9,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,38959.1,,,,,,,fee schedule,37103.9,105712,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,49992.72,,,,,,,fee schedule,20985.15,58839.04,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44667.35,,,,,,,fee schedule,20985.15,58839.04,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,49992.72,,,,,,,fee schedule,20985.15,58839.04,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35735.16,,,,,,,fee schedule,20985.15,58839.04,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,58839.04,,,,,,,fee schedule,20985.15,58839.04,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,51164.38,,,,,,,fee schedule,20985.15,58839.04,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19939.72,19939.72,19939.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],48341.95,48341.95,49624.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10927.93,10927.93,10927.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],30961.29,30961.29,30961.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19138.61,19138.61,19138.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12467.05,12467.05,12467.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32047.77,32047.77,32047.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19203.37,19203.37,20545.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,34217.22,34217.22,34217.22,1 through 10,percent of total billed charges,,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22034.41,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20985.15,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20985.15,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20985.15,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20985.15,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20985.15,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20985.15,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37773.27,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37773.27,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22034.41,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20985.15,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20985.15,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22034.41,,,,,,,fee schedule,20985.15,58839.04,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42182.88,,,,,,,fee schedule,14952.95,42182.88,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31350.81,,,,,,,fee schedule,14952.95,42182.88,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42182.88,,,,,,,fee schedule,14952.95,42182.88,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25081.54,,,,,,,fee schedule,14952.95,42182.88,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41297.53,,,,,,,fee schedule,14952.95,42182.88,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35910.89,,,,,,,fee schedule,14952.95,42182.88,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15700.6,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14952.95,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14952.95,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14952.95,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14952.95,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14952.95,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14952.95,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26915.31,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26915.31,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15700.6,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14952.95,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14952.95,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15700.6,,,,,,,fee schedule,14952.95,42182.88,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,37767.87,,,,,,,fee schedule,13565.17,37767.87,
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28287.16,,,,,,,fee schedule,13565.17,37767.87,
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,37767.87,,,,,,,fee schedule,13565.17,37767.87,
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22630.54,,,,,,,fee schedule,13565.17,37767.87,
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37261.87,,,,,,,fee schedule,13565.17,37767.87,
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32401.63,,,,,,,fee schedule,13565.17,37767.87,
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9606.92,9606.92,11769.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13176.24,11131.62,13225.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17460.72,13267.92,44439.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27249.93,27249.93,27249.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13385.41,13385.41,13434.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13385.41,13385.41,13385.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],13538.66,13538.66,13538.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8686.49,8686.49,14912.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8686.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19901.97,19901.97,19901.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8609.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17626.84,17626.84,17626.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30147.77,30147.77,30147.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12399.29,9171.88,13274.93,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",207390.01,207390.01,207390.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],12812.98,12812.98,12812.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14243.43,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24417.31,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24417.31,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14243.43,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14243.43,,,,,,,fee schedule,13565.17,37767.87,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20570.9,,,,,,,fee schedule,8328.95,22035.08,
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16727.82,,,,,,,fee schedule,8328.95,22035.08,
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20570.9,,,,,,,fee schedule,8328.95,22035.08,
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13382.73,,,,,,,fee schedule,8328.95,22035.08,
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22035.08,,,,,,,fee schedule,8328.95,22035.08,
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19160.94,,,,,,,fee schedule,8328.95,22035.08,
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6447.97,929.54,9200.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8066.2,7446.33,8133.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5343.24,5343.24,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16795.55,10874.46,19895.01,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8207.79,8207.79,8207.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],929.95,929.95,929.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5343.24,5343.24,8686.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5343.24,5343.24,8686.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],8713.45,8713.45,8713.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7448.79,7448.79,7448.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12461.38,12461.38,17232.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5343.24,4123.6,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17578.84,17578.84,17578.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8048.2,6333.2,8150.89,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4334.16,4334.16,4334.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],11406.89,11406.89,11406.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,10978.28,10978.28,10978.28,1 through 10,percent of total billed charges,,,
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8745.4,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8328.95,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8328.95,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8328.95,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8328.95,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8328.95,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8328.95,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14992.11,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14992.11,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8745.4,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8328.95,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8328.95,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8745.4,,,,,,,fee schedule,8328.95,22035.08,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,15518.7,,,,,,,fee schedule,5945.32,15518.7,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11465.75,,,,,,,fee schedule,5945.32,15518.7,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,15518.7,,,,,,,fee schedule,5945.32,15518.7,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9172.93,,,,,,,fee schedule,5945.32,15518.7,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15103.51,,,,,,,fee schedule,5945.32,15518.7,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13133.49,,,,,,,fee schedule,5945.32,15518.7,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5589.79,5589.79,5589.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15006.27,15006.27,15006.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4123.6,4123.6,4123.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4209.09,4209.09,4209.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5639.39,5639.39,5639.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5640.33,4734.48,5827.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8317.3,8317.3,8317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,16061.68,16061.68,16061.68,1 through 10,percent of total billed charges,,,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6242.59,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5945.32,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5945.32,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5945.32,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5945.32,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5945.32,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5945.32,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10701.58,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,10701.58,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6242.59,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5945.32,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5945.32,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6242.59,,,,,,,fee schedule,5945.32,15518.7,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,68620.73,,,,,,,fee schedule,16357.18,68620.73,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34450.74,,,,,,,fee schedule,16357.18,68620.73,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,68620.73,,,,,,,fee schedule,16357.18,68620.73,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27561.58,,,,,,,fee schedule,16357.18,68620.73,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45380.98,,,,,,,fee schedule,16357.18,68620.73,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39461.73,,,,,,,fee schedule,16357.18,68620.73,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17175.04,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16357.18,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16357.18,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16357.18,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16357.18,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16357.18,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16357.18,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29442.92,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29442.92,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17175.04,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16357.18,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16357.18,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17175.04,,,,,,,fee schedule,16357.18,68620.73,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28920.43,,,,,,,fee schedule,9817.1,28920.43,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20013.02,,,,,,,fee schedule,9817.1,28920.43,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28920.43,,,,,,,fee schedule,9817.1,28920.43,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16010.99,,,,,,,fee schedule,9817.1,28920.43,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26362.59,,,,,,,fee schedule,9817.1,28920.43,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22923.99,,,,,,,fee schedule,9817.1,28920.43,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],35569.19,35569.19,35569.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9446.86,9446.86,9446.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10307.96,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9817.1,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9817.1,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9817.1,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9817.1,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9817.1,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9817.1,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17670.78,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17670.78,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10307.96,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9817.1,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9817.1,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10307.96,,,,,,,fee schedule,9817.1,28920.43,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23822.97,,,,,,,fee schedule,7589.2,23822.97,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15094.76,,,,,,,fee schedule,7589.2,23822.97,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23822.97,,,,,,,fee schedule,7589.2,23822.97,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12076.24,,,,,,,fee schedule,7589.2,23822.97,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19883.9,,,,,,,fee schedule,7589.2,23822.97,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17290.35,,,,,,,fee schedule,7589.2,23822.97,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7968.66,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7589.2,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7589.2,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7589.2,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7589.2,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7589.2,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7589.2,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13660.56,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13660.56,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7968.66,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7589.2,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7589.2,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7968.66,,,,,,,fee schedule,7589.2,23822.97,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25403.74,,,,,,,fee schedule,10790.46,29193.08,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22161.78,,,,,,,fee schedule,10790.46,29193.08,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25403.74,,,,,,,fee schedule,10790.46,29193.08,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17730.06,,,,,,,fee schedule,10790.46,29193.08,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29193.08,,,,,,,fee schedule,10790.46,29193.08,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25385.29,,,,,,,fee schedule,10790.46,29193.08,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10897.24,10897.24,10897.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10458.65,10458.65,10465.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25422.91,24339.53,25485.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4974.53,4974.53,4974.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10565.63,10565.63,10565.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6302.03,6302.03,6302.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10864.84,10864.84,10864.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4901.77,4901.77,4901.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18798.25,18798.25,18798.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9447.79,7799.07,10536.84,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10438.61,10438.61,10438.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11329.98,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10790.46,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10790.46,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10790.46,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10790.46,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10790.46,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10790.46,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19422.83,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19422.83,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11329.98,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10790.46,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10790.46,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11329.98,,,,,,,fee schedule,10790.46,29193.08,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16082.77,,,,,,,fee schedule,7755.32,20366.97,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15461.48,,,,,,,fee schedule,7755.32,20366.97,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16082.77,,,,,,,fee schedule,7755.32,20366.97,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12369.63,,,,,,,fee schedule,7755.32,20366.97,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20366.97,,,,,,,fee schedule,7755.32,20366.97,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17710.41,,,,,,,fee schedule,7755.32,20366.97,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1532.49,1532.49,7631,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7573.85,7325.23,7573.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14508.44,7662.34,15558.44,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4101.77,4101.77,4901.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7479.08,7479.08,7479.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7438.88,7438.88,7438.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7352.81,7352.81,7352.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4901.77,4901.77,4901.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4901.77,4901.77,6302.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4901.77,4901.77,6302.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8945.89,8945.89,8945.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18430.78,18430.78,18430.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6302.03,4901.77,7637.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12892.7,8448.21,16109.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7019.05,5941.14,7363.8,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11615.55,11615.55,11615.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4901.77,4901.77,4901.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],17634.28,17634.28,17634.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,11146.06,11146.06,11146.06,1 through 10,percent of total billed charges,,,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,5937.2,5937.2,5937.2,1 through 10,percent of total billed charges,,,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8143.09,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7755.32,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7755.32,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7755.32,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7755.32,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7755.32,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7755.32,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13959.58,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13959.58,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8143.09,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7755.32,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7755.32,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8143.09,,,,,,,fee schedule,7755.32,20366.97,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22632.17,,,,,,,fee schedule,12384.16,33827.54,
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25680,,,,,,,fee schedule,12384.16,33827.54,
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22632.17,,,,,,,fee schedule,12384.16,33827.54,
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20544.74,,,,,,,fee schedule,12384.16,33827.54,
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33827.54,,,,,,,fee schedule,12384.16,33827.54,
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29415.25,,,,,,,fee schedule,12384.16,33827.54,
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],21868.46,21868.46,21868.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12919.57,12919.57,12919.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],15361.32,15361.32,15361.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13003.37,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12384.16,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12384.16,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12384.16,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12384.16,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12384.16,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12384.16,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22291.49,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22291.49,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13003.37,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12384.16,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12384.16,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13003.37,,,,,,,fee schedule,12384.16,33827.54,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17607.83,,,,,,,fee schedule,7514.8,19667.53,
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14930.5,,,,,,,fee schedule,7514.8,19667.53,
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17607.83,,,,,,,fee schedule,7514.8,19667.53,
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11944.83,,,,,,,fee schedule,7514.8,19667.53,
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,19667.53,,,,,,,fee schedule,7514.8,19667.53,
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17102.2,,,,,,,fee schedule,7514.8,19667.53,
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16520.05,15226.1,17026.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6195.07,6195.07,6195.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6195.07,6195.07,6195.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5816.36,5816.36,5816.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6195.07,6195.07,6195.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12746.21,12746.21,12746.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10338.54,10338.54,10338.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7179.63,7176.93,7364.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7890.54,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7514.8,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7514.8,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7514.8,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7514.8,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7514.8,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7514.8,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13526.64,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13526.64,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7890.54,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7514.8,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7514.8,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7890.54,,,,,,,fee schedule,7514.8,19667.53,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21846.63,,,,,,,fee schedule,10647.7,28777.94,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24728.25,,,,,,,fee schedule,10647.7,28777.94,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24728.25,,,,,,,fee schedule,10647.7,28777.94,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17477.93,,,,,,,fee schedule,10647.7,28777.94,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28777.94,,,,,,,fee schedule,10647.7,28777.94,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25024.3,,,,,,,fee schedule,10647.7,28777.94,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11180.08,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10647.7,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10647.7,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10647.7,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10647.7,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10647.7,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10647.7,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19165.86,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19165.86,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11180.08,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10647.7,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10647.7,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11180.08,,,,,,,fee schedule,10647.7,28777.94,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13159.93,,,,,,,fee schedule,6712.75,17335.2,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,13617.6,,,,,,,fee schedule,6712.75,17335.2,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,13617.6,,,,,,,fee schedule,6712.75,17335.2,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10528.32,,,,,,,fee schedule,6712.75,17335.2,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17335.2,,,,,,,fee schedule,6712.75,17335.2,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15074.09,,,,,,,fee schedule,6712.75,17335.2,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13167.95,13167.95,13167.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4959.06,4959.06,4959.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6415.04,6415.04,6415.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7048.39,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6712.75,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6712.75,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6712.75,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6712.75,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6712.75,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6712.75,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12082.95,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12082.95,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7048.39,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6712.75,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6712.75,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7048.39,,,,,,,fee schedule,6712.75,17335.2,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20586.02,,,,,,,fee schedule,10076.67,27117.38,
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19836.22,,,,,,,fee schedule,10076.67,27117.38,
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19836.22,,,,,,,fee schedule,10076.67,27117.38,
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16469.41,,,,,,,fee schedule,10076.67,27117.38,
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27117.38,,,,,,,fee schedule,10076.67,27117.38,
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23580.33,,,,,,,fee schedule,10076.67,27117.38,
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10580.5,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10076.67,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10076.67,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10076.67,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10076.67,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10076.67,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10076.67,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18138.01,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18138.01,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10580.5,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10076.67,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10076.67,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10580.5,,,,,,,fee schedule,10076.67,27117.38,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31599.11,,,,,,,fee schedule,15065.43,41624.6,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36068.71,,,,,,,fee schedule,15065.43,41624.6,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36068.71,,,,,,,fee schedule,15065.43,41624.6,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25280.19,,,,,,,fee schedule,15065.43,41624.6,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41624.6,,,,,,,fee schedule,15065.43,41624.6,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36195.31,,,,,,,fee schedule,15065.43,41624.6,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14675.07,14657.52,14710.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16143.84,14782.25,34509.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5634.09,5634.09,5634.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1755.92,1755.92,1755.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5634.09,5634.09,5634.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12026.37,12026.37,12026.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7741.04,5634.09,10812.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28841.01,23947.78,33738.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14633.59,10902.32,14722,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,6972.88,6972.88,6972.88,1 through 10,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15818.7,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15065.43,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15065.43,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15065.43,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15065.43,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15065.43,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15065.43,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27117.77,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27117.77,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15818.7,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15065.43,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15065.43,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15818.7,,,,,,,fee schedule,15065.43,41624.6,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19386.54,,,,,,,fee schedule,9533.32,25537.34,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24971.99,,,,,,,fee schedule,9533.32,25537.34,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24971.99,,,,,,,fee schedule,9533.32,25537.34,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15509.79,,,,,,,fee schedule,9533.32,25537.34,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25537.34,,,,,,,fee schedule,9533.32,25537.34,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22206.38,,,,,,,fee schedule,9533.32,25537.34,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8138.56,8138.56,8138.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9309.57,9309.57,9309.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16361.11,8006.88,25123.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5797.59,5797.59,5797.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5634.09,1700,21890.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5669.02,5669.02,5669.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18761.84,18761.84,18761.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5634.09,5634.09,5669.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16375.34,8552.47,20469.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9116.17,7763.69,9323.57,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4325.51,4325.51,5669.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,8422.13,8422.13,8422.13,1 through 10,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10009.99,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9533.32,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9533.32,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9533.32,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9533.32,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9533.32,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9533.32,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17159.98,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17159.98,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10009.99,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9533.32,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9533.32,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10009.99,,,,,,,fee schedule,9533.32,25537.34,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13177.12,,,,,,,fee schedule,6720.54,19056.29,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19056.29,,,,,,,fee schedule,6720.54,19056.29,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19056.29,,,,,,,fee schedule,6720.54,19056.29,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10542.07,,,,,,,fee schedule,6720.54,19056.29,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17357.84,,,,,,,fee schedule,6720.54,19056.29,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15093.78,,,,,,,fee schedule,6720.54,19056.29,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],10116.08,10116.08,10116.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],8272.7,4972.12,19026.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4415.85,4415.85,4415.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4325.51,4325.51,4325.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10632.55,10632.55,10632.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5669.02,4959.06,5669.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8859.8,8859.8,13931.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6454.88,6454.88,6454.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4325.51,4325.51,4325.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],8922.35,8922.35,8922.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,7305.11,7305.11,11896.46,1 through 10,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10025.43,10025.43,10025.43,1 through 10,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7056.57,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6720.54,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6720.54,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6720.54,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6720.54,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6720.54,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6720.54,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12096.97,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12096.97,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7056.57,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6720.54,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6720.54,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7056.57,,,,,,,fee schedule,6720.54,19056.29,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38205.81,,,,,,,fee schedule,18058.17,77001.6,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,77001.6,,,,,,,fee schedule,18058.17,77001.6,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,77001.6,,,,,,,fee schedule,18058.17,77001.6,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30565.74,,,,,,,fee schedule,18058.17,77001.6,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50327.43,,,,,,,fee schedule,18058.17,77001.6,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43762.98,,,,,,,fee schedule,18058.17,77001.6,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16828.97,16828.97,16828.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18961.08,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18058.17,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18058.17,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18058.17,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18058.17,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18058.17,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18058.17,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32504.71,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32504.71,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18961.08,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18058.17,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18058.17,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18961.08,,,,,,,fee schedule,18058.17,77001.6,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29303.28,,,,,,,fee schedule,14025.45,45734.39,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45734.39,,,,,,,fee schedule,14025.45,45734.39,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45734.39,,,,,,,fee schedule,14025.45,45734.39,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23443.47,,,,,,,fee schedule,14025.45,45734.39,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38600.38,,,,,,,fee schedule,14025.45,45734.39,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33565.55,,,,,,,fee schedule,14025.45,45734.39,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14726.72,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14025.45,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14025.45,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14025.45,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14025.45,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14025.45,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14025.45,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25245.81,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25245.81,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14726.72,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14025.45,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14025.45,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14726.72,,,,,,,fee schedule,14025.45,45734.39,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44447.7,,,,,,,fee schedule,20885.65,58549.7,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,54157.04,,,,,,,fee schedule,20885.65,58549.7,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,54157.04,,,,,,,fee schedule,20885.65,58549.7,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35559.44,,,,,,,fee schedule,20885.65,58549.7,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,58549.7,,,,,,,fee schedule,20885.65,58549.7,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,50912.78,,,,,,,fee schedule,20885.65,58549.7,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],49090.23,49090.23,49090.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18628.13,18628.13,18628.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21929.93,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20885.65,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20885.65,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20885.65,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20885.65,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20885.65,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20885.65,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37594.17,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37594.17,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21929.93,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20885.65,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20885.65,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21929.93,,,,,,,fee schedule,20885.65,58549.7,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26762.98,,,,,,,fee schedule,12874.73,35254.11,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17875.93,,,,,,,fee schedule,12874.73,35254.11,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17875.93,,,,,,,fee schedule,12874.73,35254.11,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21411.15,,,,,,,fee schedule,12874.73,35254.11,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35254.11,,,,,,,fee schedule,12874.73,35254.11,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30655.75,,,,,,,fee schedule,12874.73,35254.11,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12578.61,12578.61,12578.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13518.47,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12874.73,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12874.73,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12874.73,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12874.73,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12874.73,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12874.73,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23174.51,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23174.51,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13518.47,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12874.73,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12874.73,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13518.47,,,,,,,fee schedule,12874.73,35254.11,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39800.66,,,,,,,fee schedule,18780.61,52428.28,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,49484.36,,,,,,,fee schedule,18780.61,52428.28,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,49484.36,,,,,,,fee schedule,18780.61,52428.28,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31841.67,,,,,,,fee schedule,18780.61,52428.28,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52428.28,,,,,,,fee schedule,18780.61,52428.28,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45589.81,,,,,,,fee schedule,18780.61,52428.28,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2953.07,2953.07,2953.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],41825.51,41825.51,41825.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19719.64,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18780.61,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18780.61,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18780.61,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18780.61,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18780.61,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18780.61,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33805.1,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33805.1,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19719.64,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18780.61,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18780.61,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19719.64,,,,,,,fee schedule,18780.61,52428.28,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21004.31,,,,,,,fee schedule,10266.14,27668.39,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27276.99,,,,,,,fee schedule,10266.14,27668.39,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27276.99,,,,,,,fee schedule,10266.14,27668.39,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16804.05,,,,,,,fee schedule,10266.14,27668.39,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27668.39,,,,,,,fee schedule,10266.14,27668.39,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24059.47,,,,,,,fee schedule,10266.14,27668.39,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10779.45,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10266.14,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10266.14,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10266.14,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10266.14,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10266.14,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10266.14,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18479.05,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18479.05,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10779.45,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10266.14,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10266.14,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10779.45,,,,,,,fee schedule,10266.14,27668.39,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28715,,,,,,,fee schedule,13758.97,37825.45,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,37235.14,,,,,,,fee schedule,13758.97,37825.45,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,37235.14,,,,,,,fee schedule,13758.97,37825.45,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22972.82,,,,,,,fee schedule,13758.97,37825.45,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37825.45,,,,,,,fee schedule,13758.97,37825.45,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32891.7,,,,,,,fee schedule,13758.97,37825.45,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29021.74,29021.74,29021.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10172.8,10172.8,10172.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14446.92,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13758.97,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13758.97,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13758.97,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13758.97,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13758.97,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13758.97,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24766.15,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24766.15,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14446.92,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13758.97,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13758.97,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14446.92,,,,,,,fee schedule,13758.97,37825.45,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20196.38,,,,,,,fee schedule,9900.16,31643.25,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31643.25,,,,,,,fee schedule,9900.16,31643.25,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31643.25,,,,,,,fee schedule,9900.16,31643.25,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16157.69,,,,,,,fee schedule,9900.16,31643.25,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26604.12,,,,,,,fee schedule,9900.16,31643.25,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23134.02,,,,,,,fee schedule,9900.16,31643.25,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10395.17,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9900.16,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9900.16,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9900.16,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9900.16,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9900.16,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9900.16,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17820.29,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17820.29,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10395.17,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9900.16,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9900.16,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10395.17,,,,,,,fee schedule,9900.16,31643.25,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42732.52,,,,,,,fee schedule,20108.7,72360.26,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,72360.26,,,,,,,fee schedule,20108.7,72360.26,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,72360.26,,,,,,,fee schedule,20108.7,72360.26,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,34187.24,,,,,,,fee schedule,20108.7,72360.26,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,56290.33,,,,,,,fee schedule,20108.7,72360.26,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,48948.12,,,,,,,fee schedule,20108.7,72360.26,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21114.14,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20108.7,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20108.7,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20108.7,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20108.7,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20108.7,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20108.7,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36195.66,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,36195.66,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21114.14,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20108.7,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20108.7,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21114.14,,,,,,,fee schedule,20108.7,72360.26,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28096.16,,,,,,,fee schedule,13478.65,47433.54,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,47433.54,,,,,,,fee schedule,13478.65,47433.54,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,47433.54,,,,,,,fee schedule,13478.65,47433.54,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22477.73,,,,,,,fee schedule,13478.65,47433.54,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37010.27,,,,,,,fee schedule,13478.65,47433.54,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32182.85,,,,,,,fee schedule,13478.65,47433.54,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14152.58,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13478.65,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13478.65,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13478.65,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13478.65,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13478.65,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13478.65,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24261.57,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24261.57,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14152.58,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13478.65,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13478.65,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14152.58,,,,,,,fee schedule,13478.65,47433.54,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36108.63,,,,,,,fee schedule,17108.18,47564.87,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,40783.17,,,,,,,fee schedule,17108.18,47564.87,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,40783.17,,,,,,,fee schedule,17108.18,47564.87,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28887.94,,,,,,,fee schedule,17108.18,47564.87,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,47564.87,,,,,,,fee schedule,17108.18,47564.87,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,41360.76,,,,,,,fee schedule,17108.18,47564.87,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],38069.29,38069.29,38069.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],16984.58,16984.58,16984.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17963.59,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30794.72,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30794.72,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17963.59,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17108.18,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17963.59,,,,,,,fee schedule,17108.18,47564.87,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25653.26,,,,,,,fee schedule,12372.05,33792.32,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27837.57,,,,,,,fee schedule,12372.05,33792.32,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27837.57,,,,,,,fee schedule,12372.05,33792.32,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20523.35,,,,,,,fee schedule,12372.05,33792.32,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33792.32,,,,,,,fee schedule,12372.05,33792.32,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29384.62,,,,,,,fee schedule,12372.05,33792.32,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12990.65,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12372.05,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12372.05,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12372.05,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12372.05,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12372.05,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12372.05,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22269.69,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22269.69,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12990.65,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12372.05,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12372.05,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12990.65,,,,,,,fee schedule,12372.05,33792.32,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34565.34,,,,,,,fee schedule,16409.09,45531.94,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35675.26,,,,,,,fee schedule,16409.09,45531.94,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35675.26,,,,,,,fee schedule,16409.09,45531.94,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27653.27,,,,,,,fee schedule,16409.09,45531.94,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45531.94,,,,,,,fee schedule,16409.09,45531.94,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39593,,,,,,,fee schedule,16409.09,45531.94,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17229.54,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16409.09,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16409.09,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16409.09,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16409.09,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16409.09,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16409.09,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29536.36,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29536.36,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17229.54,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16409.09,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16409.09,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17229.54,,,,,,,fee schedule,16409.09,45531.94,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21825.62,,,,,,,fee schedule,10638.18,28750.26,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28582.69,,,,,,,fee schedule,10638.18,28750.26,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28582.69,,,,,,,fee schedule,10638.18,28750.26,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17461.12,,,,,,,fee schedule,10638.18,28750.26,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28750.26,,,,,,,fee schedule,10638.18,28750.26,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25000.23,,,,,,,fee schedule,10638.18,28750.26,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6425.62,6425.62,6425.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10026.51,10026.51,10026.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11170.09,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10638.18,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10638.18,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10638.18,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10638.18,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10638.18,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10638.18,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19148.72,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19148.72,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11170.09,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10638.18,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10638.18,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11170.09,,,,,,,fee schedule,10638.18,28750.26,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12523.9,,,,,,,fee schedule,6424.64,21967.13,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21967.13,,,,,,,fee schedule,6424.64,21967.13,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21967.13,,,,,,,fee schedule,6424.64,21967.13,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10019.48,,,,,,,fee schedule,6424.64,21967.13,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16497.37,,,,,,,fee schedule,6424.64,21967.13,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14345.54,,,,,,,fee schedule,6424.64,21967.13,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6745.87,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6424.64,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6424.64,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6424.64,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6424.64,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6424.64,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6424.64,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11564.35,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11564.35,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6745.87,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6424.64,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6424.64,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6745.87,,,,,,,fee schedule,6424.64,21967.13,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22350.87,,,,,,,fee schedule,10876.11,31664.14,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31664.14,,,,,,,fee schedule,10876.11,31664.14,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31664.14,,,,,,,fee schedule,10876.11,31664.14,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17881.33,,,,,,,fee schedule,10876.11,31664.14,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29442.16,,,,,,,fee schedule,10876.11,31664.14,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25601.88,,,,,,,fee schedule,10876.11,31664.14,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10641.48,10641.48,10641.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11419.92,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10876.11,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10876.11,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10876.11,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10876.11,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10876.11,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10876.11,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19577,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19577,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11419.92,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10876.11,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10876.11,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11419.92,,,,,,,fee schedule,10876.11,31664.14,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13790.23,,,,,,,fee schedule,6998.27,18648.91,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18648.91,,,,,,,fee schedule,6998.27,18648.91,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18648.91,,,,,,,fee schedule,6998.27,18648.91,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11032.58,,,,,,,fee schedule,6998.27,18648.91,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18165.48,,,,,,,fee schedule,6998.27,18648.91,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15796.07,,,,,,,fee schedule,6998.27,18648.91,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5494.26,5494.26,5494.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7348.18,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6998.27,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6998.27,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6998.27,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6998.27,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6998.27,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6998.27,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12596.89,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12596.89,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7348.18,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6998.27,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6998.27,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7348.18,,,,,,,fee schedule,6998.27,18648.91,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28323.45,,,,,,,fee schedule,13581.61,37309.68,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,34432.23,,,,,,,fee schedule,13581.61,37309.68,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,34432.23,,,,,,,fee schedule,13581.61,37309.68,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22659.57,,,,,,,fee schedule,13581.61,37309.68,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37309.68,,,,,,,fee schedule,13581.61,37309.68,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32443.2,,,,,,,fee schedule,13581.61,37309.68,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14260.69,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13581.61,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13581.61,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13581.61,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13581.61,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13581.61,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13581.61,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24446.9,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24446.9,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14260.69,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13581.61,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13581.61,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14260.69,,,,,,,fee schedule,13581.61,37309.68,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15493.95,,,,,,,fee schedule,7770.03,20409.74,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,15003.39,,,,,,,fee schedule,7770.03,20409.74,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,15003.39,,,,,,,fee schedule,7770.03,20409.74,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12395.61,,,,,,,fee schedule,7770.03,20409.74,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20409.74,,,,,,,fee schedule,7770.03,20409.74,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17747.6,,,,,,,fee schedule,7770.03,20409.74,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],10391.59,10391.59,10391.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7460.14,5811.8,7588.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8158.53,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7770.03,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7770.03,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7770.03,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7770.03,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7770.03,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7770.03,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13986.05,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13986.05,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8158.53,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7770.03,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7770.03,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8158.53,,,,,,,fee schedule,7770.03,20409.74,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20221.21,,,,,,,fee schedule,9911.41,29098,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29098,,,,,,,fee schedule,9911.41,29098,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29098,,,,,,,fee schedule,9911.41,29098,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16177.55,,,,,,,fee schedule,9911.41,29098,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26636.83,,,,,,,fee schedule,9911.41,29098,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23162.46,,,,,,,fee schedule,9911.41,29098,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],7827.55,7827.55,7827.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10406.98,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9911.41,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9911.41,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9911.41,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9911.41,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9911.41,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9911.41,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17840.54,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17840.54,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10406.98,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9911.41,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9911.41,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10406.98,,,,,,,fee schedule,9911.41,29098,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12835.23,,,,,,,fee schedule,6565.67,19665.61,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19665.61,,,,,,,fee schedule,6565.67,19665.61,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19665.61,,,,,,,fee schedule,6565.67,19665.61,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10268.55,,,,,,,fee schedule,6565.67,19665.61,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16907.48,,,,,,,fee schedule,6565.67,19665.61,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14702.16,,,,,,,fee schedule,6565.67,19665.61,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],8882.69,8882.69,8882.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6893.95,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6565.67,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6565.67,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6565.67,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6565.67,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6565.67,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6565.67,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11818.21,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11818.21,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6893.95,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6565.67,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6565.67,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6893.95,,,,,,,fee schedule,6565.67,19665.61,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,52966.24,,,,,,,fee schedule,19180.34,53590.67,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40683.09,,,,,,,fee schedule,19180.34,53590.67,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,52966.24,,,,,,,fee schedule,19180.34,53590.67,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32547.64,,,,,,,fee schedule,19180.34,53590.67,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53590.67,,,,,,,fee schedule,19180.34,53590.67,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46600.59,,,,,,,fee schedule,19180.34,53590.67,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20139.36,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19180.34,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19180.34,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19180.34,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19180.34,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19180.34,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19180.34,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34524.61,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34524.61,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20139.36,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19180.34,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19180.34,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20139.36,,,,,,,fee schedule,19180.34,53590.67,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,42280.37,,,,,,,fee schedule,12392.82,42280.37,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25699.1,,,,,,,fee schedule,12392.82,42280.37,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,42280.37,,,,,,,fee schedule,12392.82,42280.37,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20560.02,,,,,,,fee schedule,12392.82,42280.37,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33852.7,,,,,,,fee schedule,12392.82,42280.37,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29437.13,,,,,,,fee schedule,12392.82,42280.37,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13012.46,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12392.82,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12392.82,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12392.82,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12392.82,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12392.82,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12392.82,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22307.08,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22307.08,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13012.46,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12392.82,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12392.82,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13012.46,,,,,,,fee schedule,12392.82,42280.37,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,104644.18,,,,,,,fee schedule,31678.21,104644.18,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68273.09,,,,,,,fee schedule,31678.21,104644.18,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,104644.18,,,,,,,fee schedule,31678.21,104644.18,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,54620.43,,,,,,,fee schedule,31678.21,104644.18,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,89934.21,,,,,,,fee schedule,31678.21,104644.18,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,78203.66,,,,,,,fee schedule,31678.21,104644.18,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33262.12,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31678.21,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31678.21,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31678.21,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31678.21,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31678.21,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31678.21,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57020.78,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,57020.78,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33262.12,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31678.21,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31678.21,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33262.12,,,,,,,fee schedule,31678.21,104644.18,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,55111.07,,,,,,,fee schedule,18579.89,55111.07,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39357.54,,,,,,,fee schedule,18579.89,55111.07,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,55111.07,,,,,,,fee schedule,18579.89,55111.07,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31487.16,,,,,,,fee schedule,18579.89,55111.07,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,51844.57,,,,,,,fee schedule,18579.89,55111.07,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45082.24,,,,,,,fee schedule,18579.89,55111.07,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],50390.03,50390.03,50390.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19508.88,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18579.89,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18579.89,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18579.89,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18579.89,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18579.89,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18579.89,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33443.8,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33443.8,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19508.88,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18579.89,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18579.89,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19508.88,,,,,,,fee schedule,18579.89,55111.07,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,39794.32,,,,,,,fee schedule,13457.02,39794.32,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28048.41,,,,,,,fee schedule,13457.02,39794.32,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,39794.32,,,,,,,fee schedule,13457.02,39794.32,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22439.53,,,,,,,fee schedule,13457.02,39794.32,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,36947.37,,,,,,,fee schedule,13457.02,39794.32,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32128.15,,,,,,,fee schedule,13457.02,39794.32,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14129.87,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13457.02,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13457.02,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13457.02,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13457.02,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13457.02,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13457.02,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24222.64,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24222.64,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14129.87,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13457.02,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13457.02,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14129.87,,,,,,,fee schedule,13457.02,39794.32,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,87565.6,,,,,,,fee schedule,31750.02,90143.03,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,68431.62,,,,,,,fee schedule,31750.02,90143.03,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,87565.6,,,,,,,fee schedule,31750.02,90143.03,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,54747.26,,,,,,,fee schedule,31750.02,90143.03,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,90143.03,,,,,,,fee schedule,31750.02,90143.03,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,78385.25,,,,,,,fee schedule,31750.02,90143.03,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33337.52,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,31750.02,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,31750.02,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,31750.02,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,31750.02,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,31750.02,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,31750.02,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57150.04,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,57150.04,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33337.52,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,31750.02,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,31750.02,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33337.52,,,,,,,fee schedule,31750.02,90143.03,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,55347.84,,,,,,,fee schedule,16408.23,55347.84,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34563.43,,,,,,,fee schedule,16408.23,55347.84,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,55347.84,,,,,,,fee schedule,16408.23,55347.84,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27651.74,,,,,,,fee schedule,16408.23,55347.84,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45529.43,,,,,,,fee schedule,16408.23,55347.84,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39590.81,,,,,,,fee schedule,16408.23,55347.84,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17228.64,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16408.23,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16408.23,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16408.23,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16408.23,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16408.23,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16408.23,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29534.81,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29534.81,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17228.64,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16408.23,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16408.23,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17228.64,,,,,,,fee schedule,16408.23,55347.84,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41249.74,,,,,,,fee schedule,13090.17,41249.74,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27238.57,,,,,,,fee schedule,13090.17,41249.74,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41249.74,,,,,,,fee schedule,13090.17,41249.74,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21791.64,,,,,,,fee schedule,13090.17,41249.74,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35880.59,,,,,,,fee schedule,13090.17,41249.74,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31200.52,,,,,,,fee schedule,13090.17,41249.74,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13744.68,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13090.17,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13090.17,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13090.17,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13090.17,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13090.17,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13090.17,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23562.31,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23562.31,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13744.68,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13090.17,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13090.17,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13744.68,,,,,,,fee schedule,13090.17,41249.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45226.04,,,,,,,fee schedule,16626.26,46163.46,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35044.75,,,,,,,fee schedule,16626.26,46163.46,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45226.04,,,,,,,fee schedule,16626.26,46163.46,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28036.81,,,,,,,fee schedule,16626.26,46163.46,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46163.46,,,,,,,fee schedule,16626.26,46163.46,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40142.14,,,,,,,fee schedule,16626.26,46163.46,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],41606.22,41606.22,41606.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10485.91,10485.91,10485.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16134.45,16134.45,16134.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33605,33605,33605,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",27858.82,27858.82,27858.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],29532.62,29532.62,29532.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17457.57,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16626.26,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16626.26,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16626.26,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16626.26,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16626.26,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16626.26,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29927.27,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29927.27,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17457.57,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16626.26,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16626.26,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17457.57,,,,,,,fee schedule,16626.26,46163.46,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32771.38,,,,,,,fee schedule,11486.08,32771.38,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23697.42,,,,,,,fee schedule,11486.08,32771.38,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32771.38,,,,,,,fee schedule,11486.08,32771.38,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18958.62,,,,,,,fee schedule,11486.08,32771.38,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31215.94,,,,,,,fee schedule,11486.08,32771.38,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27144.3,,,,,,,fee schedule,11486.08,32771.38,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],29891.46,29891.46,32796.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19714.99,19714.99,19714.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,64202.27,64202.27,64202.27,1 through 10,percent of total billed charges,,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12060.38,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11486.08,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11486.08,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11486.08,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11486.08,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11486.08,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11486.08,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20674.94,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20674.94,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12060.38,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11486.08,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11486.08,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12060.38,,,,,,,fee schedule,11486.08,32771.38,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44839.55,,,,,,,fee schedule,18480.39,51555.23,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39137.89,,,,,,,fee schedule,18480.39,51555.23,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44839.55,,,,,,,fee schedule,18480.39,51555.23,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31311.44,,,,,,,fee schedule,18480.39,51555.23,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,51555.23,,,,,,,fee schedule,18480.39,51555.23,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,44830.64,,,,,,,fee schedule,18480.39,51555.23,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19404.41,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18480.39,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18480.39,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18480.39,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18480.39,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18480.39,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18480.39,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33264.7,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33264.7,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19404.41,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18480.39,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18480.39,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19404.41,,,,,,,fee schedule,18480.39,51555.23,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35786.68,,,,,,,fee schedule,10593.19,35786.68,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21726.3,,,,,,,fee schedule,10593.19,35786.68,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35786.68,,,,,,,fee schedule,10593.19,35786.68,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17381.66,,,,,,,fee schedule,10593.19,35786.68,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28619.43,,,,,,,fee schedule,10593.19,35786.68,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,24886.46,,,,,,,fee schedule,10593.19,35786.68,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11122.85,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10593.19,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10593.19,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10593.19,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10593.19,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10593.19,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10593.19,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19067.74,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19067.74,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11122.85,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10593.19,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10593.19,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11122.85,,,,,,,fee schedule,10593.19,35786.68,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41507.4,,,,,,,fee schedule,15780.95,43705.33,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33178.68,,,,,,,fee schedule,15780.95,43705.33,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41507.4,,,,,,,fee schedule,15780.95,43705.33,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26543.9,,,,,,,fee schedule,15780.95,43705.33,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43705.33,,,,,,,fee schedule,15780.95,43705.33,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38004.64,,,,,,,fee schedule,15780.95,43705.33,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15553.62,15553.62,15553.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13719.39,13719.39,13719.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16570,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15780.95,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15780.95,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15780.95,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15780.95,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15780.95,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15780.95,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28405.71,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28405.71,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16570,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15780.95,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15780.95,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16570,,,,,,,fee schedule,15780.95,43705.33,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,34400.9,,,,,,,fee schedule,8189.66,34400.9,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16420.3,,,,,,,fee schedule,8189.66,34400.9,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,34400.9,,,,,,,fee schedule,8189.66,34400.9,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13136.71,,,,,,,fee schedule,8189.66,34400.9,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21630,,,,,,,fee schedule,8189.66,34400.9,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18808.7,,,,,,,fee schedule,8189.66,34400.9,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24418.83,24418.83,24418.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8599.14,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8189.66,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8189.66,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8189.66,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8189.66,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8189.66,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8189.66,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14741.39,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14741.39,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8599.14,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8189.66,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8189.66,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8599.14,,,,,,,fee schedule,8189.66,34400.9,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,51859,,,,,,,fee schedule,12754.47,51859,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26497.49,,,,,,,fee schedule,12754.47,51859,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,51859,,,,,,,fee schedule,12754.47,51859,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21198.75,,,,,,,fee schedule,12754.47,51859,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34904.38,,,,,,,fee schedule,12754.47,51859,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30351.64,,,,,,,fee schedule,12754.47,51859,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13392.19,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12754.47,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12754.47,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12754.47,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12754.47,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12754.47,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12754.47,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22958.05,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22958.05,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13392.19,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12754.47,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12754.47,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13392.19,,,,,,,fee schedule,12754.47,51859,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49041.26,,,,,,,fee schedule,22966.47,64600.66,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57604.09,,,,,,,fee schedule,22966.47,64600.66,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57604.09,,,,,,,fee schedule,22966.47,64600.66,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,39234.42,,,,,,,fee schedule,22966.47,64600.66,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,64600.66,,,,,,,fee schedule,22966.47,64600.66,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,56174.49,,,,,,,fee schedule,22966.47,64600.66,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24114.79,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22966.47,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22966.47,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22966.47,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22966.47,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22966.47,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22966.47,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41339.65,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,41339.65,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24114.79,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22966.47,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22966.47,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24114.79,,,,,,,fee schedule,22966.47,64600.66,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28187.84,,,,,,,fee schedule,13520.18,37131.04,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31124.45,,,,,,,fee schedule,13520.18,37131.04,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31124.45,,,,,,,fee schedule,13520.18,37131.04,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22551.08,,,,,,,fee schedule,13520.18,37131.04,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37131.04,,,,,,,fee schedule,13520.18,37131.04,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32287.86,,,,,,,fee schedule,13520.18,37131.04,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14196.19,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13520.18,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13520.18,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13520.18,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13520.18,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13520.18,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13520.18,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24336.32,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24336.32,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14196.19,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13520.18,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13520.18,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14196.19,,,,,,,fee schedule,13520.18,37131.04,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35176.54,,,,,,,fee schedule,16685.96,53457.18,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,53457.18,,,,,,,fee schedule,16685.96,53457.18,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,53457.18,,,,,,,fee schedule,16685.96,53457.18,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28142.24,,,,,,,fee schedule,16685.96,53457.18,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46337.06,,,,,,,fee schedule,16685.96,53457.18,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40293.1,,,,,,,fee schedule,16685.96,53457.18,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17520.26,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16685.96,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16685.96,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16685.96,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16685.96,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16685.96,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16685.96,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30034.73,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30034.73,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17520.26,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16685.96,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16685.96,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17520.26,,,,,,,fee schedule,16685.96,53457.18,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20777.02,,,,,,,fee schedule,10163.19,27368.98,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24592.46,,,,,,,fee schedule,10163.19,27368.98,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24592.46,,,,,,,fee schedule,10163.19,27368.98,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16622.21,,,,,,,fee schedule,10163.19,27368.98,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27368.98,,,,,,,fee schedule,10163.19,27368.98,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23799.12,,,,,,,fee schedule,10163.19,27368.98,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10671.35,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10163.19,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10163.19,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10163.19,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10163.19,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10163.19,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10163.19,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18293.74,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18293.74,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10671.35,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10163.19,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10163.19,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10671.35,,,,,,,fee schedule,10163.19,27368.98,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18345.59,,,,,,,fee schedule,9061.78,24166.12,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18610.61,,,,,,,fee schedule,9061.78,24166.12,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18610.61,,,,,,,fee schedule,9061.78,24166.12,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14677,,,,,,,fee schedule,9061.78,24166.12,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24166.12,,,,,,,fee schedule,9061.78,24166.12,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21014.02,,,,,,,fee schedule,9061.78,24166.12,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9514.87,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9061.78,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9061.78,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9061.78,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9061.78,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9061.78,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9061.78,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16311.2,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16311.2,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9514.87,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9061.78,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9061.78,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9514.87,,,,,,,fee schedule,9061.78,24166.12,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27349.35,,,,,,,fee schedule,13140.35,36026.52,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28986.58,,,,,,,fee schedule,13140.35,36026.52,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28986.58,,,,,,,fee schedule,13140.35,36026.52,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21880.26,,,,,,,fee schedule,13140.35,36026.52,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,36026.52,,,,,,,fee schedule,13140.35,36026.52,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31327.41,,,,,,,fee schedule,13140.35,36026.52,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6396.44,6396.44,6396.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11875.4,11875.4,11875.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13797.37,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13140.35,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13140.35,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13140.35,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13140.35,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13140.35,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13140.35,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23652.63,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23652.63,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13797.37,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13140.35,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13140.35,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13797.37,,,,,,,fee schedule,13140.35,36026.52,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18698.94,,,,,,,fee schedule,9221.84,24631.58,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19797.92,,,,,,,fee schedule,9221.84,24631.58,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19797.92,,,,,,,fee schedule,9221.84,24631.58,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14959.69,,,,,,,fee schedule,9221.84,24631.58,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24631.58,,,,,,,fee schedule,9221.84,24631.58,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21418.77,,,,,,,fee schedule,9221.84,24631.58,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9195.71,9195.71,9195.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9682.93,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9221.84,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9221.84,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9221.84,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9221.84,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9221.84,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9221.84,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16599.31,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16599.31,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9682.93,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9221.84,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9221.84,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9682.93,,,,,,,fee schedule,9221.84,24631.58,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12674.79,,,,,,,fee schedule,6492.99,18485.26,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18485.26,,,,,,,fee schedule,6492.99,18485.26,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18485.26,,,,,,,fee schedule,6492.99,18485.26,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10140.19,,,,,,,fee schedule,6492.99,18485.26,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16696.14,,,,,,,fee schedule,6492.99,18485.26,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14518.38,,,,,,,fee schedule,6492.99,18485.26,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5972.67,5972.67,5972.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],9922.09,9922.09,9922.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6817.64,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6492.99,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6492.99,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6492.99,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6492.99,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6492.99,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6492.99,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11687.38,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11687.38,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6817.64,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6492.99,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6492.99,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6817.64,,,,,,,fee schedule,6492.99,18485.26,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19243.29,,,,,,,fee schedule,9468.43,25348.64,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23708.07,,,,,,,fee schedule,9468.43,25348.64,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23708.07,,,,,,,fee schedule,9468.43,25348.64,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15395.18,,,,,,,fee schedule,9468.43,25348.64,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25348.64,,,,,,,fee schedule,9468.43,25348.64,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22042.3,,,,,,,fee schedule,9468.43,25348.64,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],6113.39,6113.39,6113.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4346.36,4346.36,4346.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18130.81,18130.81,19614.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9941.85,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9468.43,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9468.43,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9468.43,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9468.43,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9468.43,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9468.43,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17043.17,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17043.17,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9941.85,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9468.43,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9468.43,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9941.85,,,,,,,fee schedule,9468.43,25348.64,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10896.57,,,,,,,fee schedule,5687.49,14425.4,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14425.4,,,,,,,fee schedule,5687.49,14425.4,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14425.4,,,,,,,fee schedule,5687.49,14425.4,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,8717.57,,,,,,,fee schedule,5687.49,14425.4,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,14353.75,,,,,,,fee schedule,5687.49,14425.4,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,12481.52,,,,,,,fee schedule,5687.49,14425.4,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5971.86,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5687.49,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5687.49,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5687.49,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5687.49,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5687.49,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5687.49,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10237.48,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,10237.48,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,5971.86,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5687.49,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5687.49,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,5971.86,,,,,,,fee schedule,5687.49,14425.4,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20467.6,,,,,,,fee schedule,10023.02,26961.39,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16267.31,,,,,,,fee schedule,10023.02,26961.39,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16267.31,,,,,,,fee schedule,10023.02,26961.39,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16374.67,,,,,,,fee schedule,10023.02,26961.39,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26961.39,,,,,,,fee schedule,10023.02,26961.39,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23444.69,,,,,,,fee schedule,10023.02,26961.39,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10524.17,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10023.02,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10023.02,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10023.02,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10023.02,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10023.02,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10023.02,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18041.44,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18041.44,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10524.17,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10023.02,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10023.02,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10524.17,,,,,,,fee schedule,10023.02,26961.39,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32275.25,,,,,,,fee schedule,15371.71,42515.27,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,41430.79,,,,,,,fee schedule,15371.71,42515.27,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,41430.79,,,,,,,fee schedule,15371.71,42515.27,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25821.12,,,,,,,fee schedule,15371.71,42515.27,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42515.27,,,,,,,fee schedule,15371.71,42515.27,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36969.8,,,,,,,fee schedule,15371.71,42515.27,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],33430.04,33430.04,33430.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9571.32,9571.32,9571.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16140.3,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15371.71,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15371.71,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15371.71,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15371.71,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15371.71,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15371.71,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27669.08,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27669.08,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16140.3,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15371.71,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15371.71,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16140.3,,,,,,,fee schedule,15371.71,42515.27,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19151.61,,,,,,,fee schedule,9426.9,25227.87,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20971.32,,,,,,,fee schedule,9426.9,25227.87,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20971.32,,,,,,,fee schedule,9426.9,25227.87,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15321.84,,,,,,,fee schedule,9426.9,25227.87,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25227.87,,,,,,,fee schedule,9426.9,25227.87,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21937.28,,,,,,,fee schedule,9426.9,25227.87,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4681.3,4681.3,4681.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9898.24,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9426.9,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9426.9,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9426.9,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9426.9,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9426.9,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9426.9,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16968.42,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16968.42,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9898.24,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9426.9,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9426.9,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9898.24,,,,,,,fee schedule,9426.9,25227.87,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,11361.35,,,,,,,fee schedule,6415.99,16472.21,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12504.8,,,,,,,fee schedule,6415.99,16472.21,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,11361.35,,,,,,,fee schedule,6415.99,16472.21,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10004.2,,,,,,,fee schedule,6415.99,16472.21,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16472.21,,,,,,,fee schedule,6415.99,16472.21,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14323.66,,,,,,,fee schedule,6415.99,16472.21,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25416,25416,25416,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5025,5025,5025,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6736.79,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6415.99,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6415.99,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6415.99,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6415.99,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6415.99,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6415.99,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11548.78,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11548.78,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6736.79,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6415.99,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6415.99,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6736.79,,,,,,,fee schedule,6415.99,16472.21,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16068.86,,,,,,,fee schedule,8030.46,21167.06,
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,13433.06,,,,,,,fee schedule,8030.46,21167.06,
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,13433.06,,,,,,,fee schedule,8030.46,21167.06,
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12855.55,,,,,,,fee schedule,8030.46,21167.06,
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21167.06,,,,,,,fee schedule,8030.46,21167.06,
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18406.14,,,,,,,fee schedule,8030.46,21167.06,
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8431.98,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8030.46,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8030.46,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8030.46,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8030.46,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8030.46,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8030.46,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14454.83,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14454.83,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8431.98,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8030.46,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8030.46,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8431.98,,,,,,,fee schedule,8030.46,21167.06,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46892.51,,,,,,,fee schedule,21993.12,61770.17,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33708,,,,,,,fee schedule,21993.12,61770.17,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33708,,,,,,,fee schedule,21993.12,61770.17,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,37515.35,,,,,,,fee schedule,21993.12,61770.17,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,61770.17,,,,,,,fee schedule,21993.12,61770.17,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,53713.19,,,,,,,fee schedule,21993.12,61770.17,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23092.78,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21993.12,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21993.12,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21993.12,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21993.12,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21993.12,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21993.12,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39587.62,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,39587.62,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23092.78,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21993.12,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21993.12,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23092.78,,,,,,,fee schedule,21993.12,61770.17,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20247.95,,,,,,,fee schedule,9923.52,26672.05,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23224.09,,,,,,,fee schedule,9923.52,26672.05,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23224.09,,,,,,,fee schedule,9923.52,26672.05,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16198.94,,,,,,,fee schedule,9923.52,26672.05,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26672.05,,,,,,,fee schedule,9923.52,26672.05,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23193.09,,,,,,,fee schedule,9923.52,26672.05,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10419.7,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9923.52,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9923.52,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9923.52,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9923.52,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9923.52,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9923.52,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17862.34,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17862.34,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10419.7,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9923.52,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9923.52,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10419.7,,,,,,,fee schedule,9923.52,26672.05,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18294.02,,,,,,,fee schedule,9038.42,24098.19,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19853.63,,,,,,,fee schedule,9038.42,24098.19,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19853.63,,,,,,,fee schedule,9038.42,24098.19,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14635.74,,,,,,,fee schedule,9038.42,24098.19,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24098.19,,,,,,,fee schedule,9038.42,24098.19,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20954.95,,,,,,,fee schedule,9038.42,24098.19,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9490.34,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9038.42,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9038.42,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9038.42,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9038.42,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9038.42,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9038.42,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16269.16,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16269.16,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9490.34,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9038.42,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9038.42,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9490.34,,,,,,,fee schedule,9038.42,24098.19,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18174.78,,,,,,,fee schedule,14532.16,30490.75,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30490.75,,,,,,,fee schedule,14532.16,30490.75,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30490.75,,,,,,,fee schedule,14532.16,30490.75,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14532.16,,,,,,,fee schedule,14532.16,30490.75,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23941.68,,,,,,,fee schedule,14532.16,30490.75,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20818.85,,,,,,,fee schedule,14532.16,30490.75,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15774.18,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15023.03,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15023.03,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15023.03,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15023.03,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15023.03,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15023.03,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27041.45,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27041.45,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15774.18,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15023.03,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15023.03,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15774.18,,,,,,,fee schedule,14532.16,30490.75,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12305.3,,,,,,,fee schedule,9839.05,22113.37,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22113.37,,,,,,,fee schedule,9839.05,22113.37,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22113.37,,,,,,,fee schedule,9839.05,22113.37,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9839.05,,,,,,,fee schedule,9839.05,22113.37,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16209.8,,,,,,,fee schedule,9839.05,22113.37,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14095.48,,,,,,,fee schedule,9839.05,22113.37,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10934.79,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18745.36,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18745.36,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10934.79,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10414.09,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10934.79,,,,,,,fee schedule,9839.05,22113.37,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10564.4,,,,,,,fee schedule,8447.07,20215.75,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20215.75,,,,,,,fee schedule,8447.07,20215.75,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20215.75,,,,,,,fee schedule,8447.07,20215.75,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,8447.07,,,,,,,fee schedule,8447.07,20215.75,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,13916.51,,,,,,,fee schedule,8447.07,20215.75,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,12101.31,,,,,,,fee schedule,8447.07,20215.75,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9499.42,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9047.07,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9047.07,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9047.07,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9047.07,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9047.07,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9047.07,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16284.73,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16284.73,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9499.42,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9047.07,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9047.07,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9499.42,,,,,,,fee schedule,8447.07,20215.75,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34422.09,,,,,,,fee schedule,16344.2,114960.97,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,114960.97,,,,,,,fee schedule,16344.2,114960.97,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,114960.97,,,,,,,fee schedule,16344.2,114960.97,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27538.66,,,,,,,fee schedule,16344.2,114960.97,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45343.24,,,,,,,fee schedule,16344.2,114960.97,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39428.91,,,,,,,fee schedule,16344.2,114960.97,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17161.41,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16344.2,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16344.2,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16344.2,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16344.2,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16344.2,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16344.2,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29419.56,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29419.56,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17161.41,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16344.2,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16344.2,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17161.41,,,,,,,fee schedule,16344.2,114960.97,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,113521.09,,,,,,,fee schedule,52174.88,211868.43,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,211868.43,,,,,,,fee schedule,52174.88,211868.43,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,211868.43,,,,,,,fee schedule,52174.88,211868.43,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,90820.13,,,,,,,fee schedule,52174.88,211868.43,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,149538.1,,,,,,,fee schedule,52174.88,211868.43,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,130033.14,,,,,,,fee schedule,52174.88,211868.43,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",78513.94,22765.71,137295.13,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],204872.5,204872.5,204872.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],197033.36,68962.23,276314.88,117,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1958.81,1958.81,1958.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",137295.13,22465.42,308979.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",43307.6,14808.4,164659.81,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],74876.93,74876.93,79244.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23835.38,11056.72,236706.13,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],104864.52,47380.68,552674.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],207272.17,170807.29,477660.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",62715.62,12928.47,204585.62,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],171597.41,68517.09,437152.34,92,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],148042.16,58198.09,292483.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",79143.84,66209.94,113837.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],119301.77,43875.84,282077.05,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,63040.44,52768.62,816149.32,1 through 10,percent of total billed charges,,,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,315785.78,278091.91,421339.15,1 through 10,percent of total billed charges,,,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,265992.2,265992.2,380358.21,1 through 10,percent of total billed charges,,,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,128238.1,128238.1,128238.1,1 through 10,percent of total billed charges,,,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,77137.49,47125.25,144521.78,1 through 10,percent of total billed charges,,,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,54783.62,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,52174.88,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,52174.88,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,52174.88,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,52174.88,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,52174.88,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,52174.88,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,93914.78,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,93914.78,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,54783.62,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,52174.88,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,52174.88,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,54783.62,,,,,,,fee schedule,52174.88,211868.43,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,77527.06,,,,,,,fee schedule,35870.12,102124.2,
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,68206.39,,,,,,,fee schedule,35870.12,102124.2,
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,68206.39,,,,,,,fee schedule,35870.12,102124.2,
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,62023.87,,,,,,,fee schedule,35870.12,102124.2,
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,102124.2,,,,,,,fee schedule,35870.12,102124.2,
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,88803.65,,,,,,,fee schedule,35870.12,102124.2,
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],65954.2,34394.58,79826.73,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",35810.03,7516.21,54735.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",44966.3,39738.7,229995.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],70355.52,70355.52,70355.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11103.65,7070.38,107519.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],54698.22,54698.22,54698.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22676.78,12885.31,72673.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17855.59,5795.62,63688.54,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],59986.34,59986.34,59986.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],55562.62,33514.29,246321.03,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],48507.09,48507.09,281665.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],63355.88,53007.73,135156.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,120620.09,57303.82,198958.64,13,percent of total billed charges,,,
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,93682.74,93682.74,128151.36,1 through 10,percent of total billed charges,,,
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,37663.63,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35870.12,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,35870.12,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,35870.12,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,35870.12,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,35870.12,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,35870.12,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,64566.22,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,64566.22,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,37663.63,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,35870.12,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,35870.12,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,37663.63,,,,,,,fee schedule,35870.12,102124.2,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46779.82,,,,,,,fee schedule,21942.07,61621.73,
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23760.29,,,,,,,fee schedule,21942.07,61621.73,
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23760.29,,,,,,,fee schedule,21942.07,61621.73,
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,37425.2,,,,,,,fee schedule,21942.07,61621.73,
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,61621.73,,,,,,,fee schedule,21942.07,61621.73,
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,53584.11,,,,,,,fee schedule,21942.07,61621.73,
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",36445.06,36445.06,36445.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23020.76,23020.76,23020.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22975.73,18309.86,34994.39,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13195.3,9217.3,31997.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],40544.07,40544.07,40544.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21757.39,16898.01,85455.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9121.12,4900.13,34466.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],1126,1126,3003.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9121.12,5036.55,35964.04,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11039.46,10801.06,11088.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10118.66,8831.57,11039.46,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9046.64,8833.76,10118.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",46978.19,33799.91,92688.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],79322.49,35047.61,130742.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,153385.17,112036.16,157576.93,1 through 10,percent of total billed charges,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,95096.52,62055.19,134785.99,1 through 10,percent of total billed charges,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23039.17,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,21942.07,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,21942.07,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,21942.07,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,21942.07,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,21942.07,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,21942.07,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39495.73,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,39495.73,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23039.17,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,21942.07,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,21942.07,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23039.17,,,,,,,fee schedule,21942.07,61621.73,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,79639.53,,,,,,,fee schedule,31998.4,104906.89,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31998.4,,,,,,,fee schedule,31998.4,104906.89,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31998.4,,,,,,,fee schedule,31998.4,104906.89,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,63713.91,,,,,,,fee schedule,31998.4,104906.89,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,104906.89,,,,,,,fee schedule,31998.4,104906.89,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,91223.38,,,,,,,fee schedule,31998.4,104906.89,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],30582.48,11194.26,58706.08,95,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11492.18,5888.94,77081.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],80151.61,80151.61,80151.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5148.97,5148.97,5148.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",12398.05,7070.38,50571.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],685121.39,685121.39,685121.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9121.12,1700,82381.73,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],50263.45,50263.45,53326.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7070.38,2434.11,39212.95,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14423.56,14423.56,222801.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9857.27,4672.57,58333.93,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16337.09,14303.25,231716,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13786.2,10775.93,14423.56,77,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12592.01,10592.01,150602.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14808.4,7070.38,47876.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],41824.43,20626.96,683410.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,24488.82,24488.82,49055.62,1 through 10,percent of total billed charges,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,10564.11,4175.55,37498.31,1 through 10,percent of total billed charges,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,75851.28,75851.28,75851.28,1 through 10,percent of total billed charges,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,40014.58,40014.58,40014.58,1 through 10,percent of total billed charges,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38668.38,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,36827.03,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,36827.03,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,36827.03,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,36827.03,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,36827.03,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,36827.03,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66288.65,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,66288.65,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,38668.38,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,36827.03,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,36827.03,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,38668.38,,,,,,,fee schedule,31998.4,104906.89,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28189.75,,,,,,,fee schedule,5828.65,37133.56,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,5828.65,,,,,,,fee schedule,5828.65,37133.56,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,5828.65,,,,,,,fee schedule,5828.65,37133.56,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22552.61,,,,,,,fee schedule,5828.65,37133.56,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37133.56,,,,,,,fee schedule,5828.65,37133.56,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32290.05,,,,,,,fee schedule,5828.65,37133.56,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],5636.19,5265,9399.04,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5795.62,3783.08,12243.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5915.13,4489.22,14203.42,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],29135.03,29135.03,29135.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5795.62,1700,9146.22,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],19888.54,19888.54,19888.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5148.97,5148.97,5795.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],2920.13,2920.13,2920.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5795.62,2244.21,9146.22,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4808.09,3832.21,8362.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4180.95,3532.99,4180.95,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],2555.02,2555.02,2555.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5795.62,5795.62,5795.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],20037,10792.67,47836.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,17895.17,11687.68,48215.36,1 through 10,percent of total billed charges,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,46271.86,46271.86,62229.53,1 through 10,percent of total billed charges,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,75539.44,75539.44,86957.61,1 through 10,percent of total billed charges,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,17805.71,17805.71,17805.71,1 through 10,percent of total billed charges,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14197.09,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13521.04,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13521.04,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13521.04,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13521.04,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13521.04,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13521.04,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24337.87,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24337.87,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14197.09,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13521.04,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13521.04,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14197.09,,,,,,,fee schedule,5828.65,37133.56,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,3816.19,,,,,,,fee schedule,2480.18,5026.96,
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,3823.1,,,,,,,fee schedule,2480.18,5026.96,
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,3823.1,,,,,,,fee schedule,2480.18,5026.96,
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,3053.06,,,,,,,fee schedule,2480.18,5026.96,
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,5026.96,,,,,,,fee schedule,2480.18,5026.96,
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,4371.27,,,,,,,fee schedule,2480.18,5026.96,
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2244.21,2244.21,2244.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],3653.92,2957.49,3696.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4489.22,4489.22,4489.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",2017.28,1958.81,4489.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],2850.19,1784.23,2850.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],3971.6,3971.6,3971.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,2604.19,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,2480.18,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,2480.18,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,2480.18,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,2480.18,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,2480.18,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,2480.18,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,4464.32,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,4464.32,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,2604.19,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,2480.18,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,2480.18,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,2604.19,,,,,,,fee schedule,2480.18,5026.96,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22289.75,,,,,,,fee schedule,10848.43,29361.65,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26016.55,,,,,,,fee schedule,10848.43,29361.65,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26016.55,,,,,,,fee schedule,10848.43,29361.65,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17832.44,,,,,,,fee schedule,10848.43,29361.65,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29361.65,,,,,,,fee schedule,10848.43,29361.65,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25531.87,,,,,,,fee schedule,10848.43,29361.65,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11390.85,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10848.43,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10848.43,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10848.43,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10848.43,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10848.43,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10848.43,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19527.17,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19527.17,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11390.85,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10848.43,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10848.43,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11390.85,,,,,,,fee schedule,10848.43,29361.65,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19107.68,,,,,,,fee schedule,9407,25170,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21542.34,,,,,,,fee schedule,9407,25170,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21542.34,,,,,,,fee schedule,9407,25170,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15286.69,,,,,,,fee schedule,9407,25170,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25170,,,,,,,fee schedule,9407,25170,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21886.96,,,,,,,fee schedule,9407,25170,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9877.35,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9407,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9407,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9407,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9407,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9407,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9407,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16932.6,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16932.6,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9877.35,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9407,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9407,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9877.35,,,,,,,fee schedule,9407,25170,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18280.65,,,,,,,fee schedule,9032.36,24080.58,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19327.87,,,,,,,fee schedule,9032.36,24080.58,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19327.87,,,,,,,fee schedule,9032.36,24080.58,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14625.04,,,,,,,fee schedule,9032.36,24080.58,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24080.58,,,,,,,fee schedule,9032.36,24080.58,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20939.63,,,,,,,fee schedule,9032.36,24080.58,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9483.98,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9032.36,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9032.36,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9032.36,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9032.36,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9032.36,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9032.36,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16258.25,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16258.25,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9483.98,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9032.36,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9032.36,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9483.98,,,,,,,fee schedule,9032.36,24080.58,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86502.17,,,,,,,fee schedule,39935.71,113946.85,
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,91991.06,,,,,,,fee schedule,39935.71,113946.85,
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,91991.06,,,,,,,fee schedule,39935.71,113946.85,
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,69204.22,,,,,,,fee schedule,39935.71,113946.85,
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,113946.85,,,,,,,fee schedule,39935.71,113946.85,
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,99084.23,,,,,,,fee schedule,39935.71,113946.85,
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,41932.5,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,39935.71,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,39935.71,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,39935.71,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,39935.71,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,39935.71,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,39935.71,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,71884.28,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,71884.28,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,41932.5,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,39935.71,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,39935.71,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,41932.5,,,,,,,fee schedule,39935.71,113946.85,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,53659.65,,,,,,,fee schedule,25058.53,70684.34,
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,66938.99,,,,,,,fee schedule,25058.53,70684.34,
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,66938.99,,,,,,,fee schedule,25058.53,70684.34,
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,42929.26,,,,,,,fee schedule,25058.53,70684.34,
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,70684.34,,,,,,,fee schedule,25058.53,70684.34,
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,61464.64,,,,,,,fee schedule,25058.53,70684.34,
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],64728.65,64728.65,64728.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26311.46,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25058.53,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25058.53,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25058.53,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25058.53,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25058.53,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25058.53,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,45105.35,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,45105.35,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,26311.46,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25058.53,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25058.53,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,26311.46,,,,,,,fee schedule,25058.53,70684.34,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36460.07,,,,,,,fee schedule,17267.37,64776.75,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,64776.75,,,,,,,fee schedule,17267.37,64776.75,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,64776.75,,,,,,,fee schedule,17267.37,64776.75,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29169.1,,,,,,,fee schedule,17267.37,64776.75,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48027.81,,,,,,,fee schedule,17267.37,64776.75,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,41763.32,,,,,,,fee schedule,17267.37,64776.75,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],44853.93,44853.93,44853.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32951.79,32951.79,32951.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18130.74,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17267.37,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17267.37,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17267.37,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17267.37,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17267.37,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17267.37,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31081.27,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31081.27,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18130.74,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17267.37,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17267.37,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18130.74,,,,,,,fee schedule,17267.37,64776.75,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,76096.47,,,,,,,fee schedule,35222.08,100239.72,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,84727.87,,,,,,,fee schedule,35222.08,100239.72,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,84727.87,,,,,,,fee schedule,35222.08,100239.72,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,60879.36,,,,,,,fee schedule,35222.08,100239.72,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,100239.72,,,,,,,fee schedule,35222.08,100239.72,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,87164.98,,,,,,,fee schedule,35222.08,100239.72,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36983.18,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,35222.08,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,35222.08,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,35222.08,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,35222.08,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,35222.08,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,35222.08,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,63399.74,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,63399.74,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,36983.18,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,35222.08,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,35222.08,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,36983.18,,,,,,,fee schedule,35222.08,100239.72,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,35505.06,,,,,,,fee schedule,16834.77,46769.81,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46072.13,,,,,,,fee schedule,16834.77,46769.81,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46072.13,,,,,,,fee schedule,16834.77,46769.81,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,28405.07,,,,,,,fee schedule,16834.77,46769.81,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46769.81,,,,,,,fee schedule,16834.77,46769.81,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40669.4,,,,,,,fee schedule,16834.77,46769.81,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],37830.19,37830.19,37830.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",24971.48,24971.48,24971.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],186129.51,186129.51,186129.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,205315.35,205315.35,205315.35,1 through 10,percent of total billed charges,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17676.51,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,30302.59,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,30302.59,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17676.51,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16834.77,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17676.51,,,,,,,fee schedule,16834.77,46769.81,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25899.65,,,,,,,fee schedule,12483.66,44136.21,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44136.21,,,,,,,fee schedule,12483.66,44136.21,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44136.21,,,,,,,fee schedule,12483.66,44136.21,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20720.47,,,,,,,fee schedule,12483.66,44136.21,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,34116.88,,,,,,,fee schedule,12483.66,44136.21,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29666.85,,,,,,,fee schedule,12483.66,44136.21,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23104.49,23104.49,23104.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13107.84,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12483.66,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12483.66,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12483.66,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12483.66,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12483.66,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12483.66,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22470.59,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22470.59,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13107.84,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12483.66,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12483.66,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13107.84,,,,,,,fee schedule,12483.66,44136.21,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20612.76,,,,,,,fee schedule,10088.78,27152.61,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16375.24,,,,,,,fee schedule,10088.78,27152.61,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16375.24,,,,,,,fee schedule,10088.78,27152.61,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16490.8,,,,,,,fee schedule,10088.78,27152.61,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27152.61,,,,,,,fee schedule,10088.78,27152.61,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23610.96,,,,,,,fee schedule,10088.78,27152.61,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10593.22,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10088.78,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10088.78,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10088.78,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10088.78,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10088.78,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10088.78,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18159.8,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18159.8,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10593.22,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10088.78,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10088.78,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10593.22,,,,,,,fee schedule,10088.78,27152.61,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,14401.43,,,,,,,fee schedule,7275.14,18970.59,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,13687.24,,,,,,,fee schedule,7275.14,18970.59,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,13687.24,,,,,,,fee schedule,7275.14,18970.59,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11521.56,,,,,,,fee schedule,7275.14,18970.59,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18970.59,,,,,,,fee schedule,7275.14,18970.59,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,16496.17,,,,,,,fee schedule,7275.14,18970.59,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7638.9,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7275.14,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7275.14,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7275.14,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7275.14,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7275.14,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7275.14,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13095.25,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13095.25,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7638.9,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7275.14,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7275.14,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7638.9,,,,,,,fee schedule,7275.14,18970.59,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,7824.75,,,,,,,fee schedule,6259.43,12162.18,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,12162.18,,,,,,,fee schedule,6259.43,12162.18,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,12162.18,,,,,,,fee schedule,6259.43,12162.18,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,6259.43,,,,,,,fee schedule,6259.43,12162.18,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,10306.96,,,,,,,fee schedule,6259.43,12162.18,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,8962.57,,,,,,,fee schedule,6259.43,12162.18,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6913.94,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6584.7,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6584.7,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6584.7,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6584.7,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6584.7,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6584.7,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11852.46,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11852.46,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6913.94,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6584.7,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6584.7,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6913.94,,,,,,,fee schedule,6259.43,12162.18,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42170.98,,,,,,,fee schedule,19854.33,60358.25,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,60358.25,,,,,,,fee schedule,19854.33,60358.25,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,60358.25,,,,,,,fee schedule,19854.33,60358.25,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33737.99,,,,,,,fee schedule,19854.33,60358.25,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,55550.63,,,,,,,fee schedule,19854.33,60358.25,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,48304.9,,,,,,,fee schedule,19854.33,60358.25,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18128.8,18128.8,18128.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],65729.58,65729.58,65729.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9456.72,9456.72,9456.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",30931.38,30931.38,30931.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1110993.46,1110993.46,1110993.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26829.55,26829.55,26829.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6294.94,6294.94,6294.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20847.05,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19854.33,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19854.33,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19854.33,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19854.33,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19854.33,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19854.33,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35737.79,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35737.79,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20847.05,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19854.33,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19854.33,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20847.05,,,,,,,fee schedule,19854.33,60358.25,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24178.74,,,,,,,fee schedule,11704.11,31849.97,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29400.93,,,,,,,fee schedule,11704.11,31849.97,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29400.93,,,,,,,fee schedule,11704.11,31849.97,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19343.69,,,,,,,fee schedule,11704.11,31849.97,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31849.97,,,,,,,fee schedule,11704.11,31849.97,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27695.63,,,,,,,fee schedule,11704.11,31849.97,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23374.14,14813.59,29423.12,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16331.91,16331.91,16331.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6294.94,6294.94,9989.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5515.13,5515.13,18361.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,6294.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15225.93,15225.93,15225.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6294.94,6294.94,24815.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23935.88,20775.61,25408.83,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10973.37,10973.37,10973.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9456.72,9456.72,12334.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],25530.8,25530.8,89304.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,85982.9,85982.9,85982.9,1 through 10,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,15075.89,12364.34,22271.19,1 through 10,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,12907.69,12907.69,12907.69,1 through 10,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,12330.99,12330.99,12330.99,1 through 10,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12289.32,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11704.11,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11704.11,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11704.11,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11704.11,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11704.11,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11704.11,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21067.4,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21067.4,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12289.32,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11704.11,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11704.11,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12289.32,,,,,,,fee schedule,11704.11,31849.97,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19990.1,,,,,,,fee schedule,9806.72,26332.39,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26033.96,,,,,,,fee schedule,9806.72,26332.39,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26033.96,,,,,,,fee schedule,9806.72,26332.39,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15992.66,,,,,,,fee schedule,9806.72,26332.39,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26332.39,,,,,,,fee schedule,9806.72,26332.39,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22897.73,,,,,,,fee schedule,9806.72,26332.39,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25174.31,25174.31,25174.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14019.33,14019.33,14019.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19102.28,19102.28,23130.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5515.13,5515.13,5515.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,14695.17,14695.17,14695.17,1 through 10,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,8902.46,8902.46,8902.46,1 through 10,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10297.06,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9806.72,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9806.72,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9806.72,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9806.72,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9806.72,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9806.72,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17652.1,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17652.1,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10297.06,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9806.72,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9806.72,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10297.06,,,,,,,fee schedule,9806.72,26332.39,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26822.19,,,,,,,fee schedule,12901.56,35332.1,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,34916.21,,,,,,,fee schedule,12901.56,35332.1,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,34916.21,,,,,,,fee schedule,12901.56,35332.1,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21458.52,,,,,,,fee schedule,12901.56,35332.1,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35332.1,,,,,,,fee schedule,12901.56,35332.1,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30723.57,,,,,,,fee schedule,12901.56,35332.1,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13153.14,13153.14,13153.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12405.4,12405.4,12405.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",46816.24,46816.24,46816.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],30099.15,12369.6,34942.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12357.86,12357.86,12357.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11682.09,11682.09,11682.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7848.55,5828.36,8948.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8948.13,5910.57,24178.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9643.92,9643.92,9643.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18645.75,18645.75,18645.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11930.25,10310.07,16358.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8948.13,8948.13,8948.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13546.64,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12901.56,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12901.56,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12901.56,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12901.56,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12901.56,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12901.56,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23222.81,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23222.81,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13546.64,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12901.56,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12901.56,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13546.64,,,,,,,fee schedule,12901.56,35332.1,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17537.66,,,,,,,fee schedule,8695.8,24049.29,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24049.29,,,,,,,fee schedule,8695.8,24049.29,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24049.29,,,,,,,fee schedule,8695.8,24049.29,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14030.63,,,,,,,fee schedule,8695.8,24049.29,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23101.86,,,,,,,fee schedule,8695.8,24049.29,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20088.57,,,,,,,fee schedule,8695.8,24049.29,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7210.08,7210.08,7210.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24067.44,24067.44,24067.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5828.36,4446.92,5910.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19686.99,10531.54,24067.44,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8494.12,8494.12,8494.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6767.94,6767.94,6767.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5828.36,5828.36,5828.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4412.82,1700,8948.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7848.55,7848.55,7848.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16979.12,16979.12,16979.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5828.36,4411.73,5828.36,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16524.8,16524.8,17911.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8340.02,6727.96,8509.34,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5828.36,4411.73,8196.66,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,33455.76,33455.76,33455.76,1 through 10,percent of total billed charges,,,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9130.59,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8695.8,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8695.8,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8695.8,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8695.8,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8695.8,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8695.8,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15652.44,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15652.44,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9130.59,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8695.8,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8695.8,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9130.59,,,,,,,fee schedule,8695.8,24049.29,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29133.29,,,,,,,fee schedule,13948.45,44453.06,
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44453.06,,,,,,,fee schedule,13948.45,44453.06,
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44453.06,,,,,,,fee schedule,13948.45,44453.06,
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23307.47,,,,,,,fee schedule,13948.45,44453.06,
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38376.46,,,,,,,fee schedule,13948.45,44453.06,
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33370.83,,,,,,,fee schedule,13948.45,44453.06,
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7429.5,7429.5,7429.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14846.54,12528.08,42985.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8335.31,8335.31,16566.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16566.65,8335.31,16566.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21699.82,21699.82,21699.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16566.65,8335.31,16566.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13590.63,13590.63,13619.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",16566.65,16566.65,16566.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],10652.01,10652.01,10652.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,9466.9,9466.9,9466.9,1 through 10,percent of total billed charges,,,
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,8683.04,8683.04,8683.04,1 through 10,percent of total billed charges,,,
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14645.87,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13948.45,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13948.45,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13948.45,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13948.45,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13948.45,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13948.45,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25107.21,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25107.21,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14645.87,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13948.45,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13948.45,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14645.87,,,,,,,fee schedule,13948.45,44453.06,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40620.06,,,,,,,fee schedule,19151.79,58202.97,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,58202.97,,,,,,,fee schedule,19151.79,58202.97,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,58202.97,,,,,,,fee schedule,19151.79,58202.97,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32497.21,,,,,,,fee schedule,19151.79,58202.97,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53507.64,,,,,,,fee schedule,19151.79,58202.97,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46528.39,,,,,,,fee schedule,19151.79,58202.97,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13155.31,13155.31,58246.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7848.55,7848.55,7848.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22503.84,22503.84,22503.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,28680.78,28680.78,28680.78,1 through 10,percent of total billed charges,,,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,25380.01,25380.01,25380.01,1 through 10,percent of total billed charges,,,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20109.38,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19151.79,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19151.79,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19151.79,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19151.79,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19151.79,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19151.79,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34473.22,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34473.22,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20109.38,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19151.79,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19151.79,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20109.38,,,,,,,fee schedule,19151.79,58202.97,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23784.67,,,,,,,fee schedule,9524.67,25512.18,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19367.44,,,,,,,fee schedule,9524.67,25512.18,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23784.67,,,,,,,fee schedule,9524.67,25512.18,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15494.51,,,,,,,fee schedule,9524.67,25512.18,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25512.18,,,,,,,fee schedule,9524.67,25512.18,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22184.5,,,,,,,fee schedule,9524.67,25512.18,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8060.02,8060.02,8060.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],23244.2,23244.2,23244.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5792.35,5792.35,5792.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],248271.5,248271.5,248271.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16582.71,16582.71,16582.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5792.35,5792.35,5792.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16118.63,16118.63,16118.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10000.9,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9524.67,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9524.67,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9524.67,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9524.67,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9524.67,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9524.67,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17144.41,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17144.41,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10000.9,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9524.67,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9524.67,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10000.9,,,,,,,fee schedule,9524.67,25512.18,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17001.98,,,,,,,fee schedule,6219.59,17001.98,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12071.23,,,,,,,fee schedule,6219.59,17001.98,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17001.98,,,,,,,fee schedule,6219.59,17001.98,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9657.33,,,,,,,fee schedule,6219.59,17001.98,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15901.08,,,,,,,fee schedule,6219.59,17001.98,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13827.03,,,,,,,fee schedule,6219.59,17001.98,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5792.35,5792.35,5792.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15868.08,14146.2,16440.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5792.35,5792.35,5792.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13235.31,13235.31,13235.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],9369.12,9369.12,9369.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10641.94,10641.94,10641.94,1 through 10,percent of total billed charges,,,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6530.57,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6219.59,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6219.59,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6219.59,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6219.59,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6219.59,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6219.59,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11195.26,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11195.26,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6530.57,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6219.59,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6219.59,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6530.57,,,,,,,fee schedule,6219.59,17001.98,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45577.7,,,,,,,fee schedule,20491.99,57404.92,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43578.65,,,,,,,fee schedule,20491.99,57404.92,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45577.7,,,,,,,fee schedule,20491.99,57404.92,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,34864.17,,,,,,,fee schedule,20491.99,57404.92,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,57404.92,,,,,,,fee schedule,20491.99,57404.92,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,49917.32,,,,,,,fee schedule,20491.99,57404.92,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21516.59,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20491.99,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20491.99,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20491.99,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20491.99,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20491.99,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20491.99,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36885.58,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,36885.58,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21516.59,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20491.99,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20491.99,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21516.59,,,,,,,fee schedule,20491.99,57404.92,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29063.19,,,,,,,fee schedule,10780.94,29165.4,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22140.77,,,,,,,fee schedule,10780.94,29165.4,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29063.19,,,,,,,fee schedule,10780.94,29165.4,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17713.25,,,,,,,fee schedule,10780.94,29165.4,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29165.4,,,,,,,fee schedule,10780.94,29165.4,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25361.22,,,,,,,fee schedule,10780.94,29165.4,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11319.99,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10780.94,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10780.94,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10780.94,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10780.94,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10780.94,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10780.94,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19405.69,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19405.69,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11319.99,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10780.94,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10780.94,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11319.99,,,,,,,fee schedule,10780.94,29165.4,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17492.92,,,,,,,fee schedule,8191.39,21635.03,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16424.12,,,,,,,fee schedule,8191.39,21635.03,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17492.92,,,,,,,fee schedule,8191.39,21635.03,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13139.77,,,,,,,fee schedule,8191.39,21635.03,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21635.03,,,,,,,fee schedule,8191.39,21635.03,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18813.07,,,,,,,fee schedule,8191.39,21635.03,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8600.96,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8191.39,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8191.39,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8191.39,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8191.39,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8191.39,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8191.39,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14744.5,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14744.5,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8600.96,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8191.39,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8191.39,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8600.96,,,,,,,fee schedule,8191.39,21635.03,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,156614.6,,,,,,,fee schedule,51493.97,156614.6,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,112017.91,,,,,,,fee schedule,51493.97,156614.6,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,156614.6,,,,,,,fee schedule,51493.97,156614.6,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,89617.55,,,,,,,fee schedule,51493.97,156614.6,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,147558.02,,,,,,,fee schedule,51493.97,156614.6,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,128311.33,,,,,,,fee schedule,51493.97,156614.6,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,54068.67,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,51493.97,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,51493.97,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,51493.97,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,51493.97,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,51493.97,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,51493.97,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,92689.15,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,92689.15,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,54068.67,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,51493.97,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,51493.97,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,54068.67,,,,,,,fee schedule,51493.97,156614.6,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,68185.5,,,,,,,fee schedule,20119.95,68185.5,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42757.35,,,,,,,fee schedule,20119.95,68185.5,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,68185.5,,,,,,,fee schedule,20119.95,68185.5,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,34207.11,,,,,,,fee schedule,20119.95,68185.5,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,56323.04,,,,,,,fee schedule,20119.95,68185.5,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,48976.56,,,,,,,fee schedule,20119.95,68185.5,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",51857.56,51857.56,51857.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],44014.02,44014.02,44014.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21125.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20119.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20119.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20119.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20119.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20119.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20119.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36215.91,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,36215.91,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21125.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20119.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20119.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21125.95,,,,,,,fee schedule,20119.95,68185.5,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,47235.08,,,,,,,fee schedule,11168.55,47235.08,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22996.45,,,,,,,fee schedule,11168.55,47235.08,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,47235.08,,,,,,,fee schedule,11168.55,47235.08,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18397.82,,,,,,,fee schedule,11168.55,47235.08,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30292.57,,,,,,,fee schedule,11168.55,47235.08,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26341.36,,,,,,,fee schedule,11168.55,47235.08,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16031.99,16031.99,16031.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11726.98,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20103.39,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20103.39,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11726.98,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11168.55,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11726.98,,,,,,,fee schedule,11168.55,47235.08,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,132816.01,,,,,,,fee schedule,40419.36,132816.01,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,87569.86,,,,,,,fee schedule,40419.36,132816.01,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,132816.01,,,,,,,fee schedule,40419.36,132816.01,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,70058.4,,,,,,,fee schedule,40419.36,132816.01,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,115353.29,,,,,,,fee schedule,40419.36,132816.01,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,100307.22,,,,,,,fee schedule,40419.36,132816.01,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],41462.01,41462.01,41462.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",69425.24,69425.24,69425.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],223648.68,223648.68,223648.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",39897.52,39897.52,39897.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17492.14,17492.14,17492.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39938.2,39938.2,39938.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42440.33,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40419.36,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,40419.36,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,40419.36,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,40419.36,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,40419.36,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,40419.36,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,72754.85,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,72754.85,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,42440.33,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,40419.36,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,40419.36,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,42440.33,,,,,,,fee schedule,40419.36,132816.01,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,64961.29,,,,,,,fee schedule,20353.55,64961.29,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,43273.05,,,,,,,fee schedule,20353.55,64961.29,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,64961.29,,,,,,,fee schedule,20353.55,64961.29,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,34619.68,,,,,,,fee schedule,20353.55,64961.29,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,57002.36,,,,,,,fee schedule,20353.55,64961.29,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,49567.27,,,,,,,fee schedule,20353.55,64961.29,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],275533.74,275533.74,275533.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21371.23,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20353.55,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20353.55,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20353.55,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20353.55,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20353.55,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20353.55,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,36636.39,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,36636.39,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21371.23,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20353.55,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20353.55,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21371.23,,,,,,,fee schedule,20353.55,64961.29,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,54390.32,,,,,,,fee schedule,12426.56,54390.32,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25773.59,,,,,,,fee schedule,12426.56,54390.32,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,54390.32,,,,,,,fee schedule,12426.56,54390.32,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20619.61,,,,,,,fee schedule,12426.56,54390.32,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33950.82,,,,,,,fee schedule,12426.56,54390.32,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,29522.46,,,,,,,fee schedule,12426.56,54390.32,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],35201.05,35201.05,35201.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13047.89,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12426.56,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12426.56,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12426.56,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12426.56,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12426.56,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12426.56,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,22367.81,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,22367.81,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13047.89,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12426.56,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12426.56,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13047.89,,,,,,,fee schedule,12426.56,54390.32,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,83185.4,,,,,,,fee schedule,41224,117693.17,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89346.17,,,,,,,fee schedule,41224,117693.17,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,83185.4,,,,,,,fee schedule,41224,117693.17,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,71479.5,,,,,,,fee schedule,41224,117693.17,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,117693.17,,,,,,,fee schedule,41224,117693.17,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,102341.89,,,,,,,fee schedule,41224,117693.17,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,43285.2,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41224,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,41224,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,41224,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,41224,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,41224,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,41224,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74203.2,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,74203.2,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,43285.2,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,41224,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,41224,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,43285.2,,,,,,,fee schedule,41224,117693.17,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,82401.98,,,,,,,fee schedule,20748.09,82401.98,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44144.01,,,,,,,fee schedule,20748.09,82401.98,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,82401.98,,,,,,,fee schedule,20748.09,82401.98,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35316.48,,,,,,,fee schedule,20748.09,82401.98,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,58149.65,,,,,,,fee schedule,20748.09,82401.98,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,50564.92,,,,,,,fee schedule,20748.09,82401.98,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21785.49,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20748.09,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20748.09,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20748.09,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20748.09,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20748.09,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20748.09,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37346.56,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37346.56,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,21785.49,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20748.09,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20748.09,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,21785.49,,,,,,,fee schedule,20748.09,82401.98,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,56594.35,,,,,,,fee schedule,15492.84,56594.35,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32542.65,,,,,,,fee schedule,15492.84,56594.35,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,56594.35,,,,,,,fee schedule,15492.84,56594.35,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26035.05,,,,,,,fee schedule,15492.84,56594.35,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42867.51,,,,,,,fee schedule,15492.84,56594.35,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37276.09,,,,,,,fee schedule,15492.84,56594.35,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12775.15,12775.15,12775.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16267.48,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15492.84,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15492.84,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15492.84,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15492.84,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15492.84,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15492.84,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27887.11,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27887.11,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16267.48,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15492.84,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15492.84,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16267.48,,,,,,,fee schedule,15492.84,56594.35,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,113045.94,,,,,,,fee schedule,28091.94,113045.94,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,60356.13,,,,,,,fee schedule,28091.94,113045.94,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,113045.94,,,,,,,fee schedule,28091.94,113045.94,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,48286.63,,,,,,,fee schedule,28091.94,113045.94,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,79505.41,,,,,,,fee schedule,28091.94,113045.94,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,69135.14,,,,,,,fee schedule,28091.94,113045.94,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],48053.36,35196.53,107156.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10568.31,10568.31,10568.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],318220.16,318220.16,318220.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10678.33,10678.33,15502.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10568.31,10568.31,10568.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28419.39,28419.39,61893.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",112402.37,112402.37,112402.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],207456.8,207456.8,207456.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29496.54,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28091.94,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28091.94,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28091.94,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28091.94,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28091.94,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28091.94,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,50565.49,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,50565.49,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,29496.54,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28091.94,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28091.94,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,29496.54,,,,,,,fee schedule,28091.94,113045.94,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30974.73,,,,,,,fee schedule,13772.82,37865.71,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28745.56,,,,,,,fee schedule,13772.82,37865.71,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30974.73,,,,,,,fee schedule,13772.82,37865.71,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22997.27,,,,,,,fee schedule,13772.82,37865.71,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37865.71,,,,,,,fee schedule,13772.82,37865.71,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32926.71,,,,,,,fee schedule,13772.82,37865.71,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14461.46,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13772.82,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13772.82,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13772.82,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13772.82,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13772.82,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13772.82,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24791.08,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24791.08,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14461.46,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13772.82,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13772.82,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14461.46,,,,,,,fee schedule,13772.82,37865.71,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22967.8,,,,,,,fee schedule,11155.57,30254.83,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21378.69,,,,,,,fee schedule,11155.57,30254.83,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21378.69,,,,,,,fee schedule,11155.57,30254.83,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18374.9,,,,,,,fee schedule,11155.57,30254.83,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30254.83,,,,,,,fee schedule,11155.57,30254.83,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26308.55,,,,,,,fee schedule,11155.57,30254.83,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6129.59,6129.59,6129.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11713.35,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11155.57,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11155.57,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11155.57,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11155.57,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11155.57,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11155.57,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20080.03,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20080.03,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11713.35,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11155.57,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11155.57,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11713.35,,,,,,,fee schedule,11155.57,30254.83,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13782.59,,,,,,,fee schedule,6994.81,18155.41,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,13596.71,,,,,,,fee schedule,6994.81,18155.41,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,13596.71,,,,,,,fee schedule,6994.81,18155.41,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11026.47,,,,,,,fee schedule,6994.81,18155.41,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18155.41,,,,,,,fee schedule,6994.81,18155.41,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15787.32,,,,,,,fee schedule,6994.81,18155.41,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3188.32,3188.32,3188.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],2337.22,2337.22,2337.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3945.15,3945.15,3945.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7344.55,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6994.81,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6994.81,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6994.81,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6994.81,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6994.81,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6994.81,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12590.66,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12590.66,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7344.55,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6994.81,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6994.81,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7344.55,,,,,,,fee schedule,6994.81,18155.41,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,9987.41,,,,,,,fee schedule,5275.65,13156.13,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,8729.05,,,,,,,fee schedule,5275.65,13156.13,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,8729.05,,,,,,,fee schedule,5275.65,13156.13,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,7990.22,,,,,,,fee schedule,5275.65,13156.13,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,13156.13,,,,,,,fee schedule,5275.65,13156.13,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,11440.12,,,,,,,fee schedule,5275.65,13156.13,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5539.43,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5275.65,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5275.65,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5275.65,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5275.65,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5275.65,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5275.65,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,9496.17,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,9496.17,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,5539.43,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5275.65,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5275.65,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,5539.43,,,,,,,fee schedule,5275.65,13156.13,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,104857.31,,,,,,,fee schedule,48250.32,256930.82,
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,256930.82,,,,,,,fee schedule,48250.32,256930.82,
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,256930.82,,,,,,,fee schedule,48250.32,256930.82,
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,83888.86,,,,,,,fee schedule,48250.32,256930.82,
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,138125.55,,,,,,,fee schedule,48250.32,256930.82,
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,120109.19,,,,,,,fee schedule,48250.32,256930.82,
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22721.1,22721.1,22721.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31822.6,31822.6,31822.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,188533.62,188533.62,188533.62,1 through 10,percent of total billed charges,,,
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,50662.84,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,48250.32,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,48250.32,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,48250.32,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,48250.32,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,48250.32,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,48250.32,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,86850.58,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,86850.58,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,50662.84,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,48250.32,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,48250.32,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,50662.84,,,,,,,fee schedule,48250.32,256930.82,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39838.86,,,,,,,fee schedule,18797.92,123972.05,
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,123972.05,,,,,,,fee schedule,18797.92,123972.05,
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,123972.05,,,,,,,fee schedule,18797.92,123972.05,
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31872.23,,,,,,,fee schedule,18797.92,123972.05,
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52478.6,,,,,,,fee schedule,18797.92,123972.05,
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45633.57,,,,,,,fee schedule,18797.92,123972.05,
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28569.32,28569.32,28569.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",35065.01,35065.01,35065.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28569.32,28569.32,28569.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],203381.38,203381.38,203381.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18506.52,18506.52,18506.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19737.82,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18797.92,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18797.92,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18797.92,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18797.92,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18797.92,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18797.92,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33836.26,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33836.26,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19737.82,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18797.92,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18797.92,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19737.82,,,,,,,fee schedule,18797.92,123972.05,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23292.5,,,,,,,fee schedule,11302.66,35511.61,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35511.61,,,,,,,fee schedule,11302.66,35511.61,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35511.61,,,,,,,fee schedule,11302.66,35511.61,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18634.67,,,,,,,fee schedule,11302.66,35511.61,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30682.55,,,,,,,fee schedule,11302.66,35511.61,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26680.48,,,,,,,fee schedule,11302.66,35511.61,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23182.82,23182.82,23182.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11867.79,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11302.66,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11302.66,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11302.66,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11302.66,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11302.66,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11302.66,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20344.79,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20344.79,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11867.79,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11302.66,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11302.66,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11867.79,,,,,,,fee schedule,11302.66,35511.61,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,91762.32,,,,,,,fee schedule,42318.48,140935.73,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,140935.73,,,,,,,fee schedule,42318.48,140935.73,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,140935.73,,,,,,,fee schedule,42318.48,140935.73,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,73412.49,,,,,,,fee schedule,42318.48,140935.73,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,120875.9,,,,,,,fee schedule,42318.48,140935.73,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,105109.48,,,,,,,fee schedule,42318.48,140935.73,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],66246.72,66246.72,66246.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],134699.36,110699.79,159240.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",152470.2,152470.2,152470.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17473.06,17473.06,32633.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],100495.24,92112.95,337246.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7688.66,7688.66,7688.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,44434.4,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,42318.48,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,42318.48,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,42318.48,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,42318.48,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,42318.48,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,42318.48,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,76173.26,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,76173.26,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,44434.4,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,42318.48,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,42318.48,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,44434.4,,,,,,,fee schedule,42318.48,140935.73,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39869.42,,,,,,,fee schedule,18811.76,62903.5,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,62903.5,,,,,,,fee schedule,18811.76,62903.5,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,62903.5,,,,,,,fee schedule,18811.76,62903.5,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31896.68,,,,,,,fee schedule,18811.76,62903.5,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52518.86,,,,,,,fee schedule,18811.76,62903.5,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45668.58,,,,,,,fee schedule,18811.76,62903.5,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],60120.03,55172.33,82729.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7680.4,7680.4,17473.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],25848.15,17105.82,53936.66,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7688.66,7688.66,7688.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",20324.37,20324.37,20324.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26060.21,26060.21,26060.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7688.66,7688.66,7688.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],40707.52,37312.11,40707.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7688.66,7688.66,7688.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],39503.33,39503.33,39503.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19752.35,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18811.76,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18811.76,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18811.76,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18811.76,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18811.76,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18811.76,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33861.17,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33861.17,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19752.35,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18811.76,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18811.76,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19752.35,,,,,,,fee schedule,18811.76,62903.5,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27578.55,,,,,,,fee schedule,13244.18,36328.44,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31267.21,,,,,,,fee schedule,13244.18,36328.44,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31267.21,,,,,,,fee schedule,13244.18,36328.44,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22063.63,,,,,,,fee schedule,13244.18,36328.44,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,36328.44,,,,,,,fee schedule,13244.18,36328.44,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,31589.95,,,,,,,fee schedule,13244.18,36328.44,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],31290.81,31290.81,31290.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20981.25,20981.25,30234.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7680.4,7680.4,7680.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6297.12,6297.12,6297.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13906.39,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13244.18,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13244.18,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13244.18,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13244.18,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13244.18,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13244.18,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23839.52,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23839.52,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13906.39,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13244.18,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13244.18,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13906.39,,,,,,,fee schedule,13244.18,36328.44,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61786.72,,,,,,,fee schedule,28739.97,106503.5,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,106503.5,,,,,,,fee schedule,28739.97,106503.5,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,106503.5,,,,,,,fee schedule,28739.97,106503.5,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,49431.15,,,,,,,fee schedule,28739.97,106503.5,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,81389.89,,,,,,,fee schedule,28739.97,106503.5,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,70773.82,,,,,,,fee schedule,28739.97,106503.5,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21243.84,21243.84,21243.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",124984.35,124984.35,124984.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27047.22,27047.22,27047.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30176.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28739.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28739.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28739.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28739.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28739.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28739.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51731.95,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,51731.95,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30176.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28739.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28739.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30176.97,,,,,,,fee schedule,28739.97,106503.5,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31159.81,,,,,,,fee schedule,14866.43,49957.9,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,49957.9,,,,,,,fee schedule,14866.43,49957.9,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,49957.9,,,,,,,fee schedule,14866.43,49957.9,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24928.74,,,,,,,fee schedule,14866.43,49957.9,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41045.93,,,,,,,fee schedule,14866.43,49957.9,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35692.11,,,,,,,fee schedule,14866.43,49957.9,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],46065.28,46065.28,46065.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15609.75,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14866.43,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14866.43,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14866.43,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14866.43,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14866.43,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14866.43,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26759.57,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26759.57,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15609.75,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14866.43,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14866.43,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15609.75,,,,,,,fee schedule,14866.43,49957.9,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19298.68,,,,,,,fee schedule,9493.52,31820.83,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31820.83,,,,,,,fee schedule,9493.52,31820.83,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31820.83,,,,,,,fee schedule,9493.52,31820.83,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15439.5,,,,,,,fee schedule,9493.52,31820.83,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25421.6,,,,,,,fee schedule,9493.52,31820.83,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22105.74,,,,,,,fee schedule,9493.52,31820.83,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9968.2,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9493.52,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9493.52,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9493.52,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9493.52,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9493.52,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9493.52,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17088.34,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17088.34,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9968.2,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9493.52,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9493.52,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9968.2,,,,,,,fee schedule,9493.52,31820.83,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38100.76,,,,,,,fee schedule,18010.58,50657.76,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,50657.76,,,,,,,fee schedule,18010.58,50657.76,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,50657.76,,,,,,,fee schedule,18010.58,50657.76,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30481.7,,,,,,,fee schedule,18010.58,50657.76,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50189.05,,,,,,,fee schedule,18010.58,50657.76,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43642.65,,,,,,,fee schedule,18010.58,50657.76,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18911.11,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18010.58,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18010.58,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18010.58,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18010.58,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18010.58,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18010.58,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32419.04,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32419.04,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18911.11,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18010.58,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18010.58,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18911.11,,,,,,,fee schedule,18010.58,50657.76,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,23252.39,,,,,,,fee schedule,11284.49,35090.31,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35090.31,,,,,,,fee schedule,11284.49,35090.31,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35090.31,,,,,,,fee schedule,11284.49,35090.31,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18602.58,,,,,,,fee schedule,11284.49,35090.31,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30629.71,,,,,,,fee schedule,11284.49,35090.31,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26634.53,,,,,,,fee schedule,11284.49,35090.31,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11848.71,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11284.49,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11284.49,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11284.49,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11284.49,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11284.49,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11284.49,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20312.08,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20312.08,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11848.71,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11284.49,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11284.49,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11848.71,,,,,,,fee schedule,11284.49,35090.31,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16265.59,,,,,,,fee schedule,8119.57,27482.42,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,27482.42,,,,,,,fee schedule,8119.57,27482.42,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,27482.42,,,,,,,fee schedule,8119.57,27482.42,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13012.94,,,,,,,fee schedule,8119.57,27482.42,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21426.2,,,,,,,fee schedule,8119.57,27482.42,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18631.48,,,,,,,fee schedule,8119.57,27482.42,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8525.55,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8119.57,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8119.57,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8119.57,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8119.57,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8119.57,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8119.57,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14615.23,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14615.23,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8525.55,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8119.57,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8119.57,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8525.55,,,,,,,fee schedule,8119.57,27482.42,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,49516.85,,,,,,,fee schedule,23181.91,65227.14,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,61531.64,,,,,,,fee schedule,23181.91,65227.14,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,61531.64,,,,,,,fee schedule,23181.91,65227.14,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,39614.9,,,,,,,fee schedule,23181.91,65227.14,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,65227.14,,,,,,,fee schedule,23181.91,65227.14,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,56719.26,,,,,,,fee schedule,23181.91,65227.14,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27527.04,22031.31,59499.86,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",128572.59,128572.59,128572.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10568.31,10568.31,146072.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18494.06,10568.31,107583.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],51255.22,27377.66,52036.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10568.31,10568.31,10568.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],13760.66,13760.66,88771.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24341.01,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23181.91,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,23181.91,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,23181.91,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,23181.91,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,23181.91,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,23181.91,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,41727.44,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,41727.44,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24341.01,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,23181.91,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,23181.91,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24341.01,,,,,,,fee schedule,23181.91,65227.14,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24986.67,,,,,,,fee schedule,12070.09,32914.23,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32705.22,,,,,,,fee schedule,12070.09,32914.23,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32705.22,,,,,,,fee schedule,12070.09,32914.23,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19990.05,,,,,,,fee schedule,12070.09,32914.23,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32914.23,,,,,,,fee schedule,12070.09,32914.23,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28621.07,,,,,,,fee schedule,12070.09,32914.23,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19680.43,11491.37,31625.29,97,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],17650.77,14895.85,46952.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10568.31,10568.31,10568.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10568.31,10568.31,10568.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10568.31,1700,10568.31,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10568.31,6971.61,10678.33,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25503.17,13821.97,26257.86,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6971.61,6971.61,10568.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],10335.01,6661.21,31628.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,21157.95,21157.95,21157.95,1 through 10,percent of total billed charges,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12673.59,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12070.09,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12070.09,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12070.09,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12070.09,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12070.09,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12070.09,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21726.16,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21726.16,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12673.59,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12070.09,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12070.09,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12673.59,,,,,,,fee schedule,12070.09,32914.23,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16223.57,,,,,,,fee schedule,8100.54,21370.85,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,18708.1,,,,,,,fee schedule,8100.54,21370.85,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,18708.1,,,,,,,fee schedule,8100.54,21370.85,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12979.32,,,,,,,fee schedule,8100.54,21370.85,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21370.85,,,,,,,fee schedule,8100.54,21370.85,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18583.35,,,,,,,fee schedule,8100.54,21370.85,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8505.57,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8100.54,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8100.54,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8100.54,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8100.54,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8100.54,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8100.54,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14580.97,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14580.97,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8505.57,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8100.54,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8100.54,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8505.57,,,,,,,fee schedule,8100.54,21370.85,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,51751.56,,,,,,,fee schedule,24194.19,88011.28,
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,88011.28,,,,,,,fee schedule,24194.19,88011.28,
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,88011.28,,,,,,,fee schedule,24194.19,88011.28,
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,41402.73,,,,,,,fee schedule,24194.19,88011.28,
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,68170.86,,,,,,,fee schedule,24194.19,88011.28,
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,59279.01,,,,,,,fee schedule,24194.19,88011.28,
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14861.34,14861.34,14861.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25403.9,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24194.19,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24194.19,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24194.19,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24194.19,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24194.19,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24194.19,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43549.54,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,43549.54,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25403.9,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24194.19,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24194.19,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25403.9,,,,,,,fee schedule,24194.19,88011.28,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,165396.8,,,,,,,fee schedule,75673.81,225545.22,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,225545.22,,,,,,,fee schedule,75673.81,225545.22,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,225545.22,,,,,,,fee schedule,75673.81,225545.22,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,132322.18,,,,,,,fee schedule,75673.81,225545.22,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,217872.5,,,,,,,fee schedule,75673.81,225545.22,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,189454.36,,,,,,,fee schedule,75673.81,225545.22,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],191718.88,180815.8,218097.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28569.32,28569.32,28569.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",50391.32,50391.32,50391.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",55189.42,55189.42,55189.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",43351.77,43351.77,43351.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],168083.46,168083.46,168083.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],184886.91,184886.91,184886.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",38895.84,38895.84,38895.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,79457.5,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,75673.81,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,75673.81,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,75673.81,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,75673.81,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,75673.81,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,75673.81,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,136212.86,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,136212.86,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,79457.5,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,75673.81,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,75673.81,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,79457.5,,,,,,,fee schedule,75673.81,225545.22,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,94327.46,,,,,,,fee schedule,43480.45,124254.88,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,112025.75,,,,,,,fee schedule,43480.45,124254.88,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,112025.75,,,,,,,fee schedule,43480.45,124254.88,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,75464.67,,,,,,,fee schedule,43480.45,124254.88,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,124254.88,,,,,,,fee schedule,43480.45,124254.88,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,108047.73,,,,,,,fee schedule,43480.45,124254.88,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],40512.44,22445.7,66381.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],107175.13,41540.54,238981.74,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9533.67,9533.67,15083.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],58550.5,58550.5,58550.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",15083.98,15083.98,15083.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7803.25,7803.25,7803.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],42720.69,42720.69,42720.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",22233.92,7803.25,94855.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],99318.67,99318.67,99318.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],77934.93,38561.47,196872.13,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],40315.78,26831.71,42500.2,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,18167.98,18167.98,18167.98,1 through 10,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,45654.47,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,43480.45,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,43480.45,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,43480.45,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,43480.45,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,43480.45,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,43480.45,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,78264.81,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,78264.81,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,45654.47,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,43480.45,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,43480.45,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,45654.47,,,,,,,fee schedule,43480.45,124254.88,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38163.79,,,,,,,fee schedule,18039.13,50272.08,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38422.46,,,,,,,fee schedule,18039.13,50272.08,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38422.46,,,,,,,fee schedule,18039.13,50272.08,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30532.13,,,,,,,fee schedule,18039.13,50272.08,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50272.08,,,,,,,fee schedule,18039.13,50272.08,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43714.85,,,,,,,fee schedule,18039.13,50272.08,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16979.8,16979.8,16979.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16713.88,16713.88,16713.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],26493.27,17613.45,37447.94,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17690.86,17690.86,17690.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15718.34,15718.34,15718.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8678.01,8678.01,8678.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9533.67,5634.09,69142.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],26919.99,26919.99,26919.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7803.25,6428.09,9675,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23554.01,20830.74,25052.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9533.67,5634.09,9749.07,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30591.77,20443.75,40107.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16890.04,13804.41,17394.74,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35012.65,35012.65,35012.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9533.67,9533.67,9533.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],43730.99,43730.99,43730.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,103794.56,103794.56,103794.56,1 through 10,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,20652.03,20652.03,20652.03,1 through 10,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18941.09,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18039.13,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18039.13,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18039.13,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18039.13,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18039.13,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18039.13,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32470.43,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32470.43,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18941.09,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18039.13,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18039.13,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18941.09,,,,,,,fee schedule,18039.13,50272.08,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28596.58,,,,,,,fee schedule,13705.33,37669.46,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30435.04,,,,,,,fee schedule,13705.33,37669.46,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30435.04,,,,,,,fee schedule,13705.33,37669.46,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22878.08,,,,,,,fee schedule,13705.33,37669.46,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37669.46,,,,,,,fee schedule,13705.33,37669.46,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32756.06,,,,,,,fee schedule,13705.33,37669.46,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],26961.41,26961.41,26961.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8838.45,8838.45,8838.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22718.11,22718.11,22718.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14390.6,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13705.33,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13705.33,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13705.33,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13705.33,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13705.33,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13705.33,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24669.59,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24669.59,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14390.6,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13705.33,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13705.33,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14390.6,,,,,,,fee schedule,13705.33,37669.46,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,86880.35,,,,,,,fee schedule,40107.02,114445.02,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,113188.69,,,,,,,fee schedule,40107.02,114445.02,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,113188.69,,,,,,,fee schedule,40107.02,114445.02,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,69506.77,,,,,,,fee schedule,40107.02,114445.02,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,114445.02,,,,,,,fee schedule,40107.02,114445.02,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,99517.41,,,,,,,fee schedule,40107.02,114445.02,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],95248.88,95248.88,101693.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",48288.54,48288.54,48288.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14358.75,14358.75,14358.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],60370.49,60370.49,60370.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11144.03,11144.03,11144.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],72225.08,34239.43,82996.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34552.34,27316.51,38423.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42112.37,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,40107.02,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,40107.02,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,40107.02,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,40107.02,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,40107.02,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,40107.02,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,72192.64,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,72192.64,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,42112.37,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,40107.02,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,40107.02,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,42112.37,,,,,,,fee schedule,40107.02,114445.02,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,40902.74,,,,,,,fee schedule,19279.84,53880.01,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45898.04,,,,,,,fee schedule,19279.84,53880.01,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45898.04,,,,,,,fee schedule,19279.84,53880.01,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,32723.36,,,,,,,fee schedule,19279.84,53880.01,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,53880.01,,,,,,,fee schedule,19279.84,53880.01,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,46852.19,,,,,,,fee schedule,19279.84,53880.01,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17130.66,17130.66,17130.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11144.03,11144.03,11144.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],44382.48,31461.87,45932.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18881.77,18881.77,18881.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9032.17,6542.14,14358.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21764.53,21764.53,21764.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11144.03,11144.03,11144.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43734.34,40086.47,43734.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18843.13,17530.29,18896.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,15533.81,15533.81,15533.81,1 through 10,percent of total billed charges,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20243.83,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19279.84,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19279.84,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19279.84,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19279.84,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19279.84,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19279.84,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,34703.71,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,34703.71,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20243.83,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19279.84,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19279.84,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20243.83,,,,,,,fee schedule,19279.84,53880.01,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26604.45,,,,,,,fee schedule,12802.92,35045.28,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31974.03,,,,,,,fee schedule,12802.92,35045.28,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31974.03,,,,,,,fee schedule,12802.92,35045.28,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21284.32,,,,,,,fee schedule,12802.92,35045.28,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35045.28,,,,,,,fee schedule,12802.92,35045.28,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30474.16,,,,,,,fee schedule,12802.92,35045.28,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13842.13,13842.13,13842.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25860.44,25860.44,25860.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11395,11395,11395,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13443.07,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12802.92,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12802.92,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12802.92,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12802.92,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12802.92,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12802.92,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23045.26,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23045.26,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13443.07,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12802.92,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12802.92,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13443.07,,,,,,,fee schedule,12802.92,35045.28,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34832.74,,,,,,,fee schedule,16530.22,45884.18,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32412.75,,,,,,,fee schedule,16530.22,45884.18,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32412.75,,,,,,,fee schedule,16530.22,45884.18,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27867.19,,,,,,,fee schedule,16530.22,45884.18,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,45884.18,,,,,,,fee schedule,16530.22,45884.18,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,39899.29,,,,,,,fee schedule,16530.22,45884.18,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16666.53,16666.53,16666.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15937.73,15937.73,15937.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6542.14,6542.14,6542.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24061.12,19217.32,32437.21,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33213.55,33213.55,33213.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],38539.89,38539.89,38539.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14359.29,14359.29,14359.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6542.14,6542.14,6542.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6542.14,6542.14,6542.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36903.92,36903.92,36903.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25673.81,14826.4,36903.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15986.26,14768.21,16140.21,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6542.14,6542.14,6542.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,50150.64,50150.64,50150.64,1 through 10,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,10173.85,10173.85,10173.85,1 through 10,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,92105.09,92105.09,92105.09,1 through 10,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,10233.8,10233.8,10233.8,1 through 10,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17356.73,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29754.4,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29754.4,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17356.73,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16530.22,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17356.73,,,,,,,fee schedule,16530.22,45884.18,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19059.93,,,,,,,fee schedule,9385.37,25107.1,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,22322.28,,,,,,,fee schedule,9385.37,25107.1,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,22322.28,,,,,,,fee schedule,9385.37,25107.1,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15248.49,,,,,,,fee schedule,9385.37,25107.1,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25107.1,,,,,,,fee schedule,9385.37,25107.1,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21832.27,,,,,,,fee schedule,9385.37,25107.1,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5234.64,5234.64,5234.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14509.52,11636.97,21334.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6625.17,6625.17,6625.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12848.29,12848.29,12848.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6542.14,6542.14,31988.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20029.6,20029.6,20029.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9006.07,9006.07,9009.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],6979.57,6979.57,6979.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,8868.33,8868.33,8868.33,1 through 10,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,3363.04,3363.04,3363.04,1 through 10,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9854.64,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9385.37,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9385.37,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9385.37,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9385.37,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9385.37,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9385.37,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16893.67,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16893.67,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9854.64,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9385.37,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9385.37,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9854.64,,,,,,,fee schedule,9385.37,25107.1,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16955.11,,,,,,,fee schedule,8431.91,22334.48,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20490.82,,,,,,,fee schedule,8431.91,22334.48,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20490.82,,,,,,,fee schedule,8431.91,22334.48,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13564.57,,,,,,,fee schedule,8431.91,22334.48,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22334.48,,,,,,,fee schedule,8431.91,22334.48,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19421.29,,,,,,,fee schedule,8431.91,22334.48,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1849.14,1849.14,1849.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8124.42,8124.42,8124.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19814.21,18973.02,20506.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10777.86,10777.86,10777.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5804.35,5804.35,5804.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16315.38,16315.38,16315.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],37469.49,9229.36,154583.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8853.51,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8431.91,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8431.91,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8431.91,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8431.91,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8431.91,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8431.91,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15177.44,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15177.44,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8853.51,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8431.91,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8431.91,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8853.51,,,,,,,fee schedule,8431.91,22334.48,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28617.59,,,,,,,fee schedule,13714.85,37697.14,
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35400.19,,,,,,,fee schedule,13714.85,37697.14,
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35400.19,,,,,,,fee schedule,13714.85,37697.14,
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22894.89,,,,,,,fee schedule,13714.85,37697.14,
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37697.14,,,,,,,fee schedule,13714.85,37697.14,
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32780.12,,,,,,,fee schedule,13714.85,37697.14,
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6983.07,6983.07,6983.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],35426.91,34231.27,35426.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9062.73,9062.73,9062.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4485.4,4485.4,4485.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29623.9,29623.9,29623.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6983.07,6983.07,6983.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14400.59,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13714.85,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13714.85,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13714.85,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13714.85,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13714.85,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13714.85,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24686.73,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24686.73,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14400.59,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13714.85,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13714.85,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14400.59,,,,,,,fee schedule,13714.85,37697.14,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16609.39,,,,,,,fee schedule,8275.31,21879.08,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,15950.46,,,,,,,fee schedule,8275.31,21879.08,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,15950.46,,,,,,,fee schedule,8275.31,21879.08,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13287.99,,,,,,,fee schedule,8275.31,21879.08,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21879.08,,,,,,,fee schedule,8275.31,21879.08,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19025.29,,,,,,,fee schedule,8275.31,21879.08,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4485.4,4485.4,4485.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],10048.15,6925.42,15454,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4485.4,3859.48,4548.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3859.48,3859.48,4485.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3859.48,3859.48,3859.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4485.4,4485.4,7109.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19578.41,19578.41,19578.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10193.89,10193.89,10193.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8037.36,8037.36,8037.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],21036.54,21036.54,21036.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,7206.76,7206.76,7206.76,1 through 10,percent of total billed charges,,,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,14611.17,14611.17,14611.17,1 through 10,percent of total billed charges,,,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,10647.51,10647.51,10647.51,1 through 10,percent of total billed charges,,,
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8689.08,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8275.31,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8275.31,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8275.31,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8275.31,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8275.31,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8275.31,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14895.56,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14895.56,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8689.08,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8275.31,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8275.31,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8689.08,,,,,,,fee schedule,8275.31,21879.08,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39980.2,,,,,,,fee schedule,18861.94,78749.5,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,78749.5,,,,,,,fee schedule,18861.94,78749.5,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,78749.5,,,,,,,fee schedule,18861.94,78749.5,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31985.31,,,,,,,fee schedule,18861.94,78749.5,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52664.79,,,,,,,fee schedule,18861.94,78749.5,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45795.47,,,,,,,fee schedule,18861.94,78749.5,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",88677.96,88677.96,88677.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29464.32,29464.32,29464.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24747.36,24747.36,24747.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18609.81,18609.81,18609.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,39508.32,39508.32,39508.32,1 through 10,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,52817.4,52817.4,52817.4,1 through 10,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19805.04,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18861.94,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18861.94,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18861.94,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18861.94,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18861.94,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18861.94,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33951.49,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33951.49,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19805.04,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18861.94,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18861.94,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19805.04,,,,,,,fee schedule,18861.94,78749.5,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19694.05,,,,,,,fee schedule,9672.62,30031.15,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30031.15,,,,,,,fee schedule,9672.62,30031.15,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30031.15,,,,,,,fee schedule,9672.62,30031.15,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15755.81,,,,,,,fee schedule,9672.62,30031.15,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25942.41,,,,,,,fee schedule,9672.62,30031.15,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22558.62,,,,,,,fee schedule,9672.62,30031.15,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],28247.16,22568.05,30053.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16715.85,16715.85,16715.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6542.14,6542.14,6542.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9391.48,9391.48,9391.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18399.12,18399.12,18399.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],16003.49,16003.49,16003.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,22567.8,22567.8,22567.8,1 through 10,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10156.25,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9672.62,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9672.62,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9672.62,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9672.62,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9672.62,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9672.62,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17410.72,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17410.72,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10156.25,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9672.62,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9672.62,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10156.25,,,,,,,fee schedule,9672.62,30031.15,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13937.3,,,,,,,fee schedule,7064.89,29421.82,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29421.82,,,,,,,fee schedule,7064.89,29421.82,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29421.82,,,,,,,fee schedule,7064.89,29421.82,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,11150.24,,,,,,,fee schedule,7064.89,29421.82,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,18359.21,,,,,,,fee schedule,7064.89,29421.82,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15964.53,,,,,,,fee schedule,7064.89,29421.82,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2009.88,2009.88,2009.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],29296.49,29296.49,29296.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4136.79,4136.79,4136.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,20051.5,20051.5,24415.22,1 through 10,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7418.13,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7064.89,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7064.89,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7064.89,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7064.89,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7064.89,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7064.89,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12716.8,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12716.8,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7418.13,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7064.89,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7064.89,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7418.13,,,,,,,fee schedule,7064.89,29421.82,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,132015.66,,,,,,,fee schedule,60552.65,186847.7,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,186847.7,,,,,,,fee schedule,60552.65,186847.7,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,186847.7,,,,,,,fee schedule,60552.65,186847.7,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,105616.31,,,,,,,fee schedule,60552.65,186847.7,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,173900.47,,,,,,,fee schedule,60552.65,186847.7,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,151217.81,,,,,,,fee schedule,60552.65,186847.7,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7335.94,7335.94,7335.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14133.37,14133.37,14133.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],128145.57,72018.94,180677.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",89441.06,89441.06,89441.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",28266.74,18575.79,118256.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",31359.99,28019.65,62649.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],130666.66,67039.02,391887.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],56461.61,33133.24,59184.32,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",62156.08,62156.08,62156.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,202914.15,202914.15,202914.15,1 through 10,percent of total billed charges,,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,63580.28,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,60552.65,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,60552.65,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,60552.65,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,60552.65,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,60552.65,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,60552.65,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,108994.77,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,108994.77,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,63580.28,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,60552.65,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,60552.65,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,63580.28,,,,,,,fee schedule,60552.65,186847.7,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37101.83,,,,,,,fee schedule,17558.08,48873.18,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,46145.25,,,,,,,fee schedule,17558.08,48873.18,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,46145.25,,,,,,,fee schedule,17558.08,48873.18,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29682.53,,,,,,,fee schedule,17558.08,48873.18,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48873.18,,,,,,,fee schedule,17558.08,48873.18,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42498.42,,,,,,,fee schedule,17558.08,48873.18,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16920.28,1661.91,17897.75,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],34856.87,16289.58,44634.99,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16976.33,1990.37,17143.65,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7803.25,5634.09,14133.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2061.7,2061.7,2061.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17105.59,17105.59,17105.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17028.02,17028.02,17028.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5634.09,5115.13,7803.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15081.95,15081.95,15081.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],34201.87,34201.87,34201.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7803.25,5634.09,22643.96,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],23904.49,23904.49,23904.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7803.25,5115.13,7803.25,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16165.43,16111.27,17897.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27121.43,10850.81,28664.55,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7803.25,5411.45,15083.98,77,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],75488.35,75488.35,75488.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31641.95,11729.41,39386.8,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16544.45,10269.56,17088.02,350,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17937.7,12975.78,34385.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20443.68,20443.68,20443.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7803.25,7233,40821.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],19495.12,10474.85,93682.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17757.38,17757.38,17757.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,26830.72,10294.82,54460.33,1 through 10,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,74342.55,74342.55,74342.55,1 through 10,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,15366.48,15366.48,15366.48,1 through 10,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,7987.48,7987.48,15801.33,1 through 10,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18435.98,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17558.08,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17558.08,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17558.08,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17558.08,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17558.08,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17558.08,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31604.54,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31604.54,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18435.98,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17558.08,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17558.08,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18435.98,,,,,,,fee schedule,17558.08,48873.18,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19545.07,,,,,,,fee schedule,9605.13,25746.17,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21336.91,,,,,,,fee schedule,9605.13,25746.17,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21336.91,,,,,,,fee schedule,9605.13,25746.17,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15636.62,,,,,,,fee schedule,9605.13,25746.17,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25746.17,,,,,,,fee schedule,9605.13,25746.17,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22387.97,,,,,,,fee schedule,9605.13,25746.17,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9622.82,9250.11,9638.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9257.76,9234.41,9397.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20409.4,20409.4,20409.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5634.09,5634.09,6641.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16065.88,8211.83,21136.24,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9415.88,9415.88,9415.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9299.96,9299.96,9299.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5634.09,5162.61,7803.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],12807.36,12807.36,12807.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5634.09,5611.17,7803.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5057.29,5057.29,5792.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9794.37,9794.37,9794.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14453.47,14059.25,18191.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5162.61,4101.77,7803.25,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16109.59,11090.25,20539.42,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9215.14,7497.16,9296.27,105,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12651.09,12651.09,12651.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6641.46,6641.46,6641.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],22599.8,11326.24,27898.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,13858.33,13858.33,13858.33,1 through 10,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,9257.59,9257.59,9257.59,1 through 10,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10085.39,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9605.13,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9605.13,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9605.13,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9605.13,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9605.13,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9605.13,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17289.23,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17289.23,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10085.39,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9605.13,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9605.13,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10085.39,,,,,,,fee schedule,9605.13,25746.17,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73819.74,,,,,,,fee schedule,34190.76,97240.65,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,69167.39,,,,,,,fee schedule,34190.76,97240.65,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,69167.39,,,,,,,fee schedule,34190.76,97240.65,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,59057.91,,,,,,,fee schedule,34190.76,97240.65,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,97240.65,,,,,,,fee schedule,34190.76,97240.65,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,84557.09,,,,,,,fee schedule,34190.76,97240.65,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9860.54,9860.54,9860.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,35900.3,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34190.76,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,34190.76,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,34190.76,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,34190.76,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,34190.76,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,34190.76,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61543.37,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,61543.37,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,35900.3,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,34190.76,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,34190.76,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,35900.3,,,,,,,fee schedule,34190.76,97240.65,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,18339.86,,,,,,,fee schedule,9059.19,25351.51,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,25351.51,,,,,,,fee schedule,9059.19,25351.51,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,25351.51,,,,,,,fee schedule,9059.19,25351.51,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14672.41,,,,,,,fee schedule,9059.19,25351.51,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,24158.57,,,,,,,fee schedule,9059.19,25351.51,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21007.46,,,,,,,fee schedule,9059.19,25351.51,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24514.4,24514.4,24514.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24229.71,10277.8,39000,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6126.32,6126.32,6126.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6126.32,4246.93,6209.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6126.32,6126.32,8242.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19240.78,13089.22,19240.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8645.61,8645.61,8645.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],19308.92,19308.92,19308.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,25725,25725,25725,1 through 10,percent of total billed charges,,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9512.15,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9059.19,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9059.19,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9059.19,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9059.19,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9059.19,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9059.19,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16306.54,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16306.54,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9512.15,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9059.19,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9059.19,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9512.15,,,,,,,fee schedule,9059.19,25351.51,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17971.23,,,,,,,fee schedule,8892.2,23672.99,
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14547.26,,,,,,,fee schedule,8892.2,23672.99,
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14547.26,,,,,,,fee schedule,8892.2,23672.99,
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14377.5,,,,,,,fee schedule,8892.2,23672.99,
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23672.99,,,,,,,fee schedule,8892.2,23672.99,
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20585.21,,,,,,,fee schedule,8892.2,23672.99,
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],30752.71,30752.71,66000,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,16250,16250,16250,1 through 10,percent of total billed charges,,,
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9336.81,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8892.2,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8892.2,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8892.2,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8892.2,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8892.2,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8892.2,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16005.96,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16005.96,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9336.81,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8892.2,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8892.2,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9336.81,,,,,,,fee schedule,8892.2,23672.99,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20509.62,,,,,,,fee schedule,10042.06,38871.62,
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,38871.62,,,,,,,fee schedule,10042.06,38871.62,
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,38871.62,,,,,,,fee schedule,10042.06,38871.62,
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16408.29,,,,,,,fee schedule,10042.06,38871.62,
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,27016.74,,,,,,,fee schedule,10042.06,38871.62,
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23492.82,,,,,,,fee schedule,10042.06,38871.62,
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],36177.88,36177.88,36177.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7130.95,7130.95,7130.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10544.16,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10042.06,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10042.06,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10042.06,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10042.06,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10042.06,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10042.06,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18075.71,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18075.71,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10544.16,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10042.06,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10042.06,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10544.16,,,,,,,fee schedule,10042.06,38871.62,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28217.09,,,,,,,fee schedule,17764,49471.99,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37556.41,,,,,,,fee schedule,17764,49471.99,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28217.09,,,,,,,fee schedule,17764,49471.99,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30046.2,,,,,,,fee schedule,17764,49471.99,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,49471.99,,,,,,,fee schedule,17764,49471.99,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43019.12,,,,,,,fee schedule,17764,49471.99,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27102.53,27102.53,33000,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8493.56,8493.56,12744.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5886.32,5886.32,5886.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],202500,202500,202500,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,40555.47,40555.47,40555.47,1 through 10,percent of total billed charges,,,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18652.2,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17764,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17764,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17764,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17764,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17764,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17764,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31975.2,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31975.2,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18652.2,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17764,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17764,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18652.2,,,,,,,fee schedule,17764,49471.99,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29776.97,,,,,,,fee schedule,14671.76,40479.83,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,30730.05,,,,,,,fee schedule,14671.76,40479.83,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29776.97,,,,,,,fee schedule,14671.76,40479.83,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24584.93,,,,,,,fee schedule,14671.76,40479.83,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,40479.83,,,,,,,fee schedule,14671.76,40479.83,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35199.85,,,,,,,fee schedule,14671.76,40479.83,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1625.98,1625.98,1625.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18000,13988.57,24000,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4929.6,4929.6,4929.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,1900,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29700,29700,29700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14642.33,14642.33,14642.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21371.24,21371.24,21371.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,23749.09,23749.09,23749.09,1 through 10,percent of total billed charges,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,62259.92,62259.92,62259.92,1 through 10,percent of total billed charges,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15405.35,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14671.76,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14671.76,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14671.76,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14671.76,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14671.76,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14671.76,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26409.17,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26409.17,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15405.35,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14671.76,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14671.76,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15405.35,,,,,,,fee schedule,14671.76,40479.83,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,23816,,,,,,,fee schedule,12836.66,35143.4,
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,26678.94,,,,,,,fee schedule,12836.66,35143.4,
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,23816,,,,,,,fee schedule,12836.66,35143.4,
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21343.91,,,,,,,fee schedule,12836.66,35143.4,
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35143.4,,,,,,,fee schedule,12836.66,35143.4,
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30559.48,,,,,,,fee schedule,12836.66,35143.4,
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],21000,15000,66000,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13087,13087,13087,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19542.6,13959,24300,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15108.64,15108.64,15108.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,22050,22050,22050,1 through 10,percent of total billed charges,,,
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,23891,17065,23891,1 through 10,percent of total billed charges,,,
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13478.49,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12836.66,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12836.66,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12836.66,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12836.66,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12836.66,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12836.66,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23105.99,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23105.99,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13478.49,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12836.66,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12836.66,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13478.49,,,,,,,fee schedule,12836.66,35143.4,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29860.53,,,,,,,fee schedule,18707.07,52214.42,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39638.31,,,,,,,fee schedule,18707.07,52214.42,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29860.53,,,,,,,fee schedule,18707.07,52214.42,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31711.79,,,,,,,fee schedule,18707.07,52214.42,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,52214.42,,,,,,,fee schedule,18707.07,52214.42,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45403.85,,,,,,,fee schedule,18707.07,52214.42,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19642.42,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18707.07,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18707.07,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18707.07,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18707.07,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18707.07,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18707.07,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33672.73,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33672.73,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19642.42,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18707.07,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18707.07,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19642.42,,,,,,,fee schedule,18707.07,52214.42,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24366.14,,,,,,,fee schedule,10016.97,26943.78,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,20454.23,,,,,,,fee schedule,10016.97,26943.78,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24366.14,,,,,,,fee schedule,10016.97,26943.78,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,16363.97,,,,,,,fee schedule,10016.97,26943.78,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,26943.78,,,,,,,fee schedule,10016.97,26943.78,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,23429.38,,,,,,,fee schedule,10016.97,26943.78,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],14180,14180,14180,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5190.99,5190.99,5190.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17988.25,17988.25,17988.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],18144.62,18144.62,18144.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10517.82,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10016.97,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10016.97,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10016.97,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10016.97,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10016.97,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10016.97,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,18030.55,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,18030.55,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10517.82,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10016.97,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10016.97,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10517.82,,,,,,,fee schedule,10016.97,26943.78,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,13680.28,,,,,,,fee schedule,6088.94,15521.17,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11782.81,,,,,,,fee schedule,6088.94,15521.17,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,13680.28,,,,,,,fee schedule,6088.94,15521.17,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9426.59,,,,,,,fee schedule,6088.94,15521.17,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15521.17,,,,,,,fee schedule,6088.94,15521.17,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13496.67,,,,,,,fee schedule,6088.94,15521.17,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6393.39,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6088.94,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6088.94,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6088.94,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6088.94,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6088.94,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6088.94,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10960.09,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,10960.09,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6393.39,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6088.94,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6088.94,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6393.39,,,,,,,fee schedule,6088.94,15521.17,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,32510.24,,,,,,,fee schedule,12999.32,35616.41,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,27038.02,,,,,,,fee schedule,12999.32,35616.41,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,32510.24,,,,,,,fee schedule,12999.32,35616.41,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,21631.19,,,,,,,fee schedule,12999.32,35616.41,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,35616.41,,,,,,,fee schedule,12999.32,35616.41,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,30970.79,,,,,,,fee schedule,12999.32,35616.41,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13649.29,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12999.32,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12999.32,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12999.32,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12999.32,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12999.32,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12999.32,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,23398.78,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,23398.78,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,13649.29,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12999.32,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12999.32,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,13649.29,,,,,,,fee schedule,12999.32,35616.41,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35877.21,,,,,,,fee schedule,15850.17,43906.61,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33331.48,,,,,,,fee schedule,15850.17,43906.61,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35877.21,,,,,,,fee schedule,15850.17,43906.61,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26666.14,,,,,,,fee schedule,15850.17,43906.61,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43906.61,,,,,,,fee schedule,15850.17,43906.61,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38179.66,,,,,,,fee schedule,15850.17,43906.61,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27500.5,15061.27,35904.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5852.92,5852.92,5852.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7416.9,7416.9,7416.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23854.82,23854.82,23854.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10084.65,10084.65,13222.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15537.61,15537.61,15617.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28671.08,28671.08,28671.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],25818.56,25818.56,25818.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16642.68,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15850.17,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15850.17,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15850.17,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15850.17,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15850.17,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15850.17,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28530.31,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28530.31,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16642.68,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15850.17,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15850.17,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16642.68,,,,,,,fee schedule,15850.17,43906.61,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,17078.58,,,,,,,fee schedule,8389.52,22211.2,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16861.52,,,,,,,fee schedule,8389.52,22211.2,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,17078.58,,,,,,,fee schedule,8389.52,22211.2,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13489.7,,,,,,,fee schedule,8389.52,22211.2,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22211.2,,,,,,,fee schedule,8389.52,22211.2,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19314.08,,,,,,,fee schedule,8389.52,22211.2,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7904.07,7904.07,7904.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13749.33,6877.27,16590.54,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16322.86,16322.86,16322.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],15697.16,15697.16,15697.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7416.9,7416.9,7416.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],11875.19,11875.19,11875.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8331.55,8331.55,8331.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8248.68,8248.68,8248.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11755.39,10172.43,16605.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8192.96,7528.18,8192.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15259.61,15259.61,15259.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],10890.3,10890.3,10890.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,5772.13,5772.13,5772.13,1 through 10,percent of total billed charges,,,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,8463.01,8463.01,8463.01,1 through 10,percent of total billed charges,,,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,9566.63,9235.85,24141.47,1 through 10,percent of total billed charges,,,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8809,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8389.52,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8389.52,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8389.52,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8389.52,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8389.52,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8389.52,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15101.14,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15101.14,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8809,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8389.52,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8389.52,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8809,,,,,,,fee schedule,8389.52,22211.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80155.23,,,,,,,fee schedule,37060.64,105586.2,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,98321.1,,,,,,,fee schedule,37060.64,105586.2,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,98321.1,,,,,,,fee schedule,37060.64,105586.2,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,64126.48,,,,,,,fee schedule,37060.64,105586.2,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,105586.2,,,,,,,fee schedule,37060.64,105586.2,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,91814.1,,,,,,,fee schedule,37060.64,105586.2,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35856.02,35856.02,35856.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38913.67,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37060.64,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,37060.64,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,37060.64,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,37060.64,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,37060.64,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,37060.64,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66709.15,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,66709.15,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,38913.67,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,37060.64,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,37060.64,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,38913.67,,,,,,,fee schedule,37060.64,105586.2,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,36567.03,,,,,,,fee schedule,17315.82,64021.18,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,64021.18,,,,,,,fee schedule,17315.82,64021.18,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,64021.18,,,,,,,fee schedule,17315.82,64021.18,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,29254.67,,,,,,,fee schedule,17315.82,64021.18,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,48168.71,,,,,,,fee schedule,17315.82,64021.18,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,41885.83,,,,,,,fee schedule,17315.82,64021.18,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5915.13,5915.13,5915.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26599.42,26599.42,26599.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38084.14,38084.14,38084.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18181.61,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17315.82,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17315.82,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17315.82,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17315.82,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17315.82,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17315.82,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31168.48,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31168.48,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18181.61,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17315.82,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17315.82,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18181.61,,,,,,,fee schedule,17315.82,64021.18,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22339.41,,,,,,,fee schedule,10870.92,35570.8,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35570.8,,,,,,,fee schedule,10870.92,35570.8,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35570.8,,,,,,,fee schedule,10870.92,35570.8,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17872.17,,,,,,,fee schedule,10870.92,35570.8,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29427.07,,,,,,,fee schedule,10870.92,35570.8,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25588.75,,,,,,,fee schedule,10870.92,35570.8,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],102423.11,102423.11,102423.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11414.47,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10870.92,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10870.92,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10870.92,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10870.92,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10870.92,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10870.92,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19567.66,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19567.66,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11414.47,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10870.92,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10870.92,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11414.47,,,,,,,fee schedule,10870.92,35570.8,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,70156.36,,,,,,,fee schedule,32531.3,92414.98,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,87920.75,,,,,,,fee schedule,32531.3,92414.98,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,87920.75,,,,,,,fee schedule,32531.3,92414.98,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,56127.1,,,,,,,fee schedule,32531.3,92414.98,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,92414.98,,,,,,,fee schedule,32531.3,92414.98,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,80360.85,,,,,,,fee schedule,32531.3,92414.98,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],61968.24,61968.24,61968.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34157.86,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32531.3,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32531.3,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32531.3,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32531.3,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32531.3,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32531.3,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,58556.34,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,58556.34,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,34157.86,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32531.3,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32531.3,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,34157.86,,,,,,,fee schedule,32531.3,92414.98,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,28333,,,,,,,fee schedule,13585.93,39265.07,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,39265.07,,,,,,,fee schedule,13585.93,39265.07,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,39265.07,,,,,,,fee schedule,13585.93,39265.07,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,22667.21,,,,,,,fee schedule,13585.93,39265.07,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,37322.25,,,,,,,fee schedule,13585.93,39265.07,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,32454.14,,,,,,,fee schedule,13585.93,39265.07,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],39294.71,39294.71,39294.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14265.23,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,13585.93,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,13585.93,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,13585.93,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,13585.93,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,13585.93,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,13585.93,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,24454.67,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,24454.67,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14265.23,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,13585.93,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,13585.93,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14265.23,,,,,,,fee schedule,13585.93,39265.07,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,37518.21,,,,,,,fee schedule,17746.7,55041.43,
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,55041.43,,,,,,,fee schedule,17746.7,55041.43,
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,55041.43,,,,,,,fee schedule,17746.7,55041.43,
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30015.64,,,,,,,fee schedule,17746.7,55041.43,
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,49421.67,,,,,,,fee schedule,17746.7,55041.43,
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,42975.37,,,,,,,fee schedule,17746.7,55041.43,
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18634.04,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,17746.7,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,17746.7,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,17746.7,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,17746.7,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,17746.7,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,17746.7,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,31944.06,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,31944.06,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18634.04,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,17746.7,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,17746.7,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18634.04,,,,,,,fee schedule,17746.7,55041.43,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,73330.78,,,,,,,fee schedule,33969.26,96596.56,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,95173.49,,,,,,,fee schedule,33969.26,96596.56,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,95173.49,,,,,,,fee schedule,33969.26,96596.56,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,58666.73,,,,,,,fee schedule,33969.26,96596.56,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,96596.56,,,,,,,fee schedule,33969.26,96596.56,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,83997.01,,,,,,,fee schedule,33969.26,96596.56,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],41921.64,31542.59,95245.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",59046.49,59046.49,59046.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],49274.78,49274.78,49274.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],79955.82,79955.82,79955.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",140829.82,140829.82,140829.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],77061.47,77061.47,77061.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],32542.97,31313.02,33654.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,85562.59,85562.59,85562.59,1 through 10,percent of total billed charges,,,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,19020.12,19020.12,19020.12,1 through 10,percent of total billed charges,,,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,35667.72,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33969.26,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,33969.26,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,33969.26,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,33969.26,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,33969.26,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,33969.26,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61144.67,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,61144.67,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,35667.72,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,33969.26,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,33969.26,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,35667.72,,,,,,,fee schedule,33969.26,96596.56,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38108.4,,,,,,,fee schedule,18014.04,50199.11,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48516.4,,,,,,,fee schedule,18014.04,50199.11,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48516.4,,,,,,,fee schedule,18014.04,50199.11,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30487.81,,,,,,,fee schedule,18014.04,50199.11,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,50199.11,,,,,,,fee schedule,18014.04,50199.11,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,43651.4,,,,,,,fee schedule,18014.04,50199.11,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],46914.38,43076.29,79439.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",14358.75,14358.75,14358.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10185.78,10185.78,10185.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],40484.72,40484.72,40484.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17469.58,13536.95,17609.76,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,38708.6,38708.6,38708.6,1 through 10,percent of total billed charges,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,19834.19,19834.19,19834.19,1 through 10,percent of total billed charges,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18914.74,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18014.04,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18014.04,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18014.04,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18014.04,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18014.04,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18014.04,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32425.27,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32425.27,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,18914.74,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18014.04,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18014.04,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,18914.74,,,,,,,fee schedule,18014.04,50199.11,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,25072.62,,,,,,,fee schedule,12109.03,33027.45,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31779.05,,,,,,,fee schedule,12109.03,33027.45,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31779.05,,,,,,,fee schedule,12109.03,33027.45,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,20058.82,,,,,,,fee schedule,12109.03,33027.45,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,33027.45,,,,,,,fee schedule,12109.03,33027.45,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28719.53,,,,,,,fee schedule,12109.03,33027.45,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11245.27,11245.27,11245.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],30372.83,30372.83,30372.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7917.85,7917.85,7917.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15806.75,15806.75,15806.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11268.75,11237.23,12013.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,8145.24,8145.24,8145.24,1 through 10,percent of total billed charges,,,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12714.48,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,12109.03,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,12109.03,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,12109.03,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,12109.03,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,12109.03,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,12109.03,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21796.25,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21796.25,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12714.48,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,12109.03,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,12109.03,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12714.48,,,,,,,fee schedule,12109.03,33027.45,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31220.93,,,,,,,fee schedule,14894.12,41126.44,
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,30891.17,,,,,,,fee schedule,14894.12,41126.44,
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,30891.17,,,,,,,fee schedule,14894.12,41126.44,
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,24977.64,,,,,,,fee schedule,14894.12,41126.44,
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41126.44,,,,,,,fee schedule,14894.12,41126.44,
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35762.12,,,,,,,fee schedule,14894.12,41126.44,
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7874.19,7874.19,7874.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15638.83,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14894.12,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14894.12,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14894.12,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14894.12,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14894.12,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14894.12,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26809.42,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26809.42,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15638.83,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14894.12,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14894.12,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15638.83,,,,,,,fee schedule,14894.12,41126.44,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16913.09,,,,,,,fee schedule,8412.88,24630.76,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24630.76,,,,,,,fee schedule,8412.88,24630.76,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24630.76,,,,,,,fee schedule,8412.88,24630.76,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13530.95,,,,,,,fee schedule,8412.88,24630.76,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22279.13,,,,,,,fee schedule,8412.88,24630.76,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19373.15,,,,,,,fee schedule,8412.88,24630.76,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16919.8,16919.8,16919.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6023.18,6023.18,6023.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8179.79,8179.79,8179.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18391.74,18391.74,18391.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8833.52,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8412.88,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8412.88,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8412.88,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8412.88,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8412.88,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8412.88,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15143.18,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15143.18,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8833.52,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8412.88,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8412.88,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8833.52,,,,,,,fee schedule,8412.88,24630.76,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32118.63,,,,,,,fee schedule,15300.77,45027.57,
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,45027.57,,,,,,,fee schedule,15300.77,45027.57,
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,45027.57,,,,,,,fee schedule,15300.77,45027.57,
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25695.82,,,,,,,fee schedule,15300.77,45027.57,
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,42308.96,,,,,,,fee schedule,15300.77,45027.57,
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,36790.4,,,,,,,fee schedule,15300.77,45027.57,
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18655.5,18655.5,18655.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31971.3,31971.3,31971.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6219.63,6219.63,6219.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16065.81,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15300.77,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15300.77,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15300.77,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15300.77,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15300.77,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15300.77,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,27541.39,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,27541.39,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16065.81,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15300.77,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15300.77,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16065.81,,,,,,,fee schedule,15300.77,45027.57,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,12726.36,,,,,,,fee schedule,6516.35,16764.07,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,16034.02,,,,,,,fee schedule,6516.35,16764.07,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,16034.02,,,,,,,fee schedule,6516.35,16764.07,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10181.45,,,,,,,fee schedule,6516.35,16764.07,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,16764.07,,,,,,,fee schedule,6516.35,16764.07,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,14577.45,,,,,,,fee schedule,6516.35,16764.07,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15504.57,12889.39,23931.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13327.64,13327.64,13327.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23821.78,23821.78,23821.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13184.36,13184.36,13184.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6171.49,6171.49,6175.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6842.17,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6516.35,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6516.35,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6516.35,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6516.35,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6516.35,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6516.35,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11729.43,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11729.43,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6842.17,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6516.35,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6516.35,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6842.17,,,,,,,fee schedule,6516.35,16764.07,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29956.5,,,,,,,fee schedule,14321.35,39460.85,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36225.4,,,,,,,fee schedule,14321.35,39460.85,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36225.4,,,,,,,fee schedule,14321.35,39460.85,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23966.06,,,,,,,fee schedule,14321.35,39460.85,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,39460.85,,,,,,,fee schedule,14321.35,39460.85,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,34313.78,,,,,,,fee schedule,14321.35,39460.85,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14445.54,14445.54,14445.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19931.45,7005.84,34576.96,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7874.19,7874.19,7874.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6537.23,6537.23,8120.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],12699,12699,12699,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6537.23,1700,8120.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6637.03,6537.23,11480.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29427.8,29427.8,29427.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6537.23,4861.38,8120.85,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25050.51,15043.84,32909.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13771.84,12488.64,14363.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4755.52,4755.52,4755.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6537.23,6537.23,6537.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],30048.11,30048.11,30048.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,19318.33,19318.33,19318.33,1 through 10,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15037.42,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14321.35,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14321.35,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14321.35,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14321.35,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14321.35,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14321.35,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25778.43,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25778.43,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15037.42,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14321.35,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14321.35,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15037.42,,,,,,,fee schedule,14321.35,39460.85,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,16370.64,,,,,,,fee schedule,8167.16,21564.58,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14804.92,,,,,,,fee schedule,8167.16,21564.58,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14804.92,,,,,,,fee schedule,8167.16,21564.58,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13096.99,,,,,,,fee schedule,8167.16,21564.58,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,21564.58,,,,,,,fee schedule,8167.16,21564.58,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,18751.81,,,,,,,fee schedule,8167.16,21564.58,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],9406.25,5744.53,14316.06,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],7014.81,7014.81,7014.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4755.52,3710.5,8120.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4755.52,3710.5,4755.52,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,4755.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],10459.02,10459.02,10459.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1900,1900,4238.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3744.18,3628.65,4861.38,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9253.18,9253.18,9253.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12461.23,7138.74,17751.46,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8061.18,8061.18,8061.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],3959.25,3959.25,3959.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4861.38,4861.38,4861.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],8690.28,6550.71,13647.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,12303.28,12303.28,12303.28,1 through 10,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,11580.96,11580.96,11580.96,1 through 10,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,2449.65,2449.65,2449.65,1 through 10,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,16665.78,16665.78,16665.78,1 through 10,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8575.52,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8167.16,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8167.16,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8167.16,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8167.16,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8167.16,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8167.16,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,14700.89,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,14700.89,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8575.52,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8167.16,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8167.16,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8575.52,,,,,,,fee schedule,8167.16,21564.58,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,34968.35,,,,,,,fee schedule,16591.65,49957.9,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,49957.9,,,,,,,fee schedule,16591.65,49957.9,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,49957.9,,,,,,,fee schedule,16591.65,49957.9,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,27975.69,,,,,,,fee schedule,16591.65,49957.9,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,46062.82,,,,,,,fee schedule,16591.65,49957.9,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,40054.63,,,,,,,fee schedule,16591.65,49957.9,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16591.81,16591.81,16591.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],11721.87,9397.09,36440.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5112.37,5112.37,5112.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,4956.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11240.07,11240.07,17021.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16950.43,16950.43,16950.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4956.88,4956.88,14719.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28830.45,15114.66,33399.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15895.62,15885.1,16261.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],13379.15,13379.15,13379.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,9275.32,9275.32,9275.32,1 through 10,percent of total billed charges,,,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17421.23,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,16591.65,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,16591.65,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,16591.65,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,16591.65,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,16591.65,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,16591.65,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,29864.97,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,29864.97,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,17421.23,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,16591.65,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,16591.65,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,17421.23,,,,,,,fee schedule,16591.65,49957.9,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19143.97,,,,,,,fee schedule,9423.44,28244.95,
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28244.95,,,,,,,fee schedule,9423.44,28244.95,
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28244.95,,,,,,,fee schedule,9423.44,28244.95,
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15315.73,,,,,,,fee schedule,9423.44,28244.95,
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25217.81,,,,,,,fee schedule,9423.44,28244.95,
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,21928.53,,,,,,,fee schedule,9423.44,28244.95,
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9112.1,9112.1,9112.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],19258.81,19258.81,19258.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],18022.92,17690.68,28707.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8066.83,6162.88,8066.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7856.01,7856.01,7856.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19036.01,19036.01,19036.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8484.74,7259.74,28035.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],35832.5,35832.5,35832.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,5713.16,5713.16,5713.16,1 through 10,percent of total billed charges,,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9894.61,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9423.44,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9423.44,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9423.44,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9423.44,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9423.44,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9423.44,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,16962.19,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,16962.19,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9894.61,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9423.44,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9423.44,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9894.61,,,,,,,fee schedule,9423.44,28244.95,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,13148.47,,,,,,,fee schedule,6707.56,20901.68,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,20901.68,,,,,,,fee schedule,6707.56,20901.68,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,20901.68,,,,,,,fee schedule,6707.56,20901.68,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,10519.15,,,,,,,fee schedule,6707.56,20901.68,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,17320.1,,,,,,,fee schedule,6707.56,20901.68,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,15060.96,,,,,,,fee schedule,6707.56,20901.68,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],13947.65,13947.65,13947.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",1700,1700,1700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4956.88,4956.88,4956.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13801.34,13801.34,13801.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],5957.59,5957.59,5957.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,7085.42,7085.42,7085.42,1 through 10,percent of total billed charges,,,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7042.94,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6707.56,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6707.56,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6707.56,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6707.56,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6707.56,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6707.56,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,12073.61,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,12073.61,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,7042.94,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6707.56,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6707.56,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,7042.94,,,,,,,fee schedule,6707.56,20901.68,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,33413.61,,,,,,,fee schedule,15887.37,107492.35,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,107492.35,,,,,,,fee schedule,15887.37,107492.35,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,107492.35,,,,,,,fee schedule,15887.37,107492.35,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26731.85,,,,,,,fee schedule,15887.37,107492.35,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,44014.8,,,,,,,fee schedule,15887.37,107492.35,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,38273.74,,,,,,,fee schedule,15887.37,107492.35,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],61690.23,17021.22,99740.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9364.5,9364.5,9364.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9364.5,9364.5,9364.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",44055.1,44055.1,44055.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9364.5,9364.5,14068.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15320.86,15320.86,15320.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],12932.32,12932.32,12932.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16681.74,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15887.37,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15887.37,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15887.37,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15887.37,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15887.37,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15887.37,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28597.27,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28597.27,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16681.74,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15887.37,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15887.37,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16681.74,,,,,,,fee schedule,15887.37,107492.35,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,19438.11,,,,,,,fee schedule,9556.68,29630.73,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29630.73,,,,,,,fee schedule,9556.68,29630.73,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29630.73,,,,,,,fee schedule,9556.68,29630.73,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,15551.05,,,,,,,fee schedule,9556.68,29630.73,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,25605.27,,,,,,,fee schedule,9556.68,29630.73,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,22265.45,,,,,,,fee schedule,9556.68,29630.73,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9567.76,9567.76,9567.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3372.71,3372.71,3372.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9364.5,9364.5,9364.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17386.03,17386.03,17386.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10034.51,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,9556.68,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,9556.68,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,9556.68,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,9556.68,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,9556.68,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,9556.68,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,17202.02,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,17202.02,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,10034.51,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,9556.68,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,9556.68,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,10034.51,,,,,,,fee schedule,9556.68,29630.73,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,407795.4,,,,,,,fee schedule,185476.81,862776.54,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,862776.54,,,,,,,fee schedule,185476.81,862776.54,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,862776.54,,,,,,,fee schedule,185476.81,862776.54,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,326248.02,,,,,,,fee schedule,185476.81,862776.54,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,537177.3,,,,,,,fee schedule,185476.81,862776.54,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,467110.72,,,,,,,fee schedule,185476.81,862776.54,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",88952.66,88952.66,88952.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,194750.65,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,185476.81,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,185476.81,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,185476.81,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,185476.81,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,185476.81,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,185476.81,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,333858.26,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,333858.26,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,194750.65,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,185476.81,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,185476.81,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,194750.65,,,,,,,fee schedule,185476.81,862776.54,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,136998.86,,,,,,,fee schedule,62809.96,180464.7,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,172004.48,,,,,,,fee schedule,62809.96,180464.7,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,172004.48,,,,,,,fee schedule,62809.96,180464.7,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,109603.02,,,,,,,fee schedule,62809.96,180464.7,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,180464.7,,,,,,,fee schedule,62809.96,180464.7,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,156925.84,,,,,,,fee schedule,62809.96,180464.7,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],61014.44,61014.44,61014.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",58931.99,58931.99,58931.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",134020.49,134020.49,134020.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,65950.46,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,62809.96,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,62809.96,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,62809.96,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,62809.96,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,62809.96,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,62809.96,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,113057.93,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,113057.93,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,65950.46,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,62809.96,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,62809.96,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,65950.46,,,,,,,fee schedule,62809.96,180464.7,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,61517.41,,,,,,,fee schedule,28617.98,81035.13,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,79926.37,,,,,,,fee schedule,28617.98,81035.13,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,79926.37,,,,,,,fee schedule,28617.98,81035.13,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,49215.69,,,,,,,fee schedule,28617.98,81035.13,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,81035.13,,,,,,,fee schedule,28617.98,81035.13,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,70465.34,,,,,,,fee schedule,28617.98,81035.13,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10773.5,10773.5,10773.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30048.88,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,28617.98,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,28617.98,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,28617.98,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,28617.98,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,28617.98,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,28617.98,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,51512.36,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,51512.36,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,30048.88,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,28617.98,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,28617.98,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,30048.88,,,,,,,fee schedule,28617.98,81035.13,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,74379.38,,,,,,,fee schedule,34444.26,97977.84,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,73853.99,,,,,,,fee schedule,34444.26,97977.84,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,73853.99,,,,,,,fee schedule,34444.26,97977.84,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,59505.63,,,,,,,fee schedule,34444.26,97977.84,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,97977.84,,,,,,,fee schedule,34444.26,97977.84,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,85198.13,,,,,,,fee schedule,34444.26,97977.84,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",29642.67,29642.67,29642.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",25213.27,25213.27,25213.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36166.47,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,34444.26,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,34444.26,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,34444.26,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,34444.26,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,34444.26,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,34444.26,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,61999.67,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,61999.67,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,36166.47,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,34444.26,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,34444.26,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,36166.47,,,,,,,fee schedule,34444.26,97977.84,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,42222.55,,,,,,,fee schedule,19877.69,55618.56,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36260.22,,,,,,,fee schedule,19877.69,55618.56,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36260.22,,,,,,,fee schedule,19877.69,55618.56,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,33779.25,,,,,,,fee schedule,19877.69,55618.56,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,55618.56,,,,,,,fee schedule,19877.69,55618.56,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,48363.97,,,,,,,fee schedule,19877.69,55618.56,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20871.57,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,19877.69,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,19877.69,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,19877.69,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,19877.69,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,19877.69,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,19877.69,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,35779.84,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,35779.84,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,20871.57,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,19877.69,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,19877.69,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,20871.57,,,,,,,fee schedule,19877.69,55618.56,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,39346.08,,,,,,,fee schedule,18574.7,51829.48,
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,35368.86,,,,,,,fee schedule,18574.7,51829.48,
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,35368.86,,,,,,,fee schedule,18574.7,51829.48,
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,31477.99,,,,,,,fee schedule,18574.7,51829.48,
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,51829.48,,,,,,,fee schedule,18574.7,51829.48,
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,45069.11,,,,,,,fee schedule,18574.7,51829.48,
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],15241.62,13611.8,34268.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21477.67,21477.67,21477.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6814.44,6814.44,6814.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38720.67,38720.67,38720.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],6562.32,6562.32,6562.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19503.44,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18574.7,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18574.7,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18574.7,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18574.7,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18574.7,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18574.7,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,33434.46,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,33434.46,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19503.44,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18574.7,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18574.7,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19503.44,,,,,,,fee schedule,18574.7,51829.48,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,69304.5,,,,,,,fee schedule,32145.42,91292.84,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,84989.01,,,,,,,fee schedule,32145.42,91292.84,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,84989.01,,,,,,,fee schedule,32145.42,91292.84,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,55445.58,,,,,,,fee schedule,32145.42,91292.84,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,91292.84,,,,,,,fee schedule,32145.42,91292.84,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,79385.08,,,,,,,fee schedule,32145.42,91292.84,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25229.13,25229.13,25229.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33752.69,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,32145.42,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,32145.42,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,32145.42,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,32145.42,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,32145.42,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,32145.42,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,57861.76,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,57861.76,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,33752.69,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,32145.42,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,32145.42,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,33752.69,,,,,,,fee schedule,32145.42,91292.84,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,57269.83,,,,,,,fee schedule,20970.44,58796.26,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,44634.88,,,,,,,fee schedule,20970.44,58796.26,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,57269.83,,,,,,,fee schedule,20970.44,58796.26,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,35709.19,,,,,,,fee schedule,20970.44,58796.26,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,58796.26,,,,,,,fee schedule,20970.44,58796.26,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,51127.19,,,,,,,fee schedule,20970.44,58796.26,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],117825.94,117825.94,117825.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9089.47,9089.47,9089.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22018.96,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,20970.44,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,20970.44,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,20970.44,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,20970.44,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,20970.44,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,20970.44,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,37746.79,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,37746.79,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,22018.96,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,20970.44,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,20970.44,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,22018.96,,,,,,,fee schedule,20970.44,58796.26,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48028.94,,,,,,,fee schedule,18295.23,51016.81,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,38729.15,,,,,,,fee schedule,18295.23,51016.81,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48028.94,,,,,,,fee schedule,18295.23,51016.81,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,30984.43,,,,,,,fee schedule,18295.23,51016.81,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,51016.81,,,,,,,fee schedule,18295.23,51016.81,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,44362.45,,,,,,,fee schedule,18295.23,51016.81,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9089.47,9089.47,9089.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19209.99,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,18295.23,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,18295.23,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,18295.23,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,18295.23,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,18295.23,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,18295.23,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,32931.41,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,32931.41,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,19209.99,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,18295.23,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,18295.23,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,19209.99,,,,,,,fee schedule,18295.23,51016.81,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,49860.41,,,,,,,fee schedule,14150.04,49860.41,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29578.32,,,,,,,fee schedule,14150.04,49860.41,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,49860.41,,,,,,,fee schedule,14150.04,49860.41,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23663.51,,,,,,,fee schedule,14150.04,49860.41,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38962.68,,,,,,,fee schedule,14150.04,49860.41,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33880.6,,,,,,,fee schedule,14150.04,49860.41,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14857.54,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14150.04,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14150.04,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14150.04,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14150.04,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14150.04,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14150.04,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25470.07,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25470.07,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14857.54,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14150.04,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14150.04,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14857.54,,,,,,,fee schedule,14150.04,49860.41,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,28568.76,,,,,,,fee schedule,10673.66,28853.42,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,21903.93,,,,,,,fee schedule,10673.66,28853.42,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,28568.76,,,,,,,fee schedule,10673.66,28853.42,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,17523.77,,,,,,,fee schedule,10673.66,28853.42,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,28853.42,,,,,,,fee schedule,10673.66,28853.42,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,25089.93,,,,,,,fee schedule,10673.66,28853.42,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11207.34,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,10673.66,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,10673.66,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,10673.66,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,10673.66,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,10673.66,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,10673.66,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19212.59,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19212.59,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11207.34,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,10673.66,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,10673.66,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11207.34,,,,,,,fee schedule,10673.66,28853.42,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,33293.66,,,,,,,fee schedule,11734.4,33293.66,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24245.59,,,,,,,fee schedule,11734.4,33293.66,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,33293.66,,,,,,,fee schedule,11734.4,33293.66,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19397.17,,,,,,,fee schedule,11734.4,33293.66,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,31938.03,,,,,,,fee schedule,11734.4,33293.66,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,27772.2,,,,,,,fee schedule,11734.4,33293.66,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22830.4,22830.4,22830.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27347.83,26953.58,28973.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],4910.16,4910.16,4910.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3015,3015,3015,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22575,22575,30023.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13800.12,13800.12,13800.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],13935.53,13935.53,13935.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7516.21,7516.21,7516.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],31855.79,31855.79,31855.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7516.21,7516.21,7516.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25479.08,23232.85,25814.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24132.05,9878.57,48413.06,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,51497.53,51497.53,51497.53,1 through 10,percent of total billed charges,,,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12321.12,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11734.4,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11734.4,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11734.4,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11734.4,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11734.4,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11734.4,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21121.92,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21121.92,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12321.12,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11734.4,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11734.4,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12321.12,,,,,,,fee schedule,11734.4,33293.66,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,26023.51,,,,,,,fee schedule,7677.46,26023.51,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,15289.58,,,,,,,fee schedule,7677.46,26023.51,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,26023.51,,,,,,,fee schedule,7677.46,26023.51,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,12232.1,,,,,,,fee schedule,7677.46,26023.51,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,20140.53,,,,,,,fee schedule,7677.46,26023.51,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,17513.51,,,,,,,fee schedule,7677.46,26023.51,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17741.56,6963.38,29903.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7483.57,7035,7516.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],24536.63,24536.63,24536.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],16125,8140.81,35475,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5166.43,5166.43,5166.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13065,7516.21,19095,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8040,8040,8040,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16067.44,16067.44,16067.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4020,3780.35,7516.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15947.01,15947.01,15947.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15947.01,14616.87,15947.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17263.15,7165.13,25348.17,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],11690.11,11690.11,11690.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8061.33,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,7677.46,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,7677.46,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,7677.46,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,7677.46,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,7677.46,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,7677.46,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,13819.43,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,13819.43,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8061.33,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,7677.46,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,7677.46,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8061.33,,,,,,,fee schedule,7677.46,26023.51,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,24181.6,,,,,,,fee schedule,11044.83,29932.78,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22723.32,,,,,,,fee schedule,11044.83,29932.78,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,24181.6,,,,,,,fee schedule,11044.83,29932.78,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18179.31,,,,,,,fee schedule,11044.83,29932.78,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,29932.78,,,,,,,fee schedule,11044.83,29932.78,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26028.51,,,,,,,fee schedule,11044.83,29932.78,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25685.25,25685.25,25685.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27352.3,27352.3,29539.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],31770,12774,38700,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11055,11055,11055,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6030,6030,6030,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15124.97,15124.97,16678.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8040,7035,11055,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21655.41,21655.41,21655.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21655.41,19849.14,21655.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22507.64,17219.29,33315.74,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",21105,21105,21105,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],40049.06,40049.06,40049.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,6652.97,6652.97,6652.97,1 through 10,percent of total billed charges,,,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11597.07,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11044.83,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11044.83,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11044.83,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11044.83,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11044.83,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11044.83,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,19880.69,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,19880.69,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11597.07,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11044.83,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11044.83,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11597.07,,,,,,,fee schedule,11044.83,29932.78,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,14662.16,,,,,,,fee schedule,6182.38,15792.89,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,11989.1,,,,,,,fee schedule,6182.38,15792.89,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,14662.16,,,,,,,fee schedule,6182.38,15792.89,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,9591.62,,,,,,,fee schedule,6182.38,15792.89,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,15792.89,,,,,,,fee schedule,6182.38,15792.89,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,13732.95,,,,,,,fee schedule,6182.38,15792.89,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],22239,22239,22239,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7035,7035,7035,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",7035,7035,7035,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17517.09,16217.67,21807.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24874.59,24874.59,24874.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],74498.59,74498.59,74498.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6491.5,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,6182.38,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,6182.38,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,6182.38,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,6182.38,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,6182.38,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,6182.38,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,11128.28,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,11128.28,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,6491.5,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,6182.38,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,6182.38,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,6491.5,,,,,,,fee schedule,6182.38,15792.89,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,10564,,,,,,,fee schedule,5562.03,13988.93,
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,10619.62,,,,,,,fee schedule,5562.03,13988.93,
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,10564,,,,,,,fee schedule,5562.03,13988.93,
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,8496,,,,,,,fee schedule,5562.03,13988.93,
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,13988.93,,,,,,,fee schedule,5562.03,13988.93,
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,12164.28,,,,,,,fee schedule,5562.03,13988.93,
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],10215.17,10215.17,10215.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6481.02,6481.02,6481.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",3780.35,3780.35,3780.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9968.91,9968.91,11378.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5356.04,5356.04,5356.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6411.17,6411.17,6411.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,6492.62,6492.62,6492.62,1 through 10,percent of total billed charges,,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5840.13,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,5562.03,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,5562.03,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,5562.03,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,5562.03,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,5562.03,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,5562.03,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,10011.65,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,10011.65,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,5840.13,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,5562.03,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,5562.03,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,5840.13,,,,,,,fee schedule,5562.03,13988.93,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,262982.31,,,,,,,fee schedule,58989.22,262982.31,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,128564.28,,,,,,,fee schedule,58989.22,262982.31,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,262982.31,,,,,,,fee schedule,58989.22,262982.31,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,102855.11,,,,,,,fee schedule,58989.22,262982.31,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,169354.07,,,,,,,fee schedule,58989.22,262982.31,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,147264.42,,,,,,,fee schedule,58989.22,262982.31,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,61938.68,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,58989.22,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,58989.22,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,58989.22,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,58989.22,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,58989.22,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,58989.22,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,106180.6,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,106180.6,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,61938.68,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,58989.22,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,58989.22,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,61938.68,,,,,,,fee schedule,58989.22,262982.31,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,162338.8,,,,,,,fee schedule,33309.11,162338.8,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,71873.45,,,,,,,fee schedule,33309.11,162338.8,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,162338.8,,,,,,,fee schedule,33309.11,162338.8,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,57500.82,,,,,,,fee schedule,33309.11,162338.8,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,94676.85,,,,,,,fee schedule,33309.11,162338.8,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,82327.7,,,,,,,fee schedule,33309.11,162338.8,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],94745.45,94745.45,94745.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",17042.5,17042.5,17042.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],31621.1,26368.49,32562.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34974.57,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,33309.11,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,33309.11,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,33309.11,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,33309.11,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,33309.11,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,33309.11,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,59956.4,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,59956.4,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,34974.57,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,33309.11,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,33309.11,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,34974.57,,,,,,,fee schedule,33309.11,162338.8,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,223024.35,,,,,,,fee schedule,66679.16,223024.35,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,145540.39,,,,,,,fee schedule,66679.16,223024.35,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,223024.35,,,,,,,fee schedule,66679.16,223024.35,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,116436.49,,,,,,,fee schedule,66679.16,223024.35,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,191716.23,,,,,,,fee schedule,66679.16,223024.35,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,166709.77,,,,,,,fee schedule,66679.16,223024.35,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,70013.12,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,66679.16,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,66679.16,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,66679.16,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,66679.16,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,66679.16,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,66679.16,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,120022.49,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,120022.49,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,70013.12,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,66679.16,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,66679.16,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,70013.12,,,,,,,fee schedule,66679.16,223024.35,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,105897.66,,,,,,,fee schedule,37210.32,106021.47,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,80485.66,,,,,,,fee schedule,37210.32,106021.47,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,105897.66,,,,,,,fee schedule,37210.32,106021.47,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,64390.84,,,,,,,fee schedule,37210.32,106021.47,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,106021.47,,,,,,,fee schedule,37210.32,106021.47,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,92192.59,,,,,,,fee schedule,37210.32,106021.47,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39070.84,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,37210.32,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,37210.32,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,37210.32,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,37210.32,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,37210.32,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,37210.32,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,66978.58,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,66978.58,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,39070.84,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,37210.32,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,37210.32,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,39070.84,,,,,,,fee schedule,37210.32,106021.47,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,63136.78,,,,,,,fee schedule,26223.96,74073.38,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,56232.43,,,,,,,fee schedule,26223.96,74073.38,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,63136.78,,,,,,,fee schedule,26223.96,74073.38,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44987.56,,,,,,,fee schedule,26223.96,74073.38,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,74073.38,,,,,,,fee schedule,26223.96,74073.38,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,64411.64,,,,,,,fee schedule,26223.96,74073.38,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27535.16,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,26223.96,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,26223.96,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,26223.96,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,26223.96,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,26223.96,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,26223.96,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,47203.13,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,47203.13,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27535.16,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,26223.96,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,26223.96,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27535.16,,,,,,,fee schedule,26223.96,74073.38,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,83049.61,,,,,,,fee schedule,24404.44,83049.61,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,52215.69,,,,,,,fee schedule,24404.44,83049.61,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,83049.61,,,,,,,fee schedule,24404.44,83049.61,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,41774.05,,,,,,,fee schedule,24404.44,83049.61,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,68782.24,,,,,,,fee schedule,24404.44,83049.61,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,59810.65,,,,,,,fee schedule,24404.44,83049.61,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],106104.16,106104.16,106104.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],54526.92,54526.92,54526.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25624.66,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,24404.44,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,24404.44,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,24404.44,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,24404.44,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,24404.44,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,24404.44,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,43927.99,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,43927.99,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,25624.66,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,24404.44,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,24404.44,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,25624.66,,,,,,,fee schedule,24404.44,83049.61,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,36430.83,,,,,,,fee schedule,14011.61,38560.12,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,29272.72,,,,,,,fee schedule,14011.61,38560.12,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,36430.83,,,,,,,fee schedule,14011.61,38560.12,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,23419.02,,,,,,,fee schedule,14011.61,38560.12,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,38560.12,,,,,,,fee schedule,14011.61,38560.12,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,33530.54,,,,,,,fee schedule,14011.61,38560.12,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",4776.25,4776.25,4776.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],35268.28,35268.28,35268.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13232.16,13232.16,13232.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14712.19,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14011.61,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14011.61,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14011.61,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14011.61,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14011.61,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14011.61,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,25220.9,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,25220.9,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,14712.19,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14011.61,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14011.61,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,14712.19,,,,,,,fee schedule,14011.61,38560.12,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,21914.9,,,,,,,fee schedule,8888.74,23662.92,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17963.59,,,,,,,fee schedule,8888.74,23662.92,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,21914.9,,,,,,,fee schedule,8888.74,23662.92,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,14371.39,,,,,,,fee schedule,8888.74,23662.92,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,23662.92,,,,,,,fee schedule,8888.74,23662.92,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,20576.46,,,,,,,fee schedule,8888.74,23662.92,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],20246.82,20246.82,20246.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",6902.3,6902.3,6902.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,13719.34,13719.34,13719.34,1 through 10,percent of total billed charges,,,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9333.18,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8888.74,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8888.74,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8888.74,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8888.74,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8888.74,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8888.74,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15999.73,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15999.73,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,9333.18,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8888.74,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8888.74,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,9333.18,,,,,,,fee schedule,8888.74,23662.92,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,196053.77,,,,,,,fee schedule,53713.21,196053.77,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,116917.07,,,,,,,fee schedule,53713.21,196053.77,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,196053.77,,,,,,,fee schedule,53713.21,196053.77,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,93537.01,,,,,,,fee schedule,53713.21,196053.77,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,154011.54,,,,,,,fee schedule,53713.21,196053.77,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,133923.09,,,,,,,fee schedule,53713.21,196053.77,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,56398.87,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,53713.21,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,53713.21,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,53713.21,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,53713.21,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,53713.21,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,53713.21,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,96683.78,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,96683.78,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,56398.87,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,53713.21,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,53713.21,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,56398.87,,,,,,,fee schedule,53713.21,196053.77,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,63478.01,,,,,,,fee schedule,23570.38,66356.83,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,50374.45,,,,,,,fee schedule,23570.38,66356.83,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,63478.01,,,,,,,fee schedule,23570.38,66356.83,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,40301,,,,,,,fee schedule,23570.38,66356.83,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,66356.83,,,,,,,fee schedule,23570.38,66356.83,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,57701.59,,,,,,,fee schedule,23570.38,66356.83,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24748.9,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,23570.38,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,23570.38,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,23570.38,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,23570.38,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,23570.38,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,23570.38,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,42426.68,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,42426.68,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,24748.9,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,23570.38,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,23570.38,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,24748.9,,,,,,,fee schedule,23570.38,66356.83,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,75525.29,,,,,,,fee schedule,25721.28,75525.29,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,55122.72,,,,,,,fee schedule,25721.28,75525.29,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,75525.29,,,,,,,fee schedule,25721.28,75525.29,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,44099.75,,,,,,,fee schedule,25721.28,75525.29,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,72611.59,,,,,,,fee schedule,25721.28,75525.29,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,63140.51,,,,,,,fee schedule,25721.28,75525.29,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25112.83,25112.83,25112.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27007.34,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,25721.28,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,25721.28,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,25721.28,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,25721.28,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,25721.28,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,25721.28,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,46298.3,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,46298.3,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,27007.34,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,25721.28,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,25721.28,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,27007.34,,,,,,,fee schedule,25721.28,75525.29,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19829.26,,,,,,,fee schedule,11955.89,32582.12,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24734.55,,,,,,,fee schedule,11955.89,32582.12,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19829.26,,,,,,,fee schedule,11955.89,32582.12,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19788.35,,,,,,,fee schedule,11955.89,32582.12,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32582.12,,,,,,,fee schedule,11955.89,32582.12,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28332.28,,,,,,,fee schedule,11955.89,32582.12,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10228.34,10228.34,10228.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11687.59,11687.59,11687.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12553.68,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11955.89,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11955.89,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11955.89,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11955.89,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11955.89,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11955.89,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21520.6,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21520.6,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12553.68,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11955.89,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11955.89,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12553.68,,,,,,,fee schedule,11955.89,32582.12,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,19254.75,,,,,,,fee schedule,8561.69,22711.88,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,17241.61,,,,,,,fee schedule,8561.69,22711.88,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,19254.75,,,,,,,fee schedule,8561.69,22711.88,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,13793.78,,,,,,,fee schedule,8561.69,22711.88,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,22711.88,,,,,,,fee schedule,8561.69,22711.88,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,19749.46,,,,,,,fee schedule,8561.69,22711.88,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8989.77,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,8561.69,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,8561.69,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,8561.69,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,8561.69,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,8561.69,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,8561.69,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,15411.04,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,15411.04,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,8989.77,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,8561.69,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,8561.69,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,8989.77,,,,,,,fee schedule,8561.69,22711.88,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,29484.49,,,,,,,fee schedule,11979.25,32650.05,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,24786.12,,,,,,,fee schedule,11979.25,32650.05,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,29484.49,,,,,,,fee schedule,11979.25,32650.05,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,19829.61,,,,,,,fee schedule,11979.25,32650.05,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,32650.05,,,,,,,fee schedule,11979.25,32650.05,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,28391.35,,,,,,,fee schedule,11979.25,32650.05,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12578.21,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11979.25,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11979.25,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11979.25,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11979.25,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11979.25,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11979.25,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,21562.65,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,21562.65,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,12578.21,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11979.25,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11979.25,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,12578.21,,,,,,,fee schedule,11979.25,32650.05,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,154616.01,,,,,,,fee schedule,41345.13,154616.01,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,89613.57,,,,,,,fee schedule,41345.13,154616.01,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,154616.01,,,,,,,fee schedule,41345.13,154616.01,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,71693.43,,,,,,,fee schedule,41345.13,154616.01,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,118045.41,,,,,,,fee schedule,41345.13,154616.01,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,102648.19,,,,,,,fee schedule,41345.13,154616.01,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39972.93,39972.93,39972.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13900.84,13900.84,13900.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],77759.8,55126.99,295927.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],148278.28,148278.28,148278.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13429.97,13429.97,13429.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",109350.47,109350.47,145667.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",34345.45,34345.45,34345.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],42122.4,42122.4,42122.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",23651.6,12221.24,468548.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],254544.26,34379.81,1363028.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],40303.15,26171.16,40360.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18891.88,18891.88,18891.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,43412.39,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,41345.13,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,41345.13,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,41345.13,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,41345.13,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,41345.13,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,41345.13,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,74421.23,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,74421.23,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,43412.39,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,41345.13,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,41345.13,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,43412.39,,,,,,,fee schedule,41345.13,154616.01,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,46957.45,,,,,,,fee schedule,22022.53,64477.31,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,64477.31,,,,,,,fee schedule,22022.53,64477.31,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,64477.31,,,,,,,fee schedule,22022.53,64477.31,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,37567.31,,,,,,,fee schedule,22022.53,64477.31,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,61855.71,,,,,,,fee schedule,22022.53,64477.31,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,53787.58,,,,,,,fee schedule,22022.53,64477.31,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28965.84,28965.84,28965.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27074.57,27074.57,64525.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13429.97,13429.97,13429.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",18891.88,18891.88,18891.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",10054.11,8223.99,40130.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21111.68,20751.18,21520,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23123.66,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,22022.53,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,22022.53,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,22022.53,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,22022.53,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,22022.53,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,22022.53,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,39640.55,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,39640.55,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,23123.66,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,22022.53,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,22022.53,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,23123.66,,,,,,,fee schedule,22022.53,64477.31,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,32737.47,,,,,,,fee schedule,15581.09,48826.29,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,48826.29,,,,,,,fee schedule,15581.09,48826.29,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,48826.29,,,,,,,fee schedule,15581.09,48826.29,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,26190.91,,,,,,,fee schedule,15581.09,48826.29,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,43124.14,,,,,,,fee schedule,15581.09,48826.29,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,37499.25,,,,,,,fee schedule,15581.09,48826.29,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27088.61,27088.61,27088.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",11000.51,11000.51,11000.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9857.27,9857.27,9857.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14519.53,14519.53,14519.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],63834.57,63834.57,63834.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16360.14,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,15581.09,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,15581.09,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,15581.09,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,15581.09,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,15581.09,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,15581.09,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,28045.96,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,28045.96,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,16360.14,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,15581.09,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,15581.09,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,16360.14,,,,,,,fee schedule,15581.09,48826.29,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,65482.58,,,,,,,fee schedule,30414.14,115371.83,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,115371.83,,,,,,,fee schedule,30414.14,115371.83,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,115371.83,,,,,,,fee schedule,30414.14,115371.83,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,52387.94,,,,,,,fee schedule,30414.14,115371.83,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,86258.34,,,,,,,fee schedule,30414.14,115371.83,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,75007.26,,,,,,,fee schedule,30414.14,115371.83,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",34656.71,34656.71,34656.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],111780.92,111780.92,111780.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",71370.79,71370.79,71370.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",13988.47,13988.47,13988.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29847.63,24253.64,29978.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31934.85,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,30414.14,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,30414.14,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,30414.14,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,30414.14,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,30414.14,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,30414.14,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,54745.45,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,54745.45,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,31934.85,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,30414.14,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,30414.14,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,31934.85,,,,,,,fee schedule,30414.14,115371.83,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,31392.83,,,,,,,fee schedule,14971.99,44999.71,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,44999.71,,,,,,,fee schedule,14971.99,44999.71,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,44999.71,,,,,,,fee schedule,14971.99,44999.71,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,25115.16,,,,,,,fee schedule,14971.99,44999.71,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,41352.88,,,,,,,fee schedule,14971.99,44999.71,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,35959.03,,,,,,,fee schedule,14971.99,44999.71,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14160.98,14160.98,14160.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",5888.94,5888.94,5888.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14938.01,14736.02,14985.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15720.59,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,14971.99,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,14971.99,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,14971.99,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,14971.99,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,14971.99,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,14971.99,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,26949.58,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,26949.58,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,15720.59,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,14971.99,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,14971.99,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,15720.59,,,,,,,fee schedule,14971.99,44999.71,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,22904.77,,,,,,,fee schedule,11127.02,31497.01,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,31497.01,,,,,,,fee schedule,11127.02,31497.01,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,31497.01,,,,,,,fee schedule,11127.02,31497.01,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,18324.47,,,,,,,fee schedule,11127.02,31497.01,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,30171.8,,,,,,,fee schedule,11127.02,31497.01,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,26236.35,,,,,,,fee schedule,11127.02,31497.01,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],27914.68,27914.68,27914.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",8678.01,8678.01,8678.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",9857.27,9857.27,9857.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19830,19830,19830,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11683.37,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,11127.02,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,11127.02,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,11127.02,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,11127.02,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,11127.02,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,11127.02,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,20028.64,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,20028.64,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,11683.37,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,11127.02,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,11127.02,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,11683.37,,,,,,,fee schedule,11127.02,31497.01,MSDRG Base Rate
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,All Commercial Plans,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Complete Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 3060] [Rehab-Per Diem: 3345],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,BCBS,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Care Resources,PACE Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Community Pace,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Life Circles,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Ambetter Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Meridian Health Plan,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Exchange,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Cigna   HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 86.01] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Core Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 74.79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Narrow Network Exchange,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 53.72] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Priority Health,Tiered Network HMO/PPO,,,[Stop Loss: Total Charges > 235625.46 | Total % of Charge: 65.30] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,,[All Other IP (%BC): 81],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.michigan.gov/mdhhs/assistance-programs/medicaid/portalhome/medicaid-providers]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Aetna,Existing Business All Commercial Plans,,81,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Cofinity,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,All Commercial Plans,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,ASR Other Commercial Plan,,79.17,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Health Alliance Plan,Exchange,,78.7,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Kent County,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,McLaren Health Plan,All Commercial Plans,,67.62,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,facility,inpatient,,,,,,Michigan Amish Medical Board,All Commercial Plans,,35,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
LORAZEPAM 2 MG/ML PO CONC [4571],0054-3532-44,NDC,,,,,facility,both,6,ML,,42.22,42.22,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG PO TABS [2327],0054-8175-25,NDC,,,,,facility,both,336,UN,,98.91,98.91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP [28836],0121-0431-30,NDC,,,,,facility,both,1,ML,,3.98,3.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 2 MG/ML PO CONC [3585],0121-0581-04,NDC,,,,,facility,both,6,ML,,20.34,20.34,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GM/10ML PO SUSP [11441],0121-0747-00,NDC,,,,,facility,both,1,ML,,25.5,25.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN [111224],0143-9519-10,NDC,,,,,facility,both,2,ML,,31.76,31.76,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT INH AERO [81737],0186-0372-28,NDC,,,,,facility,both,10,GR,,70,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 5 MG PO TABS [10814],0406-0552-23,NDC,,,,,facility,both,2,UN,,15.26,15.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML PO SOLN [10655],0406-8003-30,NDC,,,,,facility,both,11,ML,,80.29,80.29,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.5 MG PO TABS [12491],0555-0899-02,NDC,,,,,facility,both,2,UN,,13.84,13.84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG REC SUPP [1080],0574-7050-12,NDC,,,,,facility,both,2,UN,,6.85,6.85,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE BESYLATE 2.5 MG PO TABS [9070],0904-6369-61,NDC,,,,,facility,both,12,UN,,39.72,39.72,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG PO CSDR [126883],0904-6615-61,NDC,,,,,facility,both,32,UN,,156.02,156.02,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG PO CAPS [18308],0904-6666-61,NDC,,,,,facility,both,20,UN,,69.5,69.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN ER 600 MG PO TB12 [37651],0904-6718-39,NDC,,,,,facility,both,2,UN,,3.98,3.98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG PO TABS [10449],0904-6798-61,NDC,,,,,facility,both,12,UN,,38.28,38.28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 500 MG PO TAB DR [2553],0904-6861-90,NDC,,,,,facility,both,6,UN,,22.14,22.14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE SODIUM 50 MCG PO TABS [4421],0904-6950-61,NDC,,,,,facility,both,4,UN,,28.92,28.92,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE SODIUM 150 MCG PO TABS [4425],0904-6956-61,NDC,,,,,facility,both,11,UN,,40.93,40.93,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG PO TABS [4971],0904-7057-61,NDC,,,,,facility,both,1,UN,,6.87,6.87,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG PO TABS [26817],0904-7124-61,NDC,,,,,facility,both,19,UN,,71.42,71.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 750 MG PO TABS [26818],0904-7125-61,NDC,,,,,facility,both,14,UN,,12.32,12.32,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 100 MG PO TABS [93298],0904-7245-68,NDC,,,,,facility,both,40,UN,,193.6,193.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 8.6 MG PO TABS [18138],0904-7252-61,NDC,,,,,facility,both,65,UN,,49.03,49.03,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG PO TABS [15747],0904-7306-61,NDC,,,,,facility,both,7,UN,,43.26,43.26,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UT) PO TABS [76950],20555-03300,NDC,,,,,facility,both,5,UN,,19.9,19.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE HCL 10 MG/ML IJ SOLN [4236],25021-682-20,NDC,,,,,facility,both,2,ML,,25.57,25.57,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 G PO PACK [95420],43598-478-01,NDC,,,,,facility,both,40,UN,,37.09,37.09,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN [161453],44567-611-01,NDC,,,,,facility,both,9,ML,,2214.9,2214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SODIUM 20 MG PO TBEC [26224],50268-585-11,NDC,,,,,facility,both,2,UN,,13.7,13.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SODIUM 40 MG PO TBEC [26225],50268-639-11,NDC,,,,,facility,both,9,UN,,59.04,59.04,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG PO TABS [6582],50268-685-11,NDC,,,,,facility,both,1,UN,,10.1,10.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GM/10ML PO SUSP [11441],50268-745-11,NDC,,,,,facility,both,9,ML,,272.07,272.07,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG PO TABS [18293],50268-756-11,NDC,,,,,facility,both,10,UN,,40.8,40.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG PO TABS [102],50580-457-11,NDC,,,,,facility,both,15,UN,,10.61,10.61,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE DIPROPIONATE AUG 0.05 % EXT CREA [9175],51672-1310-1,NDC,,,,,facility,both,5,GR,,170.9,170.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL HCL 100 MG/10ML IV SOLN [82387],55150-194-10,NDC,,,,,facility,both,1,ML,,23.42,23.42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG PO CHEW [11018],60687-156-95,NDC,,,,,facility,both,20,UN,,141.1,141.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS [34505],60687-396-11,NDC,,,,,facility,both,1,UN,,7.44,7.44,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 G PO PACK [25424],60687-431-99,NDC,,,,,facility,both,7,UN,,81.13,81.13,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG PO TABS [3720],60687-593-11,NDC,,,,,facility,both,5,UN,,33.9,33.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG PO TABS [310],60687-677-11,NDC,,,,,facility,both,5,UN,,34.2,34.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS [6257],60687-841-11,NDC,,,,,facility,both,5,UN,,51.6,51.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE (PF) 0.9 % IJ SOLN [154940],63323-186-10,NDC,,,,,facility,both,2,ML,,22.79,22.79,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG PO TABS [3774],63739-486-10,NDC,,,,,facility,both,5,UN,,33.5,33.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE HCL 10 MG PO CAPS [10069],65862-192-01,NDC,,,,,facility,both,6,UN,,36.78,36.78,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 15 MG PO TBDD [154927],65862-895-10,NDC,,,,,facility,both,3,UN,,55.38,55.38,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG PO TABS [25519],68084-270-11,NDC,,,,,facility,both,10,UN,,67.9,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN HCL 0.4 MG PO CAPS [97848],68084-299-11,NDC,,,,,facility,both,6,UN,,41.88,41.88,,,,,,,,,,,,,Gross Charge Type: Pharmacy
Bilateral Procedure,,,,,,,facility,both,,,50,,,Aetna,Existing Business All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,BCBS,Complete Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,BCBS,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,BCBS,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Care Resources,PACE Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Cofinity,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Community Pace,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Health Alliance Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Health Alliance Plan,ASR Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Health Alliance Plan,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Health Alliance Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Health Alliance Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Kent County,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Life Circles,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,McLaren Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,McLaren Health Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,McLaren Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Meridian Health Plan,Ambetter Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Meridian Health Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Michigan Amish Medical Board,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Molina Healthcare,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Molina Healthcare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Priority Health,Cigna   HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Priority Health,Core Network HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Priority Health,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Priority Health,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Priority Health,Narrow Network Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Priority Health,Tiered Network HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,facility,both,,,50,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Aetna,Existing Business All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,BCBS,Complete Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,BCBS,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,BCBS,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Care Resources,PACE Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Cofinity,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Community Pace,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Health Alliance Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Health Alliance Plan,ASR Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Health Alliance Plan,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Health Alliance Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Health Alliance Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Kent County,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Life Circles,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,McLaren Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,McLaren Health Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,McLaren Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Meridian Health Plan,Ambetter Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Meridian Health Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Michigan Amish Medical Board,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Molina Healthcare,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Molina Healthcare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Priority Health,Cigna   HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Priority Health,Core Network HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Priority Health,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Priority Health,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Priority Health,Narrow Network Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Priority Health,Tiered Network HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Catastrophe/disaster related,,,,,,,facility,both,,,CR,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Aetna,Existing Business All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,BCBS,Complete Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,BCBS,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,BCBS,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Care Resources,PACE Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Cofinity,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Community Pace,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Health Alliance Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Health Alliance Plan,ASR Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Health Alliance Plan,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Health Alliance Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Health Alliance Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Kent County,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Life Circles,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,McLaren Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,McLaren Health Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,McLaren Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Meridian Health Plan,Ambetter Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Meridian Health Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Michigan Amish Medical Board,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Molina Healthcare,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Molina Healthcare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Priority Health,Cigna   HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Priority Health,Core Network HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Priority Health,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Priority Health,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Priority Health,Narrow Network Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Priority Health,Tiered Network HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,facility,both,,,NTX,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Aetna,Existing Business All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,BCBS,Complete Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,BCBS,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,BCBS,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Care Resources,PACE Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Caresource Medicaid Managed Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Cofinity,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Community Pace,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Health Alliance Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Health Alliance Plan,ASR Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Health Alliance Plan,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Health Alliance Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Health Alliance Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Kent County,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Life Circles,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,McLaren Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,McLaren Health Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,McLaren Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Meridian Health Plan,Ambetter Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Meridian Health Plan,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Michigan Amish Medical Board,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Molina Healthcare,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Molina Healthcare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Priority Health,Cigna   HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Priority Health,Core Network HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Priority Health,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Priority Health,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Priority Health,Narrow Network Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Priority Health,Tiered Network HMO/PPO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,UnitedHealthCare,MICHILD Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,UnitedHealthCare,UHCCP Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,facility,both,,,PN,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,BCBS,Blue Care Network Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Care Resources,PACE Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Community Pace,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Health Alliance Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Life Circles,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,McLaren Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Meridian Health Plan,Ambetter Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Molina Healthcare,Exchange,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Molina Healthcare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Priority Health,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,Trinity Health Plan of Michigan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,facility,outpatient,,,TC,,,University of Michigan Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.